Välfärdsektorn, en arena för makt och motstånd : Studier av sjukvård och hemtjänst

Sammanfattning: Today there is a growing interest in research on concrete practice within organizations, which has implications for the understanding of how performance management works. New control ideals are often introduced in an organizational and socially embedded practice, where taken for granted assumptions about what is right and wrong or good and bad actions are already established. Governance can ideally be seen as an interaction between structure and actor, where the former both guides and limits the conduct of the latter. However, in this thesis I can show that local actors can act differently and exhibit resistance in interactions with their superiors, thus they are not as passive as the ideal assumes. The theoretical framework is based on Giddens' structuration theory that stresses there is a dialectical relationship between structure and actor. (New)institutional theory contributes to get insights into the participants' behavior and that meaning is shaped by wider institutional influences.The empirical data in this thesis consists of two studies; an inter-organizational care chain project and a study in assisted living. Both studies were carried out as case studies where qualitative interviews, observations, and various official documents have been used. In the care chain project the aim is to produce knowledge about how a change process has been undertaken to promote the development of a seamless chain of care between different healthcare providers. The assisted living study examines how the interaction between actor and structure manifests at three critical events. Within the work units (the actors) knowledge and practices are established, based on care ideals. Economically administrative ideal (the structure) is based on a hierarchical approach in which goals and metrics are linked to budgets, activities and standards and where decision-making is decoupled from the actual work. This decoupling can make the work more clearly measured, monitored and streamlined, thus keeping players accountable for their actions and achievements. The actors are seen as cogs in a machine rather than as insightful and engaged. Therefore they are assigned to an inconspicuous place in the framework that the financial administrative ideal has determined. This ideal is the cornerstone of New Public Management (NPM) and holds the private sector as a model in terms of management, steering and control of a business. Although local actors can exhibit resistance towards this ideal, they still are limited by its authoritative power of determining the allocation of resources.