Work, psychosocial work environment and wellbeing among district nurses in the county of Stockholm, Sweden and in the county of Zagreb, Croatia

Abstract: This thesis uses longitudinal and cross-sectional comparative studies to explore the relationship between work contents, psychosocial work environment and wellbeing among district nurses during periods of reorganisation of the primary health care in Sweden and during periods of peace and war in Croatia. The goal is to increase knowledge about psychosocial work environment and sources of stress among district nurses. Four different groups of female district nurses were studied. Papers I-III present analyses of a stratified random sample of 61 district nurses in Stockholm County, who were organised in three different ways. They were studied with questionnaires, physiological and biochemical measurements four times during 12 months in 1985/86 during a process of change of the primary health care, mainly due to the introduction of primary health care teams. Although district nurses in the primary care teams had a lower objective workload compared to district nurses in traditional models, they reported more problems and conflicts, which however decreased, possibly an adaptation to new tasks and a redefined role. In the whole group of district nurses there was a deterioration of the psychosocial work environment on the fourth measurement occasion, accompanied by small but significant elevations of cholesterol, triglycerides and calcium. There was no significant interaction with age or smoking status. Analyses revealed that the menstrual cycle phase did not have any influence on the findings. Paper IV makes a comparative analysis of 236 (out of 768) district nurses in the county of Stockholm and 69 (out of 81) district nurses in the county of Zagreb, both groups working with individual responsibility for all aspects of nursing care, besides health promotion and prevention. The district nurses in Stockholm surveyed in 1992/93 experienced another kind of reorganisation with the introduction of the family physician system, economic incentives and privatisation. The district nurses in Zagreb were surveyed during peacetime in 1989/90 before the phase of radical reorganisation from a socialist system to a capitalist market economy. District nurses from both countries reported high levels of job satisfaction as well as high levels of stress. There were other similarities in self-perceived psychosocial working environment. Organisational sources of stress were of importance for the district nurses from Stockholm, while the district nurses from Zagreb perceived a significantly higher level of lack of resources, higher demands but also greater control than their colleagues from Stockholm. Paper V. Forty district nurses from Zagreb were surveyed a second time in 1994/95 during wartime conditions, showing small differences in various psychosocial variables compared to the 41 district nurses who only were surveyed in 1989/90. Of 39 sources of stress, 31 were higher during war time conditions. The perception of control and demand did not change, although job dissatisfaction increased. Conclusion. These district nurses have a comparatively high job satisfaction, although they perceive their task as demanding and often stressful, not least during reorganisations decided by others. They seem to have high endurance and considerable coping skills. These personal qualities, together with social support from the family and at work and a high degree of autonomy, may explain their high level of job satisfaction and commitment despite deteriorating work conditions. The role of the district nurse as competent professionals could be better considered in the health care with its greater emphasis of out-patient care of high quality, not least in the future.