Browsing by Author "Bejerot, E"

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    Dentistry in Sweden Healthy work or ruthless efficiency?
    (Arbetslivsinstitutet, 1998) Bejerot, E
    The general objective of this thesis is to offer understanding of the organization of Sweden's Public Dental Health Service (PDHS) and the problems it has faced. This is achieved against the background of its historical development. Work conditions in the PDHS have been discussed for a long time, with a focus on how dentists should be managed in the light of their almost constant dissatisfaction with salaries, pace of work, and management style. A brief review is conducted of work conditions and job satisfaction in dental care, both internationally and in a Swedish setting. From this review, two essentially different images emerge: working with dentistry can be very stimulating and rewarding; or, very stressful, pressurizing and exhausting with low rewards. On this basis, it is argued that that there are two contrasting aspects of work conditions in dentistry: "healthy work" and "ruthless efficiency". Some of the philosophical foundations of the concepts of "healthy work" and "ruthless efficiency" are described. The genesis of ruthless efficiency is captured in the image of the ÒPanopticonÒ : a disciplinary strategy with long historical roots. One modern management doctrine in particular, Human Resource Management (HRM), is analyzed from this perspective. The thesis comprises five papers, based on two empirical studies : one conducted in 1987, the other in 1992. Both studies use self-reports from mailed questionnaires. The sample for the first study was based on county lists of staff: 769 dentists and 493 dental nurses responded (response rate 88% and 85%, respectively). The second study was based on a random sample of dentists from the membership register of the Swedish Dental Association: 312 dentists in PDHS, and 160 dentists in private practice responded (response rate 66%-77%). This sample of dentists was part of a larger study of Swedish professional workers. The same questionnaire as for dentists was administrated to a random sample of two percent of the members of the Swedish Confederation of Professional Associations (SACO). The questionnaire was returned by 3,595 graduate employees, giving a response rate of 75%. The material was analyzed with statistical methods (PCA, logistic and multiple regressions, interaction models). The objective of the first study was to investigate the properties of Òhealthy workÒ among professionals, and to see whether differences could be found between various types of occupations (Paper I). It was observed that when graduate workers report what they consider to be very important for healthy work, they virtually always stress the Òintellectuality of work". In some professional groups, such as physicians and dentists, the importance of the Òvalue of workÒ is also emphasized. The difference between ideal and reality, between conception of healthy work and its actual fulfillment, was found to differ considerably between dentists in the PDHS and those in private practice. Indeed, dentists in the PDHS showed the greatest discrepancy between ideal and reality of all the professional groups. Differences were particularly evident with regard to independence and the encouragement of initiative-taking. It seems probable that the reasons for these lie in factors such as work organization and leadership style. Paper II contains a description of the development of the PDHS control system, from the travelling inspectors in the 40s to the use of modern information technology. The staff opinion on the present control system was analyzed. PDHS dentists reported that they felt constantly supervised and evaluated. Their pace of work was adapted to surveillance, competition and demands of the employer, not to patient queues or piece-work wages. It is concluded that the system of productivity evaluation was an effective management approach for increasing the work output of staff, but at the same time it contributed to poor work conditions for dentists. The study supports tenets drawn from Foucault's metaphor of the Panopticon. The third objective was to continue investigation of management control systems by examining how these have changed in the assessments of publicly employed professionals, in particular dentists in the PDHS. In Paper III, it is reported that perceived changes in control systems tend to be distributed along two different dimensions, corresponding to aspects of two HRM technologies: Òmanagement by objectivesÒ, and Òmanagement by dialogueÒ.The dimensions were interpreted as mirroring ÒhardÒ and ÒsoftÒ HRM models respectively. An analysis of changes in management style in the PDHS showed that ÒhardÒ HRM technologies predominate, but also that ÒsoftÒ HRM has increased. A clear duality was apparent in changes to managerial control systems in the PDHS. The succeeding goal was to investigate the impact on work conditions of dual aspects of HRM in both a pathogenetic and a salutogenetic context, as operationalized by "effort-reward balance" and "the core of healthy work" respectively. Dentists were also compared with other publicly employed professionals. The results of Paper IV show that the combined effects of ÒhardÒ and ÒsoftÒ HRM tend to be more negative for dentists than for other publicly employed graduate workers. Organizational efficiency was reported to have increased considerably in the PDHS, far more so than in other parts of the public sector. This was interpreted as a form of Òruthless efficiencyÒ, where work effectiveness is gained at the cost of a lack of balance between efforts and rewards. With regard to Òthe core of healthy workÒ, the results showed that the dual aspects of HRM did not improve the opportunities for dentists in the PDHS to work professionally : contrary to the prediction of HRM advocates. In the final study several threads were tied together. Its general aim was to investigate relations between objects of work, management control systems, and perceived work conditions. Graduate workers were divided into two groups according to whether their knowledge lay in "things/data" or in "life". The analysis showed that managerial changes contributed to a polarization between human-service work and that of other professionals. While opportunities for healthy work increased among graduates who worked with things and data, the same changes led to worsened effort-reward balance for human-service workers (when there was a pronounced duality to HRM strategies). Negative effects were found to be much more pronounced for dentists than for human-service workers as a whole. Dentists seem to constitute an extreme subgroup among human-service workers. Dentists' special vulnerability is discussed on the basis of the work of Hirschman (1970). His concepts concern individuals' reactions to negative circumstances by leaving ÒexitÒ, by protesting ÒvoiceÒ, or by doing neither ÒloyaltyÒ. One interpretation is that dentists have been forced into a position where "loyalty" is the only option available.