The results of the study show that many District Medical Officers feel invisible and that their role is poorly defined. Organisational contexts, personal qualities and competence, and managerial follow-up and expectations were the primary influencing factors. The analysis also demonstrated a basic tension between two different identities that are both needed for the role of District Medical Officer: a clinical identity and a public health identity. In combination with the other factors, this impacted on their perception of the role. This is consistent with research on hybrid professions (7–11). Most doctors have a strong clinical identity (7, 12). In the role of District Medical Officer, this clinical identity is especially appropriate for providing clinical advice in individual cases in the health service, and this requires clinical competence, authority, and visibility on the primary care level. The public health identity on the other hand, focuses on the population and is appropriate for providing advice on a general level. This requires public health competence, authority, and executive visibility. Although there is a sliding scale between the two identities, it can be maintained, in simple terms, that they need different terms of reference and are intended to deal with different tasks.
Our own study is consistent with other studies (7) in that it identifies certain practitioners as hybrid professionals who can change between identities without adversely affecting their role perception and performance. According to our results, this is an experience reported by District Medical Officers from small municipalities. In their case, it was their contracted working hours that restricted their role performance and identity development. However, we found that the larger the municipal organisation, the larger the gap between the two identities, and this had an adverse effect on the balance and the role performance.
Several District Medical Officers in large municipalities listed organisational contexts and managerial expectations as factors that obstruct their access to high-level public health work and work in other municipal sectors. This had a restrictive effect on their development of a public health identity and heightened their sense of being invisible and increased their role uncertainty. The results suggest that outside the health sector, municipal executives fail to recognise the relevance of public health competence, which is why they fail to seek this expertise to the same extent that the health sector does. Various organisation and management theories support our findings as they assert that organisational contexts will influence an individual's motivation, sense of mastery and role appreciation (14–16). This is supported by studies such as Berg et al. 2017 (12).
Studies on hybridity show that an emphasis on clinical identity may delay the development of an administrative identity, thereby adversely affecting role performance (7), (10–12). Various motivational theories show that we are attracted to tasks that engage our skillset and give us a sense of mastery (7, 10). Local authorities should therefore seek to prioritise the development of a public health identity for the role of District Medical Officer, to enhance role performance. This will require organisational contexts and expectations to encourage public health work efforts on a variety of levels in different municipal sectors. If the contexts primarily promote the clinical identity, this may obstruct the development of a public health identity, heighten the sense of being invisible and increase role uncertainty. Figure 1 shows the relationship between the basic identities, the influencing factors and role perception.
The study suggests that District Medical Officers need their public health identity to accord with the three influencing factors in order for their sense of invisibility and role uncertainty to be reduced and their identity developed. This is particularly the case in large municipalities, where such adjustments may come at a cost to clinical advice in individual cases. In small municipalities, it appears that contracted working hours is the factor with the greatest influence on the District Medical Officers' perception of their own role.
In order to limit the effect of the first author's bias, the second author was actively involved throughout the process. The first author's background and experience of working as a District Medical Officer made it easier to make participants feel at ease within the focus groups, encourage openness and ask follow-up questions and further examine statements. The focus group interviews were conducted in person. This meant that all informants were from southern Norway, but there was variety in respect of geography, size of municipalities, years of experience, sex, FTE of contracted working hours, and seniority within the municipality. All the informants were able to report extensively on the problems raised and provide nuanced details. Focus group participants were observed to talk freely and frankly, and they engaged in productive dialogue. The first author conducted the focus group interviews alone, which may have resulted in loss of some nuances.
The study examines the perceptions that a sample of District Medical Officers have of their own role, and the results cannot be generalised to encompass all District Medical Officers in Norway. Nevertheless, the information richness of the sample was considered to be good, despite the relatively limited number of participants. It is therefore likely that the findings are relevant and applicable to other District Medical Officers in Norway. Some of our findings, especially the role uncertainty observations, are reflected in other studies (7), (10–12). This strengthens the validity of our findings. However, the study examines perceptions that District Medical Officers have of their own role. The experiences and thoughts that municipal executives may have in respect of the District Medical Officer role have not been examined, and neither have any measures that may have been implemented to ensure good role performance. This could have brought extra depth to the material. The study was conducted immediately before the COVID-19 pandemic and gives an insight into how some District Medical Officers in southern Norway saw their own role at the time when the pandemic struck. There has been significant pressure, but also increased focus, on the District Medical Officer role during the pandemic, and it would be interesting to conduct a post-pandemic follow-up study to explore whether, and if so how, this has altered perceptions of the role.