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

Abstract

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 Second Side of the Coin—Resilience, Meaningfulness and Joyful Moments in Home Health Care Workers during the COVID-19 Pandemic

“…The high frequency of mentions indicates that finding ways to deal with challenges is part of the daily working routine in home health care work. An observational study on home health care workers [ 65 ] showed that nurses develop different strategies for organizational challenges and lack of time. Strandas et al [ 63 ] observed that nurses frequently juggle minutes between patients and manipulate the timer that documents the time needed for every visit, as nurses have an exact amount of time that is assigned to every single patient.…”

“…Focus-group participants stated that only a hero or a saint would take this type of job. Home care workers themselves described the fundamental drive behind their efforts not as doing something heroic but as a sense of joy and meaning in doing a good job [ 65 ]. Audio diary entries in this study confirmed this statement, as the feeling of doing something meaningful, fulfilling and good was mentioned as a source of intrinsic reward that can balance the high efforts of care work [ 69 ].…”

“…Home care workers have to work within a tighter schedule than nurses working in residential care [ 46 ]. Frequently, they have to visit five patients within 20 min, including time for transportation and documentation [ 65 ]. Several home health care workers feel bound by the strict time frame [ 65 ], which limits the autonomy of working alone.…”

“…Frequently, they have to visit five patients within 20 min, including time for transportation and documentation [ 65 ]. Several home health care workers feel bound by the strict time frame [ 65 ], which limits the autonomy of working alone. A systematic review [ 75 ] summarized ethical dilemmas in nursing in the following three themes: (1) balancing harm and care, (2) work overload affecting quality and (3) navigating in disagreement.…”

The value of the ethnographic approach to research issues in palliative care

“…In focused ethnography, the researcher uses different techniques to collect data, such as informal conversations, documentary analysis, interviews, and focus groups. Most of the time the researcher can use technology to record specific expressions and other visuals [34,35].…”