Aim: The aim of this study was to illuminate registered nurses’ (RNs) perceptions of Trust-Based Public Management (TBPM) in Swedish health care. Design: This study follows a phenomenografic approach guided by Ference Marton’s philosophy. Methods: Semi-structured interviews were used to identify variations in RNs’ perceptions of TBPM. Between February and April 2019, 24 RNs from five Swedish public healthcare departments participated in the study. Results: The results show that none of the participants had previously heard about the work of the Swedish Delegation for TBPM. The study revealed perceptions those politicians and managers were absent from the workplace, that power had been displaced to HR, and that perceptions of trust in the leadership and of working to guidelines varied. Perceptions varied between RNs employed by the municipalities and by the hospitals concerning administration, the time allotted for work, cooperation, and education.
With New Public Management (NPM) came the idea that public organizations should be led by professional managers, referred to as new managerialism. This study explores how new managerialism affect professional autonomy and the trust based public management (TBPM) in a public organization. Based on the findings from this study, Registered Nurses (RN) highlights the importance of shared governance if the quality of care is to be delivered.
The term NPM came from the private sector to the public sector in the early 1990s. NPM works as a role model for the public sector in terms of governance, leadership, and economic restraint where work discipline is prioritized. NPM was coined by scholars from UK and Australia who were working in the areas of public administration [
Much has appeared in the literature about trust between RNs and patients [
Four departments in four hospitals and four health care departments in four municipalities were invited to participate in the study. The criteria for the invitation were based on the scope of the study, the department was chosen by size of population and geographical location in southern Sweden. Two departments in two hospitals and three health care departments in three municipalities agreed to participate. The study was conducted in the Departments of Operation Theatre and of Medicine in two hospitals and in the Department of Healthcare in three municipalities and took place between February and May 2019 (N = 24).
The study was performed in accordance with the phenomenographical approach by Ference Marton [
The method for data collection was individual face-to-face interviews [
Female and male in the ages between 25 and 64 years with a variety of experience participated in the study. The RNs had worked in their current positions for between six months and 23 years.
The first step in the analysis was to read the text from the transcribed interviews several times to gain familiarity with the material and a clear idea of the content. In the second step, all statements related to the purpose of the study were identified. Parts of the text that were deemed to be of no importance for the study’s objective were discarded. In the third step, the sentences retained were condensed to extract their most essential parts. In the fourth step, preliminary categories (groups) were created into which the condensed sentences were placed, based on their content, in to reveal any correlations between them. The sentences were examined many times and the categories were revised twice. In the fifth step, the essential parts in each of the preliminary categories were analysed, to find similarities and differences between categories in different groupings.
| Characteristics | N = 24 (%) (MV) = Mean Value |
|---|---|
| Female | 20 (83) |
| Male | 4 (17) |
| Age groups years | N, (%), (MV) |
| 25 - 42 | 11, (46), (33) |
| 43 - 54 | 4, (38), (50) |
| 55 - 64 | 9, (16), (59) |
| Number of years as RN | N, (%), (MV) |
| 1 - 11 | 12, (50), (5) |
| 12 - 24 | 7, (29), (17) |
| 25 - 34 | 5, (21), (29) |
| Number of years in the current workplace | N (%), (MV) |
| 6 months - 8 year | 20, (84), (3) |
| 9 - 16 | 2, (8), (13) |
| 17 - 23 | 2, (8), (20) |
The answers were reviewed several times to ensure that the categories were relevant to the purpose of the study. In the sixth step, the categories were given names according to their essential content, based on the various experiences collected throughout the study. In the seventh and final step, (based on the analysis,) similarities, differences and the unique characteristics among the categories were created. This is defined as the sample space or possibility space and constitutes the result of the study. Based on TBPM, the categories and the perceptions were sorted, according to relevance, under each of the three cornerstones (culture, steering, organization).
Adhering to the guidelines of the Helsinki Declaration [
Below, the variations in RNs’ perceptions are presented, in categories under the three cornerstones in TBPM (culture, steering and organization).
Category 1: Leadership
The amount of trust in leadership varied depending on how the manager acted in various situations and was perceived differently for different activities. In two of the five workplaces did participants feel they could mainly trust the managers at all levels (
“Just outside this area, we have something that we call the luxury corridor. The luxury corridor is the place where management has its offices. Employers, accountants, HR. We are not allowed to pass through their corridor when we are going to dialysis with a patient - we have to walk around the area to another elevator. That gives me the “them and us”-feeling. Because honestly, if we did not have any patients, they would not be sitting in that corridor. It is really simple for me, I am not here for their sake, I am here for the patients.” [RN 1] “The employer is not interested in what we need, to be able to trust them” [RN 7] “We have had a lot of improvements because our employer listens to us, that I have to say. Our employer works hard.” [RN 18]
| Trustworthy leadership | Effects of a trustworthy leadership | Lack of trustworthy leadership | Effects of the lack of trustworthy leadership |
|---|---|---|---|
| The manager: · Relays suggestions · Gives feedback · Listens to RN · Has an open climate to share opinions | The RNs: · Relate to the value words · Feel proud · Share their opinions · Want to be involved in new projects · Feel secure about patient care | · Control from the top · No possibility to influence anything · The manager does not convey improvement suggestions upwards in the organizations · Lack of feedback from the manager | The RNs: · Feel less involvement · Experience stress · Feel that time has been taken from patient care and wasted · Avoid participating in the next project · Cannot identify with the vision of the organization · Experience a feeling of “us and them” between staff and managers |
Category 2: Accessibility
There was a recurring experience among the participants that the employers and politicians were not present in the workplaces (
“It would be great if politicians were interested in our work and joined us at work for a day” [RN 6] “Sometimes we get information by email from the employers. We haven’t so much contact with them. They don’t use to be here so often” [RN 24]
Category 3: Decision
The absence of managers and politicians was closely linked to the participants’ experiences that decisions did not benefit the patients or were economically indefensible (
“Now and then there are decisions from higher management that we are told to just adapt to”. If we had been able to participate more, they would also understand that these decisions are not always in the patients’ best interest.” [RN 2] “I think our politicians make a lot of weird decisions, and I believe that if we had a say in the matter, health care would have worked differently than it does today”. [RN 9]
Categories: Administration, Information/Meeting, Routines, Time.
Category 4: Administration
Administration support
In all the workplaces, there was a lack of trust in the human resources department (HR) (
“Us nurses were on a forum in the region for the future of nurses. A person from the central department of HR gave lectures and called us “the foot people”. The trust in the region was a hefty blow. Then you start to wonder? Is this an approach that is anchored in the leading top?” [RN 3] “HR have become our new manager, our managers have no mandate anymore” [RN 8] “There are directives for salary auditing, and so there is a budget and HR, and then there was something else” [RN 10]
| 2. Accessibility | 3. Decision |
|---|---|
| · Lack off accessibility from the top leadership · Want politicians and top managers to be more present · Want to cooperate. | · Hard to understand the meaning of decisions · Decisions that neither benefit the patient nor are economically defensible · Want to get involved in decisions and contribute knowledge · A feeling of lack of in the professional’s knowledge from the top leadership |
| 4. Administration support (HR) | 5. Information/meeting | 6. Routines | 10. Responsibility |
|---|---|---|---|
| · Lack of trust in the people working in the HR department · Don’t know who HR are or their role · HR have more power than the mangers have | · Good information from employers · RNs want dialog instead of monologue · Different kind of meetings · Talk about basic values in the team · Doesn’t prioritize talking about trust · Important to talk about trust | Guidelines: · Which are up to date · Which are not up to date · Which are followed by colleagues · Have not been followed by colleagues · Feel a lack of trust when colleagues don’t follow the guidelines | RNs: · Want to be included in decisions-making processes · Want a solution from the manager · Don’t want to take decisions by themselves · Who don’t take responsibly for decisions? · Need to get more involved in meetings · Go to meetings when employers invite |
Documentation
RN in the municipal organizations considered documentation necessary and did not see it as a burden imposed by the participants working in the hospital's medical department (
“The administration is necessary and shows what we do” [RN 14] “We spend a lot of time on administrative work. Different drug lists, Journal systems and laboratory values that are difficult to find. We find it difficult to get an overall picture of the patient, which creates a lack of trust” [RN 5]
Category 5: Information/meeting
The quality of information varied within the workplaces, which affected trustworthiness. The structure of the meetings depended on what organization they were employed in. None of the participants had heard about Trust-Based Public Management before the interviews (
“News that are good to know are published on the intranet. Our managers are good at informing us, both on what comes from them but also higher up” [RN 4] “It is difficult to have conversations when the manager is holding back information as a secret. It’s ok to say the wrong thing and come back and say it was wrong” [RN 11] “I am missing continuous communication at all levels.” [RN 15] “There is good information on the intranet, but it is usually predominantly positive things which isn’t good because we, the employees, know that there are huge problems that need to be lifted. We can use chat to discuss problems, to meet politicians. I’ve never met them” [RN 19]
Category 6: Routines
It was important for RNs to have guidelines. Some guidelines were updated and easily accessed, and some were out of date. Some employees followed the guidelines, and some didn’t (
| Category | RN in the municipalities | RN in the hospitals |
|---|---|---|
| 4. Documentation | · Think documentation is important · Do not perceive documentation as a burden · Think documentation confirms what they do · Documentation provides feedback on results · Documentation helps develop care | · Documentation reduces time spent with patients · Too many different technological systems to use · Time taken for documentation affects patient safety |
| 7. Time for work | · Have enough time for the work · Enough of RN | · Stressful · Shortage of RNs · No time for breaks · Each RN have too many patients to take care of · Not enough time to update PMs · Pressure to produce. |
| 8. Cooperation | · Good cooperation with colleagues · Call for better cooperation with doctors and nursing assistants · Do not know if the patient gets the right care · Many of the nursing assistants lack competence and commitment · No continuity of doctors (employed in primary care) | · Good teamwork with different kinds of professionals · A lot of competence (professional) |
| 9. Education | · Need and want more education · Request for local training to be adapted to RNs’ competence and experience. | · Satisfied with the continuity of education and the different forms of training |
“The staff can’t do as they should when the standard treatment plan is not up to date” [RN 17] “We have updated guidelines but not all employees follow them” [RN 8]
Category 7: Time for work
There was a clear difference in the experience of stress between hospitals employees and those in municipal workplaces. The RNs at the hospitals do not have enough time to care for their patients, take breaks or update PMs. The work in the operating theatres described as a stressful working environment with many patients and a “pressure to produce”, which RN in the municipalities did not perceived (
“Nurses ends the job all the time because it’s too heavy, it’s too stressful, we don’t have time, so we don’t have time” [RN 12] “It’s a lot about production and we’re in a hurry. As a surgical nurse, you sometimes feel that the program is delayed. They often ask if I’m not finished with the tables soon. But the set-up is included in the production and it must be done correctly otherwise you can risk that the patient gets a post-operative wound infection, or if not, or that the right instrument is not at hand, which can cause complications or delays in the operation” [RN 16]
Categories: Cooperation, Education, Responsibility
Category 8: Cooperation
The experiences of trust and lack of trust in relation to colleagues emerged as a key topic. There was a difference in the trust experienced between municipal and hospital employees. The teamwork on the wards in both hospitals functioned well but in the municipal workplaces there were uncertainties about whether the tasks were completed and whether the patient had received the proper care. The participants working in the hospitals had more trust in other professionals than those working in municipal organizations (
“Between my colleagues it’s wonderful. I have hundred percent trust to them. We are helping each other’s with all the duties” [RN 13] “It would have been so fun and much easier to do a good job if everyone who chose this profession was here to do their best. To put an honour in the job, gather knowledge and seize his knowledge. I do not think the RN feel it that way, but among nursing assistants there is a lack of professional pride. I don’t know why? because it’s a hugely important job” [RN 20] “I have a colleague who is a nursing assistant that I feel I can trust. She always doing the “little extra for the patient” [RN 4] “At meetings we agree with the nursing group not to criticize a colleague’s assessments before the nursing staff. When we talk about it, there are many who have been involved in doing so. Some colleagues say they can take it because they have been nurses for so long. They think that it is more the younger nurses who care. I rather think it depends on how you are as a person than how long you have been a nurse” [RN 23]
Category 9: Education
It was important for the confidence of the participants that the employer invested in education. The participants who worked in the hospitals were satisfied with the range of training offered (lectures, team training and Case seminars). Those working in the municipality wanted more education and local training adapted to the RNs’ level of knowledge and experience (
“We have had special case seminars at special events and where the doctors have been involved. I can see it as part of trust where you are not looking for errors but instead, want to highlight what we did well and above all what we can improve so that it does not happen again” [RN 2] “I am thinking of the internal training that our managers say we must go to that affect the experience of trust. These trainings are more adapted to new RN and not to RN who have been in the municipality for 20 years. Then I think that the managers do not have control. You get frustrated at being forced to take a course that gives nothing. Don’t the managers think we have more skills than that?” [RN 22] “We need more education because it was a long time ago that I finished my nursing degree” [RN 11]
Category 10: Responsibility
There were various opinions about the amount of responsibility that the participants were prepared to take in order to meet the dilemmas and challenges within the organization (
“I feel like we are trusted more when we get to participate in the decision-making process but not everyone does as we have decided” [RN 14] “My view is that the employers listening to us because I’m used to go to meetings and see that they have a good will. Many of my colleagues don’t go to the meetings and see what the employers do” [RN 21]
The aim of this study was to illuminate RNs’ perceptions of TBPM in their work and reveal any eventual effects of the Swedish Delegation’s framework in the RNs’ workplace. The study confirms results of previous studies when employees feel involved in the work and organization, they contribute to improved results and feel more satisfied about handling difficult moments in a better way [
The absence of politicians and managers and displacement of power to HR generated different perceptions of trust in the leadership and in whether guidelines existed and were followed. There were variations in perceptions between the activities of the municipalities and the hospitals with reference to administration, time for work, cooperation, and education. The use of NPM as a form of governance has been criticized for increasing unnecessary administration that can be stressful for the professionals and takes time from the patients [
The results of the present study indicate that participants’ perceptions result from heavy responsibility and the expectation that a quality service will be delivered. The respondents’ questioning in cases where incorrect decisions have been made indicates a high level of responsibility. It would, therefore, seem a good idea to use the competence of RNs and other healthcare professionals in decision-making processes to reduce the risk of making decisions that benefit neither the patients nor the economy. The perception of the shift in power from the formal management to HR caused the participants a lot of concern. There is a lack of research into HR and it would be interesting and useful to have some investigative research into power. The perceptions emerged particularly with reference to the managers’ fear of making their own decisions before they had consulted HR. The supportive function that HR is supposed to have vis-à-vis the manager becomes subverted. Evidence from neuroscience shows that fear limits productivity and that individuals and organizations are more successful when people are encouraged to take risks, explore new ideas, and channel their energies in ways that work for them [
The result shows that relationship between trust and control is a central theme and connecting with Galvin & Timmins [
Since TBPM do not have implemented in the activities that the participants worked in, there have been limitations in finding out what results for patients TBPM may have given. There have also been limitations in obtaining previous research as TBPM is relatively new as a concept.
The participants can see a variety of benefits with TBPM and think it is necessary to allow competence and experience to contribute to the decision-making processes if quality care is to be delivered in the future. Based on the results of this study, the following actions are proposed in connection with practical implementing of TBPM:
· That politicians and management show a willingness to get involved in health care to understand the work that the staff does.
· All levels of the organization are made aware of what constitutes trust-based governance and management.
· Structures are created that enable TBPM (common values, objectives, policy, measurement, follow-up).
· Meeting arenas are created where management and staff can build the feeling of togetherness.
· Training in trust-based management is introduced into the nursing program and the education of all professionals who meet patients.
· Patients and staff are being involved at all stages from the beginning in the process of TBPM.
We thank the Registered Nurses’ who generously shared their perceptions with us. We also thank the managers in the various organizations who gave permission for the study. You have all made it possible for the study to be carried out.
Authors BE and AH contributed equal to the conceptions and design of the study. BE was responsible for recruitment, data collection, the first data analyse and drafting of the original manuscript.
BE and AH cooperated during the analysis part. AH reviewed and edited the manuscript. Both authors critically revised the manuscript and have read and approved the final version of the manuscript.
The authors declare no conflicts of interest with respect to the authorship and/or publication of this article.
Estev, B. and Hommel, A. (2020) Registered Nurses’ Perceptions of Factors Contributing to Trust-Based Public Management. Open Journal of Nursing, 10, 1126-1141. https://doi.org/10.4236/ojn.2020.1011080