Professionals and the New Public Management - Multi professional teamwork in psychiatric care

Abstract

This study examines the cooperative work of several professions in Swedish multi-professional teams in child and adolescent psychiatric open care units in an environment of strong economic and efficiency controls resulting from the so-called New Public Management (NPM) reforms. Previous studies indicate teamwork is a network of semi-independent professionals who tend to represent their professional organisations and groups despite sharing a mutual interest in the patients. The research problem deals with finding explanations for what promotes and what hinders cooperation in a multi-professional health care team. A qualitative approach is used to study and interpret the individual professionals’ actions. Data were collected in interviews and from observations of planning and treatment discussions where it was possible to witness team members’ strategies and attitudes toward patients and their treatment. The main theoretical concepts are exogenous and endogenous institutions, boundary objects, standardised procedures, service ideal, discretionary power and professional dominance. Two NPM elements are applied: customised care and increased accountability. The study offers an actor perspective that complements the traditional cultural perspective. The latter perspective explains cooperation problems as the result of the professionals’ confusion over their expectations of themselves in their team roles and their expectations of others in their team roles. The actor perspective shows that while norms may influence cooperation, they are not determinative. Actors are aware of the institutionalised conditions, and take them into consideration; however, their actions are not determined by these conditions, nor even primarily guided by them. The determinative factor for actors’ actions is their context. Leaders and co-workers can create endogenous institutions that bridge their differences in professional norms and also bridge professional norms and NPM reforms. The institutionalised conditions are secondary factors that explain the outcome of cooperation efforts. This study offers an interpretation useful in understanding how the actors create endogenous institutions. Star and Griesemer’s theory on boundary-spanning objects does not address this aspect of cooperation. Unintended consequences of NPM reforms for patients are traditionally said to imply that NPM reforms are ill conceived and unrealistic. In the light of this study the significance of such consequences may be reinterpreted to be a possible mechanism of driving the development of the public organisation. Usually NPM reforms are regarded either destructive or harmless to professional autonomy. This is scarcely a realistic description of professionals’ long-term behaviour. This study offers co-optation as an alternative explanation, defined as the process by which actors absorb external strategic elements in their policy decisions. Co-optation of NPM reforms explains the gradual institutionalisation of NPM reforms. Research investigating professions has not dealt with the fact that multi-profession cooperation has the same character as mono-professional cooperation, to preserve collegiality through co-existence. Such professionals do not wish to challenge others’ approaches and practices; nor do they wish to learn from them. This result challenges the general idea of professional dominance in theories on professions.