Section on Occupational Health and Safety

EMPLOYER CONTROL AND THE WORK ENVIRONMENT: A STUDY OF THE SWEDISH PUBLIC DENTAL SERVICE Eva Bejerot and Tores Theorell The Public Dental Service in Sweden has a system of surveillance and supervision based on time studies, piecework wages for dentists, and detailed time reporting. This control system and its development are described in this article. The focus is on the effects of the system on the staff. A representative group of Swedish dentists (n = 8%) and dental nurses (n = 600)was asked to participate in a uestionnaire study exploring the work environment in the Public Dental Service. response rate was 87 percent. The dentists reported that they felt constantly supervised and evaluated. Their work tempo was related to surveillance, competition, and demands of the employer. There was no correlation between work tempo and piecework results. A high percentage of the staff mentioned weaknesses in the charging and piecework system that they thought could result in an undesirable influence on dentists’ work. A majority would have preferred f i e d salaries. The results are discussed in terms of gender, motivation, proletarianization, and management style.

he

Postmodern development in professional groups is under current debate within sociology: whether professional groups form a new governing class, or there is a tendency toward proletarianization, or there is no assimilation into either the governing or the working class; also, whether their monopoly of knowledge gives professionals a privileged position in society, even though this is modified by an increase in bureaucratic control of their work (1). Proletarianization is a concept that is primarily used to describe. the dequalification of workers in industrial society: their loss of control over knowledge, technique, and the goal of their work. Frederick Taylor’s (2) theories have been decisive for the introduction of principles of work organization, which are primarily applied to industry and which entail the division of work into smaller entities. Innovations required in implementing such principles are time studies, assembly lines, and piecework wages. Braverman (3) has analyzed the concept of Taylorism and shown that control and

This research was made possible by financial support from the Swedish Work Environment Fund and the Swedish Center for Working Life. These results were published in part (in Swedish) in March 1989 (Bejerot, E. Tandvdrd pd ackord Stressfonhingsrapport nr 216. Statens institut for psykosocial Miljomedicin, Stockholm, 1989).

International Journal of Health Services, Volume 22,Number 4, Pages 669-668,1992

0 1992, Baywood Publishing Co., Inc.

669

doi: 10.2190/G6L6-46QW-KJGC-1KAG http://baywood.com

670 / Bejerot and Theorell comprehensive regulations are the basis of this system. Several sociologists have analyzed developments in this area and have found that, although the employer’s strategy has changed, control over the workers is of equal importance for management today as it was in Taylor’s time, or of even more importance (4,5). Piecework wages usually result in a higher intensity of work. They also lead to stress and involuntary behavior, thus increasing the risk of injuries and accidents (6). In a study of the building industry it was found that time-planning, production norms, etc., may exert a pressure on productivity that is equal to or even greater than that resulting from piecework wages (7). Management style has been shown to be one of the most important factors affecting the stress level of employees (8). This perspective gives interest to the present study of the systems of surveillance and control of a professional group, dentists, in a state-organized sector, the Public Dental Service (PDS) in Sweden. This article, which is part of a larger study on the PDS in Sweden, includes a description of the piecework and surveillance system and the results of a questionnaire to the staff of the PDS. The aim is to investigate the management of the PDS and to describe its effect on the staff.

DENTISTRY ORGANIZATION IN SWEDEN

Swedish dentistry differs from that in other Scandinavian and European countries through its well-developed PDS (introduced in 1938) and national dental insurance system (introduced in 1974) with which practically all private dentists are affiliated (9, 10). These two reforms have provided the State with close control of the dentistry sector. The National Board of Health and Welfare is responsible for planning and following developments in dental care, while the National Board of Insurance is responsible for collecting statistics on economy and the treatment panorama in the PDS and in private dentistry. The PDS is organized under county council administration and financed by local government taxes and government funds. There are 5,700 dentists working in the PDS, half of all the dentists in Sweden. It is intended that, as well as children and young people, 30 to 35 percent of all adults should be treated in the PDS. In each of the 27 county councils there is an administrative Center of the PDS that has local responsibility. The local head of the PDS in the county is usually a dentist, and under him or her are a number of district chiefs, each with responsibility for several clinics. Every PDS clinic has a head dentist and a first nurse. In the present process of modernization, more emphasis has been placed on the position of the clinic leadership as the local representative of the employers. Responsibility for budget and staff questions has been delegated to this level. The promoted dentists, like their unpromoted colleagues, work mainly with patients. However, the district chiefs and heads of clinics are entitled to spend time on administrative work. There is, to varying degrees, a common policy on clinical questions-either nationally, within a county council, or at individual clinics. This may concern matters such as intervals between treatments, prophylactic programs, giving priority to certain groups, policy on orthodontics, treatment with certain materials.

Employer Control and Work Environment / 671 THE SYSTEM OF CONTROL IN THE PUBLIC DENTAL SERVICE The charging list, reporting regulations, and wage rewards are all seen as part of a management and surveillance system in the PDS. The following is a description of the background and construction of this system, which affects dentists directly and dental nurses more indirectly. From Inspectors to Computer Systems

Already in the planning of the PDS in 1935 (ll), the need and possibility for surveying dentists’ work in the PDS was discussed and direct inspection and a careful system of reports were suggested. Here we find the earliest description of all the variables to be followed for the individual dentist: for example, the number of patients and the number of teeth treated, the type of treatment, epidemiology. This ambition of the State was not fully achieved until 40 years later, with the introduction of modem computer systems. The supervisory system of the PDS has been changed over time. From 1939 to the early 1960s visiting inspectors checked dentists’ work on patients twice a year, a system the dentists felt to be humiliating. (Today, local inspections are made only in special cases.) In addition, there were simple statistics on proceeds, number of children treated, and number of “black’’ and “white” fillings. This statistical material has, in the last decades, become more comprehensive through detailed surveillance in the form of circumstantial reporting and computer systems. Apart from data on quantitative results, the computer systems record epidemiological data and other qualitative assessments of treatment. Type of treatment, time spent on different categories of patients, and number of patients who do not arrive for treatment (as a measure of psychological care) are examples of data that now can be followed for individual dentists. The use of computer techniques was introduced in the PDS in 1972 (12) and was further developed when the dental insurance system was introduced. During the 1980s the computer systems were made more effective for detailed surveillance and rapid reporting back (13). Developments in computerization were promoted by the leadership of the county councils and the PDS and by the Swedish Planning and Rationalization Institute for the Health and Social Services. The Swedish Dentists’ Association noted the increase in surveillance and control in the PDS during the 1980s. The uneasiness that arose was not only over the detailed surveillance of work through the central treatment program; it was also feared that this easily accessible computer technique might be abused by employers in assessing employees (14, 15). Time Studies and Piecework

The traditional system in private dentistry in Sweden was an open cartel with standardization of work tasks and recommendations on charging rates (16, 17). In connection with the initiation of the PDS and the national dental insurance system, the traditional agreements within the profession were replaced by fmed charges based on cost and time studies (Method Time Management) (18-21). Annual negotiations on

672 / Bejerot and Theorell wage rates take place between the Swedish Dentists’ Association and the National Board of Insurance. Since the commencement of the PDS, dentists have had some form of piecework wages. From 1939 to 1965 piecework only applied to adult patients, but in two stages, in 1965 and 1971, piecework was also introduced into pediatric dentistry. Dentists protested vigorously. The Swedish Dentists’ Association has never been really satisfied with this wage system, but accepted it in the hope that it would lead to higher salaries (22); unfortunately this did not happen. The dental insurance “price list” includes about 80 service items. Apart from piecework, some treatments are also carried out on hourly rates. Dentists receive piecework rates of 6.3 percent of the cost according to the list of charges. Piecework wages average one-third of the total remuneration, but they vary considerably. Female dentists in the PDS have somewhat lower piecework rates than the men, and the income of dentists falls with increasing age (23). Dentists with any type of managerial function have had fixed salaries since the early 1980s.All dental nurses have fixed wages. The dental staff has a 40-hour working week, all of which (except administrative time for promoted dentists, clinic meetings, etc.) should be recorded as patient treatment time. For some but not all tasks or situations in which the patient is not sitting in the dentist’s chair, an average standard piecework rate is used. There are careful rules for the use of this system, which may vary in different counties. In one county a brochure has been printed containing 71 items indicating which tasks are allotted an average standard piecework rate. These 71 items are an example of the detailed level of reporting and control that has developed, and include headings for everything from “educational conversation with a superior,” “repetition of one’s own work,” “technical breakdown causing a sloppage of work,” “reduced assistance from the dental nurse,” “visit from a dental products firm,” to “dismissal interview, own” (24). Since 1987 a new system of remuneration has been introduced with individual wages, and the previous subdivisions in the wage scales (for instance, based on length of employment) have disappeared. The piecework system has been maintained parallel to individual wages. Today there are signals from both the employers and the Swedish Dentists’ Association that they wish to abolish the piecework wage system. It is now possible to use individual wages to bring about differences in remuneration. Economic Crisis Consciousnessand Competition

During the 1980s the effectiveness of the public sector was questioned in Sweden. A number of investigations on efficiency within various sectors of public administration was carried out during that decade. For adult dentistry, comparisons were made between the public and private sectors (25, 26). These comparisons indicated that the private sector was superior in productivity,’ and the legitimacy of the PDS was questioned by politicians and in the media. After these reports the representatives of the employers in

’

Charges for adult patients in the private sector average 40 percent higher than those for adults in the PDS. One reason is the difference in the treatment panorama. There is more work on crowns and bridges in private dentistry (25).

Employer Control and Work Environment / 673 the PDS increased their interest in efficiency and productivity, as manifested in piecework and financial results. This interest has resulted in more time studies, a strengthening of leadership at the clinic level, decentralization of budget responsibility, and the development of new computer systems and various forms of bonus systems. There are also attempts to increase the motivation of dental staff by stimulating competition. Charges, mean duration of treatment, and other data are circulated within the clinics and to other clinics in the area. In this way, all dentists are kept informed about their own individual competitiveness. Comparisons of productivity are mainly presented at the individual and clinic level, but also between counties and between private dentistry and the PDS. Everywhere there are signals to increase productivity, but the strength of these signals has varied from county to county. During the 198Os, for the first time in Sweden, instead of a shortage there was unemployment of dentists. This contributed to increased competition and, accordingly, to greater pressure. RESEARCH METHODS Study Sample A questionnaire was sent to 896 dentists and 600 dental nurses in the PDS throughout the country. The sample was based on the county lists of staff. A stratified selection was made. Regardless of the size of the county, 50 persons were chosen at random: 30 dentists and 20 dental nurses from each county, with the exception of Stockholm and Gothenburg from which a larger sample was made (Stockholm, 200 persons; Gothenburg, 100 persons). One county was excluded since a local work environment study was being carried out at the same time.

Questionnaire

Initially, 40 half-structured interviews of an hour’s duration were conducted with dentists and dental nurses in the PDS. From these interviews we identified the central problems. On this basis, a questionnaire was constructed consisting partly of questions that had been used in other studies on work environment and partly of questions designed specially for this study. Efforts were made throughout to offer both positive and negative reply alternatives in order to obtain a balanced picture. Many parts of the questionnaire included opportunities for spontaneous comments. These have usually enhanced the impression obtained from the statistics. The questionnaire consisted of 101 questions, several of them embracing many subsidiary questions. It was estimated that the questionnaire would take at least an hour to answer, and it included questions on health symptoms; burnout (Maslach Burnout Inventory); sickness absence; demands and discretion at work (Karaserneorell index); support and appreciation; cooperation in a team; causes of psychic stress at work; changes that have taken place; desired changes; the wage, charges, and reporting system; views on management, the trade union, and education. All the questions and replies have been published elsewhere (27). In this article we report responses to

674 / Bejerot and Theorell

questions on the wage, charges, and reporting system; views on management; and desired changes. Statistical Methods

Since a stratified sample was used, the results were subjected to a weighting procedure. Thus when the prevalence was estimated for the whole country, the result from a small county was reduced in importance, and vice versa. The rates in the distribution of alternative answers after weighting did not differ more than 2 percent in the total sample compared with the unweighted result. Accordingly, in this report the unweighted material was used, but the result may be regarded as a representative national average. The statistical methods used in the analysis are the chi-squared test, t-test, and Pearson’s product-moment correlations. In the statistical analyses the participants have been divided according to occupation, sex, age, position, and form of remuneration (promoted dentists/with futed salaries, unpromoted dentists/with piecework wages). In this article we have given priority to the description of distribution of replies. Differences in age, sex, and position, as well as results of statistical tests, are reported when they are of particular interest.

RESULTS The Participants Eighty-five percent of the dental nurses and 88 percent of the dentists filled in the questionnaire (Table 1). Among the dentists in the PDS, 56 percent were women. A larger proportion of women than men were unpromoted (Table 2). The mean age of unpromoted dentists and dental nurses was 37.8 and 37.4, respectively; among promoted staff, mean ages were 44.5 and 44.8, respectively. Sixty-five percent of the staff were under 40; only 10 percent were over 50. Female dentists and dental nurses had the same pattern of employment: 45 percent worked full time, compared with 90 percent of the male dentists.

Table 1 Number of questionnaires sent out to staff in the Swedish Public Dental Service, nonresponse and response rates Dentists Questionnaires sent out Nonresponses, accountable‘ Number of responses (response rate) Nonresponses

896 21 774 (88%) 101 (12%)

Dental nurses

600 22 493 (85%) 85 (15%)

‘Moved, retired, private practice, prolonged absence for care of children, elc. The response rale has been calculated after the exclusion of these accountable cases.

Employer Control and Work Environment / 675 Treatment Charges The replies revealed a widespread uncertainty about the use of the list of charges for treatment (Table 3). The staff also reported that the list of charges did not give fair prices for the patients in relation to the work carried out. Half of the staff thought that employers wanted them to charge patients more than their conscience really permitted (Table 4), and about 25 percent thought that the employer actually wanted them to charge more than the list of charges really allowed. This demand was felt equally by dentists and dental nurses. The unpromoted dentists were more conscious of signals to overcharge than the promoted dentists (conscience permits: t = 4.03,P < .OOOl; list of charges permits: t = 3.03, P = .003). In reply to a question about possible strategies for raising reported productivity results still further (Table S), many dentists replied: “to change the level of ambition” in pediatric practice (e.g., to stop repairing milk teeth, to reduce time given to orthodontics) and “to charge more” in adult treatment. A larger proportion of the male than of the

Table 2 Participants in the questionnaire to staff in the Swedish Public Dental Service, sex and position

Dentists, male Dentists, female Dental nurses

Total no.‘

Unpromoted

Promoted

Specialists

335 434 493

223 (67%) 376 (87%) 358 (73%)

101 (30%) 47 (11%) 49 (10%)

11 (3%) 11 (2%) 86‘(17%)

“Five dentists did not report their gender. bNurses who do not work within a team:prophylaxis nurses, receptionists, practical nurses.

Table 3 Questionnaire to dentists (n = 774) and dental nurses (n = 493) in the Swedish Public Dental Service; reply to the question: What is your opinion of the following statements? Percent response Agree

Disagree

Dont’know

A. The list of charges gives rise to some uncertainty about practice of charging.

Dentists Dental nurses

67 49

20 19

12 32

B. The list of charges is neutral

Dentists Dental nurses

16 26

61 17

23 57

Dentists Dental nurses

14 28

60 31

26 41

in relation to choice of therapy. C. The list of charges provides “fair“ charges for patients in relation to the work performed.

676 / Bejerot and Theorell Table 4 Questionnaire to dentists (n = 774) and dental nurses (n = 493) in the Swedish Public Dental Service; reply to the question: Do you feel that your employer would like you to charge patients: A. More than your conscience really permits? B. More than the list of charges really permits? Percent response

Yes, Yes,to definitely some extent A. More than your conscience really permits? Dentists Dental nurses

1s

No, hardly

No, not at all

16

39 43

29 23

17 18

4 2

18 21

44 44

33 32

B. More than the list of charges really permits? Dentists Dental nurses

Table 5 Questionnaire to dentists (n = 774) in the Swedish Public Dental Service; reply to the question: What courses of action would you consider possible if you really had to: A. Raise your hourly rates in adult dentistry? I3. Reduce your average treatment time in pediatric dentistry? Percent response

Charge more Increase pace of WorWeffectiveness Alter level of ambition about quality of treatment Don’t know Other Have no adulVpediatric patients

A. Adult dentistry

B. Pediatric dentistry

73 39 17 13 12 5

29

40 22

25 4

female dentists thought that they would be able to increase their work tempo/effectivity (P< .OOol). Wages Piecework Wages. The participants in the questionnaire study were asked to take a stand on three statements about the piecework system (Table 6). These referred to the connection between the wage system and: balance between quantity and quality, negative effects on cooperation between dentists and dental nurses, and degree of effort. About 40 percent of the staff agreed with each one of the statements that piecework affected quality, cooperation, and intensity of work. Compared with dentists, the nurses

Employer Control and Work Environment / 677 considered that the wage system had a greater effect on intensity of work and cooperation. The dentists’ own piecework results, high or low, did not affect their attitude to these three statements on the effect of the wage system on their work. The dentists were also asked to state to what extent six different factors contributed to differences between the piecework incomes of individual dentists (Table 7). Pace of work and the manner of charging were the two factors considered to have the greatest effect on the individual piecework incomes. Routine and skill, assistance, type of patients, and choice of treatment were ranked as somewhat less important. There is no correlation between the piecework incomes of an individual dentist and his or her estimation of the causes of piecework results. Nor is there any connection with year of qualification.

Table 6 Questionnaire to dentists (n = 774) and dental nurses (n = 493) in the Swedish Public Dental Service; reply to the question: What is your attitude to the following statements? Percent response Agree

Disagree

Dont’know

25

The piecework system affects the balance between quantity and quality in treatment.

Dentists Dental nurses

41 42

47 33

The piecework system negatively affects cooperation between dentists and dental nurses.

Dentists Dental nurses

39 49

46

Piecework is a stimulus that results in dentists working harder.

Dentists Dental nurses

41 65

46

11

15

20

9

12 17

34

Table 7 QuestioMaire to dentists (n = 774) in the Swedish Public Dental Service; reply to the question: To what extent do you consider that the following factors contribute to differences in dentists’ wages resulting from piecework? Evaluate each factor. Percent response

Work pace Charging technique Routine and skill Assistance Type of patients Choice of therapy

Contribute greatly

Contribute considerably

Hardly contribute

66 66 57 47 45

32 30 38 45 44

40

47

2 4 5 8 11 11

678 / Bejerot and Theorell Dental staff did not openly discuss the reason for individual differences in piecework incomes; 80 percent replied that this subject was not discussed at their place of work. Individual Wages. In the 1987 wage negotiations, the piecework part of wages was increased from about one-quarter to one-third of the total remuneration, and individual wages were introduced. Of the dentists, 46 percent replied that they considered this a negative development; 34 percent considered it positive; 22 percent had no opinion. This relatively negative attitude was found even though the negotiations gave a considerable increase in wages. Women, in particular, were negative to the agreement; only 28 percent of them, compared with 42 percent of the men, considered the negotiation results positive. Among dentists with piecework incomes, those with high incomes were significantly more satisfied with the agreement than those with average or low piecework results ( P = .OOl). Desired Changes

Concerning hopes for future changes (Table 8)-the direction that the staff hoped that changes would t a k e t h e two alternatives “greater individual differences in wages” and

Table 8 Questionnaire to dentists (n = 774) and dental nurses (n = 493) in the Swedish Public Dental Service; reply to the question: What changes are important for improving work environment in the PDS? Percent replying “very important”

Organization and stuffwelfare Opportunity to work part time if desired Guaranteed further education Better opportunities for staff welfare Consideration for elderly dental personnel Lower retirement age Administrative time, e.g., 1 hr/day Telephone time More assisting personnel More education and qualified work for dental nurses Possibility for establishing private practice

Dental nurses

Dentists

91 80 51 65 53 52 23 32 20

82 93 68 56 58 61 19 27 18 40

48 1 24 8 35 11

61 19 16 15 32 29

35

Wages Getting rid of the piecework system Higher percentage of wages from piecework Piecework wages also for nurses Greater individual differences in wages Bonus on clinic basis Charges per hour only (no piecework charges)

’Reply alternatives: “very important,” “less important,” “unimportant,” “no opinion.”

Employer Control and Work Environment / 679 “higher percentage of wages from piecework” were considered the least important among 16 alternatives on the suggested list of improvements. To “get rid of the piecework system” was an alternative often chosen. Among the 16 alternatives, priority was given to further education, the opportunity to work part time if one wished, improved staff welfare, and care of elderly dental personnel. Attitude of the Employers

In the preparatory interviews, several dentists said that the effects of the wage system were different today than previously. In the 1960s and 1970s they could, to some extent, ignore the piecework system and personally take the consequences of their method of working. A t that time they did not have to consider the economic aspects and were able to ignore charging techniques and detailed time reporting-accepting the fact that it entailed lower piecework incomes. This attitude is felt to be less acceptable to employers today. Seventy-two percent of the dentists and 66 percent of the dental nurses considered that the main interest of employers today is the economic aspect of their activity. Only 3 percent and 6 percent, respectively, answered that their employers’ main interest was long-term improvement in health and a high quality of work, while 23 percent and 26 percent, respectively, thought that employers kept a good balance between interest for economic and odontological values. Supervision and Evaluation

In reply to the question about whether dentists felt that they were continuously supervised and evaluated the majority, 70 percent, said that they were exposed to such evaluation to a great extent. Unpromoted dentists experienced a higher degree of supervision than promoted dentists (P = .006). Of the dental nurses, 28 percent felt that they were exposed to continual supervision and evaluation. At the clinics where individual rates were presented every month (which applies to 48 percent of dentists), the dentists felt that they were continually evaluated to a significantly greater extent (P = .001) (Table 9). When the sexes were analyzed separately the differences were found to be more conspicuous among female dentists, who were, accordingly, more affected than their male colleagues by this type of feedback (male dentists, n.s.; female dentists, P = .004). Among dentists there is a significant correlation between degree of decentralization (in the form of local budget responsibility) and computerization on the one hand, and the feeling of being the target for continuous evaluation of their work on the other. Each of the factors-computerization and decentralizationsignificantly increased the proportion of dentists who felt that they were “continuously’’ and “to a great extent” supervised/evaluated from 62 to 73 percent and from 61 to 74 percent, respectively. Decentralization also led to significantly increased work tempo for dentists. None of these correlations were found among dental nurses.

680 / Bejerot and Theorell Table 9 Questionnaire to dentists (n = 774) in the Swedish Public Dental Service; relation between dentists’ feeling of being constantly assessed/evaluated and the presentation each month of their individual results“ Dentists with monthly results

Feeling of being constantly assessed/evalua ted, % response To a high degree To some extent Hardly at all

Dentists without monthly results

Total

Male

Female

Total

Male

Female

77

72 23 5

80 19 1

66 31 3

64 32 4

66 31 3

20

3

~~~

~

“There were 352 dentlsts with monthly individual results and 374 dentlsts without monthly individual results, 48 dentists did not reply to questions on “gender,” “assessed,” or “monthly results” and are not included in this table

Competition

The staff differed in how they felt about competition (Table 10). Dentists were far

more conscious of competition than were the dental nurses (P < .oOOl). The most frequent forms experienced were group competition between the private sector and the PDS system and between different PDS clinics. Individual competition between dentists and between different categories of staff was less frequent; it was more often experienced as a negative factor in work than was group competition. While dentists and nurses had about the same opinion on competition as a positive or negative factor at work, the promoted dentists were significantly more positive than unpromoted dentists to all forms of competition (categories of staff, P = .0014; dentists in the PDS, P = .0088;PDS clinics, P = .0061; PDS/private dentistry, P = .0302). The analysis also showed that female dentists were significantly more negative in their views on group competition than were their male colleagues (PDS clinics, P = .OO01; PDS/private dentistry, P = .0329). The Cause of High Work Tempo

More than half of those who took part in the investigation43 percent of the dentists and 48 percent of the dental nurses-said that their work tempo was too high “more or less all day” (18 percent and 12 percent, respectively) or “for some periods of the day” (45 percent and 36 percent, respectively). Excessive work tempo was considered, in the first place, to be due to lack of time buffers for unforeseen events at work, the employers’ demand for high productivity, and the dentists’ and nurses’ own high standards (Table 11). The pressure of the patient queue was considered a less important factor, as was the piecework system. Female dentists reported more often than males that the “employers’ demand for productivity” was a primary cause of their high work tempo ( P < .OO01).

Employer Control and Work Environment / 681 Table 10 Questionnaire to dentists (promoted and unpromoted) and dental nurses in the Swedish Public Dental Service (PDS); reply to the questions: A. To what extent in your county is there competition between: different categories of staff in the PDS, dentists in the PDS, PDS clinics, PDS and private clinics? B. If comwtition exists, is it a positive or negative factor at work?

B. “Negative factor‘”

A. Competition exists“

Dentists

Dentists Dental Promoted Unpromoted nurses Promoted Unpromoted Categories of PDS staff Dentists in the PDS PDS clinics PDS vs. private clinics

21 41 62 85

19 34 58 75

13 23 43 49

67(24) 62(39) 45(47) 54(79) (n = 154)

Dental nu-

93(105) 80(154) 61(193) 66(265) (n = 599)

83 (52) 80 (69) 57 (92) SS(lO5) (n = 493)

~~

‘IReplyalternatives: “To a high degree,” “to some extent,” “not at all,” “don’t know”; expressed as percent res me g n l y those whose reply to questionA indicated that competitiondid exist answered question B. Expressed as percent response, with number of responses in parentheses.

Table 11 Questionnaire to dentists and dental nurses in the Swedish Public Dental Service; reply to the question: Which of the following factors do you consider to be the primary causes of too high a work tempo? Name two factors at the most.‘ Percent response Dentists

Lack of time buffer for unforeseen events Employers’ demand for productivity High professional ambition Pressure from patient queue Piecework system

Male

Female

60

54 53

32 41 32 16 (n = 294)

40 28 14 (n = 390)

Dental nurses 48 44 37 32 30 (n = 413)

“Those who reported low frequenciesof high work tempo were told to leave out this question. As a result 8 percent of the dentists and 18 percent of the nurses in the study did not answer the question.

682 / Bejerot and Theorell Work T e m p and Wages

Piecework wages were not of decisive importance for tempo, as was shown by the lack of correlation between the experience of high work tempo and the form of wages (piecework or fixed wages) or with any type of self-reported productivity (high, average, or low piecework results in either pediatric or adult dentistry) (Table 12). The factors “feeling of being constantly assessed/evaluated” and “the existence of competition” were more strongly correlated to reported high work tempo than was pressure from the amount of work pending. The work tempo of dentists was affected by competition between dentists and between PDS clinics. Nurses were affected by competition between different categories of staff within the PDS. Dental nurses who worked with female dentists had a significantly higher percentage of perceived high work tempo than did those who assisted men (P= .002). The sex of the dentist was thus one cause of differences in the work tempo of the nurses. Tempo and Work Environment

The opportunity of working ergonomically and finding time for administrative work were the factors most frequently reported to suffer during periods of high work tempo (Table 13). The use of protective safety equipment and the psychological quality of work were also reported to be neglected during such periods. Psychological quality was reported as neglected among a higher percentage of male than female dentists

(P= .002).

Table 12 Questionnaire to dentists and dental nurses in the Swedish Public Dental Service; significant correlations“ between reported work tempo and: piecework result (high, low), patient situation (queue, shortage), feeling of being assessed/evaluated, competition @tween different categories of staff in the PDS, dentists in the PDS, PDS clinics, and the PDS and the private sector) Pearson’s product-moment correlation coefficient Competition between: ~~~

~

Piece- Patient Assessed/ Categories PDS vs. work situation evaluted of staff Dentists Clinics private Female dentists: Unpromoted (n = 359) Promoted (n = 47)b Male dentists: Unpromoted (n = 214) Promoted (n = 101T Dental nurses (n = 4 ~ 9 ) ~

.13

-

.10

-

-

.21

.17

-

-

-

-

.14 .30 .22

-

.23 .26

.23

.22

-

-

.16

-

.12

-

.31

“P< .05, two-tailed tests. Dashes denote not significant. %rotnoted dentists and dental nurses do not have piecework wages.

-

Employer Control and Work Environment / 683 Table 13 Questionnaire to dentists and dental nurses in the Swedish Public Dental Service; reply to the question: When you have periods with too high a work tempo, does one (or do several) of the following aspects often suffer?“ Percent response Dentists

Working ergonomically Work planning and the administrative quality of your work The nurses’work conditions The psychological quality of treatment Use of protective equipment (ear-covers. protective glasses, gloves) Odontological quality of treatment

Male

Female

Dental nurses

85

88

77

69 50 42

74 53 34

-

35 8 (n = 294)

29 7 (n = 390)

32 5 (n = 413)

57 33

‘As in Table 11,8percent of the dentists and 18 percent of the nurses in the study left out this question as they had previously answered that they seldom had too high a work tempo.

Coffee or lunch breaks were often used by the staff to mitigate the lack of a time buffer. Twenty-seven percent of the dentists and 19 percent of the dental nurses were detained by work almost every day, so that lunch or coffee breaks were curtailed. For a further 50 percent and 41 percent, respectively, this occurred at some time or several times every week. Thus, a majority of the staff had to curtail their coffee or lunch breaks regularly, dentists significantly more often than nurses. The 30 percent of the staff who reported that cooperation in the treatment room did not function “very well” reported “too high a work tempo” as an essential reason for this. What Was Different?

Among the dentists a high percentage expressed disappointment with their work; 45 percent of the dentists, compared with 28 percent of the dental nurses, regretted their choice of occupation. To the open question, “What is different from what you had expected when you chose your profession?” the replies indicated that important causes of the dentists’ dissatisfaction lay in the organization of work: working conditions and management style. The following statements were typical of this attitude. It is absurd that treatment is evaluated in economic terms. 1want to work like district physicians: concentrate on case histories, status, diagnosis, therapy, and patient contact without having to reportprofits every five minutes. It is not very stimulating when my wellconsidered therapy results in a tangle of economy cards and invoices.

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Too much paper work and bureaucracy. Stress is laid on quantity and economy instead of on quality. An unceasing struggle to give patients the treatment they have the right to demand. Continuous time pressure. Seldom an opportunity even to receive a private telephone call. Private practice is no alternative, as colleagues in private practice experience a similar situation. It is almost impossible to change to any other qualified work. Cuughf in u frup.

I feel deprived of enthusiasm and professional pride. The result of five years of study is a very monotonous job with a constant high demand for attention,and where my knowledge is reduced to a point where I function like a mechanical tool. It is actually not the clinical work which is the problem, but the form it t a k e s monotony, stress, continuous efforts to keep up with time which 40 hours of clinical

work entails.

SUMMARY AND DISCUSSION Given the size of the s a m p l e 8 9 6 of 5,700 dentists and 600 of 7,700 dental nurses from the whole of Sweden-and the high response rate, the results may be regarded as representative for dentists and dental nurses in the Swedish Public Dental Service. In formulating the questions and interpreting the replies we have been conscious of the risk of bias. The subject touches upon sensitive and taboo areas-professional pride and self-esteem-and here there is a risk of glossing over replies. Alternatively, a desire to bring about a change may result in an excessively negative description of conditions of work. Some of the objective working conditions, however, were such that we expected them to have effects on the psychosocial work milieu. The introductory description of the organization and the control system in the PDS may be of some help to the reader in judging the problems and the relevance of the results. The fact that tempo was self-reported may give rise to false correlations-it is possible that individuals have a tendency to over- or under-report problems in their work. For the staff in the PDS, however, productivity results would hardly be a more objective measure of the intensity of work than self-reported tempo. The staff report that productivity results, to a large extent, depend on factors other than intensity and amount of work (Table 7). There are also significant differences in piecework results by gender and age (23). Significant correlations between reported tempo and the rate of reported health symptoms and sickness absenteeism confirmed the view that self-reported tempo was a useful variable in our analyses of the effects of the control system (27).

The Construction of the Control System An extensive, bureaucratic surveillance of the staff has developed in the PDS (rates based on time studies, reporting system, wage system, production norms, qualitative evaluation, influence on clinical work, etc.). The need for circumstantial reporting due to piecework wages and the insurance system has legitimated an exhaustive system of surveillance, but far more data are collected than are required for these insurance and wage systems. Thus the inherent possibilities in the charges, wage, and reporting systems have been used to increase employer control. The amount and effects of this surveillance have increased during the last decade, because of the development of

Employer Control and Work Environment I 685 computer systems, economic crisis consciousness in the public sector, and unemployment among dentists. Responsibility for the quality of work in the PDS lies both legally and psychologically with the individual dentist. This situation has been exploited by employers who have tended to ignore the conflict between quantity and quality and to focus their interest mainly on the quantitative aspects. The Effects of the Control System

The management and surveillance system in the PDS was constructed in order to direct and check the work of dentists. The replies of dental nurses to our questionnaire show that they often experience the system in the same way as dentists, although the effects are less substantial for them. The difference in type of remuneration (piecework versus fwed wages) was not an essential factor in determining the work tempo of dentists. (There is, however, a bias here in that the type of wage is related to promotion.) Nor is there any correlation between self-reported productivity (piecework results) and reported work tempo. Objective pressure in the form of a patient queue was also of little importance for work tempo. Awareness of supervision and competition was more important. The relation between surveillance and competition on the one hand and the pace of work on the other suggests that the present system of evaluating productivity is an effective management style for increasing work output by the staff. This also means that no decisive change in working conditions will be brought about if piecework wages are removed but the present surveillance system and the focus on economic factors are maintained. The results of the questionnaire show that piecework, wages, and reporting systems in the PDS may lead to the development of strategies in areas such as choice of treatment, quality, and charging technique. When piecework wages are affected by factors other than work presentation, productivity will appear low for those who are not familiar with these kinds of strategies, refuse to use them, or dare not do so. If effort is not experienced as having any connection with results, this may lead to a feeling of hopelessness and depression, an acquired helplessness (28). Dentists may perhaps tackle the problem by attributing little value to piecework rates and the evaluations on which they are based. Another explanation of the low importance that dentists give to the piecework system as a driving force has to do with keeping up professional self-esteem. There may be an unconscious attempt to counter the traditional view of dentists as more interested in their incomes than in their patients. If the underlying motivation of dental staff in the PDS is intrinsic rather than extrinsic (29), and the employers wish to make the staff more interested in economy and more production-oriented, then the whip (supervision, competition, crisis consciousness, lack of security) may be more effective in influencing behavior than the carrot (money). Female Dentists

Women have lower piecework wages, although the n u m s who work with female dentists report a significantly higher work tempo than those who work with male dentists. Women have the same productivity results as men in pediatric treatment (for

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which patients do not pay), but less productivity in adult dentistry (23).* This may indicate that female dentists are less inclined or less able to use such strategies as high charging and reporting, strategic choice of therapy, or lower standards of care. [Female dentists are reported to the Malpractice Committee by dissatisfied patients less often than are male dentists (31).] Possibly a lack of self-confidence in women results in their underestimating and undercharging for their own work, which may explain both their low piecework results and their reaction to surveillance. Female dentists stay in the PDS, where to a great extent they remain unpromoted, whereas male dentists are more often promoted within the PDS or leave the PDS for work in the private sector. The women remain in a work situation with circumstantial surveillance of their achievement, conditions that the male dentists generally leave behind them. The position of dentists as a professional group has changed during the development of the welfare state. These changes have involved increased surveillance of dentists’ work and have reduced their incomes. In the PDS we can see the proletarianization of the unpromoted dentists. At the same time, a small group of highly promoted dentists have moved nearer the governing class. The significance of the monopoly of odontological knowledge in obtaining a privileged position in society seems to have been reduced through the development of a bureaucratic control system concomitant with formation of the PDS and the dental insurance system. Theories associated with the private sector of society and industry are gaining ground in Sweden in areas where they were previously excluded. A government investigation has analyzed the possibility of increasing results in the public services through regular comparisons of costs and achievement (32). The aim is to promote competition between regions or local units, to increase effectiveness, and to foster competition based on reported achievement. Those who fare poorly in the comparisons will thus be encouraged to make improvements. The government investigation proposes that the system should be introduced into health services, the university, the police force, employment exchanges, and elsewhere. This form of competition contains a large element of employer control. It may be expected to have quite different effects in the work milieu than competition on the free market or in the system of “public competition’’ suggested by Saltman and von Otter (33), where the driving force emanates from the demand to satisfy customers/patients. Experience of the working conditions in the Swedish Public Dental Service is cause for uneasiness about the spread of this type of management style-ampetition instigated by the employers-to other branches of public service. REFERENCES 1. Murphy, R. Proletarianization or bureaucratization: The fall of the professional? In The Formation of Professions, edited by R. Torstendahl and M. Burrage. Sage Publications, London, 1990. A productivity study in 1941 showed that female dentists were 10 to 12 percent more productive than their male colleagues (30).

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Direct reprint requests to: Eva Bejerot Department of Stress Research Box 60 205 S-104 01 Stockholm Sweden