We developed four categories during the data analysis, denoting different types of changes in the nurses’ values, working practices, and status in relation to the patient safety programme: reconstructing trust; reconstructing work; reconstructing values; and reconstructing professional status. These are presented in the following.
Reconstructing trust relationships – from trusting professional knowledge to trusting the system
The introduction of standards in the form of patient safety programmes can imply that trust is thought of as something that is built into standardised systems instead of directed towards professionals or experts [
26‐
28]. This means that, whereas people previously trusted health care professionals to conduct good treatment of patients based on their medical discretion, trust is now transferred to standardised systems and routines. It is, to a larger extent, the standardised routine - and the documentation of this - that should guarantee a patient’s safe treatment in the hospital. These perspectives on safety work were expressed by our informants in different ways, for example by one of the nurses in a group interview:
If the documentation is not there, it [the work] has not been done. And that is what has also changed. (Group Interview 1 with six nurses).
The nurse explained that documentation was even more vital after the introduction of the patient safety programme and that it is ‘proof’ that the required work has been performed. It is not enough to conduct patient safety work or to say that it has been carried out (trust in professionals): it has to be documented (trust in systems). This is in line with the perspectives linking managerialism to NPM and the argument that NPM is associated with a rise in audit systems, which leads to ‘audit rituals’ of verification to produce government and societal confidence [
35].
A similar perspective was also offered by a manager, with an emphasis on measurements:
What you cannot measure, you have no good possibility to do something about. (Hospital management).
The manager connects documentation and measurements to the ability of managers and health personnel to change work practices and perform better. He argues that to address patient safety (improve it) it is necessary to measure something. Measurements can thus be seen as trusted signs that patient safety is being addressed (or not), and as tools for improvement.
Documentation and measurements form an important part of a system built around standardised routines and guidelines. Standardisation can make medical practice more transparent (trust is implied through transparency) [
26]. Nursing practice is made more transparent to managers and patients, but one of the nurses also pointed out that their practice and knowledge can be made more transparent even to co-workers:
It is not that we have not done this before, but now it is systematised, and that system also makes us cover almost all patients, and makes the nurses feel safe. You can have someone who has worked here for thirty years, and someone who has worked here for one year, and to them the system is easier to relate to in a new work practice. In addition, as a patient, you get the same nurse, if you understand what I mean. (Group Interview 1 with six nurses).
The nurse explained that the patient safety programme, in addition to making the patients safe, also makes the nurses trust that they are performing their job properly. For new nurses with less experience in particular, it is easier to relate to a transparent and standardised guideline. This also ensures, the nurse argued, that patients have ‘the same nurse’ (meaning the same treatment) independently of the nurse being less or more experienced, indicating trust in systems instead of professional knowledge. Traditionally, nurses have had an oral tradition regarding the transfer of skills and knowledge [
50]. This implies that nurses’ professional knowledge has a tacit dimension [
39] that is difficult for new and less experienced nurses to grasp. With the introduction of the patient safety programme, tacit knowledge can be made explicit to a larger extent, much in line with Nonaka and Takeuchi’s description of tacit knowledge being externalised into articulated knowledge in one part of their knowledge conversion model [
42]. Explicit knowledge can then be made tacit again through a process of internalisation. For less experienced nurses, use of the standardised system can represent a phase in their learning process in which tacit knowledge is articulated to them, making it possible to internalise it in a later phase.
On the negative side, the increased use of standardised routines and guidelines in nurses’ work may suggest that nurses experience a reduction in their professional autonomy and the potential for individual adjustments for each patient. One of the nurses in a group interview explained safety work in a clinical setting in the following way:
For example, the pressure ulcer rounds, […] then there are two persons who are going around the entire department. We are supposed to check the patients daily for pressure ulcers, and we document that as we should. But still they have to come in and check. Then I feel it a little bit… is that trust in us? […] We cannot use our medical gaze anymore, cannot think for ourselves. Which is both positive and negative, of course. (Group Interview 2 with three nurses).
The nurse stated that their opportunities to use their professional knowledge and discretion has been limited. This can also be experienced as distrust [from the employer], as explained by a nurse:
It’s a little bit like … ok, we do not do a good enough job. I can feel a bit like that. Because I do my job, and then I expect my employer to trust that I do it. (Group Interview 2 with three nurses).
The nurse explained that the introduction of measurement and control gives her a feeling that she does not conduct her work well enough, and she argues that her employer should trust her and her work without having to rely on measurements. Professional autonomy is a vital part of the role and identity of health professionals [
25], and a profession’s power is normally shown by the autonomy that its members have in everyday work [
26]. The introduction of standardised systems, regulating the details of everyday work for nurses, can thus represent a threat to this autonomy/power and be in conflict with professional identity.
The introduction of the patient safety programme implies that measurement and control are given more attention and importance. Whereas the nurses were previously trusted because of their professional judgement and patient safety was an integrated part of their work, they now have to document how they work with patient safety in a predefined, systematic way. This is experienced as both positive and negative. The nurses valued the systematic work and explained how these systems can make them trust their own work and can make their (often) tacit knowledge more explicit to others, however, some also articulated a feeling of distrust from their employer and argued that they should be trusted as professionals, independently of the documented measurements.
Reconstructing work – from invisible to visible work
Nursing work has traditionally consisted of a considerable amount of invisible work, which some researchers estimate as high as 70%: work that makes the organisation function but that is noticeable only when something goes wrong or unplanned events happen [
17]. This creates challenges in the form of legitimacy; only work that is visible is valuable [
44]. With the introduction of the patient safety programme, the explication of actions contributed to making more of the nurses’ work visible – thus contributing to making their work more valuable. One nurse said:
We have been doing patient safety work all the time, it is just that we have not systematised it. And we have not discussed and talked about it, as we do now. (Group Interview 1 with six nurses).
Nurses reported that documentation of patient safety work and the use of metrics and indicators allowed them to translate previously tacit nursing activities into something to which other professions could relate. One nurse recounted from a conversation with a doctor:
I was going through all the things we did as nurses, and then it was like ‘Oh my God – do you do all this!’ They didn’t know this. (Group Interview 1 with six nurses).
This illustrates one of the very important motivators for making work visible. As we pointed out earlier, a professional involves and employs a substantial amount of tacit knowledge in their practical work, which they cannot easily explain afterwards [
62]. What they undertake is not necessarily transparent or understandable for others – a point that is even more valid for professions with tacit work practices and knowledge boundaries [
41] and maybe even more so for the nursing profession, relying heavily on the oral form of knowledge transfer. When working together with other professions, however, this visibility of work actions contributes to making the profession’s work more valuable.
Making their work visible involved activities that the nurses normally did not perform. Measuring activities entailed time and effort, and sometimes they involved time that nurses would rather have spent with a patient. Largely, however, this was interpreted positively, because patient safety had now turned into a more palpable phenomenon. Managers would argue that, while they previously (before the programme) could be asked about the status of patient safety and not have an answer, they were now able to give clear answers based on the numbers. In other words, they felt more in control. Making patient safety work more visible contributed to the uncovering of previously unaccounted errors. For instance, there was previously a ‘concern’ among the nurses that medications were wrongly administered. This was, however, based more on a feeling or hunch or maybe even rumours. Now, with numbers, they could:
… analyse the data, categorise it, and risk analyse it … we do also see where the problems are, namely preparation and administration. We as nurses report the most, but also doctors … so we need to find appropriate actions. (Nurse).
Documented patient safety work also enabled cross-boundary support. Other professions, such as physiotherapists and doctors, were involved on the basis of the documentation of patient safety. Apparently, the numbers made it more interesting for doctors to engage in discussions and reflections at joint meetings such as the ‘pre-visit’. One nurse reported:
The doctors join in on our ‘pre-visit’ … then we discuss some of the things we work with, such as falls, infections, what we can do differently … doctors feel that this is extremely exciting, that we address things that are important for us. (Group Interview 1 with six nurses).
On the critical side, nurses also reported challenges in the reporting activity itself, when it opposed interpersonal relationships with patients (which we will turn to next). The nurses overall welcomed the programme, however, on the basis of making visible practices that were previously tacit. This involved important benefits of heightened recognition from other professions, easier cross-boundary collaboration and the systematisation of safety deviations.
Reconstructing nursing values – from ‘care’ to ‘cure’
Nursing practices are rooted in an approach to medical treatment which can be described as holistic, while doctors are inclined to rely on data from consultations and tests [
49]. This difference is sometimes described with the notion that doctors treat the disease while nurses treat the patient [
52]. Some advocate that doctors adhere to ‘cure’ while nurses adhere to ‘care’ [
51]. Thus, nurses tend to approach patients in a different way from doctors, relying more on dialogue and mental support, and in some instances establishing a closer relationship with them than doctors. Nursing values are thus often rooted in holistic and immeasurable care for patients, contrasted with the reductionist and quantifiable cure of doctors. The safety programme challenged these values in a way that we will describe as moving from ‘care’ to ‘cure’.
The traditional holistic approach was challenged by the quantifiable aspects of the programme, especially measurement and documentation activities. Whereas they had traditionally emphasised the caring aspect with patients, for instance holding their hands, there was now a shift towards performing more of the tasks that could be counted (and be accountable). There were concerns related to the reporting activity itself, when it opposed the interpersonal relations to patients. One nurse recounted that they were supposed to measure the weight of patients every seventh day:
And I see that we struggle with keeping up with this … […] maybe if we have a focus on what is important for the patient – food, nutrition, beverage… rather than getting the patient out of the bed, in the wheelchair and up on the scales. (Group Interview 1 with six nurses).
The nurse here was pointing out not only the struggle of the measuring itself but also that the attention should be on the patient and their well-being – not on the measuring activity. The opinion that ‘real’ nursing work should be performed in relation to the patient rather than a computer screen was shared by some nurses. One nurse said the following:
I have heard nurses say that, while I am on the computer, documenting that the patient has a risk of falling, the patient is actually falling in the room. (Group Interview 1 with six nurses).
While some nurses appreciated the new ways of working, more in line with the physicians’ ‘cure’ tradition, other nurses reported that the documentation of patient safety work challenged their professional values as a nurse. This differs from what has previously been reported as problematic with similar programmes and professionals – that they resent measurement because it is seen as a form of surveillance and control by others [
29,
35]. The nurses in our project seemingly put more weight on the measuring activity as a challenge to professional values. As such, it can be argued that the resentment was more a threat to their clinical autonomy (everyday practice [
26]) than to their professional autonomy (markers of professional boundary [
26]). Their clinical autonomy was only challenged if they could not see the measuring activity as meaningful or in other words something that they themselves judged to be important.
The administration and coordination side of nursing has necessarily always involved some form of documentation [
17], however, this was now taken to a different level. The nurses themselves resented the measuring activity itself – not the measures themselves – but on the other hand needed to develop, adjust and adapt to these new demands.
Nurses were approaching the physicians’ way of using measurements in their own work, wanting evidence about whether and how their activities were working. Although their aims and means were different, nurses were influenced by the programme into working towards a more measurable way of curing the disease. The more difficult-to-measure caring activities of, for instance, holding hands and developing meaningful conversation, could in some sense be downplayed. The visualisation of patient safety work through numbers is in accordance with a ‘cure’ discourse, also contributing to a heightened professional status which we will turn to next.
Reconstructing professional status – from lower to higher (perceived) status
The nursing profession has in many instances been contrasted with that of physicians and the ‘care’ and ‘cure’ dichotomy [
51]. Nurses’ practices have been described as holistic, while doctors’ practices are referred to as more specific, and as data driven by tests and consultations [
49]. The status differences related to the responsibility and medical authority of physicians have been discussed extensively [
53,
54].
As illustrated above, the reconstructions that originated from the patient safety programme were perceived as both positive and negative by the nurses. Several of the informants explained that the programme overall had heightened the nurses’ professional status. Some of the ways in which trust, values and work were reconstructed seem to be accompanied by the strengthening of the nurses’ professional self-esteem and the perception of their professional status. In general, the informants expressed considerable pride in what they had accomplished in relation to the patient safety programme:
I think people are proud of being as good in patient safety as we are. We have a good score on the patient safety culture surveys. And discussing incidents and errors is encouraged. (Group Interview 1 with six nurses).
The nurses related their accomplishments to an improved safety culture and open discussions about safety issues and errors. The improved professional pride can partly be regarded as a consequence of the increased visibility of their patient safety efforts. The nurses explained that:
I think it has put us on the map on a national level. It has a great significance for the employees here, that we can congratulate ourselves with something. (Group Interview 1 with six nurses).
The nurses’ newly won ability to refer to numbers in describing patient safety in a clinical setting was important – it allowed them to gain attention at the national level. Ritualistic defences towards being audited reported in other contexts [
35] seem to be of varying relevance in our case, possibly because of the positive effects that have been observed:
It has become a huge professional boost, because often it is difficult to define what our work tasks are. (Nurse).
The increased visibility of their work tasks was thus considered to have a motivational effect for the nurses as well. Bowker et al. claimed that only visible work can be identified as valuable, and at least some parts of the nurses’ work have become more transparent [
45]. The measures of patient safety seem to have served as a visualisation of some of their tacit activities, not only to themselves but maybe more importantly to both patients and third-party actors. More precisely, the patient safety programme makes it possible to consider the quality of the selected aspects of ‘care’, much in the same way as ‘cure’ is considered. The methods for measurement are comparable and recognisable across the professions. This might give the nurses access to medical authority [
53,
54], increasing their professional status.