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Social capital in healthcare A resource for sustainable engagement in organizational improvement work MARCUS STRÖMGREN
Doctoral Thesis (No. 8, 2017) KTH Royal Institute of Technology Technology and Health Unit of Ergonomics SE-141 57 Huddinge, Sweden
TRITA-STH Report 2017:8 ISSN 1653-3836 ISRN/KTH/STH/2017:8-SE ISBN 978-91-7729-463-4 © Marcus Strömgren, 2017 Print: US-AB, Stockholm Academic dissertation which with permission from Kungliga Tekniska Högskolan (Royal Institute of Technology) in Stockholm is presented for public review for passing the doctoral examination on Friday 29 September at 13:00 in lecture hall T1 (Emmy Rappesalen), Hälsovägen 11C, Huddinge, Sweden.
Abstract
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 organizational improvement work in hospitals and how social capital and engagement are created during organizational improvement work. In Study I, the aim was to assess dimensions of engagement among healthcare professionals and to investigate how these are related to work conditions during organizational redesign of care processes. In Study II, the aim was to assess working conditions and social capital association with intention to leave, and to investigate if social capital moderates the association between job demands and intention to leave. Study III aimed to investigate the importance of social capital for job satisfaction, work engagement, and engagement in clinical improvements among healthcare professionals. In Study IV, the aim was to explore whether qualities of leadership have impact on social capital among employees in hospital settings over time, and if so, what those qualities are. The empirical material is based on data from one research program including three research projects. Data were collected by a questionnaire at three times over a period of two years, and all studies are quantitative. The studies are based on a hospital cohort including five hospitals. In Study II, cross-sectional data were analysed. In studies I, III, and IV, longitudinal data were analysed. 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.
Keywords Healthcare, social capital, engagement, leadership, sustainability.
Sammanfattning
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.
Nyckelord
Sjukvård, socialt kapital, engagemang, ledarskap, hållbarhet.
Preface
This thesis is most certainly influenced by my background and previous experiences. I have been practicing sports for most part of my life and I have also been involved from the coaching side. I believe this is where my interest for leadership and the ability to create group engagement started. During my bachelor’s studies in health promotion, I identified several issues regarding leadership, health and group engagement. This increased my interest for the topic and left me with unanswered questions regarding the subject. After my bachelor’s degree I started my career as a Health Planner where I worked with public health in a county council. This meant analyzing and communicating results of epidemiologic studies to politicians and managers within healthcare and municipalities.
In 2003 I was given the opportunity to attend a leadership course, Understanding Group and Leader (UGL). This was a real eye-opener and provided me with valuable insights of the importance of leadership in relation to group development. A few years later I became a licenced UGL-trainer, and have since then worked with employees and managers from different kinds of organizations. These experiences have provided me with the knowledge of the need for leadership and the importance of human relations for both organizational outcomes and for well-being.
In 2007 I earned my master’s degree in leadership, which added theoretical insights to my experiences of working with leadership development. This also inspired me to search for future possibilities to study the concepts of leadership and engagement within healthcare. In 2012, while working on a project to evaluate an intervention of health-promoting leadership, I met with a research team that made it possible for me to start studying the concepts of engagement, leadership, and social capital. In this thesis, theoretical knowledge and my practical experiences have been combined to investigate social capital, engagement, and leadership with respect to organizational improvement work in healthcare. Although I have come across new questions during this journey, I am about to bring closure to some of the previous ones.
Köping, August 2017
Marcus Strömgren
List of studies
This thesis is based on the following studies, which are referred to in the text by their
Roman numerals.
Study I
Dellve L., Strömgren M., Williamsson A., Holden R., Eriksson A. Health care clinicians’
engagement in organizational redesign of care processes: The importance of work and
organizational conditions (In review process).
Study II
Strömgren M. (2017). Intention to leave among health care professionals: The importance
of working conditions and social capital. Journal of Hospital Administration, 6(3), 58-66.
Study III
Strömgren M., Eriksson A., Bergman D., Dellve L. (2016). Social capital among healthcare
professionals: A prospective study of its importance for job satisfaction, work engagement
and engagement in clinical improvements. International Journal of Nursing Studies, 53,
116-125.
Study IV
Strömgren M., Eriksson A., Ahlstrom L, Bergman D., Dellve L. (2017). Leadership quality:
a factor important for social capital in healthcare organizations. Journal of Health
Organization and Management, 31(2), 175-191.
Strömgren´s contribution
Study I: Strömgren contributed in the writing and the analyses. Strömgren contributed in
revising the manuscript throughout the process.
Study II: Strömgren is the corresponding author, no co-authors.
Study III: Strömgren is the corresponding author. Strömgren designed and wrote the
paper. Strömgren performed the analyses.
Study IV: Strömgren is the corresponding author. Strömgren designed and wrote the
paper. Strömgren performed the analyses.
In all studies, Strömgren participated in collecting the empirical data.
Summary of studies: aims, designs, and conclusions
Study Aim Design Conclusion
I To assess dimensions of engagement among healthcare professionals and to investigate how these are related to work conditions during organizational redesign of care processes.
Quantitative study over time T1: n = 865 T2: n = 908
The study contributes to the knowledge about how and when healthcare professionals are mobilized to engage in healthcare improvement work. Increased work and organizational resources have importance for healthcare professionals’ clinical engagement in improving care processes.
II To assess the association of working conditions and social capital with the intention to leave, and to investigate whether social capital moderates the association between job demands and intention to leave.
Cross-sectional study n = 849
Social capital was associated with healthcare professionals’ intention to leave their jobs. Social capital did not interact with job demands with respect to intention to leave. Working conditions and social capital had different importance among occupational groups regarding intention to leave.
III To investigate the importance of social capital for job satisfaction, work engagement, and engagement in clinical improvements among healthcare professionals.
Quantitative, prospective cohort study n = 477
Social capital predicted healthcare professionals’ general work engagement, engagement in clinical improvements in patient safety and job satisfaction.
IV To explore whether qualities of leadership have impact on social capital among employees in hospital settings over time, and what those qualities are.
Quantitative study over time T1: n = 865 T2: n = 908 T3: n = 632
Leadership was an important factor for building social capital. Levels of leadership quality correlate with levels of social capital over time.
Study II has been reprinted with the kind permission of Sciedu Press.
Study III has been reprinted with the kind permission of Elsevier Ltd.
Study IV has been reprinted with the kind permission of Emerald Group Publishing
Limited.
Abbreviations
COPSOQ Copenhagen psychosocial questionnaire
HCWs Healthcare workers
JD-R model Job demands resources model
LP Lean production
MWQ Modern work-life questionnaire
NPM New public management
RN Registered nurse
SWEBO The Swedish scale for work engagement and burnout
Contents
1. Introduction ..................................................................................................................... 11
2. Background ..................................................................................................................... 13
2.1. Bio ecological system ............................................................................................... 13
2.2. System approach to organizational improvement work ......................................... 14
2.2.1. Organizational improvement work in Swedish healthcare ............................... 15
2.2.2. Sustainability perspectives on organizational improvement work .................. 16
2.2.3. Sustainable organizational improvement work in healthcare ......................... 16
2.3. Social capital ............................................................................................................. 17
2.3.1. Social capital in healthcare ............................................................................... 18
2.3.2. Social capital as a resource for organizational improvement work ................. 18
2.4. Work engagement ................................................................................................... 19
2.5. Intention to leave ..................................................................................................... 20
2.6. Importance of working conditions for engagement ................................................ 20
2.6.1. Challenges in engaging healthcare professionals ............................................. 21
2.7. Leadership ............................................................................................................... 22
2.7.1. Leadership in healthcare .................................................................................. 24
3. Aim .................................................................................................................................. 27
3.1. Specific aims ............................................................................................................ 27
4. Method ............................................................................................................................ 28
4.1. Research design ....................................................................................................... 28
4.2 Sample ...................................................................................................................... 28
4.3. Data collection ......................................................................................................... 30
4.4. Measures.................................................................................................................. 30
4.4.1. Attitudes to engaging in organizational improvement work (I)....................... 30
4.4.2. Work engagement (I, II) .................................................................................. 31
4.4.3. Engagement in clinical improvements (I, III) ................................................. 31
4.4.4. Working conditions (I, II) ................................................................................ 32
4.4.5. Top-down initiative to implement LP (I) ......................................................... 32
4.4.6. Organizational improvements at units (I) ....................................................... 32
4.4.7. Quality of leadership (I, IV) ............................................................................. 32
4.4.8. Social capital (II, III, IV) .................................................................................. 33
4.4.9. Job satisfaction (III) ........................................................................................ 33
4.4.10. Intention to leave (II) ..................................................................................... 34
4.4.11. Control variables ............................................................................................. 34
4.5. Analyses ................................................................................................................... 34
4.5.1. Study I ............................................................................................................... 34
4.5.2. Study II ............................................................................................................. 34
4.5.3. Study III ........................................................................................................... 35
4.5.4. Study IV ............................................................................................................ 36
4.6. Ethics ....................................................................................................................... 36
5. Results ............................................................................................................................. 37
5.1. Study I ...................................................................................................................... 37
5.2. Study II .................................................................................................................... 38
5.3. Study III ................................................................................................................... 39
5.4. Study IV ................................................................................................................... 39
6. Discussion ....................................................................................................................... 41
6.1. Employee engagement in organizational improvement work ................................. 41
6.2. Social capital as a resource for employee engagement ........................................... 42
6.3. Leadership, a factor important for social capital .................................................... 44
6.4. From a systems perspective .................................................................................... 45
6.5. Practical implications .............................................................................................. 46
6.6. Method discussion ................................................................................................... 47
7. Conclusions and future research ..................................................................................... 51
7.1. General conclusion .................................................................................................... 51
7.2. Specific conclusions .................................................................................................. 51
7.3 Future research .......................................................................................................... 51
Acknowledgements ............................................................................................................. 52
References ........................................................................................................................... 53
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1. Introduction
The intention of this thesis is to investigate aspects that may contribute to explaining
healthcare professionals’ engagement in organizational improvement work. The focus is to
investigate possible promoting factors for sustainable organizational improvement work in
healthcare.
Public hospitals are facing challenges of how to develop care processes with high quality
and at the same time decrease costs. Influenced by new public management (NPM), many
Swedish hospitals have carried out a number of changes with the purpose to decrease costs
and increase efficiency while maintaining good quality of care and the well-being of
healthcare professionals (Bezes et al., 2012; Hood, 1995; Jansson von Vultée et al., 2007;
Pollitt and Bouckaert, 2004). Employee engagement is described as crucial to reaching
success in organizational improvement work in healthcare (Riches and Robson, 2014).
Knowledge of factors promoting healthcare professionals’ engagement in organizational
improvement work need therefore to be revealed. Previous research shows that there are
challenges in engaging healthcare professionals in organizational improvement work, and
also that there is a lack of knowledge and research about conditions that lead employees to
engage in improvement work (Braithwaite et al., 2007). There is also lack of knowledge
about processes that promote sustainable organizational improvement work, and
specifically, what leads healthcare professionals to engage in clinical improvements.
For the improvement work to be sustainable, previous research indicates that it depends
on how the organization manages to engage healthcare professionals in clinical
improvements (Ham, 2003; Riches and Robson, 2014) and argues for approaching system
perspectives to gain deeper knowledge about how conditions interact (Bakker and
Demerouti, 2007; Dellve and Eriksson, 2017; Porras and Robertson, 1992; Riches and
Robson, 2014). Sustainable work organizations are characterized by good health,
enthusiasm, and cooperation springing from promotion of employees’ resources to perform
and develop their professional work (Kira et al., 2010). However, consequences of top-
down initiation of reorganization in healthcare have shown it to be less sustainable because
of increased job demands, work pace, stress, absenteeism (Koukoulaki, 2014; Westgaard
and Winkel, 2011), low engagement (Ham, 2003), and turnover (Hertting et al., 2004).
Before the actual turnover happens, a prior state—intention to leave—has been recognized
as an indicator of future staff turnover (Cho et al., 2009). The potential risk of turnover
among healthcare professionals as a consequence of strategic initiation of changes in
healthcare makes it vital to understand the factors that may influence healthcare
professionals’ intention to leave, when a top-down initiative to organizational improvement
work is implemented. Engagement, social capital, and job resources could possibly balance
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intention to leave and are in this thesis considered as promoting factors related to
sustainable organizational improvement work.
The importance of job resources and job demands for employees’ job satisfaction as well as
their work engagement is known (Demerouti et al., 2001). There is, however, a gap in
knowledge of how work conditions during organizational improvement work in hospitals
relate to dimensions of healthcare professionals’ engagement. This argues for investigating
job resources and job demands related to healthcare professionals’ engagement in clinical
improvement work as well as their attitudes to engaging in strategic initiative of
improvement work.
A potential resource, as a complement to other forms of capital and resources, that may
contribute to promoting healthcare professionals’ engagement in organizational
improvement work is social capital. Previous studies of social capital indicate that social
capital is associated with organizational advantages, cooperation, job satisfaction, well-
being, and patient safety (Hofmeyer and Marck, 2008; Nahapiet and Ghoshal, 1998;
Ommen et al., 2009; Putnam et al., 1994; Waisel, 2005). However, the knowledge of its
association with and impact on healthcare professionals’ work engagement, job
satisfaction, clinical engagement, and intention to leave during ongoing organizational
improvement work is deficient. To study social capital in such context would increase the
knowledge of its potential impact on healthcare professionals’ engagement in
organizational improvement work.
Leadership is suggested to be associated with social capital (Kristensen, 2010). Based on
previous studies of leadership (Day, 2001; Day et al., 2004; De Clercq et al., 2014; Li, 2013),
there are arguments for considering that leadership can have an impact on social capital,
but this has not yet been investigated longitudinally with prospective analyses. Most
knowledge of the relation between leadership and social capital has been derived the other
way around, that is, from looking at how social capital and social networks influence
leadership (Day et al., 2004; De Clercq et al., 2014; Li, 2013). This argues for investigating
and increasing knowledge of the potential impact of leadership on social capital.
This thesis focuses on gaining knowledge of how social capital and engagement can
contribute to sustainable organizational improvement work in healthcare. In the framing
of this thesis, I have chosen a systems theory approach, because investigated factors and
the specific aims of the thesis concern mechanisms at individual, workplace, and
organizational levels. The thesis also focuses on well-being, which gives reason to choose a
systems theory approach that relates to health and well-being (Dellve and Eriksson, 2017).
The thesis can contribute to increased knowledge of important factors with respect to
healthcare professionals’ engagement in organizational improvement work.
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2. Background
As background, models based on systems theories of health, work engagement,
organizational improvement, and sustainable working conditions are described and related
to the overall aim and also contextualized to organizational improvement work in Swedish
healthcare. Thereafter, the concepts and conditions of social capital, work engagement, and
intention to leave, as well as of leadership, are described in relation to healthcare and
organizational improvement work.
2.1. Bio ecological system
Ecological systems theory considers different structures attached to each other. A systems
approach aims to consider different subsystems as interlinked and able to influence one
another. Research with a systems approach puts forward questions as to whether there are
other possible explanations for the phenomena found in subsystems other than where the
outcomes are studied. Also, it is suggested to have a holistic approach, which takes into
account all the different systems and therefore the contextual conditions that may influence
what is studied. Taking such an approach allows for a broader understanding of the
multiple factors involved in employee health and sustainability (Dellve and Eriksson,
2017).
Building on Bronfenbrenner’s bioecological model (Bronfenbrenner, 1999), Bone (2015)
made a conceptual model of workplace health. Dellve and Eriksson (2017) extended the
model to include how well-being could be crafted through managerial work. This model
contains structures such as individual, micro, meso, exo, macro, and chrono systems. A
basic assumption of the model is that an interaction takes place between the different
systems and that they influence each other. For example, individuals’ perceptions of their
health and well-being are influenced by factors in the micro system, that is, relationships
at work. The individual is also influenced by environmental settings such as the society,
culture, community, organization, and workplace (Bone, 2015).
The chrono level is described as trends in society, trends in organizational development,
and managerial systems being implemented in organizations that have importance
regarding occupational health, sustainability of change processes, and workers’ health and
well-being (Dellve and Eriksson, 2017). New public management is one example of a trend
that has influenced Swedish healthcare in the last decades. In Sweden there are policies
and legislation (The Swedish Work Environment Authority’s Statute Book) making
organizations responsible for the health and well-being of their employees and referring to
structures in the exo level (Bone, 2015) or macro level (Dellve and Eriksson, 2017). The
meso-system level can be described as where the organizational structures (work
organization) and culture lie. Organizational preconditions for managerial practice, and
health and safety management systems, are examples of factors that refer to the meso level.
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The micro-system level is directly experienced by the employees, and interaction occurs on
a daily basis and reflects whether the employees perceive the workplace as supportive or
detrimental (Bone, 2015). On the micro-system level the interaction between colleagues
and between manager and subordinates is to be found. Interactions between people in
different roles, as well as how the demands, resources, control, social support, and
engagement are distributed and perceived, further describe the micro-system level (Bone,
2015; Dellve and Eriksson, 2017). Previous research stresses the need to critically examine
the social relations within the work context at the micro-system level (Bone, 2015). The
individual level includes the people handling strategies related to work and the person’s
identity, work engagement, health, and well-being. The individual level further reflects the
person’s knowledge, capability, attitudes, values, lifestyle, and behavior (Dellve and
Eriksson, 2017).
2.2. System approach to organizational improvement work
Applied to the organizational context, a systems approach may be helpful to understand
and reflect upon when performing research within organizations. One example is the
opportunities to analyze whether results in one system have possibly been influenced by
interaction with another system or level. In organizations, work settings can be described
by four key subsystems (1) organizing arrangements, (2) social factors, (3) technology, and
(4) physical settings. Of these four subsystems, social factors contains five specific
elements: culture, management style, interaction processes, informal patterns and
networks, and individual attributes (Porras and Robertson, 1992). These subsystems are
highly interdependent in the sense that a change in one subsystem will affect the others.
For example, a change in management style (element in the social factors category) can
occur as a new reward system (element in the organizing arrangements category)
(Robertson et al., 1993). It is stressed that the five elements in the social factors subsystem
are the most difficult to change and that they are crucial for successful organizational
improvement work when managed right (Porras and Robertson, 1992). Within the
subsystem of social factors, both social capital and engagement are developed regarding
the social interaction between manager and employees, between employees themselves,
and between the individuals and their networks. The systems approach with respect to
organizational improvement work is in this thesis aligned to Dellve and Eriksson’s (2017)
model as well as Porras and Robertson’s (1992) framework of systems within organizations.
The argument for that is that the aims of the thesis concern different levels with respect to
systems theory and the models described. Also, having hospitals with ongoing
organizational improvement work initiated at a strategic level makes the systems approach
useful for understanding possible consequences at different organizational levels. Dellve
and Eriksson’s (2017) model, with an integrated well-being approach as well as
perspectives on practice, is suitable to use with respect to this thesis aims and investigated
15
variables, which also concern well-being (i.e., job satisfaction) and practice (i.e.,
engagement in clinical improvements).
2.2.1. Organizational improvement work in Swedish healthcare
A number of reforms and organizational changes in healthcare organizations have been
carried out during the last decades. In the 1990s, Swedish public hospitals were facing
major challenges, including how to decrease healthcare costs without comprising quality of
care (Magnussen et al., 2009) or employee well-being (Elstad and Vabø, 2008; Jansson
von Vultée et al., 2007). These changes have been influenced by ideals from NPM, focusing
on customer orientation, rationalization, process flow, efficiency, and economics (see, e.g.,
Blomgren, 2003, or Bezes et al., 2012). The implementation of NPM has resulted in a
strengthened administration because of the different techniques implemented, such as new
forms of control, measuring and evaluating performance, and results management to
achieve objectives (Bezes et al., 2012). This development has proceeded since the 1980s
and has inspired many reforms in a number of national public administrations in western
countries (Pollitt and Bouckaert, 2004). Sweden is considered to be one of those countries
that has adopted NPM to a high degree (Hood, 1995). Inspired by NPM, most hospitals in
Sweden are working to develop their care processes using the management concept lean
production (LP) (Weimarsson, 2011), and these processes need healthy and engaged
employees. Previous research has shown that healthcare professionals have criticized the
NPM reforms and have actively resisted them (Bezes et al., 2012). The reforms, influenced
by NPM, in Swedish healthcare during the 1990s were no exception. The criticism raised
by the healthcare professionals concerned, for example, standardization and control by
managers, which were seen as threats to their professional autonomy and judgment on the
job (Bezes et al., 2012; Blomgren, 2003). However, research shows that the reforms have
not changed power structures, and physicians still have great impact within healthcare
organizations (Kuhlmann and Burau, 2008). On the other hand, consequences related to
the reorganizations were a decrease in numbers of employees, especially assistant nurses
and assistant staff, job insecurity, increased job demands, reduced job control, and sickness
absence (Hertting et al., 2005; Kivimäki et al., 2000; Landsbergis et al., 1999; Petterson et
al., 2005; Vahtera et al., 1997). In contrast, there was an increase in numbers of physicians
and of registered nurses (RNs) (Federation of Swedish County Councils, 2002). Many of
the effects of the changes in Swedish healthcare during the 1990s were negatively
associated with staff well-being (Hertting et al., 2004). This could possibly have led to
negative attitudes towards organizational improvement work, and it is likely that these
attitudes are still present in the memories of healthcare staff. Earlier experience from, or
threats of employee redundancies have shown to reflect adverse consequences for health
(Ferrie et al., 1998), and Lindberg and Trägårdh (2000) concluded that a future threat of
savings could increase anxiety among staff. Hence, there could be connections between the
past and the future regarding organizational improvement work.
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2.2.2. Sustainability perspectives on organizational improvement work
Viewing organizational improvement work from a sustainability perspective, the resources
should be developed parallel to the consumption of them. Employees, for example, are a
human resource, and to maintain or increase their engagement and health could be an
example of a parallel process of developing a resource. In this sense, one cannot risk the
employees’ health when developing the healthcare organizations with respect to the ideas
of sustainability. Research shows that engaged employees are a precondition for success in
organizational improvement work (Demerouti et al., 2010). What is the key to promoting
engagement in organizational improvement work in healthcare and to reaching
sustainability? When creating sustainable work systems in healthcare, models of human
factors take into consideration goals of improving both well-being and human performance
(Carayon, 2006; Docherty et al., 2009; Holden, 2011). Sustainability refers to parallel
development of ecological, economic, human, and social resources used in work processes
(Docherty et al., 2009).
Research on employees with high work engagement has shown better individual (job
satisfaction) as well as organizational (efficiency and quality) outcomes compared to
employees with low work engagement. Job satisfaction has shown to be associated to
employee health (Dellve et al., 2007; Grawitch et al., 2007; Shain and Kramer, 2004) and
intention to leave (Ommen et al., 2009) and is therefore connected to sustainable
organizational improvement work. Increased efficiency and quality could also be associated
with sustainable organizational improvement work (Lindskog, 2016). Research shows that
to reach sustainability in organizational improvement work, there is a need to balance job
resources and job demands and to support employees with resources to increase job
satisfaction and engagement (Lindskog, 2016).
2.2.3. Sustainable organizational improvement work in healthcare
Healthcare systems can be viewed as complex work systems with several dimensions of
complexity (Carayon, 2006). A challenge for those involved in organizational improvement
work and design of work systems is to manage increased complexity. To work across
organizational, cultural, and temporal boundaries is a trend that has contributed to
increasing the complexity in the work system (Carayon, 2006). Two of the dimensions of
complexity described in the literature are social system and heterogeneous perspective. The
former refers to many people having to work together as, for example, healthcare providers,
staff, and patients and their families. The latter refers to professionals having different
disciplines, cultures, and backgrounds (Carayon, 2006).
In the healthcare context, the complexity could manifest when different professional
groups from different care providers have to work together. Different views of, for example,
patient pathways may obstruct improvement work. To pass this obstructing condition is
time-consuming but necessary, and even considered as a key factor of successful
17
collaboration because of increased mutual understanding developed between professional
groups (Docherty et al., 2009). The development of sustainable work organizations can be
defined as promoting employees’ resources to perform and develop professional work with
cooperation, good health, and enthusiasm (Kira et al., 2010), and organizational
improvement work in this thesis is related to engagement in improvements of care
processes in hospitals.
2.3. Social capital
Social capital has been studied by researchers within different scientific disciplines (e.g.,
public health, social science, economy) and at different levels: individual, organizational,
and societal levels, and a cause of that is a variety of definitions (Adler and Kwon, 2002). A
common theme of the earlier research on social capital is such key factors as trust,
recognition, and norms of reciprocity (Bourdieu, 1985; Coleman, 1988; Macinko and
Starfield, 2001; Putnam, 2000).
Social capital seems to be an important aspect of relations, systems, and trusting
relationships (Nahapiet and Ghoshal, 1998; Tsai and Ghoshal, 1998) and has been
variously used among researchers (Ahnquist et al., 2010). Within these relationships
respect, friendship and gratitude are cornerstones for obligations (Bourdieu, 1985), and in
the networks of recognition and mutual acquaintance social capital is found embedded
(Nahapiet and Ghoshal, 1998). Social capital is a resource both for individuals (Poortinga,
2006; Portes, 2000) as well as for communities (Kawachi et al., 1997; Putnam et al., 1994).
These two approaches are both acknowledged (Lin, 2001; Rostila, 2011), and adding the
organizational level (Kristensen et al., 2007) of social capital, one can conclude three
approaches. Social capital at work has been viewed as a relational resource, for example,
the occurrence of networks, norms, and trust, promoting coordination and collaboration
for a common good (Olesen et al., 2008). Literature often describes social capital in positive
terms, but there are also critics. The criticism refers to what is called the dark side of social
capital (Gargiulo and Benassi, 1999; Putzel, 1997). An example is that when a group has
built high levels of social capital, that is, high trust for each other in the group, high and
strong norms of social reciprocity and recognition, then social capital can be protective and
resilient. A negative consequence could be that this type of constellation might not
cooperate with others, not engage in changes that could pose a threat to the group, and so
forth (Gargiulo and Benassi, 1999; Putzel, 1997). When managing organizational
improvement work, social capital that is too strong could hinder the necessary influence of
the manager. In this case, strong social capital in a group could obstruct instead of support
organizational improvement work (Gargiulo and Benassi, 1999). This thesis focuses on
social capital as employees’ perceptions of trust in and norms of reciprocity for each other,
trust in managers, and recognition in relation to both co-workers and managers.
18
2.3.1. Social capital in healthcare
Previous research stresses that there is a possibility of building and increasing social capital
in healthcare organizations by forging relations to foster bonding, bridging and linking
social capital within and between healthcare professional groups; to build solidarity and
trust; to foster collective action and cooperation; to strengthen communication and
knowledge exchange; and to create capacity for social cohesion and inclusion (Hofmeyer
and Marck, 2008). However, more empirical studies would increase knowledge of the
potential beneficial qualities of social capital in healthcare. Promotion of social capital is
associated with increased patient safety (Hofmeyer and Marck, 2008) and collaboration
between professional groups for the common good (Waisel, 2005). Both job satisfaction
and intention to leave are mentioned as two important aspects linked to sustainability. In
healthcare, social capital has shown to be important for job satisfaction, especially for
physicians (Ommen et al., 2009). With respect to intention to leave and negative health
consequences among healthcare professionals, both positive social climate and ties
between co-workers have shown to be protective factors (Garrett and McDaniel, 2001;
Mossholder et al., 2005). This reflects the importance of having good relations, and trust,
recognition, and social reciprocity, which constitute social capital in this thesis, and may
facilitate a positive social climate as well as strengthening the ties between co-workers.
2.3.2. Social capital as a resource for organizational improvement work
One potential job resource to consider with respect to organizational improvement is social
capital. Based on trust, recognition, and social reciprocity, it is most likely that social capital
among healthcare professionals can be a resource that promotes employees’ well-being and
engagement in organizational improvement work as well as associated with employees’
intention to leave their jobs.
As social capital is found in both the vertical dimension (linking) as well as in the horizontal
(bonding and bridging), it has the potential to move between employees and between
employees and their manager. This could also manifest at the organizational level, where
social capital can be spread within and between professional groups. Social capital has
shown potential for bridging organizational challenges within healthcare (Gittell, 2009)
and contributing to more sustainable work organizations, including increased well-being
of employees and of employees’ engagement in clinical improvements (Eriksson and
Dellve, 2014). It is also suggested that social capital is an important determinant of health
and well-being (Ahnquist et al., 2012). However, there is a lack of knowledge based on
empirical studies in this subject. Much of the previous research on social capital and health
has focused on risks and negative outcomes such as stress, burnout, and poor self-rated
health (Oksanen et al., 2008), which calls for studies with positive health-related outcomes
(i.e., job satisfaction). Although, social capital has a dark side (Gargiulo and Benassi, 1999;
Putzel, 1997), previous research on social capital suggests considering it as a positive
19
resource (Ahnquist et al., 2012; Garrett and McDaniel, 2001; Gittell, 2009; Hofmeyer and
Marck, 2008; Ommen et al., 2009; Waisel, 2005). In this thesis, social capital is regarded
as a positive resource that may enable engagement of professionals in organizational
improvement work.
There are not only obstacles in healthcare organizations working with development of their
care processes but also possibilities. To gain knowledge of social capital as a resource
regarding improvement work in hospitals would be a contribution to previous research.
This doctoral thesis provides increased understanding of how social capital and
engagement contribute to sustainable organizational improvement work and how social
capital and engagement are created during organizational improvement work.
2.4. Work engagement
In recent years, there has been a growing interest and recognition of work engagement
(Eldor, 2016; Saks, 2006). Maslach et al. (1997) described work engagement as one end of
a continuum between engagement and burnout, consisting of three parallel but opposite
dimensions. Vigor, involvement, and efficacy constitute engagement, and exhaustion,
cynicism, and ineffectiveness, burnout. Based on Maslach, Jackson, and Leiter’s work,
Schaufeli et al. (2002) defined work engagement as a state of mind characterized by vigor,
dedication, and absorption. Vigor involves high levels of energy and mental resilience while
working. Dedication refers to being deeply involved in one’s work and experiencing
inspiration, pride, enthusiasm, and challenge. Lastly, absorption means full concentration
on the work, experiencing that time flies and having difficulties detaching from work
(Schaufeli et al., 2006).
Work engagement is stressed to be associated with positive employee outcomes and
organizational success (Saks, 2006) and several studies in the last decade have stressed the
importance of work engagement. High work engagement has, for example, been associated
with positive organizational outcomes (i.e., organizational commitment, good job
performance, lower levels of staff turnover) and individual outcomes, that is, low levels of
depression (Hakanen and Schaufeli, 2012), physical/psychosomatic health, sleep quality
(Kubota et al., 2010), and proactive behavior (Salanova and Schaufeli, 2008). In a recent
study, Eldor (2016) argues that work engagement can create a competitive advantage for
organizations. Work engagement can help increase energy and may boost initiative to work
towards the goals of the organization (Frese and Fay, 2001; Grant and Ashford, 2008). As
a consequence of being engaged, the staff experience positive emotional responses,
including enthusiasm, joy, and inspiration (Bindl and Parker, 2010). This have shown to be
associated with proactive initiative (Fritz and Sonnentag, 2009) and creative solutions
(Cropanzano and Wright, 2001). Staffs that are engaged are in some way also more involved
in their work, which differs from those less engaged (Demerouti et al., 2010), in how they
pay attention and use their energy to achieve goals. According to the potential of work
20
engagement, there has been an increased focus on identifying work conditions (job
resources and job demands) that influences employees’ engagement in their work (Bakker
and Demerouti, 2008; Demerouti et al., 2001; Eldor, 2016).
Previous research in hospitals have shown that clinicians’ attitudes towards engagement in
organizational improvement work can be an antecedent factor for their general work
engagement (Lindgren et al., 2013). Also, it seems that clinicians’ active engagement in
improving clinical practice is closely associated to their work engagement (Greenfield et al.,
2011). In sum, when studying the concept of work engagement in hospital context, it could
be important to consider clinicians attitudes to engagement (Lindgren et al., 2013), their
general work engagement as a cognitive state (Schaufeli et al., 2006) and their active
engagement in clinical practice (Greenfield et al., 2011).
2.5. Intention to leave
Cost savings and rationalization in Swedish public hospitals have led to work-related illness
(Hasselhorn et al., 2005) caused by increased workload and stress (Westgaard and Winkel,
2011). The negative effects of increased workload and stress are associated with an
imbalance between job resources and job demands (Jourdain and Chenevert, 2010). A
potential risk is the healthcare professionals’ leaving the organization (voluntarily or
through sick leave), which could be detrimental for sustainability of the organizational
improvement work. Because of the risk of staff turnover, a prior state, intention to leave,
would be of interest to study when working with organizational improvements. There are,
however, other reasons for staff turnover and intention to leave that might be considered.
Private issues and personal desires to try a new job or to reduce travel time to work have
shown to be reasons for healthcare professionals’ intention to leave their jobs (Gardulf et
al., 2005). Intention to leave has in previous research been shown to indicate and predict
future staff turnover (Cho et al., 2009). Intention to leave in this thesis refers to the
subjective estimation of the likelihood of leaving the organization in the near future
(Mowday and Porter, 1982). To minimize healthcare professionals’ intention to leave their
jobs, there is a need to gain knowledge of preconditions that may influence intention to
leave. To decrease staff turnover and intention to leave, there has been a focus on increased
engagement and increased job resources (Carter and Tourangeau, 2012; Collini et al.,
2015). Whether social capital is a resource that has potential to reduce healthcare
professionals’ intention to leave their work during organizational improvement work is
limited in research. Studies that could increase knowledge of the associations between
social capital and intention to leave could therefore contribute to filling the gap in research.
2.6. Importance of working conditions for engagement
Specific contextual factors, also known to influence work systems, are seen as a key
principle in human factors models and have been stressed to be important when studying
21
organizational improvement work in healthcare (Holden et al., 2015). A model that
considers contextual factors of job resources as well as demands is the job demands–
resources (JD-R) model (Demerouti et al., 2001). According to the JD-R model, every
organizational context as well as occupation has its specific resources and risks. Job
resources can be related to physical, psychological, social, or organizational sides of the job.
They refer to different aspects of the job required to achieve organizational goals, to reduce
job demands to decrease both psychological as well as physical costs, and to facilitate
personal development and growth (Bakker and Demerouti, 2007). Job resources shown to
be important for engagement during organizational improvement work in healthcare are
leadership, development opportunities, predictability, recognition, and influence of work
(Dellve et al., 2015). The job demands that have shown to be important for engagement
during organizational improvement work are quantitative demands and work pace (Dellve
et al., 2015). The JD-R model also considers how job resources in the work environment
are connected to staff health and engagement in work (Demerouti et al., 2001). Job
resources can be found at different levels in the organization, and according to the model,
the job resources can contribute to decreasing job demands and increasing goal
achievement and personal engagement. The job resources and job demands interplay, and
job resources have been shown to buffer job demands’ negative influence related to staff
work engagement and organizational outcomes. The model takes into consideration
research on both work engagement and specific job characteristics perspectives on stress.
Previous research has shown that job demands are associated with many negative
outcomes, namely, high stress, low job satisfaction, low work engagement, and staff’s
intention to leave their jobs (Demerouti et al., 2001; Hayes et al., 2006). On the other hand,
job resources can balance job demands and by themselves facilitate changing work
engagement as well as health-related outcomes in a positive direction (Bakker, 2011). The
model provides a framework for understanding how job demands and job resources are
associated and gives opportunities to study them. As it has its roots in positive psychology
(Seligman and Csikszentmihalyi, 2014), focus can be maintained on what is creating
positive qualities (i.e., work engagement) as opposed to negative. Research on work
engagement in healthcare organizations has shown to be associated with more patient-
oriented care with high quality (Abdelhadi and Drach‐Zahavy, 2012). However, healthcare
professionals may have certain preconditions for engaging in organizational improvement
work. Further knowledge is needed of what conditions play an important role for healthcare
professionals to engage in improvement work.
2.6.1. Challenges in engaging healthcare professionals
Glouberman and Mintzberg (2001) describe four different logics, cure, care, control, and
community, of how the work in hospitals is performed. These logics have their own
languages, forms of culture, and ways of understanding the work. The logics are connected
to different stakeholders: cure to physicians, care to registered nurses (RNs) and allied
22
healthcare staff, control to management and administration and community to citizens.
When developing healthcare, it is necessary for these different logics to cross and to bridge
with each other so that the institutions can functions more collaboratively and use the
resources more effectively (Glouberman and Mintzberg, 2001). However, earlier research
has identified limited trust in the culture of healthcare organizations as well as limited
collaboration between different groups of professionals and between different
organizational levels (Glouberman and Mintzberg, 2001; Mitchell et al., 2010). Conflicts of
interests with respect to how healthcare should be managed can arise between the logics
(Glouberman and Mintzberg, 2001). These four logics feature a complex organization
where several interests play important roles and can have considerable impact on the
outcomes of organizational improvement work. Previous research indicates that a key
aspect of developing more sustainable healthcare organizations depends on successfully
engaging healthcare professionals in clinical improvements (Eriksson and Dellve, 2014).
When redesigning care processes, the engagement of healthcare professionals is crucial for
sustaining the change (Riches and Robson, 2014). However, there could be difficulties in
engaging healthcare professionals in organizational improvement work to redesign care
processes (Braithwaite et al., 2007; Riley et al., 2010). The use of business logic to justify
changes has been described as increasing healthcare professionals’ frustration and
hesitancy to support the changes (Choi et al., 2011). Physicians in particular have been hard
to engage (Ahgren, 2007; Choi et al., 2011; Eriksson, 2005; McNulty and Ferlie, 2004). As
they have considerable power and influence in the organization, they are important to
engage. This could be an example of where Glouberman and Mintzberg's (2001) logic
“control” (managers and administrators) encounters the logic “cure” (physicians). In the
Swedish context there is also a risk of negative experiences of reorganization (downsizing)
from the mid-1990s creating lots of mistrust for these kinds of changes (Hertting et al.,
2004). To overcome the barriers within the culture of healthcare organizations is a
challenge to consider when expecting engagement in redesign of care processes. The
described theories and empirical experiences assume participation, and that requires
involvement of the staff, which could be manifested in their engagement at the clinical level.
Why healthcare professionals choose to engage in clinical improvements and what
processes promote sustainable organizational improvement work in healthcare needs
further research (Lindgren et al., 2013).
2.7. Leadership
In the literature there is a distinction between management and leadership (Yukl, 2006).
Management is usually described as having focus on control, evaluating plans and goals,
administering formal systems. Leadership, on the other hand, is often described in terms
of handling human relations, culture, and informal systems (Bryman, 2013, Kotter, 2008).
Leadership is founded in a social understanding and acceptance of differences among
23
humans. Most scholars seem to agree on an integration of management and leadership and
acknowledge that leadership is crucial for the success of a manager (Yukl, 2006).
Leadership has many definitions, and when researchers define leadership the definition is
often influenced by the researchers’ own perspectives and by the phenomenon they are
interested in studying (Yukl, 2006). However, many of the definitions have in common the
assumption that it is a process of influence of one person over other people to give structure
and guidance and to facilitate relations and activities (Yukl, 2006). Critics of the many
definitions of leadership raise the question whether it can be used in science (Alvesson and
Sveningsson, 2003); however, both practitioners and scientists stress the importance of
leadership regarding organizational effectiveness (Yukl, 2006). Leadership, viewed as a
resource within the context of an organization, can be defined as “a process whereby an
individual influences a group of individuals to achieve a common goal” (Northouse, 2010).
Northouse’s definition of leadership seems to align with the common assumption of an
influential process. In contrast to the traditional view of leadership (formal managerial role
influencing the employees), there are other, complementary, approaches to leadership.
Concepts of distributed and collective leadership argue that leadership is a function of the
group and an outcome of team effort (Day et al., 2004; Friedrich et al., 2009). According
to these theories, leadership may alternate among the members of the team. However, in
this thesis leadership is viewed in a more traditional perspective, that is, as a leader
influencing employees.
Some of the most studied leadership theories are transactional, transformational, and
authentic leadership (Avolio et al., 1999; Bass and Avolio, 1994; Gardner et al., 2005).
These theories have been described and included in a model called developmental
leadership (Larsson et al., 2003; Larsson and Eid, 2012). Transactional leadership can be
referred to as conventional leadership, including control, demand, and rewards. Typical
leadership behaviors connected to transactional leadership are to seek agreements by
demand and rewards and to measure by control (Larsson and Eid, 2012). In contrast, the
main focuses of transformational leadership are individualized consideration through
caring and confronting, and inspiration and motivation through promoting creativity and
participation. The authentic leadership theory contributes to the developmental leadership
model with focus on the leader as an exemplary role model, acting in line with values,
setting a good example, and taking responsibility (Larsson and Eid, 2012). In the
developmental leadership model, relational focus as well as structure are important
dimensions of necessary leadership behaviors.
According to the JD-R model, leadership may be counted as a job resource (Demerouti et
al., 2001), and leadership is attached to the healthcare logic “control” (Glouberman and
Mintzberg, 2001). Whether and how leadership is associated with social capital is rarely
24
described in previous research. The studies performed indicate that there are associations
between leadership and social capital, and leadership quality and social capital. However,
a common presumption is that leadership is influenced by social capital and social network
(Day, 2001; Day et al., 2004; De Clercq et al., 2014; Li, 2013), which points to a need for
knowledge of whether social capital can be influenced by leadership. Taking into account
the three most-researched leadership theories (transactional, transformational, and
authentic leadership) makes it possible to distinguish between two different approaches to
leadership influence. One approach focuses on relationships between leaders and followers
to reach the common goal. The other approach focuses on the tasks to be accomplished
(Cummings et al., 2010). This is associated with social capital as a relational resource that
promotes coordination and collaboration for a common good (Olesen et al., 2008).
2.7.1. Leadership in healthcare
Leadership has been studied by different academic disciplines, including the military,
management, and psychology fields, and in different organizational settings, including
healthcare. Research findings shows that leadership is of importance for staffs’ health and
well-being and affects factors in the work environment such as job satisfaction and work
engagement (Cummings et al., 2010). Also, how experienced the manager is, has shown to
be of importance for employee engagemen in redesign of care processes (Palm et al., 2015).
With respect to positive effects on staff job satisfaction, engagement, and productivity, both
relation-oriented leadership as well as a combination of relation-oriented and task-
oriented types have proven to be successful (Boumans and Landeweerd, 1993).
In the context of healthcare, previous research investigating different forms of leadership
shows that relational leadership (resonant, supportive, and considerate), was associated
with greater levels of all investigated outcomes, while task-oriented leadership was
negatively associated with investigated outcomes (Cummings et al., 2010). The investigated
outcomes were staff’s work environment factors—job satisfaction, role and pay—and staff’s
relationships with work, health and well-being, productivity, and effectiveness, with
respect to a nursing workforce. Characteristics of relations between employees and their
manager can be revealed by employees’ perceptions of leadership quality (Kristensen et al.,
2007). With respect to social climate as well as to trust at work places, leadership has shown
to play an important role (Alimo-Metcalfe et al., 2008; Gittell et al., 2013; Luria, 2008;
Wheelan, 2005). However, when employees assess leadership qualities of their leaders, the
assessments have shown to be influenced by factors of group dynamics (Larsson and
Hyllengren, 2013). Studies of group development have revealed that when there are
problems of group dynamics the group can project these problems onto their leader
(Wheelan, 2005). Also shown in previous research, is that different leadership behaviors
fit better or worse, according to what the group (Wheelan, 2005) or the individual (Hershey
and Blanchard, 1988) needs.
25
Whether and how social capital can be influenced are still novel areas in research, but as
there are indications that leadership is an important factor to aspects related to social
capital, there lies an interest in further investigations. Such investigations could lead to
increased knowledge and practical use for leaders.
In sum, healthcare organizations have to consider many different logics of management
and at the same time work with organizational improvement work to increase efficiency
and quality. A precondition to success is having engaged staff working to develop the
organization and the care processes. Previous consequences of improvement work in
hospitals bear witness to the opposite, that is, disengagement, exhaustion, stress, and high
workload. Previous research in the literature of organizational improvement work and of
occupational health has provided extensive knowledge of such negative consequences. This
knowledge is important, but knowledge of the important factors and resources that create
the opposite (i.e., job satisfaction, engagement, well-being) of the negative have also to be
considered important. It is most likely that healthcare in the future will still need engaged
employees with good well-being and enthusiasm for their work and in future organizational
improvement work. Less research has been devoted to knowledge of what creates health,
well-being, and engagement in organizational improvement work and how this relates to
sustainability. There is a need of knowledge of the important resources that contribute to
positive outcomes and engagement during organizational improvement work while
maintaining healthcare professionals’ health and well-being. Inspired by the JD-R model
(Demerouti et al., 2001), social capital, along with other job resources and job demands, is
hypothesized to be a resource associated with sustainable organizational improvement
work in healthcare. This is manifested by its association with job satisfaction, general work
engagement, and attitude to engagement, and with healthcare professionals’ intention to
leave their jobs, and their clinical engagement in patient safety and quality of care.
Leadership is suggested as a precondition for social capital.
26
Figure 1. Solid lines shows associations which was hypothesized and investigated in this thesis. Dotted lines indicate
associations found in previous studies. Roman numbers links to each of the studies in the thesis. The model was adapted
and modified from the Job Demands Resources model (Demerouti et al., 2001).
27
3. Aim
The overall aim of this thesis is to understand how social capital and engagement contribute
to organizational improvement work in hospitals and how social capital and engagement
are created during organizational improvement work.
3.1. Specific aims
The specific aims are
to assess dimensions of engagement among healthcare professionals and how these
are related to work conditions during organizational redesign of care processes
(Study I);
to assess the association of working conditions and social capital with the intention
to leave, and to investigate whether social capital moderates the association
between job demands and intention to leave (Study II);
to investigate the importance of social capital for job satisfaction, work engagement,
and engagement in clinical improvements among healthcare professionals (Study
III); and
to explore whether qualities of leadership have impact on social capital among
employees in hospital settings over time, and what those qualities are (Study IV).
28
4. Method
4.1. Research design
In this thesis a quantitative approach has been used to answer the overall and specific aims.
All studies are based on the same hospital cohort and have used the full sample when
appropriate. Prospective analyses of the cohort have been made in three studies, in studies
I and III with data from two years and in Study IV from three years. Study II had a cross-
sectional design and analysis performed with data from baseline. Hypothesis-driven
analysis was used in studies I, II and III, while Study IV had an explorative approach. The
hypothesized parts in studies I, II and III were generated based on previous knowledge and
theories. The explorative parts in Study IV were conducted to elaborate knowledge.
Material from one research program including three research projects has been used to
fulfill the aim of this thesis. One project focused on the implementation of the lean
management model in hospitals and the consequences for work environment, quality of
care, and efficiency. The second project focused on the reorientation of healthcare towards
a health-promoting and -developing work environment by strengthening learning,
enthusiasm, and well-being during organizational improvement work. A third project
focused on how intention to leave and turnover are predicted by and interact with
organizational demands and resources, work engagement, and health.
4.2 Sample
A sample was made of five hospitals with ongoing developments and redesign of processes
of care (Fig. 2). The following criteria were used in the sampling process: similar size, urban
area, implementing a model to develop processes of care, and interested in participating in
a four-year study. Five small (approximately 100-bed) or midsize (approximately 500-bed)
hospitals were selected, with the number of employees varying between 700 and 4200.
Three hospitals had started to implement concepts and methods related to the LP model to
develop their care processes; this initiative was labeled as strategic implementation of lean.
The other two hospitals were not using LP as a model to develop their care processes;
however, LP approaches and tools were to some degree applied at the operative level in all
five hospitals. This knowledge was gained from structured interviews with operative
managers (Dellve et al., 2015) and was labeled as degree of LP at operative unit. Among the
hospitals, different types of units were selected and included. The emergency department
was selected at all hospitals. The other inclusion criteria were one medical and one surgical
ward, and the medical and surgical emergency intake units that shared a patient flow with
the emergency unit, the medical unit and surgical wards. In the small hospitals the
intensive care unit replaced the medical/surgical intake units. The specific units to be
included in the study were identified by the hospital management in consultation with the
29
research group. One of the hospitals did not consent to include a surgical unit due to lack
of time with respect to ongoing participation in other research development projects.
Figure 2. Schematic diagram of the study sites and subjects.
The hospitals were invited to include all their employees working in the selected units and
all physicians at the hospitals (because physicians often work across several units). To be
eligible for the survey, the employees had to have had a minimum of six months’
employment in the actual unit. In total 224 physicians, 381 RNs, 233 assistant nurses, and
16 administrative workers (HCWs) participated in the study at baseline (of 1602 invited to
participate, 865 participated, a 54% response rate). At the one-year follow-up 260
physicians, 355 RNs, 239 assistant nurses, and 14 HCWs participated (of 1548 invited to
follow up, 908 participated, a 59% response rate). At the two-year follow-up only those who
had answered the questionnaire earlier were invited to participate (of 947 invited to follow
up, 632 participated, a 67% response rate). The average number of employees at the units
was 45 (range 23–87). The response rate at the units varied from 37% to 96%. In Study I
30
the group of HCWs was not included in the analyses because they are not as a profession
involved in the care processes. In Study III the group of HCWs was included in the overall
analysis to investigate social capital but not as a single group, due to the few respondents.
Most participants were women, and nearly 50% at baseline and 40% at one-year follow-up
had worked for more than 14 years in their profession. Each participant was given a unique
code to enable the research team to follow the same respondents over time and perform
longitudinal analyses.
4.3. Data collection
Data were collected through questionnaires at baseline, and at one- and two-year follow-
up. The questionnaires were distributed by e-mail, or, if the participants preferred, a sealed
envelope (with a stamped reply envelope) was sent to them. Non-responding participants
received two reminders, which were sent in paper form. Data collection at baseline
occurred during April to May 2012 (for two of the hospitals) and October to November 2012
(for three of the hospitals), during October to November 2013 for all five hospitals, and
during October to November 2014 for all five hospitals. Five validated tools were used to
collect data. The Copenhagen Psychosocial Questionnaire (COPSOQ II) is an instrument of
psychosocial work environment factors, for example, quality of leadership and dimensions
of social capital. The indices in COPSOQ II could be used as both independent and
dependent variables (Pejtersen et al., 2010). The Swedish Scale for Work Engagement and
Burnout (SWEBO) was used to assess data on work engagement (Hultell and Gustavsson,
2010a), and the Modern Work-life Questionnaire (MWQ) was used to assess one of the
dimensions of social capital (Oxenstierna et al., 2008). The instrument Attitudes to
engagement was used to assess data on positive and negative attitudes to engaging in
organizational improvement work (Dellve et al., 2012). The instrument Clinical
engagement in patient safety and quality of care was used to assess healthcare
professional’s engagement in clinical improvements of patient safety and quality of care
(Strömgren et al., 2016).
4.4. Measures
4.4.1. Attitudes to engaging in organizational improvement work (I)
The instrument used to measure attitudes to engaging in organizational improvement work
was developed from a qualitative study (Lindgren et al., 2013). With respect to attitudes,
beliefs, and motivation, substantive codes and central statements were formulated into
items with a 4-point Likert scale (1, do not agree at all; 4, fully agree). Both items and scale
were tested for construct validity as well as for clarity and the test was performed with
healthcare professionals (Dellve et al., 2012).
In total, 11 statements symbolizing attitudes to participating in organizational
improvement work were grouped into indices, and all showed satisfactory internal
31
consistency. The attitudes to engaging in organizational improvement work were further
formed into two indices, positive attitude (six items, Cronbach’s alpha 0.83) and negative
attitude (five items, Cronbach’s alpha 0.71). Positive attitudes to engaging in organizational
improvement work consisted of the indices Participating in a continuous process for
improvements (three items, Cronbach’s alpha 0.70) and Learning about and improving
healthcare (two items, Cronbach’s alpha 0.73), and the single item Performing according
to one’s assignment. Negative attitudes to engaging in organizational improvement work
consisted of the indices Risking time conflicts (three items, Cronbach’s alpha 0.74) and
Being part of a meaningless process (two items, Cronbach’s alpha 0.74).
4.4.2. Work engagement (I, II)
Work engagement was measured with SWEBO (Hultell and Gustavsson, 2010b). The
instrument has its origin in the theoretical frameworks of work engagement (Schaufeli and
Bakker, 2004; Watson and Clark, 1984) and burnout (Demerouti et al., 2001; Maslach et
al., 1986; Shirom, 1989; Watson and Clark, 1984). The scale consists of two separate
dimensions, one of which captures the state mood of work engagement, and the other which
captures burnout through work-related items based on adjectives describing a perceived
state during the last two weeks. The aim of the thesis was to focus on the positive
engagement and therefore the dimension of burnout was left out. The work engagement
instrument consists of three dimensions: vigor (three items, Cronbach’s alpha 0.83),
dedication (three items, Cronbach’s alpha 0.84), and attentiveness (four items, Cronbach’s
alpha 0.85). As suggested by Hultell and Gustavsson (2010b), the original dimension
absorption was replaced by attentiveness, as it better reflects a cognitive state. Answers
were given on a five-point Likert scale (1, not at all; 5, all of the time).
4.4.3. Engagement in clinical improvements (I, III)
Two indices were developed to assess engagement in clinical improvements, patient safety,
and quality of care, and the indices were tested for internal consistency. The test was
conducted through individual interviews with physicians, RNs and assistant nurses (n =
11). Both the understanding of the questions and the understanding of the response scale
was tested. Participants were asked to answer the questions, and then they were asked to
describe how they had interpreted the questions and why they had answered as they did,
and also to describe how they would interpret another person’s answer to the same
question. All items were assessed on a five-point Likert scale (1, disagree; 5, agree
completely). The results of the pilot testing showed reasonably good face validity of both
the questions and response scale. Engagement in clinical improvements of patient safety
consisted of four items, with an introductory statement: “At our clinic, we (a) work actively
to improve patient safety; (b) discuss how to avoid errors; (c) work actively to improve
reporting of errors; and (d) report directly and without hesitation when we see something
that can harm patients’ safety” (Cronbach’s alpha 0.80). Engagement in clinical
32
improvements of quality of care consisted of three items, namely: “At our clinic (a) we have
an active dialogue about how to improve good care for the patients; (b) we have the
possibility to meet patients’ needs; and (c) the values of providing good care are my own
values (Cronbach’s alpha 0.72).
4.4.4. Working conditions (I, II)
All variables of working conditions (job resources and job demands) were selected from
COPSOQ II (Kristensen et al., 2005). Each item was assessed on a five-point Likert scale
(1, to a very small extent; 5, to a very large extent). Regarding job resources, the following
validated indices were used: predictability (two items, Cronbach’s alpha 0.61), role clarity
(three items, Cronbach’s alpha 0.78), recognition (three items, Cronbach’s alpha 0.85),
influence (four items, Cronbach’s alpha 0.70), possibilities for development (four items,
Cronbach’s alpha 0.69), and quality of leadership (eight items, Cronbach’s alpha 0.93). For
job demands, the following validated indices were used: quantitative demands (four items,
Cronbach’s alpha 0.83) and work pace (three items, Cronbach’s alpha 0.83). The
investigated job resources and job demands were assessed in two overall indices.
4.4.5. Top-down initiative to implement LP (I)
Hospitals starting to implement concepts and methods related to the LP model were
considered as hospitals with top-down implementation of LP. Information about this was
obtained from hospital top management.
4.4.6. Organizational improvements at units (I)
The degree of organizational improvement at the clinical unit was measured through
structured interviews with all ward managers of the investigated units, using the LP Index
Questionnaire (Ståhl et al., 2015). The 11 items assessed to what degree the work at the unit
could be characterized by improvement work in terms of continuous improvements,
standardized work practice, patient orientation, working with values, teamwork, cost
reductions, value-stream mapping, visual management of processes, results, and
improvements. All items were assessed on a five-point Likert scale (1, not at all; 5, to a very
high degree). All items were summed into a mean score referred to as degree of
organizational improvement at the unit.
4.4.7. Quality of leadership (I, IV)
Quality of leadership was measured by using an index from COPSOQ II consisting of eight
items (Cronbach’s alpha 0.94): “To what extent would you say that your immediate
superior (a) appreciates the staff and shows consideration for the individual? (b) makes
sure that the individual member of staff has good development opportunities? (c) gives high
priority to further training and personnel planning? (d) gives high priority to job
33
satisfaction? (e) is good at work planning? (f) is good at allocating the work? (g) is good at
solving conflicts? (h) is good at communicating with the staff?” The items were assessed on
a five-point Likert scale (1, to a very small extent; 5, to a very large extent).
4.4.8. Social capital (II, III, IV)
Social capital was measured by the sum of four indices: reciprocity, trust regarding
management, mutual trust between employees, and recognition (Cronbach’s alpha 0.73).
Reciprocity was measured using an index from the MWQ (Oxenstierna et al., 2008). The
indices trust regarding management, mutual trust between employees, and recognition
were from COPSOQ II. All items were rated on a five-point Likert scale (1, to a very small
extent; 5, to a very large extent).
Reciprocity was assessed with a three-item scale from the MWQ (Oxenstierna et al., 2008),
(Cronbach’s alpha 0.89): (1) At my workplace we care for each other, (2) At my workplace
we treat each other with respect, and (3) At my workplace I feel safe and accepted. All items
were rated on a five-point Likert scale (1, to a very small extent; 5, to a very large extent).
Trust regarding management was assessed with two items: (1) Can you trust the
information that comes from the management? and (2) Does the management withhold
important information from the employees? (reversed score). Mutual trust between
employees consisted of two items: (1) Do the employees withhold information from the
management? (reversed score) and (2) Do the employees in general trust each other? The
items of trust were rated on a five-point Likert scale (1, to a very small extent; 5, to a very
large extent).
Recognition was measured using a three-item scale as an index consisting of three items
(Cronbach’s alpha 0.82): (1) Is your work recognized and appreciated by the management?
(2) Does the management at your workplace respect you? (3) Are you treated fairly at your
workplace? All items used a five-point Likert scale (1, to a very small extent; 5, to a very
large extent).
4.4.9. Job satisfaction (III)
Outcome of job satisfaction was measured by an index consisting of six items from the
COPSOQ II (Cronbach’s alpha 0.82): Regarding your work in general. How pleased are you
with: (1) your work prospects? (2) the physical working conditions? (3) the way your
department/clinic is run? (4) the way your abilities are used? (5) the interest and skills
involved in your job? (6) your job as a whole, everything taken into consideration? All items
were rated on a four-point Likert scale (1, Very unsatisfied; 4, Very satisfied).
34
4.4.10. Intention to leave (II)
Outcome of staffs’ intention to leave was assessed by a single item: How often have you
thought about applying for another job? The response scale had five grades (1,
Never/Almost never; 5, Always).
4.4.11. Control variables
In some analyses, when appropriate, we controlled for contextual conditions such as top-
down initiative to develop care processes, managerial conditions such as managerial
experience, and group conditions such as problems of group dynamics. Analyses were also
controlled for such variables as gender and years in the profession. Analyses performed
stratified to occupational groups can be regarded as controlled for different professions
(assistant nurses, RNs, and physicians).
4.5. Analyses
In the studies (I, II, III, and IV), the data were approximately normally distributed. In the
analyses, statistical significance was considered when p < 0.05. The correlation was
considered to be very strong at r = 0.81–1.00, strong at r = 0.61–0.80, moderate at r =
0.41–0.60, fair at r = 0.21–0.40, and weak at r ≤0.20 (Altman, 1990). All statistical
calculations were performed using JMP version 10.0.2 (SAS Institute, Cary, NC, USA).
4.5.1. Study I
Study I was based on data from an employee questionnaire performed at two occasions,
baseline and one-year follow-up. Descriptive statistics, stratified to occupational groups,
were conducted to assess knowledge of why healthcare professionals engage in
organizational improvement work. To investigate differences between occupational
groups, Student’s t-test was performed. Bivariate Pearson’s correlation between variables
of kinds of engagement was computed. Work conditions was stratified to occupational
groups and was then compared using Student’s t-test. Kinds of engagement, work
resources, and work demands were stratified to occupational groups, and associations
between them were analyzed using Pearson’s correlation. To investigate the contribution
of work-related resources and work-related demands, resources for kinds of engagement,
and top-down initiation of LP, a linear regression model was used. The variables were
stratified to occupational groups.
4.5.2. Study II
Study II was based on data from an employee questionnaire performed at a single occasion.
Descriptive statistics of job demands, social capital, other job resources, and intention to
leave, stratified into occupational groups, were conducted. Student’s t-test was used to
investigate differences between occupational groups. Pearson’s correlation was performed
35
for bivariate associations between investigated variables. Student’s t-test was used to
compare whether levels of social capital in relation to levels of intention to leave differed.
To test the hypothesized moderating effect of social capital in the relationships between job
demands and intention to leave, linear regression models were used. This was performed
stepwise. For example, to examine hypothesis 2, the simple effect of job demands was
added in the first step, and social capital was added in the second step. Finally, the product
of job demands and social capital was added in a third step. The predictors (job demands
and social capital) were centered by subtracting each value from its respective mean before
the creation of the interaction term. This was performed to achieve a better estimate of the
interaction term (Aiken et al., 1991). To investigate the contribution of social capital, job
demands, and other job resources for intention to leave, linear regression models were
performed, first, with the whole sample, and second, stratified into occupational groups. It
has been suggested that there might be a difference between older staff compared to
younger (Flinkman and Salanterä, 2015). Information on age was not present, but
information about how long the respondents had worked in the present occupation was
available. The variable was dichotomized into two approximately similar-sized groups (0 =
up to 14 years, and 1 = more than 14 years).
4.5.3. Study III
Study III was based on data from an employee questionnaire performed at two occasions,
baseline and one-year follow up. First, descriptive statistics of individuals, stratified to
occupational groups and units, were conducted. To investigate differences between
occupational groups, the Student’s t-test was performed. Second, bivariate Pearson’s
correlation between social capital and job satisfaction, work engagement, clinical
engagement in patient safety, and clinical engagement in quality of care was performed.
The third step was to investigate explanatory variance between social capital and the
outcome measurements, and analyses were performed using multivariate linear regression.
Lastly, a prospective analysis was performed, using logistic regression models, to assess
whether increased social capital predicts increased job satisfaction, work engagement,
clinical engagement in patient safety, and clinical engagement in quality of care. The
variables were dichotomized into categorical variables where increased magnitude from
baseline to one-year follow-up was labeled 1 and where there was no increase in magnitude
the variable was labeled 0. Tests and confidence intervals on odds ratios were likelihood
ratio based. Analyses were controlled for sex, occupation, and years in occupation. To
investigate whether the cohort (those participants who had responded at both baseline and
one-year follow-up) could be assumed to be a representative sample according to the
baseline sample, t-test was performed.
36
4.5.4. Study IV
The data in Study IV were based on employee questionnaires performed at three occasions:
baseline, one-year follow-up, and two-year follow-up. Descriptive statistics of quality of
leadership and social capital were conducted. Test of correlation between social capital and
quality of leadership was tested using Pearson’s correlation test. To further explore whether
different levels of leadership quality correlated with different levels of social capital,
leadership quality was divided into three groups: high, medium, and low levels of
leadership quality. The division was performed according to quantiles, and mixed-models
repeated measurements were performed. Mixed-models repeated measurements were
used to investigate within and between variance of both the independent variable
(leadership quality) and the dependent variable (social capital). The explanatory variable
for the different models was levels of leadership quality and time (baseline, one-year follow-
up, and two-year follow-up). Social capital was the outcome variable within groups as well
as between groups over time. Missing values were imputed as the average score of the other
items in the indices. To investigate different types of leadership quality, the indices were
divided into three categories (relation oriented, development oriented, and task oriented).
This was based on previous research (Avolio et al., 1999; Jacobs and Washington, 2003;
Judge et al., 2004). Because of multicollinearity between the different leadership
orientations, it was only possible to test each one of them separately with respect to social
capital. Finally, to explore the explanatory variance of relation-, development- and task-
oriented types of leadership quality for increased social capital, linear regression was used.
Because of possible influencing factors (contextual, managerial, and group factors) the
analyses were controlled for organization working with redesign of care processes
(contextual), degree of experience of the managers (managerial), and problems of group
dynamics (group).
4.6. Ethics
Ethical principles for research have been considered. All respondents were informed that
participation was voluntary and that they could choose not to participate at any time.
Information given on the first page of the questionnaire stated that by answering the
questionnaire the respondent agreed to participate in the study. Information was also given
on how the results would be used, on the funders of the study, and on how to contact the
persons responsible for the study. By this procedure, informed consent was fulfilled. The
study was approved by the Central Ethical Review Board at Karolinska Institutet,
Stockholm, Sweden (2012/ 94-31/5). The questionnaire responses in all studies as well as
the coded list for identification were handled confidentially. Between the occasions of data
collection, results were reported back to the participating wards. This was done at the ward
level to ensure that no participants could be identified.
37
5. Results
5.1. Study I
The positive attitudes to engaging in organizational improvement work differed among the
professional groups. The positive attitudes were higher among RNs and assistant nurses,
while the summed negative attitudes were higher among physicians. Among all
occupational groups, the most common perceptions were increased learning and
understanding for the contribution to the development of a better healthcare service (see
Table 2 in Study I). The possibility of time conflicts was the most perceived risk among
physicians when engaging in organizational improvement work. Physicians also believed
to a higher degree that their engagement in developments would not lead to meaningful
results.
The summed work engagement was higher among assistant nurses (see Table 2 in Study I).
No significant differences could be found in levels of dedication between the groups of
professionals. The dimensions attentiveness and vigor were higher among RNs and
assistant nurses compared to physicians.
The association between positive or negative attitudes to improvements of processes of care
and work engagement showed fair positive and negative associations. Clinical engagement
to improve patient safety and quality of care rated highest among assistant nurses, while
this was rated equally high among RNs and physicians (see Table 2 in Study I). An
association was found between positive attitudes to organizational improvement work and
stronger clinical engagement in developing quality of care and patient safety. Negative
attitudes were associated with decreased clinical engagement. This occurred among all
professional groups. The impact of negative attitudes was, however, stronger among RNs
and physicians. Specifically, physicians’ negative attitude to organizational improvement
work was associated with their clinical engagement in development of quality of care.
The impact of improved work and organizational conditions on increased engagement
showed that all increased work resources were associated with all assessed kinds of
increased engagement (Table 3 in Study I). Decreased demands were not associated with
increased engagement in clinical improvement of patient safety and were weakly associated
with changed attitudes to organizational improvement work and engagement in clinical
improvements of quality of care. The same analyses were performed by occupational group.
The same patterns were shown, except for increased work demands, which was associated
with increased clinical engagement in patient safety matters among physicians and
increased clinical engagement in quality of care among RNs.
38
The importance of work conditions, attitudes to organizational improvement work, work
engagement, and degree of LP at operative levels for healthcare professionals’ clinical
engagement in patient safety and quality of care was analyzed (see Table 5 in Study I).
Among RNs, the models explained 32% of the variation in clinical engagement in quality of
care and patient safety. Among physicians, the model explained 34% of their clinical
engagement in patient safety but only 3% of their clinical engagement in quality of care.
Among assistant nurses, the model explained 17% of the variance of their clinical
engagement in patient safety but only 6% of their engagement in quality of care.
5.2. Study II
Intention to leave was associated with job demands, social capital, and other job resources.
Social capital and other job resources were about equal negatively associated with intention
to leave, while job demands was positively associated. Hypothesis 1, social capital is
negatively associated to intention to leave, was confirmed.
Among the occupational groups, physicians showed the highest ratings of job demands and
social capital compared to RNs and assistant nurses. The lowest perceived job demands
were found among the assistant nurses. Regarding intention to leave, there was no
significant difference between RNs and assistant nurses, while physicians reported the
lowest levels of intention to leave. Levels of other job resources were approximately equal
among the occupational groups.
The analyses of the moderating effect of social capital showed no interaction effect with job
demands with respect to intention to leave (see Table 2 in Study II). Social capital regarded
as a resource had no buffering effect on the job demands, and therefore, the second
hypothesis, social capital moderates the relationship between job demands and intention
to leave, was not confirmed.
The third hypothesis, levels of social capital are associated with levels of intention to leave
such that high levels of social capital are associated with low levels of intention to leave and
low levels of social capital are associated with high levels of intention to leave, was
confirmed. Analyses of both the whole sample and the sample stratified to occupational
groups supported the hypothesis. The results revealed that those with high levels of social
capital showed a lower level of intention to leave compared to those with low levels of social
capital, where the degree of intention to leave was higher.
Analyses made of the whole sample of the importance of job demands, social capital, and
other job resources revealed that all predictors had importance for intention to leave. When
stratified to occupational groups, the result showed that social capital had different
importance with respect to intention to leave. Among physicians, the explained variation
of intention to leave was highest, while it was lowest for RNs (see Table 3 in Study II). The
39
results also showed that the explained variation was higher for professionals who have
worked fewer years in their current profession.
5.3. Study III
The dimension of social capital that showed the highest level was reciprocity, and this
occurred among all groups of healthcare professionals (see Table 2 in Study III). The
dimension trust regarding management scored the lowest, especially among assistant
nurses and RNs, while approximately half of the physicians rated trust in management as
high. Among all health professionals, physicians reported the highest level of social capital.
Most of the healthcare professionals had high job satisfaction (see Table 2 in Study III).
With respect to work engagement, about half of all professional groups rated work
engagement as high. All aspects of social capital showed positive associations with job
satisfaction. Recognition was the strongest dimension of social capital associated with job
satisfaction, followed by reciprocity and trust regarding management.
Most healthcare professionals (approximately 60%) were engaged in clinical
improvements regarding patient safety. With regard to engagement in clinical
improvements of quality of care, half of the healthcare professionals were engaged. The
strongest association was found between engagement in clinical improvements of patient
safety and the dimension trust regarding management, followed by the dimension
recognition. Regarding engagement in clinical improvements of quality of care, the
dimension reciprocity had the strongest association as it did as well for work engagement.
Analyses on baseline data to assess the importance of social capital for the investigated
outcomes revealed that social capital explained 36% of the variation in job satisfaction and
12% of the variance in work engagement. Social capital explained 18% of the variance in
engagement in clinical improvements of patient safety work and 19% of engagement in
clinical improvements of quality of care (see Table 3 in Study III).
The importance of increased social capital for increased job satisfaction, work engagement,
and engagement in clinical improvements was analyzed. The results showed that increased
social capital predicted job satisfaction, work engagement, and engagement in clinical
improvements of patient safety. It also indicated to predict engagement in clinical
improvements of quality of care, but not at the level of significance (p < 0.05.).
5.4. Study IV
There was close to high correlation (see Table 3 in Study IV) between employees’ perceived
quality of leadership and employees’ perceived social capital. The strongest associations
40
with social capital regarding the single items in the index of quality of leadership were
appreciates the staff and shows consideration for the individual.
Differences in levels of social capital between the groups of low, medium, and high levels
in quality of leadership were found. These differences between the groups were maintained
over time (see Fig. 2 and Table 4 in Study IV). Differences within the groups over time only
revealed a change in the group categorized as high social capital, which increased from
baseline to the second follow-up.
All types of leadership qualities were associated with social capital (see Table 5 in Study
IV). The strongest association was found between the relation-oriented type and social
capital, while development- and task-oriented types were moderately associated with social
capital.
Leadership quality was shown to be an important resource for increased social capital, and
different types of leadership orientations had different importance with respect to
contextual, group dynamic, and managerial conditions. The importance of the relation-
oriented type of leadership quality for increased social capital decreased under the
contextual condition of redesigning care processes (see Table 6 in Study IV). In contrast,
the importance of task-oriented and developmental leadership quality for social capital
decreased with top-down-driven redesign of care processes. The results further reveal that
the importance of development-oriented leadership quality for social capital increased
where there was a low degree of problems with group dynamics. For all three types of
leadership quality the importance for social capital decreased when there were group
dynamics problems. Finally, the results showed that the importance of task-oriented
leadership quality for social capital increased when managers were inexperienced in their
roles as managers (see Table 6 in Study IV).
41
6. Discussion
In this thesis, the overall objective was to understand how social capital and engagement
contribute to organizational improvement work in hospitals and how social capital and
engagement are created during organizational improvement work. The results showed that
working conditions (job demands and job resources) were important for healthcare
professionals’ work engagement and clinical engagement. Social capital, as a resource,
seemed to be crucial for employee work engagement and for employees’ job satisfaction
and clinical engagement in patient safety and quality of care. Quality of leadership was
shown to be an important factor for social capital and could partly explain how to influence
social capital positively. With respect to sustainability, the result showed that social capital
was associated with and influenced employee engagement and job satisfaction. Further,
social capital was also associated with employees’ intention to leave their jobs, such that
high levels of social capital were associated with low levels of intention to leave and vice
versa.
6.1. Employee engagement in organizational improvement work
Employee engagement has been described in previous studies as crucial to reaching success
in organizational improvement work in healthcare that is, developing care processes
(Riches and Robson, 2014). In Study I, engagement among the healthcare professionals
was explained differently according to working conditions. The possible explanations of
employee engagement could be decreased job demands and increased job resources as well
as individuals’ attitudes to organizational improvement work. In Study I, increased job
resources (leadership, recognition, role clarity, and predictability) and decreased job
demands (work pace and quantitative demands) were important for work engagement
during organizational improvement work. This is in line with previous research using the
JD-R model (Bakker and Demerouti, 2007). Previous research has shown that there are
difficulties in engaging healthcare professionals in organizational improvement of care
processes (Braithwaite et al., 2007; Hertting et al., 2004; Lindgren et al., 2013; Riley et al.,
2010). In Study I, the results revealed that physicians scored the lowest levels of
engagement among the occupational groups. A possible explanation could be that
physicians also scored the highest levels of negative attitudes to organizational
improvement work. Though earlier studies have stressed that physicians have considerable
impact on developments in healthcare, they are often hard to engage (Ahgren, 2007; Choi
et al., 2011; Eriksson, 2005; McNulty and Ferlie, 2004). In Study I, the physicians perceived
the risk of time conflicts as the greatest risk when engaging in organizational improvement
work, which is in line with previous research and could be a possible explanation of their
negative attitude to engaging in organizational improvement work. In contrast to
physicians, RNs and assistant nurses to a higher extent showed positive attitudes, which
could be beneficial for their clinical engagement in patient safety and quality of care. In
42
study I, associations between positive attitudes and stronger clinical engagement were
found, and also that negative attitudes were associated with decreased clinical engagement.
Previous studies of how to manage healthcare bring forward a picture of the healthcare
organization as a complex organization consisting of different logics (Glouberman and
Mintzberg, 2001). Healthcare professionals’ attitudes towards organizational improvement
work can possibly be explained according to these logics. If the logics of care (nurses), cure
(physicians), and control (management) can cross and bridge with each other, they will be
function well. However, this requires trust, and previous research has shown that trust is
limited in healthcare organizations (Glouberman and Mintzberg, 2001; Mitchell et al.,
2010). With respect to employees’ clinical engagement in patient safety and quality of care,
Study I showed that increased job resources had great impact for all occupational groups.
According to the JD-R model, both increased job resources and decreased demands can
have impact on increased work engagement (Bakker and Demerouti, 2007; Demerouti et
al., 2001). The results in Study I are in line with previous research and in contrast to the
idea of increasing engagement by decreasing demands: on one hand, in line because of the
positive influence of increased job resources on work engagement, and on the other hand,
in contrast because of the non-existent association between decreased job demands and
work engagement. Instead, results revealed an increase in clinical engagement in patient
safety among physicians where there was an increase in the job demands, and the same for
the nurses with respect to engagement in quality of care. A possible explanation could be
that it reflects the professional ethics related to the patients’ safety (Arries, 2014; Greenfield
et al., 2011). But to recommend an increase in job demands to increase engagement in
patients’ safety and quality of care would probably be wrong and lead to higher workload
and stress in a longer perspective (Demerouti et al., 2001). Both general work engagement
and engagement in clinical improvements of patient safety and quality of care were in Study
III shown to be associated with and influenced by social capital.
6.2. Social capital as a resource for employee engagement
According to the results in Study III, social capital was shown to influence employee work
engagement and clinical engagement in patient safety. Social capital has in previous
research rarely been described as a resource shown to be an important factor for work
engagement. However, one study of German physicians suggested that social capital could
play an important role for their work engagement (Susanne et al., 2013). In studies II, III,
and IV, social capital was operationalized as horizontal and vertical trust, recognition, and
social reciprocity, and is likely to indicate associations with understanding and
collaboration between different professional groups and between the different logics in the
organization (Glouberman and Mintzberg, 2001). As a resource, embedded in the relations
between individuals, between managers and employees, and between different groups in
the organization as well as between professional groups, social capital could possibly
facilitate the relational coordination and be beneficial for enhanced communication,
43
teamwork, and patient outcomes (Gittell, 2006). One previous study showed improved
trust, communication, and cooperation between professional groups as well as
improvements in work environment in surgical rooms generated from social capital
(Hofmeyer and Marck, 2008). In this thesis communication and teamwork were not
measured; however, as the mechanisms influencing enhanced communication and
teamwork lie in the dimensions of social capital, one can possibly conclude such an
association (Day et al., 2004).
The results in Study III revealed that most (60%) of the healthcare professionals were
engaged in clinical improvements of patient safety. The dimension of social capital that was
most important for engagement in clinical improvements of patient safety was trust
regarding management. Regarding employee engagement in clinical improvements of
patient safety, it seems that a focus on increasing trust in management would be a
promising strategy. In Study III, the results showed that half of the employees had high
work engagement, which indicates a potential to increase work engagement. This potential
also concerns engagement in clinical improvements. As the results of the logistic regression
of the cohort in Study III revealed, increased social capital is implied to predict increased
work engagement and engagements in clinical improvements of patient safety.
In Study II, the results revealed that social capital, job demands, and other job resources
had importance with respect to staffs’ intention to leave their jobs. According to research
on sustainable organizational improvement work, the resources should be generating new
resources in parallel, while using them in the development processes (Docherty et al.,
2009). This also includes having the employees enthusiastic and in good health (Kira et al.,
2010). Staff turnover and the prior state intention to leave could be outcomes of a
misconducted organizational improvement process, with consequences leading to non-
sustainable organizational improvement work. Results in Study II did not confirm the
hypothesized moderating effect of social capital between job demands and intention to
leave. As stressed in the framework of the JD-R model (Bakker and Demerouti, 2007), a
specific resource can buffer a negative influence of the effect a specific job demand, and the
interpretation of this is that social capital (as a specific job resource) does not interact with
quantitative demands or work pace (as specific job demands).
Results in Study II showed that the physicians reported the lowest levels of intention to
leave compared to other groups of healthcare professionals. Levels of job resources among
the healthcare professionals were approximately equal (Study II); however, levels of social
capital (studies II and III) differed among the professional groups, where physicians
perceived the highest level. Social capital could be a possible explanation of the lower
degree of intention to leave among physicians, but other possible factors not investigated
in this thesis could also account for this finding. Another possible explanation with respect
44
to results in Study I is that increased resources were shown to be especially important for
high engagement during organizational improvement work, which could be interpreted as
having a buffering effect on physicians’ intention to leave. The possible buffering effect of
job resources for the impact of job demands on, for example, work engagement would be
in line with previous research (Demerouti et al., 2001; Schaufeli and Bakker, 2004).
Job satisfaction and intention to leave have shown to be associated (Ommen et al., 2009).
The result in Study III revealed that social capital had a predictive influence on employees’
job satisfaction. This implies that social capital has not only a direct impact on intention to
leave but an indirect impact on intention to leave as well. Affecting job satisfaction is also
believed to have an effect on employees’ health and well-being (Grawitch et al., 2007; Piko,
2006; Shain and Kramer, 2004). That connects well to the thoughts on promoting
sustainability by contributing to more resources (i.e., health), while using them in
development processes (Docherty et al., 2009; Kira et al., 2010).
6.3. Leadership, a factor important for social capital
In this thesis, social capital was investigated, and results revealed its importance for
healthcare professionals’ intention to leave (Study II) and job satisfaction (Study III) (and
therefore also its importance for sustainability) as well as for work engagement and clinical
engagement (Study III). Because of its beneficial qualities, the question whether social
capital can be influenced is adequate. Based on the operationalization of social capital in
this thesis (mutual trust between employees, trust regarding management, recognition and
reciprocity), there is reason to believe that social capital can be influenced by leadership.
Previous research has shown that leadership is important to the social climate at
workplaces (Alimo-Metcalfe et al., 2008; Gittell et al., 2013; Luria, 2008; Wheelan, 2005),
and with respect to social capital, leadership and quality of leadership are indicated as
important (De Clercq et al., 2014; King, 2004; Kristensen, 2010; Oh et al., 2006). However,
previous studies showed deficiency in longitudinal designs and prospective analyses.
Previous research on leadership and social capital has examined how social capital
influences leadership, but few earlier studies have investigated how leadership influences
social capital. Leadership quality has in Study I shown to be important for engagement as
well as for social capital (in Study IV). Leadership seems to influence engagement both
directly and indirectly by its importance for social capital, which in turn has impact on
engagement. The results in Study IV showed that leadership quality is associated with levels
of social capital and lasts over time. High levels of leadership quality is associated with high
levels of social capital, and low levels of leadership quality to low levels of social capital.
This implies that leaders who function well in their leadership roles will probably have
higher social capital among employees.
45
According to the results in Study IV, different leadership orientations were shown to have
different impact on social capital. For instance, relation-oriented leadership had the
strongest association with social capital. A possible explanation could be that the
dimensions of social capital are related to their character. Previous research has stressed
that relation-oriented leadership is superior to task-oriented leadership with respect to
employee health and organizational outcomes such as productivity and effectiveness
(Cummings et al., 2010). With respect to the previously mentioned direct association with
employee engagement, previous research has shown that relation-oriented leadership
motivates the employees beyond their intention (Bass and Avolio, 1994). However, both
development- and task-oriented leadership were important to social capital, which is in line
with previous research on leadership. Task orientation has shown to be important for
relational-focused leaders to provide structure during conditions of pressure (Skakon et al.,
2010), and developmental orientation have been shown to be of importance to engage
employees in development programs (Judge et al., 2004). This also implies that different
leadership orientations are more or less suitable, depending on different conditions or
situations. In line with that, the results in Study I showed that increased leadership quality
was important for employee engagement during top-down initiation of organizational
improvement work in care processes. Also, the results in Study IV give support for
differential importance of leadership with respect to different conditions. For example, the
result indicates that task-oriented leadership was important for social capital when the
manager was inexperienced and that relation-oriented leadership had importance for
social capital when organizational improvement work was not initiated from the top down.
With respect to development-oriented leadership, it was shown to be less important for
social capital if there were problems of group dynamics. In research on, for example, group
development (Sloan et al., 2014; Wheelan, 2005), different types of leadership are adequate
with respect to different stages of the group development. Accordingly, one has to consider
that the leadership–social capital relationship possibly interacts with organizational,
group, and individual factors.
6.4. From a systems perspective
According to the theoretical framework of Bronfenbrenner (1999), and recently, Dellve and
Eriksson’s (2017) model, different levels in a system, that is, individual, micro, meso, exo,
macro, and chrono levels, are interlinked with each other. The levels are interlinked and
dependent on each other, and the results are connected to different levels. In Study III, the
outcome of job satisfaction, work engagement, is, according to systems theory, based on
the micro level and connected to the interfaces between the individual, micro, and meso
levels, while dimensions of social capital are based on the micro level and connected to the
micro and meso levels, where other social dynamics also manifest (e.g., co-worker ship and
social support) (Bone, 2015; Dellve and Eriksson, 2017). The results in Study IV showed
that leadership (operating from the meso level) is important to support social capital. This
46
can be considered as an example of an outcome at one level (work engagement at the
individual level) associated with at least two other levels (dimensions of social capital at
micro level and leadership at meso level), according to systems theory. Further on, the risk
of healthcare professionals’ intention to leave their jobs (individual level) was shown to be
correlated to levels of social capital (bridged from the micro level). Dellve and Eriksson
(2017) in their review argue that some leadership approaches (e.g., servant, authentic,
transformational, and relational) bridge more successfully over system levels having
positive impact on employees’ health and engagement. This is supported by results in the
present thesis (Study IV) regarding the impact of relational leadership approaches on social
capital. Also, job demands and job resources (micro level) had impacts on healthcare
professionals’ engagement (individual level). The organizational context (meso level) was
hospitals, and Glouberman and Mintzberg (2001) have problematized that four logics of
how to manage healthcare are important in matters of efficiency and collaboration. The
results in Study I reflect differences between the professionals’ work conditions and
engagement, and this could be related to these different logics. Swedish hospitals have been
highly influenced by NPM (macro level) and management concepts such as LP. These
trends in developments over the last decays could also have impact on what was studied in
this thesis, and the changes and developments are connected to the chrono level (Bone,
2015). When implementing concepts of rationalization in hospitals, there is an increased
risk for negative consequences of increased demands and work pace and worsened working
conditions (Westgaard and Winkel, 2011). However, the results regarding risks vary due to,
for example, occupational groups and contexts. For instance, RNs experienced increased
influence two years after rationalization was implemented, while physicians gained
increased role clarity through standardization (Dellve and Eriksson, 2017). Developments
(chrono level) for different professional groups also are thus interlinked with the other
levels, according to systems theory and the bioecological model. Yet, this gives support for
the results in this thesis to be viewed in a systems perspective, as they are interlinked with
each other and for explanations and consequences to be found at various levels. With
respect to the development of sustainable work organizations (Kira et al., 2010), there is a
need to take into consideration and to develop different levels in the organization to reach
success and not just one of them. This harmonizes well with a view of the individual
healthcare professional as connected to a complex system where different levels are
interlinked and influence each other.
6.5. Practical implications
The results stress the need to consider social capital, job demands, and other job resources
as important factors when working with organizational improvement work within
healthcare. Their importance concerns possibilities to engage employees in the
development of care processes, which is crucial for the success of the changes. Further, to
improve the effect and the sustainability of the organizational improvement work,
47
enhanced social capital and increased job resources as well as decreased job demands are
important factors to focus on.
With respect to sustainability, social capital has a direct impact on job satisfaction of staff
and therefore also on their health and well-being; it also has an indirect effect by its impact
on work engagement, which negatively influences staffs’ intention to leave. The use of the
resource social capital could render a positive process where the resources are strengthened
(not only consumed) and sustainability of organizational improvement work is created.
Leaders who function well are more likely to increase social capital at their workplaces. By
investing in the resource social capital, organizations could realize advantages of
developing good leadership because of the importance of leadership for social capital.
When healthcare organizations are developing leadership, they should also foster
interpersonal skills. At workplaces, ability to work to increase social capital should be
possible in terms of increased focus on factors such as social reciprocity, trust, and
recognition.
Knowledge of the results in this thesis could benefit other departments responsible for
attracting, recruiting, retaining, and developing employees in hospitals. This points to a
need to communicate and transfer results from research at one level in the organization to
other organizational levels within the hospital.
6.6. Method discussion
A potential limitation of this thesis is the possibility to generalize the results to other
organizations beside healthcare. With respect to external validity, precautions have to be
taken when interpreting results for sectors other than healthcare. Also, the sample
contained data mostly (but not only) from wards that had connections to the emergency
department, which can present problems when in generalizing to other departments and
wards in hospital settings. However, much of the theoretical framework presented in this
thesis reveals that previous research on social capital, engagement, job satisfaction, and
leadership has been carried out in different sectors and in other types of wards, which
argues for social capital as a resource outside hospital settings.
A potential limitation of all studies in this thesis is that of self-reported data using
questionnaires, which could lead to common source bias (Podsakoff et al., 2003). However,
when studying working conditions, it has been stressed that self-rated working conditions
could be compared to working conditions that have been objectively measured (Härenstam
et al., 2003). Further, the four studies in this thesis used quantitative methods. One,
however, has to consider the advantages of using qualitative methods (i.e., interviews),
which offer the possibility of understanding the underlying complex relationships between
48
the investigated variables that could have biased the results of the quantitative analyses.
There could be other aspects in the organization that influence the variables, but using a
quantitative approach accounts for greater objectivity than qualitative approaches and also
provides support for generalizations about investigated phenomena, due to a larger amount
of data. However, this assumes a satisfactory response rate and a large sample size. Another
advantage of quantitative research is the reduction of personal bias by having the
researcher distanced from the respondents, which in an interview situation is nearly
impossible. However, the risk of structural bias can arise with the use of questionnaires. To
reduce such risk, it is important to use validated and reliable instruments and tools. In this
thesis, all measures came from validated scales, except for the indices clinical engagement
in patient safety and clinical engagement of quality of care. However, these indices were
tested using Cronbach’s alpha for reliability and face validity, where both questions and
response scale were tested for interpretation. Also to be mentioned, in Study I a comparison
was made between hospitals working to develop their care processes using the concept of
LP. This was labeled as top-down initiative. The other hospitals did not use top-down
implementation of LP. They were working to develop their care processes in other ways,
and accordingly, all hospitals were working with organizational improvement work to
develop their care processes (knowledge from interviews with key persons in the
organizations). However, when distinguishing between redesigning care processes or not
in Study IV, this should be understood as a top-down initiative to redesign care processes
from a strategic level. Another possible limitation concerns the analyses stratified to groups
of healthcare professionals. Knowledge of the response rate among the different healthcare
professional groups was difficult to reach. The results of the analyses stratified to
professional groups must therefore consider a possible selection bias, if the response rate
was low in a specific healthcare professional group. This possible issue concerns analyses
stratified to groups of healthcare professionals.
When having longitudinal design and performing analyses over time, one has to consider
respondents lost to follow-up. The respondents’ professions were self-reported in the
questionnaires, which increased the knowledge of the study population and the different
groups of healthcare professionals. Having this knowledge made it possible to detect
whether there were changes between baseline and follow-up with respect to groups of
healthcare professionals. The changes in the study population between baseline and one-
year follow-up were that the proportion of physicians increased from 26% to 29%, and the
proportion of RNs and assistant nurses decreased from 44% to 39% and 27% to 26%,
respectively. This indicates that the proportion of healthcare professionals was stable, and
the loss was less than 5% or equal, which could be interpreted as of little concern (Schulz
and Grimes, 2002). At second follow-up, questionnaires were only sent to those who had
answered at the previous occasion. The proportion among physicians was 28%, among RNs
34%, and among assistant nurses 25%. Having an overall satisfactorily response rate and a
49
stable proportion of physicians, RNs and assistant nurses could possibly reduce the risk of
attrition bias and of possible problems due to loss of respondents to follow-up.
The strength of Study I was the longitudinal design, where data were collected at two
occasions with approximately one year between. The questionnaires had a unique code
assigned to each participant, which was in favor of the reliability of the analyses because of
the knowledge of a real change at individual level. A possible limitation in Study I could be
the risk of common source bias because of omitted or false answers when using the self-
reported questionnaire. However, this risk was considered decreased by having the unique
codes of the participating respondents, making it possible to compare results over time.
Also, the informed consent was fulfilled and could possibly increase the reliability of the
answers given. Having data from two occasions and a satisfactorily sample size and
response rate made it possible to make some assumptions about relationships and
predictive values compared to a cross-sectional design. However, this had to be done with
caution because of other potential influencing factors not included in the analyses.
Study II had a cross-sectional design. The results should therefore be interpreted with
caution regarding the possibilities of causal conclusions. However, the aim of Study II was
not to come to a conclusion about causality. In its favor, Study II had a satisfactorily sample
size as well as response rate. A possible limitation in Study II could be the same as in the
other studies, where data derived from self-reported questionnaires were used. In cross-
sectional studies with large samples and high response rates there is a risk of finding
correlations between many variables. Based on a solid theoretical foundation and
hypothesis-driven research, there is a logic to what is to be tested or investigated. Other
factors that were not investigated in Study II could possibly explain healthcare
professionals’ intention to leave and have to be considered when interpreting the results.
These factors could be linked to private life or to other levels in the organization. Although
Study II was of cross-sectional design, it was theoretically hypothesis-driven, which may
have reduced the risk of inadequate correlations.
Study III had the strength of being longitudinal over a period of one year. Similar to Study
I, it had the benefits of the unique codes to be able to make reliable analyses of a predictive
value of social capital for investigated outcomes. When performing analyses of a cohort as
in Study III, there is a risk of having a selection bias. However, a comparison of levels of
social capital between the cohort and the remaining sample showed no difference, which
was satisfying in the sense of potential selection bias.
Study IV had a longitudinal set-up very similar to studies I and III, however, with data from
three occasions. This made it possible to perform repeated measures analyses over time. A
strength is that the method needs values from two out of three occasions and imputes an
50
average value where it is suitable. This allows the analyses to consider a larger amount of
the gathered data, but at the same time, caution has to be taken with respect to the degree
of imputed data. A possible limitation in Study IV was the multicollinearity between the
different leadership orientations. This made it impossible to include them in the same
statistical model.
51
7. Conclusions and future research
7.1. General conclusion
The results of this thesis have reach several conclusions. Important conditions for
healthcare professionals’ engagement in organizational improvement work were in this
thesis found to be social capital, increased job resources, and decreased job demands.
Leadership quality as a precondition is important for developing social capital. 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.
7.2. Specific conclusions
Increased psychosocial work and organizational resources have importance for
healthcare professionals’ clinical engagement in improving care processes.
Social capital predicted healthcare professionals’ general work engagement,
engagement in clinical improvements in patient safety, and job satisfaction.
Social capital is associated with healthcare professionals’ intention to leave.
Levels of social capital are associated with levels of intention to leave, such that high
levels of social capital are associated with low levels of intention to leave.
Levels of leadership quality are correlated to levels of social capital.
7.3 Future research
Social capital was shown to be an important resource for healthcare professionals´
engagement and the results also showed that leadership quality was important for social
capital. There would be of interest to investigate this further by considering dimensions of
social capital as outcomes when working with leadership development programs in the
health care sector. Since social capital seems to be stable over the project period of three
years, one could ask if there is a greater variance in social capital if it was measured more
frequently than yearly. Combined with the idea to investigate if social capital can be
influenced as an effect of managers participating in a leadership development program,
dimensions of social capital could be measured more frequently. Moreover, the method
used in this thesis was quantitative, and the results produced can be further validated by
considering a qualitative approach in future research. The results in this thesis point on
social capital to be associated with healthcare professionals’ intention to leave. Interviews
with health care professionals about trust, recognition and reciprocity could validate these
results and extend knowledge of the connection between social capital and intention to
leave. Lastly, taking into consideration a system perspective, future research should focus
on elaborating knowledge of multilevel investigations because of the context dependency.
This could yield knowledge of how different levels in the organization support or hinder
employee engagement in organizational improvement work.
52
Acknowledgements
This has been an amazing experience and journey. It has been filled with hard work, fun
times and to be honest, some disparing moments. Self-support is needed, but also the
support from others. I would like to express my sincere gratitude to everyone involeved in
this thesis and say the following:
Thank you, Lotta Dellve, my main scientific supervisor, for noting my interest and
including me in your research team. You have been generous with time, support, and
academic brightness in a constructive and encouraging way. I cannot count the times my
partner in life has said: “How lucky you are to have Lotta.” I very much agree.
Andrea Eriksson and David Bergman, my co-supervisors, a sincere thank you—Andrea, for
your constructive advice, critical analyses, and valuable support, both in supervising and
as a co-worker in our research projects; David, for your support and valuable insights from
a different academic perspective and for believing in my ideas.
Anna Williamsson, for all the work with gathering data, for statistical discussions, and for
mutual support as PhD students and co-worker. Jörgen Andreasson, for our discussions
about managerial perspectives and our adventures at scientific conferences. Linda
Åhlström and Göran Jutengren for statistical tutorial and discussions.
I am sincerely grateful to the colleagues at the Ergonomics Unit for a creative academic
environment with good discussions and humor. Also, to my colleagues at the Competence
Center for Health at Region Västmanland, thank you for your support and interest in my
research, and a special gratitude to Fredrik Söderqvist for statistical discussions, to Anu
Molarius and Bo Simonsson for advices, and to Sevek Engström for creating space.
I would like to thank Lena Tell, the former HR director in Region Västmanland, for
including me in the meetings with the research team from KTH, and Ann-Sophie Hansson,
my former boss, for supporting the start of my PhD studies.
I am grateful to AFA Insurance and FORTE - Swedish Research Council for Health Working
Life and Welfare for the funding of the research projects that have supported me to fulfill
the aim of this thesis.
My parents, Ann-Marie and Bert-Olov, and my sisters, Marie-Louise and Matilda, thank
you for your love and support.
Susanne, my partner in life, your relentless support during this journey has been
inestimable. Sofia and Max, for your support and for reminding me of the important things
in life.
Friends and other colleagues, thank you!
53
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