Working with Health

The Tensions between Cost-effectiveness and Care in Health Services

(Last modified August 2012)

The German health system is in the midst of a process of fundamental change, with economic criteria becoming central to health care. Alongside other legislative reforms, the flat rate per case arrangements (G-DRG) introduced in 2004 especially are causing enormous changes in the working situation of hospital staff.

This Ph.D. project examines the consequences of this restructuring for actors in the hospital sector using qualitative problem-centered interviews at various levels of the hospital hierarchy. The sample comprises 21interviews, seven of which were conducted with management-level staff (including nursing managers, business managers, strategic managers). Fourteen interviews were conducted with nursing staff directly involved in patient care. This pluri-perspectival method provides insights into hierarchical structures. In order to paint the fullest possible picture, the interviews were conducted in a range of hospitals run by different types of organization (private, public, and voluntary sector). The study is designed to be explorative and explicitly seeks to capture the subjective perspectives of those who are directly affected by structural change in this sector.

The central research interest is the effects of legislative reforms on nursing staff, with interviews designed to elicit information on the influence of the introduction of new economic criteria on nursing work and whether this has led to a shift in the self-image of the profession. Management plays a central role in this restructuring process. According to Simon (2001), management concepts and senior managers' values play a decisive role in determining how external developments are translated into internal processes of change in hospitals. Comparison of the two interview spheres will reveal how management implements external change in the internal work environment of the hospital and what consequences ensue for nursing practice.

The initial results show that increased application of business management methods in hospitals leads to an intensification of work in the field of nursing and an acceleration of various processes, both on the nursing side and the management side.

For most nursing staff the new nursing arrangements create tensions. The new business principles are experienced as stressful and place nurses under pressure, as they are often incompatible with their professional ethos. The surveyed nursing staff regard caring for their patients as their priority. The holistic orientation on the individual patient that dominates in the interviews conflicts with the functionalization of patient care processes which is structurally embedded in the flat rate per case arrangements. The empirical findings suggest that nursing staff compensate this structural deterioration with individual (often voluntary and unpaid) responses in line with their nursing ethics and principles.

Interviews with managers show that they largely comply with economic requirements. Respondents describe an increase in business management activities required of nursing managers, hierarchical restructuring, and strategic reorientation of hospitals for a politically desired competition situation. Most management-level interviewees either accept business-led restructuring without question or see it as a positive development.

The findings reveal conflict between the logic of nursing and the business thinking that predominates at management level. The surveyed health system actors accordingly adopt the ideas of economization to different degrees. The new business orientation determines the normative alignment of many hospitals but is rejected by many of those involved in immediate patient care with reference to their specific professional ethos.