#2928 - Topic 5 Reading Ordering A Profession – Swedish Nurses Encounter New Public Management Reforms - Accounting in the New Public Sector

“New Public Management” (Hood, 1995)

An expectation had been that the reforms would lead to a decentralized health care system where the financial responsibility would be allocated to a level closer to the patient

• i.e. the head nurses

Roots in the profession’s internal constitution has a structure that is not coherent but heterogeneous

• Hence the contradictory responses from different people

In the American context Scott et al. (2000) have called the transition a ‘decline of Professional dominance’ and ‘advance of Managerial-Market orientation’

Just as we might expect to find conflicting groups within an organization (Cyert and March, 1963), we might also expect to find competing segments within a profession (Bucher and Strauss, 1961)

Ongoing ordering process within a profession aimed at establishing and defending different ideas of identity (Law, 1994)

Two ideas of a nurse:

• As an expert in caring

• As an administrative leader

  • Longer history within the profession according to Lannerheim (1994)

Role of a professional should not be seen as finally settled agreements, rather as ordering processes

The aim of the reforms should not be seen simply as improving public sector services in general, but also as attempts to redistribute power and control (Kurunmaki, 2000)

Shifted emphasis from professional standards and expertise towards more explicit and measurable standards of performance provided by different accounting techniques (Hood, 1995)

Could be seen as signaling decreasing trust in the professional and a limitation in their possibilities of self-management

Blurring of professional boundaries that occurred when UK doctors became clinical directors adopted medical manager hybrid roles by accepting increased commercial and managerial responsibility (Kitchener, 2000)

It is likely that factors such as the design, implementation, and context of the reform, as well as the history, position and knowledge-system of the professional might have consequences for the encounter

• Can link this to the current reforms of the NHS where the culture and history is portrayed to be at risk by campaigners

Heterogeneity of professions (Abbott, 1988)

Swedish nursing profession has 3 best recognized segements:

• Mini-doctors

• Administrative leaders

• Experts in caring

Heterogeneous in various ways

Differ in terms of education

Competence of ordinary nurses is quite fragmented

Different disciplines such as medicine, caring, psychology, pharmacology and administration (Heyman, 1995)

Rather strong but contested idea of the nurses as mini doctors (Lannerheim, 1994)

• Means that nursing education should include a stronger medical component and that the nursing profession should move in a direction closer to that of doctors (Vardfacket)

• Evident during the 1950s and 1960s when there was a shortage of doctors due to rapid expansion of Swedish health care (Lannerheim, 1994)

• Others argue that nurses can never truly compete with doctors

• Nurses might be delegated simpler medical procedures but could never really have access to the abstract knowledge supporting them

  • Considered a dangerous strategy by other parts of the profession

Every time the nursing education has been reformed, the medical component has diminished, and the subjects outside the doctors’ control have increased (Heyman, 1995)

Since 1982, caring has become a core subject in nursing education

• Attempts to establish caring as core competence

Administrative leadership in health care has always been considered a possible career route for nurses

• Complement and as a possible career choice

• Usually seen as the role of head nurses and chief nurses

The rise of an administrative hierarchy has been a general trend in the hospitals organizational development in Sweden during a large part of the 20^th Century (Gustafsson, 1987)

Since doctors by tradition have been the leaders in health care, nurses have been fighting this battle from an inferior position

Whether caring should be seen as the nurses’ jurisdiction or as subordinate to medicine has been a much-debated topic

Physicians argued that they should have total responsibility for the clinical units since they were the only ones with sufficient education

Nurses on the other hand, argued that it was not necessary to have an extensive medical education in order to be an administrative leader

“Responsibility without authority wears people down”

Expectation that the NPM reforms would bring about a more decentralized health care organization where head nurses would be given greater financial responsibility (Vardfacket, 1991)

Despite the nursing professions expectations that the reforms would lead to a decentralized organization, practice has proved otherwise

The question of ownership of the accounting/costing function is akin to this administrative debate

Three basic principles:

• 1) County Council was organized according to a purchaser and provider model

• 2) Patients should be given the option to choose their health care providers

  • The money should follow the patient

  • Competition between health care units was encouraged

• 3) Financial responsibility was claimed at different levels of health care (Spri-rapport, 1994)

Generally, the transformation of clinical units into profit centres at the Stockholm hospital had quite different consequences for the head nurses depending on whether or not they had been delegate the financial responsibility for their wards

• Was considered essential to be financially responsible

In many places the nurse’s position as head of the ward was confirmed

• This authority wasn't given automatically, some had to fight for it

• Physicians seem to want the power but not the responsibility of financial matters

Turning clinical units into profit centres also meant that the boundaries of the clinical units were reinforced (Llewellyn, 1994)

• But once the units became profit centres, the possibilities for solving problems, informally and without paying were gone

  • i.e. the sharing of beds etc.

The chief nurse established a contact group for the hospital’s chief nurses and head nurses

Nurses as administrative leaders in that the external relations to primary care units and expectant parents now also included marketing of their own wards