Swedish Healthcare Managers and the Media – A Study of Strategies and Support During Mass Media Attention

The activities of Healthcare organizations are attracting an increased amount of public interest, which is why the demand for insight into these organizations is also increasing (Johansson, Dellgran, Höjer, Andersson, Bäck & Bergmark, 2015). At the same time the news media (which will be referred to simply as “the media” in this article) has become an important channel for organizations to use in their desire for increased visibility (Levay & Waks, 2006; Strömbäck, 2004, 2014). These forces combined have led to increased media exposure of the people managing and working in these organizations (Johansson et al., 2015; Norbäck & Targama, 2009). A recent study (Dellve, Wramsten Wilmar, Jacobsson & Ahlborg, 2014) showed that 80 percentage of Swedish Healthcare managers have experience of being a spokesperson for their organization under critical media scrutiny. Fifty-six percent of the studied managers were the spokesperson at least once a month. Hence, meeting the media is an increasingly important managerial task. The purpose of this study is to identify how Healthcare managers interact with the media in terms of what strategies they use and what kind of support they ask for and receive. Managers in Healthcare, such as hospital and municipal Healthcare, have been featured more prominently in public debate. (Johansson, 2004; McKee & Healy, 2002). In recent years one organization model which has had great influence upon the Healthcare sector is New Public Management (NPM), which aims to mimic the private sector based on a desire to increase effectivity and create an organization with a clearer sense of management (Pollit & Bouckaert, 2004; Almqvist, 2006; Berlin & Kastberg, 2011). Johansson et al. (2015) show how NPM increases the use of standardized measuring methods and production standards for assessing efficiency, which replaces the different professions’ quality assessments. This management model emphasises the importance of personal responsibility among Healthcare managers. Skagert, Dellve and Ahlborg (2012) conducted a study that showed that among Healthcare managers 40 percent had resigned from their management position within a four-year period. Similar results were presented in a study performed by Stengård (2013) concerning municipal care services, where 20 percent of the managers had resigned within a two-year period. The reasons behind the managers’ resignations were multifaceted, but the explanations suggested and discussed in both studies were that Healthcare managers seemed to have ORIGINAL ARTICLE

Wramsten Wilmar, M., et al (2017).Swedish Healthcare Managers and the Media -A Study of Strategies and Support During Mass Media Attention.Scandinavian Journal of Work and Organizational Psychology, 2(1): 3, 1-10, DOI: https://doi.org/10.16993/sjwop.18 The activities of Healthcare organizations are attracting an increased amount of public interest, which is why the demand for insight into these organizations is also increasing (Johansson, Dellgran, Höjer, Andersson, Bäck & Bergmark, 2015).At the same time the news media (which will be referred to simply as "the media" in this article) has become an important channel for organizations to use in their desire for increased visibility (Levay & Waks, 2006;Strömbäck, 2004Strömbäck, , 2014)).These forces combined have led to increased media exposure of the people managing and working in these organizations (Johansson et al., 2015;Norbäck & Targama, 2009).A recent study (Dellve, Wramsten Wilmar, Jacobsson & Ahlborg, 2014) showed that 80 percentage of Swedish Healthcare managers have experience of being a spokesperson for their organization under critical media scrutiny.Fifty-six percent of the studied managers were the spokesperson at least once a month.Hence, meeting the media is an increasingly important managerial task.The purpose of this study is to identify how Healthcare managers interact with the media in terms of what strategies they use and what kind of support they ask for and receive.
Managers in Healthcare, such as hospital and municipal Healthcare, have been featured more prominently in public debate.(Johansson, 2004;McKee & Healy, 2002).In recent years one organization model which has had great influence upon the Healthcare sector is New Public Management (NPM), which aims to mimic the private sector based on a desire to increase effectivity and create an organization with a clearer sense of management (Pollit & Bouckaert, 2004;Almqvist, 2006;Berlin & Kastberg, 2011).Johansson et al. (2015) show how NPM increases the use of standardized measuring methods and production standards for assessing efficiency, which replaces the different professions' quality assessments.This management model emphasises the importance of personal responsibility among Healthcare managers.
Skagert, Dellve and Ahlborg (2012) conducted a study that showed that among Healthcare managers 40 percent had resigned from their management position within a four-year period.Similar results were presented in a study performed by Stengård (2013) concerning municipal care services, where 20 percent of the managers had resigned within a two-year period.The reasons behind the managers' resignations were multifaceted, but the explanations suggested and discussed in both studies were that Healthcare managers seemed to have

Swedish Healthcare Managers and the Media -A Study of Strategies and Support During Mass Media Attention
Maria Wramsten Wilmar * , Gunnar Ahlborg † , Lotta Dellve ‡ , Inga Tidefors * and Christian Jacobsson * The aim of this study was to explore how Healthcare managers handle media attention focused on themselves or their organizations and the kind of support they seek and receive at such times.Altogether 40 persons were interviewed, of which 24 were managers with recent experiences of being the focus of mass media attention and 16 were people working with or otherwise familiar with the managers.Thematic analysis was used to extract themes from the data.The results showed that managers used both problem-focused coping such as openness and emotion-focused coping as avoidance of dealing with media representatives.The data implied that earlier experience of meeting the media influenced the coping with media attention, more positive experiences contributed to more openness.The openness strategy could be proactive or reactive, and the avoidance strategy could entail either avoiding information from media or contact with reporters.The managers identified several potential sources of social support that they seek within their organizations.However, receiving support from close actors within the organizations seldom occurred.The main support came from people who were particularly trusted by the managers as information specialists or family members.The findings contribute to an understanding for the complexity of interpersonal behavior and communication.It also makes us aware of the relevance of shared strategies with regard to communication with the media.
inadequate conditions for successful management as well as deficiencies in their psychosocial work environment.According to Skagert, Dellve, Eklöf, Pousette and Ahlborg (2008) and Skagert, Dellve and Ahlborg (2012), the most common perceived stressors among Healthcare managers are the following: unclear expectations, conflicts of legitimacy, conflicts regarding objectives, value conflicts and loneliness.
Wramsten Wilmar, Ahlborg, Jacobsson and Dellve (2014) studied Healthcare managers in negative media focus.The results implied that the degree of personification seems to determine the personal consequences as well as the consequences for their managerial practice.Organizational support for managers appearing in the media would probably be beneficial for both manager and the organization.
The Healthcare organizations desire for visibility and the citizens' interest in activities in these organizations has contributed to the fact that the Healthcare managers nowadays have more interactions with the media than ever before.Interaction with the media seems to be an emergent work environment factor for managers in these organizations.Miller and Cardinal (1994) highlight the importance of strategic planning, especially when the organization is complex and its environment is ambiguous.Healthcare organizations share these characteristics according to Hasenfeld (1992).Healthcare organizations may have strategies with regard to the core business, but do they have plans for how to handle the media?In a study of Healthcare managers and their contacts with the media, Dellve et al. (2014) showed that 20 percent of Healthcare managers knew that their organization had a documented strategy with regard to handling contact with the media.Fifty-one percent said their organization had a strategy, but that it was not documented.One third reported their organization did not have any strategy at all for their meetings with the media.According to Yukl and Kaulio (2011), the central behaviours in effective leadership ensure the protection of the organization's reputation and the maintenance of good relations with external stakeholders.Maintaining good relations with the media is a natural part of a managers' function, but strategies for handling the media seem to vary considerably.One way to manage mass media is simply to avoid them, in some cases however, this strategy has led to managers actually retiring from their positions.An alternative strategy is to do the opposite, and to maintain active contact with the media (Wramsten Wilmar, et al., 2014).

Managers' interaction with the media
Being a spokesperson in relation to the media might be a stressful experience if the manager appraises the situation as a stressor leading to strain.Lazarus and Folkman (1984) suggested two major coping strategies in stressful situations corresponding to the strategies mentioned above; problem-focused and emotion-focused coping strategies.Problem-focused coping is to change the situation itself, in this situation for instance being open and responsive to the media.Emotion-focused coping would be to change the relation to the situation, for instance to withdraw and reflect in order to handle an emotional reaction.As with all aspects of management, earlier experiences contribute to a manager's ability to handle a new situation.Successful experiences tend to give the manager the confidence to handle similar situations effectively.Tolerance for handling high-demand situations increases with positive experiences and develops as a result of the managers increasing ability to interpret situations as less stressful as they become more familiar with them (Yukl & Kaulio, 2011).On the other hand, less successful experiences of being a spokesperson could result in decreased self-confidence and perhaps more stress reactions when meeting the media.
Klijn, van Twist, van der Steen and Jeffares (2016) studied public managers' viewpoints on their relationship with the media, using Q methodology.They found three types of managers with different views on the media; adaptors, communicators and fatalists.The adaptors saw media as a natural phenomenon that has to be taken into account by a manager.Media could be very dominant and intrusive but also be influenced by the managers; however it was hard to predict the media.The communicators saw the media as part of the work as a public manager and the relationship to the media could be steered and partly controlled by the ways of communication.The media could be "played" by for instance communicating strong images.Lastly, the fatalists saw the media as an independent negative force, a disturbing factor.Their strategies were more to wait and let the media attention pass, hoping that tomorrow will be another day.These different viewpoints on the relationship with the media also imply different ways or strategies for handling contact with the media.
The first research question is: In what ways do Healthcare managers handle media attention focused on themselves or their part of the organization?Thylefors (1999) and Wramsten Wilmar et al. (2014) suggested that whenever the managers were surrounded by an organization that regarded the interactions with the media as a joint responsibility, the managers found it much easier to regard the interview with the journalist as an issue on an organizational level.If the responsibility was put on the individual instead, it became harder for the managers not to regard the interactions with the media as a measure of their own competence as managers.

Social support
Two prospective studies compared the importance of different kinds of support in relation to manager endurance on the job.The results showed that the major influencing factors upon the managers' execution of leadership were their attitudes towards their managerial assignment and the support available to them in the workplace (Dellve, Andreasson & Jutengren, 2013).The role of social support as a buffer to stress reactions is well known (Cohen & Wills, 1985).Having colleagues and supporters in times of difficulty helps managers to perceive the situations as less threatening and more controllable compared to having little or no support (Cooper, Cooper & Eaker, 1988).Antecedents of social support include a perceived need from the potential recipient of support plus a social network and a climate that are conducive to the exchange of social support (Finfgeld-Connett, 2005).Since most Swedish human service managers are part of one or two management teams -the team they are leading themselves and the team their manager leads -the management team(s) might play an important role in supporting the manager who is in the media spotlight.An internal team environment consistent of shared purpose, social support and voice has also been found to be important precursors to shared leadership in teams (Carson, Tesluk & Marrone, 2007).Further, shared leadership in teams have been found to contribute to higher performance than vertical leadership in many cases (Wang, Waldman & Zhang, 2014).Choi, Sung & Kim (2010) and Kobasa & Puccetti (1983) found that support from higher-level managers played a key role in overcoming major challenges.However, Arman, Wikström & Dellve (2009) pointed out that Healthcare managers spend a relatively small amount of time with their own senior managers.Several studies also show that Healthcare managers often refrain from seeking assistance and support because of a fear that this may have a negative impact on their career development (Tengelin, Kihlman, Eklöf & Dellve, 2011).Managers instead tend to choose to receive support from sources outside of the workplace, eg.mentors, colleagues from other organizations, family or friends, whereas support from their senior managers or co-workers is often lacking (Dellve, Wikström & Ahlborg, 2006;Dellve & Wikström 2009).The more support available, the lower the levels of stress experienced.Appraisal support, which may be given in the form of mentoring, has shown itself to have a good effect by contributing to strengthening the managers' self-confidence (Sandahl, Falkenström & von Knorring., 2010).
The second research question is: From whom do Healthcare managers seek social support when they are in contact with the media and from whom do they receive support?

Method
The study was based on interviews with managers, superior managers, colleagues, partners, or information/human resource (HR) professionals with the attempt to bridge a gap in the research on how the media focus might influence managers, how they cope with the situation, and in what way they ask for and receive social support.

Participants and procedure
After approval from the regional ethical review board, managers in municipal and hospital Healthcare were selected for the study primarily by asking top HR managers in such organizations in different areas of Sweden.The HR managers were informed about the study through a national network for HR managers, and they were asked to suggest managers who had undergone a period of intense media attention within the last three years.The inclusion criterion was that the participants had been spokespersons in relation to media in cases such as organizational changes or withdrawals.Cases where the media attention was due to personal mistakes, criminal or suspicious activities by the participants were excluded.The HR managers first asked managers if they were interested in participating in the study, and all who were contacted agreed.The final inclusion criteria were that the managers had been exposed by name in media and that they identified themselves as having been the focus of media attention.After the selection procedure, 24 individuals in top-or middle-management positions in Healthcare organizations were included.Twelve of the interviewed managers worked in hospital Healthcare organizations, and twelve managers worked in municipal Healthcare.The managers were also asked if it was possible to interview their superior, a colleague or an important relative.This was done in order to ensure a full-bodied description of managers and their management teams.Altogether 40 persons were then interviewed, of which 24 where managers who had been under media scrutiny and 16 were subordinates, friends or others familiar with the managers (Table 1).The participants were Healthcare managers working in organizations from all over Sweden.
Managers were asked Open-ended questions, allowing them to describe in their own words the procedures and strategies they used in their roles as Healthcare managers when under media focus.All interviews with the managers started with the same information about the study objective and the initial open question "Have you experienced what it's like to be the focus of the media?If so, were you personally in focus and what's your experience from it?" For the purpose of the present study we investigated the following areas: • the situation when the manager was in the media spotlight (the event and his/her way of handling media attention) • relations and experience of supportive communication whilst under pressure during this situation • reactions and actions from the management group • family reactions and involvement • training to prepare to deal with the media Interviews with the managers lasted between one and two hours.All interviews were transcribed verbatim.

Analysis
Our point of departure was a qualitative approach, according to a thematic analysis which can be described as data driven or bottom up (Braun & Clarke, 2006).The transcripts were first read and reread by two of the authors.As a first step, comments specifically describing strategies and support were selected for coding.Only those parts of the transcripts that dealt with these topics were analyzed.The data set was coded separately by the authors, without trying to fit data into a preexisting framework.Ideas concerning a possible structure of the data were noted.These ideas were discussed and used in the coding process.Codes were organized into two themes concerning different strategies to handle media and strategies to take care of one self.All data extracts were discussed in relation to the main themes.Subthemes were created to give structure to the material and finally the data extracts were reviewed to find the quotes that best represented the essence of each theme and subtheme.

Findings
The managers in this study used various strategies to handle their contacts with the media, and individual managers shifted from one strategy to another at different times.
Past interaction with the media seemed to have a considerable impact on how managers handled media contact in the situation under consideration.In the thematic analysis, two main themes, each with two subthemes emerged.
The themes and subthemes are shown below.
• Strategies to handle the media To give some context, each quote is marked with gender and function.

Strategies to handle the media
In this theme, related to the first research question, focus was on the different strategies that participants used when the media became interested in their work areas.
A majority talked about the good in being open whereas others reflected about situations leading forward to avoiding the media.Meeting representatives of the media was defined as a natural part of their work and the participants talked about their interaction with the media in a way that could be categorized as both being reactive or proactive.
Openness.The degree of openness a manager demonstrated towards the media seemed to be an effect of support and experience.Open, in a reactive sense, entails both accepting direct contact with the media representatives and providing requested information for press articles, television news, and reports on the Internet.
Managers described how becoming more open towards the media helped them to develop trusting relationships and allowed them to feel comfortable reporting both good news and bad.These managers had learnt that it was necessary to be as transparent as possible to avoid antagonizing media representatives or giving the impression of evasiveness or dishonesty.
"I realized that this must come to an end as fast as possible . . .I did not want any more articles . . .I decided to ensure that the whole story was told at once . . .not to hide anything . . .It proved to be successful . .." (male manager) Some managers with experience of being at the centre of media attention described the importance of going beyond reactive cooperation with the media, adopting a proactive stance incorporating networking and strategizing within the organization.Some managers with previous negative experiences did not believe in the usefulness of proactive work, but those who had had better experiences, or who had been part of their colleagues' positive experiences with being proactive, pointed out the importance of this approach.
"I try to contact the media when we have something positive to say.Usually they are not that interested in reporting about the good stuff, but we keep telling them about it . .." (male manager) Proactive managers differ from reactive managers by initiating contact with media representatives, for example, when there was good news to share, rather than waiting for and reacting to questions as they arise.Another proactive strategy was the use of presentations (e.g., PowerPoint slides) during press conferences, which require journalists to focus on the slides and not the manager presenting them.A few managers described difficulties in preparing for and being open in their meetings with the media.They felt they needed a different way of preparation for interviews on TV or in a newspaper.
"The media react to each other . . .newspapers start and radio reacts to the papers . . .so it escalates . . .if radio is talking about it, TV might . . .It's like escalation steps . . .but it gives me a chance to prepare to handle the media . . ." (male manager) Avoidance.Avoidance could both be about avoiding information from the media or contact with the journalists.The participants described that the media tend to highlight the individual managers more than the organizations.As a consequence, some managers tended to avoid contact with media instead of confronting them.Managers who felt alone in the situation were more likely to try to hide from media than managers who felt supported.Avoidance tended to occur in stressful situations when the managers did not know what else to do.This behaviour could be categorized as avoiding information from media and/or avoiding contact with the media.Some managers described themselves, or were described by others, as trying to hide from media attention, but none of them found that strategy constructive.
Managers described how they stopped reading newspapers containing reports about their work.

"I stopped my newspaper . . . I did not want it any longer . . ." (male manager)
In some cases they described how they asked someone else to read the newspaper before they would open it themselves, but mostly they no longer read it at all.Managers whose name and picture had been published commonly tried to avoid being seen in the community where they worked and where the citizens could recognize them and react negatively.

." (female manager)
Managers who were new to their positions were the most likely to describe wanting to avoid any contact with the media.Managers who had had no media training were especially likely to wish to avoid media contact.The main reason they talked about was being afraid of being misquoted.Most managers with both experience and training in dealing with media did not avoid them in this way, even though many would rather not deal with the media at all if they had the choice.

"I thought, what is the best way to meet the media this time . . . ? I tried to find an instructive way by getting all the facts . . . I gave those to the journalist . . . but it was meaningless . . . the journalist wrote something else . . . so I was still guilty." (male manager)
To summarize, the importance of earlier experience of the media was often highlighted.If the managers had a good experience of meeting the media they were more open than if they had a more traumatic earlier experience.Most managers expressed that meeting the media was a delicate part of their work.

Strategies for self protection
In this theme, related to the second research question, the focus was on the need to protect oneself from the media attention since this was a part of their job that they naturally had to cope with on their own.They thought that asking for help or showing vulnerability in their dealings with the media might be seen as a sign of weakness.However, beneath different statements a wish for support was present.Initiatives to support the manager seemed to be limited and in some cases non-existent.When expectations of support from the organization were not fulfilled, the managers described feelings of insecurity and uncertainty about what kind of support they could expect in the future.
Endless seeking.Superior managers were described as potential sources of support, but in most cases they did not fulfil that function.One reason for this, explained by the managers themselves, was that they thought the superior managers did not want to undermine their subordinate's authority.Another reason was that they believed the managers could handle the situation themselves.Some participants stressed that superior managers who had had a similar experience with the media did not tend to be more helpful.

"I did ask my superior for support, but I did not get any. I was surprised because he has had the same experience . . ." (male manager)
Managers also described how they tried to seek support from their own management team during meetings, but felt that they did not get any.Their superior managers explained that they did not have time to help during their management meetings, and they could not prioritize the matter.
"I tried to get support from my colleagues during our meetings, but my superior manager said that we did not have time for the matter . .

." (female manager)
The participants talked about the same experiences concerning colleagues; they did not expect support from them, and so they did not ask for it.The reason for this could be earlier bad experience or a conviction that it was their own responsibility.

"I do not expect any support from my colleagues in my management group. . ." (male manager)
Another manager described how colleagues sometimes asked in the hallway about the situation, but there were no questions in more formal meetings.

"My colleagues asked me if I was okay in the corridor, but never in a meeting when my other colleagues were present . . ." (male manager)
The managers described the management teams more as collections of individuals than as cohesive teams.The media attention tended to split the group more than to unify it.

"This is a single-person organization . . . we say that we should act as a group and support each other, but we don't . . ." (female manager)
The participants gave also examples about others experiences of lack of support.One example was given from a female participant about her husband.She told about a situation where her husband met a colleague in a corridor and how this manager colleague just turned around and walked away when seeing her husband.
"I noticed that no one called on the phone, no one contacted him . ..No one asked how he felt . ..someone walked towards him in the corridor, but turned around and walked the other way."(wife of a male manager) Sometimes finding.Managers who had support during media exposure seemed to interact with the media more openly and more reactively than managers who did not get the support they needed.Some managers knew of colleagues, who had been in the same situation in the past, and whose support would benefit them; however, those colleagues with more media experience most often wanted to avoid any association with the new case, not wanting to attract any more media attention to themselves.
Instead of seeking support within the organization, a few managers handled their need for support by contacting professional therapists in private." . . .I found a therapist on my own . . .She helped me to see the situation in a more constructive way . .

." (male manager)
The role of the information and HR specialist in this context was unclear to the managers.In some cases the specialists themselves did also see their role as unclear and confusing in this context.

"We were like a telephone exchange…The media called and told us who they wanted to talk to…Then we got hold of the telephone number and provided them with the contact information." (female information specialist)
In organizations that had a media strategy, the roles were easier to identify.When the specialist was involved, the managers felt much more confident.
"We decided not to let me answer the questions . . .my superior and colleagues answered together with the communications manager . . .As a result, the media dropped the case . .

." (female manager)
One solution to compensate for the lack of support was to turn to people they felt safe with, with no regard to if these persons belonged to the organization or in what position they were.It could be a secretary or a friend since the most important was to feel safe with the person they talked to.

"I do just talk to a few. I'm not sure what kind of reaction I would get if I asked my colleagues for support . . ." (male manager)
Most of the trusted people did not work within the organization but were part of their social network, for example a friend, a distant colleague, or a family member.They took the role of good listener, adviser, or leadership coach.

"I talked to my husband . . . he has had the same experience . . ." (female manager)
Altogether, among the 24 interviewed managers there were few participants who reported that they asked for and received support.In the cases where the managers received support the most common sources were information specialists or family members.Many managers had an expectation that they would be supported by their superior managers, however these expectations were seldom met.

Managers' strategies to handle the media
The study showed two subthemes with regard to the main theme: strategies to handle the media, openness and avoidance.The subtheme openness could be reactive or proactive, and avoidance appeared as avoiding information from the media and/or avoiding contact with the media.Managers' experiences of success or failure in their dealings with the media influenced their degree of openness.The influential experiences, however, did not have to be the manager's own and could include vicarious experiences of a friend, colleague, or superior manager who successfully handled the media.
Appreciation of the value of being open towards the media, in both reactive and proactive ways, was widespread among the interviewed managers.Answering directly when telephoned by a reporter was classified as reactive, while inviting the reporter to a meeting and preparing for that meeting was categorized as proactive openness.Another proactive strategy was keeping the media informed about events -both positive and negative -as they occurred and striving to develop good relations with the journalists who were reporting about the organization.This kind of interaction can be compared with Lazarus and Folkman' (1984) problem focused coping strategy, addressing the problem or stress-evoking event itself.It can to some extent also be compared with the findings of Klijn et al. (2016), managers who viewed themselves as "communicators".This is especially true of the managers' who prepare their messages and really arrange their meetings with the media.The interviewed managers saw contact with the media as a central and natural part of their function, regardless of having a strategy for this or not.In that way, most managers' were "adapters" according to Klijn et al. (2016).They were adapting to a situation where both citizens and the media expect openness from the Healthcare organizations.
Another way to manage the media was to avoid them, which can be compared with Lazarus and Folkman' (1984) emotion-focused coping strategy in general or more specific avoidance coping strategy (e.g.Roth & Cohen, 1986).There were participants who tried to change their relation to the situation or in some cases more specific to avoid it.Avoidance might also correspond to the manager viewpoint "fatalists", suggested by Klijn et al. (2016), i.e. seeing the media as an independent negative force and maybe hoping that they will lose their interest in the matter soon.None of the more experienced managers interviewed saw avoidance coping as a successful way to handle the media.Their experiences was that avoiding media contact only made their situation worse, by making reporters more determined to pursue them.Managers who did not have experience with handling media contact successfully tended to avoid information from the media by not reading the newspapers or watching television news programmes in which their names might be mentioned.
Similarly, some managers tried to hide from reporters and otherwise avoid media contact.In some cases managers felt so powerless against a reporter's aggressive pursuit of them that they considered leaving their position in the organization.Such avoidance is a consequence of the ways media reporters chase a story, as noted in earlier research (Wramsten Wilmar et al, 2014;Runsjö & Nilsson, 2009).Avoidance coping is a basic reaction to stressful and anxiety-provoking events (e.g.Roth & Cohen, 1986) such as being in the media spotlight.Being a manager in a human service organization is stressful work in general, and high levels of turnover among managers have been noted in earlier research (Skagert, 2010).

Managers' strategies for self protection
Since most of the managers did not expect much support, they tried to handle both their contacts with the media and their own reactions to the situation by themselves.However, they identified several potential sources for support as a strategy for self protection.Choi et al. (2010) concluded in an empirical study on how groups reacted to unexpected threats that support from the superior manager played a key role in the organizations' ability to overcome crises.However, according to Dellve et al. (2013) and Arman et al. (2009) support from superior managers is often lacking managers.In the present study, managers were identified as a potential source of support, but they seldom fulfilled that function for the managers interviewed.The main reason for this seemed to be that the higher managers did not understand the importance of themselves playing an active role when their organization was under media scrutiny, by meeting media representatives together with the manager in question, for instance, or by taking over contact with the media.As Stazyk and Goerdel (2011) showed, support in managerial work is important, the superior manager in the study could thus play a considerable role in directing the media's focus from the manager as a person to the organization as a whole.Another person within the organization who might be helpful in keeping the focus on the organization is the information specialist.As shown by the results of this study, an active specialist helped a manager to keep an organizational perspective.However, the results also pointed to cases in which the manager did not know that the information specialists existed or what kind of expertise they could offer.
Researchers have described a mature group as one that has a team climate of openness, support, and cohesion, and task-oriented members who have clear roles and goals (Wheelan, 2005).The opposite, immature groups, fail to be open, supportive, and adaptive to the situation (Wheelan, 2005).In the present study, it seems that organizations with managers who adopted a stance of media avoidance failed to act as mature groups, and those managers did not expect any support from their colleagues.On the contrary, in those organizations the colleagues in the management team where the interviewed managers' were members' showed clear signs of withdrawal, protecting their own best interests and being afraid of themselves becoming the object of media focus.Maybe this could have been different if the organizations as a proactive action had a common and documented strategy for meetings with the media?A strategy that also included what kind of support the focal managers should get.
The results of the present study suggest that the main sources of support were from people other than superior managers, management group members, managerial colleagues, or specialists.In fact, the people offering the most support were either in distant positions within the organization or outside of the organization altogether.For instance, an important supporter might be an administrator from another department or a close friend from outside the organization.The thing they had in common was that they were trusted by the manager dealing with the media attention.One conclusion that can be drawn from this study is that because managers did not feel they were supported by people close to their position or function at work, their organizations lost control over the managers' handling of the media attention.It might be better for an organization if it could influence media relations more fully.Another conclusion is that a closer involvement with the organization would probably also minimize the feeling of loneliness that the managers described in the interviews.Since it seems like Healthcare managers meetings with the media are increasing (Wramsten Wilmar et al., 2014) it has become an emergent work environment factor.More knowledge about Healthcare managers' interaction with the media would probably increase sustainability of these managers.
Both parties, the manager and the management team, would probably gain from handling the media and following a media strategy together.The feeling of control would most likely increase for both parties.

Method discussion
Our point of departure was a qualitative approach, thematic analysis, to identify the themes in the textual data through a systematic classification process of coding and identifying themes or subthemes (Braun & Clarke, 2006).Finding the themes and subthemes can be complicated, and the results must be interpreted cautiously.One of the inclusion criteria for this study was that the managers had been personally exposed by name in media reports and had not done something illegal.Also, managers who had been in the media spotlight but had not felt focused upon personally were not included in the study.Therefore the question of whether or not they experienced similar processes hasn't been investigated.Furthermore, the small sample used in a qualitative approach might be a source of error in drawing conclusions; however, only a limited number of managers in Healthcare organizations have been in the media spotlight, and therefore the sample would be small in any study design.Lastly, with regard to validity, the themes are the result of three researchers' finding agreement and the themes were checked through member checking (Creswell, 2014) in seminars with respondents and other Healthcare managers.

Suggestions for future research
A study based on data from a larger sample would be valuable to support the results.More qualitative studies would make it possibilities to investigate whether the themes in this study is possible to replicate or further elaborate.A quantitative study would add support for generalizability.Future studies might also focus on people around the managers and their reactions and feelings.Individuals who work in the organizations in focus may react in similar ways even if they are not the direct subjects of media attention.It would also be interesting to compare different levels of personalization in intra-organizational relations and communications between different management levels and professional groups, and how those levels of personalization might explain negative media attention that focuses on particular characteristics of either the manager or the organization.

Practical implications
The results of this study, even though based on a small population, may contribute to improved understanding of how managers in Healthcare organizations handle the media and what kind of support they ask for and receive.The study might contribute to more proactive work with better strategies at the individual and organizational levels.Such improvements could decrease the risk of personalization of individual managers in media.

Conclusion
The ways managers in this study handled media attention varied.Most of the more experienced managers tried to be as open to the media as they could, both reactively and proactively.A few tried to avoid exposure to media information and contact with the media, but none found this strategy successful in handling the situation.Since most of the managers thought that contact with media was a natural and expected part of their function, the managers did not seek support within their organizations.There seemed to be no connection between the managers' positions and their sources of support, and the position of the supporter seemed to be secondary.Although some support came from within the organization and some from outside it, all support came from people the managers trusted.This finding suggests that the organization has little control over the managers' handling of media relations.Increased support, through a documented common strategy within the organization, would probably be better both for managers and for their organizations.

Funding Information
We are grateful for financial support from AFA Insurance (an organization owned by Swedish labour market parties).

"
I do not go to the centre of this town where I'm working . . .Everybody knows me and has an opinion . . .I'm happy I live in another town . .

Table 1 :
Study sample.Figures refer to number of interviewed persons.