Article 2

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Article 2

Kristiansen M, Obstfelder A, Lotherington AT. (2015) Nurses sensemaking of contradicting

logics, an underexplored aspect of organisational work in nursing homes. Scandinavian

Journal of Management, Vol 31, Iss 3 pp 330-337.

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Nurses ’ sensemaking of contradicting logics: An underexplored aspect of organisational work in nursing homes

Margrethe Kristiansen

^a,

*, Aud Obstfelder

^a

, Ann Therese Lotherington

^b

aDepartmentofHealthandCareSciences,UiT,ThearcticuniversityofNorway,Tromsø,Norway

bCentreforWomen’sandGenderResearch,UiT,ThearcticuniversityofNorway,Tromsø,Norway

ARTICLE INFO Articlehistory:

Received3July2014

Receivedinrevisedform7April2015 Accepted23April2015

Availableonline26May2015 Keywords:

Organisationalwork Contradictinglogics Sensemaking Nursinghome Norway

ABSTRACT

Organisationalwork,understoodasthepracticesbywhichcareservicesareorganised,isoftenreferredto asthe gluein healthcare organisations.In responsetohealthcare reforms,organisationalworkin Norwegian nursing homes has undergone extensive changes. With increased standardisation and efﬁciencydemands,newmanageriallogicoftenstandsinstarkcontrasttotraditionalprofessionallogic.

Althoughorganisationalworkisessential forall actionincare,thereisalackofresearchonhow contradictinglogicsinﬂuenceorganisationalworkinnursinghomes.Inthisstudy,wecombinethe institutionallogicperspectivewithsensemakingtodemonstratehownursescreatenewpatternsand routinesinorganisationalwork.Ouranalysisindicatesthatcontradictinglogicscreate incongruous eventsthatnursesattempttoclarifythroughsensemaking.Toillustratenurses’sensemaking,werelyon newtheoreticaldevelopmentsfromtheinstitutionallogicperspective.Thestudycontributeswithanew understanding of nurses’ organisational work in nursing homes. In addition, by combining the institutional logic perspective with sensemaking, the study adds to previous knowledge in the institutionalliteraturebydemonstratinghowsensemakingenablescontradictinglogicstoco-exist.

ã2015ElsevierLtd.Allrightsreserved.

1.Introduction

Previously dominated by professional logics that relate to professionalauthorityandautonomy(Abbott,1988;Evetts,2009, 2013;Freidson,2001),healthcareorganisationsarenowincreas- inglyinﬂuenced bymanagerial logics representedbyefﬁciency demandsandincreasedstandardisationofcare(Clarke,Gewirtz&

McLaughlin,2000;Lægreid,Roness&Rubecksen,2006;Pollit&

Bouckaert, 2011; Scott, 2000). This shift has challenged the previouslydominatinglogicofprofessionalautonomyinorganis- ingdailywork.Organisationalworkisregardedasaninherentpart ofprofessionals’practices(Muzio&Kirkpatrick,2011;Suddaby&

Viale,2011),andthisworkconsistsofcoordinatingandplanning patientcare.Throughorganisationalwork,nursescontributetothe quality,safetyandefﬁciencyofhealthcareservicesinanimportant way. This phenomenon is thoroughly described by researchers suchasOlsvold(2012);Allen(2014);Orvik,Vågen,Axelsson,and Axelsson(2013); Rankin and Campbell (2006); Scott-Cawiezell etal.(2004).Thesestudieshighlighttheimportanceofobtaininga greaterunderstandingoforganisationalworktogaininsightinto thepossibilitiesandlimitationsofhealthcarereformchanges.Such

knowledgeisofinteresttobothpolicymakersandprovidersthat aimtoimproveservicedeliveryinhealthcareorganisations.Rather than focusing solely on nurses’ organisational work, as in the previouslymentionedstudies,weaiminthisarticletoenrichour understanding by investigating how nurses make sense of contradictinglogicswhenorganisingtheirdailywork.Inparticu- lar,weaimtoinvestigatehowandwhynewmanagerialdemands challengenursestoorganisetheirdailywork inadifferentway.

This objective involves gathering more knowledge about the interconnection between nurses' working practices and new managerial demands. To do so, we chose to draw on the perspectiveofinstitutionallogic(Thornton,Ocasio,&Lounsbury, 2012).

Theinstitutionallogicperspectiveprovidesametatheoretical frameworkforanalysingtheinterrelationshipsamonginstitutions, individuals, and organisations (Thornton et al., 2012). This perspectiveprovidesanewtheoreticalapproachforunderstand- inghowinstitutionallogicsgovernorganisationalstructuresand shapethebehaviourofindividualsintheirpractices(Friedland&

Alford, 1991). Researchers within this discipline report that competing and contradictinglogics areparticularly likely tobe found within healthcare organisations (Greenwood, Raynard, Kodeih,Micelotta,&Lounsbury,2011; Scott,2000).Professional logicandmanageriallogicarefoundedinvariousinstitutionalrule

*Correspondingauthor.Tel.:+4747234906.

http://dx.doi.org/10.1016/j.scaman.2015.04.003 0956-5221/ã2015ElsevierLtd.Allrightsreserved.

ContentslistsavailableatScienceDirect

Scandinavian Journal of Management

j o u r n a l h o m e p a g e : w w w . e l s e vi e r . c o m / l o c a t e/ s c am a n

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systemsofsociallyconstructednormsandbeliefs(Thorntonetal., 2012). Until recently, most research on competing logics has focusedonissuessuchasmanagingtherivalryin careservices (Reay & Hinings, 2009), practical implicationsand professional approaches(Arman,Liff,&Wikström,2014)andtheestablishment ofnewpractices(Lounsbury,2007).Reportswithinthisstreamof researchindicatethatalthoughprofessionalandmanageriallogics compete,theycanalsosimultaneouslyco-exist(Greenwoodetal., 2011;Lounsbury,2007;Reay&Hinings,2009;Suddaby&Viale, 2011). Suchco-existence between competing logics is possible boththroughcooperationbetweenprofessions(Reay&Hinings, 2009)andthroughhybridformsofprofessionalism(Greenwood et al., 2011). However, none of the studies cited above has combinedtheinstitutionallogicperspective(Thorntonetal.,2012) withsensemaking(Weick,1995).Furthermore,littleresearchhas exploredhow competinglogicsinﬂuence nurses’ organisational workinnursinghomes.

Withintheinstitutionallogicperspective,Thorntonetal.(2012) argue thatunderstanding theconnectionbetweenpracticeand institutionallogicsrequiresafocusonthesocialinteractionsof individuals. Thornton et al. (2012) present developments that bridgetheperspectiveofinstitutionallogicwithmorepractice- basedtheories.Sensemaking,asproposedbyWeick(1995),isone suchcomplementarytheory.Sensemakingisoftendescribedasthe socialprocessthroughwhichpeopleworktounderstandissuesor eventsthat are novel, ambiguous, or confusing or that violate expectationsinsomeway(Maitlis&Christianson,2014).Sense- makingisthusregardedasakeymechanismofsocialinteraction andasameansoflinkinginstitutionallogicstothedynamicsof practicesacrossorganisations(Thorntonetal.,2012).Forinstance, whennewmanagerial demandsarise andcreate incongruityin howtoorganisedailywork,sensemakingisusedbythenursesto clarifycontradictingdemands.Thus,sensemakingcanbeseenasa mechanismthathelpthenursestounderstandincongruousevents tobeabletomakedecisionsaboutwhattodoandwhattoignorein theirwork.Inthismanner,contradictinglogicswillinﬂuenceand become tangibly manifested in organisational work through nurses’sensemaking.

Thenumberofempiricalstudiescombiningtheperspectives ofinstitutionaltheorywithsensemakingremainssmall(Maitlis&

Christianson,2014;Weber&Glynn,2006).Althoughresearchers have recommended more research linking sensemaking and institutional theory, Weber and Glynn (2006) argue that institutionsarestillprimarilyunderstoodasconstrainingsense- makingandshapingwhatweexpectandtakeforgranted,that againrestrictthesubstanceofsensemaking.However,asWeber andGlynn(2006)demonstrate,theinfluenceofthisrelationship also flows in the other direction. Therefore, more empirical studies are needed to show the two sides of the relationship betweeninstitutionsandsensemaking.Inanattempttofillthis research gap, our study explores nurses’ sensemaking in organisational work by combiningsensemaking (Weick,1995) withtheinstitutionallogicperspective(Thorntonetal.,2012).We arguethatthistheoreticalcombinationwillenrichouranalytical lens.First,abridgedviewofthetwofieldswillhelpustoalternate betweendifferentlevelsofanalysis.Second,abridgedviewwill allowustoinvestigatethecognitive andsocialmechanismsof incongruousevents thathelp toexplainhow andwhycontra- dicting logics influence nurses’organisational work. This view willin turnprovide insightinto whichtypes oflogics become salient in sensemaking processes and why some logics are employedwhileothersarenot.Inthismanner,thestudypresents newanalyticaldimensionsfortheempiricalstudyofcompeting logics.

Thesetting ofthestudyis threenursinghomes innorthern Norway.Norwegiannursinghomesoperateasmedicalinstitutions

that provide accommodations and medical care to elderly individualswhocannolongerobtainsuitablecareintheirhomes butwhoneverthelessdonotneedhospitalcare(Jacobsen,2005).

Theextensiveworldwidechangesinhealthcarethathaveoccurred in thelastﬁftyyears havebeenlessmarket orientedin Nordic countries. In Norway as in other Scandinavian countries, such changes are characterised by a comprehensive decentralisation trend in the public sector along with the increased use of managerial tools to control subordinate organisation from an arm's length distance (Lægreid, Roness, & Rubecksen, 2007;

Meagher&Szebehely,2013).Innursinghomes,suchmanagerial demandsinvolvetheuseofstricterpredeﬁnedﬁnancialtargetsor outcomesforwork,moretask-orientedproceduresforstaff,and growing standardisation and monitoring systems to measure performance(Dooren,Bouckaert,&Halligan,2010;Næss,Havig,&

Vabø,2013).Researchonnursingleadershipandworkconditions in nursing homes indicates that nurses are struggling to renegotiate theirnewidentityand professionalworkaccording tonewmanagerialdemands(Carvalho,2012;Harvathetal.,2008;

Ingstad, 2010; Jacobsen, 2013; Scott-Cawiezell et al., 2004;

Venturato, Kellett, & Windsor, 2007). These studies report on howincreasedmanagerialdemandsgeneratemoreadministrative tasks that take time away from patient work, which in turn providesaninsufﬁcientbasisfornurses’action.Thisincongruityin organisational work makes nursing homes fertile grounds for studyingthesensemakingofcontradictinglogics.

This paper is structured as follows. First, we review the theoreticalliteraturewiththegoalofcombininginstitutionallogic withsensemaking.Second,we presentourcase studyand then describeourresearchdesignandmethodsfordatacollectionand data analysis. Third, we present our analysis of nurses' sense- makingoforganisingdailyworkandhowthissensemakingrelates to contradicting logics. Finally, we discuss our ﬁndings and concludewithcommentsonourstudy’scontribution.

2.Theoreticalframework

In thispaper, weexplorehownursesmake senseofcontra- dictinglogicswhenorganisingtheirdailywork.Ourexplanatory lens is a combination of theinstitutional logic perspective and sensemaking.ConsistentwithThorntonetal.(2012),wearguethat itisinsufficienttoexplaininstitutionalchangesbyfocusingonlyon institutionalstructures.Inunderstandingindividualandorganisa- tional behaviour, we must also study social interactions and dynamicsinpractice(Friedland&Alford,1991).Theassumptionis thatnurses'sensemakingoforganisingworkisunlikelytooccuras acontext-freeact.Similarly,itisdifficulttothinkofsituationsin whichnurses’sensemakingoforganisingworkwillnotreflectback tothecontextofcontradictinglogics.

2.1.Theinstitutionallogicperspective

Institutionaltheoryhaslongemergedasadominanttheoryin studies of organisations (Scott, 2008). From prior interest in organisationalsimilaritiesand mechanismsthat driveorganisa- tions towardshomogeneity(DiMaggio&Powell,1983;Meyer&

Rowan, 1977), there has been a reorientation of institutional researchtowardsstudiesoforganisationalheterogeneity(Fried- land&Alford,1991).SuddabyandViale(2011)arguethatthisshift is a resultof theinabilityof institutional theorytoexplainthe socioculturalprocessesofinstitutionalchange. Inthispaper,we adopttheperspectiveofinstitutionallogicthatcriticises earlier institutionaltheoryfornotsituatingactorswithintheappropriate organisationalcontexttounderstandinstitutionalpersistenceand change(Greenwoodetal.,2011;Lounsbury,2008;Thorntonetal., 2012).Thisperspectivehelpstoexplainandelucidateconnections

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betweeninstitutional logic and practice that create a sense of commonpurposeandunitywithinorganisationalcontexts.

TheworkofThorntonetal.(2012)proposessixidealtypesof institutional logics: the market, corporations, professions, the state,thefamilyandreligions.Eachhasdistinctivecharacteristics thatareusefulforstudyingmultiplelogicsinconﬂict.However,to be active, the logics require carriers such as individuals and organisationsthatafﬁrm,embody,transmitandactinaccordance withthesecharacteristics.In this paper, weprimarilybuild on studiesfrom hospitalsthat explorethe dilemmas and tensions betweenprofessionallogicandmanageriallogicthatprofessionals encounterintheirdailywork(Armanetal.,2014;Lounsbury,2007;

Lounsbury,2008;Reay&Hinings,2009;Scott,2000).Forinstance, in their study of competing institutional logics in hospitals in Alberta,ReayandHinings(2009)investigatehowcompetinglogics areabletocontinuetobothco-existandcompeteoverlongperiods oftime.Theresearchersreportthatphysiciansandmanagersare abletomanagebothprofessionalandmanageriallogicsthrough thedevelopmentoflocalisedcollaborativerelationshipsin their day-to-daywork.Inanotherstudy,Armanetal.(2014)investigate competinglogicsinpsychiatriccareinSweden,andtheyreport thatincreasedquantiﬁcationincaresupportshierarchisation,on thegroundsofwhichprofessionalandmanageriallogicscanco- exist.Inathirdstudy,Lounsbury(2007)exploreshowcompeting logicsshapepracticesinmutualfundsandarguesfortheneedto giveincreasedattentiontothecomplexinterplayofprofessional andorganisationalelementstounderstandchangesinpractices.

Allthe studiescited above adequatelyexplain the activityand strategiesthatprofessionalsdeveloptocopewiththecomplexity thatariseswhendifferentlogicsmeetandcompete.However,as alreadyargued,theexplanatorypowerofthesestudiesislimited becausetheyfailtoconsiderthesensemakingprocessbehindthe copingstrategies thatactorsdevelopwhen facingcontradicting logics.

2.2.Sensemaking

According to Thornton et al. (2012), sensemaking can be regardedas a complementarytheory withintheperspective of institutionallogic,focusingontherelationshipbetweencognition andaction.Sensemakingisreferredtoasthekeymechanismof socialinteractionthatsituatestheidentitiesandpracticesofactors withinthebroaderculturalstructure(Thorntonetal.,2012;Weber

&Glynn,2006).By focusingonongoingretrospectiveprocesses that rationalise organisationalbehaviour, sensemakinghelps to resolveincongruityinwaysthatenableactivitytooccur(Hernes&

Maitlis,2010;Maitlis&Christianson,2014).ReferringtoStarbuck andMilliken (2013),incongruous eventsareevents thatviolate perceptualframeworksandthusemergeasanessentialoccasion for sensemaking (Weick, 1995). To make sense of incongruous events,actorsseekreasonsthatwillenablethemtoresumethe interruptedactivityandremaininaction.Sensemakingisthusan ongoingprocesswithafocusonoccasionsofsensemakingrather thanonsensemakers.Inotherwords,sensemakingaddressesthe cognitiveandsocialmechanismsforhandlingunexpectedevents, uncertaintyandincongruityinorganisationsthathelptoexplain actors’behaviourinpractice.Thus,sensemakingcanbeviewedas thefeedstockforinstitutionalization(Weick,Sutcliffe,&Obstfeld, 2005).

Sensemakingisusedinseveralresearchstudiesoforganising processes(Maitlis&Christianson,2014).Inarecentstudy,Patriotta andBrown(2011) showhowstudentsmadesenseofunsettling eventssurrounding examevaluationsthrough theuseof meta- phors.Themetaphorshelpedstudentstoassignuncleareventsto something familiar to reduce their fear of exam evaluations.

Sensemaking is also used in studying healthcare issues. For

instance, Apker (2004) shows how nurses make sense of the managed care era within a US hospital primarily through interpretationsgeneratedfromtheircaregivingrole.Inthestudy, Apker emphasises the importance of professional identity constructionamongtheprofessionswhenencounteringmanaged care.Similarly,inastudyfromalargeSwedishhospital,Ericson (2001)demonstratestheneedforsensemakinginunderstanding strategicchangeprocesses.Hearguesthatthroughsensemaking,it is possible to see new aspects of the complexity of strategic changes. However, as all of the studies cited above show, sensemakingalonedoesnotexplicitlyconceptualisethechange ininstitutionalstructuresinwhichmeaningisconstructed.This essential pointbecomes clearer whenconsideringthe studyby Jensen,Kjærgaard,andSvejvig(2009),whoexplorethepotential for combining neo-institutional theory with sensemaking pro- cesseswhenexamining thesocialaspectsoftheimplicationsof informationsystemadoptioninaDanishhospital.Intheirstudy, the researchers demonstrate how an Electronic PatientRecord (EPR)systemwasformedandbecameusefulinspeciﬁcorganisa- tionalcontextsthroughdoctors’meaningproductionandactions inpractice.

3.Thecaseandresearchdesign

We draw on data from three nursing homes in northern Norway,allpubliclyownedandgovernedbylocalmunicipalities.

The nursing homes were strategically selected based on the criterionofoptimalvariation(Creswell,2007).Thenursinghomes variedin theirsize,ageand numberof beds.Onehad 39 beds dividedintothreecareunits,andtheothertwohad90and27beds dividedintonineandthreecareunits,respectively.

Thestudyincludes100hofobservationofdailyhandoversand staffmeetingsinadditionto18semistructured interviewswith ninenursemanagersandninestaffnurses(seeTable1).Fifteen informants were women, and three were men. Their average durationofworkexperienceinnursinghomeswas11years.During a one-weekstayat each nursinghome,wealternatedbetween conducting observation and interviews. To the greatest extent possible,weattempted tocombineobservationswithfollow-up interviewswiththeinformantsobserved.In theinterviews, we focusedontheinformants’experiencewithorganisingdailywork byaskingthemtodescribehowandwhytheworkwasorganised thewayitwas.Whentheinformantsdescribedsituationsthatthey had experienced as challenging, we asked them to provide a detailed account of howand why theyactedin that way. This approach gave us rich data on both the nature of nurses' organisationalworkandthesensemakingprocesses.Theinform- antswereselectedbythenursemanagersineachnursinghome, and the data were collected in 2012. Each interview lasted approximately60minandwasconductedduringworkinghours.

Theinterviewswererecordedandtranscribed.

Table1 DataCollection.

Interviews Observations

Nursemanagers Handovers

Siteone 3 11

Sitetwo 3 11

Sitethree 3 11

Staffnurses Meetings

Siteone 3 2

Sitetwo 3 3

Sitethree 3 2

Total 18 40

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Onadailybasis,threehandoversoccurredineachwardatthe nursinghomes (morning, afternoon and night). The handovers constitutedthemainareafordecisionmaking,workprioritiesand dailyworkcoordination.Dailyhandoversalsoinvolvedinforma- tionexchange.Tounderstandnurses’ongoingorganisingactivities, wechosetoobserveallthehandoversthatoccurredwithinoneday ateachofthewards.Nursemanagersweresporadicallypresent duringthehandovers.Duringtheobservations,wefocusedonthe actionsofnurses,thetoolsthattheyusedandthenarrativesthat theyapplied whenplanningand coordinatingdaily work.Field noteswerewrittencontinuouslyduringobservations.

ThestudywasapprovedbytheNorwegianSocialScienceData Service (NSD). Anonymity and conﬁdentiality were assured accordingtostandardprocedures.

3.1.Analysis

Intheanalysis, ouraimwastodeterminehow nursesmade senseofcontradictinglogicsin organisingtheirdailywork.We operationalised contradicting logics as incongruous events in whichnursemanagersandstaffnursesexperienceddilemmasand tensions between available resources and requirements for professional performance. Template analysis (King, 1998) was usedtoanalysethedata.Inaddition,weusedaqualitativeanalysis softwaretool(NVIVO)toassistinthecodingprocess.First,weread andre-readthedata,searchingforincongruouseventsthatwere prominentastriggersforsensemaking.Second,duringthecoding process, we focused on how sensemaking processes were implementedthroughspeciﬁcactionsandstrategiesasameans ofclarifyingtheseevents.Third,wecategorisedthesensemaking processesintothemes basedonhowtheywerereﬂectedin the organisation of daily work. We distinguished between nurse managers and staff nurses in the coding process to determine whethersensemakingdifferedbetweenthetwopositions.During the analysis, we interpreted the relationship between sense- makingprocessesandcontradictinglogicsbyalternatingbetween ourtheoreticalframeworkandtheempiricaldata.

Atotalofthreethemesemerged.Thesethemesreﬂectaspects ofnurses’workinwhichcontradictinglogicscreatedincongruous eventsthattriggeredsensemakingandtheestablishmentofnew proceduresandadjustmentsofexistingproceduresandroutinesin organising daily work. We named the themes making sense through adjusting to tight budgets, making sense through adjustmentofdocumentationandmakingsensethroughworking harder.Next,weexplaineachthememorethoroughly.

4.Results

Inthis section,wepresentouranalysisofhow nursesmade senseofcontradictinglogicswhenorganisingdailywork.Making senseoftighterbudgetswhilestillattemptingtomaintaintheir professionalstandardsofcarewasacommonmeta-themeamong thenurses.Thisgeneral themewasexpressedin threedifferent ways. In each theme, some differences between the nurse managersandstaffnurseswereobserved.

4.1.Makingsensethroughadjustingtotightbudgets

Standardised measurements and an increased focus on efficiencygaverisetoincongruousevents.Thenursesexplained thattheimplementationof managerialdemandswithastricter focusonbudgetarydisciplineandfinancialcontrolwasinconflict withtheirprofessionalstandardsandthusgenerateduncertainty andaninsufficientbasisforactionindailywork.Thenursesstated thattheycontinuouslyfelta needtoadjust howtheyorganised theirdailyworktoensurethatitwouldcomplywithwhatwas

considered acceptable behaviour. For example, both nurse managers and staff nurses referred to the use of overtime as unacceptable behaviour because of the enormous costs that it generated.Oneofthestaffnursesexpressedthisissueasfollows:

Insituationswhenasickpatientneedsextracare,management says we are notallowed to hireextra personnel due tothe financialsituation.Ifindsuchsituationsverydifficulttohandle;

wealwayshavetothinkabouttheeconomy(Bodil,staffnurse).

Observing daily handovers, we repeatedly encountered situations in which the staff counted the employees’ number of workinghourstoavoidtheuseofovertime.Weweretoldthatin some cases, temporary staff members were removedfrom the workschedulebecausetheworkshiftwouldincurovertimepay.

Consequently,theremovaloftemporarystaffledtosituationsin which thenumber of staffwas lowerthan initiallyplanned,as expressedherebyastaffnurse:

When in charge as a nurse with responsibility for all 80 residentsatthisnursinghome,thenormalpracticeistohire oneextrapersonsothatthenursescangoontop.However,one timeatChristmasEvethereweren’tanyextrapersonnelhired duetoeconomicconsiderations,withtheresultthatwewent understaffedforalongperiodoftime(Heidi,staffnurse).

Asdemonstratedinthequotation,tighterstaffingroutineswere particularly linkedtothenegativeinfluenceof newmanagerial demands. Although the nurses expressed unease about this situationinreferringtothequalityaspectsofcare,theyfollowed stricterstaffingproceduresasaresultoftheseefficiencydemands.

Compared with staff nurses, nurse managers showed more acceptanceoftheneedtoadheretoexternalﬁnancialexpectations in organising work.For example,one nursemanager explained thatbyviewingthenursinghomeresourcesituationinthecontext of the overall economic situation within themunicipality, one could more easily understand how the inﬂuence of external demandshadcreatedtheneedfortighterbudgets:

Thisnursinghomehasabudget,andasanursemanagerIhave noauthoritytogobeyondthatﬁnancialframework.Thus,when someoneisillandweneedtohireadditionalstaff,Icannotdo thatbecauseitwillleadtofurtherconsequences.Itwillalways affectsomethingelseifthenursinghomespendsmoremoney onforinstanceincreasedstafﬁng(Vigdis,nursemanager).

Another nurse manager emphasised the need for greater awarenessamongthestafftoconsiderthedailyworkinnursing homeswithinawidercontext:

Manyofthestaffnursesstilldon’tunderstandtheﬁnancialside ofnursingcareandtheneedtoviewthenursinghomeasoneof severalsubordinateunitswithinthemunicipality(Lars,nurse manager).

Expandingthis viewwas anessential strategy for thenurse managers in adapting to managerial demands. Through this strategy,nursemanagersmadesenseofsituationsinwhichthe ﬁnancial requirements of the nursing home lost the battle in allocatingresourceswithinthemunicipality.

4.2.Makingsensethroughadjustmentofdocumentation

Another sourceof incongruous events that triggered sensemaking was theincreased use of documentationin organising dailywork.Allthenursesexplainedthatstandardisedmeasuresof budgeting and accounting systems,quality procedures, stafﬁng systems,andvariouschecklistsandregistrationsystemsrequired more time to be allocated to documentation. Although the intention was to produce indicators tocontrol the quality and resourcesusedindailycare,staffnursesinparticularexpressed

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that increased documentation narrowed their ﬂexibility in organisingdailywork.

Forexample,duringhandoversweobservedthatthedistribu- tion of tasks was systematically coordinated following stand- ardisedworklists.Theseworklistspreparedbynursemanagers containedinformationaboutwhowasatworkandregulatedthe distributionofworktasks.Weobservedthateachshiftbeganby conductingadivisionoflabouraccordingtotheselists.Thestaff nurses stated that the work lists assisted in coordinating and controllingdailywork.However,theworklistsbecameasourceof incongruouseventswhentheypreventednursesfromhavingthe appropriate level of professional autonomy in making ethical decisionsaboutpatientcare,asexpressedbyastaffnurse:

Muchofthestaffistooconcernedaboutfollowingprocedures.

Forexample,afterdinner,somearealwaysleftinthekitchento clean. Cleaning is more prioritised than giving care to the residents.Ifthekitchendoesn’tshine,theythinktheyhavenot donetheirjob.However,thatisnotwhattheaimofourjobis, evenifitismorevisibleandtangible.So,Ifeelthatsittingdown togetherwiththeresidentsislessprioritised(Perstaffnurse).

Anotheraspectofa moretask-orientedapproach wasthatif timeforpatient-relatedcarewasprioritisedoverdocumentation requirements,thentheinformationgiventotheauthoritiesmight notreﬂecttheactualconditionsofthecareservices.Theinability to document challenges in daily practices was expressed as a sourceof incongruous events.For example,onenurse manager saidthataslongasthenursinghomeoperatedwithinbudget,it wassignalling that thepatientswerereceiving theappropriate care. During the handovers, we observed several instances in whichthenursesremindedoneanothertowritedownandreport anydiscrepanciesinpracticeasameanstohighlightthem.Such discrepancies could involveregistrations of patientswho were deprivedoftheopportunitytoshowerasoftenastheydesired, marginalisationofresident-orientedactivitiesandregistrationof bed-riders.Bed-ridersrefertopatientswhoreceivecareinbed.

Onestaffnursereportedthatbed-ridingwascommonatherward becausethepatientswereverysickandgivingcaretosuchpatients inbedtooklesstimeandwaslesscostly.Allthenursesstatedthat reportingonsuchdiscrepanciesinpracticewasimportanttobe abletocommunicateunethicalcaresituationstothosehigherupin theorganisation,asnicelyexpressedherebyanursemanager:

I have presented tothepoliticians documentationthat says somethingaboutthequalityofcareinthenursinghome.The documentation speciﬁes the content of care given to the residents, describing theirmorning care, feeding,showering and medication. Ifoneshouldgodowninquality,it implies fewer offers to shower, and maybe we should feed more residents simultaneously. The purpose of this way of documentation is to make politicians more accountable for the qualityofcarewhendeterminingthenursinghome'seconomic conditions.Anditwillbeeasierforustodealwithambiguityin dailyworkwhenitisthepoliticianswhodecidethequalitywe aretoprovide(Tone,nursemanager).

As the quotation illustrates, documentation was used as a meanstotransferfinancialandqualityresponsibilityhigherupto thepoliticallevel.Themajorityofthenursesstatedthattheyfelt morejustifiedinsupportingefficiencyandreducedqualityofcare whenthesedemandscamefromthepoliticallevel.Theassump- tion was that political decisions were made on the basis of adequate information and that decision makers knew the consequencesthatanydownwardadjustmentwouldentail.

However,severalnursemanagerssaidthatalthoughtheyhad documentedtheneedforresources,themessagefrompoliticians wasclear:thenursinghomewouldnotreceivemoreresources.

Ratherthantransferringtheresponsibilityforqualityhigherupin theorganisation,thenursemanagerreportedthatresponsibility wassimplygivenbacktothenursinghome.Thissituationwasa sourceofincongruousevents.Althougheconomicdemandsplaced limitations on their professional values, the nurses still felt responsible for providing care services at a level that was consideredtobegoodenough.Whatwasconsideredgoodenough waslinkedtothenurses'professionalnormsandvaluesandwas basedontheirprofessionalknowledge.Boththenursemanagers andstaffnursesstatedthatdocumentationwasdeliberatelyused to promote professional considerations over economic conse- quencesinorganisingdailywork.

During handovers, we observed several occasions in which nursessolvedproblemsarisingfromincongruouseventsthrough theuseofdocumentation. Anexampleisgivenherebyanurse manager:

Ononeoccasion,Ihiredmorestaffforfourhourssothatsome residentswouldhavetheopportunitytoenjoyadancegalafor theelderly.AlthoughIwasabletodocumentthattheresidents hadagoodexperienceandwegotpraisefromresidents,the request from management afterward asked how we could affordit.Howhadwebeenallowedtohirestaffforfourhours?

Then, Isaid Ichosenot toaskfor that. Ithink thatin such situations,Ihavearesponsibilityasaprofessional(Beate,nurse manager).

As the quotation illustrates, documentation was used to promoteprofessionalconsiderationsovereconomicconsequences.

4.3.Makingsensethroughworkingharder

All the nurses emphasised the challenges in nursing care delivery resulting from increased workloads and delegated responsibilities.Althoughallnursesfeltthattheywereinformed about the strategic work in general and that they were often involvedininternalreorganisationprocessesinwork,thenurse managersespeciallystated thattheyhad tospenda significant amountoftimeexplainingandinformingstaffnursesaboutthe difficultsituationandtheneedforchange.Forexample,atastaff meeting,weobservedhowanursemanagerattemptedtoinvolve thestaffnursesinestablishinga commonunderstandingofthe needtoworksmartertomeetrequirementsforsavings.Through dialoguewiththestaff,thenursemanagerconstructedasetting that allowed for the expression of scepticism and frustration, despiteemphasisingallstaff members’individualresponsibility and duty to comply with the cost saving requirements as a consequenceofthefinancialsituation.Duringthemeeting,one staffnursestatedthatalthoughthisstyleoftop-downmanage- ment involved uncertainty and was generally disliked, she felt obligedtocomplybasedonloyaltytoherimmediatesupervisor and,aboveall,tohercolleagues:

Itisthepoliticianswhohavegiventhemanagersaknifeattheir throat. They say that the nursinghome must save because budgetﬁguressaythatwe spendtoomuch money.Itis the mangers who must address this and adopt measures for savings.Weasnurseshavenosayingsinthis(Lone,staffnurse).

Asthequotationillustrates,thenursesfeltobligedtocomply withthedecisionsadoptedtoincreasecareefﬁciency.Toclarify thisincongruousevent,onestaffnursesaidthatthenurseswere abletoexertadditionaleffortstoensurequalityincarebecausethe majorityofthenurseshadconsciencesbyvirtueofbeingwomen:

Thestaffnurses,whoaremainlywomen,areveryconscientious and have a knack for getting through the day. That’swhat rescuesus;simultaneously,itiswhatdrivesusintodisability.

Becauseifthisprofessionweremoremaledominated,Ithink

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more time would be used to document discrepancies and deﬁcienciesonthebasisofalackofstafﬁngresources(Mette, staffnurse).

Thus, as women, the nurses saw themselves as having the ability to compensate and ensure quality in care. However, a majority of the staff nurses expressed concerns that such compensatingwould leadtoinadvertently concealingthe chal- lengestheyactuallyencounteredindailywork.Byhandlingthese caregaps,thenursesalsounderminedtheirprofessionalnorms andvalues.

Forexample,intheirroleasdirectcareproviders,manystaff nurses expressed that they occasionally left their jobs feeling dissatisfiedandguiltyasaresultofalltheworkthattheyhadbeen unabletocomplete.Especiallyduringweekends,withlowstaffing andmanytemporaryunskilledstaffonduty,itwasdifficulttowork alone asa nurse withsoleresponsibility for allpatientsat the nursinghome.Onestaffnurseexplainedthatwhendiscrepancies orcomplaintsaboutthequalityofcarearoseonsuchoccasions,the nurseresponsiblefortheshiftwas alwaysthepersonwhowas blamedforthefailure:

Onweekends,Iamaloneasanurse,andsometimesIamneeded atanotherunit.Then,thereisonlyonepersonleftinmyunitto helptheresidentswhoneedtheassistanceoftwopersons.The situation is unfortunate. In addition, I often work with temporary unqualiﬁed staff. Then, I ask the manager what they thinkabout thesituation.Whatqualitydo they expect fromme?Ithinkthatasmanagers,theyhavetotellmehowto prioritiseandtellmewhattorefrainfromdoing(Linda,staff nurse).

Despite the overwhelming responsibility, the nurses had neithertheauthoritynorthemeanstoadequatelyinﬂuencethe situationsforwhichtheywereheldresponsible.Thus,toclarify thisincongruousevent,itbecameimportanttoobtainsupportand approvalfromthedirectsupervisorintermsofdirectionandwork prioritiesregardingwhattodoandwhattoignore:

Wedowhatwearetold,andwedothebestwecan.Perhapsone runsalittlebitfastertobeabletodoeverything.ThisishowI seeitbeingdone(Evastaffnurse).

Asillustratedinthequotationabove,thenursesmadesenseof thesituationbyworkingfasterandfollowingdirections.

5.Discussion

Thisstudyexploresnurses’sensemakingofcontradictinglogics inorganisationalwork.Theﬁndingsfromthestudyrevealhowan increaseinmanageriallogicchallengedtheprofessionallogicin organising nurses’ daily work.Contradicting logicsgave rise to incongruous events, which in turn triggered sensemaking.

Throughnurses’sensemakingprocesses,weobservedtheestab- lishmentofneworganisationalpracticesin nursinghomes.We thusarguethatnurses’sensemakingplaysakeyroleinhandling contradictinglogicsinorganisationalwork.

Wefirstdemonstratedthat thestrong presenceofefficiency demands challenged the professional autonomy of nurses. We foundthatthroughsensemaking,thenursesfocusedonwhatwas regarded as acceptable or unacceptable behaviour in care.The acceptedbehaviourinvolvedtheestablishmentofneworganisa- tional routines, including stricter staffing routines and the avoidance of overtime. There were, however, some differences amongthenurses.Whilestaffnursesshoweddifficultiesmaking sense of the situation as a result of quality concerns, nurse managersweremoreawareofexternalconsequencesandthereby showedgreaterunderstandingoftheneedtofollowtightbudgets.

Thestaffnurseswerethenencouragedbythenursemanagersto

followstricterstaffingproceduresincare.Suchestablishmentof newpracticesindicatesanewaspectoftheinfluenceofcontra- dictinglogicsinorganisationalworkbydrawingonamanagerial logic more than a professional logic. In this manner, it is the manageriallogicthatguidessocialbehaviourandlegitimisesnew organisationalpracticesinnurses’organisationalwork.Withinthe perspectiveofinstitutionallogic,thismovementindicatesashift from professional logic to managerial logic (Greenwood et al., 2011). This finding differs from Apker (2004) study, in which hospital nurses generated sensemaking through collaboration grounded primarily in their caregiving role. As Apker (2004) argues,thestrongpresenceofprofessionallogicleadsnursesto viewmanagedcarewithagreatdealofambiguity.However,we foundthatnursesattemptedtoclarifyambiguitybydrawingon managerial logic over and above professional logic in their sensemaking. Thereby, we argue that through nurses' sensemaking, new practices in organisational work arose, involving restrictions in nurses' ability to exercise professional control accordingtobudgets.However,thisdoesnotmeanthatthenurses denigrateprofessionallogicinallaspectsoforganisationalwork,as becameclearinthesecondtheme.

Within the second theme, we found increased use of documentation. Through nurses’ sensemaking, we found that increased documentation, in addition to being viewed as a reproductionofmanageriallogic,becameastrategicinstrument underpinning theirprofessional logic. Based on nurses’ fear of actingagainsttheirprofessionallogic,documentationprovideda rationaletopromoteprofessionalaspectsinorganisingtheirwork.

ConsistentwiththestudyofAllen(2014),thefindingsindicatethat nursesclarifiedtheinstitutionalmisalignmentsbetweenmanage- riallogic andnurses’professionalunderstandingthroughdocu- mentation.Inadditiontousingdocumentationtoclarifyissuesin dailycare,asdemonstratedbyAllen(2014),ourstudyshowsthat through sensemaking, nurses were encouraged to document deviations in care with the aim of transferring financial and quality responsibility higher upto thelevel of politicians. This understandingindicatesthatnurses’adjustmenttodocumenta- tion requirements is based more onprofessionallogic than on manageriallogic.However,whethersuchanestablishmentofnew documentationroutinescanberegardedasaformofresistanceto managerialdemandsorareproductionofmanageriallogicisnot clear. Perhaps one needs to consider managerial logic as a reference object with respect to the ability to identify and formulateaprofessionallogicinadditiontomanageriallogic.In thismanner,professionallogicwillnotalwaysbeinoppositionto thepursuitofmanageriallogic.Indeed,bothlogicscanbeserved simultaneously. Thus, we observed that nurses,through sensemaking, adjust their documentation routines in organisational work. This observation reveals a co-existence of contradicting logicswithinnewaspectsoforganisationalworkrelativetothe studiesof Armanetal. (2014)and ReayandHinings (2009).In addition, suchco-existenceof competinglogics showsthat the nursescannotbeconsideredpassiverecipientsinimplementing managerial demands. This argument is consistent with the findingsofJensenetal.(2009),whoobservethatdoctorsappear tobeactiveplayersinadaptinginformationsystemstosafeguard theirprofessionallogic.ConsistentwithWeberandGlynn(2006), wefindthattheinfluenceofmanagerialdemandsalsoflowsinthe otherdirection,whichaidsinimplementingprofessionallogic.

Within thethird theme, we foundincreasedworkloads and individualresponsibilityatwork.Wefoundthatnurses,through sensemaking, clariﬁed the incongruous situation by working harder. The sensemaking process was based on nurses’ moral responsibilityasfemaleprofessionalsandontheirloyaltytotheir immediatesupervisorandcolleagues.Alloftheseelementsspeak to a professional logic in which nurses are professionals with

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expertknowledgewhoaretrainedtohandleuncertaintyincare.By contrast,thesensemakingprocessesalsoconstructedanimageof thenursesaspowerless,conscientiousandsubordinate,withthe riskofactingasaflexibleandalmostinvisibleresourceinnursing care;wefoundthatstaffnursesinparticularexhibitedinstancesin whichtheydeclinedtoacceptthemanageriallogic.Staffnurses hadbeguntoseeksupportandapprovalfortheirprioritiesfrom theirimmediatesupervisorasacollaborativestrategytobeableto makedecisionsaboutwhattodoandwhattoignoreinorganising care. Such collaboration in the establishment of clarification routinesisconsistentwiththestudyofReayandHinings(2009)in which physicians and managers developed mechanisms of collaborationto manage conflicting logics. However, compared with Reay and Hinings (2009), the maintenance of separate identitiesinthiscollaborationwaslessclearwithinourfindings.

Instead, we argue that collaboration was a response to the increased workloads and individual responsibility among staff nurses. Thus, more need for consulting with the immediate supervisormadesensebecauseithelpednursestolegitimisethe minimum standards in care. In this manner, the sensemaking processhelpstoenrichthecircleofobligationsbetweenthenurse managersand staffnurses,which webelieve ismore aimedat developing a common identity rather than a separate identity.

However,whenthecollaborationinvolvessupportingacommon identityofincreasedindividualself-disciplineatwork,thedanger isthattheprofessionallogicmaybeunderminedbecauseitcan lead to a growing lack of conﬁdence in one’s professional competence, as shown by Evetts (2009). Thus, we argue that throughnurses’sensemaking,whetheritinvolvesworkingharder orclarifyingindividualresponsibilitythroughcollaboration,there isadangerofminimisingtheprofessionallogicinfavourofthe manageriallogic.

6.Conclusionandimplications

In this article, we explored how nurses made sense of contradictinglogics when organisingdaily work.Wecombined the institutional logic perspective and sensemaking to ensure greater explanatory power in understanding how and why competing logics influence nurses’ organisational work. Our empirical study demonstrates that managerial logic challenged thepreviouslydominating professionallogic.We observedthat incongruouseventstriggeredaneedforsensemaking.Throughthe sensemakingprocess, we found that nurses were coping with efficiency demands while still attempting to comply with the professionallogic.Thissituationinvolvedacontinuousreorienta- tioninvariousaspects ofnurses’organisationalwork,whereby manageriallogicco-existedwithprofessionallogicbyfollowing budgetrestrictions,documentingissuesandworkingharder.Such adjustmentsinorganisationalworkinvolvedtheincorporationof newmanagerial logic in an already existing practice that was simultaneously changing. Thus, the implementation of new managerial logic did not occur automatically but was shaped through nurses' sensemaking. Hence, we argue that nurses’ sensemakingplaysacriticalbutofteninvisibleroleindetermining howcontradictinglogicsinfluenceorganisationalwork.

The study adds new knowledge to previous research on sensemakingandorganisationalchangesinhealthcarebyshowing how nurses adjust and adapt their organising work through sensemaking.Furthermore,thestudyshowshownurses’sense- makingreproduces managerial and professionallogics through various modes of action that permit rather than constrain contradictinglogicstoco-existinnursinghomes.Byillustrating nurses’ sensemaking processes, this study offers a new under- standingofcontradictinglogicsinnurses’organisationalwork.The

descriptionofnurses’sensemakingprocessesindicatesimportant requirements for implementing new managerial demands in variousaspectsoforganisingworkinnursinghomes.Inaddition, by combining the institutional logic perspective with sensemaking,thisstudyaddstopreviousknowledgeintheinstitutional literaturebyshowinghowcontradicting logicsaresustainedin organisationalworkthroughsensemaking.

Basedonthesmallnumberofnursinghomesinthestudy,itis unclearwhetherthenewpatternsobservedinnurses’organisa- tionalworkarecommoninotherhealthcareorganisations.Thus, weproposethatmoreresearchcombininginstitutionallogicand sensemakingisneededtoidentifyothersensemakingprocessesin healthcarepracticesthatsupporttheco-existenceofcontradicting logics.

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