The results are derived from the data of the individual interviews before and focus group discussions with leaders of middle management of a hospital in Germany after the intervention and are presented together. We focus on the results of the focus group discussions. These are enriched by selected results of the individual interviews for a deeper understanding of potentials and limits in the implementation of stress-preventive leadership. The quotes are given with the respective source attributions to the individual interviews or to the focus group discussions. Within single quotes there may be several aspects addressed, so that the quotes may be used also elsewhere within the results section for illustration. This illustrates the complexity and the interaction of various work-related factors in the hospital setting.
The participants described various barriers in the practical implementation of stress-preventive leadership and supportive measures within their scope of action. Barriers to the implementation of stress-preventive leadership in general, but also regarding specific measures from the intervention were reported. In connection with the barriers mentioned, some requirements for the implementation of a stress-preventive leadership style were explicitly mentioned, others can be derived. The barriers mentioned can be divided into the three areas leader-related barriers, subordinate-related barriers, and organizational barriers. Examples for these three areas are presented first. Afterwards, selected examples illustrate further specific barriers in the sandwich position, perceived scope of action regarding supportive measures as well as requirements for a stress-preventive leadership style on middle management.
Leader-related barriers, subordinate-related barriers and organizational barriers
The barriers related to leaders include available resources (e.g., exhaustion of the leader), personal skills (e.g., recall of learned contents, discipline) and work practices (e.g., insufficient breaks). Leaders expressed that the implementation of stress-preventive measures in day-to-day work would become difficult over time. Although the positive effects of breaks and finishing work on time are known, they were hindered, e.g., by the discipline of the individual and by a lack of awareness (Quote 1).
Quote 1 – Focus group discussion: “Unfortunately, taking breaks doesn’t always work. Punctual closing time does not work at all right now [due to a] wave of sickness. But in between it worked quite well. I realized I need to work on myself a little bit better. It is dangerous that this is quickly lost in everyday life if you do not make yourself aware of it.”
Stress-preventive measures for leaders in sense of SelfCare, which were part of the intervention, could be forgotten in moments where the suffering was not so great (Quote 2).
Quote 2 – Focus group discussion: “[Measures] that I had to implement on my own, [such as the One-Moment-Meditation], it was rather the problem that whenever I didn’t suffer [ …], I quickly forgot [to apply them].”
The implementation of stress-preventive leadership measures could also become more difficult due to subordinate-related aspects e.g., insufficient team orientation of subordinates and their willingness to be integrated into the team (Quote 3).
Quote 3 – Focus group discussion: “Nevertheless, if the team is big enough, you always have someone with you who pulls out, and that’s exactly the point where it’s very, very difficult to remain team-oriented and somehow do the right thing, the best thing for the whole team. If you have some who don’t really want to actively integrate themselves into the team. [ …] And getting someone like that into the team is often difficult.”
Organizational barriers result from the given working conditions of clinical care and the organizational design of the workplace hospital. They include aspects such as staff shortages, unscheduled staff absences, large teams, or work intensity. These aspects were addressed as secondary themes in some of the selected quotations (e.g. Quotes 1, 3, 10, 11, 14, 16) and can therefore be taken as examples of organizational barriers. Furthermore, various leadership hierarchies are established in the organizational structure of hospitals, so that the scope of action for leaders of middle management is perceived as limited, e.g. with regard to team-oriented leadership (Quote 4).
Quote 4 – Focus group discussion: “We want team-oriented leadership. For team-oriented leadership we need a team structure and not a hierarchy. At the moment when there is a top-down hierarchy and when this is lived every day in the executive in such a way that one individual has the absolute ultimate decision-making authority, I don’t even need to start with team structure, at least with regard to certain processes that need to be changed.”
Specific barriers in the sandwich position
Some challenges for leaders of middle management were mentioned in the interviews with senior physicians and senior nurses and during the focus group discussions. For example, leaders of middle management emphasized a lack of exchange with other leaders (Quote 5).
Quote 5 – Interview: “As a leader you are often alone. Even though I talk things over with my senior nurse or with another leader, which I already do because I know two leaders in my group of acquaintances or friends - thank God. But I realize I really miss that as support.”
Additionally, an increased work intensity due to the own sandwich position was mentioned. Demands and work-related pressure would be addressed to leader of middle management by top management and by subordinates. Top management would demand the implementation of structural requirements, while subordinates would become dissatisfied if difficulties arose during implementation (Quote 6).
Quote 6 – Focus group discussion: “I’m in a sandwich position, which means I have my supervisor on top of me and the team below me. I get pressure from above to implement a clear structural specification and pressure from below, by the team: No, you can’t do it that way. Or I experience dissatisfaction [in the team] directly, as I also work at the base on some days.”
Participants also stated that work-related pressure and stress would be passed through several hierarchical levels to the lower levels of management (Quote 7).
Quote 7 – Interview: “I realize that my supervisor is under a lot of pressure from her leader and that this pressure causes her stress. She then passes on this stress.”
Scope of action regarding supportive measures
The leaders interviewed perceived limits in terms of organizational structure and saw potentials to influence given psychosocial demands through appropriate leadership behavior. In terms of perceived influence, participants distinguished between situational measures and future-oriented possibilities of regulation. Situationally, leaders of middle management could support their subordinates in patient care, whereby they could cause additional stress for themselves due to the associated extra work. According to the interview partners, work-related stress for subordinates could be avoided or reduced with a sustainable planning of the duty roster (Quote 8).
Quote 8 – Focus group discussion: “I have experienced the point as at least ambiguous in day-to-day [work]. There are immediate methods how I can help to minimize stress and those that are more future-oriented and will pay off in the medium term. For example, when I say OK, I’m going to work with you and take the next patient [ …]. This means, however, that I reduce stress on [the side of the subordinates] by creating additional one for myself, because this keeps me away from my other tasks and my to-do list. But then there are also control options. We receive the duty roster for review before it is released to see if we still have ideas, so I can have some influence on it.”
The participants reflected the intervention contents also concerning the leadership behavior of the top management and noticed divergences. During the discussions, it was stated that the top management would not exercise a stress-preventive leadership. This aspect is described in more detail in the section “Requirements across hierarchical management levels”. Furthermore, it was explicitly stated that a situation-related stress-avoiding behavior of leaders of middle management towards subordinates could lead to an additional burden on leaders. Participants recognized that this additional burden must have limits and feedback of the burden must be communicated to the top management (Quote 9).
Quote 9 – Focus group discussion: “So many times I asked myself: what are our leaders doing? They really don’t do much of what we have been taught here. And you try to optimize the situation for your subordinates. It is always at my expense, without exception. We were understaffed at one point and as a senior physician you support the routine work and do patient care. [Afterwards] you do your main work in the evenings until midnight [ …] You have to seek the dialogue with your leader because you can’t work in the red zone all the time. [ …] I realized that very clearly through the intervention.”
The participants emphasized several times, both in the individual interviews and in the focus group discussions, that stress-preventive leadership was also dependent on staffing ratio. Inadequate staffing could mean, for example, that in the event of absences due to illness, substitution by other employees was necessary, or understaffed shifts result. At the same time, the leaders of middle management perceived no opportunity to influence the staffing ratio. In the case of increased work intensity due to an insufficient number of staff, one possibility for leaders to prevent stress could be a conscious relationship-oriented leadership style, in which subordinates are shown appreciation for their willingness to take on stand-in duties (Quote 10).
Quote 10 – Focus group discussion: “What runs counter to the team concept: We have a tight staffing and as soon as one drops out, it’s patchwork and then you try to make it work somehow. The same people always step in and don’t refuse when they are asked. I can only partially change that, it’s not in my power. I am not responsible for the sickness absence and I am also not responsible for the staffing ratio and I cannot change anything about it. But I can notice the persons who always step in and who always say ‘yes’ and I can also mirror that, and that helps.”
In addition, a clear prioritization of tasks with subordinates and the communication of this prioritization to members of other sections or to the top management were mentioned. The responsibility for setting priorities towards third parties was assumed by the participants in their role as leaders, e.g. if tasks were not carried out (Quote 11).
Quote 11 – Focus group discussion: “Over the summer, I had one subordinate less. [ …] We all sat down together, and I, as team leader, said that certain tasks would simply remain undone, and that’s it. [ …] When someone else came and complained about it to my team, I stood up and said: you can take over these tasks yourself, you don’t need us to do that and we are currently understaffed.”
The prioritization of tasks by the leaders of middle management and the skipping of certain tasks seemed to be easier if they were supported by the top management. In contrast, leadership hierarchies could limit the setting of priorities by the leaders of middle management and hinder stress-preventive leadership if suddenly different priorities were set (Quote 12).
Quote 12 – Focus group discussion: “I had made a note of the fact that, at short notice and from the outside, i.e. the head of department or others, laws or changed priorities make the whole thing incredibly difficult (agreement). You have made a plan, you have a weekly plan, you only have a daily plan or a morning plan and a call comes in: our priorities are from now on and for the next two weeks … boom.”
After participating in the intervention, leaders reflect on the compatibility of demands of the top management and a stress-preventive leadership style. Participants indicated that they would like to give a higher priority to the concerns of their subordinates (Quote 13).
Quote 13 – Focus group discussion: “If the head secretary’s office calls with a matter [from time to time], then I just reflect on [the prioritization] even more and think to myself, why is this now the first priority and the people I’m with every day, why do I put [their matters] on hold. Now I think: o.k. even when those from the head secretariat call a third time because the matter has not yet been settled, then I do not care. The matters on ward are [considered] first.”
Requirements across hierarchical management levels
A special characteristic of middle management became apparent in the role model function of the top management and the dependence on top management and decision-makers (Quotes 4, 12). In the focus group discussions, participants expressed a discrepancy between the content learned about stress-preventive leadership style and the behavior of the top management (see also Quote 9). They saw no possibility of influencing the awareness and implementation of a stress-preventive leadership style of their division leader. However, the reflection and awareness of a stress-preventive leadership style of the divisional leader is seen as important in order to implement self-referential stress-preventive working practices (SelfCare) in the middle management and, e.g. carry out breaks (Quote 14).
Quote 14 – Focus group discussion: “An important issue for me was that I actually don’t have much scope of action [ …]. Our divisional leader makes all the mistakes that can be done in terms of stress. It starts with the duty roster [ …]. There are no conversations in a calm atmosphere. We have a high stress level during work, so breaks cannot be taken. [ …] I do it like you do now, when I run through the corridors, then I consciously make myself walk slowly and take a deep breath. And then I do one thing at a time. I have now become very aware of the fact that my divisional leader does not [ …] do the staff care that is actually necessary. And I cannot do anything about it as long as he [divisional leader] is not aware of it himself. I wish he would participate in this course.”
Stress prevention would also require that agreements between hierarchical levels on work procedures are adhered to (Quote 15).
Quote 15 – Focus group discussion: “Interviewee (I): For me, stress prevention includes structure and maintaining agreements. So when the chief physician […] consults with his senior physicians that rounds are always at [the same time] and it will be decided who can be sent home the next day and the reports are ready then […] - and
I: Mostly it is not that way.
I: And then nobody does [what was agreed upon].”
The example of time management illustrates that certain work practices occur across hierarchical levels and could cause stress. Leaders of top management would place orders without sufficient time budget to leaders of middle management. This insufficient time management would in turn be passed on to their subordinates. And consequently, it would be accepted that tasks would also be processed at weekends or after working hours (Quote 16).
Quote 16 – Interview: “We need to think about a general communication structure within the hospital. This is not well practiced from above. Tasks are set without sufficient time budget. And you tend to behave in the same way and to say: Here you have a subtask. And the other one says: when should I do it? And then you say: just like me on the weekend or in the evening. That is not a good answer.”
Appropriate time management was perceived as a stress-preventing working practice and as a leadership task. Subordinates would like to have appropriate time management at work (Quote 17).
Quote 17 – Interview: „I think subordinates would like the leader to be able to estimate realistically how much time a particular task requires. I think this is regularly misestimated.”
Repeatedly, it became clear in the conversations that the topic of stress-preventive leadership style should also be addressed at higher levels of management. This would be decisive for the implementation of stress-preventive leadership at subordinate management levels. The need was formulated that contents from the discussions of the intervention should be passed on to the top management so that they could become aware of the requirements of a stress-preventive leadership culture and react accordingly (Quote 18).
Quote 18 – Interview: “It should not be just an intervention for leaders [of middle management]. Each participating group should work out a few things that are communicated to higher management. That it is not only something for us, but that they also receive feedback on a few key points that occur frequently in the courses. So they may be able to react and benefit from it.”