Organizing to reform: The social aspects of organizational change in a Danish hospital department.

The Danish healthcare reform from 2007 aims at a considerable structural change of the hospital sector to provide a framework for the better organization of clinical work. Integrated Emergency Departments (IEDs) work as central admission units in the new acute care hospitals. They have been established as spearheads in a sweeping reorganization of clinical work, which is perceived as lagging behind in terms of the integration, coordination, quality, and efficiency of the care pathways.
In the context of an IED (termed department E), I investigate how ideas concerned with the generation of better, safer, and more efficient hospital services materialize as tools for organizational improvement in nursing to solve what are perceived as problems of organizational performance. The following research question has guided my work:
How do ideas concerned with the generation of better, safer, and more efficient hospital services materialize as tools for organizational improvement? How do these tools influence nursing in the IED and how do the nurses respond to them?
A Bourdieusian ethnographic multilevel approach is applied to capture the dialectic between the experience of the organizational tools on the hospital shop floor and factors that structure work and organizational life. My analyses focus on standardization and merger as organizational improvement tools in the department, and I examine their genesis as well as the way they influence practice.
The thesis shows that the attempts to create better and more secure hospital services are engendered by a new national and international political agenda in which nations are seen to compete on their ability to create economic growth, and institutional reforms are seen as instruments to achieve such goals. The healthcare reform is thus enveloped in a landscape of public sector reforms in Denmark, in which more should be accomplished for less. Given this atmosphere, a new focus on the performativity of clinical practice is increasingly linked with the modes of knowledge informing it. Perceived as better and safer, medical evidence blends into to the reform agenda, and this mode of knowledge has achieved a position as the dominant and most legitimate in the healthcare field. These factors are primary in explaining the direction of the transformations and associated tools for organizational improvement I have studied.
The nurses in department E find themselves in a situation in which traditional roles and hierarchies are challenged, and work practices are subjected to revisions, standardization, and monitoring to accommodate the demands of accountability and quality and safety improvements. Despite the historical battles of the nursing profession for status and independence from medicine, nursing standardization is predominantly based on medical evidence. The thesis suggests that this apparent paradox should be understood in the light of the reform pressure, but also in the light of the nursing professionalization battles in which a professionalization strategy is to accept and adopt medical evidence.
The thesis comprises three articles, one book chapter, and a supporting framework consisting of an introduction, a theoretical section, a methodological section, and a contextualizing section that situates the phenomenon of organizational change, as it is experienced in practice, in its broader context. The thesis framework finishes with a conclusion and a discussion of the results.
Through a novel conceptualization of culture, article A examines the complexities involved in becoming an IED through merger. The article demonstrates that the problems in the merger process can be realted to the nurses’ struggles to carve out attractive professional identities and positions in the department. The results thus point to other explanations for problems in healthcare mergers than the ones commonly stated in the literature as ‘lack of integration’ and ‘cultural clashes’. Book chapter B has a methodological focus. It illustrates how an understanding of meaning, logic, and apparent paradoxes in standardized nursing practice can be provided by means of a Bourdiean ethnographic methodology. In article C the nurses’ responses to new steering tools in practice is examined. I suggest that an understanding is obtainable by virtue of the concepts of ‘curing’ and ‘caring’ that designate approaches to nursing informed by opposing modes of knowledge. The article shows that nursing in the department is polarized as caring or curing, but that many nurses respond by seeking to navigate between the two poles. Finally, article D builds on the knowledge established in article C. I first examine the epistemological poles of knowledge that inform curing and caring. I then thematise the analysis of my empirical data by asking how modes of knowledge organize nursing as curing and caring. The article advances that these modes of knowledge create different orientations towards the patient and thereby result in fundamentally different organizations of nursing with consequences for care. A point of the article is that the forms of knowledge informing caring and curing are political products that promote particular perspectives on nursing.
A finding of the thesis is that the modes of knowledge to inform nursing practice carry symbolic properties and have profound organizing influence on practice. Caring is associated with basic care for patients, comfort, holism, and interpersonal intimacy, but also with stagnation, mothering, and subjectivism. Curing is associated with science, the rational, the measurable, and with nursing progression. Caring and curing concern deeply rooted historical tensions in the profession that concern the character of work as well as the way knowledge is seen to inform nursing. My empirical studies illustrate how caring organizes nursing around and in physical proximity to the patient body, whereas curing organizes nursing dislocated from the patient body and around digital technologies in practice.
Another finding that emerges from my data is that, despite the fact that a primary objective of the establishment of the IEDs is to change the organizing mechanisms for practice from medical specialization to care pathway flow, and thereby from specialization to generalization, medical specialization is still the primary structuring mechanism of work. Moreover, medical specialization is symbolic capital in the field. Therefore, it is the primary differentiating and subconscious mechanism between practitioners against which competence and professional identity are valued. A central argument of the thesis is that medical specialization is immensely powerful because it resides in the genetic code of the medical field. It is thus the overarching structuring principle for all activity in the field – including nursing, and the symbolic as well as material effects of medical specialization derive from this circumstance.
The thesis puts forth that centrally in the transformation taking place in the hospital sector is a change in the assumptions held about practitioners and work. Hence, trust in the competence of the individual practitioner has overall been substituted for a belief in steering and a trust in technologies and systems based on universal and objective knowledge. The thesis points to some of the consequences of this shift to work, practitioners, and patient care.