Acting between guidelines and reality- an interview study exploring the strategies of first line managers in patient safety work.

Background: Safety culture can be described and understood through its manifestations in the organization as artefacts, espoused values and basic underlying assumptions and is strongly related to leadership-yet it remains elusive as a concept. Even if the literature points to leadership as an important factor for creating and sustaining a mature safety culture, little is known about how the safety work of first line managers' is done and how they balance the different and often conflicting organizational goals in everyday practice. The purpose of this study was to explore how health care first line managers perceive their role and how they promote patient safety and patient safety culture in their units.

Methods: Interview study with first line managers in intensive care units in eight different hospitals located in the middle of Sweden. An inductive qualitative content analysis approach was used, this was then followed by a deductive analysis of the strategies informed by constructs from High reliability organizations.

Results: We present how first line managers view their role in patient safety and exemplify concrete strategies by which managers promote patient safety in everyday work.

Conclusions: Our study shows the central role of front-line managers in organizing for safe care and creating a culture for patient safety. Although promoted widely in Swedish healthcare at the time for the interviews, the HSOPSC was not mentioned by the managers as a central source of information on the unit's safety culture.