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:

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:

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:

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:

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:

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:

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 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:

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.