Table 1 Sub-factors applied to Subscales A & B and examples from the literature and interviews

 • Knowledge and understanding (A & B):

The knowledge and understanding of how economic efficiency/quality requirements affect how his/her work is to be conducted.

Awareness and understanding [17]

Information and analysis [22]

Planning for quality [23]

A: “If I don’t meet enough patients we get less money. So that’s very obvious. I think everyone knows and has an awareness of being a part of it.” (Respondent 5)

B: “Quality follow-up. That’s done a lot right now. There are different ways. At the work place meetings. Some have white boards where they take notes continuously. And print graphs to share. They are educational and easy for staff to follow.”

(Respondent 2)

 • Opportunity to influence (A & B):

The experience of participating and being able to influence the financial situation/ quality improvement work at the unit.

Control [17]

Strategic planning for quality analysis [22]

A: “They (staff) are not involved. You are not involved in the decision-making. You never get to know what financial resources there are, and what the costs are.” (Respondent 2)

B: “So it is quite common that you measure quality in different ways, on the other hand there might be a lack of feedback. / ... / And if you get feedback it might not be obvious, what did I do that made a difference? Or you get feedback at a higher level of abstraction, and it’s difficult to know if you make a difference or not. You need to experience that you can influence quality.” (Respondent 3)

 • Motivation (A & B):

The experience of motivation and engagement in improving the unit’s financial situation/quality.

Goal importance [16]

Job satisfaction [21]

Work load [21]

Financial reward [14]

Staff motivation [13]

Human resource utilization analysis [22]

Managerial role (Berlowitz et al., 2003

A: “My experience is also that, usually, healthcare workers do not really think about this (economic efficiency), or are engaged in this.” (Respondent 7)

B: “Taking a quality perspective, I think it’s much easier to discuss, and it feels better than when you refer to money. Because people are not like that. Physicians, and all healthcare professionals, are guided by their ethics. It’s so central, you want to provide good care, and you’re in this to create good things for patients. To work for better health, that’s the intrinsic driving force. ”(Respondent 1)

 • Impact on professional autonomy (A):

The experience of economic efficiency requirements affecting his/her professional autonomy in meeting patient needs.

Clinical relevance [16]

Impact on professional autonomy [16]

Impact on clinical behavior, clinical relevance [17]

Impact on clinical roles, alignment professional values [14]

Impact on clinical autonomy, changed clinical practice [12]

A: “I feel that it is part of care, to do good /…/ It’s a driving force that’s part of who we are. It is in ethical perspectives we end up many times, in the ethical dilemmas. When I can’t do what I know is best for the patient. Although I would like to, and could, if the conditions were right.” (Respondent 3)

 • Organizational alignment (A):

The experience that the unit’s financial resources are in line with its mission.

Impact on quality of care [21]

Unintended consequences for patients [17]

Supporting improvement, unintended consequences for patients [14]

Fairness, appropriateness [13]

A: “It is always so, that we (health care providers) should do more using fewer resources. And it seems to me that the more promises of that kind that you throw into the political game, the better. But then what? /…/ Then we have to provide the same services, with less money.” (Respondent 4)