Experiences of job demand and control: A study of first line managers in for-profit psychiatric and addiction care

Abstract

BACKGROUND:

The complex position of a first line manager is characterized by heavy workload and contradictory demands. Little is known about how first line managers experience demand and control in their work.

OBJECTIVES:

The aim of this study was to explore experiences of demand and control among first line managers within psychiatric and addiction care.

METHOD:

In the present study, interviews with ten managers in for-profit psychiatric and addiction care in Sweden were analyzed with a phenomenographic approach.

RESULTS:

The managers experiences of demand and control implied varied and extensive responsibilities for a wide range of professions; regulation by organizational, economic, and political frameworks; creating balance in their work; and handling the emergence and consequences of acute crisis. These experiences of demand and control involved high and contradictory demands together with coexisting high and low levels of control. Many of their work characteristics could be described in terms of both demand and control.

CONSLUSION:

The first line managers experiences of demand and control are more complex than implied by the job demand control theory. Our results suggest that the organizational position and branch should be considered when identifying health hazards in the work environment of first line managers.

Keywords

Managerial position job strain for-profit care interviews occupational health

1 Introduction

Conflicting and expectations from superiors, clients, and case holders demands have been found to result in limited control over work for first line managers (FLMs) in health care. Extensive laws and guidelines governing the content and execution of their work adds further complexity to these FLMs’ work situation [1 –8]. FLMs are located in between upper management and subordinate workers; a position that generally implies a result-oriented monitoring role involving responsibilities for planning, scheduling, allocation, prioritization, reporting, and managing the work performance of subordinate workers [4 , 10]. The health care FLM is also responsible for unit budget and financial results [4 , 9–11]. The role of the FLM is sometimes described as ‘performance-oriented supervision’ [4]. FLMs respond on a daily basis to a broad range of professions including doctors, nurses, and human resources staff, as well as superior managers, subordinate workers, and patients and their families [2–4 , 11]. They thus face high demands for efficacy in the management of a wide range of organizational matters [1 , 12]. Nevertheless, their position at the bottom of the managerial hierarchy means that FLMs have restricted formal responsibilities for subordinate workers as well as for the maintenance of quality of care [2 , 11]. In fact, being a FLM has been described as particularly challenging as compared to superior managerial positions [2 , 12]. According to Karasek’s [13] and Karasek and Theorell’s [14] job demand control (JDC) theory, such work conditions could be characterized as a high strain job, which brings the possibility of work-related health risks such as stress.

1.1 Job demand and control

According to the JDC theory [13, 15], a high degree of control over work in combination with a low degree of job demand will reduce stress (a low-strain job), whereas a low degree of control combined with a high degree of demand will increase stress (a high-strain job). Moreover, high control combined with high demand is proposed to increase learning (an active job), while low control combined with low demand is classified as a passive job [13, 15]. Demands are defined as both psychological and physical (e.g. intense concentration, fast work pace, and lifting heavy loads) [15, 16]. The control dimension consists of two sub-dimensions: skill discretion (e.g. if the job is repetitive, requires creativity, or gives opportunities for learning new things) and decision authority (e.g. if the job allows the person to make their own decisions). In the late 1980s, social support, defined as social resources providing support from colleagues and/or supervisors [14, 16], was added as another factor that buffers the negative health effects of high demands, thus creating the Job demand control and support (JDC-S) model [17].

The JDC-S model has been found to explain variance in a wide range of health outcomes [10 , 18–24]. Nevertheless, many studies fail to confirm the hypothesis that follows from a deduction strictly close to the theory [10 , 25]. One proposed explanation for this is that the definitions of demand, control, and support are too narrow [18 , 25]. The model has also been criticized for not including aspects of the work-related social and contextual surroundings, which elsewhere have been found to be of importance for work-related health issues [10 , 23]. Baker et al. [26] found that the association between control, support, and stress differed depending on the respondent’s place in the organizational authority structure. In a similar manner, Kim et al. [27] argued that the characteristics of certain occupations and industry interact with the organizational authority structure and as such give rise to different types of experiences of job demand and control.

In order to gain a deeper understanding of the work situation of FLMs in health care, and the high levels of stress that have been identified among them [1–4 , 29], there is a need for a qualitative study of how FLMs conceive of job demand and control in their work. The aim of this study was therefore to explore experiences of demand and control among FLMs within psychiatric and addiction care.

2 Method

2.1 Design

In order to capture the context of how FLMs conceptualize demand and control at work in the context of psychiatric and addiction care, this study used a qualitative design with a phenomenographic approach. Phenomenography is rooted in phenomenology [30], however while phenomenology aims to identify the essence of individuals’ lived experiences [31, 32], phenomenography has an explicit focus on variation and difference in experiences of a certain phenomenon [31, 32]. Thus, phenomenographic studies seek to understand the different ways in which people experience phenomena in their surrounding world [31], in order to describe differences and nuances in people’s experiences of a certain phenomenon as well as their conceptions of reality as it is experienced in the context in which they participate [31]. The results of a phenomenographic study comprise a set of descriptions of people’s various lived experiences, ordered in categories showing the variation (within and between individuals) in ways of experiencing a specific phenomenon or circumstances [31].

2.2 Participants

The study participants comprised a convenience sample of 10 FLMs from privately operated psychiatric and addiction care clinics in Sweden. The gender distribution (seven women and three men) was considered to be representative of the gender distribution among FLMs in the participating company. The participants had different educational backgrounds and included assistant nurses, registered nurses, cognitive behavior therapists, addiction treatment assistants, and social workers. They worked at departments focusing on adult care with patients from age 18 suffering from several comorbidities and substance abuse problems. Their experience of being a FLM ranged from a few months to about 10 years, and their span of control varied from 5 to 60 subordinates.

2.3 Data collection

An e-mail with an invitation for participation along with a description of the study aim was sent to the human resources department of a private for-profit care company. The department director forwarded this invitation to all of the unit managers in the adult psychiatric and addiction care units. Unit managers who were interested in participating received extended information regarding the study aim and study design via e-mail. These unit managers then asked all their FLMs if they were willing to participate in the study, and 10 FLMs registered their interest by responding to the first author by e-mail. To ensure that the Swedish Research Council’s ethical guidelines [33] were met, the 10 participants were informed about confidentiality, that participation was voluntary, that they could withdraw at any time, and that they had the right to receive copies of their interview. All FLMs’ gave written and verbal consent to participate before the data collection started. Nine interviews were held in person at the FLMs’ worksites, and one was conducted via telephone. The interviews lasted from 22 to 47 minutes and were recorded and transcribed verbatim by the first author.

The interviews followed a semi-structured interview guide with four focus areas with questions considering FLMs’ experiences of demand and control in relation to their managerial position, work characteristics, superior management and subordinates.. In order to avoid leading questions, the specific words “demand” and “control” were replaced by the concepts of responsibility, challenges, and expectations (demand); and possibilities, ability, and exercising/performing (control). These words have been used in previous research to define the content and meaning of the demand and control dimensions of the JDC model [13 , 34].

2.4 Data analysis

The analysis was conducted by the first author in accordance with the procedure set forth by Sjöström and Dahlgren [32]. In the first step, familiarization, the transcribed interviews were read several times. In the second step, compilation, all of the answers to each question were compiled and the most significant statement in each answer from the respective informants was identified. In the third step, condensation, the answers were reduced to their main constituent parts. In the fourth step, grouping, a preliminary grouping of similar answers was performed. In the fifth step, comparison, a preliminary comparison of categories was constructed. This was followed by the sixth step, naming, in which the categories were labeled. Finally, the seventh step, contrasting comparison, consisted of the process of defining the unique character of each category as well as the similarities between them. This process ensured that the categories that emerged from the analysis consisted of the informants’ most clearly pronounced experiences of demand and control related to their position as a FLM and to the organizational context.

3 Results

The analysis resulted in four collective conceptions describing the experience of being a FLM in private psychiatric and addiction care. This position (1) implied varied and extensive responsibilities for a wide range of professions, (2) was regulated by organizational, economic, and political frameworks, (3) implied the ability to create work balance, and (4) implied the ability to handle the emergence and consequences of acute crisis. Below, these conceptions are presented through categories describing the nuances and variations between each collective experience.

3.1 Varied and extensive responsibilities for a wide range of professions

The first collective conception was represented by three categories: extensive responsibilities, the importance of knowledge, and responding to requests.

3.1.1 Extensive responsibilities

The implications of the FLM position were experienced as wide and extensive. The informants described how they held both an internal and an external responsibility for their organizational unit, including both detailed and overall responsibilities. Their internal responsibilities included leading their organizational work unit, while external responsibilities included the monitoring of surrounding competitive organizational activities and threats. Detailed responsibilities included regular contact with caseworkers and performing work quality inspections, while overall responsibilities were related to aspects such as handling the organizational unit budget. The informants summarized the experiences of their comprehensive work content as being responsible for everything:

My role is to lead the operations, to make sure everything keeps flowing. Full responsibility actually for accounting, HR, the content of the operations, properties, food –everything. [...]get everything to work according to plan –the budget has to work and staff must be content and engaged in their work and the conditions surrounding it. Clients must feel happy –they need to feel they will receive the assistance to which they are entitled under the placement agreements we have with the case holders. (Informant J)

3.1.2 Importance of knowledge

The FLMs managed a wide range of professions. As well as the workers in the operative core (e.g. assistant/registered nurses, treatment assistants, social workers), they also monitored the organizational units’ service structure including cleaners, janitors, and canteen staff. Above this, the FLMs provided the cooperative support functions (e.g. human resources, finance, and IT) with information concerning, for example, salaries, sick leave, and maternal leave. The informants highlighted the importance of possessing enough knowledge to be able to lead, support, and provide the right information to all their subordinates in their unit. However, they considered it more or less impossible to actually hold all the necessary knowledge, and explained that this knowledge could not always be found at a superior organizational level either. Consequently, the informants experienced it as difficult to possess sufficient knowledge to fulfill the responsibility that the FLM role entailed:

[...] And when we get to issues I’m not familiar with, such as renovations and other things that you get drawn into. And my immediate supervisor is not always familiar with the issues either. But that’s where it can be difficult to think that “Yeah, but this I can deal with on my own”. (Informant L)

3.1.3 Responding to requests

The FLMs served as channels and spokespeople for their superiors as well as their subordinates, and also responded to questions and requests from clients and case holders. The informants described their opportunity to respond to all these parties as a trigger for work task conflict. Each party considered their own questions, requests, or problems as the most important, and paid little or no attention to the FLMs’ other requests and work duties. The FLMs saw the ability to prioritize among all these different requests as one of their most challenging and difficult work tasks:

[...] it’s about getting everything to work together...client preferences, central operations’ preferences, staff preferences and requirements –balancing them all somehow...You can’t please everyone, but even so, the operations have to work smoothly, so I have to try to help out as much as possible, so we end up doing the best we can do. (Informant C)

3.2 Regulation by organizational, political, and economic frameworks

The second collective conception was represented by one category: work regulations.

3.2.1 Work regulations

The informants repeatedly used the word framework in a symbolic way to describe their possibilities to act, to affect and/or change the organizational properties, and/or to contribute to the organizational development. They considered their organizational position to be strongly affected by the laws and guidelines regulating private psychiatric and addiction care. Above all, these regulations affected their decision latitude over their subordinates in their organizational work unit (see Informant L, below). The organizational unit budget was also a part of this framework, and was described by the informants as both a natural part of their work in private for-profit health care and a constraint on their ability to offer their subordinates work development, for example through education.

As our external framework, we are governed by legislation in many ways, and there are rather a lot of laws. Within that framework lies another, in which management draws up its guidelines and policies and routines that we have to comply with. And then, within that framework is the innermost framework, where I have my freedom to act. (Informant L).

3.3 The ability to create work balance

The third collective conception was represented by two categories: creating work boundaries, and conditions for delegation.

3.3.2 Creating work boundaries

The informants used a coaching rather than a controlling leadership style. However, their ambition to create independent and solution-oriented work groups collided with their subordinates’ requests for a more governing and controlling leadership style.

In part, the informants explained this experience as a consequence of the FLMs’ availability due to their physical placement in the organizational unit facilities. This availability contributed to their subordinates preferring to ask for help rather than trying to solve work-related problems on their own. Because of this, the informants described constant interruptions in their daily work, which affected their other work duties, especially their administrative work tasks. An important prerequisite in order for the FLMs to carry out all their work tasks was therefore the ability to create boundaries for their subordinates:

It (the physical placement of the office space) can be a limitation when I need some distance, when I need time to reflect about things that have happened. My office is wall to wall with the operations and it is very easy for people to go in and look for me. [...]The proximity is both a help and a hinder. (Informant E)

3.3.3 Conditions for delegation

The informants’ capacity to handle all the work tasks assigned to the FLM position was dependent on their ability to delegate. They experienced a feeling of resistance against delegating their responsibilities to the assistant manager or to the subordinates in their unit work group, because they held the primary responsibility for all the work performed in their work unit. They felt the opportunity to delegate was meaningless, because even if they did delegate and someone else performed the work tasks they still held the final responsibility. Therefore, rather than taking the blame for someone else’s mistakes, which would possibly imply an even heavier workload, the FLMs preferred to do everything by themselves:

[...] and isn’t just management’s expectations, it’s everyone’s expectations. Which no doubt makes it sometimes difficult for me to let go of control in my leadership, because it’s like there’s always somewhere...When things are going to hell, it falls to me to deal with it, so it’s better to have control over the situation all the time. (Informant L)

3.4 The ability to handle the emergence and consequences of acute crisis

The fourth collective conception was represented by two categories: performing leadership in crisis, and handling sudden workload.

3.4.1 Performing leadership in crisis

The informants described how their work environment entailed a constant risk for the emergence of acute crisis, including situations with elements of threat and/or violence, suicide attempts, and overdoses among clients. They experienced this risk as a natural part of their work environment in psychiatric and addiction care, and did not consider it to affect their work. Instead, the emergence of these kind of events usually resulted in stress reactions in the work group, which in turn created stress among the FLMs, as Informant C describes below. Their experiences of stress in these crisis situations were not a result of their subordinates’ stress reactions per se, but rather a consequence of the FLMs’ concern over how stress could affect their subordinates’ work performance.

[...] when clients exhibit aggression and substance abuse. This puts a lot of stress on staff and they will want to talk about it, which is great, but it also puts more stress on me. I’m not the person who can be out there with the staff –they have to figure it out, although I can support them: I can say “Okay, how should we set this up?” I sometimes find that stressful. Clients’ aggression and substance abuse –because it is a strain on staff, and then I have to interrupt everything else and try to regulate staff so they can regulate the clients. (Informant C).

In crises, the informants had to prioritize their clients’ needs over the needs of their subordinates, because clients were the source of the organizational income. Successful treatment of the clients was a prerequisite for keeping the organization’s “customers” (e.g. municipality case holders). The informants explained that if their subordinates failed to handle and treat the clients, this could be a potential threat to the organizational unit’s income. The subordinates did not always accept this prioritization, and the informants described how they experienced this forced prioritization as a source of conflict in their leadership. Due to this need to focus on the clients, the FLMs had only limited possibilities to support their subordinates during and after these crises.

3.4.2 Handling sudden workload

While the emergence of a crisis could cause experiences of stress, the FLMs expressed the aftermath of such crises as even more challenging. When a crisis emerged, the FLMs’ quantitative (administrative work tasks) and qualitative (leading and supporting subordinates) workload increased. After the crisis had abated, the FLMs had to handle several additional work tasks as well as their original ones. Because of this, the informants experienced crises as one cause of their heavy workload:

...it can take a whole week, ten days, before we’ve worked through some incident that has happened in a unit. And that kind of thing can sometimes feel like...“God, what kind of job is this?” [...] So those are the negative aspects of the job. Because however you look at it, at the end of the day I’m the one in charge –I cannot just go home. (Informant A)

4 Discussion

4.1 FLMs’ conceptualizations and the JDC theory

As shown above, the FLMs in this study conceptualized demand and control in relation to the specific context of for-profit psychiatric and addiction care. Here, the findings will be discussed in relation to the framework of JDC theory. The results revealed that demand and control could be categorized into four overall conceptions: varied and extensive responsibilities for a wide range of professions; organizational, economic, and political regulative frameworks; the ability to create work balance; and the ability to handle the emergence and consequences of acute crisis. The results included many examples of work characteristics that could be described in terms of both demand and control. However, it is not obvious that the analysis of the FLMs’ experiences of stress benefitted from applying the JDC model as a means for deeper understanding of the interplay between demand, control, and stress. As such, the results highlight some of the weaknesses that the JDC theory has been said to suffer from. This applies in particular to the matter of the universal validity of predefined demand and control dimensions across organizational contexts [35]. For instance, the FLMs’ descriptions of how they led various professions and had extensive responsibilities for a wide range of the operations showed that they had a great deal of formal decision latitude. This situation was nevertheless experienced as demanding, since they lacked the knowledge needed to be in control. This is, to some extent, congruent with Karasek’s [13, 15] theory that the control dimension is constituted by both decision authority and skill discretion. However, our findings makes the complexity, of the conceptualization of demand and control as two distinctly separated dimensions, visible. In this particular situation, it was the very lack of skills that was demanding, and so the lack of control was the source of demand. This certainly complicates the JDC model, in which control is thought to buffer the burden of high demand. Another example described by the FLMs regarding the difficulty of separating job demand and control resources was the importance of work regulations. By making it clear what is permitted, expected, and forbidden, the legal framework and the different policies and guidelines give guidance in work. As such, the regulative framework harbors the potential of giving the FLMs control. Nevertheless, the FLMs experienced this as something restricting their decision latitude, even though at the same time the regulations made it clear where their freedom of action lay.

This interlacing of demand and control was not only a matter of the work tasks per se. In some instances, it was the specific organizational position of the FLMs that shaped the preconditions for their experiences of demand and control. This was, for example, seen in the description of conditions for delegation. Although the FLMs were in a position which allowed them to distribute tasks and responsibilities further down the chain of command, and as such indeed be in control, they chose not to do so. They thought delegation was meaningless, since it was still they who had the final responsibility in relation to their superior managers. As such, this decision latitude was interfered with by the possibility of the high demand that would follow if the operation broke down due to poor subordinate performance. Thus, even though the FLMs had a high degree of decision latitude and skill discretion, their organizational position complicated their perceived possibility to make use of this control, partly due to fear of future high demand.

Contrary to what could be expected, unexpected events were not experienced as demanding in themselves. Rather, it was the type of leadership expected by their subordinate employees and the subsequent administrative tasks that were thought of as demanding. That is, crises occurring in the organization were described as being a source of both demand and stress. By virtue of their position, the FLMs had the authority to handle these potentially demanding situations according to their best judgment. It could be argued that having the decision latitude and skill discretion needed to handle the real-time tasks should make it possible to handle this kind of situation without stress. However, the FLMs appeared to lack the leadership skills needed in the aftermath. They also seemed to lack control when it came to handling the administrative burden. Lack of sufficient knowledge to fulfill the responsibilities that the FLM role entails could be interpreted as an instance of what Häusser et al. [25] refer to as matching demand and control; that is, the control that comes from being in a superior position with the authority to make decisions in the midst of a crisis does not seem to be of much importance in a time where such authority cannot solve the problems at hand. To some extent, the FLMs’ organizational position was also related to the demand and sudden increase in workload experienced during times of crisis. Due to being responsible for the bottom-line results of the private care company, the FLMs had to prioritize the clients rather than their subordinate employees in order to satisfy the customers (municipality case holders). This was experienced as an inner conflict in their work, which could be regarded as a form of demand.

Although the JDC theory aids interpretation of the present results to some extent, these results could also be said to add to the critique that has been directed at the theory [18 , 35–37]. The FLMs’ experiences of control seemed to be more complex than suggested by both the buffer hypothesis and the strain hypothesis. It seems possible for high and low control to coexist in this particular organizational position. As mentioned by De Jong et al. [38] decision latitude could itself be a possible source of stress, which seemed to be the case in the present study. That is, the experience of control does not necessarily equal either the decision latitude that a worker has over their tasks and behavior during a work day, or their skill discretion. The separation of demand and control in the JDC model [13] are followed by various results in empirical studies [15 , 25]. In this study, we were interested specifically in the contextualization of the concepts. The findings from this study illuminate the difficulty of separating demand and control as well as the trouble with defining demand and control as either supporting or aggravating.

4.2 Strengths and limitations of the study

The study design gave a broad picture of the conceptualizations among FLMs in health care by including women and men with varied experiences of being FLMs and different educational backgrounds. However, the findings and recommendations of this study should be interpreted in relation to the study’s strengths and limitations. Firstly, the results are based on interviews with FLMs in for-profit psychiatric and addiction care in Sweden, meaning that the findings relate to the situation in Sweden, to for-profit organizations, and to organizations dealing with psychiatric and addiction care. We cannot guarantee that the findings are transferable either to other countries or to other kinds of care.

Whereas the heterogeneity of the sample could be viewed as a strength, as it facilitates a varied and nuanced picture of the topic under study, it could at the same time be argued that a more homogenous sample would have facilitated a more focused and deeper understanding. The potential for such a shortcoming were however addressed in the planning phase of the study; in order to evaluate the relevance and clarity [39, 40] of the questions asked, the interview guide was tested in telephone interviews with four individuals representative of the study population who was not included in the final sample. The interview guide was then evaluated and revised in accordance with suggestions and comments.

A small and heterogeneous sample also gives a risk that the conclusions made by the researchers are more in line with the statements made by some individual study participants than others [39, 40]. In order to strengthen the conformity [40] of the research findings, the study participants were given the opportunity to read and comment upon the study before the article were finalized. Because the participants considered that the interpretations made in the study were consistent with their experiences, no changes were made in the study results.

4.3 Research implications

As shown here, the interplay between control and the specific qualities of the work characteristics that are imposed by the organizational position of an FLM seems to be the key to understanding. Such an interpretation is congruent with the work of Baker et al. [26], who found that the association between control, support, and stress differed depending on the respondent’s place in the organizational authority structure. In a similar manner, Kim et al. [27] argued that the characteristics of certain occupations and industry interact with the organizational authority structure and as such give rise to different types of experiences of job demand and control. From this, we agree with previous researchers that there might be a need to broaden the JDC theory and pay greater attention to the social and contextual surroundings when analyzing experiences of the work situation [18 , 42]. The fact that support for the relationship between demand-control and mental strain has been found to be weak in studies of homogenous groups of workers [19 , 44]adds further weight to the argument for paying attention to contextual factors [43 , 46] in future studies. There is a need for further investigation of the relevance of context and constant contextual changes.

5 Conclusions

This study has revealed conflicting demands and coexisting low and high levels of control, which can be understood as partially in line with previous research [10 , 47]. However, our findings illuminate how demands and expectations from superiors and subordinates sometimes conflict with each other in the specific context of the FLM position. We conclude that paying particular attention to the context can reveal many examples of work characteristics that could be described in terms of both demand and control. This would mean that the experience of work in complex contexts, such as different sorts of expectations and responsibilities in relation to a broad range of professions, patients, and families, cannot straight away be analyzed within the framework of the JDC-theory. Context specific details needs to be considered in order to fully understand what aspects of work that are experienced as demanding and what aspects are enhancing the experience of control. In practical terms, this knowledge could facilitate the prevention of work environmental risks related to job strain for workers with a FLM position in health care settings.

Footnotes

Acknowledgments

The authors would like to thank those who participated in this study.

Conflict of interest

None to report.

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