Introduction
The psychosocial work environment in healthcare has long been recognized as poor worldwide.1–5 Research has highlighted numerous challenges faced by healthcare workers, including excessive workload, high levels of physical and psychological stress, low job satisfaction, high turnover, and poor work-life balance.6 Several contributing factors have been identified, such as frequent organizational changes, increasing administrative burdens, and inadequate psychosocial work from supervisors.7–9
These adverse working conditions can result in serious health consequences for healthcare workers, including depression, burnout, and sleeping disorders. Moreover, they contribute to detrimental work-related outcomes, such as increased turnover, staff shortages, and employee dissatisfaction, as highlighted in previous research.4 This situation is concerning, not only for the individual healthcare worker but also for the healthcare system as a whole, which is already grappling with staff shortages.10,11
Swedish primary healthcare is not exempt from the ongoing challenges related to poor psychosocial work environments.12–15 In addition to the known issues already mentioned, the Swedish healthcare system is also challenged in terms of different governmental decisions; for example, to pursue several changes regarding eHealth,16 such as the introduction of digital ways of meeting patients. The pandemic forced primary healthcare into frequent changes, resulting in uncertainty and increased workload, which persisted even after the decline of the pandemic.17,18 The sick leave rates are high in Swedish primary healthcare and both nurses and physicians consider leaving their job several times a month.12,13,19 Both nurses and physicians present high levels of sickness absence due to psychiatric diagnoses such as burnout.19
Initiatives to address the known problems with psychosocial work environment in healthcare have largely focused on individual-oriented interventions that aim to improve employees’ management of and response to, various stressors in the work environment.20 These include initiatives for individual employees to reduce stress and anxiety levels, among other things. In contrast, organizational initiatives seek to change employees’ work-related conditions, that is, the psychosocial work environment in which they operate. These initiatives aim, for example, to improve employees’ recovery through schedule changes, introduce routines for mentorship, and increase healthcare workers’ autonomy in managing their own schedules.20,21
Research shows that individually focused initiatives can improve healthcare workers’ job satisfaction and reduce stress levels. However, there is a significant lack of knowledge regarding their long-term effects.22,23 Studies on organizational initiatives aimed at improving the psychosocial work environment remain scarce, with most research focusing on identifying and documenting problems rather than exploring effective solutions. This gap is particularly concerning because organizational initiatives are widely regarded as having far greater potential for achieving long-term and sustainable improvements in the psychosocial work environment than initiatives focusing on individuals.24,25
Some studies have identified key characteristics of a healthy workplace and examined how managers influence healthcare workers’ perceived organizational support.26,27 However, there is a notable lack of empirical research on organizational initiatives aimed at improving the psychosocial work environment. Therefore, the aim of this study was to explore characteristics of primary healthcare units where organizational initiatives to improve the psychosocial work environment have been successfully carried out. To the best of our knowledge, no previous study has explored this issue. Understanding the factors that contribute to successful organizational initiatives aimed at improving the psychosocial work environment is essential for promoting employee well-being, reducing burnout and enhancing the overall quality of care.
Methods
A multiple case approach was used, allowing various cases to be investigated and enabling identification of similarities and common patterns across the units. Multiple case studies facilitate an in-depth examination of a phenomenon within its natural context, focusing on the participants’ perspectives. In this study, each case represents a specific workplace within Swedish primary healthcare. This approach is particularly well-suited for addressing “how” and “why” questions, especially when contextual significance is anticipated.28,29 Case studies are useful when trying to identify decisions, policies, and practices and how they were carried through and with what results.30 According to Schramm,30 the characteristics of a case study can be described as:
the essence of a case study, the central tendency among all types of case study, is that it tries to illuminate a decision or set of decisions: why were they taken, how were they implemented and with what result.
Case studies can be especially useful in contributing to policy and decision-making.30
Setting
Swedish primary healthcare serves as the initial point of contact for citizens seeking medical care that does not require the specialized expertise of hospitals. Primary healthcare is publicly funded through taxes, ensuring uniformly low fees for all citizens to guarantee accessibility. Primary healthcare units comprise a range of occupational categories, including physicians, nurses, nurse assistants, medical administrators, and occasionally physiotherapists and psychologists.31
Definitions
The term “psychosocial work environment” is used throughout the paper. However, in Sweden, this term is often replaced with “organizational and social work environment” by the Swedish Work Environment Authority. The aim is to shift the focus from individual characteristics to the broader contextual prerequisites of work.32 “Psychosocial work environment” is the internationally established term,33,34 therefore we use it interchangeably with the Swedish Work Environment Authority’s expression and definition.
Identification of Cases
We contacted representatives from the Swedish Association of Local Authorities and Regions to identify workplaces where organizational initiatives to improve the psychosocial work environment had been undertaken. They facilitated contact with a national network of occupational health and safety strategists with knowledge of successful initiatives across various workplaces. In addition, we attended national conferences on primary healthcare, where one unit presented its organizational initiatives aimed at improving the psychosocial work environment. This prompted us to reach out and invite them to participate in the study, which they accepted. Moreover, librarians, supported by the Swedish Agency for Work Environment Expertise, conducted comprehensive literature searches across multiple databases, including grey literature sources. In our research group, we also identified cases through searches in various professional and trade union journals. Finally, the HR departments of different regions in Sweden were contacted to inquire if they have any recommendations/knowledge on units that have implemented organizational initiatives resulting in a positive psychosocial work environment for health care staff.
Twelve healthcare units were identified as suitable cases. Of these, four declined participation or did not answer. Of the eight units who accepted, four were primary healthcare units and were therefore included in this study (Figure 1). The remaining four cases, which were not primary healthcare units, were analyzed separately and will be reported elsewhere.
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Figure 1 Flowchart of included organizations.
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All four primary healthcare units had undertaken organizational changes that aimed to improve the psychosocial work environment. The organization-oriented initiatives carried through by these units encompassed various types of changes (Table 1).
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Table 1 Case Characteristics
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Participants
Information emails were sent to managers of the identified units, explaining the study and how their unit was identified and that we were interested in interviewing 3–5 employees/managers from the unit. If the manager was positive, they were asked to share the study information with their employees and share Email contact information. Subsequently, information and invitations to participate were sent to the employees.
Nineteen managers and employees were invited, of whom 15 agreed to participate (3 managers, 6 physicians, 4 nurses, 1 assistant nurse, 1 medical secretary). No specific reasons for declining were provided. The invitation Email contained information about the study, the voluntary nature of participation, and the researchers’ titles and professional backgrounds.
Data Collection
Data were collected through semi-structured interviews with healthcare personnel from the four units. The interviews were conducted between September 2023 and February 2024, by investigators HF and EK, both experienced in qualitative methodology. Only the researcher and the participant were present during each interview session. The interviews were conducted on-site at one unit, according to the manager’s preference. For the remaining units, interviews were held via online communication platforms. Audio files were saved for transcription, and video files were deleted after the interviews. Fifteen individuals participated in the interviews (Table 1), which lasted between 33 and 61 minutes. The number of participants was deemed sufficient to obtain rich data with information power.35,36
A semi-structured interview guide (Appendix A) was developed by the research team in line with the study’s objectives. The interview guide covered key topics such as the rationale behind the change initiatives, how employees and managers carried through, evaluated, and sustained these changes, their perceptions of facilitating factors and the impact on their psychosocial work environment.
We performed one pilot interview to assess the effectiveness of the guide. After this pilot, the introduction for the interview was slightly revised to enhance its flow. Nevertheless, the pilot interview provided valuable information and was included in the study.
Data Analysis
The interviews were transcribed verbatim by a professional transcription firm. Initially, HF, EK, and PN each read the transcribed interviews to gain a preliminary understanding of the content. The interviews were then read and analyzed case by case. EK and HF consolidated their findings into a shared document to enable identification of common themes, both within and across cases. As the data collection and transcription occurred simultaneously, HF continuously reviewed and analyzed new transcripts as they became available. All authors read all interviews to be able to participate in the discussion of the analysis.
The analysis was based on qualitative, inductive content analysis.37 Categories and subcategories were iteratively refined and cross-checked against the empirical material, involving a continuous process of revisiting and reassessing the data, primarily led by HF. The findings were discussed in multiple meetings until consensus was reached. Transcripts were not returned to participants for review or member-checking.
Ethical Considerations
According to the Swedish Ethical Review Act (2003:460) informed consent must be documented. In this study, all participants received detailed written information in advance, explaining the purpose, procedures, confidentiality, and voluntary nature of participation. Before each interview, the participants were asked if they had read the information, were given the opportunity to ask questions, and were explicitly asked to confirm their willingness to participate. Their oral consent was documented by the researchers. This procedure was approved by the ethical review authority.
Confidentiality has been ensured in accordance with international ethical guidelines outlined in the Declaration of Helsinki.38 Interview quotes have been anonymized before publication. Personal data have been handled in compliance with the General Data Protection Regulation and guidelines at Linköping University by storing data encrypted on file storage provided by the university. No unauthorized person has access to the data, and the data are used solely for research purposes. In Sweden, ethical review of research involving humans is conducted by the Swedish Ethical Review Authority, which is a national governmental body independent from universities and institutions. The ethical approval for this study was granted by the Swedish Ethical Review Authority (dnr 2023–03326-01) in accordance with Swedish law and ethical guidelines.
Results
We identified four cases where organizational initiatives had been implemented to enhance the psychosocial work environment and had achieved positive outcomes. The characteristics of these cases are specified in Table 1. Fifteen participants were included in the study, 4 men and 11 women, aged 39 to 62 years (mean, 49 years). Their tenure at the units ranged from 1 to 24 years (mean, 6 years).
The results encompass four main categories and 16 subcategories (Table 2). These categories highlight the key aspects that characterize primary healthcare units that have successfully fostered a favorable psychosocial work environment through organizational initiatives.
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Table 2 Categories and Subcategories
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Engaged Leadership
The first main category consists of five subcategories, all focusing on the characteristics and abilities of managers. The interviews underscored the importance of managers demonstrating decisiveness and being physically present in the workplace; their presence fosters dialogue, trust, and relationship-building between employees and leadership. In addition, encouraging employees and adopting a down-to-earth attitude were crucial leadership traits that contributed to a supportive psychosocial work environment.
Decisiveness
Participants emphasized the importance of a manager who was decisive and willing to take the lead when necessary. The ability to make decisions, whether easy or difficult, and taking responsibility for managing workloads to prevent employees from becoming overwhelmed were valued leadership qualities. Although limiting the workload in primary healthcare is inherently challenging, participants appreciated managers who actively sought to protect their staff from excessive demands.
This subcategory also highlighted the importance of managers who supported their employees, particularly during periods of change. Participants described leaders who led rather than merely managed, listening attentively to employees and taking decisive action when necessary. This was exemplified by managers affirming and guiding their teams, helping them set priorities and manage workloads. Some participants compared their current managers with past experiences of inadequate leadership in previous workplaces.
We now have clear and decisive leadership, a manager who dares to lead, who can be firm when needed while also being understanding and a good listener. This has been the biggest improvement in our workplace in terms of the work environment. Nurse, #8
The most important thing for me is having a manager who dares to say: ‘This is your defined task.’ Without that, I wouldn’t feel I’m doing a good job, and I would be stressed. That clarity is absolutely crucial. Physician, #11
The manager’s ability to set boundaries for both employees and the healthcare center as a whole was a critical factor. Ensuring employees had the right conditions to perform their work, including structured processes and sufficient time for tasks, was seen as fundamental.
You need time for your tasks, time to fulfill your responsibilities properly. Creating that time can involve structural improvements and better organization. Manager, #1
Presence
The manager’s presence and accessibility were key factors in fostering a favorable psychosocial work environment. Managers ensured that employees knew when they were available, when they were away, and how to reach them in urgent situations. Presence was demonstrated through an open-door policy, a centrally located office, and regular check-ins with employees.
She is a very present leader, and I think that’s extremely important. She is always available for questions or concerns. If there are ‘visible’ and ‘invisible’ managers, she is definitely a visible one. Nurse, #3
Be on-site, be attentive, keep the door open so that people feel welcome to come in. Managers should invite communication rather than create barriers. There are so many resources available within the region to support leaders, and they should use them. Manager, #9
Trust
Both managers and employees emphasized the importance of trust in the workplace. Managers who cared about both their employees’ work situations and personal well-being fostered stronger engagement. Employees felt a high degree of responsibility and motivation when given autonomy and trust. Participants also described how managers encouraged them to take the initiative in improvement projects.
Being a small healthcare center helped, but the most important thing was that our manager trusted us and gave us the authority to make changes. Physician, #14
We have had excellent leadership. Our manager, a nurse by background, was deeply committed to staff well-being. She understood that when employees feel good and have freedom, they take responsibility. She didn’t impose her own ideas but encouraged us to drive our own initiatives. Physician, #10
Greater autonomy empowered employees to take on more responsibility and fostered professional growth. Physicians particularly appreciated the increased flexibility and efficiency that came with self-directed scheduling, which also relieved stress on other healthcare professionals.
Having trust from the manager allowed for flexibility; for instance, being able to work remotely when needed. It made work smoother and more adaptable If I finish early, I can go home and still check if any urgent calls come in later. That kind of autonomy is a success factor. Physician, #2
Encouragement
Participants valued managers who provided constructive feedback and supported professional development. A validating and encouraging attitude from leadership had positive ripple effects throughout the workplace. Recognizing employees’ competencies and contributions not only boosted individual morale but also contributed to a positive and dynamic work culture.
Our manager is very good at recognizing people’s competencies, encouraging them, and giving them opportunities to develop. We often create working groups for specific issues, and if you choose not to participate, you accept the group’s decision. Physician, #10
Down-to-Earth Leadership
A down-to-earth leadership style was another key theme. This meant managers were humble, open and willing to admit mistakes, creating a psychologically safe environment where employees felt comfortable raising concerns. Clear and transparent communication further contributed to a sense of security and mutual respect.
We wanted a manager who listened to us, someone we could have discussions with to determine the best course of action. It was important to have transparency, where we could voice our thoughts without fear of repercussions. And we got exactly that. Nurse, #7
Open Workplace Climate
The second main category consists of five subcategories that highlight how managers and employees described the workplace atmosphere as being characterized by an open-minded approach and numerous formal and informal communication opportunities. Both groups played a crucial role in fostering this open climate through continuous dialogue, active participation, and collaboration. An innovative mindset among managers and employees further contributed to maintaining this openness.
Dialogue
Dialogue between employees and managers took various forms within the workplace. The interviews revealed multiple communication channels and opportunities for discussion, including regular workplace meetings, dedicated reflection time, and informal discussions in break rooms, which served as natural spaces for spontaneous conversations. These discussion forums fostered cohesion, teamwork, and a positive psychosocial work environment.
I feel that I can go to my managers and say what I think and feel. I don’t know if everyone shares this view, but for me, it’s reassuring to have this kind of climate where I can say ‘This isn’t working, we need to find a solution together,’ and then we actually do. That feels really good. Assistant nurse, #6
It can be as simple as doctors eating together with colleagues from different professions or keeping an open-door policy where people feel free to drop by. Physician, #7
Inclusivity
The interviews revealed that a fundamental aspect of an open workplace climate was valuing all employees’ voices equally. Participants emphasized the importance of a tolerant and inclusive atmosphere, where everyone felt comfortable expressing their opinions. Physicians were seen as playing a crucial role in reducing hierarchical structures, ensuring that authority was only applied where medical expertise was required.
As physicians, we are at the top of the hierarchy when it comes to medical decisions, but it is easy for that hierarchy to extend beyond medical matters. We have the greatest responsibility in ensuring that we remain equal colleagues in all other aspects. Physician, #7
Participants also noted that employees have different responses to workplace changes and that these differences should be respected and accommodated. Allowing individualized solutions was seen as a strength that enhanced flexibility and promoted a healthy psychosocial work environment.
The idea that everyone must have the same schedule feels outdated. Some people need a half-day for administrative work, while others prefer to spread it out. Being able to tailor one’s schedule is key. Physician, #2
Openness to Innovation
There was a low threshold for trying new ideas in these workplaces; employees generally felt that they could experiment with new approaches without fear of failure. This culture was reinforced by supportive managers who encouraged innovation. Employees described how regular follow-ups and backup plans helped ensure that new initiatives were evaluated and adjusted as needed, fostering a sense of security in the workplace.
We try things out. If someone has an idea, we say, ‘Go ahead, test it, and we’ll see.’ Sometimes it results in a shift in schedules or workflows, affecting a large part of the workplace. But we embrace it and move forward. Physician, #10
Collaboration
Participants described a strong culture of collaboration, whereby employees supported one another and worked together to develop the organization. One effective approach was forming interprofessional workgroups to address specific development needs. Participation in these groups was voluntary, allowing employees to engage in areas that matched their interests and expertise. Working across professions improved overall understanding, teamwork, and prioritization of collective goals over individual interests.
A team is crucial. We help each other, we understand why we’re here, and we recognize that while we have different roles, each one is equally important. We’re all working toward the same goal. Manager, #9
Participation
Creating opportunities for employees to participate in workplace development was seen as essential for engagement and job satisfaction. Participants noted that involvement in decision-making fostered a sense of responsibility and professional growth. Participation was encouraged by cultivating a culture where all opinions were valued, where employees felt appreciated both professionally and personally, and where they had real influence over their work environment.
Employees and managers emphasized that fostering participation required a collective effort. Participants also pointed out that bottom-up initiatives, where frontline employees drove change, were more effective than top-down directives.
It’s about creating participation so that everyone is involved and contributing because that’s what people want. We need to build a culture grounded in equal value, where everyone is important regardless of personality or profession. We all have our strengths and weaknesses, but together, we create something great. Manager, #1
Participants also stressed the importance of hiring employees who align with the workplace culture. Some candidates were not hired because they were not deemed a good fit for the team; it was recognized that a poor fit could disrupt the group dynamic.
There have been times when we turned down a candidate, not because they weren’t qualified, but because they wouldn’t have meshed well with the team. It’s important to protect the group dynamic. Of course, we also have the trust of primary care leadership, and any hiring decisions must be approved at a higher level as well. Physician, #10
Conditions for Improvement
The third main category consists of three subcategories that describe the key conditions required to implement successful organizational initiatives in the workplace. It emphasizes the importance of maintaining a balance in the frequency and scale of changes because excessive or continuous modifications can lead to employee fatigue. This category also highlights the need for structured problem-solving and continuous evaluation to ensure sustained improvement.
Balanced Change Management
Participants stressed that constant changes can be exhausting, potentially leading to burnout. Improvement initiatives are necessary, but changes must be carefully managed to avoid overwhelming employees. Moreover, organizations should recognize that employees react differently to changes and require varied levels of support. Notably, participants highlighted that small-scale, localized improvements can be just as impactful as large-scale initiatives.
Not everyone is always completely comfortable with change. We are different, and some prefer things to remain as they are. But in the end, once they adapt to the new way of working, it often turns out to be positive. Medical secretary, #4
While emphasizing balance in change management, participants also noted that organizations must continuously evolve. Complacency should be avoided, and organizations should learn from others who have successfully implemented similar changes.
There is always room for improvement; things can always be better, and you’re never truly finished. Nurse, #7
Take the time to carefully think through routines before implementing changes. Seek guidance from others who have experience, then adapt it to your own needs rather than simply copying. Consider the pros and cons carefully. We haven’t implemented identical solutions to other units; we’ve selected what we believe works best for us, given our specific conditions. Physician, #2
Structured Problem-Solving
Participants emphasized the importance of systematically identifying and addressing workplace challenges. A structured approach to problem-solving enables organizations to tap into employees’ experiences and create effective solutions. Various methods were described, including using problem-identification notes displayed on a board for regular review and discussion, and systematic deviation reporting to pinpoint structural inefficiencies or recurring workplace issues. Encouraging employees to actively contribute to problem-solving fosters a sense of ownership and engagement, and creates opportunities for broader improvement efforts.
I encouraged staff to report deviations so we could review them, determine how to proceed, and ensure that we identify what isn’t working and make patient care as safe as possible. Manager, #9
We have a system whereby employees write down problems on notes and pin them to a board. We then discuss them in weekly meetings or workplace gatherings. Someone might propose an excellent solution, and sometimes the decision-making process is remarkably fast. Nurse, #3
Continuous Evaluation
Participants highlighted the critical role of regular follow-ups to assess the effectiveness of initiatives and ensure continuous learning. Follow-ups were ideally structured and scheduled, but spontaneous check-ins also played an important role. Face-to-face discussions within the organization were particularly valuable because they enabled employees to share insights about both successes and areas needing improvement.
This learning process was seen as an integral part of competence development, fostering both professional growth and overall workplace development. In some cases, frequent follow-ups were necessary in the initial stages of an initiative, gradually reducing over time.
At every physician meeting in the beginning, we addressed this issue as a standing item. Eventually, when things settled, we didn’t need to discuss it anymore. However, we did evaluate it in workplace meetings. Physician, #15
Participants also emphasized that follow-ups help effectively conclude initiatives, allowing organizations to shift focus to new priorities as needed.
A couple of years ago, we identified several areas that needed development because there was a general sense that things weren’t working optimally. We worked on these issues across different professional groups. Now, we feel that some of these groups have fulfilled their purpose, so we are considering shifting focus. This will be discussed in upcoming workplace meetings – whether we should continue in the same way or focus on new priority areas for the coming year. Physician, #11
Structured Work Organization
The fourth main category consists of two subcategories: employee buy-in and structured processes. It highlights the importance of establishing clear organizational structures and ensuring that changes are well-anchored among employees before implementation.
Employee Buy-In
Participants stressed that thorough preparation and planning are essential for executing organizational initiatives successfully. Despite careful preparations and risk analyses, unforeseen issues often arise. However, when ample time has been invested in planning, these challenges can be resolved through collaborative problem-solving.
A key aspect of successful implementation is ensuring employees understand the reasons behind changes, how they will be carried out, and the intended benefits. Proper anticipation fosters deeper alignment and engagement.
Secure buy-in properly so that everyone understands what it’s about; that’s the first step. Physician, #2
Sometimes employees were skeptical about certain changes, but with ongoing dialogue and preparation, we could explain why adjusting workflows was beneficial. This increased their willingness to try it out. Physician, #13
Structure
Participants emphasized the importance of clear organizational structures because unnecessary confusion and inefficiencies can have a negative impact on the workplace. Having systems that simplify work processes ensures smoother operations. Participants also highlighted that structured processes help ensure that ideas are acted upon rather than just discussed.
Efficiency isn’t about working faster; it’s about working smarter. It’s about order, structure, and systematization. Having a designated place for everything creates a sense of security. We should eliminate unnecessary distractions and focus on what truly adds value. Walking around the workplace is good, but we shouldn’t waste time searching for things. Manager, #1
In addition, clear and coherent communication helps prevent employee overload and uncertainty. Employees appreciate structured processes because they create a sense of stability and clarify priorities.
I believe that the rest of the staff at our healthcare center appreciated having a sense of structure – knowing that both the manager and I had a clear plan. It created clarity, regardless of what we were implementing. I don’t think people regularly refer to the detailed guidelines and routines we’ve written down, but they know they’re there if needed. Physician, #13
Discussion
The aim of this study was to explore the characteristics of primary healthcare units where organizational initiatives to improve the psychosocial work environment have been successfully carried out. We identified key factors that support the development of initiatives for enhancing the psychosocial work environment. Our results highlight that engaged leadership, open workplace climate, well-functioning conditions for improvement, and structured work organization are crucial for achieving a favorable psychosocial work environment in Swedish primary healthcare.
The findings of our study indicate that the four main categories are closely interconnected and mutually reinforcing in creating a favorable psychosocial work environment. Our findings emphasize that engaged leadership plays a pivotal role in this development. However, it is important to recognize that leadership is not solely a top-down process; engaged leaders depend on their employees, who act as co-creators of a favorable psychosocial work environment, as well as on structured work organization and supportive conditions.
Furthermore, our findings indicate that engaged leadership is not only a key component but may also serve as a fundamental prerequisite for achieving a favorable psychosocial work environment. For example, participants who had managers who were willing to acknowledge mistakes and make necessary changes perceived the workplace climate as more open and supportive. This type of environment encouraged them to express their thoughts, share concerns, and actively participate in innovation and workplace development.
Defining leadership is inherently complex, and numerous attempts have been made to capture its essence.39 One widely cited definition describes leadership as “a process whereby an individual influences a group of individuals to achieve a common goal”.31 This perspective emphasizes the interactive dynamics between leaders and followers rather than focusing on the leader’s personal traits. However, our findings challenge this definition because participants described their managers not only in terms of their influence but also highlighting distinct personal qualities, such as being down-to-earth, encouraging, decisive, and trustworthy. This suggests that, although leadership is undeniably a relational process, the individual characteristics of managers also play a crucial role in fostering a favorable psychosocial work environment in Swedish primary healthcare. Thus, our findings underscore the multifaceted nature of leadership in healthcare, where both the leader’s relational approach and personal attributes are essential in shaping effective leadership and a positive psychosocial work environment.
Our findings align with transformational leadership models.40,41 The transformational leaders engage with others, build strong connections and enhance both their own and their followers’ motivation and ethical standards, contributing to the creation of a culture of innovation and continuous development, rather than accepting existing conditions.40,41 These leaders are often regarded as change agents with a clear vision, courage, and the ability to inspire others, making them highly beneficial for employee well-being.42,43 However, Lundqvist et al43 highlight the lack of empirical knowledge on how managers enact this type of leadership in practice.
Our study contributes to addressing this gap by identifying the prerequisites and actions necessary for both managers and organizations to foster transformational leadership. The leadership characteristics described in our findings closely align with participants’ descriptions of their managers, reinforcing the relevance of transformational leadership in Swedish primary healthcare. Research on leadership in healthcare has consistently shown that transformational leadership positively influences healthcare settings.44,45 Healthcare employees working under transformational leaders report higher job satisfaction and overall well-being.43,45–47 This association is important because job satisfaction has been shown to enhance employee retention48 and reduce adverse events involving patients, thereby improving patient safety.49
Our study highlights the critical importance of engaged leadership in primary healthcare. However, earlier reports indicate that four in ten managers in Swedish healthcare are considering leaving their positions, with a majority seeking to exit the healthcare sector entirely.50 This alarming trend highlights the challenges and strains faced by healthcare managers, who operate in high-pressure environments, often with insufficient resources to meet escalating demands. Their role is inherently complex, characterized by conflicting expectations and an administrative burden.51 A survey conducted by the Swedish Medical Association (the labor union for physicians in Sweden) found that managerial positions in primary healthcare are widely perceived as unattractive. The survey revealed that only one in five managers feel they have enough time to meaningfully engage with their teams, citing limited administrative support and financial constraints as major obstacles.52 This persistent issue is particularly concerning given our findings, which emphasize the essential role of managers in fostering a positive psychosocial work environment. Without adequate support and structural improvements, the ability of healthcare managers to lead effectively and sustain a positive psychosocial work environment remains at risk.
Furthermore, our findings highlight the importance of managers being physically present in the workplace and fostering open, honest and transparent communication. This aligns with previous research on effective leadership practices.27,53,54 Swensen et al55 identified five key leadership practices, highlighting transparency, including the willingness to share both failures and successes, as a critical factor in cultivating an open and inclusive workplace culture. This reinforces the idea that visible and communicative leadership is essential for building trust, engagement, and a positive psychosocial work environment in healthcare settings.
Leadership and workplace culture are closely interrelated, often viewed as two sides of the same coin.56 Organizational culture encompasses an organization’s values, norms, perceptions, and behaviors, collectively shaping how members interact and respond to different situations.56 Managers play a pivotal role in shaping workplace culture through their values, behaviors, decision-making, and communication styles. At the same time, organizational culture shapes the effectiveness of various leadership styles, reinforcing or constraining their impact. Organizational culture has also been described more succinctly by Verbeke et al57 as “the way things are done in an organization”, highlighting its practical and pervasive nature.
Workplace culture is closely linked to workplace climate.58 Workplace climate can be defined as “the reflection of the way people perceive and come to describe the characteristics of their environment”.57 According to the participants in our study, workplace climate was a crucial factor in creating the favorable psychosocial work environment they strived for, an observation that aligns with previous research on organizational climate and culture.59,60
The workplace climate was highlighted as a fundamental precondition to creating a favorable psychosocial work environment by the participants in this study. Our findings show that the cases were characterized by positive social relationships as well as a sense of cohesion, teamwork, and collaborative problem-solving. These findings support earlier research on employee engagement, which suggests that organizational climate, along with social support, feedback, and autonomy, is closely linked to employee engagement.59,61 Engagement, much like leadership, is a complex concept. Schaufeli et al62 define it as “a positive, fulfilling work-related state of mind characterized by vigor, dedication, and absorption”. The importance of having engaged employees is not only important for the psychosocial work environment in general but it has also been shown that engaged medical residents conduct fewer medical errors63 and there seems to be an association between high levels of work engagement and patient safety culture, although more research is needed. Job engagement is also important for retaining healthcare workers because research has shown that higher levels of engagement result in lower levels of turnover, ie, leaving the organization and/or profession among nurses. Adequate job resources, referring to sufficient materials as well as a good relationship with co-workers and managers also improve job engagement among healthcare workers.
Furthermore, our results indicate that a unit’s capacity for continuous improvement is crucial for fostering a favorable psychosocial work environment. Participants emphasized the importance of avoiding overly frequent or excessive organizational changes. While change is inevitable in healthcare, as in other work environments, it is crucial to strike a balance between stability and predictability on the one hand and necessary change initiatives on the other. Failing to maintain this balance can lead to staff feeling overwhelmed and increased stress levels.18,63
This delicate balance became particularly evident during the COVID-19 pandemic, as highlighted by previous research from our team, which demonstrated how rapid and extensive organizational shifts affected healthcare workers’ well-being.13,18 Previous research has also shown that frequent organizational changes can lead to change fatigue among healthcare workers.64,65 This, in turn, has been found to have a negative impact on employees’ job satisfaction,65 further underscoring the need for thoughtfully implemented change management strategies in healthcare settings.
Strengths and Limitations
A multiple case study design was used in this study and cases identified through personal knowledge of units, human resources departments, literature searches and conferences. Given this selection process, certain limitations must be considered when interpreting the results. The cases were selected because the participants wanted to highlight their successful efforts, which may have introduced a positivity bias; participants might have been reluctant to share shortcomings, particularly if their workplace is perceived as successful in the literature or by general opinion. In addition, in research, there is always a risk that those who choose to participate are the most interested in the subject, the most critical, or the most satisfied, potentially leading to selection bias. The multiple case design does not support statistical generalization, but the identification of recurring themes across several cases may offer transferable insights of relevance to other primary care settings. Our primary analytical focus was to identify similarities across the cases, which inherently carries a risk of overlooking potentially meaningful differences. Although this approach aligned with our aim to highlight transferable insights, it may have limited our ability to fully capture case-specific nuances. This analytical decision reflects a trade-off between breadth and depth and may be seen as a limitation in terms of contextual variation.
In this study, organizations recognized for having a good psychosocial work environment were recruited. The intentional selection of “successful examples” may have influenced the results by encouraging organizations to showcase their strengths and focus on their achievements. Moreover, participant recruitment was facilitated by their respective managers, therefor there is a possibility that more critical voices would be underrepresented because employees with negative experiences or differing perspectives may have been less likely to be invited or willing to participate.
Nevertheless, the study also has considerable strengths. The multiprofessional composition of the research team enhances the trustworthiness of the analysis by incorporating diverse perspectives. In addition, eligible primary healthcare units were identified by librarians specialized in systematic search strategies, minimizing the risk of overlooking potential cases and enhancing the comprehensiveness of the study.
The study also includes a diverse selection of primary healthcare units, varying in geographical location and urbanization levels, ensuring a broader representation of different healthcare contexts. Moreover, at least two different professional groups from each organization were represented among those interviewed. In terms of gender distribution, most of the participants were women, which is consistent with the overall gender composition of the healthcare workforce in Sweden.66
Inductive content analysis was considered appropriate because it allows for interpretation beyond the literal meaning of spoken words and enables a deeper analysis of underlying themes in the interview material. The inductive approach is particularly relevant for conducting research in an area with limited existing knowledge. The approach facilitates an open-minded perspective and reduces the risk of overlooking unexpected or surprising findings.37
Conclusion
This study identifies the key characteristics of primary healthcare units that contribute to creating a favorable psychosocial work environment in Swedish primary healthcare. Engaged leadership, an open workplace climate, conditions for improvement, and a structured work organization are all essential. Engaged leadership involves managers being physically present, decisive and trusting of employees, actively shaping the workplace climate. An open climate promotes inclusivity, equal treatment and collaboration, encouraging healthcare workers to participate in daily operations and development work. Conditions for improvement require balanced, structured changes, ensuring they are neither too frequent nor excessive and continuously evaluating the changes. Structured work organization emphasizes the importance of involving healthcare workers in decision-making processes related to changes and development efforts and maintaining a well-organized workplace, reducing inefficiencies. Our findings highlight the need for further research on the specific challenges managers face in primary healthcare and effective organizational strategies for staff recruitment and retention.
Data Sharing Statement
Data available upon reasonable request to the corresponding author.
Ethical Approval and Informed Consent
The study received ethical approval from the Swedish Ethical Review Authority (dnr 2023-03326-01). Participants provided oral consent, confirming that they had read the study information, acknowledging their understanding of the voluntary nature of their participation and agreed to take part in the study. The participants were informed that anonymized data from the interviews would be used in scientific publications. In accordance with Swedish ethical guidelines, explicit consent for direct quotes was not required as long as anonymity was protected. All quotes presented in this article have been carefully de-identified to ensure confidentiality.
Acknowledgments
This manuscript is included as one of the constituent studies described in the comprehensive summary of the first author’s doctoral thesis,67 which is publicly available through the university’s repository, in accordance with standard academic practice in Sweden. The manuscript itself, in its full version as submitted here, has not been previously published or peer-reviewed, and is not available online.
We would like to express our sincere gratitude to all participants who took the time to share their experiences and reflections with us. We are also grateful to Marjan Vaez and Karin Guldbrandsen at the Public Health Agency of Sweden for their valuable comments on the manuscript and for engaging in thoughtful discussions. We also would like to thank the Public Health Agency of Sweden for funding this study. Finally, as our native language is not English, we have used ChatGPT (version 4o) to support the translation of, for example, participant quotations and to assist with language refinement where deemed appropriate.
Funding
The authors received financial support for this study from the Public Health Agency of Sweden.
Disclosure
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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