The multivariate modelling in this study regarding whether school principals' experiences that they could work for an extended working life proved statistically significant associations with their experience of burdens in terms of the responsibilities in the role of a manager, as well as the support from the managers' colleagues in their performance of their managerial duties. The role of a school principal includes the need for skills, knowledge and competence development to cope with and execute the work tasks as a manager and in the role of a leader. Otherwise, if school principals do not have adequate or full knowledge of how to cope with their role as a manager, the role of a school principal, with a great deal of responsibility, will be mentally demanding and may make the school principals' personal stress harder to cope with and control. Furthermore, previous research into other professions and the SwAge model state that both adequate knowledge to manage work tasks and the mental work environment, with a balance of demand and control, are important for individuals' assessments of whether they can work for an extended working life or not [2–7,29,38].

The other multivariate modelling in this study—whether school principals wanted to work until 65 years of age or beyond—also proved a statistically significant association with their experience of burdens in terms of the responsibilities of the role of being a manager but was also related to the support from executive management in performing their managerial duties. These results are in accordance with previous studies on other professions, which state the need for support and confirmation from their managers and from the management in order to see their own work effort as an important part and their own role as a part of the organisation's purpose; otherwise, the work can be perceived as meaningless [2–7,29,38]. Social and instrumental support, coherence and inclusion in a group are important determinant factors that affect whether individuals want to stay in the workplace and keep working until an older age, as shown in the SwAge model [2–7,14–18,29,38].

#### *4.4. Limitations*

A limitation of this study was that the survey mostly focused on the mental and organisational issues of school principals' work situations and did not investigate all nine determinant areas for a sustainable working life stated in the SwAge model [2–7,14–18,29,38]. However, the difficulties and complexities in the school principals' work situations are probably, to a large extent, contingent on mental and organisational workloads and to a lesser extent on the physical workload. Another limitation could be that the study used questions from previous studies and did not investigate the school principals' retirement considerations in depth. However, the questions used in the survey were validated and reliability controlled in previous studies, providing robustness to the present study. Additionally, the opportunities of this dataset, being based on a follow-up study and using the same participating respondents in two consecutive years, increase the robustness of the results. This investigation included Swedish school principals throughout the country, from north to south, including principals working at schools in small villages and large cities and school principals from pre-school to high school and adult school. Although framed in a Swedish context, we presume that school principals in other countries and cultures might share similar challenges in their work situations and perceived health due to the occupational similarity of schools; however, the organisations of school systems could be quite different.

#### **5. Conclusions**

The results show that circa 17% of Swedish school principals do not perceive that they can work until 65 years of age or beyond, and circa 49% do not want to work until 65 years or beyond. In addition, most indicators that covered exhaustion symptoms, poor health, poor mental resources and low work ability in relation to the physical and mental demands of work were positively associated with reports of not being able to work or not wanting to work until 65 years of age or beyond. In contrast, reporting a high workability in relation to respondents' lifetime best performance and expressing a higher work engagement decreased the probability of reporting being unable or not wanting to work until or beyond 65 years of age. Furthermore, among the organisational variables assessing demanding and supportive circumstances, the multivariate analysis showed that role demands seem to be the best indicator for reporting not being able to work as well as not wanting to work until 65 years of age or beyond. Collectively, the present results seem to suggest that interventions that aim to improve school principals' individual health and well-being and strive to reduce their role demands are likely to be beneficial for the principals and thus for the school organisation they manage. However, the results also suggest that it might be worthwhile in future research to address the question of school principals' withdrawal from the labour market from a more comprehensive theoretical framework such as the SwAge model; i.e., that employability and whether people can and want to work depend on four spheres: the health impacts of the work environment, financial resources, social support and experiences of social participation and self-fulfillment through work tasks. In order to

increase the likelihood and capacity to function as a school principal, a work environment with a positive impact on health— that is, with a sense of community in the organisation, trust and social support, acceptance from the employees' executive management and a generally manageable stress exposure—appears to be an important determinant. This could probably reduce the risk of developing health problems. Furthermore, such interventions may likely increase school principals' willingness and ability to work for an extended working life. A work situation experienced as healthy, supportive and trustful, as well as stimulating and meaningful for individuals' professional roles and duties, is likely a good way to inspire school principals to keep working for an extended working life.

**Author Contributions:** Conceptualisation, K.N., A.O., I.A., C.H., K.Ö., U.L. and R.P.; methodology, K.N., and A.O.; formal analysis, A.O. and K.N., original draft preparation, K.N.; writing, review and editing, K.N., A.O., I.A., C.H., K.Ö., U.L. and R.P.; funding acquisition, R.P. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by AFA Insurances Sweden, grant number 170094.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by The Regional Ethical Review Board in Lund, Sweden (reg. no. 2018/247). Written informed consent statements were obtained from all subjects involved in the study.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** In accordance with the ethical approval by the Regional Ethical Review Board, crude data are not to be published on the internet. Consistent with the study protocol, anonymised data are stored locally at the Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden. Access to data will be granted to eligible researchers wanting to audit our research. Requests should be directed to the corresponding author.

**Acknowledgments:** The authors wish to thank all participants who responded.

**Conflicts of Interest:** The authors declare no conflict of interests. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

#### **References**

## *Article* **Should I Stay or Should I Go? Associations between Occupational Factors, Signs of Exhaustion, and the Intention to Change Workplace among Swedish Principals**

**Inger Arvidsson 1,\*, Ulf Leo 2, Anna Oudin 1,3, Kerstin Nilsson 1,4, Carita Håkansson 1, Kai Österberg 5 and Roger Persson 1,5**

**Abstract:** A high turnover among principals may disrupt the continuity of leadership and negatively affect teachers and, by extension, the students. The aim was to investigate to what extent various work environment factors and signs of exhaustion were associated with reported intentions to change workplace among principals working in compulsory schools. A web-based questionnaire was administered twice, in 2018 and in 2019. Part I of the study involved cross-sectional analyses of the associations 2018 (n = 984) and 2019 (n = 884) between occupational factors, signs of exhaustion, and the intention to change workplace, using Generalized Estimating Equations models. Part II involved 631 principals who participated in both surveys. The patterns of intended and actual changes of workplace across two years were described, together with associated changes of occupational factors and signs of exhaustion. Supportive management was associated with an intention to stay, while demanding role conflicts and the feeling of being squeezed between management and co-workers (buffer-function) were associated with the intention to change workplace. The principals who intended to change their workplace reported more signs of exhaustion. To increase retention among principals, systematic efforts are probably needed at the national, municipal, and local level, in order to improve their working conditions.

**Keywords:** psychosocial working conditions; mental health; school leader

#### **1. Introduction**

The leadership of principals is of great importance for the school. The reports of a high turnover among principals are worrying [1–4], since it may disrupt the continuity of the leadership and negatively impact the school climate [5]. Long-term relationships are required to build mutual trust within the organization [6,7], which forms the basis for being able to offer support and adequate development opportunities for teachers [8]. It has been observed that frequent changes of principals results in lower teacher retention, which is particularly harmful for low-achieving schools with many inexperienced teachers [1]. Moreover, associations between principal turnover and student performance have been observed [1–3]. In a Swedish context, the National Agency for Education [9] and the Swedish schools-inspectorate [10] have expressed concerns that a high principal turnover may impair opportunities for students to achieve their goals. According to The Teaching and Learning International Survey (TALIS) [11], the median number of years working at their current school was three years for Swedish principals. Corresponding values in the Nordic countries ranged between four and six years, and the median value was five

**Citation:** Arvidsson, I.; Leo, U.; Oudin, A.; Nilsson, K.; Håkansson, C.; Österberg, K.; Persson, R.  Associations between Occupational Factors, Signs of Exhaustion, and the Intention to Change Workplace among Swedish Principals. *IJERPH* **2021**, *18*, 5376. https://doi.org/10.3390/ ijerph18105376

Academic Editor: Paul B. Tchounwou

Received: 13 April 2021 Accepted: 11 May 2021 Published: 18 May 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

years across all 48 countries participating in TALIS 2018. It thus seems as if a problematic principal turnover occurs to a large extent in Sweden and it is therefore important to improve the understanding of its underlying factors.

There may be a variety of reasons why principals decide to change workplaces. One reason may be that the change represents a natural career move, for example, from being an assistant principal to principal. Other reasons may have more practical and private origins. Anyhow, complex and demanding working conditions among principals have been reported [12–15], which may be of importance for the principals' inclination to stay or change workplaces. In a review of principal-turnover research [2], it was pointed out that inadequate preparation and professional development, poor working conditions, and a lack of decision-making authority were some of the reasons why principals leave their jobs. In addition, in Sweden, large variations in principal turnover have been observed between schools and municipalities [3], as well as between different school forms [10]. These indicate variable conditions depending on both external factors (e.g., socioeconomic factors) and the working conditions within the organizations.

While work environment factors and stress-related health among teachers have gained a large interest among researchers [16–20], less scientific studies have focused on the work environment and health among principals [13,21,22]. Anyhow, evidence has been provided of an association between principals' satisfaction with their work characteristics and their mental health status [12]. Furthermore, several sources of occupational stress have been identified, for example work overload, handling relationships with staff, teacher climate, lack of resources and personal characteristics [13,23,24]. As a leader of the school, the principals' work is associated with a wide range of responsibilities and roles comprising pedagogical development, staffing, finances, premises, and work environment issues, to name a few. Furthermore, the principal may experience numerous expectations from the school owner, superintendents, the schools-inspectorate, co-workers, parents, and students [14]. Whether these demanding organizational and social work environment factors are balanced by supportive management, supportive manager colleagues, or organizational structures, is most likely of great importance for their well-being and intention to stay in the organization [25]. A previous literature review of studies in different occupational groups has shown that risk factors such as high demands, low job control, and a high workload, increased the risk for exhaustion and poor mental health [26]. The association between burnout and high job demands and low job control also applied to Swedish teachers [19,20]. In a previous study of the present study population [22], 29% of the principals and assistant principals in compulsory school met the exhaustion criteria according to Karolinska Exhaustion Disorder Scale (KEDS) [27]. This prevalence rate is almost twice as large as the prevalence rate observed in a highly educated but occupationally diverse study sample [28]. Since a clear association has been found between a high level of stress and the intention to change jobs among teachers [29], it is of interest to find out whether this is true also among principals. Furthermore, to gain knowledge for preventive actions, there is a need to identify which specific occupational factors are of importance for the principals' intention to stay at, or leave, their current workplace.

#### *Aims*

The aims of the present study were twofold. The first aim (Part I) was to identify which occupational factors (organizational structures and work environmental factors) were associated with the intention to stay or the intention to change workplace, among principals and assistant principals in Swedish compulsory schools. The second aim (Part II) was to describe the patterns of intended and actual change of workplace across two years (2018 and 2019), and the associations with occupational factors and signs of exhaustion.

#### **2. Materials and Methods**

#### *2.1. Study Design*

The present study was a part of a longitudinal study of working conditions and health among principals in 277 municipalities in Sweden that included two web-based questionnaires using the software Textalk Textalk (Mölndal/Gothenburg, Sweden; www. textalk.com/products/websurvey/ accessed on 11 November 2019). The questionnaires were administered with a one-year interval in September/October 2018 and in September/October 2019.

In the present study, both cross-sectional and longitudinal analyses were performed, and the study comprised two parts. Part I involved cross-sectional analyses of the associations of year 2018 (n = 984) and year 2019 (n = 884) between occupational factors, signs of exhaustion, and the intention to change workplace, among principals and assistant principals working in compulsory schools. The cross-sectional analyses accounted for the fact that some participants had responded to the survey on both occasions and thus had repeated measurements (see statistical analyses).

Part II was a longitudinal analysis comprising 631 principals and assistant principals who participated in both surveys and who worked in compulsory schools in 2018. The patterns of intended and actual changes of workplace across two years (2018 and 2019) were described. Analyses were performed of associations between changes of the intention to stay, or leave the current workplace between 2018 and 2019, and changes of occupational factors and signs of exhaustion during the same period (with all actual workplace changes taken into account).

#### *2.2. Participants*

The participants in the longitudinal study were recruited via e-mail address by principals who had participated in training programs for principals funded and arranged by the Swedish National Agency for Education, during the period 2008–2017. In 2018, 9900 principals potentially working in pre-schools, compulsory schools, upper secondary schools, or adult education were invited to participate in the study. Of these, 4640 individuals either accepted (n = 2633) or declined (n = 2007) participation. Eventually, 2317 completed the entire questionnaire in 2018. The response rate was 50%, based on the principals that responded yes and also completed the survey, versus no-responders and those that did not complete the survey. In 2019, the second questionnaire was directed to the 2316 presumed still occupationally active responders in the first survey, of which 1528 responded. Furthermore, the participants who did not answer in the first assessment round (in 2018) were re-invited to the second round. Out of the 5149 previously silent individuals, 3350 were seemingly reached without technical problems (i.e., bouncing e-mail), of which 464 decided to complete the second questionnaire. Thus, the second survey comprised a total of 1992 principals. The study was approved by the Regional Ethical Review Board in Lund, Sweden, Dnr 2018/247.

Part I included principals and assistant principals working in compulsory schools, which comprised 1000 out of the 2316 respondents in 2018, and 901 out of the 1992 respondents in 2019. Participants who stated "other title" were omitted from the study (n = 15 in both years 2018 and 2019). Due to internal missing values, another three individuals (one in 2018 and two in 2019) were omitted. Thus, the present study sample comprised 984 principals (720 women and 264 men; mean age 49; range 30–67 years old) who responded to the first questionnaire and 884 principals (649 women and 235 men) who responded to the second one. Among these, 633 responded to both questionnaires. In total, 1235 principals had completed at least one of the questionnaires.

Part II involved the principals and assistant principals who participated in both surveys and worked in compulsory schools in 2018, irrespective of any change to another school-level in 2019 (n = 651). Twenty participants who stated that they would retire in 2018 or 2019 were excluded from the study, resulting in a study sample of 631 individuals.

#### *2.3. Outcome Measure*

In Part I, the outcome of the study was based on the question "Do you intend to change workplace within the coming two years?" with the response alternative 1: Yes definitely; 2: Yes, probably; 3: No; and 4: I will retire. The dichotomous outcome consisted of 1: No (i.e., intention to stay) vs. 2: yes, probably/yes, definitely (i.e., intention to leave). Participants who responded that they would retire were omitted.

#### *2.4. Independent Factors*

The data collection, for both Part I and Part II, comprised questions on gender, age, and occupational factors, i.e., job title (principal/assistant principal), school owner (municipality/other organization), seniority as principal, the number of co-workers and the number of students the principal was responsible for. Furthermore, information was collected on the staff availability (1: Full staff or more than full staff; 2: somewhat or very understaffed), overtime work (1: Once a week or less often, 2: a few times a week or every day; 3: No agreed working hours), and perceived physical working environment (1: Adequate, good or very good; 2: poor or very poor).

Demanding and Supportive organizational and social work environment factors were measured with Gothenburg Manager Stress Inventory (GMSI). GMSI-mini is a brief version of GMSI [30], which has been has been shortened by one of the authors (KÖ), in consultation with the developers Mats Eklöf and Anders Pousette. The selected items showed the highest correlation with the corresponding subscale in the original GMSI, which have been analyzed in two different samples. Demanding work environment factors were assessed in relation to the preceding six months, by 22 items distributed along eight dimensions, i.e., Resource deficits, Organizational control, Role conflicts, Role demands, Group dynamics, Buffer-function, Co-workers, and Container-function (i.e., dealing with co-workers' problems and frustrations). In each dimension, all questions were answered along a five-point scale with the options 1: "never/almost never"; 2: "Rarely"; 3: "Sometimes"; 4: "Often" and 5: "Always/almost always". The supportive organizational and social work environment factors were assessed with 10 items distributed along five dimensions, i.e., Supportive management, Cooperating co-workers, Supportive manager colleagues, Supportive private life, and Supportive organizational structures. The responses to each item were given along a five-point scale, indicating the level of agreement with various statements about supportive factors; 1: "Applies very poorly", 2: "Applies poorly", 3: "Applies to some extent", 4: "Applies well", and 5: "Applies very well". For both demanding and supportive factors, the mean score in each dimension was calculated for each individual. A higher mean score indicated more frequent experience with actual demands, and the perception of better support. In Supplementary Table S1, the number of items and a description of the included questions are given for each GMSI-dimension (this information has previously been presented in [15]).

In study specific questions, the participants were asked about "To what extent do you perceive stressful external expectations" from the following eight actors: the Swedish schools-inspectorate, the National Agency for Education, the school owner, Superintendent, immediate manager, co-workers, parents, and students. Each of the eight questions was answered along a seven-point scale ranging from 0 (verbalized as "not stressful at all") to 6 (very stressful). Thereafter, in Part I of the study, the scales were dichotomized into low (<4 points) and high (≥4 points) stressful external expectations. In Part II, the mean value on each scale was calculated for comparisons within and between specific groups of principals (see further description below).

Signs of exhaustion were measured with The Karolinska Exhaustion Disorder Scale (KEDS) [27], which includes 9 items that refer to the last 2 weeks, comprising the following domains: (1) ability to concentrate, (2) memory, (3) physical resistance, (4) mental resistance, (5) recovery, (6) sleep, (7) hypersensitivity to sensory impressions, (8) experience with demands, and (9) irritation and anger. Each item was answered on a 7-point scale (0–6). The sum score was calculated for each individual (0–54 possible) and higher values reflected

more severe symptoms. The mean value, as well as the prevalence of a score ≥ 19 points, which indicated signs of exhaustion/possible exhaustion disorder [25], was calculated for specific groups of principals.

The participants were also asked, "How many times have you changed workplace during the past five years?" (2018) and "How many times have you changed workplace during the past 12 months" (2019), with the response alternatives "none", "once", "twice", or "three times or more". The latter question was used in Part II of the study where "None" indicated no change of workplace (=No), and once or more indicated that the principal had changed workplace (=Yes).

In Table 1, descriptive estimates for the occupational factors, signs of exhaustion, and intended and actual changes of workplace are presented for 2018 and 2019, for the participants included in Part I of the study.

**Table 1.** Characteristics among participants included in Part I of the study, regarding reported conditions at work in the years 2018 (N = 984) and 2019 (N = 884). The number of participants who responded to both questionnaires was 633.

**Table 1.** *Cont.*

a The seven-point scales (0–6) were dichotomized into low (<4 points) and high (≥4 points). Bold faces may help the reader to identify the different categories of dimensions.

#### *2.5. Part II: Longitudinal Patterns of Intended and Actual Change of Workplace*

The patterns of intention to change workplace in the year 2018 and year 2019 (no vs. yes, probably/yes, definitely), together with the actual change of workplace reported in 2019, are described in Figure 1.

A large proportion of the principals remained at their workplace and had no intention of changing workplace, neither in 2018 nor in 2019. However, some principals had changed their mind concerning the intention of changing, or staying at the present workplace between 2018 and 2019. This may of course be due to the fact that they had actually changed workplace during the year, and of natural reasons had other working conditions. However, the reason for them to change their mind may also be due to changes of their working conditions and/or stress-related health at the present workplace, which is of interest to study.

To distinguish the groups, the participants were first divided into two groups based on the reports in 2018: those who intended to stay and those who intended to change workplace within the next two years. In the next step, the two groups were divided into four, based on the question in the survey in 2019 "Have you changed workplace during the past twelve months?" (No vs. Yes). In the third step, these four groups were divided into 8 groups, based on their intention to stay or leave their current workplace in 2019. This revealed eight different paths:

As an indicator of stress-related health in each of the groups, the prevalence of a sum score ≥ 19 points (signs of exhaustion; KEDS [24]) is shown in Figure 1.

For in-depth analyses of factors that may be of importance for the intention to change workplace, we chose to perform pairwise comparisons of occupational factors and signs of exhaustion in years 2019 and 2018, within and between Group 1 (Stay/No change/Stay) and Group 2 (Stay/No change/Leave), within and between Group 5 (Leave/No change/Stay) and Group 6 (Leave/No change/Leave), and within and between Group 7 (Leave/Change/ Stay) and Group 8 (Leave/Change/Leave) (Supplementary Table S2). The Groups 3 (Stay/Change/Stay) and 4 (Stay/Change/Leave) were not involved in these in-depth analyses, because they comprised a limited number of participants (N = 16 and N = 4, respectively). Longitudinal patterns of intended and actual change of workplace are shown in Figure 1, which is placed further ahead in the results (Section 3.2).

#### *2.6. Statistical Analyses*

All statistical analyses were performed with IBM SPSS software, version 24 (IBM Corp.). *p*-values ≤ 0.05 (two-tailed) were considered statistically significant.

To estimate the associations between gender, age, occupational factors, and signs of exhaustion, and the intention to change workplace (No vs. yes, probably/yes, definitely) Generalised Estimating Equation (GEE) models were used to specify a repeated measure model with a dichotomous outcome (binary logistic regression). Thus, survey data from 2018 were combined with survey data from 2019, taking into account that 633 out of 1235 study subjects had participated in both surveys (dependent observations). The intention to change workplace was first estimated in bivariate GEE models for all variables (gender, age, occupational factors, and signs of exhaustion) by Odds ratios (ORs) and their 95% confidence intervals (CIs). In the next step, ORs for intention to change workplace were estimated using multivariate GEE, for all variables with bivariate *p*-values < 0.1. In the multivariate GEE model, five variables concerning stressful external expectations were omitted from the analyses (i.e., expectations from the Swedish schools-inspectorate, National Agency of Education, school owner, superintendent, and immediate supervisor), due to a conceptual overlap with the variables in GMSI regarding demanding organizational and social work environment factors.

In Part II of the study, analysis within the groups (2019 vs. 2018) were done using the Wilcoxon Signed Rank Test for continuous variables and McNemar's test for dichotomous variables. Comparisons between the groups were performed using the nonparametric Mann– Whitney U-test for continuous variables and Fisher's exact test for dichotomous variables.

#### **3. Results**

#### *3.1. Part I*

In 2018, 98 principals out of 984 (10%) reported that they definitely intended to change workplace within the coming two years, and 304 (31%) that they probably would do so (Table 1). Corresponding values for the 884 participants in 2019 were 96 (11%) and 271 (31%), respectively.

3.1.1. Bivariate Analyses of Associations between Occupational Factors, Gender, Age, and Signs of Exhaustion, and the Intention to Change Workplace

Younger age, assistant principal, understaffing, and a perceived poor physical working environment were all associated with an intention to change workplace (Table 2). In addition, for all of the demanding organizational and social work environment factors in GMSI, high scores were statistically significantly associated with the intention to change workplace. The same was true for stressful external expectations from the school owner, superintendent, immediate manager, co-workers, and parents. Furthermore, a high sum-score on the exhaustion scale (KEDS) was associated with the intention to change workplace.

For all of the supportive organizational and social work environment factors, except for a Supportive private life, high scores were significantly associated with the intention to stay at the current workplace (Table 2). There were no statistically significant associations between the intention to change workplace, and gender, school owner, seniority, number of students and co-workers, and overtime work.

**Table 2.** Cross-sectional bivariate and multivariate binary logistic regression analysis between occupational factors, gender age, and signs of exhaustion and the dichotomous outcome of intention to change workplace (no vs. yes, probably/yes, definitely) in the total study sample, taking repeated assessments in the years 2018 (N = 984) and 2019 (N = 884) into account. Odds ratio (OR) and 95% confidence intervals (CI) are presented, which in continuous variables (GMSI and KEDS) are associated with a one-unit increase/decrease in mean score on the scale. Results in bold face are statistically significant.

**Table 2.** *Cont.*

a The variables stressful external expectations from school owner, super intendent, immediate supervisor, and co-workers were omitted from the multivariate analyses due to a conceptual overlap with the demanding and supporting dimensions in GMSI. Bold faces are remained to indicate which factors that are statistically significant (as stated in the Table text).

> 3.1.2. Multivariate Analyses of Associations between Occupational Factors, Age, and Signs of Exhaustion, and the Intention to Change Workplace

> In the multivariate analyses, younger age and assistant principal remained statistically significantly associated with the intention to change workplace (Table 2). The same was true for high scores of stressful external expectations from parents. Among the demanding organizational and social work environment factors (GMSI), Role conflicts, (OR 1.22 (CI 1.03–1.46), associated with a one unit increase in mean score, on the scale 1–5) and Buffer-function, OR 1.27 (CI 1.08–1.50) remained statistically significant, while Resource deficits, Organizational Control, Role demands, Group dynamics, Co-workers and Container-function did not. Furthermore, a high score of a Supportive private life was associated with the intention to change workplace. The strongest association with an intention to change workplace was found for a high sum-score on the exhaustion scale (KEDS) (OR 1.03 (CI 1.02–1.05), associated with a one unit increase in mean score, on the scale 0–54].

> High scores of Supportive management (OR 0.79 (CI 0.71–0.89), associated with a one unit decrease in mean score, on the scale 1–5) and Supportive manager colleagues remained statistically significantly associated with the intention to stay at the current workplace, while Cooperating with co-workers and Supportive organizational structures did not (Table 2).

#### *3.2. Part II: Longitudinal Patterns of Intended and Actual Change of Workplace*

As described in the methods section, and illustrated in Figure 1, the longitudinal analysis revealed eight different paths of intended and/or actual changes of workplace during 2018 and 2019.

#### 3.2.1. Group 1 (Stay/No Change/Stay) and Group 2 (Stay/No Change/Leave)

The principals in Group 1 (N = 274) had no intention to change workplace neither in 2018 nor in 2019, and reported no change of workplace in the survey in 2019 (Figure 1).

The longitudinal results within the group showed generally better working conditions in 2019 compared to 2018 (Table 3).

The principals in Group 2 (N = 99) had no intention to change workplace in 2018. In 2019, no actual change of workplace was reported, but they now reported that they had the intention to change workplace within the next two years (Figure 1). The longitudinal results within Group 2 showed statistically significantly impaired scores in 2019 compared to 2018, in terms of Resource deficits, Buffer-functions, and Supportive management (Table 3).

Differences between Group 1 and Group 2: Already in 2018, the principals in Group 1 reported generally better working conditions than the principals in Group 2 (Table 3). In 2019, most of the differences were accentuated. Group 2 reported statistically significantly higher scores in external expectations from school owners, immediate supervisors and co-workers, and in all of the demanding organizational dimensions. Group 2 also reported less Supportive Management and less Supportive organizational resources than Group 1. A higher proportion of the principals in Group 1 were employed in an organization other than in the municipality and they were responsible for a higher number of students. Group 2 reported significantly higher scores on the exhaustion scale (KEDS) in 2018, and the difference between the groups was accentuated in 2019.

#### 3.2.2. Group 5 (Leave/No Change/Stay) and Group 6 (Leave/No Change/Leave)

In 2018, the principals in Group 5 (N = 52) reported that they had the intention to change workplace within the next two years. In 2019, no actual change of workplace was reported, and they no longer had the intention to change workplace (Figure 1). In 2019, they reported generally better working conditions compared to 2018 (Table 4). The scores of stressful external expectations from the superintendent and the immediate supervisor declined, and the same was true for Role conflicts and Container functions. Group 5 also reported statistically significantly lower scores on the exhaustion scale (KEDS) in 2019 compared to 2018.

*IJERPH* **2021**, *18*, 5376

*IJERPH***2021**, *18*, 5376

 **between**

 **1 and Group 2**

*p***-Value A**

 and McNemar's

 <0.01

 <0.001

 0.42

 0.16

 <0.001

 0.11 **<0.01**

 0.45 **0.03**

 0.90

 0.18 **<0.01**

 0.26

 0.06

 **<0.001**

 **2019**

 analysis.

*IJERPH***2021**, *18*, 5376

test for dichotomous

 variables. C. One person with "other title" in 2019 was excluded from the statistical analysis. D.

Participants with "No agreed working hours" were excluded from the statistical analysis.

The principals in Group 6 (N = 146) reported both in 2018 and in 2019 that they had the intention to change workplace within the next two years, but no actual change of workplace was reported in 2019 (Figure 1). Within the group, there were only minor changes of the reported working conditions and signs of exhaustion in 2019 compared to 2018 (Table 4).

Differences between Group 5 and Group 6: In the survey in 2018, there were no statistically significant differences between Group 5 and Group 6, neither in occupational factors nor in exhaustion (Table 4). In 2019, the principals in Group 5 reported better conditions with regards to stressful external expectations from the immediate supervisor and co-workers, and lower scores regarding Role conflicts and Co-workers' problems, compared to Group 6. Furthermore, in 2019, Group 5 reported significantly lower scores on the KEDS exhaustions scale, compared to Group 6.

**Figure 1.** Longitudinal patterns of intended and actual change of workplace and its association with signs of exhaustion among 631 principals in compulsory schools.

#### 3.2.3. Group 7 (Leave/Change/Stay) and Group 8 (Leave/Change/Leave)

The pairwise comparisons of occupational factors and signs of exhaustion in 2019 and 2018, within and between Group 7 (N = 21) and Group 8 (N = 19), are given in Supplementary Table S2.

#### **4. Discussion**

#### *4.1. Principal Findings*

A general finding based on both parts of the study is that most of the principals with the intention to stay at the present workplace reported better working conditions and a lower mean sum score on the exhaustion scale (i.e., KEDS), compared to those who had the intention to change workplace.

The multivariate analyses indicated that the occupational factors that were most strongly associated with the intention to change workplace, were a demanding bufferfunction between management and co-workers, demanding role conflicts, and a perception of high external expectations from parents. Furthermore, an increased score on the KEDS

exhaustion scale was associated with the intention to change workplace. An intention to stay at the current workplace was most strongly associated with Supportive management and Supportive manager colleagues.

In Part II of the study, the longitudinal analyses indicated that changes in the intention to stay at, or leave, the present workplace showed associations with changes in the working conditions and the level of exhaustion. For example, the principals in Group 2 (Stay/No change/Leave) had no intention to change workplace 2018, but they did have such an intention in 2019. At the same time, they reported an increased Buffer-function, increased Resource deficits, and less Supportive management, compared to 2018. The principals in Group 5 (Leave/No change/Stay) had the intention to change workplace in 2018, but did not report any actual change in 2019. In 2019, they no longer intended to change workplace and also reported reduced Role conflicts, reduced Container functions, less stressful external expectations from the superintendent and the immediate supervisor, and markedly improved scores on the exhaustion scale, compared to 2018. Thus, the present results point to the need for improved working conditions among principals, for their wellbeing and for a reduction in their turnover. The most important preventive measures seem to be improving managerial support, reducing the demanding Buffer-function between management and co-workers, and reducing Role conflicts.

#### *4.2. Methodological Considerations*

A strength of the study is that it involved principals from 277 out of 290 municipalities in Sweden, comprising principals in cities, villages, and schools of all sizes. In this respect, the present participants are likely to be fairly representative of the entire population of principals in Swedish compulsory schools. Whether the conditions reported can be extrapolated to the working conditions among principals in an international context is more uncertain, and probably mostly due to specific circumstances in various countries and cultural settings.

Another strength of the study is the use of multiple methods to address the research questions, i.e., cross-sectional analyses with repeated measurements, together with an analysis of the longitudinal patterns in subgroups of principals with varying intentions to stay, or leave, the workplace. The fact that similar results were found in both parts of the study strengthens its validity.

The present study included principals who participated in training programs for principals funded and arranged by the Swedish National Agency for Education, during the period 2008–2017. Thus, both principals who participated in the training programs before 2008 (most likely older than the average for the study sample), and those who still had not passed the training program (most likely younger than the average) were not included. However, since the study sample is representative of Swedish principals concerning age [31], this might be a minor problem. Another concern is that principals who are better prepared for the positions are supposed to be less stressed and stay longer at the workplace [2]. Thus, the present selection of only trained principals may have resulted in an underestimation of the signs of both exhaustion and the principal turnover.

In the original study sample of principals at all school-levels, 2317 out of the 9900 who were invited responded to the questionnaire, which generated a response rate of 23 percent. However, as the invitation list included principals who participated in the training program in 2008–2017, there may have been an unknown fraction of principals who had left the profession before the first survey in 2018, and thus did no longer belong to the target group. Among the 4640 principals who were successfully contacted, 50 percent responded to the questionnaire. Although similar low response rates are common in largescale surveys [23,32], this is a limitation of the study. Another limitation is that all of the data were self-reported. Furthermore, although it is likely that adverse working conditions in many cases may have preceded the intention to change workplace, the limitations of the study design preclude a definite statement on causal relationships.

In Part II of the study, the described patterns of intended and actual changes of workplace resulted in eight different scenarios/groups. Because some of the scenarios were less common, some of the groups had a limited number of participants. This was the case in particular for Groups 3 and 4, and they were therefore omitted from further analyses. Additionally, the analyses within and between Groups 7 and 8 suffered from a low power, which limited the possibility to detect statistically significant differences, if any were present.

#### *4.3. Signs of Exhaustion*

Several previous studies have shown associations between work environment factors and burnout/signs of exhaustion (e.g., [26,33]), which most likely apply also to the principals in the present study. Thus, it is reasonable to assume that the associations between signs of exhaustion and the intention to change workplace, to a large extent, are mediated through demanding circumstances in the work environment.

#### *4.4. Should I Stay at the Present Workplace* ... *?*

A high score of Supportive management, i.e., that the principals trust that superiors, when needed, will help them solve problems and that they express a genuine interest for the principals' work and leadership, was strongly associated with the intention to stay at the present workplace. As a leader, the principal is the one that is supposed to give support to the staff [34], but the principal, in turn, needs support and guidance from the superintendent or the school owner [14]. Furthermore, a high score of Supportive manager colleagues was associated with the intention to stay. Thus, the present results confirm previous findings that support from colleagues and managers belongs to the factors that are decisive for the will to continue working in the workplace [25,35]. That supportive leadership is an important work environment issue is also confirmed by its protective effect against exhaustion and burnout [19,20,26]. Of course, due to the nature of the data, low scores in the demanding organizational and social work environment factors presented below also represent factors that were associated with the intention to stay.

#### *4.5.* ... *Or Should I Go?*

Among the occupational factors, the strongest association with the intention to change workplace was found for a high score of Buffer-function, i.e., that the principals perceived themselves to be squeezed between co-workers and higher levels in the organization, and that superiors expect them to be understanding and committed to accepting decisions that were bad for them and the organization, and to advocate for such decisions towards their subordinates [30]. The challenge of acting as a buffer function may be related to other factors that were associated with the intention to change workplace, i.e., low managerial support and stressful external expectations from the superintendent and immediate manager. Insufficient managerial support is often reflected as a lack of trust between principals and the actors in the local governance chain [14]. The Buffer-function may also be related to a lack of decision-making authority, (i.e., deficient influence, control, or autonomy to shape decisions and solutions in the school) which has been emphasized to be one of the most important reasons for principal turnover in a US context [2]. Additionally, Resource deficits, reflected by lacking resources due to decisions by superiors, politicians, or governmental authorities, can be closely related to the Buffer-function.

Burdensome Role conflicts among principals may have to do with frictions between administrative work tasks, organizational development, being a pedagogical leader, and taking part in daily activities in interactions with co-workers. Overall, this may result in an excessive workload. Thus, besides a possible perceived sense of inadequacy among principals, the association between Role conflicts and intention to change workplace may be influenced by the complexity of the job and the amount of time needed to complete all necessary activities [2].

A perception of stressful external expectations from parents was associated with the intention to change workplace. According to Leo et al. [14], most parents are supportive. However, among complaints from parents that were reported to the Swedish schoolsinspectorate, a majority concerned children and students who did not receive the support they needed, according to their parents. Responding to complaints was perceived as a stressful and time-consuming task for the principals [14]. The present finding of a high score of stressful external expectations from the Swedish schools-inspectorate can most likely be, and largely is, related to their handling of complaints from parents [14].

The intention to change workplace was more frequent among younger principals than among older ones, and more frequent among assistant principals than in principals. This may partly be explained by young assistant principals accepting an interim and challenging period of hard work as a stepping-stone in order to display merit for a future position as full principal.

Moreover, the dimension Supportive private life comprised questions on the opportunities to rest and to relax from work during leisure time. No statistically significant association was found in the bivariate analysis, but in the multivariate analyses, a high score turned out to be associated with the intention to change workplace. A possible explanation is that a supportive private life might give a principal the inner strength to decide to leave a workplace associated with difficult working conditions and declining well-being and health.

#### *4.6. Possible Implications*

Due to the fact that an unstable management function is associated with a high teacher turnover [1], which in turn may lead to poor results for the students, the situation for principals poses an important societal issue. In order to increase retention among principals, systematic efforts to establish improved working conditions for principals seem to be sorely needed. It is likely that a joint effort along the entire governance chain, i.e., at the national, municipal, and local level, intending to improve working conditions for principals, would be a fruitful endeavor.

#### **5. Conclusions**

A general finding was the clear association between the principals' working conditions and their intention to stay at or leave their current workplace. Poor working conditions in terms of, primarily, a lack of support from management, the feeling of being squeezed between management and co-workers (Buffer-function), and demanding Role conflicts were associated with a consideration to change workplace. At the same time, principals who intended to change workplace reported more signs of exhaustion.

**Supplementary Materials:** The following are available online at https://www.mdpi.com/article/10 .3390/ijerph18105376/s1, Supplementary Table S1: Description of the scales in the 32-item Gothenburg Manager Stress Inventory (GMSI)-Mini, Supplementary Table S2: Comparisons of occupational factors and signs of exhaustion in 2019 and 2018, within and between Group 7 and Group 8.

**Author Contributions:** Conceptualization, I.A., U.L., A.O., K.N., C.H., K.Ö. and R.P.; methodology, I.A. and A.O.; software, R.P., K.Ö. and I.A.; validation, I.A., U.L., A.O., K.N., C.H., K.Ö. and R.P.; formal analysis, A.O. and I.A.; investigation, I.A., K.Ö. and R.P.; resources, R.P.; data curation, I.A., R.P. and K.Ö.; writing—original draft preparation, I.A.; writing—review and editing, I.A., U.L., A.O., K.N., C.H., K.Ö. and R.P.; visualization, I.A.; supervision, R.P.; project administration, R.P. and I.A.; funding acquisition, R.P. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by AFA Insurances, grant number 170094.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by The Regional Ethical Review Board in Lund, Sweden (reg. no. 2018/247).

**Informed Consent Statement:** Written informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Consistent with the study protocol approved by the Regional Ethical Review Board, anonymized data are stored locally at the Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden. In accordance with the ethical approval, crude data are not to be published on the internet. Access to data will be granted to eligible researchers wanting to audit our research. Requests should be directed to the corresponding author.

**Acknowledgments:** The authors wish to thank all participants who responded to the questionnaire.

**Conflicts of Interest:** The authors declare no conflict of interests. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

#### **References**

## *Article* **Meetings are an Important Prerequisite for Flourishing Workplace Relationships**

**Sophie Schön Persson, Kerstin Blomqvist and Petra Nilsson Lindström \***

Faculty of Health Sciences, Kristianstad University, 291 88 Kristianstad, Sweden<EMAIL_ADDRESS>(S.S.P<EMAIL_ADDRESS>(K.B.)

**\*** Correspondence<EMAIL_ADDRESS>Tel.: +46-44-250-39-61

**Abstract:** Relationships among colleagues, managers, and care recipients are mutually important, and need to be highlighted in workplace health promotion. The aim was to explore prerequisites for flourishing workplace relationships in a municipal healthcare setting for old people. As part of this process, we explored the staff's suggestions on how work relationships could be improved. The study had a salutogenic and participatory approach, examining staff perceptions of what was required for flourishing relationships to be created, and their suggestions for the relationships to be more promotive. Four multi-stage focus groups, which met three times each, were conducted with staff (*n* = 26) in old age healthcare settings. A deductive analysis was performed, based on components of the flourishing concept: challenge, connectivity, autonomy, and competence. Informal and formal meetings at work were shown to build positively perceived relationships. The study describes meetings and relationships connected to the four components of flourishing. Suggestions for improving work relationships are also presented. This study contributes to workplace health promotion, and has a salutogenic and participatory focus on how to explore workplace relationships as a resource. The flourishing concept shows how workplace relationships can be explored as prerequisites for workplace health promotion.

**Keywords:** workplace relationships; flourishing; multi-stage focus groups; old age healthcare; participatory approach; workplace health promotion

#### **1. Introduction**

In recent years, there has been an increase, albeit slow, in work-related studies adopting a salutogenic approach [1–5], i.e., focusing on maintaining and/or increasing healthpromoting resources [6,7]. The opposite is to focus on risks of illness, which is a pathogenic approach, and studies that examine risk factors and why people feel bad through, e.g., their work. A significant factor in occupational health is relationships, and research focusing on negative work-related relationships that contribute to ill health is common [8–10]. Therefore, there is value in conducting studies with a salutogenic approach, that in different ways and from different theories examine the workplace as a health-promoting arena to understand which factors and processes can increase sustainable work-related relationships and employees' health [11–13].

Workplace health promotion focuses on factors and processes (resources) as prerequisites for doing well and feeling good at work [12]. One resource is relationships, and these could be among colleagues, managers, and, in a healthcare context, also the care recipients [3,4,14–17]. Studies about relationships at work from aspects of teamwork and communication, also in relation to a higher quality of care [18,19], are more common. However, the various interaction patterns that underlie the effects of relationships on individual health and well-being, the processes through which these effects occur [20,21], and which specific aspects of positive workplace relationships contribute to health appear to be less explored [2,15,22].

**Citation:** Persson, S.S.; Blomqvist, K.; Lindström, P.N. Meetings are an Important Prerequisite for Flourishing Workplace Relationships. *IJERPH* **2021**, *18*, 8092. https://doi.org/10.3390/ ijerph18158092

Academic Editors: Kerstin Nilsson, Tove Midtsundstad, Peter Lundqvist, Joanne Crawford and Nygård Clas-Håkan

Received: 22 June 2021 Accepted: 16 July 2021 Published: 30 July 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

Therefore, the specific aspects of relationships at work need to be further explored. A salutogenic concept that could be used to understand which aspects contribute, in a deeper sense, to positive relationships at work, is flourishing. Flourishing, as a concept, has theoretically been described by several authors in recent years. At first, it was more individually focused and used in terms of the state a person achieves when attaining the highest levels of functioning in life and perceiving psychosocial health [23]. Seligman (2012) likewise focused on the individual's well-being as a key to flourishing, but also identified relationships as one of the key elements. He highlighted five key elements of well-being that people need in life to be able to flourish: positive emotions, engagement, relationships, meaning in life, and accomplishment (PERMA) [24]. McCormack and Titchen (2014) confirmed that relationships are an assisting and important factor for flourishing. They argued that it is the interconnections between a person's health experience (physical, psychical, social, spiritual), creativity, and purposeful interactions with others, that create flourishing [25].

Later, Gaffney (2015) described from a practical point of view how flourishing could be identified and developed, and presented four important components of flourishing. The first of these is challenge. A challenge can come from oneself or from another person; it may be positive or negative; and people have different approaches for meeting and managing a challenge depending on different factors in their lives. The second component is connectivity, which is about feeling connection to oneself, to one's surroundings, and/or with other people. The third component is autonomy, which is about feeling sufficient control and having a choice about things that matter to oneself. The last component is about using one's own competencies such as intelligence, strengths, and experiences gained from challenges. Flourishing has its foundation in the circumstances and situations that enable persons to meet challenges in life and that enable them to flourish by viewing upcoming situations with optimism [26].

A situation that many individuals find themselves in on a daily basis is the work situation. When Colbert et al. (2016) applied flourishing to a work situation, they saw that workplace relationships played a key role in promoting employee flourishing. Work relationships promoted personal growth through friendship, and the opportunity to give to and help others in a work situation. Positively experienced workplace relationships also increased job satisfaction and feelings of meaningfulness at work, supported overall life satisfaction, and had benefits for both individuals and organizations by creating flourishing [27]. However, the need to further investigate the flourishing components for employees in a workplace context has been highlighted [27,28].

From previous theoretical descriptions of the associations between flourishing and relationships [23–25], together with Gaffney's (2015) practical description [26], there is both a theoretical and a practical benefit to further investigating the specific aspects of positive work relationships with flourishing as a salutogenic concept.

In summary, the introduction has highlighted that there are limited health promotion studies with a salutogenic approach concerning (a) what is required for positive workplace relationships to develop, (b) how positive workplace relationships can be enhanced, and (c) what aspects of positive relationships are already provided in work. Thus, there is a gap to fill to extend the knowledge of how workplace relationships can improve employee health and thereby also the care of care recipients.

The aim of this study was to explore prerequisites for flourishing workplace relationships in a municipal old age healthcare setting. As part of this process, we also explored the staff's suggestions on how work relationships could be improved in their work situation.

#### **2. Materials and Methods**

#### *2.1. Context and Participants*

As the number of elderly people is increasing [29,30], it is important to be able to provide elderly care with competent staff in the future. Therefore, the current study was conducted in an elderly care context. In Swedish municipal old age care settings, nurse assistants work either on a day shift or night shift, and provide regular as well as palliative care. The managers, registered nurses (RNs), occupational therapists and physiotherapists at the residential care units usually work during the daytime on weekdays [29,30].

This study is the final part of a participatory action research (PAR) project, and was conducted in two similar general residential care units in the south of Sweden during the period 2015–2016. The selection of units for participation was made in consultation between researchers and managers. The two chosen residential care units together had about 39 residents. Altogether, four working groups, one day shift team and one night shift team from each unit, were asked to participate. The care units employed only assistant nurses, and it was those who worked in the units who were included in the study. Nurses and other care professions were employed in another department and were therefore not part of this study. All 31 assistant nurses in the four working groups were invited to participate in the study, and 26 took part. In the Results section and thereafter, we refer to the participants as "caring staff".

#### *2.2. Procedure*

With our salutogenic approach, we wanted the study to be participatory and emancipatory, to give advantage to the participants in their work situation by their participation. Therefore, the study was based on methodology for PAR. A participatory approach has the intention to enable participants to extend their understanding of issues and to empower them to use their new knowledge [31]. Previous studies in this research project also investigated workplace relationships using a salutogenic approach [3,14,15]. In these studies, the meaning and significance of workplace relationships were investigated in relation to staff, managers, and care recipients. The findings showed key aspects of relationships in the workplace, see Table 1.

**Table 1.** Examples of statements made in multi-stage focus group discussions about workplace relationships with care recipients, colleagues. and managers.

#### **Positively Experienced Relationships with Care Recipients**

There is a value in sharing one's own everyday events with the care recipients.

A deeper relationship allows for more trusting conversations and is important for understanding each other's situation better. With a deeper relationship it is easier to meet and see the care recipient's needs.

Being appreciated by the care recipient makes me feel needed and makes my work feel meaningful.

#### **Positively Experienced Relationships with Colleagues**

I feel good about having an opportunity to air my views and feelings about matters concerning the work with my colleagues. I get a lot out of being able to feel community (trust, pride, harmony) with my colleagues.

It is important that the work flows well, and that we have good cooperation and good understanding for each other.

It is important that I feel respected by my colleagues.

#### **Positively Experienced Relationships with Managers**

I appreciate it when the manager feels like "one of the group".

It is important to me that the manager is open (e.g., dares to ask for help; is open to new suggestions and questions).

It is important that the manager delegates or leaves new tasks to me, because then I develop.

It is important that the manager listens to me and sees my work, because then I feel security/trust.

It is important that the manager gives me encouragement and motivates me, because then I become engaged.

It is important that I can see that my work is a part of a greater whole (in the organization).

In the current study, we wanted to further explore how these findings could be used for a health-promoting purpose in practice. To put previous results to practical use for the participants themselves, multi-stage focus groups were formed [32]. The multi-stage focus group method is characterized by the same group exploring a question or phenomenon in depth over the course of several meetings. Letting the same group meet multiple times allows participants to get to know each other in a deeper sense. A sense of shared history develops, which distinguishes the multi-stage focus group from a normal focus group that usually meets only once. Through multiple meetings the discussions in the group

can further expand and different problems can be addressed to achieve a higher level of abstraction. Multi-stage focus groups were chosen because the method itself can contribute to emancipation within the working group through ongoing discussions. Multi-stage focus groups can also be a way to create sustainable change in the workplace, as the method recognises the local context and uses the participants' experiences. Therefore, the method was considered suitable for PAR.

During information meetings in the spring of 2015, one of the researchers (S.S.P.) verbally invited potential participants to participate, informing them about the study and handing out written information. The intention of the information meetings was to increase interest in and motivation for participating in the multi-stage focus groups. The multistage focus groups were conducted from September 2015 to January 2016. Each group consisted of assistant nurses from the same working groups, as the intention was to enable dialogues in which the participants would describe experiences, share thoughts, and create suggestions for how to achieve improvements. Each group met three times and between two and nine persons attended each meeting. The focus groups lasted 70–120 min and were held in meeting rooms at the participants' workplaces. One problem with multi-stage focus groups is that it cannot be expected that all participants can attend all meetings [32]. To keep everyone updated on the process, each meeting began with a brief recap of what had been discussed last time. Those who had not attended the previous meeting were given a report of what had been discussed. However, all participants in this study attended at least two of the three meetings.

As a starting point, statements about positively experienced relationships with care recipients, colleagues, and managers were used (see Table 1). Our intention with this was to let the participants choose the subjects that were most important for them to discuss in relation to workplace relationships, rather than selecting subjects that we researchers found the most interesting. The statements were based on previous studies of positively experienced workplace relationships [3,14,15].

One researcher acted as a moderator and the other researcher (either P.N.L. or K.B.) acted as an observer. The moderator (S.S.P.) steered all the multi-stage focus group discussions by asking questions about experiences of what is required for workplace relationships to flourish, and by urging the participants to make suggestions for how to improve the workplace relationships. The observer made a written summary of the content and interaction in the group, asked for clarifications, and urged reflections in the group. Both researchers did their utmost to allow all participants to speak freely but still to guide the actual content of the discussion. At the end of each focus group, the researchers made a summary of the suggestions for improvements that had emerged, and this summary was followed by a discussion within the group about how the staff could proceed to realise their suggestions in their unit.

#### *2.3. Analysis*

Initially, all the researchers read the interviews several times and discussed them together. The interview material was thereafter read with a view to identifying different kinds of relationships: relationships between caring staff colleagues within the team; relationships between the day and night shift care workers; relationships between caring staff colleagues and other occupational groups such as RNs, occupational therapists, and physiotherapists; and relationships between caring staff colleagues and the manager. Upon further examination, we saw a pattern emerge, in that the specific relationships were connected to two types of meetings: informal and formal meetings. Therefore, the material was sorted into the two content areas: Informal meetings and Formal meetings.

After reading and discussing the material further, a deductive content analysis [33] was carried out, using a modified version of Gaffney's (2015) description of the four flourishing components [26]. We related the components of Gaffney to a work situation and workplace relationship processes as follows: (1) challenges, which refers to challenging situations in everyday work that have to be faced and managed to enhance relationships; (2) connectivity, meaning concrete actions or suggestions needed for the work relationship to be mutual; (3) autonomy, which refers to the employee's self-determination and freedom to act in work situations; and (4) competence, which relates to an expression of feeling needed and able to use personal as well as professional skills at work.

Finally, within each kind of relationship, the four key components of the concept of flourishing were applied. To identify challenges, connectivity, autonomy and competence in each relationship, the following questions were asked when examining the material: Challenges: Which relational challenges are expressed? Connectivity: Which concrete actions or suggestions are expressed, and how are the mutual relationships described? Autonomy: How is the employees' job autonomy described? Competence: Which competence is described, and how can it be used?

#### *2.4. Ethical Considerations*

The written information given to the participants covered the aim of the study, the focus for the discussions in the multi-stage focus groups, and included an assurance that participation was voluntary and that data would be handled confidentially. The researchers emphasized the importance of the discussion within the focus groups remaining confidential. This information was given again at the start of each focus group.

The participants were given the opportunity to participate by their managers, but they also had the opportunity to decline without the manager knowing about it. The study was conducted in agreement with the Swedish Ethical Review Act, SFS 2003:460, and was approved by the Ethical Review Board of Lund, Sweden (dnr: 2015/565).

#### **3. Results**

In this section, the various workplace relationships at meetings are described and how they relate to the four components of Gaffney's (2015) concept of flourishing [26]. Two main categories emerged in the analysis: Informal meetings as a prerequisite for flourishing and Formal meetings as a prerequisite for flourishing. The staff described their experiences of what was required for positive workplace relationships to occur, and also made suggestions for how to improve workplace relationships. These suggestions are presented at the end of each workplace relationship.

#### *3.1. Informal Meetings as a Prerequisite for Flourishing*

Based on the participants' descriptions, informal meetings in daily work consisted of small talk and non-work-related conversation going on all the time between people. Informal meetings took place during work but also during breaks. Our results show that most informal meetings took place (1) between caring staff colleagues; (2) between the caring staff and the RNs; and (3) between the caring staff and the manager.

#### 3.1.1. Informal Meetings between Caring Staff Colleagues

Informal meetings between caring staff colleagues mainly occurred during breaks but sometimes also during work. Regarding the relationship between caring staff colleagues, the participants described how the challenge was to maintain good interactions with and trust between each other. Connectivity was achieved when the caring staff felt they could be open with each other and that they were able to both give and take criticism. When there was good interaction between staff, the work had more flow. Everyone took more responsibility and became more self-motivated, which contributed to increased autonomy. When the colleagues in the group knew each other, they felt more confident in work situations, as everyone's competence was better used at work. The participants described good interaction between colleagues as a resource for high quality of care, allowing everyone to use their particular competence well.

Suggestions for quality improvement were to make time for joint breaks. The participants expressed how they longed for breaks with their colleagues as this was a time to air

their views and feelings, talk about difficult work situations, and have a nice time and also talk about private matters.

#### 3.1.2. Informal Meetings between Caring Staff and Registered Nurses

Informal meetings between the caring staff and RNs occurred mainly when the RN showed up at the ward. In the relationship between caring staff and the RN, the challenge was to organize informal meetings between the two. The caring staff often perceived the RN as absent from the daily work, so that informal meetings and conversation were hard to achieve. An example of a relationship as a resource was when the RN showed up at the ward just to ask if the caring staff had any questions or support needs. Another example was when the RN was available on the phone and the caring staff felt safe to call and ask about things. Such relationships between the RN and the caring staff were considered to contribute to connectivity. With stable connectivity in the relationship, the caring staff's autonomy was considered to increase; for instance, the caring staff would feel confident about making decisions on their own if required. When the RN involved the caring staff in decisions about care recipients, they felt that their competence in the organization was not only being used but also increased. By taking advantage of the staff's joint knowledge about the care recipients, the RN made the caring staff feel needed.

A suggestion from the caring staff was to introduce a notebook at the ward as an easy way to note and collect questions or information to the RN without having to leave the ward to ask the RN for advice in every single case.

#### 3.1.3. Informal Meetings between Caring Staff and the Manager

Informal meetings between caring staff and the manager occurred mainly during breaks. Challenges in the relationship between the caring staff and the manager were to create mutual respect between the two, to make the manager understand the importance of being fair, and for the manager to treat everyone equally and to express their expectations clearly. The participants said that when the manager dared to be a manager with clear directives, and when expectations were clearly stated, this created connectivity between the caring staff and the manager. When the caring staff felt respected and taken seriously, and when the manager showed respect for the caring staff's thoughts by listening and being part of the work group, autonomy was strengthened. When the manager asked the caring staff for their opinions, the participants felt that their competence was put to use in the organization and that their knowledge was considered important.

A suggestion from the caring staff was that the manager should have more open discussions with the caring staff, for instance, about planning and routines for temporary staff.

#### *3.2. Formal Meetings as a Prerequisite for Flourishing*

According to the participants, formal meetings had a defined time and agenda. Formal meetings were staff meetings, care planning meetings. and daily report meetings. Formal meetings were held: (1) between the caring staff colleagues; (2) between day and night shift workers; (3) between the caring staff and other occupational groups; and (4) between the caring staff and the manager.

#### 3.2.1. Formal Meetings between Caring Staff Colleagues

Formal meetings between caring staff colleagues were mainly staff meetings. One challenge was to plan formal meetings with time to talk about issues in the caring staff group's daily work and routines. In other words, the caring staff needed their own time to talk about matters that were important to them without the manager present. To have the opportunity to discuss freely was described to contribute to connectivity. By discussing work routines and their caring activities, the participants felt that they grew as professionals together. They also said that discussions between colleagues contributed to autonomy. It was described that the "any other matters" item on the agenda at staff meetings provided an opportunity to speak as a group, which increased the caring staff's ability to use their competence at work in a better way.

A suggestion from the participants was that they should have their own time at staff meetings, without the manager present, to be able to address issues that only concerned the caring staff.

#### 3.2.2. Formal Meetings between Day and Night Shift Caring Staff

Formal meetings between day and night shift staff were mainly care planning meetings. However, they were difficult to arrange because of different working hours and therefore were rarely scheduled. A challenge between night and day staff was to be open to each other's different work situations. Many routines hindered an understanding of each other's different work circumstances, but also led to an unawareness of each other's work. Another challenge was to create a sense of belonging between the night and day shifters. Even if they were working in the same place and with the same care recipients, the participants did not really feel that they were a united team. When the overlap between night and day shift worked well and the groups sat down together to review what had happened during their shift, feelings of connectivity between the night and day staff arose. Autonomy was increased when the meeting between night and day staff provided an opportunity to talk about something that had happened and to explain, or get an understanding of, why a task (e.g., cleaning) had not been performed.

A suggestion was to arrange discussions between day and night staff to adopt common goals and missions and make everyone aware of the importance of a common approach, not only for their own wellbeing but also for the benefit of the care recipients. By discussing these issues, everyone's competence could be strengthened. A further suggestion from the participants, regarding how the relationship could be strengthened and used as a resource, was that working hours between shifts should overlap a bit more to give a better opportunity to meet and talk to each other, now this time was experienced as too short.

#### 3.2.3. Formal Meetings between Caring Staff and Other Occupational Groups

Formal meetings between caring staff and other occupational groups largely consisted of care planning meetings. In the relationship between the caring staff group and other occupational groups such as RNs, coordinators, physiotherapists, occupational therapists, and staff at the hospital, the challenge was to create respectful verbal and also written communication. Cooperation and discussions with professionals from other occupational groups at formal meetings were found to contribute to connectivity.

Suggestions for how to improve connectivity were to have structured follow-ups and dialogues about the caring work together with other occupational groups. When these dialogues worked well, the feeling of participation and autonomy increased. The participants suggested, in addition, regular common discussions about how staff should act in difficult work situations, and clearly stated routines and values when the caring staff had to make their own decisions in challenging work situations. The participants expressed a desire to use their caring competence by cooperating with other occupational groups and believed this would be a way to improve the quality of care.

Other suggestions from the caring staff were to preserve and develop the meetings with the RN on a weekly basis, focusing on individual care recipients, and that the RN should be present in the mornings at the overlap meetings between night and day shifters.

#### 3.2.4. Formal Meetings between Caring Staff and the Manager

Formal meetings between the caring staff and the manager mainly took place at staff meetings. The challenge in formal meetings with the manager was to save meeting time during staff meetings to talk about important matters, mainly relating to how to improve the care of the care recipients. However, the participants said that much time during these meetings was spent on financial and information issues, which was not always perceived as the most important by the caring staff. Another challenge was to get the manager to stick to decisions and provide the same information to all the working groups, as they did not have staff meetings together. A manager who took the experience of the staff into consideration during discussions was regarded as contributing to connectivity between them. When they felt listened to, the participants experienced that their autonomy was strengthened. If the manager discussed their work and work situation with them, their skills could be better used in their work and they thereby felt that their competence was used.

A suggestion from the caring staff was that the manager could provide more written information instead of oral information during staff meetings. This would make more time available for important discussions between the manager and the caring staff about the care recipients and the daily caring work and aspects of the work situation.

In summary, a methodological result of the study process with multi-stage focus group meetings is that this method had an emancipatory effect, as all participating groups decided to proceed with their own suggestions and tried to put them into action at their wards. In order to give an overview on concrete examples of improvements, we condensed all the staff's suggestions and related them to the various relationships, and informal or formal meeting type (see Table 2).

**Table 2.** The two categories of meetings that lead to flourishing of different work relationships, and participants' (condensed) suggestions for improvement work.

Note: Registered nurses (RNs).

#### **4. Discussion**

Positive relationships characterized by challenge, connectivity, autonomy, and competence could have an enhancing effect on employees' health and could be useful as a starting point in workplace health promotion to develop a flourishing workplace for care professionals. To achieve this, conditions need to be created for both informal and formal meetings based on the staff's experience.

Informal and formal meetings with colleagues, other occupational groups and the manager are important for enhancing employee health. While the informal meetings in this study group were important for the ability to exchange information and make everyday decisions, the formal meetings had a predetermined agenda and gave an opportunity to discuss issues relating to the care recipients. A common factor in informal and formal meetings was the experience of support and belonging, and being able to exchange thoughts and share feelings in the different meetings. This was important, not only for job performance, but also for well-being at work. This supports previous research suggesting that a workplace atmosphere that allows open-mindedness and a positive social climate is a resource for making work comprehensive, manageable, and meaningful [2]. Furthermore, in order to create sustainable workplaces and an organization with flourishing individuals, it is important to build a work structure based on positive relationships [13,27,34,35]. To achieve this, well-thought-out strategies for informal and formal meetings in the workplace are required.

Strong relationships with colleagues and managers and positive relationships with care recipients are closely linked. Our results showed that positive informal and formal meetings seemed to have a dual purpose. They made the staff themselves flourish at their workplace, but they were also a prerequisite for providing good care and having positive relationships with care recipients, which was also central to their own well-being. In the focus groups, the caring staff rarely talked about relationships with care recipients. Instead, they spoke about relationships with colleagues, professionals from other occupations, and managers. The caring staff chose to talk about their workplace relationships, not primarily to improve their own well-being but to achieve improved relationships with care recipients as a way of providing better care, which ultimately improved their own well-being. In human care professions, when employees are faced with high emotional demands [34], awareness of types of work relationships and why they function as a resource and as a prerequisite for flourishing is valuable.

A salutogenic approach to workplace health needs to emphasise positive relationships based on respect, security, and reciprocity. One interpretation of our study results is that there existed more of a "we-feeling" between caring colleagues working the same shift and more of an "us-and them feeling" between people from different shifts and representing different care professions. The we-feeling contributed to togetherness among the caring staff and created flow and confidence at informal meetings. This "we-feeling" of togetherness also contributed to good formal meetings because of respect, security, and strong reciprocity. Such a sense of belonging and security has also been shown in previous research [3] to contribute to well-being as well as recognition of self-worth. On the other hand, the results in this study also showed more of an "us-and-them feeling" in the relationships with caring staff from other shifts, the manager, and other occupational care groups. Hence, a major part of the challenge of turning the relationships with the manager and other occupational care groups into a resource seemed to lie with the organizational structure, as physical meetings in daily situations were sometimes considered inadequate. If an organization relies on interactions between people, relationships should be emphasized as more important to the organization than, for instance, organizational principles and structures [36]. By using the relationships as a tool for the development of the organization and by having a less hierarchical structure—a structure that is based on a democratic mindset between different professions—everyone's competence can be anchored in the overall organization and everyone can work towards the same goal [35]. This salutogenic approach may in turn benefit the flourishing of the individuals, and the organization [27,28].

#### *4.1. Practical and Theoretical Implications*

In this study with a salutogenic and a participatory design, practical and theoretical implications where deeply intertwined. A theoretical implication is that the concept of flourishing, and its four specific components, can be used in practice to identify, interpret, and explain positive relationships, and situations and elements of a workplace that affect employee health. The components of flourishing have links to the three components of motivational needs in Ryan and Deci's Self-Determination Theory (2000): autonomy, competence, and belongingness [37]. These three components create inner motivation for the individual to act in situations or in relationships that are important for health experience and well-being. There is also a connection between the concept flourishing and the model of person-centredness [28]. Person-centredness is usually discussed in relation to care, but an organization can also work in a person-centred manner with its employees and in the organization of work. Different dimensions of relationships at work become important to understand and improve, as relationships are vital for flourishing. Healthful relationships among employees may thereby also contribute to a person-centredness culture.

A practical implication is to use meetings, both formal and informal, as a means to enhance relationships in everyday practice. Conditions for meetings provide the opportunity for people to share experiences and get to know each other in the work group, which in itself contributes to a health-promoting workplace [14,15,38]. Using the concept of flourishing both in the planning of work tasks and in issues concerning the psychosocial work environment, could contribute to a flourishing and sustainable workplace. Using the four components in formal meetings enables the creation of a clear model to show what challenges and suggestions have emerged, and thus makes it possible to develop connectivity, autonomy, and use of competence in an optimal way. The identified challenges and suggestions for improvements can, for instance, undergo process evaluation at the staff meetings, in order to make the relationships a resource for the flourishing of individuals and the organization alike. It is advantageous to base dialogues on the four flourishing components to highlight both the salutogenic aspects and the challenges to creating a sustainable workplace that causes the individual workers to flourish. Previous research about using dialogue as a tool has shown that a structured dialogue model makes it easier to notice what is happening in daily work relations and provides the possibility to work in a promoting way [38].

Furthermore, a practical implication of informal meetings is to create conditions for things such as joint breaks. Conditions for informal meetings contribute to the opportunity for the staff to share their thoughts and feelings about different work situations. This promotes social relationships and the opportunity to give each other more support in everyday practice. Relationships can function as a job resource that helps employees to manage strain and job demands [39]. Especially in human-related work, such as healthcare, work tasks are often challenging and energy-draining, on the one hand, and energy-giving through daily human meetings, on the other [34].

Regardless of the subject, dialogue is essential in research with a salutogenic and participatory approach. In this study the dialogues in the multi-stage focus groups developed during the study process and had the effect that all groups decided to proceed with the suggestions and try to put them into action. Our interpretation is that the groups themselves, based on the participatory approach, were an enhancing action for the workplace relationships among the healthcare staff. This further justifies dialogue as useful in improvement work to achieve a health-promoting workplace. This should be taken into account in public health and workplace health promotion, considering society's rationalisation efforts, according to which, meetings should be minimized and must be effective and production-oriented.

#### *4.2. Limitations and Trustworthiness*

The methodological aspects of credibility, dependability, and transferability need to be considered for a study to be seen as trustworthy [40]. From a credibility perspective, multistage focus groups were considered appropriate for this study, as it was hoped they would create a reflective environment for the participants, be emancipatory, and yield detailed data. Although a situation where the participants know each other very well can lead to a lack of discussion, a sense of security within the group facilitates a trustful discussion where participants feel free to share their feelings, thoughts, and perceptions [41]. If the study is to be repeated in the future, the focus group method may need to be modified according to any current pandemic restrictions, for example, by offering digital participation or smaller group sizes. Results obtained using a deductive analysis approach can be questioned from a credibility point of view [40], as the deductive analysis brings a risk that unexpected results may be neglected. However, the participants' reflections and suggestions were often unexpected. Among the unexpected results was the large gap in the relationship between night and day staff. We were also surprised that the relationship with care recipients was hardly discussed. At the meetings, the participants instead focused on the relationship with their colleagues since a good relationship with their colleagues and the manager was a prerequisite for good care and a positive relationship with their care recipients. Being a

study with a participatory approach, the weakest part is perhaps the lack of follow-up of whether the participants' suggestions for changes were introduced and how they turned out. This weakness was due to limited time for the project.

The researchers have nursing and public health backgrounds, which strengthens the credibility as it enhanced the possibility to see things from different perspectives. The fact that all researchers participated in the analysis and that there was high agreement between them also strengthens the study's credibility. Similar issues were discussed in the four focus groups, which demonstrates dependability. The transferability of the results is enhanced by descriptions of the study context, the participants, and the procedure and analysis process [40].

#### **5. Conclusions**

In view of the increased rationalization in society, in which meetings are minimized and are required to be strictly effective and production-oriented, our results regarding the importance of informal and formal meetings and work relationships need to be taken into account if we aim to create sustainable health-promoting workplaces. This study contributes to workplace health promotion research with its salutogenic and participatory approach and represents a new opportunity to explore and understand workplace relationships as a resource by strengthening, or maintaining, positive activities and processes. It is therefore vital to develop dialogues about relationship processes, and raise awareness of the importance of different relationships for improving the work situation and healthcare. The study also shows that the components of flourishing could be used to create a model for such dialogues. Taking the employees' own experiences into account in group dialogues seems to improve employee engagement and could be a fruitful way to conduct workplace health promotion interventions. However, further studies are required to explore the utility of our results in intervention studies, in various workplace settings, between night and day shifts, and among different occupational groups.

**Author Contributions:** Conceptualization, S.S.P., K.B. and P.N.L.; methodology, S.S.P., K.B. and P.N.L.; formal analysis, S.S.P., K.B. and P.N.L.; writing—original draft preparation, S.S.P.; writing review and editing, K.B. and P.N.L.; supervision, K.B. and P.N.L. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethical Review Board of Lund, Sweden (dnr: 2015/565).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Not applicable.

**Acknowledgments:** We would like to thank all the healthcare staff who participated in this study. We would also like to thank the research platform Collaboration for Health at Kristianstad University, Kristianstad, Sweden, for financial support.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

## *Article* **Nurses' Work-Related Mental Health in 2017 and 2020—A Comparative Follow-Up Study before and during the COVID-19 Pandemic**

**Cicilia Nagel 1,2,\* and Kerstin Nilsson 1,2**

**Abstract:** The COVID-19 pandemic put a lot of strain on healthcare organizations. Nurses account for over 50% of healthcare staff, and how nurses perform in their work is influenced by a number of human and work environmental factors. However, to our knowledge, there has not been a previous study with the intention to look at all areas that affect a sustainable working life and how these impact nurses' mental well-being. The aim of this study is to investigate the association between, and the effect of, different factors in nurses' work situations associated with nurses' work-related mental-health diagnoses, before and during the COVID-19 pandemic. A questionnaire was sent out to all 9219 nurses in the Swedish county of Skane in the spring of 2017 and during wave two of the COVID-19 pandemic in the fall of 2020. The data were analyzed through logistic regression analysis. The results showed that lack of joy in the daily work, an increased workload and lack of support from co-workers had an increased association with work-related mental-health diagnoses. Future research regarding the long-term impact of COVID-19 on all areas of nurses' professional and personal lives is needed.

**Keywords:** work-related; mental-health diagnoses; work situation; work environment; nurses

#### **1. Introduction**

Healthcare workers around the world, primarily the nurses, were on the frontline of the Coronavirus pandemic that started in 2019 [1]. The second wave of the pandemic in Sweden occurred during the fall/winter 2020, the most serious wave of the pandemic regarding the burden on the healthcare sector. The pandemic has been described as a gigantic strain experiment on healthcare organizations, especially on healthcare staff due to exposure to hazards, such as psychological distress, fatigue, and trauma [1–5]. Healthcare workers had to perform their duties and face higher risks to their own health, such as the risk of infection [1]. Many nurses were afraid to become ill and die of COVID-19, which was incredibly stressful [6].

Nurses comprise half of the global health workforce [7,8]; however, for much of the general public, it is not fully understood what nurses do. Being a nurse includes promoting health, preventing illness as well as caring for people who are ill, disabled and dying. Advocating patients' rights, promoting a safe environment, conducting and/or taking part in research and education are also key nursing roles [9]. Nurses are often the first healthcare staff that the patient encounters. Their roles may vary depending on workplace, but often include triage, early recognition of life-threatening conditions, administration of medications, performance of life-saving procedures and initiation of early referral [7]. Despite nurses being a common profession in healthcare, there is an increasing demand for nurses worldwide [8]. According to the World Health Organization (WHO) [7], one out of six of the world's nurses are expected to retire in the next 10 years. Several countries experienced

**Citation:** Nagel, C.; Nilsson, K. Nurses' Work-Related Mental Health in 2017 and 2020—A Comparative Follow-Up Study before and during the COVID-19 Pandemic. *IJERPH* **2022**, *19*, 15569.

https://doi.org/10.3390/ ijerph192315569

Academic Editor: Paul B. Tchounwou

Received: 30 September 2022 Accepted: 22 November 2022 Published: 23 November 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

a lack of healthcare workers prior to the pandemic and many nurses are considering leaving the profession [10]. There is a serious nursing shortage in most European countries, which is insufficient to meet current healthcare demands [11,12]. Due to an ageing population, healthcare demands are predicted to increase, resulting in an estimated worldwide shortage of almost 6 million nurses by 2035 [7]. The ageing segment of the population is rapidly expanding and, thus, consuming more health services. Unfortunately, fewer new nurses are entering the work force; therefore, providing a healthy work environment to retain nurses in their workplace is essential for sustaining the profession [13].

Being able to work has a significant positive impact on people's health, and healthy workplaces are beneficial not only for employees but also for organizations and for society [14]. Decent work is one of the UN Global Goals for sustainable society development [15]. A sustainable work situation for employees is significant for a healthy organization that attracts people to work as well as promoting better health for employees, thus, also giving a better possibility for employability to an increased age [16–19]. Working in a hospital can be complicated due to the interaction between patients, nurses and the organization. This can, under normal circumstances, cause problematic work situations, but during the pandemic this was likely even more of a factor. It is, therefore, important to detect problems and shortcomings in the work situation in order to improve and support healthy and sustainable employability and understand what measures need to be taken. Areas of employability, and whether individuals can and want to work or not, has been stated as nine impact and determinant areas connected to sustainable healthy working life in the SwAge-model [6,16–19], i.e., (1) the employees self-rated health and diagnoses; (2) factors in the physical work environment; (3) factors in the mental work environment; (4) having time for recuperation within the employees' working hours, breaks and work pace; (5) the personal financial situation; (6) the employees' personal social environment outside of work; (7) the work social environment at the workplace, with leadership, colleagues, etcetera; (8) factors related to whether the employee experiences stimulation and motivation within work tasks and appreciation from the organization/work place regarding their performed tasks; (9) if the employees' have the right competence, skills and possibility for knowledge development in work.

As earlier mentioned, nurses play a key role in delivering care to patients [11]. How the nurses perform in their work environment is influenced by a number of human and environmental factors, including the type of information available, work experience, ambiguity, unpredictability, conflicting goals and time pressure [20]. Nurses face a higher risk of developing negative mental states, such as depression, anxiety and stress [21], due to the nature of their work. Unlike depression, burnout is specific to an individual's relationship to his or her occupation and usually results from long-term exposure to occupational stress [22]. Burnout may lead to adverse outcomes, such as medical errors, suicide, depression and absenteeism [23,24]. It is known that stress and burnout are factors that can contribute to a decreased mental health [10,25]. The ICN [26] states that long and stressful shifts severely impact nurses' mental health, resulting in nurses leaving or planning to leave the profession. Stress and burnout were recognized internationally as work hazards for nurses even before the pandemic [27]. Some argue that burnout in itself is a form of mental illness. However, a more common assumption has been that burnout causes mental dysfunction, such as anxiety and depression [28]. Temporal, physical, emotional and mental workloads, as well as job stressors such as time pressure, have in previous studies been positively associated with negative stress and burnout symptoms [28,29]. Previous studies have stated that nurses' work environments contribute to high stress, job dissatisfaction and burnout [30,31]. Additionally, a previous study also stated that healthcare professionals (HCPs) in hospitals engage in many work-related tasks and experience relatively high levels of mental stress while caring for patients [32], while another study showed that workload and work pressure have an impact on job outcomes and quality of care [33]. Problems within the nurses' working environments are described as concerns over inadequate staffing, ability to provide safe care, working long hours with high levels

of fatigue and a sense of not being valued or involved in decision-making processes concerning patients [34–36]. Mental ill health has, in previous studies, been associated with different factors, such as long hours worked, work overload and work pressure, lack of control over work, lack of participation in decision making, poor social support as well as poor support from managers and an unclear work role [10,28,37]. Repeated exposure to stressful patient-related situations makes nurses especially susceptible to stress-related outcomes, such as emotional exhaustion and post-traumatic stress disorder (PTSD) [38]. Stress-related outcomes in nurses can lead to grave consequences, including depression, lower job satisfaction, increased risk of medical errors, lower productivity and higher turnover intentions [28]. Ignoring the signs of anxiety and depression presented by nursing professionals could increase physical and emotional stress for the individual but could also result in low quality patient care and higher work burden on the organizations [18].

However, even though there are investigations into nurses' stress related to health and work environment, to our knowledge, there are no previous investigations on nurses´ total work situation, i.e., that investigates all areas of impact and determination for a sustainable working life, before and during the COVID-19 pandemic. It is, therefore, important to investigate what effect the COVID-19 pandemic had on healthcare organizations' impact and determinant areas associated with nurses´ work-related mental health diagnoses.

The objective of this present study is to investigate the association between workrelated mental-health diagnoses and different factors in nurses' work situations before and during the COVID-19 pandemic. We want to test the hypothesis that there are no differences in nurses' work related mental-health diagnoses in 2017 and 2020. The specific research questions are:

This study also wants to increase knowledge and suggest measures against staff shortages and future challenges in healthcare.

#### **2. Materials and Methods**

#### *2.1. Design*

This longitudional study is part of a greater research programme, "Sustainable working life for all ages" [19,39]. In the spring of 2017, a baseline survey was performed where links to an online survey were sent out to all healthcare staff in the Swedish Region of Skane via their work e-mail. The follow-up study was performed in the fall of 2020, where all healthcare staff who were employed in 2017 and that were still employed in 2020 were invited to partake in the online survey.

#### *2.2. Study Population*

A link to a web survey was sent out via work e-mail to all employees in the Healthcare sector in the Swedish region of Skane, that is to all physiotherapists, occupational therapists, doctors, psychologists, nurses (including specialties such as midwife, CRNA, O.R nurse), nurse aids, etc. In total, the link to the 2017 survey was sent out to 22,935 employees, out of which 11,902 completed the survey. In this study, we will look specifically at nurses. In 2017 there were 9219 nurses (including specialist nurses) employed in the region, out of which 4692 completed the survey (50.9%). Some of the reasons for not answering the survey were wrong e-mail address, absence from work, lack of time and concerns about the manager finding out what they wrote. In 2020, data was collected via web-survey from the same study group during the second Covid 19-pandemic wave in Sweden, i.e., from September to December. Again, all healthcare staff who were employed in 2017 and that were still employed in 2020 were invited by e-mail to partake in the study. The survey link was sent out to all 18,143 staff, out of which 7781 participants responded. The number of

nurses completing the web survey in 2020 was 3107 (40.1%). Some of the reasons for not responding to the survey were the same as in 2017, but there were also many nurses who stated that they wanted to prioritize their work and some nurses that had left the region.

Of the 4692 participants in the 2017 survey, the median age of the participants was 48 (23–67) and among the 3107 participants in 2020 it was 52 (26–70). In 2017, 90.4% who answered the questionnaire were women and in 2020 that number was 90.5%. A large majority (54.1% vs. 59.4% respectively in 2017 and 2020) of participants had worked as nurses for more than 16 years.

#### *2.3. Themes in the Analysis Model*

The theoretical SwAge-model (sustainable working life for all ages) [17–19] was used as the theme areas in the analysis with the intention of investigating factors concerning the complexity of the nurses' work situations that could relate to their mental diagnoses caused by their work life and work environment. The SwAge-model consists of nine different impact and determinant areas that are important for a healthy and sustainable working life for all ages, and the four spheres of determination regarding employability. These four spheres and the nine impact and determinant areas are:

	- (1) Self-rated health, diagnoses and diverse physical and mental health functionality in work;
	- (2) Physical work environment with unilateral movements, heavy lifting, risk of accidents, climate, chemical exposure and risk of contagion;
	- (3) Mental work environment: stress and fatigue syndrome, threats and violence;
	- (4) Working hours, work pace and possibility of recuperation during and between work shifts.
	- (5) The personal financial situation's effects on individuals' needs and willingness to work. Issues with employability due to ill health and lack of support can jeopardize inclusion in working life and cause an inferior financial situation for the individual, e.g., through sick leave, unemployment and early retirement.
	- (6) The effects of the personal social environment with family, friends and in the leisure context;
	- (7) The social work environment with leadership, discrimination and the significance of the employment relationship context for individuals' work.
	- (8) Motivation, appreciation, satisfaction and stimulation when performing the work tasks;
	- (9) Knowledge, skills, competence and competence development.

Seven out of the nine impact and determinate areas in the SwAge-model were used as independent variables in this investigation to analyze factors in the nurses' work situation associated with work-related mental health diagnoses. The Health (1) area was used as the outcome/dependent variable in the analysis, i.e., mental health diagnoses caused by the work situation. However, the Personal finances (5) area was excluded since there were no data on the nurses' private economic situation related to the work situation that could be used in the analysis.

#### *2.4. Outcome Measures*

The dependent variable was initially two individual statements: "I have a current diagnosis of exhaustion/stress" and "I have a current diagnosis of depression/anxiety". These individual statements were put together into one variable regarding their work-related mental-health diagnoses as an outcome measure. The self-reported doctor's diagnoses included in mental health were depression, anxiety, exhaustion and stress. The response options in the survey regarding diagnoses were taken from WHO's ICD-10 codes.

The independent variables used in the univariate estimates and multivariate models were calculated using a categorical variable of diagnoses caused by work, i.e., mental health, as the outcome measures in association with the seven determinate areas for a healthy and sustainable worklife and employability in the SwAge-model that have been used in previous studies investigating factors associated to a sustainable working life (see above).

#### *2.5. Questionns and Statments*

The questionnaires were written in Swedish and contained 158 questions based on the SwAge-model that has been used in different investigations since 2004 [19]. However, in the questionnaire that was sent out in the second pandemic wave in 2020, additional questions about the COVID-19 situation were added. Some questions were simple yes/no questions and some were open answer questions where the participants could write freely. Most questions were designed as statements, a validated Lickert scale was used, and the participants had four answer options ranging from fully agree (1–2, i.e., Fully agree, partly agree) to fully disagree (3–4, i.e., partly disagree, fully disagree). The sample data was collected and handled by researcher KN. In the present study, 24 statements sorted into seven of the determinate areas of the SwAge-model were used.

#### *2.6. Statistical Analyses*

Logistic regression analysis was used to test models to predict categorial outcomes and to assess how well a predictor variable associates with a categorial dependent variable [40]. The material was analyzed with the IBM SPSS software, version 27. Data are presented as odds ratios (ORs) with their 95% confidence intervals (CIs). Questions with four answer options were dichotomized for clear distinction of the participants' experiences. A multivariate analysis of variance (MANOVA) was performed comparing and testing the statistical significance of the multivariate sample mean differences to see which statements in the multivariate model saw the most increase between 2017 and 2020. Mental health was the dependent variable and the 24 statements in the seven impact and determinate areas were the independent variables. As with the logistic regression analysis, the MANOVA was analyzed with the IBM SPSS software, version 27.

#### 2.6.1. Analyses within Each of the Seven Determinate Areas in the SwAge Analysis Model

Univariate logistic regression analysis was the first step to building multivariate models in each determinate area as well as for all determinate areas together. The univariate logistic regression analysis estimated for all statements within each of the seven determinate areas of the SwAge-model to investigate the association between the independent and the dependent variables. Initially, the associations for each statement were evaluated and the statements with *p*-values < 0.05, considered as the statistically significant level, were evaluated with other statements from the same determinate area. After this, the statements that continued to have a *p*-value < 0.05 were tested against the remaining statements one at a time. This continued for as long as the *p*-values for all included statements were <0.05.

2.6.2. Analyses including the Seven Determinate Areas in the SwAge Analysis Model

After the initial univariate analysis, a modulation was made for each determinate area in the SwAge-model. All the selected statements from the seven included determinate areas of the SwAge-model were analyzed in a logistical regression model. Thereafter, the analysis moved to step 2, where the statistically significantly statements (*p*-values < 0.05) from each determinate area was added, one determinate area at a time. These statements were tested to form the final model. In step 3, the out-sorted statements from step 2 and from each of the seven determinate areas were added one at a time to test the robustness of the model [41]. The multivariate models were tested for collinearity.

#### *2.7. Ethical Considerations*

The study was performed in accordance with the Helsinki declaration [42] and Swedish laws [43]. The benefits the knowledge this study would generate was considered to outweigh the potential risks that the study could bring. Rules for the handling and storage of data was and will be followed in accordance with university policies as well as guidelines for handling sensitive data according to GDPR [44]. The study was approved by the Swedish Ethical Review Agency (number 2016/867 and 2020-01897).

#### **3. Results**

#### *3.1. Findings*

There was an increase in diagnosis for both examined areas, i.e., exhaustion/stress and depression/anxiety between 2017 and 2020 (see Table 1). Of note, 128 nurses that previously reported no mental health diagnosis stated that they had been diagnosed with exhaustion/stress and/or depression/anxiety in 2020. In the logistic regression analysis, these diagnoses were combined into one variable: "mental health diagnoses".

**Table 1.** Percentage of nurses diagnosed with exhaustion/stress and/or depression/anxiety in 2017 and 2020.

*3.2. Univariate Estimates and Multivariate Models for Work-Related Mental Health Diagnoses and Each of the Statements in the Analysed Areas*

A logistic regression analysis was used to investigate which of the areas of importance for a healthy and sustainable work situation had the highest association with nurses' workrelated mental health diagnoses in 2017 and in the second wave of COVID-19 in 2020. The statements in each impact and determinate area were analyzed by area. There were seven impact and determinant areas included in the study, which were physical work environment (2); mental work environment (3); work pace, work time, recuperation (4); private social environment (6); work social environment, organization, leadership (7); motivation and satisfaction of and to work tasks (8); knowledge and competency (9).

In the impact and determinant area "physical work environment", both included statements had a statistical association with nurses´ mental health diagnoses caused by their work for both 2017 and 2020 in the univariate estimates and in the multivariate model in 2017. However, the statement "For the most part I cannot cope with the physical work demands" also showed an association in the 2020 multivariate model.

All five statements in the impact and determinant area "Mental work environment" were statistically significant in the univariate estimates. In the 2017 multivariate model three statements were significant, which were "My work involves many psychologically heavy work tasks" (OR 1.78), "My work tasks usually clump together to the extent that I get frustrated" (OR 1.78) and "I wish for more opportunities to determine how to perform my work" (OR 1.60). In 2020, "My work tasks usually clump together to the extent that

I get frustrated" (OR 2.05), "My work involves many psychologically heavy work tasks" (OR 1.76) and "I wish for greater control over my work (OR 1.75) showed significance.

All three of the investigated statements in the impact and determinant area "Work pace, work time, recuperation" showed an association in both the univariate estimates and the multivariate model for a healthy and sustainable working life.

In the impact and determinant area "Private social environment", both statements were statistically significant in the univariate estimates of 2017. The statement "I need to work more at home/care for relatives and will probably therefore work less in the future" showed an association in the multivariate model of 2017, whereas the statement "I want to spend more time enjoying leisure activities and will therefore work less in the future" showed an association in both the univariate estimates and multivariate model of 2020.

The area "Work social environment, organization, leadership" consisted of six statements that all indicated an association in the univariate estimates of 2017 and 2020. In 2017, three statements showed significance, which were "Not having enough staff means that I cannot perform my work in the way I want" (OR 2.04), "Big changes in my work situation causes me to want to leave" (OR 1.41) and "The social community at my workplace does not make me want to stay" (OR 1.33). In 2020, only two statements showed significance, including "I do not feel I have enough support from my co-workers" (OR 3.14) and "Big changes in my work situation causes me to want to leave" (OR 1.73).

Similar to the previous determinant area, all statements in the impact and determinate area "Motivation and satisfaction of and to work tasks" indicated an association in the univariate estimates of both 2017 and 2020. However, only two statements showed association in the 2017 and 2020 multivariate models: "I do not experience joy in my daily work" and "I do not experience satisfaction in my daily work".

The impact and determinant area "Knowledge and Competency" consisted of two statements that were both found to be statistically significant in the univariate estimates of 2017 and 2020, but only the statement "I do not feel like my competencies are being utilized in a satisfactory way" showed association with nurses' work-related mental health diagnoses in the 2017 and 2020 multivariate model (Table 2).

**Table 2.** Univariate and multivariate variables 2017 and 2020. Univariate estimates and multivariate models in each of the analyzed areas between the statements (agree vs. disagree) and work-related mental health diagnoses and other factors. OR = Odds ratio; CI = Confidence interval. \* The variable shows no statistical significance in the multivariate modelling and is, therefore, not included in the final multivariate model shown in this column.

#### **Table 2.** *Cont.*

A multivariate analysis of variance (MANOVA) was performed in the multivariate model in order to see which of the 24 statements showed the most increase between 2017 and 2020. MANOVA was used since it does not affect the Type I error rate to the same extent as other independent tests. The results of the MANOVA mirrored the logistic regression analysis and the four statements that saw the most increase were "I do not have the time to perform the work duties I have planned for the day", "I want to spend more time enjoying leisure activities and will therefore work less in the future", "I do not feel I have enough support from co-workers" and "I do not experience joy in my daily work". Results of the MANOVA showed that there was a statistical difference between the combined dependent variables. Wilks´Λ = 0.09, F(40,1582) = 4.200, *p* < 0.001, partial η2 = 0.096, observed power = 1.00. Based on the low Wilks´Λ, we want to be careful rejecting the null hypothesis. The observed power was 1.00, indicating that there was a 100% chance that the results could have been significant.

#### *3.3. Multivariate Model of all Impact and Determinant Areas in the Work Situation in Association with Nurses' Mental Health Diagnoses Caused by the Work Situation in 2017 and in 2020*

In real life, nurses are not only affected by one of the impact and determinant areas from the SwAge-model, there is impact from all nine areas. Therefore, in the next step of the analysis we aimed to make a collected analysis of the seven relevant impact and determinate areas in this study. Hence, all the statements from the seven deteminant and impact areas for a sustainable healthy working life (the swAge-model) included in this investigation were modelled into a single multivariate model for each year, i.e., 2017 and for the second wave of COVID-19 in 2020. The variables that were statistically significant (*p*-value < 0.05) from each area were used in the modelling, and each of the eliminated statements (i.e., the variables not statistic significant in the earlier analysis of each area) were added once more one at a time to test the robustness of the model.

In the 2017 multivariate model, six statements showed significance: "I do not experience joy in my daily work" (OR 1.97), "My work involves many psychologically heavy work tasks" (OR 1.66), "The work pace in my daily work is too high" (OR 1.37), "I wish for more opportunities to determine how to perform my work" (OR 1.37), "My work tasks usually clump together to the extent that I get frustrated" (OR 1.34) and "I need to work more at home/care for relatives and will probably therefore work less in the future" (OR 1.27). In 2020, five statements showed significance: "I do not experience joy in my daily work" (OR 2.17), "I do not feel enough support from my co-workers" (OR 2.00), "My work tasks usually clump together to the extent that I get frustrated" (OR 1.81), "My work involves many psychologically heavy work tasks" (OR 1.69) and "I do not get enough rest/recuperation between work shifts (OR 1.41). There were no statistically significant statements in 2017 or in 2020 from the area "physical work environment" and "knowledge and competency" in the final total multivariate model, including all relevant impact and determinant areas for a healthy and sustaniable working life (Table 3).

**Table 3.** The final multivariate model for all areas and statement together for 2017 and for 2020. Statistically significant variables in relation to nurses' work-related mental health diagnosis in 2017 and 2020. OR = Odds ratio; CI = Confidence intervl. Nagelkerke R square 0.073. \* The variable shows no statistical significance in the multivariate modelling and is, therefore, not included in the final multivariate model shown in this column.

*3.4. Multivariate Model of the Work Situation in the Second Wave of COVID-19 in Association with Nurses' Mental Diagnoses Caused by the Work Situation, including COVID-19- Specific Questions*