Framing the pandemic: Multiplying "crises" in Dutch healthcare governance during the emerging COVID-19 pandemic.

In this paper we explore the impact of the emerging COVID-19 pandemic on the governance of healthcare in the Netherlands. In doing so, we re-examine the idea that a crisis necessarily leads to processes of transition and change by focusing on crisis as a specific language of organizing collective action instead. Framing a situation as a crisis of a particular kind allows for specific problem definitions, concurrent solutions and the inclusion and exclusion of stakeholders. Using this perspective, we examine the dynamics and institutional tensions involved in governing healthcare during the pandemic. We make use of multi-sited ethnographic research into the Dutch healthcare crisis organization as it responded to the COVID-19 pandemic, focusing on decision-making at the regional level. We tracked our participants through successive waves of the pandemic between March 2020 and August 2021 and identified three dominant framings of the pandemic-as-crisis: a crisis of scarcity, a crisis of postponed care and a crisis of acute care coordination. In this paper, we discuss the implications of these framings in terms of the institutional tensions that arose in governing healthcare during the pandemic: between centralized, top-down crisis management and local, bottom-up work; between informal and formal work; and between existing institutional logics.

Mediating scarcity in pandemic times: an ethnographic study on the prevention and control of SARS-CoV-2 infections during the emergence of the corona crisis in the Netherlands.

BACKGROUND: In this paper we explore how staff involved with infection prevention managed the emerging COVID-19 crisis in the context of scarcity of Personal Protective Equipment (PPE), focussing specifically on the (re)writing of guidelines. We conceptualize guidelines as 'mediating devices' as they translate between evidence and clinical practice, between management and the workplace, as well as the different values embedded in these domains. It is this mediation, we argue, that adds to the resilience of healthcare organizations. The setting for this research is an elite academic hospital in the Netherlands during the emergence of the COVID-19 pandemic. METHODS: We conducted non-participative observations, semi-structured interviews, and document analysis during the emerging pandemic (March-July 2020). We observed meetings from the crisis team and the unit for infection prevention (210 hours), interviewed members of these teams (21 interviews) and analysed guidelines and flowcharts concerning infection prevention, as such collecting a unique and rich qualitative dataset. Analysis was done through thematic coding. RESULTS: Our results show the writing and rewriting of guidelines as a fundamental characteristic of dealing with scarcity and adding to resilience. We found three main practices our research participants engage in while trying to manage the uncertain situations emerging from the scarcity of personal protection equipment. The first practice we observe is defining safety; dealing with different perspectives and experiences of what 'working safely' means. The second entails the anticipation of scarcity by which our participants aim to control the situation through monitoring, research and creating scenarios. The third practice we observe is finding new ways to use PPE that is available, by experimenting and tinkering with the material. CONCLUSION: Infection prevention guidelines are crucial in managing the emerging crisis. We discuss how the writing of guidelines mediates between different settings, timeframes, and different worlds of quality. Through (re)writing there is a constant negotiation and discussion with the various actors about what works, and there is a continuous adaptive attitude. At the cost of a lot of work and struggle, this creates a resilient and inclusive work environment useful in a long-lasting crisis.

Layering risk work amidst an emerging crisis: an ethnographic study on the governance of the COVID-19 pandemic in a university hospital in the Netherlands.

The start of the COVID-19 pandemic early 2020 has confronted healthcare sectors with risks and uncertainties on an unprecedented scale in recent history. Healthcare organisations faced acute problems, the answers to which had to be provided, and recalibrated, at short notice and informally. University hospitals played a pivotal role in providing these answers and in (re)calibrating institutional arrangements. Based on ethnographic research in an elite university hospital in the Netherlands, in this article we explore the concrete practices of governing risks and uncertainties that COVID-19 posed for the organisation of healthcare. Our fieldwork consisted of the observation of meetings at the level of the hospital boards, the staff, and the regional level. We collected relevant documents and interviewed key-actors. This approach offers us a large dataset on acute risk governance 'from within' and allows us to offer a layered ethnographic account of managerial practices. In our analysis we focus on conceptualising the work-as-done in the university hospital as risk work. We show how the risk work of our participants is generally characterised by high speed and delineated by scarcities. We differentiate between three modes of risk work: working on numbers, working on expertise and working on logistics. This risk work appears innovative, but our analysis stresses how participants' work happened in interaction with traditional institutional logics and routines.