Time utilization and perceived psychosocial work environment among staff in Swedish primary care settings

Person-centred care and the work-related health and job satisfaction of health and social care professionals: protocol for a prospective longitudinal cohort study combined with qualitative studies (the PCC@Work project)

BACKGROUND

The interplay of ethical stress, heavy workloads, and job dissatisfaction poses challenges to both the recruitment and retention of health and social care professionals. Person-centred care, rooted in ethical principles, involves collaborative care, and is expected to improve care and job satisfaction. However, prior research on the impact of person-centred care practices on professionals' work-related health and job satisfaction has yielded mixed results, and most studies emanate from residential care. Understanding how person-centred care practices influence health and social care professionals across different care settings thus requires further exploration through rigorous methodology. The overall aim of PCC@Work is to follow, describe, assess, and explore the impact of person-centred care practices in hospital wards, primary care centres and municipal care on health and social care professionals' work-related health and job satisfaction.

METHODS

PCC@Work is designed as a prospective, longitudinal cohort study combined with qualitative studies. A web-based questionnaire will be distributed on five occasions within two years to health and social care professionals in the three care settings. In addition, focus groups and interviews will be conducted with a selection of health and social care professionals to explore their experiences of work-related health and job satisfaction in relation to person-centred practices.

DISCUSSION

PCC@Work will highlight some of the knowledge gaps on the impact of person-centred care practices regarding work-related health and job satisfaction of health and social care professionals. The uniqueness of the project lies in the multi-method design, combining a prospective longitudinal cohort study with qualitative studies, and the involvement of various professions and settings. This means we will be able to provide a comprehensive and representative understanding of person-centred care practices as a critical component for effective change in the working conditions of health and social care.

Private health insurance in the United States and Sweden: A comparative review

Background and Aims

The United States of America and Sweden both contain a public and private component to their healthcare systems. While both countries spend a similar amount per capita on public healthcare expenditures, the United States spends significantly more in the private healthcare sector. Sweden has a social democratic model of health care, and given its identity as a welfare state, private health insurance providers have a small and nuanced role.

Methods

This paper was completed after searches were queried for "Sweden," "United States," and variants of the words "insurance," "public," "private," "Medicare," "Medicaid," "public," and "costs." A preliminary search in May 2022, yielded 78 articles, of which 45 were ultimately considered relevant for this review. Inclusion criteria consisted of English language articles, topic relevance, and verification of MEDLINE-indexed journals. These searches were performed in PubMed, Google Scholar, Embase, and Cochrane. Summary findings of these searches are compiled in this review.

Results

Sweden guarantees low-cost appropriate care to all citizens with equitable access; however, drawbacks of its system include high financial burden, lack of primary care infrastructure, as well as geographical and socioeconomic inequities. On the other hand, the United States' healthcare system is built around the private sector with public health insurance reserved only for the most vulnerable patient populations.

Conclusion

Our goal is to provide an overview, compare the role of private health insurance in both countries, and highlight policies that have had beneficial effects in each nation. Possible solutions to the drawbacks of each nation's health insurance policies could be addressed by additional support to Sweden's vulnerable population by developing a program similar to the US' Medicare Advantage program. Conversely, the United States may benefit from increasing access to public health insurance, especially in instances where families face unemployment.

Mapping of referral patterns for undescended testes - Risk factors for referral of children with normal testes

BACKGROUND

Accurate referral of boys with suspected undescended testes (UDT) is of importance to preserve fertility and reduce risk of future testicular cancer. While late referral is well studied, there is less knowledge about incorrect referrals, hence, referral of boys with normal testes.

OBJECTIVE

To evaluate the proportion of UDT referrals that did not lead to surgery or follow-up, and to assess risk factors for referral of boys with normal testes.

STUDY DESIGN

All UDT referrals to a tertiary center of pediatric surgery during 2019-2020 were retrospectively assessed. Only children with suspected UDT in the referral (not suspected retractile testicles) were included. Primary outcome was normal testes at examination by a pediatric urologist. Independent variables were age, season, region of residence, referring care unit, referrer's educational level, referrer's findings, and ultrasound result. Risk factors for not needing surgery/follow-up were assessed with logistic regression and presented as adjusted odds ratios with a 95% confidence interval (aOR, [95% CI]).

RESULTS

A total of 378 out of 740 included boys (51.1%) had normal testes. Patients >4 years (aOR 0,53, 95% CI [0,30-0,94]), referrals from pediatric clinics (aOR 0.27, 95% CI [0.14-0.51]) or surgery clinics (aOR 0.06, 95% CI [0.01-0.38]) had lower risk of normal testes. Boys referred during spring (aOR 1.80, 95% CI [1.06-3.05]), by a non-specialist physician (aOR 1.58, 95% CI [1.01-2.48]) or referrer's description of bilateral UDT (aOR 2.34, 95% CI [1.58-3.45]), or retractile testes (aOR 6.99, 95% CI [3.61-13.55]) had higher risk of not needing surgery/follow-up. None of the referred boys that had normal testes had been re-admitted at the end of this study (October 2022).

DISCUSSION

Over 50% of boys referred for UDT had normal testes. This is higher or equal to previous reports. Efforts to reduce this rate should in our setting probably be directed towards well-child centers and training in examination of testicles. The main limitation of this study is the retrospective design and the rather short follow-up time, which however should have very modest effect on the main findings.

CONCLUSION

Over 50% of boys referred for UDT have normal testes. A national survey regarding the management and examination of boys testicles has been launched and directed at well-child centers to further evaluate the findings of the current study.

Organizational influences on the use of low-value care in primary health care - a qualitative interview study with physicians in Sweden

AIM

The aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC.

DESIGN

Qualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis.

SETTING

Six publicly owned primary health care centers in Stockholm.

SUBJECTS

The participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7.

MAIN OUTCOME MEASURES

Categories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC.

RESULTS

Four types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient-physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. .

CONCLUSION

The influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.KEY POINTSWe know little about how organizational factors influence the use of low-value care (LVC) in primary health care.Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.This study provides insights about how these factors influence LVC use.Strategies at multiple levels of the health-care system may be warranted to reduce LVC.

Work time allocation at primary health care level in two regions of Albania

Introduction

Although well-performing workforce is essential to equitable and efficient health service delivery, few countries have systematically addressed performance improvements. How health workers use their work time and what tasks they accomplish is here an important starting point. Therefore, a time motion study was conducted to assess the work time allocation patterns of primary health care doctors and nurses in two regions of Albania.

Methods

We used observation tool to record the time allocation along eight predefined main categories of activities. Conditional to presence at work, 48 health workers were continuously observed in early 2020 before start of the Covid-19 pandemic over five consecutive working days.

Results

The observed health workers spent 40.7% of their overall working time unproductively (36.8% on waiting for patients and 3.9% on breaks), 25.3% on service provision to users, 18.7% on administrative activities, 12.7% on outreach activities, 1.6% on continuous medical education and 1% on meetings. The study found variations in work time allocation patterns across cadres, with nurses spending more time unproductively, on administrative activities and on outreach and less on all other activities than doctors. Further, the work time allocation patterns were similar between urban and rural settings, except for nurses in rural settings spending less time than those in urban settings on administrative work.

Conclusion

This study found that primary health care workers in Albania devote a substantial amount of work time to unproductive, service provision to users and administrative activities. Consequently, there is possibility for productivity, respectively efficiency gains in how health workers use their time.

'But there are so many referrals which are totally … only generating work and irritation': a qualitative study of physicians' and nurses' experiences of work tasks in primary care in Sweden

OBJECTIVE

This study explored the perceptions of physicians and nurses in Swedish primary care regarding the legitimacy of their work tasks and the use of their professional competence.

DESIGN AND SETTING

This qualitative study was based on manifest content analysis. Data were collected with individual semi-structured interviews of physicians and nurses at publicly managed primary care centres in the Region Östergötland, Sweden. To include both large and small primary care centres, we applied strategic sampling. Among 15 primary care centres invited, nine agreed to participate, including four urban, two suburban, and three rural centres.

SUBJECTS

The study included 11 physicians and 13 nurses from nine primary care centres.

MAIN OUTCOME MEASURES AND RESULTS

The physicians and nurses perceived several of their work tasks as illegitimate. In addition, they experienced work-related difficulties, due to resource shortages, challenging electronic data systems, work inefficiencies, and that there were insufficient cooperation with, and problems drawing the line between, primary care and hospital care responsibilities. However, most found that their individual expertise was appropriately used, overall.

CONCLUSIONS

Strained work situations and illegitimate work tasks may inflate discontentment and lead to negative work stress. Nevertheless, the staff felt that competence was used appropriately in the tasks considered legitimate.Key PointsPhysicians and nurses in primary care in Sweden described several work tasks as illegitimate.Physicians and nurses described problems with heavy workloads, resource shortages, electronic data-system challenges, inefficiencies and with cooperation and drawing the line between primary care and hospital care.Overall, physicians and nurses believed their individual expertise was used appropriately.To uphold sustainable working conditions and thoughtful use of staff competence, organisational measures, such as redistributing staff from hospital to primary care were proposed.

The voice of the self: a typology of general practitioners' emotional responses to situational and contextual stressors

OBJECTIVE

To develop a comprehensive typology of emotional reactions associated with stress among general practitioners (GPs), grounded in their own experiences.

DESIGN

Data was generated using observations and unstructured interviews, using Straussian grounded theory as the overarching methodology. The typology was built using multidimensional property supplementation.

SETTING

Eleven health care centres in urban and rural communities in four Swedish regions.

SUBJECTS

Sixteen GPs and GP residents.

MAIN OUTCOME MEASURES

Characteristics of GPs' emotional reactions in everyday work situations.

RESULTS

Accounts of negative emotions connected to stress revealed four principal personal needs of the GP: trust, efficacy, understanding, and knowledge. Simultaneous threats to more than one of these needs invariably increased the level of tension. From these more complex accounts, six second-order needs could be identified: integrity, judgment, pursuit, authority, autonomy, and competence. The most extreme encounters, in which all four principal needs were threatened, were characterised by the experience of being reduced into an assistant.

CONCLUSION

The considerable resilience of GPs may belie some of the pressures that they are facing while being far from a fail-safe defence against being diverted from purposeful and morally responsible action. Our typology distinguishes between different forms of stress that may affect how GPs carry out their work, and connects to the vast literature on GP wellness. The results of this study could be used to develop tools for self-reflection with the aim of countering the effects of stress, and are potentially relevant to future research into its causes and consequences.Key pointsWhat is known•Stress among GPs may have severe consequences for themselves and their patients, and levels of stress appear to be increasing.What this article adds•Stressful situations threaten at least one of four principal needs of the GP: trust, efficacy, understanding, and knowledge.•More complex threats increase the level of tension and bring out second-order needs: integrity, judgment, pursuit, authority, autonomy, and competence.•The wealth of literature on GP stress can be clearly understood through the lens of our four-dimensional typology.

Prevalence and Clustering of Cardiovascular Risk Factors among Medical Staff in Northeast China

BACKGROUND

The clustering of cardiovascular disease (CVD) risk factors has become a major public health challenge worldwide. Although many studies have investigated CVD risk factor clusters, little is known about their prevalence and clustering among medical staff in Northeast China. This study aimed to estimate the prevalence and clustering of CVD risk factors and to investigate the association between relevant characteristics and the clustering of CVD risk factors among medical staff in Northeast China.

METHODS

A cross-sectional survey of 3720 medical staff from 93 public hospitals in Jilin Province was used in this study. Categorical variables were presented as percentages and were compared using the χ² test. Multiple logistic regression analysis was used to evaluate the association between relevant characteristics and the clustering of CVD risk factors.

RESULTS

The prevalence of hypertension, diabetes, dyslipidemia, being overweight, smoking, and drinking were 10.54%, 3.79%, 17.15%, 39.84%, 9.87%, and 21.75%, respectively. Working in a general hospital, male, and age group 18-44 years were more likely to have 1, 2, and ≥3 CVD risk factors, compared with their counterparts. In particular, compared with being a doctor, being a nurse or medical technician was less likely to have 1, 2, and ≥3 CVD risk factors only in general hospitals.

CONCLUSIONS

The findings suggest that medical staff of general hospitals, males, and older individuals have a high chance associated with CVD risk factor clustering and that more effective interventions should be undertaken to reduce the prevalence and clustering of CVD risk factors, especially among older male doctors who work in general hospitals.

Teachers' time utilisation and students' enrolment in school certificate examination: implication for school leadership

This study investigated the extent to which teachers' time utilisation influences students' enrolment in certificate examination and compared the realized teaching time by teachers in public and private secondary schools in Benin, Nigeria to draw the attention of school leadership to the importance of teachers' time utilisation to the attainment of educational goals. The survey design was employed to elicit data from three hundred and sixty randomly selected senior secondary school students from five public and five private senior schools. Questionnaire served as the data collection instrument and the data were subsequently analysed using Kolmogorov Smirnov test, Mann Whitney U test and Kruskal Wallis test. Results indicate that realised teaching time and time utilisation by the teachers in public secondary schools is significantly lower than what obtains in private secondary schools and significantly lower than the expected teaching time. The realised teaching time and time utilisation also varied significantly within the public and private secondary schools and between classes in public and private secondary schools. Lastly, class sizes were significantly large in uencthe public schools but generally small in the certificate classes, thus implying that teachers' time utilization has a significant impact on students' enrolment. The need for school leaders and administrators to ensure increased teachers' time utilisation for enhanced enrolment in certificate examinations was suggested, among others.

Does staff-assessed care quality predict early failure of dental fillings? A prospective study

OBJECTIVES

The aim of this study was to evaluate staff-assessed care quality as an indicator of register-based measures of care quality at dental clinics, more specifically register-based measures of survival of dental fillings and initiation of preventive treatments for caries patients.

METHODS

This prospective study includes data from cross-sectional workplace psychosocial risk assessment surveys at dental clinics and register data on survival of dental fillings, and initiation of preventive treatment for caries patients obtained from the Swedish Quality Registry for Caries and Periodontal Disease (SKaPa) Demographic background data on the age, gender, income level and place of birth of patients was obtained from Statistics Sweden (SCB). The data were analysed using discrete-time multilevel survival analysis and multiple linear regression analysis.

RESULTS

The results showed that staff-assessed care quality rated by the total staff or by dental nurses at the clinic predicted the risk of replacement of dental fillings made due to a caries diagnosis during the 3-year follow-up period, controlling for potential confounding due to patient demographic characteristics (age, sex, income and country of birth). In contrast, the better the staff-assessed care quality at the clinic, the smaller the proportion of the patients received preventive care in addition to operative caries therapy when controlling for potential confounding due to patient demographics. Care quality assessed by dentists at the clinic did not predict either of these outcome measures.

CONCLUSIONS

Premature failure of dental fillings is costly for both patients and society, which leads to a need for relevant measures for following dental care quality. Our findings indicate that staff-assessed care quality - a cheap and easy measure to collect and follow continuously in dental practice - can be used to monitor aspects of quality in real time in order to facilitate continuous improvement and quickly amend quality problems. Also, it can be used for integrating quality improvement in systematic work environment risk management.

Validation of the Copenhagen Psychosocial Questionnaire Version III and Establishment of Benchmarks for Psychosocial Risk Management in Sweden

This study presents the Swedish standard version of the Copenhagen Psychosocial Questionnaire, COPSOQ III, and investigates its reliability and validity at individual and workplace levels with the aim of establishing benchmarks for the psychosocial work environment. Cross-sectional data from (1) a random sample of employees in Sweden aged 25–65 years (N = 2847) and (2) a convenience sample of non-managerial employees at 51 workplaces (N = 1818) were analysed. Internal consistency reliability was evaluated as well as the effects of sex, work sector and blue/white-collar work. Population benchmarks and mean scores for major occupational groups were computed based on weighted data. ICC(1) and ICC(2) estimates were computed to evaluate aggregation to the workplace level and Pearson inter-correlations to evaluate construct validity at individual and aggregated levels. The reliability and scale characteristics were satisfactory, with few exceptions, at both individual and workplace levels. The strength and direction of correlations supported the construct validity of the dimensions and the amount of variance explained by workplace justified aggregation to the workplace level. The present study thus supports the use of COPSOQ III for measurement at the workplace level and presents benchmarks for risk management as well as for research purposes.

Legitimacy of work tasks, psychosocial work environment, and time utilization among primary care staff in Sweden

Objective: Primary care staff faces a complex work environment including a heavy administrative work load and perceive some work tasks as illegitimate. This study aimed to elucidate associations between the perceived legitimacy of work tasks, the psychosocial work environment, and the utilization of work time among Swedish primary care staff.Design and setting: The study was designed as a multicenter study involving all staff categories, i.e. registered nurses, primary care physicians, care administrators, nurse assistants and allied professionals, at eleven primary care centers in Sweden.Subjects: Participants completed the Bern Illegitimate Tasks Scale and the Copenhagen Psychosocial Questionnaire. They also recorded time spent on all work tasks, day by day during two separate weeks.Main outcome measures and results: More than a quarter (27%) of primary care physicians perceived a high proportion of unnecessary work tasks. After adjusting for profession, age and gender, the perception of having to perform unreasonable work tasks was positively associated with experiencing role conflicts and with the proportion of organization-related administration and service work tasks.Conclusion: Across all staff groups, the perception of unreasonable work tasks was more pronounced among staff with a high proportion of non-patient related administration. Also, the perception of having to perform a large amount of illegitimate work tasks affected the psychosocial work environment negatively, which might influence staffs perception of their professional roles. These results illuminate the importance of decision makers to thoroughly consider the distribution and allocation of non-patient related work tasks among staff in primary care.Key pointsWe observed an interaction between perception of having a large proportion of illegitimate work tasks and impaired psychosocial work environment. • More than a quarter of the primary care physicians perceived a high proportion of unnecessary work tasks.• Across all staff groups, performing unreasonable work tasks was associated with an experience of having role conflicts.• Across all staff groups, a perception of performing unreasonable work tasks was associated with the proportion of non-patient related administrative work tasks.