Defensive work in nursing homes: accountability gone amok.

This paper contrasts conditions in intensive care nurseries and skilled nursing facilities in order to bring out certain features of organizational functioning in nursing homes. Data stem from a study of three American nursing homes which focused on the circumstances influencing decision-making in the evaluation and treatment of acute illness. DEFENSIVE WORK--work that is institution-protective and/or self-protective-emerged as a dominant process. It is demonstrated that the avoidance strategies which constitute defensive work lead to a progression of counterstrategies and foster skewed priorities. Consequences are: an acceptance of substandard care and a diversion of attention from therapeutic work. The relationship of defensive work to the larger question of how the nation handles its sick elderly is examined in the conclusion of the paper. Recommendations are offered for organizational steps that would re-channel the wasted energy that is spent on defensive work toward more productive therapeutic work.