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AIMS: Map the existing evidence and gaps in research on the implementation and outcomes of self-managing elderly care teams. BACKGROUND: Due to increasing demand for elderly nursing care and an ageing workforce, recruiting and retaining community nurses has become challenging. Implementing self-managing teams may be a solution to address this problem. EVALUATION: Scoping review including 27 studies, varying from narrative reviews to a quantitative cross-sectional study. The studies' primary focus on self-managing teams was essential for eligibility. KEY ISSUES: Nurses' job satisfaction was high in self-managing teams due to improved relationships with patients and increased autonomy. Continuity of care and patient acceptability were high. Transformation of managers to coaches in a team with a flat hierarchy is needed to empower nurses with responsibility for their own work. Trust and teamwork should be assisted by suitable ICT support systems. CONCLUSION: International interest in self-managing teams is large, but quantitative research is limited and guidelines for implementation are needed. Recommendations for potential successful implementation were made. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse autonomy and job satisfaction can increase by implementing self-managing teams. This requires a change in management styles, from managing to coaching nurses.

A concept analysis of workplace ostracism The article describes and analyses the concept of workplace ostracism by using Rodgers´ evolutionary concept analysis. The aim of the study is to clarify, specify and distinguish the concept of workplace ostracism from other similar phenomena and concepts. The research material consists of scientific articles collected through an integrative literature review (n=35) dealing with ostracism from working life and/or the organizational perspective. An analysis of the data revealed four specific characteristics of workplace ostracism: exclusion from social interaction, ignorance and avoidance of eye contact of which are non-verbal. Workplace ostracism can occur either unintentionally or intentionally, may occur only partially within an organization. The consequences of workplace ostracism can be divided into psychological, social and pragmatic consequences. The conceptual definition of workplace ostracism is an important basis for future empirical research that will include a conceptual definition yet to be tested, amplified, and established.

ObjectivePrevious work ability studies have primarily focused on old workers and physical health. This study investigated how poor perceived work ability (PPWA) is associated with work-related factors in different health and social service (HSS) worker age groups.DesignCross-sectional survey in 2020.SettingHSS employees (general HSS and eldercare) in nine Finnish public sector organisations.ParticipantsAll employees who were employed in the organisation completed self-reported questionnaires. Of the original sample (N=24 459, response rate 67%), 22 528 gave consent for research use.Primary and secondary outcome measuresParticipants evaluated their psychosocial work environment and work ability. Lowest decile of work ability was categorised as poor. The association between psychosocial work-related factors and PPWA in different age-groups of HSS workers, adjusting for perceived health, was analysed with logistic regression.ResultsThe proportion of PPWA was highest in shift workers, eldercare employees, practical nurses and registered nurses. Considerable variation between age groups exists in the work-related psychosocial factors associated with PPWA. Among young employees engaging leadership and working time and work task autonomy were statistically significant, whereas in middle-aged and old employees procedural justice and ethical strain were highlighted. The strength of the association with perceived health also differs in age groups (young: OR=3.77, 95% CI 3.30 to 4.30; middle-aged: OR=4.66, 95% CI 4.22 to 5.14; old: OR=6.16, 95% CI 5.20 to 7.18).ConclusionsYoung employees would benefit from engaging leadership and mentoring, and from more working time and work task autonomy. As employees get older they would benefit more from job modification and from ethical and just organisation culture.

Background: Several benefits of working in a self-organizing team, such as higher job satisfaction and better en-gagement to work have been demonstrated in previous studies.Objective: To examine whether those employees working in a self-organizing team have higher job satisfaction and lower turnover intentions compared to those in non-self-organized teams. Further, to test whether psycho-social factors defined by the Job Demand-Control model would function as mediators.Design: A cross-sectional survey study.Setting(s): Home care and assisted living facilities (with 24-h assistance).Participants: Licensed practical nurses (N = 377), registered nurses, therapists and managers (N = 183), and other employees (N = 31) in services for older people.Methods: A survey for employees working in services for older people and who were either in the self-organized teams or in the non-self-organized teams. Data was analyzed using linear regression and mediation analyses.Results: Those employees who worked in a self-organizing team were more satisfied with their job and had lower turnover intentions compared to those in a non-self-organizing team (mean [SD] 3.9 [1.0] vs. 3.7 [1.0], p = 0.006 and 2.2 [1.2] vs. 2.5 [1.3], p = 0.006, respectively). Moreover, job demands and job strain partially mediated the effect of self-organizing teamwork on job satisfaction (Average causal mediation effect [95%CI] 0.09 [0.02-0.15] and 0.10 [0.03-0.18], respectively), as well as on turnover intentions (Average causal mediation effect [95%CI] -0.08 [-0.15 to -0.01] and -0.20 [-0.18 to-0.03], respectively).Conclusions: In the context of older people care services, working in self-organizing teams may enhance employee wellbeing by lowering job demands and job strain, but not by improving job control. Based on the findings of this study, self-organization seems beneficial, however, it requires real autonomy for the teams and team building.Tweetable abstract: Self-organizing teamwork increases job satisfaction and decreases turnover intentions via lower job demands and strain in older people care.(c) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

IntroductionIn Finland and in several other countries about 10 % of the users of health and social services use plenty of services within one or several sectors and produce about 80 % of its costs. The individuals with several health and/or social problems should be identified as early as possible and offer them support and integrated care to avoid human suffering and the uncontrolled grow of the costs of care. This study mapped and examined the models and tools which are in use or under development in Finland to identify the potential individuals who might benefit from integrated care.MethodsThe models and tools were examined in the health and social care organisations by a survey (n=499) in spring 2019 and by supplementary thematic interviews (n=5) in spring 2020.ResultsIn Finland only a third of the health and social care organisations have an established model for identifying individuals for integrated care. There are three main approaches for identification: 1) the individuals are most commonly identified in an initial interview or service needs assessment and when guiding the clients to different services; 2) information systems are used when segmenting and identifying the clients; 3) identifying occurs in different models of professional collaboration when the needs of clients are assessed more closely for example by multidisciplinary and paired teams or by case managers who are responsible for coordinating referrals and services. DiscussionsThe identification of individuals for integrated care is insufficient and unsystematic in Finland. It is hampered by the inadequate development of client and patient information systems, disjointed operating cultures, and the lack or inadequacy of established models. There is too much responsibility on individual professionals to identify the individuals and refer them to appropriate services. However, a variety of the good practices of identification are being developed in a number of different organizations. Nationally comprehensive training for and implementation of models and tools should be enacted in health and social care. Conclusions The models should be able to identify individuals who are outside the service system, those whose clientship has just started, and those who already access services. This requires the use of individual level data from information systems, but also other approaches, such as outreach and interactive work with clients and patients. Identification should be an integral part of the work processes and their phases.Lessons learntNationally agreed and convergent approaches are required in some aspects so that they can provide joined-up and measurable data on specific demographics, issues and diseases and also support the evidence base for monitoring, steering and peer-development purposes.LimitationsThe analysis of the models in Finland is narrow basing only on a survey and limited number of interviews Suggestions for future researchThe future research could study in a deeper level the workability – the pros and cons – of the identification practices as an initial part of the whole service processes and chains.

Background The desire to increase the role of home care in Finland has created problems in home care work. Working conditions have deteriorated, the quality of care experienced is low, and staff members suffer from time pressure and stress, amongst other things. The aim of this article is to explore the challenges, stressors, teamwork and management factors that are associated with home care staff members’ well-being, job satisfaction and experienced care quality, and further, how staff members experience their work. Methods A survey was sent to home care workers in two case organizations that participated in the study. In addition, semi-structured theme interviews with home care workers were conducted. The data from the survey was analysed using analysis of covariance, and interview data was analysed using the Grounded Theory-based method from Gioia et al. Results Respondents of the survey and the interview participants were mainly female practical nurses. The results from the survey showed, for example, that time pressure was associated with higher stress and psychological distress, and interruptions were associated with lower job satisfaction and higher stress. In addition, variables related to teamwork, such as participative safety, were shown to explain the variation in quality of care. The analysis of the interview data further brought up dissatisfaction with management practices, which seems to have led to a decrease in job satisfaction. Exhaustion and strain were present among staff members, which originated from an insufficient number of carers. Conclusions Current working conditions and work practices in Finnish home care are experienced stressful. The results from this study indicate that having more autonomy at work was associated with job satisfaction, according to both analyses. Team climate and idea implementation were related to quality of care. Therefore, increasing self-organizing team practices might be a possible development method for improving working conditions and staff members’ well-being. Implementing self-organizing team practices could possibly also attract employees to work in home care and prevent turnover.

Artikkelissa tarkastellaan luottamusta kontekstina laaja organisaatiomuutos, jossa usean kunnan sosiaali- ja terveyspalvelut yhdistettiin kuntayhtymäksi. Haastatteluaineisto kerättiin eri tasojen johtajilta sekä työntekijöiltä eri toimialoilta ja analysoitiin sisällönanalyysillä. Johtajiin sekä organisaatioon kohdistuneen luottamuksen muutosta tarkasteltiin luotettavuuden osatekijöillä, jotka vaikuttavat luottamuksen syntyyn. Luottamus sujuvoittaa yhdessä työskentelyä, edistää työtyytyväisyyttä ja edesauttaa organisaatiomuutoksen onnistumista, joten organisaatioissa kannattaa kiinnittää siihen huomiota. Muutokset johtamis- ja organisaatiorakenteessa, toimintakulttuurissa sekä osallisuuden kokemuksissa heikensivät johtajien ja uuden organisaation kokemista luotettavana. Muun muassa kuntayhtymän kehittämisen terveydenhoitokeskeisyys vaikutti tähän. Vastaavanlaisissa muutoksissa kannattaa kiinnittää enemmän huomiota muutosviestintään, työntekijöiden ja johtajien tukemiseen sekä työntekijöiden ja eri johtotasojen väliseen vuorovaikutukseen.

Health and social care for older people in Finland is increasingly provided in people's homes, leading to large caseloads of high-dependency patients for providers of home care, whose working conditions have deteriorated. Buurtzorg, a model of home care in the Netherlands that empowers caregivers to organize their own work processes, has shown promising results in terms of effectiveness and satisfaction of clients and caregivers. This article aims to provide insights about the challenges and effects of implementing self-organizing teams in three Finnish public health and social care organizations.

Introduction Care integration has been a policy aim in Finland since the1990s. The service system in Finland is rather integrated organizationally. Municipalities have responsibility to organize all health and social care and usually they also provide most of the services, except specialized care, which is provided by hospital districts. Despite the organizational integration, professionals are in many cases working in silos and the patient/client information systems are separate in many health and social services. There is a growing amount of people who need or use several different services. In siloed systems it is, however, difficult to identify these people. Models, practices and tools have been developed to identify these individuals. The aim of this paper is to describe and evaluate these practices. Methods The study is a part of a project on identifying the individuals who use several different services or might need care integration. This paper is based on a survey for health and social service providers in 2019 and comprising structured and open ended questions. Altogether 442 respondents filled in the questionnaire, of which 119 described a tool, model or practice to identify the individuals who use or might need several services. The data was analyzed using inductive content analysis. Results The clients who might benefit from care integration were identified most often because of concerns expressed by professionals. Secondly, they were identified through use of advisory services and thirdly because of multiple visits. The methods identifying these individuals were different working practices, segmentation of clients and tools using the patient information system. Typical practices were such as case manager system, multiprofessional teams in assessment of care needs, multiprofessional care plans and meetings, walk in services or reporting system of professionals' concerns of a client. These practices were described in social services, substance abuse or mental health services and in primary care. Segmentation of client was used especially in primary care provided at health center outpatient services. The clients were divided to chronic patients whose care was not in balance and who would benefit integration and to clients who need only one service and in short episode. Tools using patient information systems are based on clear criteria, such as a certain number of visits in outpatient care, or use of several services. Also certain health indicators, such as smoking, high BMI, can be indicators. In some cases the system can inform the professionals that the client uses several services. Conclusion The study showed that methods to identify the individuals in need for service integration are needed and that they are already in active use in several municipalities. Also several common tools exist, but coordination between providers is relatively scarce. Lessons learned Identifying the individuals who use several services is a challenge which requests a planned, national approach rather than local initiatives Limitations The survey to service providers can’t give a thorough understanding of methods used among service providers Suggestions for future research In-depth studies are needed to understand the use of methods and to evaluate their weaknesses.

Background To test the validity of the Finnish version of the Bernhard et al.’s Cross-Cultural Competence instrument of Healthcare Professionals (CCCHP). Methods The study sample comprised registered nurses (N = 810) from the Finnish “Competent workforce for the future” -project (COPE). Exploratory factor analyses and structural equation modelling were applied to test structural validity of the CCCHP. Internal consistency of the sub-scales was evaluated using the Cronbach’s alphas. Criterion validity was explored in terms of received education for multicultural work, perceived difficulty of patients, and job satisfaction variables. Results The revised version of the instrument including four (motivation/curiosity, attitudes, skills and emotions/empathy) of the five original dimensions provided satisfactory psychometric properties (internal consistency, a good model fit of the data). Of the four remaining competence sub-scales, motivation/curiosity, attitudes and emotions/empathy were associated with the amount of received education for multicultural work, and all with perceived difficulty of patients, and all but attitudes with job satisfaction. Conclusion This revised Finnish version of the CCCHP provides a useful tool for studies focusing on the healthcare personnel’s cross-cultural competence in delivering effective and culturally sensitive healthcare services for patients from different cultures. Electronic supplementary material The online version of this article (10.1186/s12913-019-4105-2) contains supplementary material, which is available to authorized users.

Introduction This study investigates future integrated care competencies among workforce in health and social service sectors in the context of the national health and social services reform in Finland. Methods The sample was drawn from the registers of competent workforce in the social and health sectors in Finland in three different forerunner areas. Eight working sectors were identified. A total of 1943 participants represented a 16% of the sample ( N = 12,250). Factor analyses were conducted on ratings from the COPE scale measuring integrated care competences. Logistic regression analyses were used to examine the associations between background variables and competence factors. Results The present study identifies three factors about the competences of future integrated care competencies. The factors were client-oriented needs assessment, holistic service guidance, and ensuring service path. The sectors of services for older people and administration indicated the highest level of competence needs, whereas the sector of social services indicated the lowest level. Variations between sectors and background variables are remarkable. Discussion The study points out three dimensions of generic competence needs perceived by employees that are required to secure client-oriented integrated care processes in the future. New competencies and targeted processes in organizations and between sectors are crucial in developing the quality and effectiveness of integrated care by improving future care processes. Professional education and training should advance the learning of generic competences shared by all professionals and sectors in accomplishing integrated care.

Background Care integration has been an aim in government policies since 2000s in Finland. In 8 counties municipalities have created regional joint health and social care authorities in responsibility of all health and social services to boost service integration. Joint management gives possibilities to change organizational structures and organizing care paths in new ways. Most of these joint authorities suffer from severe budget constraints and layoffs has been done. Care integration has been seen as alleviating in budget constraints and to increase efficiency. In this study the views of top and middle managers and personnel on care integration as means to develop efficiency is explored. Methods A large, newly established joint authority of 200000 inhabitants participated the study. The joint authority had a large gap in its budget, hence layoffs were planned. We compiled a data of regional policy documents, carried out individual and group interviews of management (21) and a survey to employees (N = 2047). In the interviews, views of top and middle managers on how efficiency should be developed and on views of care integration in relation to efficiency were studied. The views of employees were explored in the survey. Results The joint authority was launched in a very short time and care paths were not planned before the organizational change. The managers saw that siloed practices created inefficiency and care integration increasing efficiency although the research evidence was seen insufficient. In the survey the views of the employees of developing efficiency and care quality were more negative than managers. Both groups, however saw that care integration was underdeveloped. Developing integration especially at primary level became also a key strategy of the joint authority. Conclusions Joint management creates a good basis for integration. The implementation of care integration, however, requires managers' collaboration and organisational culture supporting integration. Key messages In managers views care integration can increase efficiency. Joint management is a good basis for integration, but care processes have to be planned.

Purpose Integrated care policies have been at the heart of recent health reforms in many European countries. The purpose of this paper is to study the integration from the perspective of health care personnel working in primary health care clinics. Design/methodology/approach The study employs data from interviews collected in a research project examining patient choice and integrated care in primary health care clinics in Finland. The interviews were conducted in five cities in Southern Finland in 17 primary health care clinics in Autumn 2014. Among the interviewees there were both doctors (n=32) and nurses (n=31). Findings The typical problems hindering integration were, according to the workers, poor communication and insufficient information exchange between professionals, unclear definition of responsibilities between professionals, and lacking contacts and information exchange between health and social care professionals. To secure availability and continuity of care, doctors and nurses did extra work and exceeded their duties or invented ad hoc solutions to solve the problem at hand. According to professionals, patients were forced to take an active role as coordinator of their own care when responsibilities were not clearly defined between professionals. Originality/value This paper highlights that successful integration requires taking into account the requirements of the day-to-day work of health care clinics, and clarifying what facilitates and what hinders practical collaboration between different actors in health care and between health care and other service providers.

Background: The ongoing Finnish health and social service reform will expand choice by opening the market for competition between public and private service providers. This study examined the attitudes of primary care patients towards choice and which patient-related factors are associated with these attitudes. Methods: A sample of attenders during one week in health centres of 12 big cities and municipal consortiums (including seven outsourced local units) and in primary care units of one private company providing outsourced services for municipalities (aged 18−95, n=8128) was used. The questionnaire included questions on choice-related attitudes, sociodemographic factors, health status, use of health services and patient satisfaction. Results: Of the responders, 77% regarded choice to be important, 49% perceived genuine opportunities to make choices and 35% were satisfied with the choice-relevant information. Higher age, low education, having a chronic illness, frequent use of services, having a personal physician and being satisfied with the physician and with waiting times were related to assigning more importance on choice. Younger patients, those with higher education as well as those with chronic illness regarded their opportunities of choosing the service provider and availability of choice-relevant information poorer. Conclusions: The Finnish primary care patients value choice, but they are critical of the availability of choice-relevant information. Choices of patients with complex health care needs should be supported by developing integrated care alternatives and by increasing the availability of information on existing care alternatives to meet their needs.

Background Since the 2000s, integrated care has been a policy aim in Finland. Reforms for creating larger care authorities have failed at national level, but municipalities have established regional joint health and social integrated care authorities. Our study focuses on integration of services for children and young people and adults’ psychosocial care. The aim is to evaluate integration in terms of success and its underpinning factors in two authorities with merged primary and specialised healthcare and social services. Methods South Karelia and North Karelia were selected as case studies, because these regions were pioneers in establishing integrated care authorities in 2010 and 2017. Document analysis and individual and group interviews with managers (32) and employees (22) were carried out; the analysis draws on Auschra’s classification of barriers and facilitators of integration. Results The regions (pop. 130.000-169.000) comprise a larger town, a specialised hospital and several rural municipalities. The integration of children’s and young people’s services is based on organisational changes, in which the services from primary healthcare, hospitals, social work and schools (pupils’ and students’ healthcare) were merged into one organisation. The health and well-being centres were created by bringing mental health, substance abuse services and social services into health centre facilities, but under their own managers. In both cases, the experiences are mostly positive but the success of implementation varies; commitment and cooperation between managers, shared goals and mutual understanding of each other’s work as well as the planning process were crucial factors to support implementation. Conclusions Comprehensive organisations with unified management foster integration. The implementation of multiprofessional work is facilitated by organisational culture and collaboration between managers.

Background Challenges in transitioning from a student to a registered nurse may contribute to new nurses high turnover rates. Final clinical practicum (FCP) before graduation is known for its importance in preparing students for the transition but little is known about the specific elements of FCPs essential for successful transition. We examined the associations between multiple FCP elements and transition experiences in new nurses and whether work characteristics modified these associations. Methods The data were collected in 2018 with electronic survey. The sample comprised 712 Finnish nurses graduated within the last two years. Linear regression analyses was used to examine the association of five FCP elements (Preparing for demands; Being part of team; Systematicness of FCP; Teacher involvement; Quality of supervision) with the transition experience that was measured with four scales demonstrating its emotional, physical, socio-developmental and intellectual domains. Work characteristics were defined based on demand-control -model and multiple potential confounders were considered. Results Several associations were found between the FCP elements and the four transition indicators (psychological distress, sleep problems, role conflict/ambiguity and perception of transition/educational preparation). Systematicness of FCP was, however, the only element associated with all the transition indicators, whereas quality of supervision was not associated with any. Multiple interactions were also detected between the FCP elements and job demands. Conclusions Our results suggest that FCP experiences reflect to new nurses’ first years of employment. Especially systematic planning and implementation of FCP, collegial work atmosphere and an opportunity for students to become an active member of the work community should be ensured for promoting a smoother transition from student to nurse. This could increase the chances to retain new nurses in the health care workforce. Key messages Well planned and implemented final clinical practicums with an opportunity to become an active member of professional team could help nursing students to obtain a smoother transition into nurses. The benefits of having a good final clinical practicum experience may be squandered if considerably high level of job demands (e.g. timepressure) is experienced in the first years of employment.

Introduction: A reform of health and social care services is a work in progress in Finland. Some counties have already started to restructure their services for the national reform by integrating their services and care. As a part of Competent Workforce for the Future project we aimed to examine if integration is associated with work stressors and quality of care (QoC) among health and social care workers. Methods: Data were gathered in 2017. A questionnaire was sent to all workers of three different health and social care districts in Finland which are in a different stage of integrating their services. Total number of respondents was 1943 (88 % females). Integration was measured with a set of questions by asking participants to assess how well the collaboration with six different sectors (e.g. elderly care services, specialized health care, primary care) works. Stress was measured with a mean of four items (time pressure, The Nurse Stress Index). For the QoC, a 5-point Likert scale was used to assess whether quality of care had improved or decreased during the past three years. Covariance analysis was used to examine the QoC and work stressors with integration and district variables. Seven sectors were examined individually. Results: The respondents assessed the collaboration to work best with social services and worst with mental health and substance abuse services (MHSA). Lower QoC in social work, elderly care services and MHSA sectors was associated with worse collaboration with primary care (F=2.5, p=.05; F=4.1, p=.003 and F=3.1, p=.023, respectively). Furthermore, in primary care lower QoC was associated with worse collaboration with specialized health care (F=2.9, p=.036). Higher rated stress in MHSA was associated with worse collaboration with specialized health care (F=4.8, p=.002). Further, higher stress in primary care was associated with worse collaboration with two sectors; other social services (F=3.9, p=.01) and specialized health care (F=5.4, p=.002). Discussion: Our study demonstrated that in several sectors lower QoC was associated with worse collaboration with primary care, but not vice versa. When examining stress, this study showed that problems in collaboration with specialized health care were associated with more stress. The results could also indicate that health and social care are still very separated, despite the integration process and that workers in social care may have troubles in collaboration with health care workers. But in primary health care collaboration with social care is not valued as much. Conclusion: It is important to facilitate the integration of services and collaboration between social and health care in order to improve the quality of care. Furthermore, since integration was associated with stress it would be important to support the workers in the implementation of the integrated services. Lessons learned: Collaboration between social and health care needs to be strengthened. Limitations: In order to get more reliable results regarding integration, a longitudinal data should be used. Suggestions for future research: In the future research is needed regarding the problems in collaboration between sectors.

Background The shortage of nurses is a global issue, and turnover rates are especially high for newly graduated nurses. The transition from student to nurse is often described as challenging, and the final clinical practicum before graduation is suggested to be important in preparing graduating students for the transition. However, little is known about the actual relationships between the final clinical practicum, transition and turnover intentions. Objectives To examine whether the final clinical practicum experience is associated with the transition experience and turnover intentions of newly graduated nurses, and whether the transition experience mediates the potential relationship between the practicum and turnover intentions. Design Cross-sectional survey study. Settings The study was carried out in Finland (October–December 2018). Participants Registered nurses graduated within the past two years (n = 712). Methods A new survey instrument with five subscales was developed for measuring the final clinical practicum experience. Transition experience was measured on four scales that demonstrated the emotional, physical, socio-developmental and intellectual domains of the transition: Psychological distress, sleep quality, role conflict/ambiguity, perception of transition and educational preparation. Turnover intentions from job and profession were asked about with two questions. Structural equation modelling was used to explore the associations between the variables. The models were adjusted for multiple potential confounders. Results Final clinical practicum experience was associated with all domains of the transition experience and turnover intentions. The association between the practicum and turnover intentions was partly mediated by the emotional (psychological distress) and socio-developmental (role conflict and ambiguity) domains of the transition. Conclusions Our findings provide new evidence about the associations between the specific final clinical practicum dimensions and turnover intentions and the specific mechanisms linking this association. These results highlight the importance of final clinical practicums and suggest targets for improving nurses' transition processes during their first years in practice.

Given the growing aging population in Finland, retaining health staff to care for them is important. In an exploration of predictors of quitting before the typical retirement age, which ranges from 63 to 68 years in Finland, we examined whether organizational justice moderated the association between job involvement and retirement intentions among nurses 50 years and over. The sample was 446 nurses (70% practical nurses) working in 134 assisted living facilities providing 24-hour care for older residents in Finland. Job involvement was measured with the Job Involvement Questionnaire, and organizational justice with a scale that tapped its three dimensions: distributive justice, procedural justice, and interactional justice. In covariance analyses, low organizational justice and low job involvement were associated with a higher likelihood of retirement intention. Both interactional justice and procedural justice moderated the association of job involvement with retirement intentions. Among nurses with low job involvement, those who experienced unjust treatment, that is, low interactional justice, and evaluated organizational procedures as unjust had significantly stronger retirement intentions than nurses with high levels of interactional and procedural justice. Distributive justice was associated with retirement intentions in both high and low job-involved respondents. Organizational justice may act as a buffer against retirement intention as one consequence of nurses' low job involvement. © 2016 Wiley Periodicals, Inc.

The final clinical practicum before graduation prepares nursing students for the transition from a student to a nurse, but the essential elements of the final clinical practicum that enhance successful transition are not known. We examined the associations of five elements of the final clinical practicum with four indicators of the transition experience in new nurses. We also tested whether psychosocial work characteristics modified these associations. The study sample comprised 712 Finnish nurses who had graduated within the previous two years before the data collection (response rate: 18%). The data were collected using a questionnaire survey in 2018. The elements of the final clinical practicum included (1) the systematicness of the practicum, (2) teacher involvement, (3) the quality of supervision, (4) preparing for the demands of a nurses work and (5) being part of a professional team. Our results, based on linear regression analysis, showed that all the elements except the quality of supervision were associated with indicators of the transition experience (beta range: from 0.08 to 0.35). Job demands modified several of these associations. The findings of this study highlight the potential for well-implemented final clinical practicums to promote a smoother transition for new nurses.

Background In the future, elderly care workers need to have competence of various different conditions due to greater amount of multimorbid elderly. Further, knowledge of national level guidelines is important since they are closely linked to improving quality of care and implementing better practices at work places. The impact of national level guidelines on quality of care at care units is, however, not widely examined in the Finnish context. In this study, the aim was to find out if worker’s experience of his/her own competence is associated with quality of care. Secondly, we aimed to see how common is addressing national guidelines and policies at workplaces, and if they are associated with quality of care. Thirdly, we aimed to see whether there are differences between different occupational statuses in competence and addressing national guidelines and policies. Methods Total number of respondents was 1997 from 273 different units. Xtreg procedure was used for examining the associations of age, occupational status, unit type, professional competence and addressing the guidelines and policies with quality of care. Results Higher grade for QoC was associated with age, supervisor position, working in institutionalized care, better competence in supporting the self-determination of a person with memory disorders and falls prevention and addressing the act for elderly care and memory policy. Conclusion This study demonstrated that national policies and guidelines are not widely addressed among Finnish elderly care workers. The study also showed that experienced competence of workers and discussion of policies and guidelines are related to quality of care. Especially competence related to memory disorders was associated with higher QoC. However, the relationship between quality of care and things influencing it seems complex and a major part of the variation in QoC remained unexplained. Although the relationships between guidelines, competences and quality of care are weak, national policies and competences seem to have impact on actual care provided. Therefore, sufficient time to address the guidelines should be provided at workplace and competences developed, which can be seen as a supervisor’s task. With knowledge about the guidelines, workers are able to change their practices at work places.

Introduction: In Finland large planned reform would integrate all health and social service under responsibility of 18 counties now 300 municipalities. The aim of the reform has been to comprise economic development by creating new, larger and stronger organizations as well as to build integrated services and service chains. On the other hand, one aim is to increase customers’ choice of provider and to increase the number of service providers and to have competition in the market. Education of health and social care professionals is mostly based on strong professions, but new service system challenges this. Service integration can be seen as making the process between components of services smoother using multi-professional collaboration, organizational integration or case managers. In earlier studies interpersonal communication, collaboration, systems thinking and holistic assessment have been noticed as core competences in integrated care. In this paper we analyze service integration in three districts, which have already made their own integration reforms. Municipalities in large areas have built organizations, which are in responsibility of purchasing services as well as providing most of services. Examples of service integration, crucial elements and competencies are presented. The experiences from these forerunner organizations can be applied in future national reform as well as internationally. Methods: The study is a part of a large Cope-project which aims to evaluate the competencies needed in future integrated health and social care. This paper is based on individual and group interviews of 81 top and middle managers and 26 frontline managers. The data was collected from three large health and social care districts. One district has been in action for several years, one has just launched the new organization and one is being planned. The data was analyzed using inductive content analysis. Results: The first results showed that care integration is implemented using three strategies: 1 collecting services into same organizational departments from hospitals, primary care and social services, 2 improving co-operation between organizational units and professionals and 3 using care integrators or case managers. These strategies vary in different sectors and districts. Same districts may use all strategies. Market orientation and increasing number of private firms is seen as contradictory to care integration. For example understanding the services needs of customers in more holistic way larger than view of own work and understanding the service system better is needed. There is a need to create multiprofessional work, and to build trust and understanding between professionals. Managing multi-professional groups and inter-organizational collaboration will demand new skills and new integrative management orientation. Conclusion: The first results of the study showed that service integration is a strong emphasis in all participant organizations, but the means of integration differ. There are several generic competencies which should be at better level among managers as well as employees in future. In education of all professions more integrated learning between health and social care is needed. Case managers need a special training combining both health and social care. Education at work places should be integrated to development of working culture.

Introduction : Patients with chronic illnesses often have complex health care needs and use multiple social and health care services. This study examined experiences about health care use among persons with chronic conditions and whether these experiences were associated with sociodemographic factors, health care needs and use of health care services. Methods : The data were from a randomly sampled population survey concerning health care experiences n=2626, response rate 46%. In this study we used a subgroup of persons with a chronic illness n=1282. The outcome measures were experiences about: access to care, respectful treatment, participation to care and coordination of care during the last 12 months. The explanatory factors were sociodemographic factors, need for care functional limitation, depression, use of health services ambulatory care and hospitalization and having a continuous therapeutic relationship regular physician. Multivariate logistic regression was used to analyze the relationships between the explanatory and outcome variables. Results : In fully adjusted models, more negative experience of care on all dimensions were reported by those with sever functional limitations ORs 0.35-0.49 and frequent visit to ambulatory care ORs 0.43-0.59, while continuous therapeutic relationship was related better experiences on all dimensions ORs 1.50-1.91. Depression was related to more negative experiences in respectful treatment OR= 0.54 and poorer coordination of care OR=0.61. Those who had been hospitalized during the past year reported more problems in respectful treatment OR=0.57 and coordination of care OR=0.41. Compared to those using public health centers as the main site of ambulatory care, better access to care was reported by those using private clinic OR=2.24, occupational health care OR=1.91 or hospital outpatient clinic OR=2.45. Participation to care was more often reported by those using hospital outpatient clinic as main site of care compared to other groups. Discussion : In conclusion, these results indicate poor responsiveness of the health care system among those with complex health care needs and frequent use of health care. The lesson learned from the study is that many of the common problems of the Finnish health care system, such as poor and inequitable access to care and problems in integration, are reflected also in experiences of those with higher health care needs. Frequent attenders 10% of health care users are estimated to cause a substantial proportion of all health care costs. Thus, organizations and responsiveness of health care should be monitored from the point of view of these vulnerable users. The limitation of the study is that we were not able to examine experiences in terms of specific illnesses. Future studies should focus on condition specific health care needs and experiences.

Introduction To assess how health care professionals outline the management of care and explore which health or social care professionals were involved in the patient's treatment. Methods A survey with a patient vignette for general practitioners (n = 31) and registered nurses (n = 31) working daily in Finnish health centres located in four cities. Respondents answered structural questions and explained in detail the care process that they tailored for the patient. The care process was examined using content analysis. Results A physician–nurse working pair was declared to be in charge of the care process by 27% of respondents, a registered nurse by 9% and a general practitioner by 11%. However, 53% reported that no single person or working pair was in charge of the care process (response rate 72%). The concluding result of the analyses of the presented process was that both treatment practices and the professionals participating in the patient's treatment varied. Collaboration with social services was occasional, and few care processes included referrals to social services. Conclusion For the patient who needs both health and social care services, the management of care is a challenge. To improve the chances of patients being actively involved in making treatment plans at least three factors need to be addressed. Firstly, a written treatment plan should explicate the care process. Second, collaboration and interaction between health and social care services should be strengthened, and third, a contact person should be named to avoid care gaps in primary health care. Next-step data from patients need to be collected to get their views on care management and compare these with those from general practitioners and registered nurses.

Background and Objective Finnish physicians have been increasingly dissatisfied with poor usability of the electronic patient record (EPR) systems, which they have identified as an overload factor in their work. Our aim is to specify which factors in EPRs are associated with work-related well-being of physicians. Methods A web-based questionnaire was sent to Finnish physicians younger than 65 years; the responses (n = 3,781) represent one-fourth of these. This was a repetition of a survey in 2010, where this questionnaire was used for the first time. In addition to statements assessing usability, there were questions measuring time pressure and job control. The relation between usability and work well-being was investigated with hierarchical multivariate regression analyses: With time pressure and job control as dependent variables, EPR usability assessments and physicians' background information were used as independent variables. Results In the multivariate analyses, technical problems that are often experienced in the EPR were related to higher time pressure and lower job control. Active participation in the development of the EPR system was related to stronger time pressure and stronger job control. In addition, use of several systems daily and the experience of time-consuming documentation of patient information for statistical purposes (billing, national registries, and reporting) were related to higher time pressure, while those with longer experience with the EPR system and those experiencing easy-to-read nursing records reported higher job control. Conclusion To relieve time pressure and increase sense of job control experienced by physicians, usability, integrations, and stability of the EPR systems should be improved: fewer login procedures, easier readability of nursing records, and decreased need for separate documentation for statistical purposes. Physician participation in the EPR development would increase the feeling of job control, but would add the time pressure. Hence, time for developmental work should be arranged.

Purpose: The purpose of the study was to explore how nurses assess their em- powerment and clarify organizational justice compared to other work-related factors. In addition, we examined the major variables pertinent to empower- ment.Design: Cross-sectional survey data were used.Methods: A total of 2,152 nurses returned the completed questionnaire. The instruments consisted of nurse empowerment, organizational justice, job con- trol, and possibilities for developing work. The data analysis was based on de- scriptive statistics and further statistical tests.Findings: Organizational justice and empowerment had a clear correlation. Job control, possibilities for developing work and organizational justice were statistically significant predictors of nurse empowerment.Conclusions: Organizational justice and the possibility to use one's individual skills at work are significant factors in staff activity and its development in nursing. They increase the level of empowerment and commitment as well as motivation to work.Clinical Relevance: The results of this study confirm that nurses regard or- ganizational justice as highly important. We can facilitate both work-related empowerment and organizational justice by creating and maintaining a cul- ture of fairness and justice. Employees should be heard and involved more in the planning and decision making of work.Key wordsNurse empowerment, organizational justice, nurses' work environmentThe development of technology and the demand for ef- ficiency have created a constant pressure for change in healthcare organizations. Work environment plays an important role in this autonomy as well as learning pos- sibilities at work (Schmalenberg & Kramer, 2008). Em- ployees expect encouragement and support from their management, who is also responsible for good working facilities (Stuenkel, Nguyen, & Cohen, 2007). Further- more, employees want progress. From the employee's perspective, significant elements include initiative and to be active and have the opportunity to influence their own work and expand their individual capacities (Malloy & Penprase, 2010). In the context of nursing re- search, empowerment has been associated with nurses' professional development and good leadership (MacPhee, Skelton-Green, Bouthillette, & Suryaprakash, 2012). Currently, only a few nursing research reports ex- ist on organizational justice (Heponiemi et al., 2007; Laschinger, 2004). The present article reports a study in which nurses assessed their empowerment as well as explains and analyzes the relationship between empow- erment and organizational justice, including work-related and demographic variables.BackgroundEmpowermentThe concept of empowerment has been used in de- scribing both an essential part of human nature and development on one hand, and the aspects of organiza- tional effectiveness and quality on the other. In literature, empowerment has been described from three aspects using critical social, organizational, and psychological theories (Chen & Chen, 2008; Kuokkanen & Leino-Kilpi, 2000) . The individual empowerment process consists of both critical introspection and outside guidance, leading to an appropriate modifying action.The psychological model of empowerment (Thomas & Velthouse, 1990) formed the framework for the qualita- tive study introducing theme-based interviews relevant to empowerment. The results of this study are shown in the Model of Nurse Empowerment. It describes what an empowered nurse is like (i.e., qualities of an empow- ered nurse [QEN] ) and how he or she performs his or her tasks in relation to the empowerment promoting and impeding factors. Moreover, five categories were formed based on these factors, comprising moral principles, per- sonal integrity, expertise, future-orientedness, and so- ciability (Kuokkanen, 2003; Kuokkanen & Leino-Kilpi, 2001) . …

Background: The association between psychosocial work environment and employee wellbeing has repeatedly been shown. However, as environmental evaluations have typically been self-reported, the observed associations may be attributable to reporting bias. Methods: Applying instrumental-variable regression, we used staffing level (the ratio of staff to residents) as an unconfounded instrument for self-reported job demands and job strain to predict various indicators of wellbeing (perceived stress, psychological distress and sleeping problems) among 1525 registered nurses, practical nurses and nursing assistants working in elderly care wards. Results: In ordinary regression, higher self-reported job demands and job strain were associated with increased risk of perceived stress, psychological distress and sleeping problems. The effect estimates for the associations of these psychosocial factors with perceived stress and psychological distress were greater, but less precisely estimated, in an instrumental-variables analysis which took into account only the variation in self-reported job demands and job strain that was explained by staffing level. No association between psychosocial factors and sleeping problems was observed with the instrumental-variable analysis. Conclusions: These results support a causal interpretation of high self-reported job demands and job strain being risk factors for employee wellbeing.

International mobility of health care professionals is increasing, though little is known about how working in a culturally diverse team affects the native physicians' psychosocial work environment. We examined Finnish physicians' perceptions of work-related wellbeing according to whether they had foreign-born colleagues (FBCs) in their work unit. We also examined whether work-related resources moderate the potential association between work-related wellbeing and working alongside FBCs. A cross-sectional survey was conducted for a random sample of physicians in Finland in 2010 (3826 respondents, response rate 55%). Analyses were restricted to native Finnish physicians working in public health care. The results were analyzed by ANCOVA. In unadjusted analyses, having FBCs was related to poor team climate (p

Introduction: Since the early 2000s, Government policies in Finland have supported administrative and operative integration of health and social care to create larger authorities for organising services and to strengthen coordination of primary and specialised care, and social services. Nationally, the policies have led to attempts to reform the service system to support integration. At the local level, municipal collaboration has been launched to create regional joint health and social care authorities to boost administrative integration and to facilitate the implementation of innovative forms of integrated care. Of these local initiatives, we address two county level joint authorities which have established comprehensive integrated care organisations merging primary and specialised health care and social services under one management. Our aim is to evaluate the success and transferability of these initiatives. Methods: We focus on two vanguard counties, South and North Karelia, which have established joint health and social care authorities in Finland. In South Karelia the authority has operated since 2010 and in North Karelia since 2017. For the multimethod study, we collected intensively data on the operation of the joint authorities and health and social services provided particularly for client groups benefiting from integration. We compiled county policy and evaluation documents on health and social care, run an online survey among employees, and carried out individual and group interviews of management and employees. Results: The two counties have several common features including the population of 130,000-169,000 inhabitants, regions of a larger town with a specialised hospital and several rural municipalities. While both counties have intensively supported to care integration, they display differences in their approaches. South Karelia has gradually developed integrated services for focused client groups, such as homebased rehabilitation services for the elderly, integrated services for children and young people, and integrated psychosocial services for adults. In North Karelia, reorganised recently, integration has focused on integrated health and welfare centres bringing earlier separate primary and mental health care, and social and substance abuse services on the same premises. In both counties, preliminary experiences on adopting integrated care models are positive. Efficiency has improved and waiting time and costs decreased without deteriorating patient satisfaction. The early experiences also underline the importance of strengthened shared management to address smooth work processes between different professional groups. Discussion and conclusions: The establishment of the joint health and social care authorities with a strong emphasis on integrated care seems to be successful. The early experiences suggest a positive impact in terms of efficiency. Transferability particularly to larger urban municipalities is challenging to assess. The national health and social system reform currently prepared in Finland may include features, such as increasing privatisation and market-based services, which request changes in the integrated care models. Limitations: The study was based only on two county-based health and social care authorities with relatively similar integrated care models. Suggestions for future research: Due to limitations in case-studies, long-term broader follow-up studies are needed for assessing and comparing the impact and outcomes of different integrated care models.