Introduction

• “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

New Public Management Reforms and Health Care Professionals

• 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

Ordering Processes and the Heterogeneity of Professions

• Heterogeneity of professions (Abbott, 1988)

• Swedish nursing profession has 3 best recognized segements:

  • Mini-doctors

  • Administrative leaders

  • Experts in caring

The Heterogeneity of the Swedish Nursing Profession

• 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 Process of Ordering Nurses Into Administrative Leaders

• 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...

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