Ordering a Profession: Swedish Nurses Encounter New Public Management Reforms

ORDERING A PROFESSION: SWEDISH NURSESENCOUNTER NEW PUBLICMANAGEMENTREFORMS

Maria Blomgren*

INTRODUCTION

`Close the wards and let them die.'(The Swedish association for health professionals,1

`The No-way!' campaign, March 1993)

The opening statement of this paper stems from one of two nationwidecampaigns the Swedish nursing association launched during October 1992 toMarch 1993. Both campaigns aimed to help nurses deal with what wereportrayed as dramatic changes in the control and organization of Swedishhealth care. At this time, the Swedish health care sector was, like most of itscounterparts in theWestern world, a target for radical transformation. Reformsinspired by management ideas and practices of the private sector, commonlyreferred to as `New Public Management' (NPM) (Hood, 1995; and Olson, etal., 1998), were introduced on a wide front. Among other things, it signalledthat market-based models, profit-centre models and incentive systems were nolonger exclusive features of corporations in a marketplace. They now extendedtheir domains to include such entities as health care units as well.

Interestingly enough, the nurses' two campaigns represented two completelydifferent strategies in relation to the New PublicManagement reforms. The `Noway!' campaign, cited above, was a clear declaration against the reforms andwas deliberately designed in a very provocative and ironic way. Withcommercials on TV and in the daily press showing pictures of old and sickpeople and using texts like: `Why care for people that never can be cured?' and`Release the lunatics and they will kill each other, then we have a solution to allsorts of problems' (VÔrdfacket, 6/93 p. 1, 6 f.), the `No way!' campaign aimed tostand up for the kind of health care that requires a lot of nursing and caring,areas the association thought were suffering due to the reforms.

Financial Accountability &Management, 19(1), February 2003, 0267-4424

ß Blackwell Publishing Ltd. 2003, 9600 Garsington Road, Oxford OX4 2DQ, UKand 350Main Street, Malden, MA 02148, USA. 45

* The author is from the Department of Business Studies, Uppsala University. She is especiallygrateful for the support, help and comments of Peter Miller and Liisa Kurunmaki. Many thanks arealso due to Kerstin Sahlin-Andersson, Ulf Holm, Martin Kitchener and the anonymous referees ofthis journal. Comments by participants at seminars at the Department of Accounting and Finance,London School of Economics and Political Science, the Department of Business Studies, UppsalaUniversity, and the CIMAworkshop, University of Edinburgh, in September 2001, are also gratefullyappreciated.

Address for correspondence: Maria Blomgren, Department of Business Studies, UppsalaUniversity, Box 513, SE-75120 Uppsala, Sweden.e-mail: [email protected]

This defensive stance towards the changes was, however, a considerabledeparture from the kind of message put forward in the nurses' previouscampaign. Fivemonths earlier, the association had launched a campaign witha completely different message (VÔrdfacket, 17/92). At that time, the attitudetowards the reforms had been muchmore positive, and the ambition had beento encourage nurses to take advantage of the opportunities the new modelsmight present. One particular expectation had been that the reforms wouldlead to a decentralised health care system where the financial responsibilitywould be allocated to a level closer to the patient, i.e., to the head nurses' level.By directing the campaign to the members of the association, the hope wasthat nurses would fight to fulfil this expectation at their local workplaces.

In the following analysis it will be shown that these differences in reaction tothe reforms should not be interpreted as the Swedish nursing association'schanging its mind, swaying from an optimistic to a pessimistic stance. Thecampaigns ran in parallel for a period in 1993, and after the completion ofthe reforms, the association primarily continued to support the first, positivecampaign (VÔrdfacket, 17/94). The argument of this paper is rather that thecontradictory responses represented by the nurses' two campaigns have theirroots in the profession's internal constitution, a structure that is not coherentbut heterogeneous. The two campaigns will be traced back to two differentordering processes (Law, 1994), progressing simultaneously but guided bydifferent ideas of where nurses should go and what they should become.Differences in predictions of whether the reforms would promote or hamperthese processes explain the variation in attitudes.

The ongoing transformation within and around professional organizationshas turned out to be part of an important research agenda (Greenwood andLachman, 1996). Changes in organizational forms and practices havebrought questions of the position, power and legitimacy of the professions tothe fore. As for the New PublicManagement reforms in health care, they havebeen analysed as attempts to redistribute power and control (KurunmÌki,2000). Generally, this redistribution has been seen as disadvantageous to theprofessionals. The reforms shifted emphasis from professional standards andexpertise towards more explicit and measurable standards of performanceprovided by different accounting techniques (Hood, 1995). In the Americancontext, Scott et al. (2000) have called the transition a `decline of Professionaldominance' and `advance of Managerial-Market orientation', and Ústergrenand Sahlin-Andersson (1998) have portrayed the Swedish development in asimilar manner ^ as a professional logic that has given way to anadministrative-managerial logic. Empirical investigations have consequentlyshown how professionals have resisted the reforms, trying to protect their coreactivities and key values (Broadbent and Laughlin, 1998).

This article addresses the question of professional responses to and handlingof managerial reforms in the context of Swedish health care. The argument isthat the overall gloomy picture of this encounter coming out of research on the

46 BLOMGREN

ß Blackwell Publishing Ltd 2003

New Public Management reforms' impact on health care professionals needsto be adjusted and complemented. This is important, not least because moststudies in the area have focused on the medical profession, which is just one ofthe professional groups working in health care. By focusing on the nursingprofession, the paper aims to broaden the scope of the debate.But the professions' encounters with the reforms also need to be redefined in

another way, from a perspective where the very concept of the profession andhow it is used in empirical analyses is problematized. The common way oftreating professions as `building blocks' that are complementary to oneanother have clear-cut identities, interests and tasks, is an unfortunateoversimplification if we want to understand the complexity of professionaland organizational life (Sahlin-Andersson, 1994; and Waks, 1999). Just aswe might expect to find conflicting groups within an organization (Cyert andMarch, 1963), we might also expect to find competing segments within aprofession (Bucher and Strauss, 1961). The professional segments, however,are not fixed or complete. They are constantly contested and negotiated, bothwithin the profession and in relation to other groups.

In this paper, the concern is with these divergent processes of becoming. Inanalysing them, the concept of ordering will be applied (Law, 1994). Orderingwas initially used for analysing processes within organizations. Applied in thepresent context, it calls attention to the ongoing processes within a professionaiming at establishing and defending different ideas of identity. The history ofthe Swedish nursing profession reveals various such ideas. Two of these will bein focus in this paper ^ the ideas of the nurse as an expert in caring and as anadministrative leader.

Considering the content of the nurses' course syllabus and taking the officialstandpoint of the nursing association into account, it is clear that caring is apromoted field of expertise for nurses (Heyman, 1995; and VÔrdfacket, 6/94,p. 26 f.). As for the ambition to endorse nurses as administrative leaders, itwas a particularly burning issue during the reform of Swedish health care inthe 1990s, but it has a longer history within the profession (Lannerheim, 1994;and Rydholm, 1992). In the course of time, the ideas of the nurse as an expertin caring and as an administrative leader have undergone contestedtrajectories, and they have been subjects of recurrent redefinitions. They havemet with resistance, both from within the nursing profession and from otherprofessions and occupational groups, such as physicians and assistant nurses(Lannerheim, 1994; and Emanuelsson, 1990). The ideas of nurses asadministrative leaders and experts in caring, therefore, should not be seen asfinally settled agreements of what nurses are, but rather as ordering processes,as promoted and desired ends in ongoing interactions and negotiations withdifferent actors, both internal and external to the profession.

When the New Public Management reforms were introduced in theSwedish health care sector, they changed the conditions for these processes.Representing new ideals of organizing and controlling, the reforms could be

SWEDISH NURSES ENCOUNTERNEW PUBLICMANAGEMENTREFORMS 47


seen as technologies (Miller, 1994), as concrete practices and methods withthe potential to realize ideals of wider societal programs. Since orderingprocesses are in constant flux, they will intertwine, mix and blend with otherattempts to order which point in other directions (Law, 1994). How thereforms were received and handled within the Swedish nursing profession'stwo ordering processes is the focus of this paper.2

Following is a discussion about possible professional responses to the NewPublic Management reforms, and a section discussing ordering processes andthe heterogeneity of professions. The rest of the paper is then structuredaccording to the two ordering processes in focus: the attempts to order nursesinto administrative leaders and the efforts to make them become experts incaring. Both processes are discussed in terms of historical background, andhow each is reflected in the nurses' divergent campaigns, launched asresponses to the New Public Management reforms. Practical examples of theimpact of the reforms on the two ordering processes at the Stockholm hospitalfollow, and the paper concludes with a discussion of its empirical findings.

NEW PUBLICMANAGEMENTREFORMSANDHEALTH CARE PROFESSIONALS

During the 1980s and 1990s, manyWestern countries radically reformed theirpublic sectors. Inspired by management ideas and practices of the privatesector, the reforms were referred to as New Public Management (Hood,1995; and Olson et al., 1998). Generally, the reforms stressed such aspects ascost control, financial transparency, decentralization of managementauthority, and the creation of quasi-market mechanisms and performanceindicators (Power, 1997). They were accompanied by arguments that thepublic sectors had become too large and inefficient, and that efficiency,productivity, quality and accountability in public-sector services could beimproved (Olson et al., 1998).

The reforms brought with them new ideals of organizing and controllingthat had previously existedmainly in the private sector (Power, 1997). In thatsense, the various tools embraced by reforms, such as new managementaccounting models, could be seen as technologies (Miller, 1994), as concretepractices and methods with the potential to realize ideals of wider societalprograms. The aim of the reforms should not, therefore, be seen simply asimproving public sector services in general, but also as attempts to redistributepower and control (KurunmÌki, 2000).

From the perspective of the health care professionals, the reforms impliedsuch an attempt to redistribute power in the sense that they shifted emphasisfrom professional standards and expertise towards more explicit andmeasurable standards of performance provided by different accountingtechniques (Hood, 1995). This could be seen as signalling decreasing trust inthe professionals and also as a limitation in their possibilities of self-

48 BLOMGREN


management. The fact that the reforms also sought to make public sectorentities, such as hospitals, into more complete organizations with distinctiveidentities, clear objectives and firm boundaries could also be seen as achallenge to professionals, whose interests, values, norms and standardsnormally extend those of the particular organization (Brunsson and Sahlin-Andersson, 2000).

Empirical investigations of health care professionals' responses to the NewPublic Management reforms have, consequently, shown the ways in whichprofessionals have tried to resist the reforms and to protect their core activitiesand key values (Broadbent and Laughlin, 1998). But other studies that havealso taken the clash between the reforms and the professionals as the point ofdeparture have revealed what seemed to be a growing convergence betweenthe orientation of the reformers and that of health care professionals (Coombs,1987; and Lindvall, 1997). The results of some studies go even further.Kitchener (2000) highlights the blurring of professional boundaries thatoccurred when UK doctors who became clinical directors adopted medical-manager hybrid roles by accepting increased commercial and managerialresponsibility. KurunmÌki (2000) also supports the idea of hybridization ofprofessional roles, but adds that the willingness with which health careprofessionals adopt managerial devices, especially accounting practices, isdependent on the relative strength of the accounting profession's claim ofjurisdiction over these techniques.

It thus seems we could expect a variety of responses from the encounterbetween the reforms and the health care professionals, everything from fierceresistance to willing adoption. The differences could be explained both byfactors concerning the particular reform and by the profession in question. Itis likely that factors such as the design, implementation, and context of thereform, as well as the history, position and knowledge-system of the profession,might have consequences for the encounter. This paper is particularlyconcerned with the latter, the characteristics of the profession. The argumentis that the view of the profession as a coherent, stable and complete entityshould be called into question. An alternative perspective on professions thatviews them as containing different ordering processes, is therefore presented.

ORDERING PROCESSES AND THEHETEROGENEITYOF PROFESSIONS

Ordering emphasizes the plurality, variety and incompleteness of reality(Law, 1994). Taken as a starting point for the analysis, this highlights someimportant aspects of professional life that usually are overlooked when theimpact of managerial reforms is analysed.One such aspect is the heterogeneityof professions (Abbott 1988, p. 118, ff.; and Bucher and Strauss, 1961).This heterogeneity can take on different forms; individuals and groups

within each profession can vary with respect to status, types of clients served,



organization of work, and career patterns. We are thus likely to find internalstatus rankings where those most closely connected to the profession'sknowledge system claim the highest ranking, and we are likely to finddifferences due to the status of the clients the professionals serve, the divisionof labour within the organization, and the position of the professional's career.

Segmentation is one possible consequence of the heterogeneity ofprofessions. Bucher and Strauss (1961) describe the medical profession asstructured into different `professional segments', which often, but not always,coincide with the medical specialities. These segments tend to developdistinctive identities with different goals and different ideas about their mostcharacteristic professional act. Within psychiatry, for example, somepractitioners use psychotherapy to deal extensively with individual patients,while others have little face-to-face interaction with patients and base theirtreatments on drug prescriptions, and still others spend a great deal of timeperforming administrative tasks.

The professional segments undergo continuous changes. New medicalmethods or techniques can give rise to new segments, which will last for awhile, but then:

. . . as time goes by they may segmentalize further along methodological perspectives.Methodological differences can cut across speciality ^ and even professional ^ lineswith specialists sharing techniques with members of other specialities, which they donot share with their fellows (Bucher and Strauss,1961, p. 328).

In due course, new professional methods and techniques thus have apropensity to create new professional segments, and at a given point in timethey may be in different phases of development, pursuing different tacticssuitable to their positions. As will be shown, the Swedish nursing professioncould be seen as heterogeneous in various ways, but three of the best-recognized segments are those aiming to make nurses into `mini-doctors',administrative leaders and into experts in caring (Lannerheim, 1994; andHeyman, 1995).

Efforts to establish professional segments like these, however, are not simplyinternal affairs. As Abbott (1988) has shown, professions exist within a systemof professions, and this means that actions affecting the boundaries of aparticular profession invariably also affect its relations to surroundingprofessions and occupational groups. The extent to which the Swedish nursingprofession has realized different ideas of identity has varied throughouthistory, and one important reason for this is that these ambitions have metresistance of various kinds, both from within the profession and from othergroups such as doctors and assistant nurses (Abbott, 1988; and Emanuelsson,1990).The segments of the profession should consequently not be seen as fixed, but

rather as dependent on constant negotiations and interactions withsurrounding groups. This fact adds to the theoretical standpoint taken in this

50 BLOMGREN


paper, namely that it seems more reasonable to describe this context as onecharacterized by processes of ordering than by orders (Law, 1994). Theconcept of ordering thus connects and integrates the various and ongoingattempts to establish consensus around questions of identity, knowledge-system and core activities within the profession with the jurisdictional fightsit involves in relation to other professions and occupational groups.

THEHETEROGENEITYOF THE SWEDISHNURSING PROFESSION

The Swedish nursing profession is heterogeneous in various ways. Forinstance, nurses differ in terms of education. After finishing the three-yeargraduate program, they can specialize in different areas such asanaesthesiology, intensive care, oncology, paediatrics or psychiatry. Nursescan also become midwives, teachers or researchers by attending various post-basic programs (VÔrdfÎrbundet, 2000). The work of a nurse specializing inanaesthesiology or intensive care, consequently, is quite different from that ofthe nurse doing research in caring.

But even without considering specialist education, the work andcompetence of ordinary nurses is quite fragmented in the sense that itcombines elements from different disciplines such as medicine, caring,psychology, pharmacology and administration (Heyman, 1995). Regardingnurses' basic education, there exist different ideas within the profession as towhat should be their core competence and professional identity. There is, forinstance, a rather strong but contested idea of the nurses as `mini-doctors'(Lannerheim, 1994, p. 177 ff.). This ideameans that nursing education shouldinclude a stronger medical component and that the nursing profession shouldmove in a direction closer to that of doctors' (VÔrdfacket, 13/93, 15^16/93, 18/93, 3/94, 6/94). Such a tendency was evident during the 1950s and 1960s whenthere was a shortage of doctors due to the rapid expansion of Swedish healthcare, and nurses actually took a greater part in medical work (Lannerheim,1994). Those who oppose this kind of development today, however, do so byarguing that nurses could never truly compete with doctors. Nurses might bedelegated simpler medical procedures but could never really have access tothe abstract knowledge supporting them (Lannerheim, 1994; and VÔrdfacket,13/93, 15^16/93, 18/93, 3/94, 6/94). This is consequently considered a danger-ous strategy by other parts of the profession, and if one examines the changesmade in nursing education, the opposite development is clear. Every timenursing education has been reformed, themedical component has diminished,and the subjects outside the doctors' control have increased (Heyman, 1995).

Even though the ambition for nursing to move closer to the medicalprofession still remains within parts of the profession, it has lost some of itspower. Since 1982, when caring became the core subject in nursing education(UHØ/SÚ, 1981), attempts to establish caring as nurses' core competence



have been very successful. Since the ambition to order nurses into experts incaring is one of the more influential ones, it is one of the two processes in focusin this article.

The second process in focus is the one that attempts to order nurses intoadministrative leaders. The administrative leadership in health care hasalways been considered a possible career route for nurses (Lannerheim,1994), and in that sense one can say that it is a rather strong idea. But incontrast to the polarized positions of those wanting to incorporate moremedicine rather than more caring in the nurses' professional role, the idea ofthe nurse as an administrative leader should not be seen as entirely opposed toother ideas of the nurses' professional identity. Hence, those promoting theidea of nurses as administrative leaders never thought that administrationshould be the main fundament upon which the entire profession should baseits work. The thought was rather that it should be seen as a complement andas a possible career choice for some nurses. Thus, promoting nurses asadministrative leaders is not the same thing as saying that all nurses shouldpursue administrative careers.

This has some practical consequences for this paper. It means, for instance,that a nurse could make statements referring to both processes during aninterview. Most statements that represent the idea of nurses as administrativeleaders are made by those who in practice come closest to this idea, namelyhead nurses and chief nurses. And those working practically with caring moreoften made the statements referring to the idea of nurses as experts in caring.But there are also exceptions to this rule. In real life, it turns out to be difficulttomake a clear dividing line to categorize people according to these ideas sincean individual nurse could adhere to both ideas. What one can do, however, isseparate nurses as administrative leaders and experts in caring as ideas, anddistinguish between the attempts to realize these ideas. Therefore, the focusin the following will be mainly on these attempts, on the processes of orderingnurses into these two identities.

THE PROCESS OFORDERINGNURSES INTOADMINISTRATIVE LEADERS

The rise of an administrative hierarchy has been a general trend in thehospital's organizational development in Sweden during a large part of the20th century (Gustafsson, 1987; and Ústergren and Sahlin-Andersson,1998). More and more people with no medical education have beenappointed, and the hospitals' staff functions have expanded. Even so, healthcare professions still hold strong positions, and many of the jurisdictionaldisputes in this area have been conflicts between two strong and large healthcare professions ^ the doctors and the nurses (Heyman, 1995). Since doctorsby tradition have been the leaders in health care, nurses have been fightingthis battle from an inferior position.3 In an official report from 1984,

52 BLOMGREN


administrative leadership responsibility in health care is defined as: `aresponsibility for planning, organizing, managing co-ordination andcontrolling the work' (Ds S 1984: 12). Both the meaning and content of thisresponsibility, and the extent to which nurses have been in possession of it,have varied throughout history.

The hospital of the early 20th century was governed by a senior physician.Subordinate to the senior physician were a matron and a qualifiedadministrator (Axelsson, 1990; and Rydholm, 1992). The matron's primaryresponsibility was the personnel (apart from the doctors), the practical caringwork and the kitchen. The qualified administrator was responsible for theaccounting functions as well as maintenance of buildings and machines.

During the expansion of the Swedish health care sector in the 1950s and1960s, the organizational structure of the hospitals changed in ways thataffected both doctors and nurses. The senior physicians were in many casesreplaced by administrative hospital managers as heads of the hospitals(Borgert, 1992; and Lannerheim, 1994). To support and advise in medicalmatters, a chief doctor position was established, directly subordinate to thehospital manager (Rydholm, 1992, p. 18 f.). The former matron's positionwas replaced by two separate positions, which were given the formalresponsibility for the practical caring work in the hospital.

In this type of hospital organization, the nurses had a relatively strongposition. The nursing director was subordinate to the hospital manager andthe chief doctor, but was head of a `nursing hierarchy' which ran in parallelwith a corresponding `medical hierarchy'. The existence of a nursinghierarchy meant that caring was formally accepted as the nurses' jurisdiction^ a nursing director with direct surveillance over the nurses' practical work,was placed in a line function on the same organizational level as the chiefphysicians at the clinical units.

Whether caring should be seen as the nurses' jurisdiction or as subordinateto medicine has been a much-debated issue. In the revised legislation of 1972,the situation changed to the disadvantage of the nurses. The position of thenursing director was no longer mentioned in the text, which meant that theformal acknowledgement of a nursing hierarchy and caring as the nurses'jurisdiction had disappeared (Rydholm, 1992, p. 23). The legislation gave nodetailed instructions on how the hospitals should be organized, and severalorganizational forms flourished. In many places the former nursing directorwas transformed into a staff function, and its commanding authority wastransformed into a consultative role.

The type of organization that includes the nursing director in a hospital stafffunction is still the most common one. Studies have shown that nurses in thisposition feel that their role is poorly defined and that their knowledge is notappreciated (Rydholm, 1992, p. 159; and Hansen, 1999, p. 169). Turningthe nursing director into a consultative function meant that the former`nursing hierarchy' was broken and that nurses' jurisdiction over caring had



been called into question. It also meant that the head nurses at the ward levelnow become the most highly positioned nurses with administrative leadershipresponsibilities.

In 1982, however, nurses got a new chance to extend their leadership whenthe physicians lost their earlier rights to the administrative leadership of theclinical units. New legislation was established which regulated only thephysicians' medical leadership responsibility, while the administrativeleadership responsibility was left open (HSL, 1982: 763). Even though thephysicians in fact held the majority of these posts, between 80 and 150 of themwere held by nurses during the period 1987 to 1990 (Rydholm, 1992, p. 35).The medical profession reacted strongly against this situation, however, and anew commission was initiated shortly after the legislation came into legalforce.

The seven-year period that followed has been described as a `strategicinteraction' between nurses and physicians (Lannerheim, 1994). Referringto the safety of the patients, the physicians argued that they should have totalresponsibility for the clinical units (medical and administrative) since theywere the only ones with sufficient education. Nurses on the other hand, arguedthat it was not necessary to have an extensive medical education in order to bean administrative leader, and therefore, nurses should also be allowed to applyfor these posts. Eventually, the discussion ended with the `chief-physician'reform, which in principle meant that the administrative leadershipresponsibility for the clinical units was given back to the physicians (Lag,1990, p. 601). The fact that the legislation was preceded by several years ofdiscussions gives some indication of the interest, importance and tensions thedifferent parties invested in the case. The official reason for the battle ^ theaspirations for better and more reliable health care ^was in fact accompaniedby an underlying fight about professional interests (Lannerheim, 1994).

From the nurses' perspective, the `chief-physician' reform was a severesetback, and they now had to look for other ways to promote theiradministrative leadership ambitions.4 One way was to turn the attention tothe leadership of the clinical wards, i.e., the sub-units of the clinical units.The situation now very much resembled the one in the beginning of the1980s. The head nurse at the ward level was the most highly positioned nursewith administrative responsibilities in a line function. Subordinate to the headnurse were the nurses, assistant nurses5 and nurses' aides6 working at the ward.Since the rhetoric surrounding the New Public Management reforms gavepromises of decentralized administrative responsibility down the hospital'shierarchy, the reforms were quite interesting with respect to the process ofordering nurses into administrative leaders. But since the administrativeleadership of the wards was not regulated by legislation, it soon became theobject of new jurisdictional disputes between nurses and physicians (Borgert,1992, p. 128). The following paragraphs present some examples of this.

54 BLOMGREN


The New PublicManagement Reforms and Nurses' First Campaign

The chances we have to influence the development of health care are to a great extentdependent on the kind of authority we possess. Many nurses, midwives and laboratoryassistants undertake a vast responsibility in their daily work without being inpossession of its formal authority. Responsibility without authority wears peopledown. [. . .] For manymembers, it is a question of receiving the formal recognition theylack today. For head nurses and other administrative leaders, it is a question of notgiving up authority they already possess (The leader of the Swedish nursingprofession,VÔrdfacket,1/91, p. 3).

This statement by the leader of the nursing profession was published at thebeginning of 1991. It is a somewhat resigned remark, indicating what mostnurses already knew ^ that they had lost the battle over the chief-physicianreform and the possibility of gaining authority over the clinical units. But italso points to the future, indicating the importance of the head nurses'position.

The nursing profession's leader continues describing the transformation ofthe Swedish health care sector, which at the time was just beginning, and thenpoints to the fact that nurses might have a chance in the new situation(VÔrdfacket, 1/91, p. 3). What this idea emphasized in particular was theexpectation that the New Public Management reforms would bring about amore decentralized health care organization where head nurses would begiven greater financial responsibility (VÔrdfacket, 18/91, p. 3; 3/93, p. 4). Laterthat year, when several County Councils had started implementing thereforms, the editor of the nursing association's journal commented on thedevelopment:

. . . it is good to let the County Councils try their new models. In many cases they arebuilt on the assumption that the responsibility and resources should be allocated to alevel near the patient ^ to the level where the competence in how to solve problemseconomically and efficiently is (VÔrdfacket,18/91, p. 3).

The profession's attitude to the new reforms was obviously rather optimistic.Bearing in mind the experiences with the `chief-physician' reform, however,the conclusion was that the profession's members needed to `strengthenthemselves' in order to gain from the new models (VÔrdfacket, 18/91, p. 3).Accordingly, a supportive campaign was initiated. The ambition with thisfirst campaign was to encourage the members to discuss how to make the bestof the situation and how to take advantage of the opportunities the newmodelsmight present to nurses (VÔrdfacket, 17/92). The campaign was designed to becarried out at the local workplaces, and the idea was that nurses should gatherand discuss the reforms and what they could do to make the most of thesituation in their everyday work. Documents to support these discussions weresupplied by the association's central office, and results from some of thesemeetings were then described in the nursing association's journal.

But despite the nursing profession's expectations that the reforms wouldlead to a decentralised organization, practice proved otherwise. An article



published in VÔrdfacket, later in 1991 showed that nurses still had to fight fortheir administrative leadership positions at the level of the clinical wards(VÔrdfacket, 12/91, p. 3). A survey conducted at 14 Swedish hospitals showedthat at 70% of the clinical units, the financial responsibility had beendelegated down to the clinical wards (Lindvall, 1997, p. 93). The study didnot, however, give any clues to whether the responsibility was given to nursesor to physicians. The situation at the Stockholm hospital will be described inthis paper, following a short description of the Stockholm model.

The StockholmModel

The Stockholm model was introduced in the County Council of Stockholm in1992. Like other New Public Management reforms, it did not refer to a singlepractice but rather to `a multitude of overlapping exercises' (Power, 1997, p.43). In addition, it was preceded by and existed in parallel with other reformsand different targets for increased savings (Jacobsson, 1994; and Charpentierand Samuelsson, 1999). Empirical studies have shown that the working staffhad difficulty distinguishing between the effects generated by the Stockholmmodel and those associated with other efforts to increase cost-consciousnessand readiness for change (Jacobsson, 1994.). One conclusion is therefore thatit is impossible to fully separate these effects from one another. All thesechanges could, however, be seen as following similar lines and are thereforetreated `as a cluster of ideas with a common programmatic aim' (Power,1997).The Stockholm model was founded on three basic principles (Spri-rapport,

1994). Under the first principle, the County Council was organized accordingto a purchaser and provider model. The purchasers, nine health care boardsrepresenting the population in different geographical areas, made health careagreements with health care providers, such as primary care units andemergency hospitals. The agreements covered volumes, prices and services,where the prices were based on modified DRG-systems (Charpentier andSamuelsson, 1999). One motivation for paying providers according toactivities undertaken was to enhance productivity and, hopefully, to reducethe waiting lists, which, for certain treatments, had become increasingly long.An evaluation of the Stockholm model showed that, up to 1994, theproductivity of the Stockholm hospitals had increased by almost 20%, andthe queues of patients had disappeared (Charpentier and Samuelsson, 1999,p. 148).

The second principle was that patients should be given the option to choosetheir health care providers. The money should consequently `follow thepatient' when this option was taken (Spri-rapport, 1994, p. 7). Competitionbetween health care units was also encouraged.

Third, financial responsibility was claimed at different levels of health care(Spri-rapport, 1994). The hospitals within the Stockholmmodel were defined

56 BLOMGREN


as external profit centres, and the clinical and service units within the hospitalswere defined as internal profit centres. Income figures were calculated for bothtypes of profit centres.

In the following, it is mainly the internal profit centres (clinical units) thatwill be in focus. Since the chief-physician reform was in legal force, it was thechief-physician who was ultimately responsible for the internal profit centre,in both medical and financial terms. Whether the financial responsibilityshould be delegated further within the internal profit centre, whether it be tothe head nurse or a senior physician, was up to the chief-physician to decide.At the studied Stockholm hospital, half of the interviewed head nurses (five)had been given the financial responsibility, while the other half (five) had not.The nurses with this responsibility were given the title `chief nurse'. Thepractical meaning of the delegated financial responsibility is described next.

Nurses Fighting for the Financial Responsibility for ClinicalWards

Generally, the transformation of clinical units into profit centres at theStockholm hospital had quite different consequences for the head nursesdepending on whether or not they had been delegated the financialresponsibility for their wards. It was considered essential to be financiallyresponsible, and those who had this responsibility were consequently pleasedwith it. The responsibility did create obligations, but the positive aspectsoutweighed any negative ones. The feeling of freedom and independence hadincreased, and the accentuated chief position meant, for instance, that therelations to the chief physician and to the other units within the hospital hadchanged. The chief nurses were now free to make purchases for the wards (upto a limit of 10,000 Skr) and to grant leave. But themost important changewasthat the nurse's position as head of the wardwas confirmed. `One great changeis that it is now declared that I am the head of the ward!', one chief nurseproudly announced.

This authority was, however, not given automatically, and one chief nursedescribed the fight she had to put up in order to get it:

The chief physician wanted to delegate it to a senior physician but I said no! What usewould it be having me here then? Now, this never took place [i.e. the senior physiciandid not get the responsibility]. But that is the way it is organized at many wards.Whyshould he be responsible for the things I do?

Another head nurse, who had not been delegated this financial responsibility,expressed her dissatisfaction like this:

I have no responsibility according to the delegation regulation . . . or . . . I amresponsible but do not have the authority. I do it in practice, but he [the seniorphysician] has the formal responsibility.

Against the background of the lost battle over the `chief-physician' reform,where the administrative leadership was legally regulated in favour of the



medical profession, the delegation of financial responsibility to clinical wardscould be seen as representing a sort of `second chance' for the nurses, althoughat another organizational level. But, as we have seen, this second chance wasnot necessarily given, and since the nursing profession's activities on this issuecontinued to be characterized by jurisdictional disputes with the physicians,they consequently followed a well-known path in the process of orderingnurses into administrative leaders.

Dealing with Reinforced Clinical Boundaries

Turning clinical units into profit centres also meant that the boundaries of theclinical units were reinforced (Llewellyn, 1994; and KurunmÌki, 2000), andthis affected the nurses in different ways. Earlier on, there had been a ratherlively collaboration betweenwards in terms of `borrowing' nurses or beds fromeach other during peak working times. But once the clinical units becameprofit centres, the possibilities for solving problems informally, and withoutpaying, were gone. The chief physician also became the central contact, theone who took care of most of the external relations. This meant that the chiefnurse's contacts with other units within the hospital decreased. One nursedescribed it like this:

When the clinical unit became a profit centre, the external contacts were totally gone!The clinical unit became a unit in itself and the chief-physician was the one whocommunicated externally. I was thinking, this is driving me crazy! I can't work likethis! [. . .] My feeling was that the dividing lines between the clinical units weresharpened, and maybe the chief-physicians wanted it to be that way, so that we [chiefnurses and head nurses] couldn't oppose things. But I don't know. . . . It's easy to feelpursued by all changes . . .

In response to this situation, the chief nurse established a contact group for thehospital's chief nurses and head nurses. The members of this group metregularly and discussed issues of common concern. As for the collaborationbetween different wards, such as providing beds and personnel, it did continuebut was restricted since the clinical units now had to pay for these services.

The reinforced boundaries also meant that the patients were redefined tosome degree (Brunsson and Sahlin-Andersson, 2000; and Forssell and Jansson,1996). As an example, the head nurse at the delivery ward described thebehaviour of expectant parents in the following way:

Today it's apparent that the parents choose theward theywant to go to.Theygoaroundand visit several hospitals. One is more concerned with marketing now.Traditionally,we haven't been good at that in health care. But nowadayswe handout brochures to theprimary care units and receive visitors here.

Patients' ability to choose which delivery ward they would like to go toapparently meant that the personnel had to receive the expectant parentssomewhat differently than before. Expectant parents had become not justpatients but also customers who were supposed to actively choose their health

58 BLOMGREN


care providers. This affected the nurses as administrative leaders in that theexternal relations to primary care units and expectant parents now alsoincluded marketing of their own wards.

Increasing Cost-Consciousness and the PatientTurnover Rate

Another consequence of the Stockholm model was the increased cost-consciousness. Such a response has been stressed in several studies of the NewPublic Management reforms in Swedish health care (Jacobsson, 1994;BrorstrÎm, 1995; and Charpentier and Samuelsson, 1999). At the Stockholmhospital, the increased cost-consciousness was obvious among the nurses. To agreat extent, the new reforms had raised in them a sense of responsibility fortheir own clinical units, an insight that their existence and future rested intheir own hands. `Today you have to accomplish in order to get money', onenurse said. The accounting system's capacity to induce self-reflection had hadan impact in the sense that nurses had been forced to rethink matters and tostart viewing themselves and their work in a new light, i.e. from a financialperspective (Miller and O' Leary, 1987). One nurse described it like this:

Nowadays it's important to shorten the time the patients spend at the clinical unit. Onetries to speedup the examinations, one tries to compress it all. One considers the cost ofeverything and one forces things in order to make them progress faster. One can, forinstance, call someone to make an appointment for an x-ray and be offered one in twodays.Thenonehas to say that's not goodenough, Ineedone tomorrow'.The personyouare talking to doesn't always realize this; my priority isn't always this person's.

In the nurses' examination of themselves and their work, their efforts to bethrifty and avoid wasting materials were evident. `The advantage is that onethinks more about what one is doing nowadays; one reflects, and one doesn'tjust do things as a matter of routine' the nurse continued.

The nurses as administrative leaders were generally pleased that theprevious unclear reporting concerning costs was now in better order. It wasconsidered good to keep tabs on things and it was easy to assent to ideas suchas `you shouldn't be wasteful' and `things are in better order today'. Thenurses evidently took pride in knowing what was spent and how much thingscost. `The accountants usually tell me: You know every cost so d-n well!' onehead nurse proudly declared. Another head nurse, however, was not as happy,and the reason was the way the hospital directorate made use of the costinformation. She said:

And then they [the hospital directorate] announce that we have to make savings. Andwhere arewe going tomake these savings? [Turning to the researcher]Onpencils!Thisclinical unit uses too many pencils! [. . .] What we need is a general policy, like in anordinary company!

Besides the increased cost-consciousness, the enhanced turnover rate ofpatients also seemed to establish itself relatively firmly as an importantprinciple in nurses' thinking about how health care should be organized.



Nurses as a group are considered to have unique control over the turnover rateof patients in health care units (Melander, 1997). They generally are the onesresponsible for organizing the patients' registrations, optimizing bedutilization, co-ordinating the personnel and operating schedules, and pre-paring for patients' departure from the ward. It is doctors who decide when apatient is ready to leave the ward, but it is through the agency of the nursesthat this process goes smoothly. Hence, the nursing profession has a relativelystrong ability to see to it that a patient's stay at the ward is shortened, andconsequently, to enhance the hospital's ability to accommodate new patients.

For the nurse as an administrative leader, an increased turnover rate wasmainly seen as positive since the patients now did not have to wait too longfor their examinations. One chief nurse said:

The good thing is that the examinations aremuchquicker, the throughput of patients isspeeded up and the queues are shorter.We meet the wishes of the patients completelydifferently now. [. . .] They do not have to sit waiting.

Another chief nurse explained that one of her main duties was to `hurry thingsup' andmake sure `there were no empty beds'. These ambitions tomaximize theoccupancy rate and increase the turnover rate of patients had implications fornurses' relations to the rest of the personnel. It was now expected of them to urgethe personnel to work harder. One chief nurse described the change like this:

We work harder at the clinical unit now, but the most important difference is perhapsthat it's possible to express that it's needed.Today it's expected from head nurses to saythat `we have to work harder'.

Several chief nurses and head nurses affirmed that it was now necessary toemphasize the message that there must not be any slack periods during workdays, and, if such periods existed, it indicated that there were too manypersonnel. At most wards, the lay-off threat was ubiquitous. One head nursesaid that, in a way, it was now easier to convey the demands down to `acomprehensible level'; `no patients, no pay' was the simple pedagogy she usedto illustrate this.

In conclusion, one could say that the general principles reinforced by theStockholm model, such as the increased cost-consciousness and faster patientturnover rate, were welcomed by the nurses as administrative leaders. Fromtheir perspective, it meant that the organization and control of health carehad improved, attitudes that are quite different from the ordering process wewill turn to now, which evolves around the idea of the nurse as an expert incaring.

THE PROCESS OFORDERINGNURSES INTO EXPERTS IN CARING

One very important task within the process of ordering nurses into experts incaring has been to establish a general definition of caring. Such efforts are vital

60 BLOMGREN


both for unifying the profession as such and also for claiming jurisdiction inrelation to others. As for the position in the system of professions, the nursingprofession has officially been recognized as the group that possesses a `specificcompetence in caring' (SOSFS, 1993: 17). But even so, this is far from enoughwhen it comes to asserting monopoly over this area. One reason is theambiguity of the word `caring' in itself (Heyman, 1995). The Swedishlanguage does not include a word such as `nursing', which directly refers tothe nursing group. The difficulties in defining the concept of caring also reflectthe profound problem of defining and protecting nurses' practical work.Whatexactly is it that nurses do, and how does it relate to others?

A main strategy that had developed in the early history of nursing was tofocus on the theoretical part of caring. The nurses searched for areas `neitherpurely administrative, nor medical in character'; areas which were notentirely practical, but not based on intuition, or on invisible everyday lifeexperiences, either (Gustafsson, 1987, p. 391). In order to achieve such aposition, nurses have been striving constantly to increase their theoreticalknowledge (Emanuelsson, 1990). It is mainly by referring to differences intheoretical education that nurses have constituted themselves as a group andset the boundaries in relation to subordinate groups. Thus, one centralmeaning of ordering nurses into experts in caring has been to make them into`theoretical nurses' (Gustafson, 1987, p. 385).The ambition to order nurses into theoretical experts in caring has had an

impact on the division of labour between nurses and subordinate groups(Gustafsson, 1987). One consequence is that this has required a staff engagedin practical work, in this case, consisting of assistant nurses and nurses' aides.This dependence has not, however, been unproblematic. Observations fromhealth care wards in 1994 indicate that while the boundary between thedoctors and the nurses are obvious and taken for granted, the boundarybetween nurses and their subordinate groups are fluid and less clear (Sahlin-Andersson, 1994). Nurses view this as a problem, and it is reasonable to see thetrend to converting assistant nurses' posts into nurses' posts, which started inthemid-1980s, as a reaction to this situation (Lannerheim, 1995). By doing so,nurses would certainly establish closure in relation to subordinate groups, buton the other hand they would also lose part of their working staff.

As for the formal recognition of nurses as theoretical experts in caring, theprocess took a huge leap forward through the reform in 1977 (SOU, 1973: 2).At that point, nurses' training became an academic education, and the subjectof caring was consequently given academic status. Turning caring into anacademic subject did not solve all the problems of claiming jurisdiction in thesystem of professions, though. An analysis of the nurses' evolving research areashows that caring as a research field is influenced to a great extent by themedical profession (Heyman, 1995).As for their practical caring work, nurses are still struggling with a major

problem ^ that their caring work is `invisible' to others (Bowker and Star,



1999). Repeatedly it is pointed out that nurses' work is based on an oraltradition; that nurses still have problems describing their work in a precisemanner; and that they lack scientific descriptions of their achievements(BjÎrklund, 1997; and Sahlin-Andersson, 1994). There is a fear that nurses'work will be neglected, and that the profession will continue to be `weak'. Since1985, nurses have had to document their work according to legislation (SFS,1985:562); however, nurses still seem to lack the tools, language and categoriesrequired to fulfil this object in a standard way (VÔrdfacket, 3/93, p. 23; 16/93, p.13). Therefore, an important task for all nurses is to make their work visible. Inthe nursing association's journal, the nursing profession's leader requests:

Every member has to make her or his work visible. Document! Sign! Otherwise [thenursingassociation] will never be able tomake any substantial accomplishments.Workconducted in silence will always be of minor importance (VÔrdfacket,1/91, p. 3).

`NoWay!' Nurses' Second Campaign

In March 1993, seven months before the nursing profession's first campaignwas concluded, the `No-way' campaign was launched (VÔrdfacket, 6/93, 6 ff.).This campaign was directed to the public and was a very explicit protestagainst the ongoing transformation of Swedish health care. It had a verychallenging tone, and the profession's argument was that neither the patientssuffering from the transformations nor the health care professionals takingcare of them (i.e., nurses) had strong enough voices in the health care debate(VÔrdfacket, 6/93, 6 ff.). The profession therefore thought that commercialssuch as the ones proclaiming: `The elderly cost too much ^ close the wardsand let them die' and `Some people get cancer ^ that's the way life is', wereneeded in order to provoke reactions.

One of the proposed actions to prevent negative effects of the reforms was todevelop and install quality assurance programs (VÔrdfacket, 6/93, p. 7). Acouple of years later this was compulsory for all personnel in health care(SOSFS, 1996:24). The rise of quality assurance could be seen as a generaldevelopment, overlapping those associated with New Public Management(Power, 1997). From the Swedish nurses' point of view, the programs wereseen as a way to protect caring from possible negative effects that could arisefrom an increased cost-consciousness and faster patient turnover rate. Inquality work in general, nurses were seen as taking a leading role comparedwith other professions and occupational groups in health care (VÔrdfacket, 5/92, p. 8; 2/95, p. 17^18). But besides guaranteeing the quality of caring, therewere other positive consequences ascribed to the programs. They would notonly protect nurses' caring work, but also make it visible to others (VÔrdfacket,5/92, p. 8 f.; 14/93, p. 24 f.; 19/94, p. 20 f.; 11/95, p. 44 ff.). The ideas of theprograms therefore aligned quite well with the process of ordering nurses intoexperts in caring. In the following sections, we will see how this process wasaffected by the reforms at the Stockholm hospital.

62 BLOMGREN


Caring at the Reformed Stockholm Hospital

Even though increased cost-consciousness was accepted as an organizingprinciple among the nurses at the Stockholm hospital, this acceptance had itslimits. Avoiding the waste of materials is one thing; being unable to affordextra personnel to sit with dying patients is quite another. So, for nurses asexperts in caring, the consequences of the Stockholm model were indeedworrying. Some of them feared for increased risks in health care since therewas no longer room for `safety margins' in their work.

The fact that a high occupancy rate and turnover rate of patients hadbecome rather strong ambitions meant that the working pace was forced andthat nurses suffered from stress when there were èmpty beds'. A perceivedpressure caused by long waiting lists could be a possible explanation for thisfeeling of stress, but at the Stockholm hospital, the existence of èmpty beds'was a source of stress even when there were no patients waiting to come to theward. The reason was that the nurses knew the clinical unit would not receiveany DRG points; `the personnel is anxious to receive revenues', a chief nurseexplained.

In contrast to the nurses as administrative leaders, nurses as experts incaring saw the increased turnover rate as mainly negative. It made it moredifficult to find the time to talk to the patients, to establish good relations withthem, and to inform them sufficiently. The fact that patients had to bereported out of the wards as soon as possible was not always consistent withproviding good care. In extreme cases, it meant that a patient who was dyingbut was no longer being treated in the ward had to be moved. In other cases itcouldmean that the patient was not exactly sent home `too early', as one nurseexpressed it, but before he or she was emotionally and psychologicallyprepared for it.

The transformation of health care had placed nurses as experts in caring onthe horns of a dilemma. On the one hand, they were aware of the need toreduce costs and speed up examinations, but on the other hand, they saw thattheir ability to provide care was suffering from this. Ìt's not that anyone[patient] will die or anything, it's just that I'm not doing a good job', one nurseexplained. And because nurses' work with caring was considered invisible toothers, no one except nurses knew it was suffering.

Establishing QualityAssurance Programs

As the leaders of the nursing profession had recommended (VÔrdfacket, 6/93, p.7), nurses at the Stockholm hospital installed a quality assurance program as away of maintaining the quality of caring work. Through this program, thenurses had worked out a common way of documenting their work and, for eachand every moment of it, considered how the quality might be improved. Theprogramwas considered important because it showedwhat kind of work nursesdid and that `nurses didn't just run doctors' errands', as one of them put it.



Others emphasized that the programs were important since they `strengthened[nurses'] professional role' and forced them to put their `thoughts into words'.This showed that the programs could be seen as promoting one of the centralambitions in the process of ordering nurses into experts in caring ^ to makenurses' work visible through extended documentation.Another aspect of the quality assurance programs, however, was the

extensive administrative work they involved. It was said repeatedly thatquality assurance is time consuming (VÔrdfacket, 5/92, p. 8 f.; 10/91, p. 6; 5/92, p. 8, 11) and that it is necessary to be very careful and systematic whenstandards and quality assurance measures have to be formulated (VÔrdfacket,10/91, p. 6 ff.). The resulting increase in administrative work was considered aparticular problem in relation to the assistant nurses. In the process ofordering nurses into experts in caring, assistant nurses constitute a threat sincethey actually domuch of the practical work around the patients (Lannerheim,1994). Giving nurses even more administrative tasks was therefore notwithout problems. One chief nurse said: `The nurses have become secretariesand sense that the assistant nurses have taken over their working tasks.'Another nurse complained that she often had to ùndertake interviews' withthe assistant nurses to be able to document properly the caring given to thepatients. The reasonwas that the assistant nurses hadmuchmore contact withthe patients and often knew more about them than the nurse did herself, sinceshe was forced to spend so much time fulfilling administrative tasks.

Ìncreasing the Competence'at theWards

The urge to widen the distance between themselves and the assistant nurseswas apparent among the nurses at the Stockholm hospital, and argumentsbased on the New Public Management reforms were intertwined in thesefights. Generally the nurses thought there was a difference between their ownunderstanding of what it took to be working in a profit centre and the assistantnurses' understanding of the same situation. According to the nurses, theassistant nurses did not realize that one nowadays was forced to work harderand reduce costs.

But the most explicit attempt to widen the distance between the nurses andthe assistant nurses concerned the efforts to transform the assistant nurses'posts into nurses' posts, hence, to actually replace assistant nurses with nurses.In the previously mentioned contact group for chief nurses and head nurses,the issue of ìncreasing the competence level at the wards' was discussed. Oneof the chief nurses describes it like this:

We will try to improve the competence at the wards by replacing assistant nurses withnurses. By being more all-round, we will also become more cost efficient.

One argument for replacing the assistant nurses was that it would ìmprovethe competence' at the wards and thus make health care more `cost efficient'.

64 BLOMGREN


Articles in the nursing association's journal describing the situation at otherhospitals used the same argument (VÔrdfacket, 1/92, p. 4 ff.; VÔrdfacket, p. 7; 1/93, p. 7). At one thoracic clinic, one could read that they had decided not toappoint any assistant nurses at all under the motto: `Better health care for lessmoney' (VÔrdfacket, 1/92, p. 4). At the Stockholm hospital, the group ofassistant nurses and nurses' aides had been reduced from approximately 26%in 1992 to 21% in 1994. For doctors and nurses, the trend was the reverse.Doctors had increased from 10% to approximately 12%, and nurses from34% to 38%, in these two years.

In conclusion one could say that, contrary to the process of ordering nursesinto administrative leaders, the organizing principles reinforced by theStockholm model, such as an increased cost-consciousness and enhancedpatient turnover rate, were not welcomed by the nurses as experts in caring.They thought that caring was suffering from these changes and their work wasbordering on the impossible. The countermove was thus to establish qualityassurance programs and, while doing so, nurses also engaged in jurisdictionalfights with the assistant nurses.

CONCLUDINGDISCUSSION

This paper has addressed the question of professional responses to, andhandling of, New Public Management reforms in the context of Swedishhealth care. From previous research we could expect a variety of outcomesfrom such an encounter, everything from fierce resistance to hybridizationdue to the professionals' willing adoption of new managerial techniques. Thispaper has shown that the responses we observe might be dependent on whichpart of the profession is in focus. The reforms do not necessarily have a uniformimpact due to the simple fact that professions are not homogenous groups. Inthis paper, a perspective on professions as internally heterogeneous, asembracing varying ideas of professional identity, has been adopted. It hasbeen claimed that the processes by which professionals try to realize theseideas are carried out both in relation to other segments within the professionand in relation to other professions and occupational groups. The concept ofordering has been applied to describe this.

The empirical investigation showed that the ordering processes within thenursing profession provided quite different conditions for the encounter withthe reforms. Overall, it seemed that the transformations brought about by theNew Public Management reforms aligned more easily with the process ofordering nurses into administrative leaders than with the process of orderingnurses into experts in caring. Even though the transformation did notautomatically provide nurses as administrative leaders with an extendedmanagerial authority (in terms of financial responsibility), the overallchanges did not severely challenge nurses' thinking about how health care



should be organized and controlled. On the contrary, nurses as administrativeleaders were, for instance, happy that the previous unclear reportingconcerning costs was in better order, that the personnel worked harder, andthat the turnover rate of patients was faster. In short, nurses as administrativeleaders thought health care had improved by this. And those chief nurses whohad been delegated the financial responsibility for their wards were evenmorecontented as they felt that their positions as head of their wards had beenacknowledged, and that their relation to the medical profession had beenstrengthened.

For nurses as experts in caring, however, the transformations were not asunproblematic. These nurses had obvious problems protecting the integrityof their caring work in a health care organization where the increased cost-consciousness and patient turnover rate had become important principles.They were placed in a situation in which they were torn between the ideals oftheNewPublicManagement reforms and those of being experts in caring, andthese ideals seemed to be very much opposed to each other. Caring takes time,which of course goes for all kinds of health care treatments, but it seemed likethe extra time required to care for patients was easiest to sacrifice when thedemands of increased performance had to be met. As a consequence, patientswere sent home before they were emotionally and psychologically prepared,and patients with only a few days left to live were moved. In these situations,and when it was considered too costly to pay personnel to sit with dyingpatients, not only the patients, but also the ideals of the nurses as experts incaring, suffered.

Even though the two ideas of the nurses' professional identity provideddifferent conditions for the encounter with the reforms, the analysis showedthat elements from the reforms were intertwined in nurses' ordering processes,hence, even in the process of ordering nurses into experts in caring. To protectthe quality of caring from possible negative effects of the reforms, nursesargued for the need to establish quality assurance programs. This proposalconstitutes one example of the ways in which the profession actively tried totranslate (Latour, 1987) the New Public Management reforms and theireffects in a way that would simultaneously further their professionalambitions. Besides preserving the quality of the practical caring work, thequality assurance programs would also pinpoint nurses' work and therebyremedy one great problem in the process of ordering nurses to experts in caringthat nurses' work with caring is considered invisible to others (Bowker andStar, 1999). As for the process of ordering nurses into administrative leaders,the ambitions to provide head nurses, instead of senior physicians, with thefinancial responsibility for clinical wards could, correspondingly, be seen assuch a translation, promoting the nurses' positions in relation to the medicalprofession.

This shows that the attempts to create consensus around questions ofidentity and practices, and the ambitions to act accordingly, simultaneously

66 BLOMGREN


imply quite concrete efforts to carve out a space in relation to others. Thenurses' two ordering processes have historically entailed jurisdictionalstrategies directed against nearby professions and occupational groups. Thetarget for the process of ordering nurses into administrative leaders has tendedto be the medical profession, while in the process of ordering nurses intoexperts in caring it has mainly been subordinate groups such as the assistantnurses. The analysis shows that the way the reforms were handled within theprocesses of ordering nurses into administrative leaders and experts in caringsimultaneously involved jurisdictional strategies directed against thephysicians and assistant nurses. One important reason why the nursingprofession supported the idea of delegation of financial responsibility was theexpectation that this would strengthen the head nurses' positions in relation tothe physicians. Against the backdrop of the lost battle over the `chief-physician' reform, the financial responsibility introduced by the Stockholmmodel gave nurses a new chance to extend their administrative authority.Likewise, the idea of making health care more cost efficient by replacingassistant nurses with nurses could be seen as a strategy directed againstsubordinate groups that had become increasingly threatening.

Lastly, if professions are internally heterogeneous, it means that each ofthem provides different conditions for hybridization in the encounter withthe new managerial reforms. Acknowledging the various tools embraced bythe New Public Management reforms as technologies (Miller, 1994), withthe capacity of transforming clinical units into profit centres, for instance,one could say that the nurses' two ordering processes took on a slightlydifferent meaning after the encounter. As has been said, the New PublicManagement reforms did align with the ambitions of ordering nurses intoadministrative leaders, just as the profession itself predicted they would in itsfirst campaign. But the reforms also marked a difference. Nurses now had toengage in the financial side of health care, promote the efficiency andproductivity of the work at the clinical ward, and take an interest inmarketing. Even though the ideals of the reforms did not severely challengethe idea of nurses as administrative leaders, they nevertheless meant adifference in the sense that nurses should become leaders of a special kind ^more like managers.

As for the process of ordering nurses into experts in caring, the empiricalfindings suggest that the reforms implied a change in the sense that theycontributed towards the administrative part of the expert role. Since the idealsof the reforms were quite challenging to nurses as experts in caring, theencounter did not provide as favourable possibilities for hybridization as inthe case with nurses as administrative leaders. Nurses as experts in caringthought that their ability to carry out this aspect of their work was suffering,and they therefore installed quality assurance programs to protect it. Thismeant, however, that nurses had to spend much more time documenting theirwork. Added to the general trend of an increased amount of administrative



work for nurses, this can mean that previous ambitions to order nurses into`theoretical' experts in caring (Gustafsson, 1987, p. 385) have been replacedby attempts to order nurses into `administrative' experts in caring.

Documentation has been seen as a major strategy in the process of orderingnurses into experts in caring. One can, however, speculate about whetherthese ambitions might possibly become a double-edged weapon. Establishingformal classifications of nurses' work is `walking a tightrope between increasedvisibility and increased surveillance; between over-specifying what a nurseshould do and taking discretion away from the individual practitioner'(Bowker and Star, 1999, p. 29). Nurses' future position in the system ofprofessions might therefore be dependent on the way classifications such asquality assurance programs are used and controlled.

NOTES

1 The Swedish association for health professionals (VÔrdfÎrbundet) is a professional associationand trade union organizing Swedish nurses, midwives and biomedical scientists. Theassociation has approximately 112,000members, and the nursing group dominates with about86%. The association organizes approximately 94% of all nurses in Sweden (VÔrdfÎrbundet,2000). Due to the nurses' dominance, and for the sake of simplifying the following discussion,the association will be referred to as the Swedish nursing association. In this paper, it is seen asrepresenting the Swedish nursing profession.

2 To investigate this, empirical material from two main sources has been analysed. The firstsource consists of 20 interviews with head nurses, chief nurses, nurses, one clinicaladministrator, one clinical accountant and one representative of the Swedish nursingprofession's association. Most of the interviews took place at an emergency hospital in theStockholm area, `the Stockholm hospital' hereafter. The clinical administrator, therepresentative of the Swedish nursing profession's association, and one of the nurses did notwork at the Stockholm hospital and have therefore given information about nurses'professional roles and ambitions and the New Public Management reforms in general.The second source involves articles from the journal of the Swedish association for health

professionals (VÔrdfacket) during the period 1991^1995. The journal is directed to Swedishnurses, midwives and biomedical scientists but will, in the following, be referred to as thejournal of the Swedish nursing association. Between 1991^1994 it put out 20 issues per year,but in 1995 it changed form and turned into a monthly journal. VÔrdfacket is regarded as themost important source of information about the association both by representatives of theassociation at the central level and by its members (VÔrdfacket, 20/94, p. 5; 12/94, p. 4^7). Sinceit is relatively widely distributed, read and appreciated by its members (VÔrdfacket, 8/93, p.18), it has a quite vital role within the profession. It is principally a means of communicationfor representatives of the association's central level, but it does also contain the voices of itsmembers, for instance, in a letters-to-the-editors column and in articles with interviewednurses working in different locales.

3 The nursing profession's inferior position has also been analysed from a gender perspective, seee.g., Witz (1992) and Hugman (1991).

4 Today the situation has changed once again, and it is now possible for those other thanphysicians to be administrative leaders of clinical units (see Lag, 1996: 787, om Ìndring i hÌlsooch sjukvÔrdslagen, 1982: 763). At the time of the empirical investigation of this article,however, the `chief-physician' reform was still in legal force.

5 A person with a three-term education at an upper secondary school's health care programme isqualified for a position as an assistant nurse.

6 A person with a one-term education at an upper secondary school's health care programme isqualified for a position as a nurse's aide.

68 BLOMGREN


REFERENCES

Abbott, A. (1988),The System of Professions: An Essay on the Division of Expert Labor (The Universityof Chicago Press, Chicago).

Axelsson, R. (1990), SjukvÔrdsadministration i organisationsteoretisk belysning (Studentlitteratur,Lund).

BjÎrklund, E. (1997), `SjukskÎterskans tanke och sprÔk som medel fÎr kommunikation i vÔrden',in A. SarvimÌki (ed.), Reflektioner kring omvÔrdnad ^ frÔn huvudsatser, bisatser till slutsatser(VÔrdfÎrbundet SHSTF, Stockholm), pp. 65^81.

Borgert, L. (1992), Organisations som mode: Kontrasterande bilder av svensk hÌlso- och sjukvÔrd(FÎretagsekonomiska institutionen, Stockholms universitet, Stockholm).

Bowker, G.C. and S.L. Star (1999), Sorting Things Out, Classification and Its Consequences (The MITPress, Cambridge).

Broadbent, J. andR. Laughlin (1998), `Resisting the ``New PublicManagement'' Absorption andAbsorbing Groups in Schools and GP Practices in the UK', Accounting, Auditing &Accountability Journal, Vol. 11, No. 4, pp. 403^35.

BrorstrÎm, B. (1995), Styrningens villkor och effekter i professionella organisationer (Studentlitteratur,Lund).

Brunsson, N. and K. Sahlin-Andersson (2000), `Construction Organizations: The Example ofPublic Sector Reform', Organization Studies, Vol. 21, No. 4, pp. 721^46.

Bucher, R. and A. Strauss (1961), `Professions in Process', American Journal of Sociology, Vol. 66, pp.325^34.

Charpentier, C. and L. A. Samuelson (1999), Effekter av en sjukvÔrdsreform en analys avStockholmsmodellen (Nerenius & Santerus, Stockholm).

Coombs, R. W. (1987), `Accounting for the Control of Doctors: Management InformationSystems in Hospitals', Accounting, Organizations and Society, Vol. 12, No. 4, pp. 389^404.

Cyert, R. M. and J. G. March (1963), ABehavioral Theory of the Firm (Prentice-Hall).Ds S (1984: 12), `Vissa ansvarsfrÔgor i hÌlso- och sjukvÔrd: betÌnkande', inUtredningen fÎr Îversyn av

vissa ansvarsfrÔgor inom hÌlso- och sjukvÔrden (Socialdepartementet, Stockholm).Emanuelsson, A. (1990), PionjÌrer i vitt: professionella och fackliga strategier bland svenska sjukskÎterskor

och sjukvÔrdsbitrÌden, 1851^1939 (VÔrdfÎrbundet SHSTF, Stockholm).Forssell, A. and D. Jansson (1996), `The Logic of Transformation: On the Conversion of Non-

Business Organization', in B. Czarniawska and G. Sevon (eds.), Translating OrganizationalChange (Walter de Gruyter, Berlin), pp. 93^115.

Greenwood, R. and R. Lachman (1996), `Changes as an Underlying Theme in ProfessionalService Organizations: An Introduction',Organization Studies, Vol. 17, No. 4, pp. 563^72.

Gustafsson, R. Ð. (1987), Traditionernas ok: den svenska hÌlso- och sjukvÔrdens organisering i historie-sociologiskt perspektiv (Esselte studium, Stockholm).

Hansen, H. (1999), `KlinikadministratÎrer: makt och fÎrÌndring', in K. Lampou and B.Anderson (eds.), Studier i sjukvÔrdsorganisation: om ekonomistyrning, ledarskap och fÎrÌndring inomsvensk sjukvÔrd (Uppsala University, Uppsala).

Heyman, I. (1995), GÔnge hatt till . . . OmvÔrdnadsforskningens framvÌxt i Sverige ^ sjukskÎterskorsavhandlingar 1974^1991 (Daidalos, GÎteborg).

Hood, C. (1995), `The `New Public Management' in the 1980s: Variations on a Theme',Accounting, Organizations and Society,Vol. 20, No. 2/3, pp. 93^190.

HSL, 1982:763, HÌlso- och sjukvÔrdslagen (Stockholm).Hugman, R. (1991), Power in Caring Professions (Macmillan, London).Jacobsson, B. (1994), `Reformer och organisatorisk identitet', in B. Jacobsson (ed.),

Organisationsexperiment i kommuner och landsting (Nerenius & Santerus, Stockholm), pp. 38^61.Kitchener, M. (2000), `The `Bureaucratization' of Professional Roles: The Case of Clinical

Directors in UKHospitals', Organization, Vol. 7, No. 1, pp. 129^54.KurunmÌki, L. (1999), `Professional vs. Financial Capital in the Field of Health Care ^ Struggles

for the Redistribution of Power and Control', Accounting, Organizations and Society, Vol. 24,No. 2, pp. 95^124.

________________________ (2000), `Power Relations in the Health Care Field: Accounting, Accountants, andEconomic Reasoning in the New Management Reforms in Finland', JyvÌskylÌ: JyvÌskylÌnYlopisto.

Lag (1990:601) om Ìndring i hÌlso- och sjukvÔrdslagen (1982: 783).



Lag (1996: 787) om Ìndring i hÌlso- och sjukvÔrdslagen (1982: 763).Lannerheim, L. (1994), Syster blir till (Sociologiska institutionen, GÎteborgs universitet,

GÎteborg).Latour, B. (1987), Science in Action (Harvard University Press, Cambridge).Law, J. (1994),OrganizingModernity (Blackwell, Oxford).Lindvall, J. (1997), Resultatansvar i sjukvÔrden (Nerenius & Santerus, Stockholm).Llewellyn, S. (1994), `Managing the Boundary: How Accounting is Implicated in Maintaining

the Organization', Accounting, Auditing and Accountability Journal, Vol. 7, No. 4, pp. 4^23.Melander, P. (1997), `Òkonomistyring i videnbaserede og politiske organisationer ^ om at

implantere Ökonomisk rationalitet i organisationer, hvor andre v×rdier er dominerende',Òkonomistyring& informatik, No. 3, pp. 159^88.

Miller, P. (1994), Àccounting as a Social and Institutional Practice: An Introduction', in A.G.Hopwood and P. Miller (eds.), Accounting as a Social and Institutional Practice (CambridgeUniversity Press, Cambridge), pp. 1^39.

________________________ and T. O'Leary (1987), Àccounting and the Construction of the Governable Person',Accounting, Organization and Society,Vol. 12, pp. 235^65.

Olson, O. andK. Sahlin-Andersson (1998), Àccounting Transformation in anAdvancedWelfareState: The Case of Sweden', in O. Olson et al. (eds.), Global Warning! Debating InternationalDevelopments in New Public Financial Management (Cappelen Akademisk Forlag, Oslo), pp.241^75.

________________________ et al. (1998), Global Warning! Debating International Developments in New Public FinancialManagement (Cappelen Akademisk Forlag, Oslo).

Ústergren, K. and K. Sahlin-Andersson (1998), Att hantera skilda vÌrldar: lÌkares chefskap i mÎtetmellan profession, politik och administration (LandstingsfÎrbundet, Stockholm).

Power, M. (1997), The Audit Society (Oxford University Press, Oxford).Rydholm, I. M. (1992), Att leda vÔrd ^ utveckling i nordiskt perspektiv (SHSTF, Stockholm).Sahlin-Andersson, K. (1994), `Group Identities as the Building Blocks of Organizations: A Story

about Nurses' Daily Work', Scandinavian Journal ofManagement, Vol. 10, pp. 131^45.Scott, R. et al. (2000), Institutional Change and Health Care Organizations: From Professional Dominance

toManaged Care (The University of Chicago Press, London).SFS (1985: 562) Patientjournallagen, svensk fÎrfattningssamling (Liber, Stockholm).SOSFS (1993: 17), OmvÔrdnad inom hÌlso- och sjukvÔrden (Socialstyrelsen, Stockholm).________________________ (1996: 24), KvalitetssÌkring i hÌlso- och sjukvÔrd inklusive tandvÔrd (Socialstyrelsen,

Stockholm).Spri-rapport (1994: 381), Stockholmsmodellen: beslutsbefogenheter och ekonomiskt ansvar (Spri,

Stockholm).UHØ/SÚ (1981), Utbildningsplan fÎr hÌlso- och sjukvÔrdslinjen (SkolÎverstyrelsen, Stockholm).VÔrdfacket (1991), `FÎrÌndringar ger mÎjligheter!', No. 1, p. 3.________________________ (1991), `KvalitetssÌkring tar tid ^ och mÔste fÔ ta tid', No 10, p. 6.________________________ (1991), `Vems intressen vÌger tyngst?', No. 12, p. 3.________________________ (1991), `Den rÌttvisa vÔrden', No. 18, p. 3.________________________ (1992), Èffektiv klinik satar pÔ sjukskÎterskor', No. 1, p. 4^7.________________________ (1992), `KvalitetssÌkra vÌlkomnandet!', No. 5, p. 8^9.________________________ (1992), `Kitsons modell visar vÌgen', No. 5, p. 11.________________________ (1992), `Snart flygfÌrdiga medlemmar mÔlet fÎr stor SHSTF-satsning', No. 17, p. 3.________________________ (1993), `Nu sjuder det av fÎrÌndringsvilja', No. 1, p. 6^7.________________________ (1993), `Modellen fÎr de starka', No. 3, p. 4.________________________ (1993), ÒmvÔrdnadsjournal en trygghet fÎr alla', No. 3, p. 23.________________________ (1993), `Tio krav fÎr bÌttre vÔrd', No. 6, p. 6^7.________________________ (1993), `NedskÌrningar hotar svaga grupper', No. 6, p. 7.________________________ (1993), `VÔrdfacket viktigt fÎr SHSTF:s medlemmar', No. 8, p. 18.________________________ (1993), `Har SHSTF medlemmarnas stÎd fÎr nya sjukskÎterskerollen?', No. 13, p. 20^21.________________________ (1993), ÒmvÔrdnaden lyfts fram i nytt manifest', No. 14, p. 24^26.________________________ (1993), `Komplexiteten i yrket gÎr sjukskÎterskan unik', No. 15, p. 12^13.________________________ (1993), `SjukskÎterskor kvalitetshÎjer?', No. 15, p. 13.________________________ (1993), `Dokumentation hÎjer kvaliteten', No. 16, p. 13^14.________________________ (1993), ÒmvÔrdnad Ìr ocksÔ medicinskt kunnande', No. 16, p. 45.________________________ (1993), ÒmvÔrdnaden hÎjer inte sjukskÎterskans status', No. 16, p. 46^47.

70 BLOMGREN


VÔrdfacket (1993), `VÔrdlag stÌrker omvÔrdnaden', No. 16, p. 46^47.________________________ (1993), Ùrgamla kvinnoroller i dagens sjukvÔrd', No. 18, p. 20.________________________ (1993), `Medicinska kunskaper Ìr en fÎrutsÌttning', No. 18, p. 21.________________________ (1993), `Vi mÔste sÌga vad vi tycker', No. 18, p. 21.________________________ (1993), `SjukskÎterskans yrkesroll fÎrÌndras fÎrvisso', No. 18, p. 22^23.________________________ (1993), `ParvÔrd Ìr en fÎrsÌmring', No. 18, p. 23.________________________ (1993), ÒmvÔrdnad sÌtter patienten i centrum', No. 18, p. 24.________________________ (1993), `BÔda kunskaperna Ìr nÎdvÌndiga', No. 18, p. 24.________________________ (1993), `Slutreplik: En bra debatt om den framtida rollen', No. 18, p. 25.________________________ (1994), ÒmvÔrdnaden tas upp pÔ nytt', No. 3, p. 18.________________________ (1994), `Patienten Ìlskar omvÔrdnad', No. 3, p. 18.________________________ (1994), `Kunskaper behÎvs inte teorier', No. 3, p. 19.________________________ (1994), `Vardagsarbetet vinner pÔ omvÔrdnadsteorier', No. 3, p. 19.________________________ (1994), `FÎr mycket omvÔrdnad', No. 3, p. 19.________________________ (1994), `Vad hÌnder med vÔra lÎner', No. 3, p. 20.________________________ (1994), `Liten synpunkt pÔ omvÔrdnaden', No. 6, p. 16.________________________ (1994), `Hellre vÔrdmedicin Ìn omvÔrdnad', No. 6, p. 16.________________________ (1994), `SÎkandet efter omvÔrdnaden', No. 6, p. 26^27.________________________ (1994), `Ja till forskningsmetodik och omvÔrdnadsteorier', No. 6, p. 16.________________________ (1994), `MedlemsenkÌten visar stort missnÎje med lÎnen', No. 12, p. 4^7:________________________ (1994), Òlydnad har varit drivkraften', No. 17, p. 18^21.________________________ (1994), `Dokumentation behÎvs fÎr att arbetet ska synas', No. 19, p. 20^21.________________________ (1994), `Med nya VÔrdfacket ska fÎrbundet mÎta 2000^talet', No. 20, p. 5.________________________ (1995), `Kvalitet ett begrepp som kommit fÎr att stanna', No. 2, p. 17^18.________________________ (1995`), `Gemensamma begrepp underlÌttar omvÔrdnaden', No. 11, p. 44^46.VÔrdfÎrbundet (2000), VÔrdfÎrbundet i siffror ^ statistik Îver medlemmar, lÎner, utbildning och

arbetsmarknad 1999 (VÔrdfÎrbundet, Stockholm).Waks, C. (1999), Òpening up a Profession', in M. Dent et al. (eds.), Professions, New Public

Management and the European Welfare State (University Press, Stoke-on Trent Staffordshire),pp. 167^83.

Witz, A., (1992), Professions and Patriarchy (Routledge, London).



Ordering a Profession: Swedish Nurses Encounter New Public Management Reforms

Documents

Transcript of Ordering a Profession: Swedish Nurses Encounter New Public Management Reforms