Gaming the system to care for patients: a focused ethnography in Norwegian public home care.

BACKGROUND: With its emphasis on cost-reduction and external management, New Public Management emerged as the dominant healthcare policy in many Western countries. The ability to provide comprehensive and customized patient-care is challenged by the formalized, task-oriented organization of home-care services. The aim of this study is to gain deeper understanding of how nurses and the patients they care for, relate to and deal with the organizational systems they are subjected to in Norwegian home care. METHODS: The focused ethnographic design is based on Roper and Shapira's framework. Data collection consisted of participant observation with field notes and semi-structured interviews with ten nurses and eight patients from six home care areas located in two Norwegian municipalities. RESULTS: Findings indicate cultural patterns regarding nurses' somewhat disobedient behaviors and manipulations of the organizational systems that they perceive to be based on economic as opposed to caring values. Rigid organization makes it difficult to deviate from predefined tasks and adapt nursing to patients changing needs, and manipulating the system creates some ability to tailor nursing care. The nurses' actions are founded on assumptions regarding what aspects of nursing are most important and essential to enhance patients' health and ensure wellbeing - individualized care, nurse-patient relationships and caring - which they perceive to be devalued by New Public Management organization. Findings show that patients share nurses' perceptions of what constitute high quality nursing, and they adjust their behavior to ease nurses' work, and avoid placing demands on nurses. Findings were categorized into three main areas: "Rigid organizational systems complicating nursing care at the expense of caring for patients", "Having the patient's health and wellbeing at heart" and "Compensating for a flawed system". CONCLUSIONS: Our findings indicate that, in many ways, the organizational system hampers provision of high-quality nursing, and that comprehensive care is provided in spite of - not because of - the system. The observed practices of nurses and patients are interpreted as ways of "gaming the system" for caring purposes, in order to ensure the best possible care for patients.

The nurse-patient relationship in the New Public Management era, in public home care: A focused ethnography.

AIM: The aim of this study was to gain deeper understandings of nurse-patient relationships in the New Public Management era, by exploring beliefs and practices of nurses and patients in Norwegian public home care. BACKGROUND: Organization of Norwegian home care services is based on New Public Management-ideologies, which have led to a rigidly formalized and task-oriented nursing practice that may jeopardize individual nursing care. Nurse-patient relationships have several positive effects on patients' health and well-being, but organizational boundaries and time pressure affect the quality of relationships. DESIGN: Focused ethnography. METHODS: Data were collected between November 2015-July 2016 using participant observation and semi-structured interviews with 10 nurses and eight patients in six different home care areas, in two Norwegian municipalities. Data analysis was based on Roper and Shapiras framework. FINDINGS: Findings demonstrate the continued importance of nurse-patient relationships in contemporary home care, while identifying extensive variations in the degree of closeness and emotional involvement. Organizational boundaries, time constraints, high workload, and disharmony between nurses "competence and patients" complex illnesses, influence practice in ways that reduce the significance of nurse-patient relationships and affect conditions under which they develop and evolve. Facing a system nurses perceive to function suboptimal, they govern practices based on their own professional assessments, and findings indicate cultural patterns in the way both nurses and patients prioritize to safeguard nurse-patient relationships. CONCLUSION: Home care cultures based on traditional nursing values continue, despite New Public Management influences, but a transition into New Public Management culture may, over time, influence the quality of nurse-patient relationships and meanings attributed to them.

Collaboration, professional identity and reflection across boundaries.

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.