All the good care: Valuation and task differentiation in older person care

Who cares about the dying? - Unpacking integration of palliative care and oncology in the Danish context

Integrating palliative care into the trajectories of patients with incurable cancer has been a priority for years. Yet, the intended outcomes of this integration remain elusive. Many patients with advanced cancer continue to receive so-called aggressive treatments in the end-of-life phase or miss out on specialised palliative care entirely. To examine this impasse in the Danish context, we employ the concept of professional value scripts to analyse policy documents and guidelines aimed at guiding professionals working with this patient group. The three identified scripts - cancer treatment, medical palliation and holistic palliative care - embody a distinct understanding of integration, contributing to the challenges of forging an integrated approach. We argue that the central role of the cancer treatment script in patient trajectories creates an obligatory passage point, influencing both the symbolic and practical enactment of integrated palliative care throughout these trajectories.

Reorganizing medical care for older persons in times of scarcity: A cybernetics analysis of work pressure and organizational change

Capacity problems in healthcare lead organizations to seek new and fluid ways of organizing care to safeguard access to services. Task reallocation, triage and stepped care models are increasingly foregrounded as promising interventions that enhance the capacity, efficiency, and resilience of medical services and through which access can be maintained for a growing client base. In this paper, we argue that interventions meant to enhance capacity and increase efficiency have their limits in a system that is already under strain. We draw on the cybernetics of Gregory Bateson and his concept of 'budgets of flexibility' to understand how stress accrues in systems and depletes their capacity for adaptive change. We analyze a case in which regional evening, weekend and night shifts (EWNs) were organized for nursing homes, which included the implementation of a new triage system and task reallocation between various professionals. We show how this initiative rerouted and reprocessed information pathways between professionals, and how this rewiring resulted in a buildup of stress and concomitant emotions of frustration, anxiety, fear and disempowerment through four different mechanisms: (1) fragmentation of information flows; (2) accumulation of information; (3) a loss of richness of information, and (4) slow-moving information flows. The accrual of stress depleted the overall capacity for adaptive change in the system and eventually culminated in a partial breakdown of the new medical service.

Human resource management in homecare in England: managing people for safe care during crisis

BACKGROUND

Human resource management (HRM) of healthcare organisations plays an important role in improving the continuity of care, managing staff, and ensuring patient safety. During COVID-19, there were several HR-related issues, creating a significant challenging situation for health and social care institutions. This study explored the HRM issues that are associated with the patient safety in homecare, and how homecare providers have responded to these HR-related challenges during the COVID-19 pandemic. The aim of this is to explore the role of HRM practices in helping care organisations operate efficiently and supporting their workforce to adapt to future disruptive changes and crises.

METHODS

Qualitative strategies include narrative inquiry involving gathering information in the form of storytelling by the research participants. Between February 2021 and December 2021, data were collected through semi-structured interviews of 31 participants, including homecare staff (homecare transition practitioners, homecare social workers, and carers), family members, and service users in England.

RESULTS

The research identified key HRM challenges during the pandemic, including staff shortages, high turnover, ineffective communication, occupational stress for front-line carers, and lack of training, all adversely affecting the safety of homecare patients. In response, homecare providers employed strategies like opportunistic recruitment, digital technology for training and communication, and flexible work arrangements to mitigate these issues.

CONCLUSIONS

Several implications are proposed, with the over-riding aim of ensuring effective management of HRM practices in responding to address key areas: staffing, performance management, and training. Homecare providers should utilise short-term adaptive recruitment strategies, while also focusing on long-term workforce development and resilience to effectively respond to current and future care needs. Prioritising staff well-being for retention and care quality are crucial. Homecare providers are encouraged to offer flexible work arrangements and digital communication methods, all while being mindful of preventing technostress and digital exhaustion among their staff. They also need to bridge training gaps and employ effective delivery methods to equip healthcare workers with essential skills, thereby enhancing resilience and adaptability in homecare.

The hidden work of general practitioners: An ethnography

High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity.

'The night is for sleeping': how nurses care for conflicting temporal orders in older person care

This paper examines the conflicting temporal orders of the regional nurse, a role which has been introduced to deal with the increasing demands of aged care and workforce shortages in regional settings. We build on ethnographic research in the Netherlands, in which we examine regional district nurses as a new professional role that attends to (sub)acute care needs, connecting and coordinating different places of care during out of office hours. We use the concept of 'temporal regional order' to reflect on the different ways caring practices are temporally structured by management and care practitioners, in close interaction with patients and informal care givers. In the results three types of disruptions of the regional temporal order are distinguished: interfering bodily rhythms and needs; (un)expected workings of technologies; and disrupting acts of patient and relatives. It was region nurses' prime responsibility to stabilise these interferences and prevent or soften a disruption of the regional order. In accomplishing this, we show how nurses craft their professional role in between various care settings, without getting involved too much in patient care, to be mobile as 'temporal caregivers'.

"We don't experiment with our patients!" An ethnographic account of the epistemic politics of (re)designing nursing work

This article draws on ethnographic research investigating experimental reform projects in local nursing practices. These are aimed at strengthening nursing work and fostering nurses' position within healthcare through bottom-up nurse-driven innovations. Based on literature on epistemic politics and critical nursing studies, the study examines and conceptualizes how these nurses promote professional and organizational change. The research draws on data from two pilot projects to show how epistemic politics frame the production and use of knowledge within reform efforts. The study finds that knowledge produced through such experimenting is often not considered valid within the contexts of broader organizational transitions. The nurse-driven innovations fail to meet established legitimate criteria for informing change, both among stakeholders in the nurses' socio-political environment, as well as within the nursing community. The research reveals that the processes inadvertently reinforce normative knowledge hierarchies, perpetuating forms of epistemic injustice, limiting both nurses' ability to function as change agents and healthcare organizations' capacity to learn.