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Logistics of care: Trust-reform and self-managing teams in municipal home care services

Published online by Cambridge University Press:  19 June 2023

Helle Cathrine Hansen*
Affiliation:
Norwegian Social Research, NOVA, Oslo Metropolitan University, Oslo, Norway
Cecilie Basberg Neumann
Affiliation:
Department of Social Work, Child Welfare and Social Policy, Oslo Metropolitan University, Oslo, Norway
*
Corresponding author: Helle Cathrine Hansen; Email: hellca@oslomet.no
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Abstract

The central idea in trust-reform is to improve service delivery by granting professional autonomy and acknowledging the experiential knowledge of professionals. In this article, we study trust-reform bottom-up from the perspective of frontline care workers. Our aim is to discuss the challenges for care work and care workers who have been organised in self-managing teams, paying particular attention to the organising of the daily work in the teams. This study draws on data from four months of fieldwork in Norwegian municipal home care services for older people. The article sheds light on some problematic aspects in trust-reform regarding the relationship between frontline workers’ autonomy and responsibility on the one hand and the lack of authority and managerial support on the other hand. The study demonstrates that trust-reforms within public service delivery can be experienced as delegation of logistical tasks and enhanced responsibility instead of delegation of the authority that is necessary for professional care work to be performed. As such, trust-reforms risk obstructing rather than advancing their declared intentions of strengthening professional agency in care work, and rather than distributing management tasks, trust-reforms need to strengthen the management function in order to succeed.

Type
Article
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© The Author(s), 2023. Published by Cambridge University Press

Introduction

Over the past four decades the public sectors, including eldercare services, in European and Nordic countries have been shaped by ideas from New Public Management (NPM), resulting in welfare service organisation and delivery being based on principles of managerialism, efficiency and performance measurements (Dahl, Reference Dahl2017; Vabø, Reference Vabø2009). Strict and detailed governing and specialisation of tasks was expected to optimise and enhance the quality of welfare services while saving money (Borge and Haraldsvik, Reference Borge and Haraldsvik2009). However, the NPM-inspired regime rather resulted in enhanced bureaucratisation, fragmentation and inflexible service provision (Hansen and Helgesen, Reference Hansen and Helgesen2011; Otnes, Reference Otnes2015; Vabø, Reference Vabø, Engelstad and Hagelund2015; Vallentin and Thygesen, Reference Vallentin and Thygesen2017). Criticisms and suggestions on how to remedy the negative effects of NPM’s intensification of control of professionals’ knowledge and autonomy through standardisation and bureaucratisation in welfare service provision have culminated in welfare reforms (Torfing et al., Reference Torfing, Greve and Klausen2020). In the European context, there has been a trend towards more collaborative and horizontal modes of governing public services, expressed as New Public Governance (NPG) reforms. Building on relational trust these reforms aim “to enhance(s) public service motivation and expand(s) the room for employee discretion” (Torfing et al., Reference Torfing, Greve and Klausen2020, p. 125). Likewise, co-creation and co-production, through citizens involvement in designing and implementing welfare policies, reflects this trend towards a joint effort to improve welfare service provision (Brandsen, Steen and Verschuere, Reference Brandsen, Steen and Verschuere2018). In the Nordic context the collaborative trend ties in with trust-reforms. The idea is that trust-reforms will contribute to reshape public welfare services in a dual vein. A smarter use of resources and increased trust in professionals’ autonomy will give more user-friendly services (Kommunal- og distriksdepartementet, 2022).

The aim of this article is to discuss the challenges for professional care work in municipal home care services that has implemented a so-called trust-reform and reorganised the care workers into self-managing teams. We address the challenges for professional care work through the experiences of care workers who are granted professional autonomy and simultaneously left with the responsibility for organising the provision of care. We ask the following question: What happens to care work when care workers are granted autonomy and responsibility through self-managing teams within trust-reform?

Inquiring into some of the basic premises in trust-reform, such as relationality, responsibility, task management and trust, we analyse what happens to the care work when turning to horizontally organised self-managing teams. Key to our findings is that the managerial level does not seem to provide sufficient support for the teams’ day-to-day work. As we shall see, this leaves the care workers with an intensified personal and collective responsibility for provision of care, which is disconnected from the impact on wider institutional and economic arrangements in the care service. The main contribution of our study is that trust-reforms within public service delivery based on ideas of delegation of responsibility to the frontline-workers easily can be experienced as delegation of logistical tasks and responsibilities instead of delegation of authority for professional care work to unfold. As such, trust reforms risk obstructing rather than advancing their declared intentions of strengthening professional agency in care work. Hence, we argue that rather than distributing management tasks, trust-reforms need to strengthen the management functions in order to succeed.

Before we elaborate on our case, we briefly present some current scholarly contributions on trust-reforms and self-organised teams in welfare services.

Trust-reforms in public services

Trust-reforms in public sector depart from a will to trust professionals and to acknowledge professional skills and competencies and to lessen hierarchical control and bureaucratic procedures (Eide, Reference Eide2021). As such, trust is inherently relational and denotes how human beings have to trust others when navigating the world under uncertain conditions of which one cannot have control (Husted and Just, Reference Husted and Just2022). Trust-reforms in public sector may target different levels and involve different types of relationships accordingly: for instance, the relationship between local authorities and the state (as in governance or administrative reforms); the relationship between leaders and employees (as in organisational or management reforms); and/or the relationship between frontline workers and service users (as in reforms aiming at improving services through citizen co-production and co-creation) (Brandsen et al., Reference Brandsen, Steen and Verschuere2018; Direktoratet for forvaltning og økonomistyring, 2023; Eide et al., Reference Eide, Gullslett, Eide, Dugstad, McCormack and Nilsen2022).

Bentzen (Reference Bentzen2019), who studied the implementation of trust-reform in Denmark in 2013, shows how municipalities have attempted to decrease the control and bureaucratic procedures between politicians and public employees through stewardship. Here, politicians’ trust in public employees is key to the lessening of control and an orientation towards new collaborative practices. To Bentzen (Reference Bentzen2019), the shift from NPM to trust-based governance and organisation of public services intersects with an ontological shift in the understanding of human actors in work life. Trust-based governance implies that governments and leaders trust employees’ dedication and willingness to do their work in cooperation with the organisation’s goals. Instead of viewing actors mainly as rational actors, i.e. self-centred and driven by pursuing their own goals, actors are also seen as interested in and capable of collaboration and pursuing common organisational goals. This ontological shift is inherently relational and forms an important basis for trust-reforms regardless at what level the reform takes place (whether it being governance or organisational reforms). Hence, it follows that not only workers but also leaders must be part of concrete trust-based designs (Klemsdal et al., Reference Klemsdal, Andreassen and Breit2022). Trust-based governance and organisation not only implies leaders who are willing to trust their employees; it also implies leaders who are willing to collaborate with their employees. For example, rather than dictating a preferred course of action in a policy-driven change of professional conduct, leaders attempting to work trust-based will facilitate change by attempting to find courses of action and ways of solving tasks beneficial to clients, professional workers and organisational goals.

Similarly, Klemsdal and Kjekshus (Reference Klemsdal and Kjekshus2021) studied managers’ responsibility for facilitating employees in adapting their work, asking how trust can be maintained through reform plans within labour and welfare services. To them, “trust (is) a social process (that) can be maintained and enhanced in situations that must have space for uncertainty to unfold and at the same time contain reasons for confidence, providing a degree of closure” (p. 242). Simultaneously, managers should commit to facilitating employees’ work by solving the everyday problems that occur in frontline service delivery along with reform implementation. In this way, reforms are shaped as pragmatic responses through collaboration and ‘situational work’ (Klemsdal et al., Reference Klemsdal, Andreassen and Breit2022, p. 4). Key to trust-based governance and organisation, is that trust is relational and processual, involves collaboration and negotiations of responsibility and finds the right balance between leaders’ involvement and control and the management of uncertainty (Julsrud, Reference Julsrud2018).

Trust-based governance in welfare organisations is closely connected to self-managing of teams. In 1993, Barker conceptualised self-managing ideals – typically based on horizontal social relations with a collective responsibility in the team to organise and perform the work. The self-managing perspective represents a shift from hierarchical supervision and top-down control of the workflow to collaborative management of the work. This means that instead of workers being told what to do by a supervisor or a designated leader, self-managing workers must gather and synthesise information, act on it and take collective responsibility within the team for those actions. While top management often provides a value-based corporate vision that guides the workers’ daily work and has responsibility for the budget, self-managing teams are usually responsible for completing a specific, predefined job function, and the team members are trained to perform any task the work requires (Proença, Reference Proença2010). They also have the authority and responsibility to make the essential decisions necessary to complete their functions. Furthermore, “along with performing their work functions, members of a self-managing team set their own work schedules, order the materials they need, and do the necessary coordination with other groups” (Barker, Reference Barker1993, p. 414). In this way, self-managing is expected to increase employee motivation, productivity and commitment.

According to Proença (Reference Proença2010), the design of self-organising teams aims to “align individual motivation with organizational objectives” (p. 338), as in trust (Eide, Reference Eide2021). The successful organisation of workers into self-organised teams depends, as a minimum, on the leaders’ will to loosen control, as well as on the leaders’ will and capacity to collaborate with employees (Bondas, Reference Bondas2018), and where the development of trust is about establishing and maintaining space for individual autonomy (Husted and Just, Reference Husted and Just2022). The development of trust in self-organised teams may also entail the management of uncertainty and control through agile leadership (Parker, Holesgrove and Pathak, Reference Parker, Holesgrove and Pathak2015). Hence, the success of self-organised teams depends on concrete support and follow-up from management or leaders (Bentzen, Reference Bentzen2019; Eide, Reference Eide2021).

While these contributions on trust-reforms and self-organised teams provide interesting theoretical perspectives on the turn from hierarchical and bureaucratic organisational designs to the conditions for (successful) collaborative enterprises, their perspectives are mainly based on the managerial level´s collaboration with workers. However, frontline workers’ practices are also recognised as playing an important role in welfare service reform implementation (Carstenen et al., Reference Carstensen, Burau, Dahl and Hald2021; Lipsky, Reference Lipsky2010). Carstensen et al. (Reference Carstensen, Burau, Dahl and Hald2021) demonstrates how frontline care workers through their everyday practices contributed to welfare service governance reform aiming at holistic services to elderly in Danish municipalities. In line with their focus on frontline care workers, our study contributes with a bottom-up perspective on care work and care workers’ practice following from a welfare service governance and organisational reform. Before we proceed, we will give a brief account of the complexity of care work regarding its relational content and conduct, and administrative procedures and management.

Care work on the ground

Care work is highly complex and contextual (Carstensen et al., Reference Carstensen, Burau, Dahl and Hald2021) and is typical of what Lipsky (Reference Lipsky2010) calls frontline work. Care workers work under constant pressure and in an everlasting gap between demands and resources. They work in one-to-one interactions with service users, yet they are held accountable in a multidimensional web of relations consisting of co-workers, managers, politicians, service users, next of kin, etc. (Hansen, Reference Hansen2022; Hupe and Hill, Reference Hupe and Hill2007). They negotiate time and tasks in uncertain situations and, through their discretionary power decide who gets what when and thereby contribute to the making of policy on the ground (Zacka, Reference Zacka2017). Trust and delegation of autonomy are necessary requirements for frontline care workers to handle comprehensive tasks in uncertain situations, and the aim with the trust-reform in home care services was exactly to strengthen professional care work through enhanced trust and autonomy for the care workers in their everyday work.

As scholars have pointed out, regardless of specific organisational arrangements, the time pressure under which home care workers perform is paramount. Several studies have emphasised the significance of time and the importance of understanding the temporal aspects of professional agency in terms of how home care work is managed and organised (Adams et al., Reference Adams, Robert and Maben2012; Bergschöld, Reference Bergschöld2018; Carstensen et al., Reference Carstensen, Burau, Dahl and Hald2021; Hirvonen and Husso, Reference Hirvonen and Husso2012; Tufte, Reference Tufte2013). Hirvonen and Husso (Reference Hirvonen and Husso2012) demonstrate how institutional demands and requirements about efficiency shape care workers’ agency and how ‘working on a knife’s edge’ may undermine the relational nature of professional care work and, as a result, ultimately damage both care workers’ professionalism and their delivery of care to service users. As Lewis and West (Reference Lewis and West2014) have pointed out: “Focussing entirely on either the carer or the care user is problematic; consideration of the care relationship leads to an emphasis on interdependence [.]” (p. 4). Adams et al. (Reference Adams, Robert and Maben2012) emphasise the role of care workers’ informal exchange of information as pivotal for providing good care and how the ever-increasing work pressure erodes the possibilities for such ‘catching ups’ during their shifts. Tufte (Reference Tufte2013) suggests that time pressure reduces care workers’ flexibility and challenges their authority while still leaving them with the responsibility for performing care work according to professional standards.

Against this backdrop, we will investigate what happens to care work based on frontline care workers’ experiences in their everyday work with service users when turning from NPM and strict organisational hierarchies to horizontal self-managing teams based on trust.

Empirical context

Norway is characterized as part of ‘the Nordic model’ (Esping-Andersen, Reference Esping-Andersen1990; Knutsen, Reference Knutsen2017; Haug, Reference Haug, Takle, Vedeler, Schoyen, Klette and Falck-Eriksen2023). The Nordic welfare model is based on universal social rights, in which the state provides (i) social security through redistribution, (ii) protection against social risks and (iii) access to the satisfaction of basic needs for all citizens. Thus, the Nordic welfare states are all countries that, to a considerable extent, guarantee the citizens help if they should suffer from health failure, social distress, or a loss of income (e.g., in the event of unemployment or old age) (Haug, Reference Haug, Takle, Vedeler, Schoyen, Klette and Falck-Eriksen2023). In addition – important for the analyses in this paper – Norway has a highly decentralised political system with core welfare functions allocated to local governments that operate with significant autonomy from the state (Ladner et al., Reference Ladner, Keuffer, Baldersheim, Hlepas, Swianiewicz, Steyvers and Navarro2019).

The responsibility for providing health care services, including homebased services to older people, is delegated from the state to the municipalities through annual block grants. Citizens’ right to homebased services is regulated in the health- and social services act (Helse- og omsorgsdepartementet, 2011). In addition, there is a regulation stating older citizens’ right to receive services in a way which supports the individual’s self-worth and form of living – the so-called ‘dignity guarantee’ (Helse- og omsorgsdepartementet, 2010). As for the organising of homebased care services, local authorities have the autonomy to adapt service provision according to local conditions. Nevertheless, the prevalent form of organising homebased care services in Norwegian municipalities was to separate service provision in a purchaser and a provider part, resulting in fragmentation of services and lack of professional autonomy in care workers’ response to service users’ needs (Vabø, Reference Vabø2009). Hence, there was a unison call from politicians, trade unions and local authorities for new ways of organising the care services (Eide, Reference Eide2021).

In our case study from a Norwegian municipality in 2020, the home care services had undergone a trust-reform in 2017, shifting from an NPM-informed purchaser-provider-split mode of organising care work to a trust-based mode with reorganisation of the care workers into self-managing teams. In accordance with political policy goals, the intention of the trust-reform was to promote professionalism and enhance quality in care service by granting care workers autonomy and trust in their everyday work. In the local district studied, the implementation of the trust-reform aimed at relocating the top-down needs-assessments task to the frontline care workers, as well as allocating responsibility for the day-to-day organising of the work in self-managing teams. Autonomy and self-management were expected to enable the care workers to pursue their professional judgements and respond rapidly to the service users’ changing needs rather than being held back by time-consuming bureaucratic procedures. In this way, the care workers who met the service users in person were trusted to use their expertise and experiential knowledge in the provision of person-centred care (Eide et al., Reference Eide, Gullslett, Eide, Dugstad, McCormack and Nilsen2022). However, the authority and power to allocate budgetary resources was not delegated from the top level to the self-managing teams, leaving the teams with the task of negotiating service users’ demands and available resources (Eide, Reference Eide2021).

Trust-reforms are in principle bottom-up reforms and should be implemented in a way that corresponds to local conditions and needs (Torfing et al., Reference Torfing, Greve and Klausen2020). Hence, implementation of trust-reform in the local district in our study resulted in the home care service being organised into self-managing interdisciplinary teams. Targeting service users with diverse needs, the teams were organised either as specialised care teams for service users with severe illness or dementia, with rehabilitation needs, or as basic care teams for service users with more general care needs. The basic care teams were responsible for the long-term service users’ daily care needs, such as personal hygiene, food and medicine and other everyday chores. In this article, the focus is on the care work in the self-managing basic care teams.

The core staff in the basic care teams were registered and practical nurses, but physiotherapists and occupational therapists were also included in the interdisciplinary teams. However, the therapists had a more independent role in the teams, related to the specialised work they do with the service users, and did not engage in the basic care teams’ everyday work and the teams’ organising of the work, as did the nurses.

As for formal leadership, all teams had a responsible manager who tended to administrative issues of the unit at a higher managerial level in the home care service. For the practical everyday organising of the work, the team members appointed a ‘leader of the day’, a role that rotated among the core staff (registered and auxiliary nurses) in the team.

Prior to the reorganisation into self-managing teams the daily work of the home care professionals was organised by a dedicated coordinator who had a detailed overview of tasks, staff and service users. After the reorganisation into flat, structured self-managing teams, however, the care workers themselves were rendered responsible for keeping track of staff and tasks and organising the work in the team, in addition to the interactional care work with the service users. As we will show in the findings section, the organising of the work was a collective undertaking within the team to which the care workers dedicated a considerable amount of time.

Data and methods

This study has a case study design (Stake, Reference Stake1995) and is based on a four-month period (2019/2020) of fieldwork, including interviews with frontline care workers, in a municipal home care service in Norway. Fieldwork is particularly well suited to understand the contexts and the content of the care work that is done, its complexity, dilemmas, workflow, tasks and organisational ramifications (Neumann and Neumann, Reference Neumann and Neumann2018). The fieldwork included 16 days of observations in five different home care teams, comprising 6 to 12 visits to service users each day and interviews with 12 care workers. We followed the care workers in all their doings, tasks and movements during the working day, from the morning meeting to visiting service users, picking up colleagues, collecting equipment, driving cars and tending to cars, talking on the phone with colleagues, service users or their next of kin, hospitals or general practitioners, having lunch, chatting with colleagues in the office corridors and attending administrative and interdisciplinary professional meetings.

The interviews with the care workers took place in the home care service office at the end of the care workers’ shift. A semi-structured interview guide served as a point of departure to cover themes of interest in the study of home care work and a strategy of active interviewing was followed (Holstein and Gubrium, Reference Holstein and Gubrium1995), allowing the interviewees to reflect on their practice and engage in meaning production. We talked about topics such as tasks, roles, and responsibility, interactions with service users, collaboration, working conditions etc. All interviews were recorded and transcribed. In the first stage of the analysis, the interviews were read in detail and coded by hand in an open manner based on what the informants spoke about, allowing themes to emerge from the data. In the next stage, the interviews and fieldnotes were coded electronically in NVivo to organise the data, using the following codes derived from the manual thematic coding: coordination, autonomy, collaboration, professionalism, competency, time/resources, interactions with service users, leadership, tasks and personnel.

In the analytical process, we used an abductive approach (Reichertz, Reference Reichertz, Bryant and Charmaz2007), meaning that we started with data – fieldnotes and transcripts of interviews – and informed our interpretations by theory as we moved forth and back between data and the literature. Through this interplay of data and theory, we analysed how care workers managed their everyday work in self-managing teams. Our attention was first drawn to how the care work was organised as a solidaric undertaking through horizontal relations within the self-managing teams and the care workers’ individual handling of the time-pressure they experienced in their everyday work. However, it was only after having read and re-read the data, discussing trust-reforms and trust-based organisation and reading literature on the topic, that we realised that the leaders were absent in the care workers’ narratives from their everyday work. With this insight in mind, we reanalysed data actively looking for how the care workers articulated their possibilities to perform care work within the new organizational regime, paying particular attention to the role of managers, their presence in the care workers’ everyday work, or lack thereof. In this way we made connections between the empirical data and theoretical concepts from the literature.

The research project was recommended by the Norwegian Centre for Research Data (NSD/SIKT). The informants signed informed consent and information from interviews and fieldnotes was anonymised.

Coordination work – care workers’ collective and bounded responsibility

Our findings demonstrate how the care workers in the self-managing basic care teams dedicated a considerable amount of time and effort to coordinating work tasks within the teams. The coordination work consisted typically of planning and distributing working lists and client visits; substituting care workers in case of absence; planning of transportation and co-driving with colleagues; discussing pick-up and drop-off spots; picking up cars in distant parking lots; charging batteries on electric cars or bicycles; bringing cars to mechanics for repair; ordering and collection of medical equipment and service users’ medicine; contacting medical doctors, hospitals and rehabilitation centres; noticing service users in case of delayed visits; keeping contact with next of kin, and checking in on colleagues’ working lists to see if their colleagues were doing ok or if they needed help.

Coordinating transport and working lists and updating and sharing information were continuous activities throughout the working day. As such, the coordination work was intrinsic to the daily work in the care teams and functioned as a kind of collective organisation of the day. Intertwined with the medical care tasks, the coordination work was the work that made the whole team function. Nevertheless, regardless of the stress and frustration the care workers experienced when trying to make the team function, they had to find solutions to their problems within the team, as noted by a nurse:

All team members are responsible for making their team function; we must find the solution within our team…when somebody calls in sick, it is not always easy to get a substitute, even less so getting hold of someone with the right qualification (registered or auxiliary nurse), that means more work on each of us.

Even though they lacked staff due to illness or for other reasons, they could not borrow or exchange staff with the other teams. The self-managing teams had to manage by themselves. The responsibility of the team itself was noted by another nurse:

Actually, if the team leader of the day asks our boss to get an extra staff tomorrow, because we are short, you almost never get that, even though it is evident that we will not manage with those few people having to serve that many service users and their many needs…you have all the arguments ready for getting an extra staff, but the answer is almost certainly ‘no, we cannot do that, we do not have the money for that’, so it’s all about money…so, then we have to solve it within the team…meaning there will be more work on your list.

Seeking support from the management level to handle the workload and time pressure seemed futile. The team seemed to handle the situation collectively with a form of solidaric responsibility: “It is up to us…we just have to solve it within the team”. In further discussing the role of the administrative leader for the team, one of the care workers noted: “We rarely see X, I do not know what she does, probably attending meetings…sometimes she puts her head in and give some information, like you just noticed, but she does not engage in our daily work”. Another commented: “we do not get an awful lot of support, neither regarding solving practical issues or emotional impacts we experience in this kind of work”. Another care worker said:

[T]hen there is the department manager for each team, right? I find that ours is not particularly supportive. It doesn’t feel like that. Maybe [she’s] a bit concerned about the budget, of course. But we [the care workers] have to live, too. We are the ones who do the work. I don’t think we waste. After all, we consider what is needed and what is important and so on. [She is] very concerned about [the] budget. You have to defend spending, of course. There is a certain budget to deal with. But I don’t think she’s supportive. It’s heavy.

Interviewer: Yes. But is she somehow close to you? In such a way that she knows what your situation is or understands what you are dealing with?

Not at all. If you ask the others, we have talked about it on the team. That’s a bit sad. I feel, we are talking about nothing else, so, yes, we [at least] need moral support. It would have been nice to have a leader who supports you like that.

The lack of close follow-up from a facilitating leader further marked the collective responsibility of the care workers in the self-managing teams. The care workers were responsible for providing the service users with the care they needed, and they were held accountable towards their colleagues through the self-managing regime, as noted by one of the nurses:

It is my responsibility to make sure that there is enough time to do the required tasks the next time one of us is visiting – that is my responsibility towards my colleagues. So, we have to facilitate our team’s everyday work to make sure that there is enough time to give the service users the help they need.

This denotes the work that took place in the teams as a collaborative undertaking, where the care workers were collectively responsible and held accountable to each other for the whole team’s provision of care services. Notwithstanding, the coordination work constituted a considerable amount of daily work, which pressured the care workers for the time they had for disposal in encountering the service users and their care needs.

Time and professional judgements – individual responsibility towards service users and team

The findings in the study point to time as a crucial factor for care workers to be able to perform care work according to the principles from the trust-reform – i.e. care work in homebased care services should be based on professional judgements and standards rather than on bureaucratic “rules” and procedures. In principle, the trust-reform should reinstall care workers with autonomy to assess service users’ needs and make decisions based on their professional judgements. However, doing proper professional assessments and tending to individual service users’ needs require time, as noted by one of the care workers:

In order to work professionally you need to observe the person and map the situation to do an evaluation…you need to look around at many different things, if there is any physical injuries, psychological issues, hygienic issues, if there is a risk of falling…so you look around in the flat, and if they live with somebody, you need to be aware of possible abuse or maltreatments and so on, so you have to talk with the person…so if you arrive and you do not have the time to do that, how can you do professional work?…in the end it all has to do with time. We are not working in a nursing home where you have seven hours in the same place, where you see the patients every day and you even bump into them several times a day. In the home care services, it is 10 minutes and maybe you see the same person the next day or the next week.

Another nurse expressed the importance of having enough time to get to know the person as a prerequisite to respond to the service users’ needs in an accountable way:

It is one thing that is very important and that is to make sure that the service user does not fall off the list. For instance, the service user tells you that you do not need to come the next few days because he will not be at home. If you mark him as ‘unavailable for visit/service’ nobody will visit him, and if that information, that which the service user told you, was not correct, it may be fatal if he is still at home and nobody is looking after him. Therefore, it is important that we know the service users – that we know whether we can trust the information they give…so you need to think twice…and we need to spend time with them to get to know them.

However, the problem is that time is still a scarce resource for care workers in self-managing teams. Hence, the care workers had to find strategies to cope with that situation, as noted by an auxiliary nurse: “When I first started working her, I was recommended not to engage in small talk or conversations with the service users, because it is time-consuming, and we do not have time for that, so I try to avoid it…if they ask about my family and children, I cut it short.” Instead of engaging in an interpersonal relationship over small talk or conversation as a means to get to know the person and assess his/her needs, this care worker used a professional approach, with which she ‘scanned’ the service users and their surroundings: “what does he/she look like in the moment…checking the room(s), the kitchen and bathroom, the refrigerator and the garbage bin for (ab)normal traces” to map the situation. With a rapid and effective clinical gaze, the care worker registered the situation and performed the prescribed tasks according to the protocol. Using this strategy, the care worker was able to fulfil her assigned chores of the day within the estimated time schedule.

On the other hand, several care workers saw it as a prerequisite to engage in conversations with the service users to be able to assess their needs. Commenting on time and service users’ fragility in expressing their needs, one of the care workers expressed her frustration over the time pressure:

The service users need time to express their needs, or if there is something wrong or they have some worries, they are not sitting there ready to tell us what the matter is and what they need upon our arrival…it takes time to talk……our problem is that we do not have that time…we do not have time to assess the service user’s situation properly.

The time spent on the relational part of the job was not considered an important part of the assessment tasks and was therefore not calculated in the time estimate of their working list. The price paid by not including relational work is that it becomes invisible, and because relational work is necessary to professionally judge the situation of the service user, the care workers oftentimes exceed working hours, or they abstain from lunch or meetings. As one of the nurses noted, “the service users are more important to me, so if the meeting is not strictly compulsory, I tend to prioritise the service users and skip those meetings”. Hence, making such considerations becomes an individual responsibility towards the service users’ well-being and the other members of the team.

Little time for professional assessments and a lot of coordination work meant less time for professional care work. Despite the self-managing of the teams and the gamble that the care workers in the teams will be solidaric and collectively responsible compared to the previous purchaser-provider split, the care workers still did not have time to work professionally. Hence, with the trust-reform they were granted autonomy and responsibility, but not the time and resources needed to provide person-oriented services, as noted by a care worker:

In principle, the trust-reform is a good idea. To be able to work professionally, to make those assessments properly is great; however, they have not given us the necessary time (resources) to make those professional assessments, so what becomes then of professional care work? It seems that it’s always we who have to be flexible, to cut corners and be efficient, learn how to be more efficient…there are so many things we should do, the most important it seems, is us being flexible and stretching to the limits, it’s always about us being efficient, we are the ones who have to learn not to spend time on unnecessary things, it’s like we have to figure it out by ourselves…there is no time left to do professional judgements.

Taken together, this means that even within a self-managing and trust-based organisation that is designed to give care workers a discretional room to manoeuvre and to decide what should be done to whom when, their professional assessments, which depend on their actual presence and observations must give way to tight time schedules due to a lack of staff and resources.

Discussion

The overall intention with the trust-reform in home care services was to provide service users with care services better adapted to their individual needs. In this study, we have explored the challenges for care work in municipal home care services where care workers have been organised into self-managing teams along with the implementation of a trust-reform. Our findings show how the self-managing organisation and trusting regime ‘burden’ the care workers with responsibility not only for providing care to the individual service user but also for organising and coordinating the care work in the teams. The time spent on coordination within the teams means less time spent on encounters with and provision of care to the individual service users and challenges the care workers’ possibility to provide service users with care based on assessments of service users’ needs, here-and-now. While studies on variants of trust-based governance and organization of home care services have found similar challenges for the conduct of care work (Carstensen et al., Reference Carstensen, Burau, Dahl and Hald2021), they also find that professionals have acquired enhanced space for professional authority and organisational collaboration. In our study, and contrary to Carstensen et al. (Reference Carstensen, Burau, Dahl and Hald2021), we find that the coordination work of the self- managing teams is not done in collaboration with the managerial level, nor with the broader organisational contexts. Rather, we have shown how the coordination work becomes a form of collective strategy that is pivotal for the teams to fulfil their obligations, while the care workers simultaneously are isolated in the sense that they individually become responsible for solving the gap between demands and resources in their encounters with individual service users (Lipsky, Reference Lipsky2010). In opposition to the intentions with the trust-reform, this situation undermines care workers’ professional autonomy and agency within the organisation, as care workers’ have little influence on budgetary priorities and adjustments to time and efficiency. This lack of authority inhibits their capacity to make proper assessments of service users’ needs and provide individually tailored care.

As we have seen in our study, care workers are willing to take on comprehensive responsibility for reaching the goals of the organisation, which is to provide service users with individually tailored care. Moreover, what the care workers demonstrate, through practice, is precisely what is part of the rationale behind the shift from NPM to trust; from viewing the care workers as self-interested rational actors to also seeing them as collaborative and responsible agents committed to the larger organisational project (Bentzen, Reference Bentzen2019). However, the change, from an NPM purchaser-provider split to a trust-based mode of providing care services, seems not to have opened up the space for professional care work in any real sense because the organising of the care work into self-managing teams has overlooked the role of the managerial level in facilitating support and creating trusting relationships (Klemsdal and Kjekshus, Reference Klemsdal and Kjekshus2021).

Hence, the political intentions of promoting professional care work through enhanced autonomy and self-management fail because in implementing the trust-reform the organisation has not paid enough attention to ameliorating the care workers’ harsh working conditions and lack of resources at the managerial level. As Klemsdal et al. (Reference Klemsdal, Andreassen and Breit2022) have shown, it is precisely the prerogative and responsibility of designated leaders to secure the boundaries for organisational change and new ways of conducting specific work tasks that are necessary for situational work to unfold. Without an operative and facilitating managerial level, care workers are left alone with comprehensive responsibility for providing care to service users, and little authority over resources and workflow (Håkansson, Reference Håkansson2022). As pointed out by scholars who have studied implementation of variants of trust-reforms in care services, support from supervisors, coaches or designated leaders is important to handle challenges in self-managing teams, for instance by assisting in distributing roles and tasks, solving conflicts, mediating high caseloads, and serving as buffer between the organisation and the teams (Hegedüs et al., Reference Hegedüs, Schürch and Bischofberger2022; Leask et al., Reference Leask, Bell and Murray2020). In our study, organising the services into self-managing teams seems to have become an obstacle to professional care work, because instead of providing care, the care workers spend a considerable amount of time on logistics and coordination of their work.

What seems to be lacking in the implementation of the trust-reform in our study is that it does not include a thorough understanding of the conditions that must be fulfilled to ensure agency for care workers so that professional care work can unfold (Dahl, Reference Dahl2017; Håkansson, Reference Håkansson2022). Professional care work depends on co-presence, observation and collaboration with service users and is based on the formation of relationships and experiential knowledge about individual service users, and this takes time (Wærness, Reference Wærness1984; Mol, Reference Mol2008). Hence, in order to develop better care relationships, satisfactory working conditions, in terms of time and resources and managerial support, are essential (Lewis and West, Reference Lewis and West2014). Taken together, these conditions constitute important parts of the foundation for trust and co-production of care with service users. As our study has shown, when the organisational conditions for care work are suboptimal, the relational work is de facto devalued (Lewis and West, Reference Lewis and West2014; Postma et al., Reference Postma, Oldenhof and Putters2015). By ignoring the relational dimension of care work and its dependency on the organisational framework, eldercare service risks becoming logistics rather than care (see Hansen, Reference Hansen2022). Also, the particular version of the trust-reform in our study overlooks the importance of understanding trust as something that depends on a collaborative environment of openness with actors capable of balancing uncertainty and confidence – both on an administrative level as well as in individual encounters with service users. It is precisely the balancing of this complexity that must be secured at an engaged and responsible managerial level for co-production of care to happen in the bottom line. As pointed out in our study, care workers who are deprived of an actively involved managerial level, that understands the complexity of the work, are left alone with a massive yet bounded responsibility for the service users, as well as for the other team members in the self-managing teams. Hence, constructing professional care work and the professional care worker as empowered through autonomy and collaboration based on solidarity and trusting relations disguises the real problem: without changing the working conditions in terms of the alignment of demand and resources, harmonising time and tasks, and providing the teams with a designated leader who facilitates their work, the trust-reform will be shaped after managerial logics, rather than a logic of trust and care (Dahl, Reference Dahl2017; Fretwell et al., Reference Fretwell, Osgood, O’Toole and Tsouroufli2018; Håkansson, Reference Håkansson2022; Klemsdal and Kjekshus, Reference Klemsdal and Kjekshus2021).

Acknowledgments

The study is part of the research project ‘Creating integrated person-centred care in different settings’ (CONTEXT), funded by the Research Council of Norway, project number 273696.

Competing interests

The authors declare none.

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