Aim: The aim of this study was to describe first-line managers’ experiences of alternative modes of funding elderly care in two communities in western Sweden.

 Background: A growing elderly population demands alternative modes of funding elderly care for better outcomes for patients and better efficiency as it is publicly funded through taxation.

 Methods: The study comprised a total of eight semi-structured interviews with first-line managers working within elderly care. The interviews were analysed using manifest qualitative content analysis. Respect for the individuals was a main concern in the study.

 Results: One category, quality improvement, and four subcategories freedom of choice, organisational structure, quality awareness and market forces effects were identified to describe first-line managers’ experiences of the operation of elderly care.

 Conclusions: Quality improvement was an important factor to deal with when elderly care was operated in different organisational perspectives, either private or public. The first-line manager is a key person for developing a learning organisation that encourages both staff, clients and their relatives to improve the organisation. Moreover, person-centred care strengthens the client’s role in the organisation, which is in line with the government’s goal for the quality improvement of elderly care. However, further research is needed on how quality improvement could be developed when different caregivers operate in the same market in order to improve care from the elderly perspective.

Implications for nursing management: This study highlights alternative modes of funding elderly care. The economical perspectives should not dominate without taking care of quality improvement when the operation of elderly care is planned and implemented. Strategies such as a learning organisational structure built on person-centred care could create quality improvement in elderly care.

Aim: The aim of this study was to describe nurses' experiences of a recently implemented quality register, Senior Alert, at two hospitals in Sweden.

Background: In Sweden, in recent decades, a system of national quality registries has been established in health and medical services for better outcomes for patients, professional development and a better functioning system. Senior Alert (SA) is one quality registry, aimed at preventing malnutrition, pressure ulcers and falls in elderly care.

Methods: The study comprised a total of eight interviews with nurses working with SA at the ward level. The interviews were analysed using manifest qualitative content analysis. Respect for the individuals was a main concern in the study. All persons who were asked to participate in the study consented to do so.

Results: One category 'Patient Advantages' and three subcategories 'Conscious Persevering', 'Supporting Structure' and 'Committed Leadership' were identified to describe staff experiences of implementing SA.

Conclusions: Implementation processes need to be sustainable at both staff and managerial levels. A key factor in implementing and using a quality registry in prevention care could be described as keeping the flame burning. However, further research is needed on how patient advantages could be developed using other quality registries in order to improve care from a patient perspective.

Implications for nursing management: The results of this study could help other organizations implement quality registries or other change processes, for example new guidelines and treatment. Strategies concerning organizational structure and committed leadership could increase the usefulness of knowledge systems on all levels, which could enable continuous learning and quality improvement in health care.

New management models develop; one of them is shared leadership where two nurse managers share tasks and responsibility for a unit. The overall aim of this study was to describe  staff’s views about shared leadership at an ICU in Sweden, and to study if there were any differences in perceptions between staff groups. This unit had changed the management organization from single leadership (one nurse manager) to shared leadership (two nurse managers). Sixty four (79%) registered nurses and assistant nurses responded to a 72 item questionnaire measuring social and organizational factors at work, especially leadership and shared leadership.

The results showed that staff reported positive views in relation to the dimensions ‘Organizational culture’, ‘Social interactions’, ‘Work satisfaction’, ‘Leadership’, ‘Shared leadership’ and ‘Work motives’. Registered nurses reported more positive views than assistant nurses in relation to the dimensions: ‘Organizational culture’, ‘Social interactions’, ‘Work satisfaction’ and ‘Leadership’. Further, females had more positive views than males on the dimension ‘Social interactions’. Staff described that shared leadership positively influenced the work in terms of confidence. In conclusion, staff reported positive views of work and the model shared leadership in the investigated ICU. One implication is that nurse managers have to be conscious of different health professionals in the unit and it is important to offer a good working environment for all staff. However, more research is needed within the area of shared leadership. A future research project could be to add a qualitative research question about how work and shared leadership affects different health professionals in the day to day practice both at the managerial as well as the team level to improve health care.

New leadership models are developing; one of them is shared leadership, which is often described at the team level. In this study, shared leadership is explored at the managerial level. The aim of this case study was to describe two nurse manager’s experiences of working together as equal partners within a shared leadership model at an intensive care unit in Sweden. The study comprised a total of 12 interviews collected over three years with two nurse managers who worked together in shared leadership. ‘Developing active influence to improve care’ was identified as the core category, which was related to five subcategories ‘Safeguarding leadership’, ‘Enabling leadership’, ‘Supporting ‘two’-getherness’, ‘Transparent determination’ and ‘Balancing power’. A new construct ‘two’-getherness’ was created, this means that two equal nurse managers within a trustful relationship share responsibility and tasks by using the couples’ strengths and minimizing their weaknesses. Nurse managers experienced increased opportunities to improve work standards and do the very best for the ward. Moreover, the shared leadership model balanced the burden of day-to-day management. A model of shared leadership was created for further research.

Aim: The overall aim of this thesis is to follow up, describe and generate a tentative theory on ongoing processes of change in health care. This will be done at a macro level, through the study of hospital mergers as well as a micro level through studies of shared leadership.

Method: ”Hospital Mergers” is based on a qualitative approach; Grounded Theory, with interviews of health professionals (I, II). ”Shared leadership” considered a change of the leadership model with interviews (III-IV) and questionnaires (V) as methods for data collection. Health professionals’ conceptions of leadership were described by a phenomenographical approach (III). In addition, two nurse managers’ experiences of working together as equal partners within a shared leadership model have also been presented by Grounded Theory (IV). In the last paper (V), a quantitative method has been used by means of a questionnaire. Some of these questions are included in the QPSNordic focusing on health professionals’ approach to work, leadership and shared leadership.

Results: Participation and balancing involvement in a change process was emphasised by the health professionals. Leadership was highlighted as an important factor for healthcare organisations in change. Nurse leadership was seen as an ideal image by the health professionals and emphasised the importance for being present and available in order to provide support and feedback to improve practice. Supportive ”two-getherness” in a shared leadership are described as a relationship based on trust and confidence. Shared leadership made it possible to share responsibilities and tasks, which gave nurse managers a good working environment. Health professionals believe that shared leadership contributes to increased availability of committed nurse managers in day-to-day work. Conclusion: Two empirical models; committed leadership and supporting ”two-getherness” were developed. Committed leadership is built on participation through support in a caring culture. Supporting ”two-getherness” uses concepts such as common value and confident relationship. Moreover, the theory of Caritative Leadership was further developed from another perspective which is that of the relationship between managers. This relationship is known as supporting ”two-getherness”.

Syfte: Avhandlingen syftar till att följa upp, beskriva samt generera tentativ teori om pågående förändringsprocesser inom hälso- och sjukvården på såväl makronivå genom studier av sjukhusfusioner som mikronivå genom studier av delat ledarskap.

Metod: ”Sjukhusfusioner” beskriver två genomförda sjukhussammanslagningar utifrån en kvalitativ ansats, Grounded Theory med intervjuer av vårdpersonal (I, II). ”Delat ledarskap” utgår från en förändrad ledarskapsmodell på en intensivvårdsavdelning med intervjuer (III-IV) samt frågeformulär (V) som datainsamlingsmetod. Vårdpersonalens uppfattningar av ledarskap redovisas genom en fenomenografisk ansats (III). Vidare beskrivs två avdelningschefers upplevelser av att ha arbetat i ett delat ledarskap genom Grounded Theory (IV). I den sista delstudien (V) används en kvantitativ metod i form av ett frågeformulär. En del av dessa frågor ingår i instrumentet QPSNordic som belyser vårdpersonalens åsikter om arbete, ledarskap och delat ledarskap.

Resultat: Vårdpersonalen uttryckte behov av delaktighet och balans mellan olika behov och krav i ett förändringsarbete. Ledarskapets betydelse lyftes fram som en framgångsfaktor för att utveckla hälso- och sjukvårdsorganisationer i förändring. Vårdpersonalens idealbild av sjuksköterskans ledarskap utgjordes av en chef som var närvarande och tillgänglig i den dagliga verksamheten. Begreppet stödjande tvåsamhet lyftes fram som kärnan i delat ledarskap. Stödjande tvåsamhet, en tillitsfull relation mellan avdelningscheferna, bidrog till en god arbetsmiljö då ansvar och befogenheter delades av aktuellt ledarpar. Vårdpersonalen hade en positiv syn på sitt arbete och ledarskapet. De ansåg att det delade ledarskapet ökade avdelningschefernas möjligheter att vara engagerade och tillgängliga i det dagliga arbetet.

Konklusion: Resultatet har bildat underlag för två empiriskt grundade modeller; engagerat ledarskap och stödjande tvåsamhet. Engagerat ledarskap utgår från begreppen delaktighet och stöd i en vårdande kultur. Stödjande tvåsamhet bygger på en gemensam värdegrund och olikheter i kompetens hos ledarparet som ligger till grund för utveckling av en tillitsfull relation. Vidare har teorin om det caritativa ledarskapet vidareutvecklats genom begreppet stödjande tvåsamhet som belyser relationen chef till chef i en vårdande kultur.