Malin Rosell Magerøy

Healthcare leaders play an important role in managing responsibilities and requirements for patients, employees and the quality and safety of the provided services. Different legislations regulate these responsibilities, and leaders play a significant role in managing the dual  responsibility for health, safety, and environment (HSE), and quality and patient safety (QPS). HSE regulations encompass health, safety, and welfare for employees, while QPS includes patient safety, quality of service delivery, clinical effectiveness, and patient experience. Keeping both patients and employees safe in healthcare is crucial, but there are complex interactions we do not know enough about between these two arenas of safety management, and research and practical experience show that it is necessary to understand HSE and QPS in a holistic way, as they can affect each other and generate conflicts of interest. There is knowledge that leadership can have a significant effect on patient safety culture and work engagement, and hierarchical leadership levels and organizational factors can affect leadership approaches, and thus the outcome for HSE and QPS, but there is not a clear understanding of leaders’ perspectives and the strategies they enact regarding this duality.

The overall aim of this thesis was to explore how leaders at different system levels in primary healthcare interpret, negotiate, and manage the dual responsibility and possible tensions between HSE and QPS.

The study was designed as a single embedded case study, and the case was defined as the two perspectives of safety: HSE and QPS in nursing homes. The embedded units involve three levels of stakeholders. The macro level consisted of politicians and the municipality director, director of health and welfare, and head of health and care services (top-level leaders). The meso level consisted of head of nursing homes (mid-level leaders), and the micro level consisted of department leaders in nursing homes (frontline leaders). Five municipalities differing in size and type of location (urban/rural) participated in this study, and the case study was divided into three substudies. Data was consisted of 40 individual interviews with leaders, five focus group interviews with elected politicians, and collected policy documents and guidelines regarding HSE and QPS.

Sub-study I (macro level) explored how healthcare leaders and elected politicians organize, control, and follow up the work of HSE and QPS. Sub-study II (meso level) explored how nursing home leaders manage the dual responsibility of HSE and QPS, the approaches they take and the dilemmas they face. Sub-study III (micro level) explored the barriers and enablers that department leaders in nursing homes encounter when managing the dual responsibility of HSE and QPS. The results shows that both politicians and leaders at all system levels experience tensions in handling the dual responsibility, and that both contextual and internal factors influence their experience. Conflicting interests, such as legislation and economic factors, led to trade-offs at all levels. Size, location, legislation, and economic situation were the external factors that had the greatest impact, while organization, system, competence, and relations were the internal factors that were most prominent.

Malin Rosell Magerøy (48) is a registered nurse and holds a master`s degree in Health Promotion from University of Southeast Norway (USN). She defended her thesis December 6^th, 2024. She is currently working as a special adviser in leadership and organizational development in Rogaland County Municipality and is employed as a postdoctoral fellow in SHARE from March 1^st, 2025.

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