Structural disavowal and personal inundation of responsibility – a local perspective on pressure on mental health front-line professionals
Strukturell ansvarsfraskrivelse og individuell ansvarsoversvømmelse – kommunalt perspektiv på dilemmaer i profesjonelt arbeidet med rus og psykisk helse

ABSTRACT

This article examines how professionals in front-line mental health and addiction services respond to the dilemmas of implementing policies at the local level of the service system. In their daily work, front-line health and social work professionals must find ways to cope with challenges balancing limited resources, professional ethical standards and client needs for varied and flexible services. Front-line professionals have significant space for discretion in finding ways to cope with these dilemmas. We discuss these ways as a drift towards moral dispositions. Drawing on qualitative interviews with local managers and professionals, we find that front-line professionals find themselves at the bottom of the service line where one cannot ‘decentralise’ responsibilities any more. We describe and denote this as ‘structural disavowal of responsibility’, as patients with severe mental health diagnoses are often discharged from specialist services to primary care that lacks the necessary resources. Furthermore, front-line professionals improvise by including measures found in the local community and even their private lives, making their work exceedingly stressful. This is denoted ‘personal inundation of responsibility’. We argue that the moral disposition of front-line professionals hence should be extended to encompass personal inundation as one perversion of their responsibilities.

SAMMENDRAG

Denne artikkelen undersøker hvordan profesjonelle i førstelinjen i rus- og psykisk helsetjenester responderer på dilemmaer ved implementering av nasjonal politikk på kommunalt nivå. Profesjonelle i førstelinjen må daglig finne måter å håndtere dilemmaer på som inkluderer begrensede ressurser, yrkesetiske standarder og brukernes behov for ulike og fleksible tjenester. De profesjonelle har betydelig rom for skjønn når de skal finne måter å håndtere disse dilemmaene på. Vi diskuterer disse måtene som et driv mot ‘moral dispositions’. På bakgrunn av kvalitative intervjuer med ledere og ansatte på kommunalt nivå, finner vi at profesjonelle i førstelinjen befinner seg på bunnen av tjenestelinjen hvor man ikke lenger kan ‘desentralisere’ ansvar ytterligere. Vi betegner dette som ‘strukturell ansvarsfraskrivelse’ ettersom brukere med alvorlig rus og psykisk lidelser ofte blir utskrevet fra spesialisttjenester til kommunale tjenester som mangler nødvendige ressurser. Videre improviserer profesjonelle i førstelinjen ved å inkludere tiltak som finnes lokalt inkludert bruk av egen fritid, noe som gjør arbeidet deres svært belastende. Dette betegnes som ‘indivuduell ansvarsoversvømmelse’. Vi argumenterer for at ‘moral dispositions’ som tjenesteytere i førstelinjen har, følgelig bør utvides til å omfatte individuell ansvarsoversvømmelse som en perversjon av deres ansvar.

KEYWORDS:

• Discretion
• front-line professionals
• health and social work
• mental health
• organisation of services

NØKKELORD:

• skjønn
• profesjonelle i førstelinje
• organisering av tjenester
• psykisk helse helse
• sosialt arbeid

Introduction

During the last 20 years, there has been a substantial growth in services to people with mental health and addiction problems in Norway. The Escalation Plan on Mental Health (1998–2008) (Norwegian Ministry of Health and Social Affairs, 1998) and the Addiction Service Escalation Plan (Norwegian Ministry of Health and Care Services, 2015) have been major national strategies to strengthen the number and competence of mental health personnel, client perspectives on services and the focus on integrated services (Bjørkquist & Hansen, 2018). However, evaluations of the national reforms conclude that while quantitative measures are generally met, quality measures still fall behind, particularly regarding strategies to provide more holistic, coordinated services.

Here, we focus upon professionals’ response to the complexity of the patients’ need. These service users have historically been treated in a fragmented, non-coordinated way – if at all – due to the complexity of their problems and the fact that the service provision system has been fragmented as well. The Norwegian health care system is divided into two tiers: the state and local authorities. State authorities are responsible for specialised hospital and polyclinic services, while local authorities are responsible for the provision of primary local health and social services. At both levels of governance, addiction and mental health services have been divided in a silo structure. Accordingly, patients with concurrent problems are identified as among those with the greatest challenges in obtaining coordinated services (Evjen et al., 2012).

According to Vike (2017), dilemmas of the welfare state include the gap between resources and often unsolved tasks. Health and social services are under constant pressure, due to several intertwined reasons: The political ambitions are greater than the actual resources (funding and personnel), and patients now have more extensive legal rights as to how much, how and when services should be provided (Bjørkquist & Hansen, 2018). Furthermore, the dynamics of professional knowledge has created expectations of medical outcomes never seen before (World Health Organization, 2005). More specifically, the complexity of the illness(es) of patients with concurrent problems has been defined as ‘where the wicked problems are’ (Hannigan & Coffey, 2011), wicked problems being those with no final solution: no plans, technologies or knowledge which will solve them once and for all (Rittel & Webber, 1973). In contrast to linear treatment processes, patients with concurrent diagnoses tend to experience broken, non-linear services from a number of (mostly uncoordinated) service units (Ådnanes & Steihaug, 2013). In particular, transitions and collaboration between specialised and primary care have proved to be challenging (Bergmark et al., 2017; Bjørkquist & Hansen, 2018). There is an abundance of knowledge of specialised mental health services and clinical research (e.g. Strand et al., 2017; Turner et al., 2015). Most of it is characterised by fragmentation, either by analysing strategies for assessment and specific treatment therapies (e.g. Mueser & Gingerich, 2013) or by focusing upon individual service units, e.g. outreach teams, such as ACT (e.g. Killaspy et al., 2006; Stuen et al., 2015).

However, knowledge of how services and individual mental health professionals respond to these challenges is generally scarce. This is particularly the case for research on local service provision. Here we intend to compensate for this situation to a modest extent. We approach the issue in two main ways. We adopt a bottom-up perspective on holistic service provision. As we see it, analyses performed in this field of research too often rest upon the perspective of specialised services, and when dealing with local services these analyses focus particularly upon the lack of resources and ambitions for the services at local levels of government. Here, structural data on personnel and competence development at local levels play a major part in the analyses (Brodwin, 2013) while data on local actors’ responses to how the service system as a whole works are generally lacking.

The performance of front-line professionals is vital to the implementation of national policies. Professional practitioners make extensive use of discretion in their daily work when they transform health and social policies into practice. In the process of operationalising ‘abstract’ policies, there is continuing professional influence, which, in interaction with management, creates professional discretionary space, which varies between different settings (Evans, 2010). Zacka (2017, pp. 48–59), in his analysis of these processes, outlines how dilemmas facing health and social work professionals are related to ambiguous, conflicting goals and values, limited resources, fuzzy boundaries, uncertainty, soft evidence, unpredictability entangles ends and information asymmetry and moral hazards.

As indicated by Matscheck and Piuva (2020, p. 2), mental health policies now intend to combine better coordination of services and simultaneously to ensure that individual patients have more influence over their own care. Generally, these parallel processes have not often succeeded, as a number of evaluations of service provision illustrate (Drake et al., 2001; Horsfall et al., 2009).

Facing these ambitions, in the context of limited resources, we focus upon the ways health and social work professionals and managers at the local level respond to the challenges of balancing concerns about the extent and complexity of patient needs, limited financial and personnel resources and the lack of evidence-based knowledge about how to cope with the ‘wicked’ problems the patients experience in efficient/adequate ways.

The aim of this study is twofold. Firstly, it attempts to identify and describe the varied experiences of managers and front-line professionals. Secondly, it purports, on the basis of the empirical content analysis, to elaborate theoretical concepts for these responses. Here, the following question will be discussed: How do health and social work professionals respond to the dilemmas they face in their daily work?

Theoretical background

Professional discretion implies that decisions are based on specialised knowledge. The use of discretion can go beyond both what services have the resources to do and what they need to do (Aase-Kvåle et al., 2019). There are ethical demands on professionals who physically meet with patients and their needs (Magelssen, 2018). At the same time, they are subject to a multitude of internally contradictory normative requirements that must be balanced. This implies that to fulfil these requirements professionals may apply discretion to negotiate the rules (Ellis, 2011). It is argued that professionals exposed to such pressure become less morally sensitive and truncate the understanding of their responsibilities (Zacka, 2017). Zacka argues that how front-line professionals respond to these dilemmas should be analysed as ‘moral dispositions’. By moral dispositions he refers ‘to how their moral sentiments are mobilized, and how they understand their role and responsibilities’ (Zacka, 2017, p. 9). He defines three distinct pathologies to elaborate on these dispositions: ‘the Indifferent’, ‘the Enforcer’ and ‘the Caregiver’. Naming them ‘pathologies’ implies that these dispositions are deviations from the policies understood as directives in a top-down implementation structure as described in a rational systems approach: ‘Moral dispositions shape how bureaucrats perceive and frame the cases they encounter and what considerations they are inclined to prioritise when responding to them’ (Zacka, 2017, p. 66). Accordingly, the moral dispositions should be considered as reductive takes on norms and expectations of the street-level worker (Zacka, 2017, p. 109). They are ‘adaptive responses’ to the dilemmas facing street-level bureaucrats, and the dispositions rest upon the ‘freedom to choose’ when having discretionary powers in facing dilemmas and challenges in encounters with clients. The pathological responses represent a complementary picture of front-line bureaucrats as defined by ‘professional decisions/ethics’. These moral dispositions emphasise different responses to the discretion offered by front-line work.

We will concentrate on the potential for understanding the way front-line professionals respond as implementers of mental health policies in the local context. Here, we focus particularly on the hierarchical relations between specialised and primary mental health care. We relate this to the structural characteristics that constitute the context of local front-line work.

We then discuss how the discretionary features of this work can lead to a drift towards moral dispositions as outlined above. While not totally neglecting the other two (the ‘indifferent’ and the ‘enforcer’ dispositions), we will pay special attention to the ‘caregiver’ disposition, for two reasons. Firstly, when referring to the ‘caregiver’ disposition, we realised that the context and the responses to the dilemmas we found expressed worries about clients that clearly were within the scope of the ‘caregiver’ disposition. Secondly, our data suggested some responses to the ‘caregiver’ disposition that we feel call for some refinement to the concept as discussed above. Accordingly, we will concentrate upon the ‘caregiver’ and follow the lines of reasoning of those identified in the analysis with that disposition, which we find to be a generalised response common to the local managers and professionals in mental health and addiction services we interviewed. In this way, we intend to show the dynamics between contextual and structural features on the one hand and the reasons for (and dilemmas of) drifting towards the ‘caregiver’ disposition on the other.

Methods and data

We focus upon the experiences of local managers and professionals, in relation to how they respond to dilemmas, ambiguities and pressure at work. The research design is based on the research question presented above. The research revolved around how these experiences were grounded in two intertwined elements. Firstly, structural pressures were identified when mental health policies were implemented through a complex, multi-level governance system (Cairney et al., 2019). The second element was how front-line professionals responded by drifting towards moral dispositions that they supposed would help them overcome their everyday work pressures. The first element pointed to the recent institutional reforms aimed at improving coordination between specialised and local services (Norwegian Ministry of Health and Care Services, 1998, 2009, 2015). The second element referred to the way the primary care system balanced between regulations to become cost-efficient and the maintenance of relevant services to patients with complex and severe mental health and addiction disorders.

The three Norwegian local authorities where this study was conducted vary in size, organisation of services and service complexity. The large city district (about 50,000 inhabitants) and the large town (31,200 inhabitants) have been selected to represent complex service systems in urban areas, while the small town (3,600 inhabitants) represents a less complex service system in a rural area. In the small town, patient care is organised in one team. The large town has one unit that includes both mental health and addiction services. However, the services are split into two sections, each with its own middle management and budget. When the interviews were conducted, the large city district had organised mental health and addiction services separately as different units with their own budgets and in different locations but within walking distance. The city district has a relatively high proportion of patients with concurrent addiction and mental health problems.

The data were collected through seven group interviews which took place during a full-day workshop. The aim was to gain knowledge of how the managers and professionals in each local authority experienced the services they provide to people with concurrent addiction and mental health problems. Mapping normative stands (the experiences) through this method made it possible to ‘unpack the complexity of the moral and political situations in which individuals and groups find themselves’ (Zacka, 2017, p. 256).

The workshop was divided into two sessions. We chose to use group interviews in both sessions, but with different compositions, as described in more detail below. The groups consisted of three to five participants. The local managers from the three local authorities constituted one group. They had a background as nurses, social workers and care workers and had previous experience from working as service providers. The objective of interviewing the managers in one group was to discuss some overriding issues across the three community services. These were challenges and success stories in community services, enablers and barriers for cooperation with specialist health care, professional perspectives guiding the services and implemented in service providers’ work practice and finally, how they responded to governmental regulations.

We chose different group compositions for the two sessions of the workshop. In the first session, all participants (nurses, social workers and care workers) were divided into three groups according to the local authority for which they worked. The groups would thus be distinct from one another but the group members had a common work context which would enable us to make comparisons across groups, here local authorities (Brandt, 1996). Some of the themes of the interview guide used here coincided with those used when interviewing the managers. More specifically, they were challenges and success stories in their community services, professional perspectives guiding their work practice, the involvement of clients and their relatives and the integration of addiction and mental health services.

In the second session, the participants were again divided into three groups, but this time the groups were heterogeneous, having only one or two members from each local authority. This combination enabled the different actors to exchange views across agencies and organisations and thus create different group dynamics from the previous group interview (Andvig, 2014). The themes included their experiences of collaboration with specialist services (physical and mental health and addiction), correctional services, housing and the Norwegian Labour and Welfare Administration. Furthermore, we conducted two more group interviews (with seven and four participants respectively) in the city district, both having participants (social workers and nurses) from both mental health and addiction services.

The agencies and organisations themselves and their managers selected participants for the workshop. The selection criteria were that front-line professionals from both mental health services and addiction services were represented.

The analysis is based on qualitative content analysis. First, both authors read the interview material and developed codes taking an inductive data-driven approach (Hsieh & Shannon, 2005). Second, we took a more deductive approach and drew on the analytical concepts of moral disposition. We concentrated on statements that related to responsibility and how patients are rejected or received in different services and by different front-line professionals. The coding resulted in the following subthemes, all taking the perspectives of local actors on their dilemmas in front-line practice: priorities made by specialised services, the privilege of specialised services to ‘dump’ severely ill patients to the local level, the feeling that primary services are ultimately always left with the responsibility, professionals taking personal responsibility, and who stretch a little further, and finally, regulating work. These were refined in three main themes: views on specialist services, views on primary services, and breaking the boundaries between work and privacy.

Responses to dilemmas in front-line practice

Here, we present the findings from interviews with local managers and front-line professionals from the mental health and addiction services of the three local authorities.

Views on specialised services

Despite improvements in communication and information between specialised and local services, e.g. in relation to discharges, local actors still voiced concerns about the content of services in terms of how the actions of specialised services burden local actors with substantial challenges.

Front-line professionals often argued that specialist care tended to refer to the national guidelines for assessment and treatment of concurrent addiction and mental illness when handing over responsibility for patients to primary care. The guidelines state that if patients do not profit from treatment, they may be termed ‘treatment resistant’, and there is thus no reason to keep them in specialist health care. One manager said:

They [the specialist services] very often refer to this treatment guideline where there are criteria for what to engage in, what kind of diagnoses they are going to treat, and so on, for how long, etc.

When patients are not accepted by the specialist services for treatment, they are discharged and information is sent to the GP and/or primary care services. This causes challenges for primary services with regard to capacity, competency and financial resources. This is also the case when front-line professionals must provide care to patients whom the specialist services assess to be so ill that they cannot help them. As the manager in the small town said:

We haven’t had the competence to accept those who can no longer be treated [in specialised services], but who just need caring for. And we haven’t had the skills to provide enough care. So we’ve had to buy [private] care services.

Another manager expressed frustration over the extent to which patients were rejected for intake to specialised services:

The outpatient clinic must have been world champions in rejecting [applications]. And we got all the applications they rejected, so we got a long waiting list because they refused patients and told them to apply to us instead.

Participants generally found that specialised services ‘decentralised’ responsibility to local services without any plan or strategy to follow up patients once discharged. The professionals reported experiencing pressure from specialised services when patients were ready to be discharged or needed continuous care from primary services. The question arose whether primary care had anything to offer. At the community level this was reported as a way for specialised services to just push away patients and the responsibility without making any actual assessment. In fact, if a therapist left her job at the outpatient clinic, her entire portfolio of patients might be transferred to primary care.

The participants working in community services argued that they could not discharge patients because ultimately, no matter the severity of the patient’s problems, they remain the responsibility of the local authority. Community service providers found that everything ended up with the person who had previously been in contact with the patient as if the service provider had the patient’s name attached to her.

Views on primary services

The managers in primary care described how they were the lowest level of service provision. Accordingly, they had nowhere to discharge patients, who no matter what remained the responsibility of the local authority. One alternative is, however, to commission private care by for- or non-profit organisations. In most cases, however, this is not an option due to the limited number of beds and the expense. Consequently, some employees choose to follow other strategies to meet the patients’ care requirements. The responses we identified were that local service providers took personal responsibility and stretched a little further.

There were many examples from participants which demonstrated how service providers handle situations where patients need more or different services than those they have been allocated. Service providers also described situations where they meet patients who do not fit in with the services to which they have access. Not only do they stretch and bend the existing rules; they are willing to go to the greatest possible lengths to find a way to meet the patients’ needs. The service providers described it as being creative and finding solutions that are out of the ordinary. At the same time, these professionals have a strong sense of the demands placed on them, which they work hard to fulfil. However, in order to work effectively with patients with addiction and mental health problems, they have to work more flexibly. They do so by taking a non-bureaucratic approach to their work, ‘cutting corners’, and in order to fulfil their obligation to look after patients they think unconventionally about how to provide services.

We found that service providers often made extra efforts to find services and measures to help patients with addiction and mental health problems. The participants referred to local services, since these are the last option for the service user. The service provider who has the patient’s name in his or her portfolio will have to try to meet the patient’s needs, whatever they are.

Everything and everyone can end up with us. Then there will be a lot I think that certainly don’t belong with me and my area of responsibility.

Accordingly, the professionals felt that everything could end up being their responsibility and that of primary services. They argue that they often have to handle patient needs and tasks that do not form part of their responsibility and job description.

Service providers in community care often accompany patients who have difficulty in getting to and from appointments. This is partly due to the distance rural patients have to travel to the specialist services located in regional centres. In addition, public transport is poorly developed, or patients will not keep the appointment if they have to take the bus or train on their own. The staff of the local addiction and mental health services have driven many patients and accompanied them if required when they needed to attend appointments with their GP or dentist, the social services or specialist care.

Some participants also described situations where they took on far more than was specified in their job description. The reason they gave was to provide what they perceived as maximum benefit for the patient. The participants frequently used their job description as a pretext to avoid following the rules, arguing that the job description was old and had not been revised for a long time. Furthermore, the tasks of mental health and addiction service providers are said to be rather unclear. This is exemplified by the quote below:

We’ve probably been very independent in a way, but we’ve had a high score because we do many practical things, like changing a door or a lock, or … we can do incredibly many practical things.

The service providers underlined that of course they do take into consideration what services a patient has been officially allocated. They understand their obligation to make seamless service transitions for patients and to this end they have to be proactive and make things happen. Otherwise, they argue, the patient would just be sitting there, struggling with his/her problems.

Breaking boundaries between work and privacy

Most local services for addiction and mental disorders are only available in office hours from 8am to 4pm on weekdays. Patients are concerned about this in different ways, emphasising that most crises occur when services are closed. Patients who need help outside office hours have to either wait or use the emergency ward. However, some employees find other, often unorthodox solutions to extend the service provision hours. Some even break the boundaries between work and privacy. In the interviews there are a number of explicit statements confirming this,. Here, the tendency to provide services outside working hours is exemplified by going to the cinema, meeting for a coffee, which the service provider may well pay for, or making a phone call when patients need a reminder or someone to talk to, also outside working hours.

One participant from one of the primary services described how he finds a way to make sure the patient is looked after when in need after office hours and during the weekend:

There was an emergency number for the weekend, but there was never any response when I called. So I had to get some people from home care, who shouldn’t have gone to the patient at all, just to have some professionals assess his medical condition – that’s something quite unorthodox to do.

One service provider described how she ‘worked her way’ into tasks, not sending a formal notice nor using an agenda when having a meeting with a patient. However, she calls people, sends them text messages and contacts them in various other ways. In this way, she keeps in relatively close contact but because she is responsible for many patients at the same time, she has also set some limits:

I’m not saying I’m equally available all the time, because that’s impossible with so many patients, but I think like being close on … I find some ways.

It is not surprising that the employees are reluctant to elaborate on their ‘secret service provision’, considering that regulating working conditions is a major union task. However, looking at these processes from the management perspective, there are some specific indications, as managers explicitly refer to formal regulation of the boundaries of ‘private service provision’. The following exchange of words took place in one group interview:

Interviewer:

Are your [employees in the department] extending work outside the [regulated] working hours, do they make extra efforts to help their patients?

Local manager:

That’s not allowed.

Interviewer:

How come that’s not allowed?

Local manager:

I say it is not allowed.

Discussion and conclusion

In this paper we have analysed how professional health and social workers respond to working in local services, relating to complex and oftentimes stressful work situations – when meeting clients with concurrent mental health and addiction problems, often referred to as wicked problems (Hannigan & Coffey, 2011). Service provision to these clients are rarely linear processes of recovery, and as performance rules are rarely clear, front-line professionals need discretion to interpret them and transform them into practice, and by that face a number of dilemmas in their daily work (Evans & Harris, 2004). Based upon empirical research in three local services in Norway, we asked how health and social work professionals respond to these dilemmas, aiming to identify and describe front line service professionals’ responses, and to elaborate theoretical concepts that potentially will contribute to further analyses of these topics. Drawing on Zacka’s (2017) approach of moral dispositions of street-level bureaucrats, we identified two levels of analysis: these dealt with the structure of service provision and the responses of individual professionals in their everyday encounters with patients. In our findings, we see that these levels are interconnected. The structural characteristics are defined as a contextual amplifier for coping with the pressure of mental health work in local services, as seen by those working at this level of service provision. We discuss two key concepts to grasp the peculiarities of the service system, ‘structural disavowal of responsibility’ and ‘personal inundation of responsibility’, respectively.

We find that the specialised services are characterised by what we call ‘structural disavowal of responsibility’, indicating that these services have the privilege of refusing and discharging patients in disregard of the workload at the local level. Pressure on the specialised services causes a system of prioritisation, referring to national guidelines. Generally, these guidelines are based upon the fundamental division in the governance system between cure (mainly but not exclusively the responsibility of specialised services) and care (mainly but not exclusively the responsibility of primary health services) (Glouberman & Mintzberg, 2001). Our results show that there is a general impression that information about patients discharged or refused has improved, while the content of medical assessments is the privilege of hospital doctors. We emphasise that the local front-line professionals did not see this as a personal disavowal of responsibility, rather as a structural problem. This problem is amplified by those in specialised services that do not follow the regulations for communication between the two levels of service provision. We argue that these processes of structural disavowal of responsibility should be understood as the combined result of the sustained reduction of hospital beds and other specialised services as part of the de-institutionalisation of mental health services on the one hand, and institutional reforms, in particular the Coordination Reform of 2009 (Norwegian Ministry of Health and Care Services, 2009), on the other. These developments have led to an increasing workload in specialist mental health care. In addition to the increased clinical workload, physicians also have to handle more administrative tasks, cf. managerial reforms, than previously (Grima et al., 2020; Noordegraaf, 2011). Furthermore, communication about discharges from hospitals to local services also appears to be deteriorating (Norlyk et al., 2020). However, others studies show how electronic communication makes patient transitions between hospital and community care more efficient as the quality of the information has improved (Melby et al., 2015).

In primary care, mental health and social work professionals have seen their workload increase for a number of reasons, including the problems of capacity in the specialised services. However, the work situation varies between the services, and the workload was significantly higher in the largest city we studied. In all local authorities, mental health and social workers emphasise their high level of discretion in their work. Working mostly with individual patients, they are relatively free to choose treatment strategies in the intersection between their knowledge of mental health problems, their proximity to a number of other health and social services and their experience of how to adapt their work to individual patients. Often, mental health and social work professionals see their work change from ‘decision maker’ to becoming a guide and coach for patients/clients into the complexity of welfare services. Generally, they were highly motivated, they find their work stimulating and well suited to their professional competence. Nevertheless, they also see the dilemmas, inherent contradictions and uncertainty in their daily work, and they obviously respond in different ways to these challenges.

Referring to the concept of moral dispositions, we find that professionals argue in ways that can easily be connected to all the three dispositions of the ‘indifferent’, ‘enforcer’ and ‘caregiver’. We find that their work with patients involves actions and words that indicate that they select alternative responses from their repertoire, showing flexibility based upon their knowledge of the individual patient. Within the wide space for discretion, front-line professionals must ensure that they remain sensitive to the plurality of normative considerations: to be fair, respectful and responsive towards patients, yet always fulfilling the overall aim of being (cost-)effective (Zacka, 2017, p. 200). These requirements are embedded in national mental health policies, and the professionals we studied faced them every day in their encounters with patients.

The inherent contradictions of these requirements were an ‘impossible situations’ (Zacka, 2017, p. 206ff.) issue that permeated the interviews and discussions at meetings: how to cope with the discrepancy. This was, however, particularly reflected in the dilemma between professional ethics and service goals on the one hand and the lack of resources on the other.

In analysing the challenges of providing ‘more for less’, given the structural disavowal of responsibility discussed above, we have concentrated on the drift towards the caregiver moral disposition. The caregiver disposition implies that professionals overstep the boundaries of their official responsibility by providing more attention and help to certain clients. By so doing, they violate the regulations on how much services and time should be provided to selected individual clients. This might easily happen gradually or spontaneously; for instance when identifying with the client’s problems the professional gets emotionally involved, and hence provides services while driving the client as part of the job. The caregiver ‘conceives of his job […] as a mission’ (Zacka, 2017, p. 93). This description is reminiscent of the ‘zealot’ role recently graduated social care professionals tend to adopt when professional ethics and ambitions encounter the harsh realities of organisational boundaries at their workplace – before professional idealism is turned into workplace realism (Mackintosh, 2006; Traynor & Buus, 2016).

Furthermore, local managers and front-line professionals shared many of same approaches to challenges and associated responses when their workload increased. According to Evans (2010), local managers, many of whom have worked as front-line professionals and might still handle cases, identify themselves with professional service providers with whom they share a professional commitment and thus promote professional discretion. However, we find one exception, where a local manager tried to regulate professionals’ working hours, at least officially in the setting of the interview. Even though there are attempts to uphold the rules and restrict their actions, the frontline professionals and management still overstep the boundaries of their official responsibility and maintain substantial discretion (Sletten & Bjørkquist, 2020).

As we see it, there are two apparently similar but still fundamentally different forms of overstepping one’s official responsibility, here referred to as ‘personal inundation of responsibility’. The first is how normative dispositions ‘drift’ into the norms of the caregiver by providing ‘biased’ services to individual patients that the professional finds to be particularly sympathetic, thus breaking the priority rules by increasing the discretional powers given to their official work. Hence, this is a different way of expanding tasks and responsibilities that are considered relevant to their profession’s field of knowledge based on competition between professional groups (Abbott, 1988). The act of overstepping one’s official responsibilities is mainly a problem in relation to managerial regulations (for the sake of fairness and cost-efficiency) and peer relations (for the sake of the work environment).

The second form of overstepping is when professionals extend their work into the private sphere, as we have discussed in this paper related to the concept of ‘personal inundation’. Why this takes place might seem rather uncomplicated to explain with reference to the processes we have described in the findings section. However, we will point out some particular aspects relevant to our study. In the context of mental health policies in Norway, we argue that it is the combined influence of structural disavowal of responsibility and the professional-scientific paradigms that dominate present-day mental health discourses that encourages this drift toward a privatisation of the caregiver disposition. In the case of the latter, the ‘recovery’ approach has been turned into an ideal of extending professional mental health care into the private sphere. Here, they advocate that front-line professionals should violate the boundaries of their work by using their own free time, money, and competencies to help individual patients (Borg & Karlsson, 2017). This tendency has been previously found in studies of home nurses’ responses to managerial restrictions, and has been called ‘secret services’ (Kamp, 2012; Kirchhoff & Karlsson, 2013), and professionals representing ‘the conscience of the welfare state’ when decentralisation has arrived at the bottom of the official social care system (Vike, 2017). However, not being able to leave work on time, or experiencing a conflict of interest between one's own family's needs and patients’ needs could lead to stressful work situations over time (Barck-Holst et al., 2019).

The implications, however, are more complex. Firstly, ‘inundation’ implies that the overall health policy and administrative measures become blurred without any transparent discussion. Consequently, the ‘kind’ approach to individual patients not only breaks the rules of the individual workplace, but the very idea of modernity, as outlined by Weber in his analyses of bureaucracy. This separation of the private and professional might easily become hard to maintain when the amount of (mental) health and social care problems increases. Furthermore, there is a need to draw attention to various rules of action, not only formal ones but especially professional norms and values, along with the expectations professionals face and the ways they make sense of what is required of them (Hupe & Buffat, 2014). As we see it, these drifts need to be further elaborated theoretically, conceptually and empirically.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Norges Forskningsråd [grant number 273312].

Notes on contributors

Catharina Bjørkquist

Catharina Bjørkquist is professor at the Master’s programme in integrated health and welfare services, Østfold University College. Her research interests are on health and social policies, work, organisations and coordination of health and welfare services and hospital management. She is engaged in projects that focus on local innovation processes including digitalisation, development of health and social services and user involvement.

Helge Ramsdal

Helge Ramsdal is professor in political science and organisation theory at Østfold University College. His research focuses on health and social policies, innovations in health and social services, and work, organisations and governance. He has written books and articles on welfare reforms, hospital management and mental health services.