The purpose of this study was to contribute to increased knowledge of how issues of competence development are handled in practice in organisations, what strategies are developed and how these strategies are shaped by different internal and external conditions.

The theoretical frame of reference has two foci. First, an overview and analysis of theory and research on professional organisations is presented. The type of organisation with which the health services and medical care are associated. Second, three theoretical perspectives on the development of strategies for competence development are outlined. A rational management perspective focusing on management rationally formulated strategies, requirement analyses and rational decision making. A conflict perspective where the keywords are power, negotiation, interests and ideologies and a cultural-institutional perspective where the emphasis is on the importance of the context for the choices made by actors or groups within the organisation.

Several groups of actors on different levels in health services and medical care have taken part in the investigation. First, the policy level is studied via interviews with central actors in the county council (n=17). Second, the department management level is studied through a questionnaire study with all the department management's in the county council (n=85). Third, the level of activities is studied through case studies of four care units; the Health Centre, Rehab, the Medical Department and Anaesthesia. The case descriptions are based on the results from the questionnaire and interview studies in which the employees took part. A total of 207 people took part in the questionnaire study and 39 in the interview study. In addition, an interview study was carried out with representatives of the department management of the respective care unit (n=8). The study thus has a combined survey and multiple case study design.

There are at least five main findings. First, the care units were found to have different strategies for competence development. The similarities between the care units' strategies seem to be dependent mostly on the medical educational culture that predominates within health services and medical care. The differences seem to depend partly on the degree of external pressure that is experienced by the department management's, partly on the relative power of different occupational groups within the care units. Second, planned formal training has mostly a medical/technical content. Informal learning is supposed to meet the need of other competence demands. Third, a general pattern is that doctors together with paraprofessionals appear to have the relatively best possibilities of learning and development in their work. Fourth, the central actors have a vague and uncertain opinion as to how competence issues are handled in practice. Fifth, care units that have a so called integrated strategy for competence development and a non-Tayloristic division of labour seem to handle personnel cutbacks in a better way than what other care units do.