The findings in this study indicate that the new regulations have limited importance, and that daily work in nursing homes is ruled by other factors. First, in our study it became very clear that the staff in the two nursing homes were not familiar with the new regulations, possibly because they had never been informed about them. The problem of information flow from policymakers to those who put the policies into practice is well known [20
]. In the Norwegian case, action was taken to overcome this problem by making the regulations short (only two pages) and easy to read and understand, and by distributing them to all local authorities. Despite these efforts, the staff did not know about the regulations. However, even if the staff had read and understood the regulations, studies indicate that knowledge about regulations is not sufficient to effect changes in nursing practice [7
]. Despite staff lacking knowledge about the new regulations, we actually saw many examples of good practice that satisfied the requirements of the regulations. Our findings reveal, for instance, that staff fulfilled the wishes of many residents in relation to the details of their care. Similar findings are described in studies by Dunér and Nordström and Sacco-Peterson and Borell [23
If the staff do not know the regulations, how is it that in many cases residents are given the right to decide matters of daily care? This might be because the regulations mirror values that are already of importance in our cultural collective. It is therefore reasonable to claim that values such as user participation influence the staff in nursing homes. In addition, similar values may have been embedded in nursing for years, demonstrated in concepts such as getting to know patients in order to deliver person-centred practice and optimize participation [25
]. This might explain why the staff were able to meet the requirements of the new regulations but were unaware of doing so.
Second, our study shows that routines are important structuring elements for the work in nursing homes; they help staff to get the care done and make the day predictable for themselves and for residents. The strength and importance of daily routines have been described in a range of empirical studies, for instance Boge [28
], Christiansen [29
], Harnett [30
], Persson and Wästerfors [10
], Sellerberg [31
], and Zisberg et al. [32
]. Routines in nursing homes might be considered rigid and as having negative consequences for residents [32
], especially if they dominate practice and reduce residents’ influence [26
]. The opportunity for participation or influence depends on staff routines, whether it is a “good match” or if it “disrupts” or “disturbs” the staff in their routines [33
]. On the other hand, routines might also be beneficial. Research confirms that daily routines facilitate well-being in older people [32
], and that residents are pleased to live according to “house rules” [34
]. For instance, residents often want to get up and be dressed before breakfast, and if something upsets the schedule, residents may remark on it [31
]. This indicates that routines can have benefits for nursing home practice; nevertheless, they should never function as a predictor of qualitatively good care.
Third, in addition to routines, our study highlights that the staff always knew what to do. Schirm et al. described a similar pattern [35
]; the findings in their study showed how nursing staff “just got to know how”, and that staff over time developed skills that were just taken for granted. But how do staff actually know what to do in their daily work? How do they know all the details and what to do all the time? To explore this issue and understand it better, Bourdieu’s concept of habitus seems helpful. Bourdieu suggests that it is not sense, or theories, or systems of regulations that govern practice, but the practical sense itself, which is creative, unpredictable and improvising [36
]. Habitus is a collective pattern of thinking and acting, and is often taken for granted within a group [38
]. Members of a group act according to a practical sense, and when asked to describe the rules they act under, they are unable to do so [36
]. Habitus regulates actions without being a product of rules; it makes a group of people act as though “collectively orchestrated without the action of a conductor” [36
]. We think that in the nursing homes we studied, the staff have developed a habitus of caring. This might have something to do with their education and training, and with the fact that they have worked in this way for a long time, as several of the staff have been employed there for 15 to 20
Fourth, our overall understanding in this study is “we just do it”. We interpret this as a combination of the staff’s habitus and the tradition of daily routines. It appears that habitus and routines form a powerful “team” and, to our knowledge, this combination has not previously been described.
What can we learn from our findings?
We know that it is a challenge to change the culture or practice in any organization. Our point is not that regulations are a waste of time and money because the staff do not know about them, but rather that, despite their importance, it is naive to expect regulations alone to be an effective instrument in driving change.
When implementing new regulations, authorities and work-place managers must clearly communicate the new vision that changes are designed to create [40
] and ensure staff participate in the change process [40
]. Furthermore, Berkhout et al. found that conditions for successful implementation were important at the ward level in particular, and that more attention should be given to educating nursing staff about changes [22
]. The findings in our study support the need for educating nursing staff, given that only two of the nurses knew about the new regulations.
However, our findings also indicate that this might not be enough. We suggest that any efforts to develop new ways of acting must be grounded in an understanding of the importance of routines and habitus. The staff’s habitus has been incorporated over years while working under the same conditions, and has a directing influence on their strategies, considerations and beliefs [42
]. Therefore, when implementing new regulations, work-place managers must consider staff’s habitus. To change this habitus, all staff need opportunities to learn and experience the new values. In situations of change, it is often easier for some people in a group to accept the new situation [42
]. According to Scalzi et al., the presence of a critical mass of “change champions” with shared values and goals seems to have an influence on bringing about sustained change in nursing homes [6
]. In this way, one can imagine that the habitus can gradually be changed, and the new regulations can be implemented in staff’s daily work.
Practice in nursing homes is very complex, because staff’s actions depend on many factors [43
]. This complexity needs to be explored and described in further research into practical actions in nursing homes. In this paper, we have focused on how routines and the flow of daily work direct practical actions. There is a need for further exploration of this topic; for example, what happens if the routines and the workflow are disturbed?
Strengths and limitations
A limitation of this study is that it was carried out in a Norwegian context. Another limitation is that data are based on observation by one researcher. Participant observation is subjective in its character and will be coloured by the researcher’s expectations. Therefore, the preliminary findings were discussed with the co-authors during the whole analytical process, before they were presented back to and discussed with the participants. Then, the findings were examined in the light of theory, to develop a possible understanding of the findings. To minimize the limitations, we have carefully described the context, data collection and analytical process.