Journal of Nursing Management, 2011, 19, 664672

Perception of budgetary control: a study of differences across managers in Swedish public primary healthcare related to professional background and sex
PIA NYLINDER
MSc (Science in Business and Economics), University Certicate (UC) in Nursing

PhD Student, Department of Business Administration, School of Economics and Management, Lund University, Lund, and Vardalinstitutet, The Swedish Institute for Health Sciences, Universities of Gothenburg and Lund, Sweden

Correspondence Pia Nylinder School of Economics and Management Department of Business Administration Lund University Box 7080 SE220 07 Lund Sweden E-mail: pia.nylinder@fek.lu.se

N Y L I N D E R P . (2011) Journal of Nursing Management 19, 664672 Perception of budgetary control: a study of differences across managers in Swedish public primary healthcare related to professional background and sex

Background The composition of managers in Swedish public primary care centres has changed since the mid-1990s, favouring nurses and female managers. In parallel, health-care professionals have become more involved in the management structure and many have experienced an increased demand for cost containment. There is limited empirical evidence about how managers with different professional backgrounds perceive tight budgetary control. Aim To examine whether perceptions of tight budgetary control across managers in Swedish public primary care are related to personal characteristics such as professional background and sex. Method A questionnaire measuring perception of tight budgetary control was administered to all (636) identied managers in Swedish public primary care centres (response rate was 59%). Differences between groups were analysed through logistic regression and factor analysis. Results Nurses and other non-physicians perceived the budgetary control to be tighter than did physicians and female physicians perceived the budgetary control to be tighter than did male physicians. Conclusions and implications for nursing management Results suggest that nurses were more committed to the budgetary control system and county council objectives than physicians. The impact of these differences are uncertain, however, nurses capacity to inuence primary care services may be more limited compared with physicians because of their lower professional status. Keywords: budgets, occupational groups, primary health care, public sector
Accepted for publication: 18 February 2011

Introduction
Most Organization for Economic Co-operation and Development OECD (2009) countries have experienced accelerated health care spending, which in turn has put a high pressure on public budgets. Cost containment strategies together with more long-term structural changes
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have been common in order to achieve better value for money (Huber & Orosz 2003). Sweden has followed this development (Anell 2005). Locally, the need to contain cost has put pressure on local health-care budgets, primarily in hospitals but also in primary health care. Along with demands for cost containment in the health-care sector there has been an increased pressure
DOI: 10.1111/j.1365-2834.2011.01192.x 2011 The Author. Journal compilation 2011 Blackwell Publishing Ltd

Perception of budgetary control

on health-care professionals to become more involved in the management control structure and the control of expenditure (Abernethy & Stoelwinder 1990, Comerford & Abernethy 1999, Lapsley 2001). Management control refers to the process where managers are inuencing other members in the organization in order to increase the probability that organizational goals are achieved (Merchant & Van der Stede 2003, Anthony & Govindarajan 2007). However, physicians have historically claimed that medical decisions should be based mainly on professional goals and standards and not according to any economic logic or administrative plan (Hopwood 1992). Researchers have tried to explain physicians resistance towards budgetary control with reference to incompatible norm systems (Mintzberg 1979, Coombs 1987, Comerford & Abernethy 1999, Lapsley 2001). Professionals, such as physicians, are trained according to professional norms and values. They work independently from both colleagues and the rest of the organization. Development of knowledge and skills is a matter mainly for the profession. This enables professionals to maintain control over the conduct of their work and the core production process in health care (Mintzberg 1979, Harrison & Pollitt 1994). Along with the professional model of behaviour goes the administrative, based on bureaucratic norms and values, characterized by a hierarchical authority system, horizontal division of labour and standardization of behaviour (Flood & Scott 1987). In Sweden, the manager position in public primary care centres has traditionally been occupied by a physician. However, the composition of managers has changed since the mid 1990s, favouring nurses and female managers (Granestrand 2005, Kennedy 2008). A change in the law in 1997 made it formally possible for nonphysicians to become managers for primary care centres and clinical departments (HSL 1982, SOSFS 1997). In just a few years the share of nurses in managerial positions increased signicantly. In 2008, 50% of the managers in Swedish public primary care were nurses, whereas only 33% were physicians (Kennedy 2008). In academic research there has been an extensive focus on physicians behaviour and attitudes toward formal management control systems. Less focus has been on other professions with managerial positions and their attitudes toward management control systems (Abernethy & Stoelwinder 1988). In the health-care organization, physicians have traditionally had an inuential position (Lindgren 1992), which stems from their specialized knowledge and skills, which are critical for health-care providers. Their power and inuence on organizational behaviour and the management control

system have been recognized (Abernethy & Vagnoni 2004). Nurses have more recently developed into professionals and their professional autonomy has increased, primarily by the enhanced educational and scientic base of nursing (Fourcher & Howard 1981, Jonsson & Petersson 2003). However, nurses have still been referred to as a non-utilized professional group when there is need for recruitment to top management positions (Lindholm et al. 2000, Jonsson & Petersson 2003). In order to obtain an effective management control system incorporating budgetary control, managers need to identify themselves with managerial values and norms (Abernethy & Stoelwinder 1990). In contrast to physicians, nurses have traditionally been seen as more bureaucratically oriented and an early study stated that nurses use rules and procedural specications to a greater extent than others (Hall 1967). However, the increase of professionalization of nurses seems to have inuenced their bureaucratic behaviour in the sense that their conicts with the bureaucratic system have worsened (Fourcher & Howard 1981). Furthermore, previous research has shown that health-care managers with different professional backgrounds have different views of the management control system, including the process of budgeting (Abernethy & Stoelwinder 1988, Nylinder 2009). The changed composition of managers in Swedish public primary care provides access to perform studies that directly focus on differences based on professional background. Budgets and budgetary processes have a central role when it comes to resource allocation and follow-up in public health-care systems (Anell 1990, Anthony & Young 2003). Budgets, together with costing data and periodic nancial reports are an integral part of the management control system used to provide the management structure with information for decision making and control (Zimmerman 2006). The control system including budgets can be more or less tight and tight control is believed to increase the likelihood of organizational goals being achieved (Merchant & Van der Stede 2003). Van der Stede (2001, p. 124) suggests that tight budgetary control exists if central management puts much emphasis on meeting the budget, does not easily accept budget revisions during the year, has a detailed interest in specic budget line items, does not lightly tolerate deviations from interim budget targets and is intensively engaged in budget-related communications. Tight budgetary control in Van der Stede (2001) denition thus concerns how committed managers are to the budget imposed by top management (Marginson & Ogden 2005). The question concerning 665

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how tightly to apply budgetary control has received little attention in academic management research and there is in practice inconclusive evidence about the positive or negative effects of tight budgetary control (Van der Stede 2001). The primary aim of this study was to examine whether perceptions of tight budgetary control across managers in Swedish public primary care were related to their personal characteristics, such as professional background and sex. Data were collected from managers in public primary care centres, responsible for both medical as well as nancial decisions. Swedish primary care centres are traditionally owned and managed by the county council. Although the range of privately owned centres is increasing, they are still rather few in number (Anell 2010). The work force in Swedish primary care centres is, for the most part, multidisciplinary with four to ten general practitioners employed together with district nurses, physiotherapist, psychologists and nurses specialized within areas such as diabetes and asthma. Physicians, as well as the other professional groups, are salaried employees (Anell 2010). Primary care centres commonly receive xed and comprehensive payments (capitation) from their county council, topped up with a smaller payment for each visit similar to the user-charges that apply for patients (Anell 2010).

ered each of the ve dimensions in the denition of tight budgetary control by Van der Stede (2001): emphasis on meeting the budget, allowance for budget revisions during the year, amount of budgetary detail, tolerance for interim budget deviations and intensity of budgetrelated communication. Twenty-ve items from Van der Stedes original questionnaire was selected (only items with standardized factor loadings above 0.40 were chosen). Respondents were asked to agree or disagree on a 7-point Likert-scale (from false to true) where a higher score indicated perception of a tighter budgetary control. Personal characteristics and organizational conditions independent variables Managers personal characteristics were measured by their professional background (if they were physicians, nurses or had another professional background), age, number of years in the current position and sex. Other variables included in the questionnaire were the nancial situation and the size of the primary care centre. The nancial situation may inuence the managers perceptions of tight budgetary control. Managers in organizations or units with decits have a tendency to attract more attention than managers in organizations or units with balanced budgets (Merchant & Van der Stede 2003). In hospitals, managers with balanced department budgets perceived the budgetary control to be tighter than did managers whose department budget were highly overspent (Nylinder 2009). The nancial situation was measured by the percentage of budget achievement during the rst 6 months of 2008. Managers perception of tight budgetary control may also be related to the size of the organization. Larger primary care centres demand more dedicated managers who are more willing to accept the budgetary control systems and the objectives of the county council. The size of the primary care centre was measured by the number of employees.

Method and data Survey design

In November 2008 a mail survey was conducted, targeting managers practicing in all public primary care centres in Sweden (a total of 636 managers). All questionnaires were mailed at the same time. Thank you/ reminder postcards were administered to all respondents 1 week after the original mail-out. After an additional 2 weeks replacement questionnaires were sent to nonresponders. The method for mail-outs (including the design of the cover letter and best time to deliver followups), was designed in accordance with the Total Design Method (Dillman 2007). In total, 374 usable questionnaires were returned, giving a response rate of 59%.

Statistical analysis
Logistic regression was employed to determine systematic variations between managers perception of tight budgetary control and their personal characteristics and organizational conditions respectively. The items measuring tight budgetary control were factor analysed separately for nurses and physicians in order to measure the components of tight budgetary control and thereby further explain differences in perceptions of tight budgetary control between the two groups. Respondents were divided into two groups depending on their perception of tight budgetary control: those

The questionnaire
Perception of budgetary control the dependent variable Managers perception of budgetary control (the dependent variable) was measured by using 25 items originally developed by Van der Stede (2001). The questions cov666

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Perception of budgetary control

Table 1 Independent variables used in logistic regression analysis Independent variables Sex and professional background 0, 1, 2, 3, 4, 0, 1, 2, 3, 0, 1, 2, 3, 4, Code values Male physicians Female physicians Male nurses Female nurses Others 15 Subordinates 610 Subordinates 1124 Subordinates More than 25 subordinates Highly overspent budget Moderately overspent budget Balanced budget Underspent budget Highly underspent budget Categories

Number of subordinates

Budget variances for the primary care centre the first 6 months of 2008

Negative deviation with more than 6% Negative deviation with 26% from budget Even, max. 2% deviation from budget Positive deviation with 26% from budget Positive deviation with more than 6%

who perceived the budgetary control to be relatively tight and those who perceived the budgetary control to be relatively loose. A standardized item score was calculated (zero mean and unit variance) for each item. Respondents who had positive values after standardization for at least 18 of the 25 questions (24.6%) were dened as belonging to the group who perceived budgetary control to be relatively tight. The independent variables used in the logistic regression analysis were screened for correlation between the variables with a cross tabulation and a nonparametric chi-squared test. The variable professional background was correlating with several variables such as sex, age and number of years in current position. As the main interest of this study was professional background, the age and number of years in current position were eliminated for further analysis. Concerning the correlation between professional background and sex, there was reason to believe that the two variables described different things. Five groups were created based on the two variables: male physicians, female physicians, male nurses, female nurses and others (both male and female). Males with other professional background were too few in number and it was therefore not possible to analyse them separately. The variables used in the binary regression analyses are presented in Table 1. Selection of independent variables was done with stepwise backward elimination with conditional statistics.

physiotherapist or social worker (see Table 2). Data matches the distribution of managers different background overall in Swedish primary care according to other sources (Kennedy 2008).
Table 2 Characteristics of respondents Characteristics n Valid % Total

Results Data
Of the managers 51% were nurses, 36% were physicians and 13% had another background such as

Age (years) 49 or less 97 5054 95 5559 103 60 or more 76 Years in current position (years) 03 126 47 69 810 109 11 or more 66 Manager for number of subordinates 15 2 610 20 1124 86 25 or more 259 Responsible for number of primary care centres 1 290 2 53 3 or more 28 Sex Male 112 Female 258 Profession/sex Male physicians 78 Female physicians 55 Male nurses 21 Female nurses 168 Others 48 Financial results compared with budget first 6 months Highly overspent budget, more than 6% 41 Moderately overspent budget, 26% 93 Balanced budget (2%) 124 Underspent budget, 26% 77 Highly underspent budget, more than 6% 25

26 26 28 20 34 19 29 18 1 5 23 71 78 14 8 30 70

371

370

367

371

370

21 370 15 6 45 13 of 2008 11 360 26 34 21 7

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In general, physicians had several other tasks in addition to their management responsibility (96% of respondents) and patient engagement was the most common task. About half of the nurses (47%) reported other responsibilities such as patient engagements and telephone counselling. Only 19% of those with other professional background reported that they were involved in other tasks in addition to their management responsibility.

Both male and female nurses perceived budgetary control to be tighter compared to male physicians (Table 4). The results could not conrm any signicant difference in perception among managers depending on the number of employees or the nancial situation of the primary care centres.

Results from the factor analysis

Separate factor analyses for physicians and nurses were done to further analyse different perceptions of tight budgetary control between the two groups. Principal factor analysis resulted in a six-factor solution for physicians and nurses, respectively. The cumulative per cent of the total variance accounted for 61.6% (physicians) and 58.7% (nurses) (Table 5). The rst factor was named Emphasis on meeting the budget and reects the importance of meeting the budget from top management. This factor was similar for both nurses and physicians.

Results from the logistic regression

Results from the logistic regression indicated signicant differences in perception of tight budgetary control between physicians on the one hand and nurses and managers with another professional background on the other hand. Non-physicians perceived budgetary control to be signicantly tighter than physicians did (Table 3). In addition, female physicians perceived budgetary control to be tighter than male physicians did.

B Step 2 Professional background Physicians Nurses Other Financial situation Highly underspent budget Highly overspent budget Moderately overspent budget Balanced budget Underspent budget Constant

SE

Wald

df

Significance

Exp(B)

Table 3 Independent variables that explain managers perception of a relatively tight budgetary control*

0.939 1.245

0.337 0.433

10.422 7.754 8.285 5.687 3.682 4.070 2.722 2.263 11.754

2 1 1 4 1 1 1 1 1

0.005 0.005 0.004 0.224 0.055 0.044 0.099 0.133 0.001

2.557 3.473

2.103 2.144 1.745 1.622 )3.641

1.096 1.063 1.058 1.078 1.062

8.194 8.534 5.728 5.064 0.026

*Note that the two independent variables have more than two categories. The effect of each category is in comparison with a reference category. For example, nurses are consequently in comparison with physicians. Variable(s) entered in step 1: professional background, budget fulfillment, number of subordinates.

B Step 1 Sex and professional background Male physicians Female physicians 1.237 Male nurses 2.161 Female nurses 1.564 Others 1.930 Constant )2.518

SE

Wald

df

Significance

Exp(B)

Table 4 Independent variables that explain managers perception of a relatively tight budgetary control*

0.586 0.677 0.504 0.566 0.465

14.641 4.448 10.175 9.650 11.645 29.329

4 1 1 1 1 1

0.006 0.035 0.001 0.002 0.001 0.000

3.444 8.680 4.779 6.889 0.081

*Note that the independent variable for sex and professional background has more than two categories. The effect of each category is in comparison to a reference category. For example, female physicians are consequently in comparison with male physicians. The odds for female physicians to perceive the budgetary control as tight is 3.44 times higher compared with male physicians. Variable(s) entered in step 1: sex and professional background.

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Table 5 Factor loadings tight budgetary control* Physicians Dimensions and items Emphasis on meeting the budget, 24.7% of variance In the eyes of my corporate superiors, not achieving the budget reflects poor performance The corporate parent achieves control over my business principally by monitoring how well my budget is on target Not achieving my budget has a strong impact on how my performance is rated by my corporate superiors Corporate superiors judge my performance predominantly on the basis of attaining budget goals In the eyes of my corporate superiors, achieving the budget is an accurate reflection of whether I am succeeding in my business Inspection of budget deviations and the managing of such, 11.6% of variance I am required to report the actions taken to correct causes of interim budget variances I am constantly reminded by my corporate superiors of the need to meet budget targets My corporate superiors do not care very much about interim budget deviations (R) From the comments made by my corporate superiors, I know that they investigate my budget in every detail My corporate superiors attach a great deal of importance to interim budget deviations My corporate superiors are interested not only in how well I achieve my overall budget, they also evaluate how well I am on target on each of the budget line items I consult with my corporate superior on how to achieve my budget Intensity of budget-related communication, 8.9% of variance My corporate superiors, myself, and my own subordinates often form a team to discuss and solve budgeting matters Budget matters are discussed regularly with my corporate superior even if there are no negative budget deviations to report Indicate the typical frequency with which you communicate with the corporate parent for budget-related issues; b. informal Indicate the typical frequency with which you communicate with the corporate parent for budget-related issues; a. formal Corporate superiors call me in to discuss budget deviations in face-to-face meetings Loading Nurses, Dimensions and items Emphasis on meeting the budget, 23.9% of variance Corporate superiors judge my performance predominantly on the basis of attaining budget goals Not achieving my budget has a strong impact on how my performance is rated by my corporate superiors In the eyes of my corporate superiors, not achieving the budget reflects poor performance The corporate parent achieves control over my business principally by monitoring how well my budget is on target I am constantly reminded by my corporate superiors of the need to meet budget targets Intensity of budget related communication, 11.2% of variance Indicate the typical frequency with which you communicate with the corporate parent for budgetrelated issues; a. formal Budget matters are discussed regularly with my corporate superior even if there are no negative budget deviations to report Indicate the typical frequency with which you communicate with the corporate parent for budgetrelated issues; b. informal Corporate superiors call me in to discuss budget deviations in face-to-face meetings My corporate superiors, myself, and my own subordinates often form a team to discuss and solve budgeting matters I consult with my corporate superior on how to achieve my budget Loading

0.842

0.798

0.824

0.796

0.809 0.760

0.764 0.747

0.601

0.539

0.791

0.799

0.716

0.742

0.595

0.723

0.558

0.667

0.509

0.569

0.469

0.511

0.456 Management of budget interim deviations and the detail level of such, 8.3% of variance I am required to report the actions taken to correct 0.670 causes of interim budget variances I am required to submit an explanation in writing about causes of interim budget variances I am required to submit control reports that explain in detail budget variances on a line-by-line basis My corporate superiors are interested not only in how well I achieve my overall budget, they also evaluate how well I am on target on each of the budget line items 0.603

0.765

0.702

0.590

0.597

0.551

0.579

0.517

Extraction method: principal component analysis. Rotation method: Varimax with Kaiser Normalization. R indicates reverse coding each item is coded in a way that makes a higher score indicate tighter budgetary control. *Only three factors (out of six) are illustrated in the Table, the factors explain most of the variance. Loadings <0.5 are considered non-significant Hair et al. 1995. One item is excluded because it had the same factor loading as another variable.
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The second factor among nurses was named Intensity of budget related communication (explained 11% of the variance) and concerns the framing of budgetary discussions. The third factor was named Management of budget interim deviation and the detail level of such (explained 8% of the variance), which concerns how budget deviations were managed, if written reports were required and the level of details in such reports. Among physicians the second factor was named Inspection of budget deviations and the managing of such (explained 12% of the variance); this concerns how budget deviations were controlled for and managed. The third factor among physicians was similar to the second factor of nurses, Intensity of budget related communication (explained 9% of the variance).

Discussion
This study suggests that perceptions of budgetary control vary across managers in Swedish public primary care, depending on managers professional background and sex. Nurses and other non-physicians perceived budgetary control to be tighter than physicians did. Furthermore, female physicians perceived budgetary control to be tighter than did male physicians. The results in this study indicate that nurses and other non-physicians with managerial responsibilities may be more committed to budgets than the average physician. These results correspond with previous research related to professionals different views about budgetary control in health-care service (Abernethy & Stoelwinder 1988, Nylinder 2009). The difculties of getting physicians in publicly owned hospitals to take responsibility for the overall use of resources have considerable support in research (Coombs 1987, Comerford & Abernethy 1999, Lapsley 2001). Even though it has been said that physicians are gradually accepting nancial responsibilities (Coombs 1987, Lapsley 2001), the results from this study provide support the notion that primary care physicians still would like to give priority to their medical responsibilities before any loyalty to bureaucratic principles determined by the county council. If nurses are more committed to budgetary control than physicians, one might argue that they are better suited for managerial positions. This would be in agreement with Abernethy and Stoelwinder (1990) who state that it is important for managers to accept and identify themselves with managerial values and norms if implementation of management accounting systems are to be effective. However, in order to get things done, and to implement changes, it is also important to have a 670

high credibility within the organization (Alexander et al. 2006, Cregard 2007). The health-care organization has its foundations in a hierarchical medical tradition where physicians have always had an inuential position. Nurses have traditionally had a position in the middle in relation to other professions, subordinate to physicians but superior to assistant nurses (Lindgren 1992, Lindholm et al. 1999). In health care, professions with a higher professional status have an unquestionable credibility behind their actions and can therefore manage the organization and get things done more easily (Alexander et al. 2006, Cregard 2007). The signicance of high credibility in the organization has been recognized in empirical research by the fact that a recurring problem for nurses in managerial positions has been to get acceptance as managers in the organization (Lindholm et al. 1999, Jonsson & Petersson 2003). The same problem is probably also applicable for other non-physician managers. The problem does not seem to be that the managers are nurses, but more that they are not physicians. There are some differences between physicians and non-physicians respective working conditions that might have inuenced the different views on tight budgetary control. Physicians had, to a greater degree, other tasks in addition to their management responsibilities. Almost all of the physicians (96%) had other tasks, where engagement with patients was the most common one. This might have inuenced the results as it may be more difcult to have a pure organizational perspective when managers are practically involved in other tasks. The factor analysis did not reveal any substantial difference between physicians and nurses perceptions in terms of important dimensions of the budgetary control system. Both groups perceived the factors Emphasis on meeting the budget and Intensity of budget related communication to be associated with tight budgetary control. This indicates that even though nurses and physicians perceived the budgetary control process in similar ways, nurses may have accepted the budgetary control to a greater extent and felt more obligated to full objectives related to nancial performance. It is important to note that the perceptions of tight budgetary control are the managers personal perceptions exclusively. No signicant association was found between the managers perception of tight budgetary control and how close the mangers were to their own budget targets. This type of association has been reported across hospital managers in Swedish health care (Nylinder 2009).

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An important limitation in this study was difculties of distinguishing between differences in managers perception of tight budgetary control as a consequence of their sex rather than their professional background. Most managers were female (70%) and male nonphysicians were too few in numbers for a statistical analysis of possible differences between male and female non-physicians. However, more male nurses perceived budgetary control to be tight than did male physicians. Nevertheless, nurses perception of tighter budgetary control might in part be explained by a female dominance among nurses. The fact that female physicians perceived budgetary control to be tighter than did male physicians supports such a hypothesis. Furthermore, in health-care services, as in many other organizations, the proportion of men tends to increase in more central positions in the organization while women more often are found in the base of the organizational hierarchy (Lindgren 1992). As physicians have a high status in the health-care organization it can be expected that male physicians in particular are more condent and have a more powerful situation and thereby do not experience the same pressure as others from management control strategies, including budgeting. The hierarchical relation across professional groups as well as physicians resistance towards bureaucratic principles and budgetary control has a long history in health-care services, even though it seems that physicians are gradually accepting the need for resource management (Coombs 1987, Abernethy & Stoelwinder 1990, Lapsley 2001). This study has shown that perception of the budgetary control system correlates with the managers professional background and sex. The impact of these differences on the development of services is uncertain and calls for further research, as nurses and other non-physicians may experience more difculties when trying to inuence services than would managers who are physicians.

Acknowledgements
This study was nancially supported by The Council for Local Government Research and Education (KEFU), Stiftelsen for framjande av ekonomisk forskning, The Swedish Society of Nursing (SSF) and Vinnvard. Thanks for comments from Anders Anell and Gert Paulsson, both at Lund University, the School of Economics and Management.

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