It is common to view work-family dilemmas like work-family conflict as the individual’s problem despite the fact that these kinds of dilemmas often have contextual sources. The aim of the present study is to explore the experience of work-family conflict among governmental employed managers by examining work demands, boundary setting strategies and organizational flexibility at the individual and at a contextual level where both the organizational belongingness and the gender composition is examined.

Our results show that organizational and contextual research on work-family issues contributes with knowledge about organizational aspects and processes that managers in organizations have to be aware of instead of understanding work-family dilemmas as individuals’ problems. We also conclude that a gender perspective both at the individual and at the organizational level is needed in the field of work-family research.

This chapter reports on the work activities, time-use patterns, and stress patterns of ten health care managers in Sweden. The qualitative and quantitative evidence reveals the fragmentation in their nine-hour working days where each activity, on average, lasts only ten minutes. The time-use patterns vary individually though some patterns are related to position and unit type. Activities deal with the coexisting and competing logics of employeeship, administration, and strategy and risk handling. None of the managers’ approaches for handling the multiple legitimation processes and delimiting their workload boundaries really challenges the complexity of the coexistence of the multiple logics or the boundlessness of their working hours. Using biophysical measures, the research finds that stress reported by the managers is caused by (a) interruptions during challenging tasks and (b) personal situations such as private dilemmas and conflict-loaded or ineffective meetings. It is important to acknowledge managers’ fragmented working situation and to recognize that management should be seen as collective process, or as part of an administrative system.

Mellan kvinnor och män finns det många olikheter i hälsa, vårdtillgång och vårdkvalitet. Fortfarande drabbas kvinnor i större utsträckning än män av kvalitetsbrister och problem i vården – till exempel rapporterar kvinnor mer än dubbelt så ofta som män att de blivit kränkta av vården. Men det finns också områden där vården misslyckas med att möta mäns behov. Denna reviderade och utvidgade upplaga av (O)jämställdhet i hälsa och vård belyser utifrån uppdaterade siffror medicinskt omotiverade könsskillnader som görs inom vården och analyserar skillnader i kvinnors och mäns livslängd och hälsa ur ett genusperspektiv.

Background

This dissertation takes a critical look at norms and normality in healthcare education, focusing on the specific case of a nursing education programme at a Swedish university college. The concepts of norms and normality have a long history in healthcare professions, and have become important for many aspects of social life. A norm-critical perspective is central to the studies, as it exposes constructions of power and privilege related to norms and normality. It may also be useful in revealing underlying assumptions and matters which healthcare professionals take for granted, and which may result in failure to provide equitable care for all.

Aim

The overall aim of the dissertation is to describe and scrutinise norms and normality in a healthcare education context from a norm-critical perspective. A further aim is to explore how a norm-critical perspective on nursing education can contribute knowledge to existing fields of critical inquiry.

Designs

The four studies were designed using qualitative approaches to written and spoken text, as well as a number of different approaches to an instrument development process.

Methods

In study I, document analysis was underpinned by thematic analysis, while critical discourse analysis was used to analyse focus group discussions in study II. Study III analysed written responses to open survey questions using a discursive approach. Instrument development and factor analytic techniques were used in study IV.

Findings

Study I revealed the occasional use of politically correct rhetoric in curricular documents and literature, in parallel with a number of outdated views in terms of identity and normality. In study II, three discourses were identified in nursing teachers’ talk, all with norm-critical potential, though criticism of norms was not strong enough to form a discourse of its own. Study III showed how nursing students used more or less politically correct or reflexive approaches to construct images of norms and normality. Study IV developed and validated the Norm-critical awareness scale.

Conclusions

This dissertation expands knowledge about norm-critical perspectives in healthcare contexts. It exposes constructions of normative, taken-for-granted aspects within healthcare education, and concludes that the apparently desirable concept of tolerance needs to be problematised more fully in relation to norms, privilege and power. Norm criticism as an educational and intellectual tool can increase awareness of the norm-related mechanisms underlying healthcare encounters, even if awareness is only a first and necessary phase of change, and is not in itself sufficient to bring about change.

Implications

In a practical sense, the findings can facilitate understanding, planning and implementation of further norm-critical initiatives in educational contexts. Where theory is concerned, the studies fill a knowledge gap by contributing to norm-critical approaches in settings where future healthcare professionals are being educated, which have barely been explored until now. The studies also add to existing research traditions involving critical, emancipatory and anti-oppressive perspectives in terms of healthcare professions.

Aim. The aim of this thesis was to deepen the knowledge concerning health care managers’ everyday work experiences and their handling of stress and balance.

Background. Health care managers’ work is characterized by daily hassles, conflicting perspectives, and unclear boundary setting. They could therefore use support in boundary and stress management.

Methods. A qualitatively driven mixed methods approach was used. Qualitative interviews, focus groups and workplace observations were used for data collection in Study I. Physiological stress indicators, stress self-assessments, workplace observations and interviewing were used in Study II. Analyses were mainly carried out on the interview data, using grounded theory methodology (Study I) and conventional content analysis (Study II).

Results. Paper I shows that a first step in managers’ boundary setting is to recognize areas at work with conflicting expectations and inexhaustible needs. Strategies can then be formed through proactive, continuous negotiating of their time commitments. These strategies, termed ‘boundary approaches’, are more or less strict regarding the boundary setting at work. Paper II shows that nonnormative, interactive feedback sessions could encourage understanding and meaningfulness of previous stress experiences through a two-step appraisal process. In the first appraisal in the study, feedback was spontaneously reacted on, while in phase two it was made sensible and given meaning. However, during the sessions, some obstacles appeared to managers’ learning about their stress, preventing a second appraisal of the feedback.

Conclusions. Awareness and continuous negotiation regarding boundary dilemmas can be effective as a proactive stress management tool among managers. Further, non-normative feedback on stress indicators may initiate key 3 processes of sensemaking which can aid managers’ stress management by increasing awareness and supporting learning about their stress. Proactive boundary awareness is a concept leading to better understanding of lower-level managers’ management of their time commitments and stress, which can be supported by continuous reflection, feedback situations and a supportive context.

Purpose: The purpose of this paper is to explore managers' boundary setting in order to better understand their handling of time commitment to work activities, stress, and recovery during everyday work and at home.

Design/methodology/approach: The paper has qualitatively-driven, mixed method design including observational data, individual interviews, and focus group discussions. Data were analyzed according to Charmaz' view on constructivist grounded theory.

Findings: A first step in boundary setting was to recognize areas with conflicting expectations and inexhaustible needs. Second, strategies were formed through negotiating the handling of managerial time commitment, resulting in boundary-setting, but also boundary-dissolving, approaches. The continuous process of individual recognition and negotiation could work as a form of proactive coping, provided that it was acknowledged and questioned.

Research limitations/implications: These findings suggest that recognition of perceived boundary challenges can affect stress and coping. It would therefore be interesting to more accurately assess stress, coping, and health status among managers by means of other methodologies (e.g. physiological assessments).

Practical implications: In regulating managers' work assignments, work-related stress and recovery, it seems important to: acknowledge boundary work as an ever-present dilemma requiring continuous negotiation; and encourage individuals and organizations to recognize conflicting perspectives inherent in the leadership assignment, in order to decrease harmful negotiations between them. Such awareness would benefit more sustainable management of healthcare practice.

Originality/value: This paper highlights how managers can handle ever-present boundary dilemmas in the healthcare sector by regulating their time commitments in various ways.

The documents and literature that regulate nursing education are based on certain values and knowledge, and the underlying power in the curriculum raises the question of how health care professionals are molded during the course of their education. Norm criticism is a concept with its roots in critical pedagogy and gender and queer studies, emphasizing the origins as well as the consequences of marginalization, power, and knowledge of what is generally accepted as "normal" and "true." Norm criticism is used in this article to analyze the documents and literature underlying a nursing program in Sweden, which are shown to include a sometimes politically correct rhetoric, but one lacking a firm basis in social justice values.

Purpose

Healthcare professionals' conscious or unconscious norms, values and attitudes have been identified as partial explanations of healthcare inequity. Norm criticism is an approach that questions what is generally accepted as "normal" in society, and it enables professionals to identify norms that might cause prejudice, discrimination and marginalisation. In order to assess norm-critical awareness, a measurement scale is needed. The purpose of this paper is to develop a scale for measuring norm-critical awareness.

Design/methodology/approach

The scale-development process comprised a qualitative item-generating phase and a statistical reduction phase. The item pool was generated from key literature on norm criticism and was revised according to an expert panel, pilot studies and one "think aloud" session. To investigate the dimensionality and to reduce the number of items of the scale, confirmatory factor analysis was performed.

Findings

The item-generation phase resulted in a 46-item scale comprising five theoretically derived dimensions revolving around function, consequences, identity, resistance and learning related to norms. The item-reduction phase resulted in an instrument consisting of five dimensions and 20 items. The analyses indicated that a summary score on the scale could be used to reflect the broad dimension of norm-critical awareness.

Originality/value

The Norm-critical awareness scale comprises five theoretically derived dimensions and can be used as a summary score to indicate the level of norm-critical awareness in educational contexts. This knowledge is valuable for identifying areas in greater need of attention.

Background: Nursing education in Sweden generally lacks norm-critical perspectives, even though this could help unveil normative judgements of patients in nurses’ daily work. To pursue work-integrated learning about norm criticism for nursing teachers at a small university college in Sweden, all teachers involved in nursing education were offered the course Norm-Aware Caring.

Aim: To describe how norm criticism in nursing education is constructed by nursing teachers’ discussions.

Methods: After the course Norm-Aware Caring, 20 of the participating 33 nursing teachers were interviewed in five focus groups about their reflections ontheir new knowledge. The interview transcripts were analyzed on the basis of Fairclough’s discourse analysis, in which words and social practice are seen as mutually constituting each other.

Results: Discursive constructions related to teaching, caring and learning were seen in the text. Norm critical teachingwas constructed as a practice of much consideration not to insult any student. Norm criticism as abasic caring valuewas closely related to person-centered care. Their own, personal learningwas expressed as fear to use their new knowledge in a wrong way. The teachers themselves considered norm-criticism as something to learn in order to improve the understanding of people who does not fit into majority norms. This perspective of tolerance was consistent in the construction of all discourses.

Discussion: It appears that the teachers’ social practice is influenced by a perspective that divides the “normal” from the “deviant”. This may prevent an internalization of norm-critical knowledge, a perspective that aims to question categorizationsofnormality. Therefore, it is important to continuously scrutinize and reflect over the role of social norms as part of work-integrated learning for nursing teachers.

Education is important in shaping professional identity, including how one approaches norms and normalisation. In the analysis presented in this study, nursing students' own constructions of norms and normality from the outlook of their education are highlighted and problematised. To deepen the understanding of these matters, the aim of this study was to explore constructions of norms and normality among students in nursing education. Students studying in a nursing department at a Swedish university college were approached and asked to consider open survey questions targeting their views on norms and normality; 154 of them replied. After a discourse analytic approach to the data, we could see how the students constructed norms and normality as (a) instrumental instructions, consisting of easy‐to‐digest statements grounded in the profession's obvious moral and ethical values, (b) limiting and frustrating obstacles for personal freedom that were important to challenge, (c) rules to be obeyed for the stability of society and (d) a matter of reflection, with each individual being responsible for understanding differences in norms, perspectives and opinions. We conclude that nursing education would benefit from norm‐critical perspectives, problematising students' own positions to norms, power and privilege.

This paper describes the discourses underlying nursing teachers’ talk about their own norm-critical competence. Norm criticism is an approach that promotes awareness and criticism of the norms and power structures that exert an excluding effect in society in general and in the healthcare encounter in particular. Given the unequal relationships that can exist in healthcare, for example relationships shaped by racism, sexism and classism, a norm-critical approach to nursing education would help illuminate these matters. The studied empirical material consisted of focus group interviews. Nursing teachers discussed their norm-critical competence based on the university course “Norm-Aware Caring” in which they had recently participated. Through a critical discourse analysis, three discourses were identified in their talk, all of which had the potential to disrupt traditional, normative nursing education. However, in all three discourses there was an underlying discourse of normality, clearly positioning the teachers as exemplifying the “normal.” The binary constructed between normality and otherness contradicts a basic tenet of the norm-critical approach and may hamper the development of genuine norm-critical competence in nursing education.

Bakgrund. Normkritisk kompetens är en förutsättning för att kunna ifrågasätta rådande, begränsande normer som skapar ojämlikhet. Att kunna mäta normkritisk medvetenhet är nödvändigt av flera skäl, exempelvis för att kunna identifiera kunskapsbehov eller utvärdera insatser. Idag finns dock inget vetenskapligt baserat instrument för detta ändamål.

Syfte. Studien syftar till att utveckla ett instrument som kan mäta graden av normkritisk medvetenhet.

Metod. Utvecklingen av instrumentet omfattade två faser: (1) generering och test av items samt (2) reducering av items genom konfirmatorisk faktoranalys. I den första fasen formulerades och testades validiteten i items genom expertbedömningar, pilotstudier och samtal med studenter, vilket resulterade i 46 items. I nästa fas analyserades dessa med konfirmatorisk faktoranalys i syfte att reducera instrumentet till 20-25 items för att få ett mer lätthanterligt instrument.

Resultat. Faktoranalysen resulterade i 20 items och fyra dimensioner. Dimensionerna var Normers konsekvenser, Att lära sig normer, Motstånd mot normer och Normers funktion. Det visade sig också att de fyra dimensionerna tillsammans mäter en bred dimension (normkritisk medvetenhet).

Diskussion. Utvecklingsprocessen reser frågor kring styrkor och svagheter med att operationalisera och kvantifiera kvalitativa fenomen så som medvetenhet om normkritik. Det utvecklade instrumentet kan användas för att mäta normkritisk medvetenhet i olika sammanhang, exempelvis effekten av normkritiska utbildningssatsningar inom högre utbildning.  

In the development of health promoting hospital organizations, 1st line managers hold a key position through their closeness to practice and integrated response-bility for practice, economy and staff. The purpose of this report is to contribute to the development of sustainable supportive structures that can strengthen managers’ own working conditions and their opportunities to balance their commitment and stress at work. The two studies describes managers’ (a) approaches to demarcations in manager practice, (b) perceived opportunities to communicate stress and problems in their organization, and (c) suggestions regarding how managers’ stress can be handled and how early signs of stress can be guarded in health care organizations. Each study started with qualitative interviews (n=10, n=6). Thereafter, the results were discussed with 1st line managers (n=71) in 13 focus groups, regarding interventions and changes.

Study 1. Strategies for demarcations between work tasks and life spheres were more or less flexible, firm, or permeable. They were characterized by different level of controlling and adapting to the present situation, others’ needs or one’s own needs. These strategies were seldom outspoken. Further, they were resulting mainly from personal experience, which made the managers ask for increased external support in boundary-setting regarding working conditions that were constantly changing and difficult to demarcate.

Study 2. Communication of stress within the organization was hindered be-cause the system was perceived to oppress problem descriptions. Fear was expressed that the higher levels in the organization considered lower level managers’ communication about their stress a failure. That could risk losing one’s reputation and career possibilities. One’s nearest manager was seen as the most important channel for meeting and managing stress. Surveys and other stress measuring methods require an open climate to handle the information received, and that actions are taken to address potential problems.Focus groups. Supportive structures that can improve managers’ own working conditions and their opportunities to balance commitment and stress at work concern:

• Possibilities for communicating stress and problem descriptions through elaborated “manager to manager”-dialogues; rewarding communication of problem descriptions in the line organization; dialogue-based development projects to influence values and culture; and an overview over the recruiting process in practice
• Efforts to increase one’s self-awareness and handling strategies through supervision; room for recurrent dialogues with manager colleagues; and health status dialogues with occupational health service that address individual sustainability in the manager work
• Clarity regarding responsibility, resources and guidelines for manager responsibility in the organization; increased direct support by resource functions; and a recruitment process permeated by a health promoting perspective

Results from this report can be used as knowledge base when formulating policies and plans for actions in order to prevent, discover, and adjust stress and exhaust-tion among managers in public health care organizations.