Hasson, Henna PhD; Villaume, Karin BSc; von Thiele Schwarz, Ulrica PhD; Palm, Kristina PhD
Implementation of organizational changes and interventions is a complex process.1 For instance, occupational interventions are often extensive programs involving many people and several components,2 which might further complicate this process.1,3 Intervention evaluations have often been conducted as effect evaluation in randomized controlled or quasiexperimental designs. Nevertheless, experimental studies do not explain why interventions do or do not have certain effects.1,4,5 Many authors have emphasized the importance of paying rigorous attention to the implementation process of intervention to be able to highlight factors affecting the outcomes.6–10 Thus, the focus should be on understanding the process of implementing an intervention as well as measuring possible effects of the program.11 This could improve the validity of intervention findings12 and help explain for what specific reasons an intervention succeeded or failed.13
Several factors can moderate or mediate the link between a change or an intervention and its outcomes.8,911,14,15 For instance, key stakeholders can potentially impact the intervention implementation and outcomes. Senior managers, line managers, employees, and consultants have been identified as key actors in organizational change processes in general and occupational health interventions in particularly.16 The importance of exploring the roles, behaviors, power, and involvement of these actors has been emphasized both in management literature17,18 and in prior studies from the occupational health field.8,16 Especially the concept of sense making has been emphasized as essential for understanding actors' reactions and activities in a change process.19 In brief, sense making involves processes by which people give meaning to an experience such as a coming change or an occupational intervention.19 This might be central in their responses to an intervention.19,20 Thus, understanding the perceptions of key stakeholders may offer useful knowledge on how these actors drive and shape intervention processes.8,16–18 Nevertheless, little attention has been given to how these key actors themselves perceive their roles, tasks, and responsibilities, which limits our understanding of how the management of the implementation of occupational health intervention can be improved.
Management literature describes line managers as a linking pin between strategic top management (ie, the level at which interventions are initiated) and the operating level implementing the changes.21–25 Line managers have been described as ultimately controlling organizational renewal projects26,27 because their role is to translate the formal organizational policies into daily practice.28,29 When it comes to occupational health, line managers are in a crucial position as they have often been delegated the responsibility for employees' work environment issues.30,31
Thus, line managers can either make or break an intervention. On the one hand, they can function as the drivers of change. For instance, line managers' supportive behaviors in the implementation of an occupational health intervention predicted the extent to which employees participated in the intervention and their appraisal of its benefits.32 In addition, their active involvement in the implementation partially mediated the relationship between the intervention and its effects on working conditions.33,34 Line managers' readiness for change predicted that of their employees', which in turn was related to intervention outcomes.35 On the other hand, line managers have been described as resistant to change and as obstructing the communication both upward and downward.36–38 In occupational health interventions, line managers have been reported to actively resist interventions, for instance in terms of not allowing their subordinates to participate in the intervention.39
The fact that line managers do not lead in a vacuum has been recognized. Employees' resources and readiness for change, as well as contextual factors such as senior managers' involvement, merging work units, or downsizing,40–42 may influence line managers' opportunities to exert leadership. Thus, there is a need to increase the understanding of the role of line managers in relation to other key stakeholders and organizational processes when implementing occupational interventions.43,44 This is important for improving line managers' possibilities to ensure the well-being of their employees.
The senior managers perceive their roles in terms of involvement in the allocation of resources to interventions.16 They consider themselves important also as role models through their attitudes and actions toward the intervention.20,45,46 The involvement of senior management in building support, energy, visibility, and acceptance for an intervention has been shown to be a crucial factor for the success of the change.46–48 Senior management may also be actively involved in intervention activities.20,45 Nevertheless, they are rarely able to closely follow the intervention development activities and implementation.8 Most of the prior research on senior management support for occupational health interventions has reported a lack of support for implementation.49 The lack of support from senior management can have a “trickle-down” effect on the commitment of line managers, who have reported being unenthusiastic about the program as they were not allocated enough resources to implement initiatives.9 Although the importance of senior management support is often discussed, it is seldom formally evaluated.14,50 In addition, few studies have investigated how senior managers perceive their own role in the implementation of occupational health interventions.
Human resource (HR) professionals deal with issues regarding workforce recruitment, planning, management, and development. The promotion of well-being, safety, and health in the workplace is thus one response area for HR professionals.51,52 The traditional view on HR professionals functioning as controllers has been changed to a more modern view of HR as managing organizational change.51,53 This includes activities such as balancing organizational and individual needs, developing the right time frame for change processes, coaching cultural changes, and overcoming barriers to change.54–56 This perspective emphasizes HR professionals' role in organizations and suggests that they are important managers and coaches for change interventions. Nevertheless, to our knowledge, the specific roles of HR in relation to occupational health interventions are undefined. Line managers have reported regarding HR professionals as important coaches in occupational health work.44 The trustworthiness of HR professionals' skills in delivering such interventions has been reported to be essential for the HR professionals to be perceived as effective.47,57,58 Nielsen and Randall16 recognized HR as a partner in developing the process evaluation model of occupational health interventions. Nevertheless, they were not included in the model as active actors.16 This illustrates the current underdefined role of HR professionals in relation to occupational health interventions.
Most prior studies on occupational health interventions have evaluated the implementation and the roles of stakeholders from the perspective of one stakeholder group.7,15,20,36,59,60 Few studies have used two or more stakeholders' perspectives,2,39,61,62 although the importance of using different data sources to collect information about the implementation process has been emphasized.4,9,63 The aim of this study was to contrast how line managers, senior managers, and HR professionals describe their own and each other's roles and tasks, and the possibilities to perform these tasks, during the implementation of an occupational health intervention.
Design and Setting
This study was a part of a longitudinal occupational health intervention conducted at nine organizations. Qualitative interviews were conducted between October 2011 and May 2012 at all of the participating organizations, which were primarily recruited via a pension company. At the start of the study, 19 organizations were contacted, and 9 of these were enrolled in the intervention study. The nine organizations varied in the number of employees (80 to 400) and represented areas such as higher education, information technology, trade union, media, and government authorities in Stockholm, Sweden. Interviews were performed 6 months after the organizations initiated participation in the intervention.
A total of 29 interviews were conducted with line managers (n = 13), senior managers (n = 7), and HR professionals (n = 9). Line managers were defined as the management level directly above nonmanagerial workers. Senior managers consisted of the CEO or others on an organization's management team. HR professionals were defined as those working in the HR department who were involved in the intervention. These three actors, together with employees, had a central role in the implementation of the intervention. A forthcoming article will focus on the role of employees, whereas this article focuses on the roles of the three other actors.
The line managers were recruited using a baseline questionnaire about the intervention, with one of the items asking all survey respondents whether they would like to participate in a research interview. Senior managers and HR professionals were recruited via direct e-mails because they did not fill in the questionnaire.
Occupational Health Intervention
The intervention was an interactive web-based system that consisted of risk evaluations and health promotion and occupational health tools at individual and group levels.30 The intervention was implemented as part of a research project aiming at improving psychosocial work environment, well-being, and job satisfaction.
The web-based system was built on the principles such as time efficiency, systematic and proactive, adaptive system, following trends rather than capturing snapshots, and multiple-level self-help and educational exercises (see Hasson et al30 for more detailed information). The system provides line managers, senior managers, and HR professionals an opportunity to see risk evaluation results at the group and organization levels regularly (ie, as often as the group has decided to use the survey). The goal is to follow trends in well-being and the psychosocial work environment.
In short, an extensive survey was used as a risk evaluation to measure health-related variables and the psychosocial work environment. Individuals received instant and tailored feedback on their answers directly after filling in the survey. They could also receive an automated referral to the occupational health care provider if symptoms of, for example, long-term stress or musculoskeletal pain were revealed in the results. The results were instantly presented at the group level to the line manager via an automatic structured display. Participants were also offered a brief survey (11 items central to well-being) to be used as often as preferred to evaluate their own well-being. Immediate, tailored feedback was given together, with suggested action plans consisting of self-help exercises in the system. Examples of exercises are techniques for relaxation, improving sleep quality, cognitive reframing, strengthening one's self-esteem, and goal setting. Line managers used the same system of surveys and self-help exercises as the employees, and were also given access to view the group results for their unit.
The implementation of the intervention at the organizations was conducted in a structured way. The process started with a presentation of the intervention and the project to representatives of the HR department and senior managers. Thereafter, a similar presentation was held for middle and line managers. After a line manager decided to participate, an inspirational implementation seminar was arranged for his/her employees. The implementation seminar usually started with one or more senior managers (or HR professionals), introducing the aim of the project in the organization. Thereafter, the researchers presented the background and previous research findings, and demonstrated the intervention. The seminar also included information on success factors concerning how the system had been applied by other organizations and which roles and responsibilities the different levels within the organization had. Line managers were advised to discuss the results of the brief surveys regularly (every other week or once a month) at unit meetings and to take action on the basis of the results and discussions. The HR professionals and senior managers had an opportunity to access group-level results for the whole organization. Human resource was responsible for the everyday management of the system, including providing support for managers and employees.
The interviews, semistructured after an interview guide and conducted in meeting rooms at each organization, were held by the first author and a research assistant. The researchers introduced themselves and explained the aim of the interview, and a written consent form was signed by the participant. The interviews focused on the participants' views on occupational health, the present intervention, roles, and responsibilities of the different stakeholders, as well as hindering and enabling factors for working with the intervention. All interviews were audio recorded, except for one, because of the participant's reluctance. In this particular case, notes were taken by the research assistant.
All the interviews (except the one described previously) were transcribed verbatim, and content analysis was used to analyze the interview data.64 The analysis was performed at two levels—first after an a priori question about how the respondents discussed roles and tasks. At the second level, an inductive approach by which categories were derived from the content of the texts was used. The analysis began with a reading of each transcript independently by the first and second authors, with an a priori focus on roles. The two authors then discussed the text content and read the transcripts again independently to identify meaning units. These were then compared and discussed between the two authors. The meaning units were then condensed and sorted into categories, which again were compared between the authors. Together, all four authors discussed the whole text, made minor changes to the categorization, and thereafter agreed on an appropriate way the categories should be labeled and abstracted to understand and summarize the respondents' descriptions. If there were differences in understanding and perception between the authors, these were discussed in detail until it was agreed that they were representative of the content. The results of the analysis were presented to a selection of respondents (approximately 15 individuals) in two project meetings for validation.
Line managers', senior managers', and HR professionals' descriptions of their roles and tasks—their own as well as each other's—are summarized in Table 1. These descriptions and the actual performance of the roles are presented next.
Line Managers' Roles
When line managers described their roles, an important vantage point was the fact that they are formally responsible for the work environment in their group. They described their roles as a positive role model for worksite well-being and an evaluator of occupational health. Involving employees in discussions concerning the results of risk evaluations, prioritization, and the execution of actions plans was an important task for line managers, as they themselves and senior managers described. Line managers felt that their engagement was essential in implementing the intervention in terms of building motivation and involvement among employees. It was their responsibility to ensure that the intervention provided concrete actions and positive results. One line manager described this as follows:
You talk about it [the intervention] in a way that lets you actually see that something's happening. Just doing things and reporting and nothing's happening, then it's a dead tool, but if you use it as a living instrument and use it in the group and talk and think about it.
From senior managers' and HR professionals' points of view, the line managers had the formal responsibility for the intervention, including deciding whether it would be implemented at their unit. They considered that it was line managers' role to act on the results of the risk assessments, to initiate and lead discussions in their group, and together identify solutions. Senior managers described the importance of line managers creating motivation among employees and interaction between line managers and their respective work groups. HR professionals also stressed line managers' role in communicating the importance of the intervention, but did not stress the importance of being enthusiastic in the same way. Rather, HR professionals stressed the formal responsibility aspect instead of the employee involvement aspect.
Senior Managers' Roles
Senior managers described two roles for themselves: making the formal decision to implement the intervention and inspiring others to use it. They expressed the importance that they show engagement, point out the advantages of the intervention, increase the knowledge about it, and make the line managers comfortable with it. One senior manager described his/her role as follows:
Being inspiring and engaged, really standing up for believing in this, I've felt like it's incredibly important that I have to show that I like this.
HR professionals and line managers emphasized the importance of senior managers making the intervention a priority. Some proposed that this could be done through inspiring line managers and employees to engage in the intervention. In contrast to senior managers' view of their own role, HR professionals and line managers pointed out that the senior managers have to give concrete signals that the intervention is to be prioritized, for example, by giving feedback on the risk assessment results and action plans.
HR Professionals' Roles
All three groups described HR professionals' role as supporting line managers in their work with the intervention, in terms of using their expertise in occupational health to give hands-on support. Senior managers considered HR professionals' role to contribute to line managers' engagement in the intervention. HR professionals did not express that it is their responsibility to sustain line managers' involvement. Their own view of their roles went beyond what senior managers described. HR professionals described themselves as the driving force behind the investment in the intervention, and felt responsible for it. They also considered it their task to frame the work around the intervention in the organization (ie, to be clear on its purpose and expected results).
Mismatch Between Described Roles and Practice
Although the stakeholders agreed almost in unison about the advantages of the intervention, they did not use it to its full extent. This lack of agreement between the ideal use of the intervention and practice was most explicitly expressed by HR professionals, who described not having developed their roles as managers for the intervention. Some of them had not provided line managers with the necessary tools to use the intervention properly, or given line managers and employees the expected feedback on the risk assessments. This contributed to HR professionals expressing feelings of guilt for not having done enough. In addition, a minority of the line managers used the intervention to continuously follow the group results of the brief survey and to discuss the results with employees. Senior managers seldom used the intervention themselves in their roles as line managers. Instead, they let someone else, such as an HR representative, take responsibility for these tasks.
All three groups expressed disappointment with how the other actors fulfilled their roles. Senior managers wanted the line managers to be more proactive in using the intervention and in health-related issues in general. They wished that line managers had more competence concerning the intervention to be able to focus on overall health questions rather than details in risk evaluations. Senior managers also believed that HR professionals' performance in coaching the line managers was underdeveloped. Most line managers described senior managers as invisible, which is illustrated in the following:
We've never talked about it at all. It just goes on. It rolls along and we get some kind of summary from the senior manager at Christmas. That's it—so we never talk about this.
There were also a few, but distinguishable, examples of HR professionals describing senior managers as deeply dedicated and highly involved in decisions regarding the implementation. They described that their senior manager was positive, used the intervention himself/herself, and discussed it with others.
Possibilities to Perform the Tasks
Two themes emerged in the analysis of the stakeholders' possibilities to perform the described roles: “champion engagement instead of strategy” and “lack of integration.”
Champion Engagement Instead of Strategy
The respondents described a high degree of personal commitment and excitement regarding the opportunity to use the intervention. They considered it innovative and, overall, a good match with their expectations and needs. The traditional approach when working with occupational health was described as too regulated. Nevertheless, it seemed that this way of working had contributed strategies and structure, which had been lacking when the current, innovative intervention was implemented. The implementation of the present intervention seemed to suffer from a lack of overall organizational strategy. Senior managers or HR professionals had not considered, or communicated, how the new way of working related to the traditional occupational health work or to the organization's goals. Senior managers vaguely described the strategy as conducting a pilot test and seeing how it worked out. Instead of a strategy, both senior managers and HR professionals emphasized the role of engaged line managers. Thus, the approach to implementing the tool seemed to be idea- and engagement-driven. A senior manager described this as follows:
There are no requirements—instead the idea is that if you're an engaged manager use it. If you're not an engaged manager in these issues, don't use it because then it can have negative repercussions.
Thus, the introduction of the intervention, including the decision to introduce it as well as its practical implementation, relied almost entirely on the engagement of certain individuals (ie, local champions). The organizations implemented the intervention because an HR professional and some senior managers personally believed in it. In a similar manner, the units implemented the intervention because a line manager showed personal interest in it. The senior managers who were actively using the intervention did so on the basis of their personal interest rather than any strategic plan.
The lack of overall strategy was highlighted by some line managers, with a hint of frustration. They described a lack of systemization in implementing the intervention, ultimately leaving the responsibility to them. One line manager described this as follows:
The system was introduced in August and then we ourselves as managers have chosen what the heck we want to do with that data. There hasn't been any kind of strategy at the organization that now we're going to use and reuse.
Some of the HR professionals also expressed frustration. A number of them wondered whether their personal involvement and excitement about the intervention were being taken advantage of by the rest of the organization. They further explained how they had been allowed to try the intervention in the organization but were actually never given the necessary means to make it work.
Lack of Integration
The organizations had not made efforts to integrate the intervention with other occupational health work or internal processes. Neither was there any integration of the intervention in relation to organizational performance measurements or follow-up systems such as productivity or quality improvement systems.
There was also little collaboration between the different actors involved in the intervention within the organization. Most line managers described having limited contact with their immediate manager concerning the intervention. They were not sure their manager knew much about the intervention, or what their perceptions or attitudes were. Another aspect regarding the integration of the intervention in everyday work was whether it was discussed between colleagues. Line managers differed in their perceptions of this. Although some had it as a recurrent point on the agenda at management meetings, others had informal discussions from time to time, and still others never spoke with colleagues about the intervention. Line managers described depending on a dialogue with other line managers in order to be able to put into perspective the results from their own group.
Another factor that contributed to the lack of integration within the organization was the role of external stakeholders; in this case, the researchers were responsible for evaluating the intervention. Senior managers expected them to be involved in the intervention in a way that blurred the roles of line management and HR professionals. Similarly, HR professionals often depended on the researchers to provide them with support and assistance. Some also expected the occupational health care provider to support the line managers, which overlapped the HR professionals' own roles.
HR professionals believed that one reason for the lack of integration was that the intervention was introduced as a pilot project. As a result, many of them felt they were not able to give it the proper time and attention. They felt they could have done so much more with the intervention. The lack of integration affected line managers' motivation and opportunity to prioritize the intervention. An HR representative described how his/her own belief in the new way of working with occupational health offered by the intervention clashed with the lack of integration:
I believe in it, but that's not enough for me to do it—there needs to be a platform within an organization when you're going to work with this and if that's not in place you shouldn't try to implement anything, if it's not anchored in the management.
Line managers, senior managers, and HR professionals generally described each other's and their own roles in a coherent fashion. Nevertheless, HR professionals described a more comprehensive role for themselves than was described by the other stakeholders. The descriptions of the roles were generally in line with the roles and tasks that prior research has described for these actors.43,55,65 The results also show that these actors seldom managed to perform according to these roles in practice. Two main reasons for the suboptimal performance of roles appeared: organizations' use of individuals' engagement rather than creating a strategy for the implementation, and a lack of integration of the intervention across relevant vertical stakeholders and organizational processes. These results are discussed next, and implications for practice and suggestions for future research are presented.
The coherent descriptions of each other's roles suggest that these actors have a shared view regarding what is expected from them and the others when implementing an occupational health intervention. The only clear discrepancy between perceptions of each other's roles concerned HR professionals. They described having great enthusiasm for creating structure for the intervention, including formulated goals, expected results, and administrating the intervention. These were not described as HR professionals' tasks by the senior or line managers. HR professionals also wanted to support line managers in their work with the intervention, which was also described by the other actors as their task. Overall, HR professionals felt they lacked the authority or resources for any of these tasks. Thus, the role of HR professionals and the responsibility for developing that role were not defined in conjunction with implementing the intervention. In addition, realistic opportunities for HR to perform any tasks in relation to the interventions were not considered. The literature describes a transition in HR professionals' role from controller to manager of organizational change.51,54–56 It is possible that the role of HR professionals is currently unclear at many organizations, which might contribute to the difficulties and frustration they experience in conjunction with occupational health interventions. This study suggests that an assessment of HR professionals' resources for managing occupational intervention processes and supporting line managers be conducted before any implementation. HR professionals often have the skills, competence, and extensive experience to be perceived as trustworthy,47,57 which can positively impact an intervention if fully taken into consideration.
Similar results were found for line managers and senior managers when it comes to the actual performance of the described roles. These actors seldom performed the described roles in practice even they reported high interest toward the intervention. One possibility is that the organizations did not need to create any role descriptions, strategies, policies, or structures for the implementation work because all these key actors were highly engaged in the concept of this intervention. Thus, initially they drove the intervention on the basis of their enthusiasm and expectations regarding the potential benefits. This implies that the managers and HR professionals understood and created sense of the intervention for themselves and employees, which resulted in a positive response to the intervention.19,20,66 The use of local champions is often regarded as a successful implementation factor.67,68 Nevertheless, some authors have also highlighted the possible negative consequences of relying on local champions.69 The engagement of the champions in this study might explain the lack of an overall strategy for implementing the intervention, which has also been seen in other studies.69 Six months after the initiation of the intervention, there was frustration among HR professionals and line managers, who perceived that the organization did not fully support the intervention. This may have contributed to decreased interest in the intervention. This emphasized the actors' sense-making process over time in the organizational context. It involved intertwined cycles of interpretation and action through time.66 This implies that relying on local champions as a main implementation strategy may interfere with a sustained and holistic implementation of interventions. In this way, champions' engagement can be problematic instead of contributing to successful implementation. This is in line with prior studies showing how senior leaders easily allow engaged individuals to implement change, without considering change in the larger organizational structure and without giving these individuals realistic chances to succeed.69
The lack of implementation strategy also meant that the intervention was not integrated across stakeholders and organizational processes at the different levels in the organization. Thus, the use of champions and the lack of integration resulted in the implementation of the intervention, sidestepping the middle levels of the organizations. The senior managers were not working vertically, as they normally do; in this case, they instead worked through HR professionals. This led to middle managers not being active in the implementation. This resulted in line managers feeling that they alone were responsible for the practical implementation work. Initially, the line managers appreciated the freedom to adapt the intervention to local needs, in contrast to traditional occupational work, which they considered too regulated and bureaucratic. Nevertheless, the flexible design of the intervention also seemed to need organizational strategies, processes, and structures to be fully and sustainably implemented. Six months after the start of the implementation, the line managers expressed dissatisfaction with the task of implementing the intervention by themselves. They felt they were supposed to make decisions about the intervention on the basis of their individual judgment rather than relying on organizational decisions, policies, or strategies. This situation corresponds to Garvin's70 description of organizational fragmentation and lack of cross-functional integration. He made the conclusion that all organizational processes and interventions need oversight coordination and control to perform effectively.70 These findings are important because reasons for line managers' lack of engagement and supportive behaviors for ensuring employees' well-being have been unclear.43 Thus, this study highlights the organizational opportunities line managers need to be able to fulfill their task of ensuring employees' well-being. Therefore, it is important to see line managers in the larger occupational puzzle when their performance in relation to the implementation of occupational health interventions is evaluated. This is in line with the study by Nielsen,43 who believes that it is important to measure the extent to which line managers have resources to manage change processes. Such measurements could provide valuable information on how line managers can get into the change cycle; without having the resources to manage change, they are unlikely to facilitate sustainable change.43 Several prior studies suggest that leaders need support in their implementation work21,31,44; nevertheless, it is unclear what level of organizational leaders should be supported. There is a risk that support offered directly to line leaders would sidestep the vertical structure.65 We suggest that support for leaders be directed at all organizational levels, focusing on supporting the leaders in monitoring and following up on the work of the managers who report to them (ie, subordinates).
The results can partly be understood in the light of the organizations implementing the intervention as a pilot project. The use of pilot groups before deciding on a large-scale implementation is common and also recommended as an implementation strategy.71 Nevertheless, it may also involve difficulties. Using pilot groups for initial implementation may not ease the integration with the rest of the organization, especially if the intervention is perceived as temporary or as not part of the already established organizational structure.65 It might possibly lead to an organization lacking alignment between organizational levels. The use of pilot groups without any strategies may hinder an intervention from having the chance to be properly implemented, thus making it difficult to measure any reliable effects on employees' well-being. This also contributed to the high dependency on external consultants in this case researchers.
Employees and external consultants (ie, researchers) were not included in this analysis. It is possible that including them might have provided a broader understanding. Future studies should include these actors when analyzing the roles of important stakeholders in the implementation of occupational interventions. In addition, only line managers who volunteered to be interviewed were included. This procedure has the potential drawback of leading to a selection effect, favoring managers who are specifically interested in the intervention, in either a positive or a negative way. The intervention in this study was a web-based intervention involving both individual and organizational level aspects. Although the content and form of the intervention may be important for understanding the roles of the different actors, the results do not indicate that it was the specifics of this certain intervention that affected their roles.
Line managers, senior managers, and HR professionals seldom managed to perform in practice the roles and tasks that were described for them. This resulted from two factors: using individuals' engagement (ie, relying on local champions) rather than having a clear strategy for the implementation, and a lack of alignment to other organizational processes and relevant actors such as middle managers. Suggestions for improving the management of occupational health interventions include creating clear role descriptions and strategies, as well as aligning an intervention to existing organizational processes before an implementation. Alignment to relevant stakeholders is also important, and can be attained by offering ongoing support to leaders at all organizational levels during an implementation. Furthermore, it is important to evaluate different stakeholders' perceptions of each other's and their own roles, especially when it comes to HR professionals, because there might be some discrepancies between perceptions.
The authors thank all of the senior and line managers and HR professionals who participated in the study, and offer a special thanks for Emma Granström, who conducted most of the interviews.
1. Lipsey MW, Cordray DS. Evaluation methods for social intervention. Annu Rev Psychol. 2000;51:345–375.
2. Nielsen K, Randall R, Christensen KB. Developing new ways of evaluating organizational-level interventions. Contemp Occup Health Psychol: Global Perspect Res Pract. 2010;1:21.
3. Egan M, Bambra C, Petticrew M, Whitehead M. Reviewing evidence on complex social interventions: appraising implementation in systematic reviews of the health effects of organisational-level workplace interventions. J Epidemiol Community Health. 2009;63:4–11.
4. Griffiths A. Organizational interventions: facing the limits of the natural science paradigm. Scand J Work Environ Health. 1999;25:589–596.
5. Øvretveit J. Evaluating Health Interventions: An Introduction to Evaluation of Health Treatments, Services, Policies and Organizational Interventions. Open University Press; 1998:324.
6. Cox T, Karanika M, Griffiths A, Houdmont J. Evaluating organizational-level work stress interventions: beyond traditional methods. Work Stress. 2007;21:348–362.
7. Landsbergis PA, Vivona-Vaughan E. Evaluation of an occupational stress intervention in a public agency. J Organ Behav. 1995;16:29–48.
8. NytrØ K, Saksvik PØ, Mikkelsen A, Bohle P, Quinlan M. An appraisal of key factors in the implementation of occupational stress interventions. Work Stress. 2000;14:213–225.
9. Saksvik PO, Nytrø K, Dahl-Jørgensen C, Mikkelsen A. A process evaluation of individual and organizational occupational stress and health interventions. Work Stress. 2002;16:37–57.
10. Kristensen TS. Intervention studies in occupational epidemiology. Occup Environ Med. 2005;62:205–210.
11. Nielsen K, Simonsen Abildgaard J. Evaluating organizational interventions: a research-based framework for process and effect evaluation [published online ahead of print 2013]. Work Stress. doi: 10.1080/02678373.2013.812358.
12. Campbell N, Murray E, Darbyshire J, et al. Designing and evaluating complex interventions to improve health care. BMJ. 2007;334:455–459.
13. Dobson D, Cook TJ. Avoiding type III error in program evaluation: results from a field experiment. Eval Program Plann. 1980;3:269–276.
14. Murta SG, Sanderson K, Oldenburg B. Process evaluation in occupational stress management programs: a systematic review. Am J Health Promot. 2007;21:248–254.
15. Nielsen R, Randall R, Albertsen K. Participants' appraisals of process issues and the effects of stress management interventions. J Organ Behav. 2007;28:793–810.
16. Nielsen K, Randall R. Opening the black box: a framework for evaluating organizational-level occupational health interventions [published online ahead of print 2013]. Eur J Work Organ Psychol. doi: 10.1080/1359432X.2012.690556.
17. Thomas R, Sargent LD, Hardy C. Managing organizational change: negotiating meaning and power-resistance relations. Organ Sci. 2011;22:22–41.
18. Rouleau L, Balogun J. Middle managers, strategic sensemaking, and discursive competence. J Manag Stud. 2011;48:953–983.
19. Weick KE, Sutcliffe KM, Obstfeld D. Organizing and the process of sensemaking. Organ Sci. 2005;16:409–421.
20. Randall R, Cox T, Griffiths A. Participants' accounts of a stress management intervention. Hum Relat. 2007;60:1181.
21. Øvretveit J. Leading improvement. J Health Organ Manag. 2005;19:413–430.
22. Rouleau L. Micro-practices of strategic sensemaking and sensegiving: how middle managers interpret and sell change every day. J Manag Stud. 2005;42:1413–1441.
23. Birken SA, Lee S-YD, Weiner BJ. Uncovering middle managers' role in healthcare innovation implementation. Implement Sci. 2012;7:28.
24. Huy QN. In praise of middle managers. Harv Bus Rev. 2001;79:72–79.
25. Dutton JE, Jane E, Ashford SJ, O'Neill RM, Hayes E, Wierba EE. Reading the wind: how middle managers assess the context for selling issues to top managers. Acad Manage Rev. 2000;25:154–177.
26. Kanter RM, Stein BA, Jick TJ. The Challenge of Organizational Change. The Free Press; 1992.
27. Floyd SW, Wooldridge B. Dinosaurs or dynamos? Recognizing middle management's strategic role. Acad Manage Exec. 1994;8:47–57.
28. Guth WD, Macmillan IC. Strategy implementation versus middle manager self-interest. Strateg Manage J. 1986;7:313–327.
29. Kompier MAJ, Cooper CL, Geurts SAE. A multiple case study approach to work stress prevention in Europe. Eur J Work Organ Psychol. 2000;9:371–400.
30. Hasson H, von Thiele Schwarz U, Villaume K, Hasson D. eHealth interventions for organizations - potential benefits and implementation challenges. In: Burke R, Cooper C, Biron C, eds. Creating Healthy Workplaces: Stress Reduction, Improved Well-being, and Organizational Effectiveness. Gower Publishing; 2013.
31. Skagert K. Leadership in Human Service Organisations: Conceptions, Strategies and Preconditions to Promote and Maintain Health at Work. Institute of Medicine. Department of Public Health and Community Medicine; 2010.
32. Coyle-Shapiro JA. Employee participation and assessment of an organizational change intervention: a three wave study of total quality management. J Appl Behav Sci. 1999;35:439–456.
33. Nielsen K, Randall R. Managers' active support when implementing teams: the impact on employee wellbeing. Appl Psychol: Health Well-Being. 2009;1:374–390.
34. Björklund C, Grahn A, Jensen I, Bergstrom G. Does survey feedback enhance the psychosocial work environment and decrease sick leave? Eur J Work Organ Psychol. 2007;16:76–93.
35. Nielsen K, Randall Reds. The importance of middle manager support for change: a case study from the financial sector in Denmark. In: Lapointe P-A, ed. Different Perspective on Work Changes. Quebec: Université Laval; 2011.
36. Randall R, Griffiths A, Cox T. Evaluating organizational stress-management interventions using adapted study designs. Eur J Work Organ Psychol. 2005;14:23–41.
37. Biron C, Gatrell C, Cooper C. Autopsy of a failure. Evaluating process and contextual issues in an organizational-level work stress intervention. Int J Stress Manange. 2010;17:135–158.
38. Scarbrough H, Burrell Geds. The Axeman Cometh: the changing role and knowledge of middle managers. In: Clegg S, Palmer G, eds. The Politics of Management Knowledge. Thousands Oaks, CA: Sage; 1996.
39. Dahl-Jorgensen C, Saksvik PO. The impact of two organizational interventions on the health of service sector workers. Int J Health Serv. 2005;35:529–549.
40. Nielsen K, Martini Jørgensen M, Munch-Hansen M. Teamledelse Med Det Rette Twist–Inspiration Til at Arbejde Med Team, Teamledelse og Forandringsprocesser. Copenhagen, DK: Det Nationale Forskningscenter for Arbejdsmiljø; 2008.
41. Nielsen K, Randall R, Christensen K. Does training managers enhance the effects of implementing team-working? A longitudinal, mixed methods field study. Hum Relat. 2010;63:1719.
42. Nielsen K, Munir F. How do transformational leaders influence followers' affective well-being? Exploring the mediating mechanism of self-efficacy. Work Stress. 2009;23:313–329.
43. Nielsen K. How can we make organizational interventions work? Employees and line managers as actively crafting interventions. Hum Relat. 2013;66:1029–1050.
44. Walinga J, Rowe W. Transforming stress in complex work environments: exploring the capabilities of middle managers in the public sector. Int J Workplace Health Manage. 2013;6:66–88.
45. Giga SI, Noblet AJ, Faragher B, Cooper CL. The UK perspective: a review of research on organisational stress management interventions. Aust Psychol. 2003;38:158–164.
46. Lindström Ked. Finnish research in organizational development and job redesign. In: Murphy LR, Joseph J Jr, Sauter SL, Keita GP, eds. Job Stress Interventions. Washington, DC: American Psychological Association; 1995:283–293.
47. Yost PR, McLellan JR, Ecker DL, et al. HR interventions that go viral. J Bus Psychol. 2011;26:233–239.
48. Kotter JP. Leading change: why transformation efforts fail. Harv Bus Rev. 2007;85:96–103.
49. Nielsen K, Randall R, Holten AL, González ER. Conducting organizational-level occupational health interventions: what works? Work Stress. 2010;24:234–259.
50. Semmer NK, ed. Job stress interventions and organization of work. In: Quick J, Tetrick L, eds. Handbook of Occupational Health Psychology. Washington, DC: American Psychological Association; 2011.
51. Jackson SE, Schuler RS, Werner S. Managing Human Resources. South-Western Pub; 2011.
52. Francis H, Keegan A. The changing face of HRM: in search of balance. Hum Resour Manage J. 2006;16:231–249.
53. Patterson M, Rick J, Wood S, Carroll C, Balain S, Booth A. Systematic review of the links between human resource management practices and performance. Health Technol Assess. 2010;14:1–334.
54. Ulrich D. Human Resource Champions. Boston, MA: Harvard Business School Press; 1997.
55. Buyens D, De Vos A. Perceptions of the value of the HR function. Hum Resour Manage J. 2001;11:70–89.
56. Caldwell R. Models of change agency. Br J Manage. 2003;14:131–142.
57. Paauwe J. Key issues in strategic human resource management: lessons from The Netherlands. Hum Resour Manag J. 1996;6:76–93.
58. Paauwe J, Boselie P. HRM and performance: what next. Hum Resour Manage J. 2005;15:68–83.
59. Logan M, Ganster D. An experimental evaluation of a control intervention to alleviate job-related stress. J Manage. 2005;31:90.
60. Randall R, Nielsen K, Tvedt SD. The development of five scales to measure employees' appraisals of organizational-level stress management interventions. Work Stress. 2009;23:1–23.
61. Nielsen K, Fredslund H, Christensen KB, Albertsen K. Success or failure? Interpreting and understanding the impact of interventions in four similar worksites. Work Stress. 2006;20:272–287.
62. Hasson H, Gilbert-Ouimet M, Baril-Gingras G, et al. Implementation of an organizational-level intervention on the psychosocial environment of work—comparison of managers' and employees' views. J Occup Environ Med. 2012;54:185–191.
63. Bouffard JA, Taxman FS, Silverman R. Improving process evaluations of correctional programs by using a comprehensive evaluation methodology. Eval Program Plan. 2003;26:149–161.
64. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277–1288.
65. von Thiele Schwarz U, Hasson Heds. Alignment in healthy organizations. Concepts of salutogenic organizations and change. In: Bauer G, Jenny G, eds. The Logics Behind Organizational Health Intervention Research. Springer; 2013.
66. Balogun J, Johnson G. From intended strategies to unintended outcomes: the impact of change recipient sensemaking. Organ Stud. 2005;26:1573–1601.
67. Philips Å. Eldsjälar: en studie av aktörsskap i arbetsorganisatoriskt utvecklingsarbete (Souls of Fire: A Study of Actorship in Work Organization Development Effort). Doctoral thesis. Stockholm: Stockholm School of Economics, Management and Organization; 1988.
68. Forsberg Aed. Att brinna för lokalt utvecklingsarbete (engagement to local development work) Relationsbyggande för ekonomisk utveckling. In: Ekstedt E, Wolvén L-E, eds. Developing Relationships for Economical Development. Vol. 13. Stockholm: Arbetslivsinstitutet; 2003:181.
69. Palm K. Det riskabla engagemanget: Om regenerativ utveckling av mänskliga resurser, eldsjälar och ledarskap i radikal utveckling (The Dangerous Commitment: About Regeneration and Development of Human Resources, Champions and Leadership During Radical Changes). Stockholm: KTH, School of Industrial Engineering and Management; 2008.
70. Garvin DA. The processes of organization and management. Sloan Manage Rev. 2012:39.
71. Pluye P, Potvin L, Denis JL, Pelletier J, Pelletier C. Program sustainability begins with the first events. Eval Program Plann. 2005;28:123–137.
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