Prioritising patient care: The different views of clinicians and managers

Recruitment and characteristics of informants

Both studies were conducted with the approval of hospital executive managers who let us contact the clinical staff. We also used the knowledge of some members of the staff to help us find research participants. We interviewed nurses, doctors, psychologists and different therapists in clinical care (healthcare professionals), but all quotes in this article originate from nurses and doctors. The executive managers we interviewed also had a background in either nursing or medicine. In both studies, we have aimed for a balanced representation of gender, age and experience. Interviews were done in hospital settings to provide a background for explanations. Focus groups were done outside the hospitals for practical reasons. In the focus groups, sensitive information was not discussed as explicitly as in the individual interviews, but they gave us a chance to explore if the expressed views were commonplace. Observations gave further validity to the study and provided valuable background information for the interviews in a social context.

In the medical study, the first and third authors (H.S. and P.N.) conducted 21 individual in-depth interviews and three focus groups with nurses and doctors in somatic medicine. In the internal medicine wards, we interviewed six doctors (three men and three women) and seven nurses (three men and four women). We also interviewed three nurses (one man and two women) and two doctors (one man and one woman) in an emergency ward. Three GPs were also interviewed (two men and one woman), but they have not been included in this study. Age varied between 24 and 61 years (mean = 38 years). Length of job experiences among the interviewees varied between 1 and 35 years (mean = 11 years). Three focus groups were conducted after we had finished the interviews, two with nurses and one with doctors. These were conducted to discuss our findings in the interviews and to substantiate our perspectives.

In the mental healthcare study, the second author (M.H.H.) was an observing participant in 119 interdisciplinary staff meetings in a locked intermediate ward in a big mental healthcare institution for 9 months, mostly in meetings where they reported on the patient’s condition and discussed treatment plans. Notes were taken during the meetings, and the notes were elaborated immediately afterwards. In addition, nine focus group interviews were performed, altogether with 27 persons (three of them were interviewed twice): executive managers (three men), doctors and psychologists (three women and one man), nurses (six women and four men) and others (occupational therapists, social workers, physiotherapists, etc.) (eight women and two men). The aim of the interviews was to explore how healthcare professionals reason regarding clinical prioritisations.

All interviews in both studies followed an interview guide. They were conducted to allow for discussion and reflection upon phenomena that were of common interest. Following the approach known as active interviewing, the participants in the interviews were considered to be part of a common process of meaning-making. ^{15 –17} The nurses and doctors were encouraged to reflect upon, assert their own opinions and tell their own stories concerning the phenomena to be discussed. The interviews were recorded and transcribed.

Data analysis

Our way of proceeding can best be described as ‘bricolage’. ¹⁵ This includes that we moved freely back and forth through the material without following certain methods or analytical techniques, an eclectic way of creating meaning in the data material. The analysis of the material took place in three stages: (a) we did a careful scrutiny of the transcriptions and the field notes, all of us together and separately, and discussed our findings. Abbreviated versions of field notes were discussed among co-authors for comments. (b) We then structured the material according to subject matter and noted patterns in respondents’ descriptions of priority settings. ¹⁸ We were guided by the aspects the respondents themselves ascribed significance when they talked about prioritising, both in the interviews and in the meetings we observed. We were eager to find out whether there was a difference between how the clinicians argued in the meetings and what they pointed out in the interviews. (c) Whenever interpretations reached a level where hypotheses could be formed, remaining interviews were reviewed in order to find opposing interpretations. ¹⁹

Ethical considerations

All informants gave written consent. The studies were undertaken conforming to the provisions of the Declaration of Helsinki, which means that basic ethical principles for research ethics such as informed consent, the right to privacy, respect for personal integrity and dignity were followed. ¹⁵ All informants were informed about the respective research projects and their rights both orally and in writing. Participant and patient anonymity is preserved throughout the text. In the medical study, the handling of informants, recordings and transcriptions was approved by the Norwegian Social Science Data Services (ref. no. 20175) and the Data Protection Offices at the respective hospitals. The mental healthcare study was approved by the Regional Committee for Medical and Health Research Ethics (ref. no. 2010/1334).

Strengths and limitations

The study is given importance through its wide base of inquiry. It has been conducted by researchers with different backgrounds (nursing, philosophy and sociology) in different areas in the healthcare system. Through a mixed-methods approach, and a relatively large number of participants for qualitative research, both studies showcased similar concerns among the clinicians and to a certain extent among the executive managers. Thus, they lend support and validity to the general claims of this article. The use of interviews, focus groups and observations helped us validate our findings through triangulation. The observations helped us compare what people say they do and what people actually do. Furthermore, the observations became an object for discussion and therefore helped us focus on what mattered most for the interviewees, how they thought about the priority settings and to discuss observed conflicts in more vivid detail.

However, the studies were conducted over a relative long period of time (4 years), something that could both be a limitation and a strength. Some information in the interviews could have been lost due to the time span, but the time span also reflects findings of an enduring quality. Another limitation could be that the interviews from the two internal medicine wards and the mental health wards were conducted within a diaconal hospital. This could have led to interviewees having very similar backgrounds, but it was our clear impression that this was not the case. Some of the healthcare professionals belonged to different Christian churches, one belonged to a Muslim community and many were non-religious.

Patient flow

Patient flow, or rather, how clinicians and executive managers understand patients who are not under treatment but still occupying hospital beds, emerged as an important theme early on in our analyses. It should be noted that many different terms were used in the interviews, but we aim for a just and fair representation. One way of bringing up this subject of patient flow was discussing time spent with the patients.

In mental healthcare work, the healthcare professionals talked a lot about the importance of relationship work. We saw that clinicians felt a special responsibility for particular patients on the basis of their clinical relationship with them. Even in the medical wards, many clinicians contemplated how they wished for ‘more time’ to spend with the patients. A medical doctor in the psychiatric ward used the term ‘problematic lack of time’. The term is of crucial importance for what the clinicians, especially the doctors and psychologists, talked about in the interviews. The same doctor who coined the phrase found that time was a theme that permeated every decision he made regarding the patients:

I think we are very quick in making a diagnosis. It’s diagnoses, then it’s treatment and this leads to further treatment and so on […] This goes fast, you know, you need much time for observation for a first time psychosis, the more we do up front, the easier it’s going to be to carry out an appropriate treatment. To decide on the type of treatment you are going to give, is a critical issue. Is the treatment medically justifiable as far as the use of powerful antipsychotic medicines is concerned, medicines with side-effects that really can cause somatic damage to the patient? Furthermore, to choose the correct medicine and to choose the appropriate treatment depends on choosing the correct diagnosis. This takes time. You have the feeling that the diagnoses should be made quickly because the treatment is supposed to continue without delay. When you have understood that in a so-called long-term treatment ward you don’t have the time you need to do the job and, realise that it is the patients who suffer from this, then you have to ask yourself whether you are willing to continue with this. This is sad, this is terribly sad!

A nurse in the same ward was worried that she was getting cynical in her daily bedside work, focusing only on the acute diseases. She said it was a dilemma for her not having enough time to ‘be there’ for her elderly patients. Instead, she had to focus on the tasks that were most medically urgent:

I hope I am not getting cynical, but […] I have to think that, well, I have given [the patients] their medications, I have helped them with food, the most essential stuff […] I often think that it is difficult to find out what is the most important and what I should prioritise first […] Because there are many severe diagnoses here, things that demand a lot of time and effort. […] To sit down and show them that you have time for them, and not be disturbed by everything around you […] If a heart stops, of course you just have to run away, but … it can be kind of hard, and I feel it is gnawing my consciousness […] I feel that I am not doing everything that I possibly can […] Some days I can’t even do the things I absolutely have to do.

Similar stories were presented often, and they illustrated how important many clinicians felt it was to have enough time, and to give the patients time. But the very different views of clinicians and managers became apparent when discussing this theme. Quite often we were told stories that illustrated how managers gave orders that made it difficult to give the patients the time they needed to get well.

Lack of time for the patients to recover enough to be discharged safely was a problem faced by many clinicians. In one psychiatric unit, a recurrent theme among the clinicians was the introduction of a new model for admitting and discharging patients:

We are expected to discharge one patient in the first week, two patients in the second week, one patient in the third week, two patients in the fourth week, so it’s the same every second week. Every week it is either one or two patients who are supposed to leave; regardless of whether they are ready for dismissal, they are expected to leave. This is telling me that it is all a question of numbers, not of treatment results or of the degree to which the patients are ready for dismissal. We are placed in a position where it is difficult to get the patients out, the situation is gradually getting tighter, and then we receive an instruction from our managers saying ‘We couldn’t care less, this is the problem for those out there, those who receive the patients. Your job is just to discharge the patients’.

For hospital managers, keeping schedules for expected time spent on patient treatment was seen as much more important than for the clinicians. Some managers said they were inspired by ‘lean thinking’ to reduce delays and to make sure patients receive the right care at the right time. This meant that patients always should ‘keep moving’ and be referred as quickly as possible. Any waits that occurred should be for medical reasons, for example, waiting to see effects of treatment. ‘Patient flow’ was perceived as important to reduce the cost of care and to keep hospital beds ready for future patients.

The logic behind keeping an effective flow of patients was found among executive managers in mental healthcare, in internal medicine wards and in emergency wards, although to a different extent. Managers had to allow for new patients to be admitted and that meant they had to discharge other patients to make room for the new. ‘The steady and predictable flow of patients […] is what is to be prioritised. In the acute ward, we admit up to 1000 patients [per year]’. This logic prevailed in the acute wards. An executive manager in the medical wards came up with a similar clear-cut solution for patients in need of more time than what was available in an acute ward:

We assume that about 100 of 1000 patients need the long-term ward, but only 60 of them are admitted. Some of the patients who are discharged from acute care facilities are more severely ill than those who are hospitalised at the long-term ward. There are 40 to 50 patients who need the long-term ward and are not admitted […] And what I wish is that there should be a faster flow of patients through the system, so that those 40 to 50 patients can be offered what they have a right to claim.

Discharging patients prematurely was frustrating for both doctors and nurses. One doctor from the mental health institution was even led to doubt his own career choice: ‘This was not why I did my medical training’. Several of the younger doctors said similar things. They described the experience of losing their professional autonomy and energy, and at the same time, they were exposed to the pressure of behaving conformably to the system, of being a ‘race car’ as one of them said. Another doctor put it like this: ‘We are supposed to be as efficient as if we were machines’.

Clinicians in both the psychiatric and medical wards expressed similar views, sometimes leading to dramatic moral and existential conflicts. A nurse in the psychiatric wards expressed his despair when accompanying a discharged patient to his home and about how desperate he felt when he had to say goodbye to the patient. The nurse said he thought ‘It’s actually now that I should begin the work with you’, after laboriously building a relationship with the patient over the course of several months: ‘It takes ages to establish trust’. It was just as the patient was discharged that he was ready to use the relationship in a constructive and future-oriented way. He said,

And I went out of the gate and down the street to the city square, walked and cried. And I thought, ‘Dammit, dammit. Why is the system like this? It’s now I should have started to work with Joe; Joe living at home, Arne and I would have set up an ACT-team [Assertive Community Treatment] around him and helped him to get on in his life. Including all kinds of activities and to get him back to work and we could have achieved a lot. And now he has to adjust and adapt to complete strangers. And he needs months to establish new relationships’.

Changing roles

Cost of treatment was an important topic in the interviews, but very few clinicians wanted to consider such questions before deciding on treatment. An experienced hospital doctor said it like this: ‘I feel greater responsibility for my patients than for the economy’, referring to the managers’ ‘economic outlook on medicine’. Both nurses and doctors commented on the new roles of middle management executive managers as enforcers of the administration’s will and no longer as the spokespersons of the clinical staff. An experienced head consultant put it like this:

Put bluntly, the economy overrules our professionalism […] The traditional senior consultant doctor role … is now often a spokesperson for the administration, and is forced to introduce changes that are often unpopular […] Speaking our cause is rarer and rarer, I think. It is more and more clear in recent years that the senior consultant is a more administrative and less the medical professional.

The changing role of the chief medical and nursing professionals was a cause of worry for many of our interviewees. Their roles were seen as changed from being mainly concerned with professional matters to becoming increasingly concerned with administrative and budgetary issues. Many interviewees complained of a lack of an open discussion for raising professional issues. Some clinicians said the clinicians were just given ‘instructions from above’. Instead of being concerned with maintaining the professional standards, the chief medical or nursing professional were seen more and more as spokesperson for the administration. For a doctor, this signified that ‘responsibility for the professional issues […] and the central values in relational patient care is left to the ordinary doctors’.

The differing values of those in administrative positions and the clinicians were emphasised in an interview with a doctor in an acute ward. He used to work as an executive manager in another hospital. At one point, he had told the board of directors that the budgets were unreasonably tight and that it would be impossible to give responsible healthcare. His worries were not taken into consideration among the directors, so to put ‘weight behind his words’, he threatened to quit his job if they would not listen to him. He said he had ‘never been so popular among his co-workers in his lifetime’. The board of directors fired him, and they hired a replacement person who promised the existing budgets could be used. Our interviewee claimed the patients had to be sent to other hospitals long before the year had ended.

Although this story was unique, many interviewees, mostly among doctors, but also among experienced nurses, told us that they felt that their representative among the executive managers simply was not present anymore. The chief nurses and medical doctors who dared to bring up the clinicians’ view points among the executive managers were simply not heard, or if they were, they were fired, often on superficial grounds according to several interviewees.

The clinicians’ understanding of the head consultants and middle managers that were chosen by the executive managers were often negative. One doctor in the psychiatric wards described a newly appointed head consultant with these words: ‘He is about to be the brightest star in a field we don’t really appreciate’. In other words, he may become a star among the executive managers, but not among the clinicians. The managers focused blindly on the budget, according to the clinicians. They were seen as unwilling to talk about professional nursing or medicine, or care for the patients.

A manager in the psychiatric wards made it clear that he would have preferred more room for discussing priority settings in the hospital. He was empathetic with the clinical therapists (doctors and psychologists) who had less autonomy than before and expressed concerns for the patients who were discharged too soon. In his view, the government’s health authorities were too eager to discharge patients: ‘Society has set up the premises for prioritising in healthcare and this means that the main treatment of patients is supposed to take place outside the hospitals’.

Budgetary constraints

Managers would rarely disagree openly with the clinicians’ values, but they focused far more on budgetary constraints than clinicians. A manager in an acute ward explained how he had to ration the limited resources at his disposal, and this also meant he had to make certain there was room for new patients:

It’s my job to assess how to use the limited economic resources I have at my disposal, how I am going to use the money. And there is permanent demand for more efficiency within the same budget frame, or even a lower one. I am expected to do more and more for less and less money.

Spokespersons for patients present in the hospital or for future patients

Healthcare clinicians often see themselves as the spokespersons of the patients. ²⁰ Clinicians are obliged to follow an ethical practice that gives priority to the individual patient, often implicitly guided by an ethics of care and proximity, rather than consequentialist ethics. ^21,22 Government and hospital budgets and guidelines were often considered either irrelevant or disturbing by many of the clinicians among our interviewees. We have previously examined other sources of priority settings, focusing on implicit and explicit professional norms. The majority of clinicians attempt to manage prioritisation implicitly, very rarely explaining the impact of financial pressures on decision making to patients, or denying care outright. ^3,11 To ‘make a difference’ for the patients seemed to permeate most of the professional norms brought to light during our interviews with the clinicians. ¹¹ This professional norm could explain both doctors’ and nurses’ voluntary function as patients’ advocates and also why the acutely ill were prioritised before the chronically ill, often elderly patients. ^23,24

Time spent with the patients emerged as an important theme early on in our analyses. It was mentioned by most of our interviewees, and it clearly contrasted clinicians’ and managers’ diverging views. In general, clinicians considered medical treatment and nursing care for the individual patients present in the hospitals as the most important part of their professional work.

Several managers understood and clearly empathised with the clinicians. Some even wanted to be seen as proponents of a professional ethics with a focus on proximity, human attention and individual empathy. The managers also wanted to ‘make a difference’ for the patients, but they had much greater focus on how to distribute the resources, so that as many patients as possible would get good treatment, including patients who were expected to arrive at later dates. Many managers, both in our study and in previous studies, expressed doubts regarding their own priority-setting decisions, sometimes expressing moral distress. ^25,26

Managers were more consequentialist than clinicians in their concern for individual patients. They focused more on people outside the hospital, that is, patients expected to arrive at later dates, and to tax payers financing the healthcare system. Neither doctors nor healthcare managers considered financial breakeven to be an ultimate goal for the health services, and both groups viewed production goals (patient treatment) to be more important. ²⁷ However, managers put more emphasis on production volume, whereas the clinicians emphasised quality.

We also found a conflict regarding who should voice the clinicians’ moral dilemmas to the managers. Several doctors and some nurses felt that their voice was lost at the managerial level. Many complained about this among their colleagues, and it was openly discussed in the focus groups. Other studies have found similar results. Gaudine et al. ²⁸ have studied differences between values (both personal and professional) of nurses and doctors and the values of their employers. They also found that the clinicians experienced voicelessness when facing personal and moral dilemmas that their organisations did not discuss with them. As in our study, this led to feelings of not being respected and supported. Discussing the use of limited resources more openly could sometimes alleviate the clinicians feeling management decisions were lacking in transparency.

Different forms of rationality

The individualised frustration among many healthcare professionals may in part stem from a professional norm, especially among doctors, that they should not complain. This norm is challenged by younger doctors, but it still seems to prevail. ²⁹ Such internal conflicts among medical colleagues could make it harder for clinicians to structure their voices in ways that will be heard by the management. In addition, some clinicians seem to expect management to speak their cause without raising their voices. But clinicians are not only responsible for their patients but, in part, also for the organisation of their work. Clinicians normally have very little experience or training in management. ³⁰

Trying to understand why the clinicians and managers regard prioritisations with such different foci, we have to look at what clinicians regard as the core values of their professions, and how these values interact with the values of society. Traditionally, professions in the healthcare services are given a great degree of autonomy to follow their ideals, in exchange for services to society. ³¹ For example, doctors are given autonomy, a (partial) monopoly on the distribution of medical drugs and services, high social status and financial rewards. In return, society expects doctors to put the patients’ needs before their own, reassure correct medical knowledge through research and a high degree of integrity to these ideals and to society’s needs. ³² But as society changes, so does society’s needs. Patient demands are different now than a few decades ago. For example, both patients and relatives now often expect to participate in the medical decision making. ³³ Also, since patients pay for their healthcare services – through their own funds, through insurance or through taxes – they demand greater control over healthcare budgets than before. Thus, the autonomy of healthcare workers is reduced. Executive managers are given authority to enforce the public’s expectations, and hospitals are often reorganised in a way that focus more on the economic aspects than the quality of the healthcare. Even less regard is given to the effects of clinicians’ work situation, and the workload often increases while time for discussions with colleagues diminishes. Thus, a friction is created between the ideals of healthcare workers and the expectations of society.

This tension between the impartiality and partiality of care can influence the level of trust between clinicians and managers. Trust is widely regarded as important in relations between healthcare professionals and patients. ³⁴ To ensure effective and humane treatment for patients with complex and diffuse illnesses, the patients need to feel that they can speak openly and are treated with respect as human beings. Only then will patients extend open mandates of trust to the healthcare professionals. ¹⁶ It is hard for healthcare professionals to inform patients if the patients distrust their independence, good will or knowledge. ³⁵ Furthermore, trust is important in relations between clinicians and managers. Without trust, a manager cannot get things done without the use of threats or force. ³⁶ If clinicians do not trust the managers as sources of information, clinicians will instead inquire into the reasons for the managers’ claims, perhaps asking whether the managers are trying to deceive them. ³⁷ Lack of trust between management and clinicians could lead to the formation of exclusive sub-groups among the clinicians, exchanging negative views on the work atmosphere. ¹⁰ Such problems were also present in our studies, most prominently in the psychiatric wards.

Overall, it seems that two different rationalities compete for healthcare priority settings: one patient-centred, individualised way of attending to needs in the particular situation, and one impartialist way of comparing needs and maximising health-related welfare across the interests of individual persons. The ultimate goal of healthcare from the clinicians’ point of view is not to aggregate impersonal utility, but it lies in the quality, professionally and ethically, to realise the values of empathy and concern for his or her patients. ³⁸ The heart of clinical medicine and nursing care is the responsibility each clinician has to the well-being of his or her patient. If these core values are obstructed, the healthcare services may lose its humanistic core. Hence, the balance between distributive and individualised care-related concerns must be proportionate, in the sense that distributive concerns must always make room for compassion and individualised care. This means that concerns of justice and impartial distribution across the interests of persons must always be tempered by individualised care and compassion. ^39,40

Implications for practice

The studies show that clinicians and managers have different views on prioritisations, especially regarding priority settings for patients present in the hospitals versus patients expected at later dates. Furthermore, clinicians sometimes feel their voices are not taken into account among the managers. We suggest clinicians and managers should have more fora for open communication on how they set priorities.