Table 3 Final coding template of interview data, differentiated by organizational level, with quotes to illustrate organizational discrepancies

1. Strenuous work situation for HCWs

1.1 Time pressure

HCWs:

Main stressor, Increasing

“It is the time pressure that wears us down, terribly. Yeah, it is tearing on us – it is the worst part, the absolute worst”.

UL:

Main stressor, Increasing

“Some say there is more time pressure and stress now compared to how it used to be. That is probably correct, too”. “The time pressure is at the sacrifice of care. You calm and make people feel safe by holding their hand, so we (HCS) are probably heading in the wrong direction…”

ML:

Improvement expected, cultural problem

“’We have never run so fast before!’ - this is a phrase, like many other expressions that are often incorrect”. “My experience is that a culture revolves around the focus on time pressure, a so-called ‘enjoying the misery’-culture”.

ED:

No objective reason

“The HCWs complaining over more time pressure… It makes no sense. It is part of ‘the game’”.

1.2 Indirect task demands

HCWs:

Increasing amount

“Well, we have all these requirements directed at us, a lot more now than it used to be, about documentation and all kinds of stuff we must register and – we’re not able to do half of what we are supposed to…”; “It is at the expense of the patients, we need to take the time from somewhere, and then we steal it from them”.

UL:

Increasing amount

“There is an increased demand of indirect tasks. It is very time-consuming, and we need more time (to accomplish these tasks)”. “We are required to spend 72 % of our workday on direct patient-related activities, but we can’t manage to do that. With all these indirect tasks, there is no chance”.

ML:

Increased internal control

“There are no reasons for an increased need of time to indirect tasks (…) The requirements of documentation today are the same as previous years, but the internal control is stricter. The follow-up is tighter now. And will be getting even tighter”.

ED:

Increased indirect time

“We see a registered increase in use of indirect time, but we don’t know whether this is due to an increase in indirect work tasks or as a consequence of improved registration”.

1.2.1 Work programs

HCWs:

New work tasks, time-consuming

‘More time-consuming, more documentation’. ‘A lot more responsibility and additional tasks’†

UL:

Time and money-consuming

“’The program’†† was not supplied with any resources; it is eating up our time – tremendously. This is an example of a contradictory pressure between demands and results, in which we are decreed a lot of tasks, and not even a penny comes with it”. “This steals a lot of time and resources. Compulsory attendance here and there – this goes off our budget, but we have no choice”.

ML:

Improved quality

“If they follow the checklists they will feel confident in doing their job. This is quality assurance”. “By doing it correct the first time they won’t have to do things twice”.

ED:

(neutral)

“When they (ML) implement work programs, they must think that there is a gain to it. Maybe they (HCWs) think it is additional work”.

1.3 Organizational changes

HCWs:

Source of work strain

“There have been some organizational changes, you know, and it tears on us – When they start with all that, I’m just like: AGAIN!?”.

UL:

Increased sick leave

“We had high sick leave for a while after the merger, and I definitely believe it was related to the merger and the subsequent effects; these things affect people; new routines, everything must be changed. It caused a lot of commotion, and it took some time before we were back on track; Even after 6 years it is still ‘them and us’, they are sitting on each side of the table”.

ML:

Change is inevitable

“The nature of the home care services is to deal with changes and adjustments. That is home care”. “There are some myths out there; that organizational changes are terrifying. I believe it is crucial to adjust the organization”.

ED:

N/A

N/A

2. Economy

2.1 Budget model

HCWs:

Unfair model (time)

“I can drive 60 km and more during my evening shifts. It is NOT taken into account. Transferring is not taken into consideration on our work lists. We have protested against that many times, we think it is HIGHLY unfair!”

UL:

Incorrect model (money)

“The budget model is not right. This district deals with a lot of psychiatry and since they are in good health physically, they score a very low ADL. They generate no money. It is wrong!”. “The real world is different from what the budget model tells us”. “A lot of the new work tasks are of indirect character not taken into consideration as they don’t generate any money”.

ML:

Improved model

“We have been working very well for a long time on quality assurance and budget allocation based on patient weight; they get more resources if patient cases are heavy. We have a GOOD allocation of the resources available”.

ED:

Misunderstandings on lower levels

“I can imagine this being a matter of discussion between the HCW and the unit leader. It seems to me that there are some misunderstandings of the model out there…”

2.2 Budget allocation

HCWs:

Poor economy, less money allocated

“You are told that the budget situation is getting worse and worse. And you are told that you have to do more and more in less time. It affects you, you feel; Ok, fine, there is a limit for – yeah – for what you can handle”. “Will there be directed even more requirements on us? I cannot run any faster and do my job any faster just because the council is short on money. It will make me ill, so I cannot do that”.

UL:

Tight budget impossible to comply

“We notice a tightening, and we are under more supervision now. Now we have to hand over monthly reports about the financial condition”. “It is an invariable requirement that we stick with our budget. But we haven’t managed that. That is serious business, oh my, I think it’s horrible”.

ML:

Increased allocation

“I believe many employees would say things have gotten worse, but that is just nonsense if you look at the budget increments”. “The budget allocations up till now have actually increased. We have objective figures that tell us that”.

ED:

N/A

N/A

3. Coping strategies

HCWs:

Stress-reducing and time-managing

“We steal time from the patients (…) Or else we wouldn’t make it”.

UL:

Reducing expenses

“My main goal has been to reduce excess spending”.

ML:

Improving quality

“There is an increase in patient load. Patients return home sooner, in a worse condition. I believe that if they (HCWs) focus on following the checklists in the work program ††, they are safe”.

ED:

N/A

N/A