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AIM: To investigate the relationship between nurses' climate of perceived organizational support, and their well-being and healthcare-unit performance. DESIGN: A two-wave cohort questionnaire study among nurses within six hospitals in Sweden. METHODS: Hypotheses were tested using cross-lagged path models on the individual (organizational support, job satisfaction, burnout, intention to stay) and aggregate levels (care-unit organizational support, team effectiveness, patient safety climate and patient safety). Analyses were based on 1.817 nurses in 228 care-units (T1), 1.362 nurses in 213 care-units (T2) and longitudinal samples of 711 nurses and 140 care-units. RESULTS: Organizational support (T1) positively influenced job satisfaction (T2) and tended to decrease burnout (T2) but did not affect turnover intent. Reversed relationships were also found. No statistically significant prospective effects were found on the aggregate level. CONCLUSION: The results indicated a prospective reciprocally reinforcing relationship between organizational support and job satisfaction. Burnout and intention to stay were predictors rather than outcomes of the organizational support climate. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: A climate where nurses perceive that their organization values their contributions and cares about their well-being is beneficial for their job satisfaction and health, which, according to previous research, may influence nurse retention. IMPACT: The study addressed perceived organizational support as a potential predictor of nurses' well-being and healthcare-unit performance. A mutually reinforcing relation was indicated between organizational support and nurses' job satisfaction and health. Job dissatisfaction, burnout symptoms and turnover intentions were prospectively negatively related to the organizational support. Identifying and implementing a variety of practical measures to support perceptions of organizational support may be an effective way for healthcare management to start and sustain the development of a healthier work environment for healthcare professionals. REPORTING METHOD: STROBE statement for cohort studies. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

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OBJECTIVE: The aim of the present study was to investigate the longitudinal relationships between nurses' organizational climate of perceived organizational support (POS-climate) and their psychosocial working conditions and psychological contracts. METHODS: A two-wave longitudinal cohort questionnaire study was carried out among registered nurses employed within six hospitals in two regions in Sweden (n = 711). Two cross-lagged panel models were tested after ensuring scalar factorial invariance of the measurement models. The first model investigated longitudinal relationships between psychosocial working conditions and the POS-climate, while the second model investigated such relationships between the psychological contracts and the POS-climate. RESULTS: The results indicated that influence at work and an ideology-infused psychological contract had positive effects on the nurses' POS-climate. CONCLUSIONS: These results highlight the importance of providing nurses with such influence, and of a shared ideology within the entire health-care organization, centered on the ethical values of the health-care professions.

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OBJECTIVE: Moral distress emanating from value conflicts comprising ethical dimensions pose a threat to nurses' health and retention, as well as to the quality of care. The aim of the present study was to investigate the relationships between the frequency of ethical value conflicts (EVC), and the perceived distress when they occur, respectively, and nurses' work-related stress, burnout symptoms, turnover intent, team effectiveness, and patient safety. METHODS: A two-wave longitudinal cohort questionnaire study was performed among registered nurses at six hospitals in two Swedish regions. Cross-sectional analyses (T1) were based on 1817 nurses in 228 care units (CU), and longitudinal analyses (T1 - T2) on 965 nurses in 190 CU. Hypothesis testing was performed using multilevel controlled regression modeling. RESULTS: The results indicated that nurses who were often exposed to EVC also to a higher extent tended to report these conflicts as stressful. Frequent exposure to EVC induced by insufficient resources, inapt organizational structures or interpersonal staff relations were cross-sectionally associated with work-related stress, burnout symptoms, turnover intent, and team effectiveness. The longitudinal analyses indicated that EVC induced by a lack of resources primarily had negative effects on nurses' health and well-being. At the CU level, such conflicts also impaired team effectiveness. At the individual level, EVC induced by organizational constraints or interpersonal relations negatively affected care effectiveness. CONCLUSIONS: EVC are related to negative consequences in healthcare, and such processes take place both on the individual and organizational levels.

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AIM: To explore if and how nurses' perceived organizational support affects their ability to handle and resolve ethical value conflicts. DESIGN: A mixed methods design with a longitudinal questionnaire survey and focus group interviews. METHODS: A questionnaire survey in six hospitals in two Swedish regions provided data from 711 nurses responding twice (November-January 2019/2020 and November-January 2020/2021). A cross-lagged path model tested the mutual prospective influence between the organizational climate of perceived organizational support, frequency of ethical value conflicts, and resulting moral distress. Four focus group interviews were conducted with 21 strategically selected nurses (April-October 2021). Qualitative data collection and analysis were inspired by Grounded Theory. RESULTS: A climate of perceived organizational support was empowering, contributing to role security. It prospectively decreased the frequency of ethical value conflicts but not the moral distress when conflicts did occur. CONCLUSION: It is important to facilitate the development of perceived organizational support among nurses, but also to reduce the occurrence of ethical value conflicts that the nurses cannot resolve. IMPLICATIONS FOR THE PROFESSION: By ensuring a shared care ideology, good inter-professional relations within the entire care organization, providing clear and supportive organizational structures, and utilizing competence adequately, healthcare managers can facilitate and support the development of perceived organizational support among nurses. Nurses who are empowered by perceived organizational support are stimulated by and take pride in their work and experience the work as meaningful and joyful. IMPACT: The study addressed the question of whether healthcare organizations could support nurses to resolving ethical value conflicts, and thus reduce moral distress. Perceived organizational support is related to factors such as ideological caring alignment and supportive organizational preconditions. This study contributes specific knowledge about how healthcare organizations can empower nurses to effectively resolve ethical value conflicts and thereby reduce their moral distress. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

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BACKGROUND: Stress-related disorders have become a major challenge for society and are associated with rising levels of sick leave. The provision of support to facilitate the return to work (RTW) for this patient group is of great importance. The aim of the present study was to evaluate whether a new systematic procedure with collaboration between general practitioners (GPs), rehabilitation coordinators (RCs) and employers could reduce sick leave days for this patient group. METHOD: Employed patients with stress-related diagnoses seeking care at primary health care centres (PHCCs) were included in either the intervention group (n = 54), following the systematic intervention procedure, or the control group (n = 58), receiving treatment as usual (TAU). The intervention included a) a training day for participant GPs and RCs, b) a standardised procedure for GPs and RCs to follow after training, c) the opportunity to receive clinical advice from specialist physicians in the research group. Outcome measures for RTW were sick leave days. RESULTS: The median number of registered gross sick leave days was lower for the control group at six, 12 and 24 months after inclusion, but the difference was not statistically significant. The control group had significantly fewer net sick leave days at three months (p = 0.03) at six months (p = 0.00) and at 12-months follow-up (p = 0.01). At 24 months, this difference was no longer significant. CONCLUSIONS: The PRIMA intervention, which applied a standardized procedure for employer involvement in the rehabilitation process for patients with stress-related disorders, actually increased time to RTW compared to TAU. However, at 24 months, the benefit of TAU could no longer be confirmed. The study was registered on 16/01/2017 (ClinicalTrials.gov, NCT03022760).

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AIM(S): This study aims to investigate care unit managers' perceptions of how the COVID-19 pandemic influenced their ability to support the nurses. BACKGROUND: The COVID-19 pandemic placed extreme pressure on health care organizations. More knowledge regarding how the pandemic influenced care unit managers' ability to support nurses is central to ensuring high-quality health care in future crises. METHOD(S): A mixed-methods study in Swedish hospitals with a survey (n = 128) and interviews (n = 20) with care unit managers. RESULTS: Approximately half of the managers reported having spent more time available to and supporting the nurses. Availability was positively predicted by their perceived organizational support while negatively by their job demands. These job demands concerned meeting staff anxiety and managing organizational restructuring. Full focus on direct patient care and strong professional and social support were important job resources. CONCLUSION(S): For care unit managers to effectively support the nurses during a crisis, they need proficient job resources and moderate job demands. Managers' perceived organizational support positively affects the quality of their crisis leadership. Creating arenas in which staff collegiality can form and develop is beneficial for the ability to meet future crises. IMPLICATIONS FOR NURSING MANAGEMENT: This study specifies important job resources that should be acknowledged and reinforced to strengthen the ability of care unit managers to actively support the nurses during a crisis.

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Healthcare unit managers are pivotal to promote nurses' Perceived Organizational Support and hence to ensure nurses' health and well-being, as well as high-quality care. Despite this fact, there is a dearth of studies addressing how healthcare unit managers act and organize their work to promote nurses' Perceived Organizational Support and which working conditions enable them to do so. Through a mixed methods approach, comprising qualitative interviews and quantitative surveys among healthcare unit managers and nurses, this paper underscores that healthcare unit managers' availability to their nursing staff was essential for their ability to promote nurses' Perceived Organizational Support, and that responsive support from the care unit managers' superior management, administration, and managerial colleagues constituted enabling working conditions. Superior manager support strongly promoted the care unit manager's own Perceived Organizational Support, which, in turn, was positively correlated with nurses' organizational climate of Perceived Organizational Support.

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OBJECTIVE: This study aimed to explore the development of working conditions within and between occupations in the Swedish labor market from 1997 to 2015 and whether any polarization in working conditions concurrently occurred between occupations. METHODS: Cross-sectional data from ten waves of the Swedish Work Environment Surveys (1997-2015) were used and an aggregated occupational-level dataset was created using the Swedish Standard Classification of Occupations. To capture the patterns of change in working conditions over time (ie, growth), growth curve modeling was used to identify the starting points for 89 occupations (intercepts) as well as both the shape (functional form) and rate of growth (slope) over time. RESULTS: The Swedish labor market was stable overall, with some small, mainly positive, changes in job demands and resources. Different occupations developed in divergent directions, but there was no evidence of polarization. CONCLUSIONS: The findings indicate that macro-level stability can hide highly heterogeneous patterns of change among different occupational groups. This type of analysis, taking context into account, could be valuable for decision makers intending to improve the work environment.

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BACKGROUND: Work-related stress has become a major challenge for social security and health care systems, employers and employees across Europe. In Sweden, sickness absence particularly due to stress-related disorders has increased excessively in recent years, and the issue of how to improve sustainable return to work in affected employees is high up on the political agenda. The literature on interventions for return to work in patients with common mental disorders is still inconclusive. This randomized controlled trial (RCT) aims to contribute with knowledge about how physicians and rehabilitation coordinators in primary health care can involve the employer in the rehabilitation of patients with stress-related disorders. The objective is to evaluate whether the early involvement of the patient's employer can reduce the time for return to work compared to treatment as usual. A process study will complete the RCT with information about what prerequisites primary health caregivers need to succeed with this endeavor. METHODS: Twenty-two primary care centers were randomized to either intervention or control group. At the intervention centers, physicians and rehabilitation coordinators underwent training, providing them with both knowledge and practical tools to involve the employer in rehabilitation. At the patient level, employed patients with an ICD-10 F43 diagnosis were eligible for participation (n=132). Difference in proportion of patients on full- or part-time sick leave at three, six and 12 months after inclusion will be investigated. Register data, logbooks and interviews with coordinators and physicians at both intervention and control centers will be used for process evaluation. DISCUSSION: Although the issue of how to tackle work-related stress can be recognized all across Europe, Sweden face an urgent need to curb the disproportional increase of stress-related disorders in the sick-leave statistics. Since physicians are limited by time constraints, the rehabilitation coordinator may be a helpful resource to take this contact. The current study will contribute to knowledge about how this collaboration can be organized to facilitate employer involvement and reduce time to return to work among patients suffering from work related stress. TRIAL REGISTRATION: Registered on 1 November 2016, ClinicalTrials.gov, NCT03022760 .

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Objectives The construction industry accounted for >20% of all fatal occupational accidents in Europe in 2014. Leadership is an essential antecedent to occupational safety. The aim of the present study was to assess the influence of transformational, active transactional, rule-oriented, participative, and laissez-faire leadership on safety climate, safety behavior, and accidents in the Swedish and Danish construction industry. Sweden and Denmark are similar countries but have a large difference in occupational accidents rates. Methods A questionnaire study was conducted among a random sample of construction workers in both countries: 811 construction workers from 85 sites responded, resulting in site and individual response rates of 73% and 64%, respectively. Results The results indicated that transformational, active transactional, rule-oriented and participative leadership predict positive safety outcomes, and laissez-faire leadership predict negative safety outcomes. For example, rule-oriented leadership predicts a superior safety climate (ß=0.40, P<0.001), enhanced safety behavior (ß=0.15, P<0.001), and fewer accidents [odds ratio (OR) 0.78, 95% confidence interval (95% CI) 0.62-0.98]. The effect of rule-oriented leadership on workers' safety behavior was moderated by the level of participative leadership (ß=0.10, P<0.001), suggesting that when rules and plans are established in a collaborative manner, workers' motivation to comply with safety regulations and participate in proactive safety activities is elevated. The influence of leadership behaviors on safety outcomes were largely similar in Sweden and Denmark. Rule-oriented and participative leadership were more common in the Swedish than Danish construction industry, which may partly explain the difference in occupational accident rates. Conclusions Applying less laissez-faire leadership and more transformational, active transactional, participative and rule-oriented leadership appears to be an effective way for construction site managers to improve occupational safety in the industry.

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INTRODUCTION: Patient safety climate/culture is attracting increasing research interest, but there is little research on its relation with organizational climates regarding other target domains. The aim of this study was to investigate the relationship between patient safety climate and occupational safety climate in healthcare. METHOD: The climates were assessed using two questionnaires: Hospital Survey on Patient Safety Culture and Nordic Occupational Safety Climate Questionnaire. The final sample consisted of 1154 nurses, 886 assistant nurses, and 324 physicians, organized in 150 work units, within hospitals (117units), primary healthcare (5units) and elderly care (28units) in western Sweden, which represented 56% of the original sample contacted. RESULTS: Within each type of safety climate, two global dimensions were confirmed in a higher order factor analysis; one with an external focus relative the own unit, and one with an internal focus. Two methods were used to estimate the covariation between the global climate dimensions, in order to minimize the influence of bias from common method variance. First multilevel analysis was used for partitioning variances and covariances in a within unit part (individual level) and a between unit part (unit level). Second, a split sample technique was used to calculate unit level correlations based on aggregated observations from different respondents. Both methods showed associations similar in strength between the patient safety climate and the occupational safety climate domains. CONCLUSIONS: The results indicated that patient safety climate and occupational safety climate are strongly positively related at the unit level, and that the same organizational processes may be important for the development of both types of organizational climate. PRACTICAL APPLICATIONS: Safety improvement interventions should not be separated in different organizational processes, but be planned so that both patient safety and staff safety are considered concomitantly.

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INTRODUCTION: The often applied engineering approach to safety management in the construction industry needs to be supplemented by organizational measures and measures based on how people conceive and react to their social environment. This requires in-depth knowledge of the broad preconditions for high safety standards in construction. The aim of the study was to comprehensively describe the preconditions and components of high safety standards in the construction industry from the perspective of both experienced construction workers and first-line managers. METHOD: Five worker safety representatives and 19 first-line managers were interviewed, all strategically selected from within a large Swedish construction project. Phenomenographic methodology was used for data acquisition and analysis and to categorize the information. Nine informants verified the results. RESULTS: The study identified four main categories of work safety preconditions and components: (1) Project characteristics and nature of the work, which set the limits of safety management; (2) Organization and structures, with the subcategories planning, work roles, procedures, and resources; (3) Collective values, norms, and behaviors, with the subcategories climate and culture, and interaction and cooperation; and (4) Individual competence and attitudes, with the subcategories knowledge, ability and experience, and individual attitudes. DISCUSSION: The results comprehensively describe high safety standards in construction, incorporating organizational, group, individual, and technical aspects. High-quality interaction between different organizational functions and hierarchical levels stood out as important aspects of safety. The results are discussed in relation to previous research into safety and into the social-psychological preconditions for other desired outcomes in occupational settings. IMPACT ON INDUSTRY: The results can guide construction companies in planning and executing construction projects to a high safety standard.

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Despite the acknowledged key role of leaders for psychosocial work environment, few studies focus on how leaders can decrease work-related stress. To gain deeper knowledge of leaders' perceptions and strategies for dealing with their own and their subordinates' stress in public human service organisations (HSO), qualitative interviews were made with leaders from hospitals and regional social insurance offices (n=21), and analysed in line with grounded theory method. The leaders handled subordinates' stress and perceived leadership demands by acting as shock absorber (core category) and used strategies characterised as leading in continuous change whilst maintaining trustworthiness. To cope with their own stress from perceived leadership demands, they tried to sustain their own integrity (core category) by either identifying with or distancing themselves from the leader role. The strategies for dealing with leaders' own and subordinates' exposures to stressors was pervaded by perceived leadership demands and are probably influencing each other. Supportive structures and improved communication about everyday dilemmas seem to be needed in order, not just to prevent stress reactions, but to improve the basic conditions for practicing leadership in HSO.

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