The Institutional Practice: Dynamics of practice at nursing homes: An ethnographic study of variation in hospitalization amidst uncertainty and continuity

In this thesis we aim to analyze how and why nursing homes vary in practices, in general and for specific practices relating to hospitalization of elderly residents. The main objective is to analyze and understand how practice is generated, shared and implemented at nursing homes, therein variation of practice. The two levels of analysis - that of regimes of practice and of the specific practices of hospitalization - will be approached alternately; each elevating the understanding of the other in a continuous interplay. Research literature state that rates of hospitalizations vary considerably between nursing home institutions, also within smaller geographical areas. The main objective of this thesis is to analyze and explain how such a variation is generated, and how it relates to variation in regimes of practices in a more general sense. Explanations, causes and connections of practice are sought after through the analysis of factors on an institutional- and structural level, and can, as such, be regarded as a supplement to the existing “knowledge bank” primarily addressing patient characteristics in analyses of hospitalizations from nursing homes. The study aims to demonstrate how decisions regarding hospitalizations are derived from an institutional practice: implicit, informal, but still shared, effective and adequate, through an adaptation of Pierre Bourdieu’s theory of practice. We will argue that the institutional practice is developed and implemented locally, in many cases related to the unit rather than the institution, based on a fundamental and encompassing uncertainty to which nursing home staff must relate. We will further argue that the fundamental uncertainty, relevant also for specific decisions on hospitalization, relates to continuity (of many facets), to a larger degree than other factors analyzed. Fieldwork, in the form of participant observation, has been conducted at six nursing homes in Norway, and two nursing homes respectively in Canada, The United States, and United Kingdom. The primary methodological approach is supplemented with interviews and statistical data