P-137 Positive deviance in community palliative care practice

Abstract

Introduction New public management (NPM) is an economic rationalist approach that emphasises managerialism and marketisation, promising ‘continuous increases in efficiency, the use of ever-more-sophisticated technologies, and a productivity focus, with a clear professional management role. NPM has been widely adopted in healthcare in UK and Australia. The potential conflict between this management style and the palliative care philosophy of holistic patient-centred care is apparent. Method Positive organisational scholarship in healthcare (POSH) is “the study of that which is positive, flourishing, and life-giving in healthcare.” This challenges the tendency to concentrate on problems and gaps. Video Reflexive Ethnography (VRE) is a qualitative research methodology that invites participants to feature in and/or gather and interpret audio-visual data using fieldwork notes, audio recordings of interviews, and/or video files. One response to organisational change and pressure in healthcare is known as positive deviance, i.e. ‘behaviours that depart from [organisational] norms, in honourable ways’. This study combined POSH and VRE to explore the intersection of NPM and community palliative care, using a generalist and specialist community-based palliative care service in two states of Australia. Results Practices observed were replete with instances in which nurses employed ‘work arounds’ intended to achieve what was needed for individual patients and families at particular times, i.e. positive deviations. By framing the study in POSH and making such ‘work arounds’ visible via VRE, the ways in which clinical teams applied what was often tacit knowledge and exercised their agency in response to organisational changes at both sites was made explicit. Conclusion The use of POSH VRE allowed the study of the impact of organisational change on palliative care clinicians. It enabled clinicians and to some extent their managers to see how they use ‘work arounds’ internally and externally to ‘engage’ other departments and agencies. In this way frontline clinicians sought to harness POS VRE for their own organisational and political agendas in advocating for their service and the needs of patients and families.