Variation,companionship and manageability important for recovery during working hours: A qualitative focus group study

1.1 Aim

The aim of this study was to explore the concept of recovery during working hours, as described by the employees working in primary health care.

2.1 Setting and participants

This qualitative study is part of a greater project exploring recovery during working hours. The project was directed to the employees of 26 primary health care centres (PHCCs) of one health care district in southern Sweden and included focus groups, an intervention and a quantitative sub-study. Information about the current part of the project was given personally to all the managers and owners of the health care centres, mostly by attendance at a general meeting, otherwise by personal visits to their centres. The managers and the owners had to give notification if their PHCCs were interested in participating in this part of the study.

Focus groups were chosen as an appropriate method to explore the variety of experiences attitudes, perceptions and opinions of the employees. The dynamic in such groups can also give rise to new perspectives, and a more fundamental understanding of the research area [22].

The Swedish concept of primary health care implies that different professions work together and collaborate at the health care centres. Participants therefore represented all different professions in primary health care, i.e. physicians, paramedical staff, nurses and administrative staff (Table 1). Managers and owners were not included in the focus groups. Among the PHCCs which had expressed any interest in taking part in the focus group study a selection was made to ensure that urban and rural, as well as public and private, PHCCs were included. Consideration was also given to the results of a previous questionnaire study at the same centres about positive work factors [21]. Centres with both high and low scores on experienced recovery were included, which was represented by the question I feel I get time for recovery during working hours.

Focus groups were conducted at eight different PHCCs, one focus group at each centre. Altogether 50 employees, 44 women and six men, took part in the focus groups with five to eight persons in each, and all groups were mixed as regards sex and profession. Most of the participants had long experience of health care work. Their prior, or current, well-being was not taken into consideration.

Two of the authors, LE and BH, conducted the focus groups, which all took place at the PHCCs. One of the authors had the role of moderator and led the interviews according to a semi-structured interview guide with questions like: “What does the term recovery mean to you?” and “What is needed for you to experience recovery?” The questions emerged from a prior quantitative study [21] that showed the importance of recovery connected to self-reported health. Depending on the discussion, clarifying questions could be asked to get a deeper understanding of the employees’ own experiences of recovery during working hours. The other author acted as an observer while taking field notes. The interviews were recorded with a digital voice recorder and transcribed verbatim by an experienced secretary.

2.3 Analysis

The analysis was inspired by systematic text condensation according to Malterud [23] and was conducted by LE, BH and AB. Initially the entire transcripts were read separately and repeatedly by the three researchers in order to get an overview of the contents. In the next step preliminary themes were identified and text according to these marked.

In the next step smaller text units with similar contents were identified and labelled with codes. Thereafter, codes were merged into broader categories and subcategories. Finally the categories were compared to the original data.

The researchers met on several occasions and all preliminary themes, codes, categories and subcategories were discussed and revised until consensus was achieved.

In the results section, quotations are identified by a number after the quotation, denoting which interview it was expressed in.

2.4 Ethics

The study was approved by the Regional Ethical Review Board in Lund (2015/490). The participants were given oral and written information about the purpose of the study, the voluntary nature of participation, the guarantee of confidentiality, and their right to withdraw from the study at any time. They gave written consent to participation at the time of the focus group.

The primary health care workers found that the variation in their work gave them a feeling of recovery. Sometimes they needed a break with the possibility to rest, but often the variation, i.e. their work not being monotonous, was enough. The three subcategories were: location, tasks and tempo.

The first subcategory was location. Changing your workspace or, as the physiotherapists described it, completely changing the surrounding environment by, for example, accompanying a patient to the gym, were enough to feel recovered.

The second subcategory on variation was tasks. If one of the employees, for instance, had been on the phone talking to patients all morning, it was enough to change work tasks for a while to experience recovery and to be ready to continue what you were doing or to take on a new work task.

Tempo was the third subcategory. The participants highlighted that changing the work pace, not giving their all at all times, could give them the recovery they needed to manage an intense day at work.

3.2 Companionship

The social parts of work, i.e. having friendly co-workers, having fun together and being part of a team, were reported to be of great importance for the employees’ recovery experience. The four subcategories were: helpfulness, appreciation, social chat and laughter.

The first subcategory was helpfulness. The importance of an open atmosphere was described, where different professions can consult and help each other across their professional boundaries. Working as a team made the employees feel recovered.

Appreciation was the second subcategory. Most employees stressed that giving each other positive appreciation and feedback were important factors related to the recovery process. To show appreciation towards your co-workers could be anything between giving a compliment and bringing a homemade cake to the coffee break.

The third subcategory of companionship was social chat. It is not enough to connect on a professional level, but a key is also to get to know your co-workers outside “the white coats”, as one of the employees described it. Often it is that short meeting, like a chat in the corridor, which gives a feeling of recovery.

The fourth subcategory was laughter. The participants across all focus groups spoke at length about the importance of laughter and a humorous atmosphere. Being able to laugh at work gave them positive energy and made them feel recovered on a daily basis.

3.3 Manageability

To have a work situation that feels manageable was important for being able to feel recovered. It was about being in control of and exerting influence on one’s work, as well as having a sense of structure in all parts of the work. The five subcategories were: completion, satisfaction, influence, control and reflection.

The first subcategory was completion. The employees highlighted that it was important to begin, carry out and complete each work task to feel recovered and be able to start fresh on the next task. Multitasking or being interrupted in the middle of a moment of flow could therefore disrupt the possibility of recovery.

Satisfaction was the second subcategory. The participants described the satisfaction they felt when they managed to perform successfully, and how it affected their chances of feeling recovered after the work was done.

The third subcategory was influence. Autonomy concerning one’s own work was an important factor to the employees. Also, having some degree of influence on the organisation was mentioned as being connected to recovery possibilities at work.

The fourth subcategory of manageability was control. They described how having an overview of the situation, i.e. knowing what to do and what to prioritise, could make them feel recovered.

Reflection was the fifth subcategory. The participants reported that there are two types of reflection: self-reflection and reflection with others. The essential thing is to toss your thoughts about a situation that has occurred, either with yourself or with your co-workers. According to the interviewees this is a way to recover.

4.1 Main findings

Three main categories emerged when exploring the concept of recovery during working hours: 1) variation, 2) companionship and 3) manageability. All three categories interact with each other and are, at various levels, prerequisites for recovery. We have not found any other available literature concerning this aspect and it can be considered as a novel finding.

It is important to point out that it is the employees’ experiences of recovery that is the basis of this study. The participants described how their work entailed many different opportunities for recovery, but there was not enough time or knowledge to accomplish them in the daily work. The workplace culture and atmosphere were significant factors for giving the employees possibilities to recover.

4.2 Variation

The results of the present study suggest that variation can contribute to recovery. Already in the 1930s, Sechenov [24] advocated that all types of distracting activities, both mental and physical, would have a positive impact on recovering from exhaustion. Also, the results of a controlled experiment study suggested that mental tasks in between tiring physical work, i.e. doing something else, may be more effective than passive breaks in terms of feeling recovered [25]. In our study the participants mentioned both variation in tasks and tempo as influential aspects for recovery.

Variation in terms of location change was another important factor in feeling recovered in our study. In a recent Swedish qualitative study [26] concerning general practitioners responsible for patients at nursing homes, the participants expressed satisfaction with the variation they got from leaving their regular workplace for a period of time.

4.3 Companionship

Appreciation was found to be an important factor for experiencing recovery at work in our study. This is in line with a previous study which found appreciation to be one key factor in psychological and physical well-being and successful performance in the workplace [27]. In this study it was stated that expressing appreciation to others builds social bonds, may help employees feel valued, and enhances motivation and desire to help others. During the interviews there was much talk about the positive value of joy and laughter, which made the workday easier. Laughter is believed to act as a coping mechanism to reduce stress, to improve self-esteem, to moderate the impact of stressful events on mood states and to improve the ability to relax [28, 29]. Also, humour plays an important role in helping individuals to bond and to signal cooperation [30, 31]. A previous study showed that, when setting a healthy work climate, an essential factor was that the manager made sure that the employees enjoy their work in a humorous atmosphere [32]. Our findings confirm that joy and laughter is important in everyday work. It is a method to bond and it increases companionship, makes work easier, and contributes to the feeling of recovery.

Communication and good social support have been found to be the strongest factors for a healthy work environment [33], which corresponds well with the results found in this study. When studying communication in primary health care teams it was found that team attributes such as approachability, availability, and proximity facilitate communication [34]. It was also shown that informal communication was the most prominent method of sharing and transferring information about patient care. However, in our study the employees considered the informal talk about something other than work valuable for the feeling of recovery. Also, cooperation and working as a team was found to help the participants to feel recuperated. Besides the possibility to help each other within their own profession, they could relieve each other between the different professional groups. This assumes good communication skills and knowledge about the different members’ daily working tasks, which was reported by the participants as well as found in earlier studies [35].

4.4 Manageability

The notion of manageability connects the results of this study to the theory of salutogenesis propounded by Antonovsky [36], comprising the three components comprehensibility, manageability and meaningfulness. From our data we identified several aspects of manageability. The importance of being able to complete tasks was convergent with the results of Aronsson et al. [37]. In the same study, the importance of being able to achieve a satisfactory quality with your work was emphasised, which is in line with our results of the significance of experiencing the work as successful. Nilsson et al. [2] conclude that much could be won by reducing time-pressure, enabling prioritisation between work tasks, and facilitating recovery during the work day. To have an influence on resources or quantity of work is also mentioned by Aronsson et al. [37] as an important work condition. For the subcategory influence, our results were in line with the results of a study on hospital physicians indicating that having an impact on working schedules could partly compensate for a heavy workload [38]. Also, a study on hospital employees showed that enhancing participation in decision-making could increase job satisfaction and affect having a positive work experience [39].

Being “on top” and feeling a sense of control over the situation was mentioned as an important factor for recovery by the participants in the present study. High demands and lack of control at work was shown to harm the physiological recovery outside work in a previous study [40]. The current study underlines the importance of reflection to feel recovered, which can be connected to a study which demonstrated that the group defined as recovered reported significantly more time for reflection [37].

4.5 Strengths and weaknesses of the study

The focus groups were conducted in quiet and secluded rooms at the participants’ own PHCCs. This created a setting with a relaxed atmosphere to make the participants comfortable to talk about their experiences on a more personal level. Since participation was voluntary, it can be assumed that the participants had potential to be both relaxed and open to talk.

The participants were a large group of primary health care workers with different professions, i.e. with diverse experience. Also, it was both males and females in different ages, which further increased the transferability [41]. Only 12% of the participants were male, which created a gender imbalance in the group. However, in Sweden there is a predominance of females among primary health care workers, which makes the distribution of our participants a reflection of reality. In the current health care district, 86% of the primary health care employees are women [21].

The four authors have different background experiences, which was important when conducting the data collection, the analysis and the writing of this article. The corresponding author works in the field of public health while the three co-authors are general practitioners. One of the co-authors, with primary health care work experience, was chosen as an observer during the interviews. When conducting the analysis, the researchers viewed and discussed the material in every step of the process to complement each other’s interpretations in order to achieve trustworthiness and credibility [42].

When conducting a focus group interview, there is a risk that the participants feel inhibited about telling the truth in front of their co-workers. However, the interviews did not concern any sensitive topics and participation was voluntary. This probably made the employees who were not open to discuss their experiences on recovery decline participation. Consequently, the possibility of selection bias and missing out on important point of views is a fact.

We acknowledge the problem of any power dynamics that may occur during focus group interviews. However, we look at each primary health care centre as one unit, without making a distinction between the different professions. With this starting point, using mixed professional groups was important. Also, in Swedish primary health care, various professions work together as a team, with a less hierarchical structure than in many other countries. In addition, two points should be mentioned: managers and owners were not included, and the moderator had no previous relation to the participants. The benefits are therefore considered to outweigh the risks.