Reorganizing medical care for older persons in times of scarcity: A cybernetics analysis of work pressure and organizational change.

Capacity problems in healthcare lead organizations to seek new and fluid ways of organizing care to safeguard access to services. Task reallocation, triage and stepped care models are increasingly foregrounded as promising interventions that enhance the capacity, efficiency, and resilience of medical services and through which access can be maintained for a growing client base. In this paper, we argue that interventions meant to enhance capacity and increase efficiency have their limits in a system that is already under strain. We draw on the cybernetics of Gregory Bateson and his concept of 'budgets of flexibility' to understand how stress accrues in systems and depletes their capacity for adaptive change. We analyze a case in which regional evening, weekend and night shifts (EWNs) were organized for nursing homes, which included the implementation of a new triage system and task reallocation between various professionals. We show how this initiative rerouted and reprocessed information pathways between professionals, and how this rewiring resulted in a buildup of stress and concomitant emotions of frustration, anxiety, fear and disempowerment through four different mechanisms: (1) fragmentation of information flows; (2) accumulation of information; (3) a loss of richness of information, and (4) slow-moving information flows. The accrual of stress depleted the overall capacity for adaptive change in the system and eventually culminated in a partial breakdown of the new medical service.