Neoliberal policy and nursing

Most but not all of the papers examined on this web page come from or have contributors who are associated with universities in South Australia. They cover a broad field and can be considered to be both Macro and Microsociology or to span both. Philosopher Michel Foucault’s concepts of discourse, power and governmentality are used in several papers and they do this.

The papers look at time and the way the neoliberal agenda has made nursing all about the use of time rather than about care. They look at neoliberal policy in health and aged care, at how this has influenced the way nursing is understood and practiced, and at the consequences as reflected in the incidence of missed care and the reasons for it.

A few additional papers look at educational attempts to foster the capacity to engage emotionally. Issues surrounding foreign nurses and male nurses as well as the increasing need for palliative care are mentioned.


Under neoliberal management nursing and nursing care has become less and less about the actual care and more and more about the time spent on care and its cost. It has become a competitive process to cram more into each hour and so pay for fewer less expensive hours.

This page starts with an examination of the nature of time and of the way a life that was historically governed only by the seasons changed and became a capitalist treadmill in which we became motivated to fill every hour. Then finally it became the primary focus of the neoliberal agenda for nurses in health care. The second paper ends by describing the immediate impact of imposing neoliberal management on staff who were previously driven by empathy and the emotional relationships of care - described as chaos and a dismal failure.

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The story of time: Religious purgatory to managerial purgatory

The invention of purgatory Contributions to abstract time in capitalism by Eileen M Willis Journal of Sociology · September 2008 DOI: 10.1177/1440783308092883

This is an interesting and very different theoretical look at the pressure and anxiety created in the workplace and the pressures on employees to serve the corporate employer.  It addresses this by looking at concepts of time in history and their relationship to work. The article quotes from many sources to look at the way time was conceived historically back to the 13th century. This was well before the classic sociological explanation by Max Weber of the way the protestant ethic gave rise to the work ethic that fueled capitalism. Weber was a late 19th century sociologist and his book The Protestant Ethic and the Spirit of Capitalism is a classic work.

Willis suggests that the ethic of work might be traced even further back to the importance of time for the 13th century medieval religious concept of purgatory (a period of suffering after you died). Time spent and the extent of suffering in purgatory to expurgate (pay for) your sins before you could ascend to heaven could be reduced if you used your time to do good things during the latter years of your life. You were exhorted to be “ever watchful redeemers of your time, and make conscience of every hour and minute” and by doing so could earn “social and economic credit on the treadmill of life”. This pressure to use your time effectively later became part of the Protestant ethic.

This pressure to escape purgatory created intense angst, which is described as “the disease in a never ending treadmill of anxiety worked out through endless labour” and “reforming the self through activities that earn social and economic credit on the treadmill of life”. This worldview was also reflected in Dante’s writing about an endless treadmill.

The argument is that “the purgatorial complex paved the way for the modern problematic relationship to time, whereby we see ourselves as responsible for our own making and remaking, rather than as creatures of nature”. As a consequence, “bureaucrats and capitalists require -- - (that) - - the contribution of the worker must come from the heart and often from the soul as well as from the body” - and we all willingly oblige.

The consequence of “this secular modern purgatory is that our lives, once regulated by the flow of seasons, are now controlled by institutions, their calendars and schedules, where we seek to be ‘approved, credentialed, tested, promoted, probated, tenured, appointed, ordained, adjudicated or elected’. Time is now a tyranny – the cure has become the disease.

Comment: I think Willis enjoyed using the idea of purgatory to trace out the way we as social animals actively embrace and enslave ourselves to ideas that don’t help us as individuals and often cause us great stress. Ants and bees do it instinctively but humans have needed this weakness and willingness to be enslaved by ideas to enable them to organize and progress in the same way -- and do so more flexibly. The question now is whether we have developed intellectually sufficiently and have enough understanding of our nature to challenge our weakness to enslave ourselves to ideas.  Are we ready to take control of our lives and use our ideas logically without becoming slaves to them.  As the opportunities for labour decrease can we step off the treadmill and still create worthwhile lives.

The Problem of Time in Ethnographic Health Care Research Eileen M Willis Qualitative Health Research · February 2010 DOI: 10.1177/1049732310361243 · Source: PubMed

This article is largely a discussion of the theories of time, the validity of ethnographic research on a moving target, and the difficulty in reporting on findings that might portray people in a poor light without holding them responsible. Some may find this part interesting.

Comment: My interest for the purpose of this web site is that this was based on a study of nurses in a hospital and the likelihood that it reflects what happened in aged care where it has not been studied. While not the focus of the article, what happened in the hospital studied illustrates and reinforces my earlier description on the page “Conflicting cultures”. This analyses what happens when a new dominant culture, which does not encompass the real life situation in the sector, is imposed from outside on a previous one developed within the sector. It also highlights the way in which identity is shaped by context. The point is that who we become and how we behave are strongly influenced by where we do things and what we do there.

Time and work: The article refers to the impact of medieval ideas in creating a context where time is “now constantly redetermined in terms of its capacity to increase productivity” at the same time as there is “the potential of technology and science to free humans from the drudgery of work and reduce the time spent in labor.” The theoretical issue addressed is the validity of research done in a context that is constantly changing.

The study: The article considers the role of time as the author looks back at a 6 year ethnographic study of nurses and young doctors as “federal and state government microeconomic policies were impacting on the day-to-day working lives of nurses and doctors” creating a rapidly changing context. The author was embedded in a major general hospital and the research was done with “methods of participant and nonparticipant observation, along with interviews, the keeping of detailed field notes, and document analysis”.

The research was directed at identifying how the “cultural world of contemporary health care creates the subjects under investigation” and “the way in which caring work reshapes for nurses their relationship to time, seeping into the very structures of their personality”. Difficulties in the study included the portrayal of a “world frozen in time” and objectifying the people you are studying as “other” – ie ‘looked at’, rather than as “people who know and are known”. The continuous unpredictable changing called for “nuanced alterations to their and my original interpretations”.

The outcome: The New management policies did not evolve into “more productive and efficient workplaces”, “Each innovation - - was a dismal failure” and created “cynical workers who later took an anomic and alienated approach to subsequent change strategies”. It was difficult to describe “the lived experience of the failure to modernize, and the descent into chaos” without appearing to stigmatise the participants. In the case of modern hospitals what is portrayed is the waste of government or public funds

The passage of time meant that “the truth of today is not the truth of tomorrow” and the research no more than “a deep slice at a particular moment in time”.

Note: We will need to look at other articles taking another slice in time to see how the nurses eventually accommodated to the required changes in order to create lives they could identify with there.

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We need to understand the way in which neoliberal policy manifests itself in human services including aged care and the world view that is created. Increasingly this becomes the basis for action and the source of participants’ identity. Both studies look at mental health rather than aged care specifically but they show what happens in a similar context 

The first study focuses on mental health community care. It examined policy as revealed in documents and considered the consequences. It suggests that the neoliberal understanding of the individual and the family actually undermines autonomy and freedom of choice.

The second study focuses on mental health in older people using Foucault’s concept of governmentality to identify the different discourses used. They study finds that these discourses characterise the elderly in conflicting and contrasting ways. This leads to a dispersed and convoluted system.

Neoliberalism and mental health

Neoliberalism, community care and mental health policy by Henderson J in Sociology Review (2005) 14: 242-254

This article gives a good description of neoliberal policy including the role of economics and market in informing governance, the diminishing role of the state in providing health services, as well as an increased reliance on self-responsibility for health and well-being. The issues in discourse discussed include

  1. Redefining problems from the antisocial effects of the market to the anticompetitive effect of the market,
  2. Human behavior seen within the context of economic theory,
  3. The market becoming a function of the state which is responsible for creating an environment for the market,
  4. A fundamental redefinition of the notion of society,
  5. A redefinition of the individual as a responsible individual exercising choice and autonomy rather than a social citizen,
  6. The role of the state is to establish the conditions for this, and
  7. Service delivery is based on contractual relationships rather than entitlements.

The neoliberal development of health policy is examined as

  1. The application of market rationalities to the sector,
  2. Moving from state involvement to a minimalist state working through the hidden hand of the market,
  3. The adoption of managerialist techniques from the market and competitive tendering,
  4. Social rights redefined as personal needs to be met by private means, A discourse that problematizes welfare dependence so placing a moral imperative on families to assume responsibility so placing a greater burden on them.

The study performs a ‘discourse analysis’ of health policy documents relating to mental health on the basis that these reflect a means of framing social problems in such a way that the recommendations become self-evident, excluding alternate representations and limiting the possible interventions. It looked to see how mental illness, the mentally ill and their families were conceptualized and whether these reflected a neoliberal framework.

The study found that “the development of ‘community care’ and ‘informal care’ in Australian policy documents reflect a neo-liberal understanding of the individual and the family, one that views the family as an autonomous unit responsible for its own maintenance”. It found that despite the language this undermines autonomy and freedom of choice. It extended control over the responsibilities of the carer by creating a moral compulsion on families – an example of using self-governance to control.

Fragmentation in Australian Commonwealth and South Australian State policy on mental health and older people: A governmentality analysis Oster C et al: Flinders University Health · May 2016 DOI: 10.1177/1363459316644490

This paper uses Foucault’s concept of ‘governmentality’ - described as “a form of activity aiming to shape, guide or affect the conduct of some person or persons”. It “demonstrates the varying ways in which mental health and ageing are problematised within the Australian policy context”. This is mediated through “discourses (that) create ‘regimes of truth’, which are acceptable formulations of, and solutions to, the problem”. They suggest that “the notion of ‘choice’ functions to deflect the discussion away from differences between what health-care systems offer and clients’ needs”.

They analysed 25 government documents and 14 documents from a number of other groups. They found that the following three interconnected discourses were “problematised in Australian policy; namely ‘being at-risk’, ‘ageing as decline and dependence’ and ‘healthy ageing’”. These three interrelated and but logically inconsistent discourses result in a fragmented system where the aged with mental illness are seen as active participants in some contexts and as passive in others.

Policies reflected a “neoliberal philosophy of governance that emphasises the role of economic markets, rather than government intervention, to govern social and economic life”. The risk to the elderly is recognized on one hand but is not “afforded priority in policy”. This absence in policy is reflected in “an economically determined policy perspective (that) positions older people as ‘unproductive and a burden on society as a whole’” . The paper indicates that ageism is evident in mental health policy.

A neo-liberal approach holds the views that “older people can and should take personal responsibility for managing risks (but this) places the burden of care onto older people and their carers, while structural factors, such as stigma and social determinants of mental health, are not adequately addressed”. “Ageist views about older people’s value and capacity are reinforced”.

Fragmentation “evident in the problematisation of mental health and ageing in Australian policy leads to a dispersed and convoluted system that is difficult to navigate, providing a significant barrier to addressing the ‘problem’ of older people and mental health”. Many end in nursing homes where their mental health needs may not be recognized.

The authors suggest that diversity of identity with all its promise of alternative forms of social engagement enabled by a long life, will be lost. They suggest a discourse that could “enable the recognition of a multiplicity of mature identities and the valuing of older people and their contributions beyond an economic imperative”.

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The pressure on nurses to do more in less time led the nursing unions and governments to study the amount of time needed to provide care and to negotiate management strategies and computer models that they could use in enterprise bargaining. This was done but as we will see in later papers it was inflexible and had its problems.

Benchmarking for enterprise bargaining

Benchmarking working time in health care: the case of Excelcare by Eileen Willis Australian health review: a publication of the Australian Hospital Association · February 2002

The 2002 article about hospitals looks at the consequences for nursing staff of government benchmarking in attempts to get greater efficiencies from nurses in hospitals and the unions successful fight in South Australia to replace it with staffing based on Excelcare in 2000. “Excelcare is a computerised workload product that measures the number of hours and minutes needed to perform a range of nursing tasks for patients on a given ward”.

Development of a Staffing Methodology Equalisation Tool for Community Mental Health and Community Health Nurses South Australia Final Report Eileen Willis Julie Henderson Bonnie Walter Luisa Toffoli July 2007

This report for the South Australian Government followed on the closing of residential psychiatric institutions. These closures placed a far greater load on community mental nurses. It described the development and evaluation of a Workload Equalisation Tool to help determine the staffing needs in the sector. It was for use in enterprise bargaining with the union.

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A doctoral thesis gives a slightly later slice in time. The thesis can be seen as expanding and illustrating the ideas of time introduced earlier. A 9 chapter 370 page in depth study for a doctorate provides a profound insight into the manner in which nurses adapt and change the way they think about their jobs and the care they provide in response to neoliberal management. The nurses come to embrace the work they are required to do in terms of nursing hours and they identify with management’s ideas of excellent care. They build lives and identities in this new context. We do not know to what extent standards of care have changed and how much if any of this excellent care is tokenism or real. Subsequent studies by others specifically address this issue.

There is a good description of Faucoult’s theories and how they play out in an ethnographic study of the things nurses now talk about. The research traces the impact of government policies from the macro-level (documents) of governance to the micro-level of the ward where they impact on the way nurses think, talk and behave. But tensions between the old mission of care and the new required responsibility for the hospital’s business interests remain.

‘Nursing Hours’ or ‘Nursing’ Hours

Nursing Hours’ or ‘Nursing’ Hours: a discourse analysis by Luisa Patrizia Toffoli RN MN
Thesis submitted in fulfilment of the requirements for the award Doctor of Philosophy Sydney Nursing School The University of Sydney April 2011

This 370 page high quality in depth thesis was a study of how nurses experienced and spoke about nursing as neoliberal policies were imposed. It describes how they responded to this very different nursing context and what they did in order to build successful lives there. Like Professor Willis’ study in Adelaide the study itself was ethnographic based on participant observation and interviews and we can see it as a deep slice from a later moment in time. It too focuses on the way in which nurses understand and manage their time. The thesis argues that, even though similar staff shortage and funding pressures occur in public and private systems, a different mentality governs the work of nurses in private health care services.

Very Brief Summary

Toffoli’s own experiences led her to embark on this study. In the first two chapters she gives a detailed explanation of Foucault’s concepts of discourse, governmentality and power before explaining how her study is an analysis of the way “the macro-level of governance play out at the micro-level of the ward” and how the discourse changed from being about patients to placing time management at the centre of their work. Nurses come to talk and think like the managers and become responsible for the economic performance of the hospital. While their worth is measured in working time rather than care, there is an “uneasy tension” here.

CHAPTER 3 THE STUDY describes the ethnographic research technique used to look behind the obvious to see how things work and why. The study was in a small non-profit local private hospital with a close-knit culture.

CHAPTER 4 TAKING CARE OF BUSINESS: This chapter describes the neoliberal changes made, the regulatory framework and managerial language used and the shift from “reliance on truth claims of expert knowledges” to “calculative regimes” written on paper. While care “is not what it used to be” this is set aside in order to give patients a 5star experience. Nurses became responsible for costs in a competitive environment.  They think about the budget and work for the viability of the organization. It became nursing as business.

CHAPTER 5 NURSES’ BUSINESS: (RE)DEFINING THE JOB: This chapter looks at nurses subjective experience and formulation of their roles as employees, and their responsibilities to their employer in managing length of stay protocols, meeting the insurers requirements, and in dealing with patients and the doctors who bring the patients.  In effect they are required to have “a degree of business management insight”. Nurses were made to feel that they were responsible for business difficulties because they cost so much. They became accountable for how they managed their time in the interests of the business.

CHAPTER 6 TIME AT WORK: The focus of this chapter is on time and how the nurses organize this in responding to the hospital business imperative. The measurement of their worth was “their working time or nursing hours” and they managed this in their discourse and activities as they preserved the hospital’s “prestige in the community”. The hospitals requirement for efficiency through flexibility in rostering and in activities is discussed as is the cost of this to staff. The way care was conceived was being rewritten and some things were no longer done. It was “re- conceptualised through economic and business management discourses”.

CHAPTER 7 PRIVATE HEALTH: INTANGIBLE NURSING CARE?: This chapter examines the way business discourse uses ‘text based practices of accountability’ to enroll nurses in the interests of the business to ‘make up’ private healthcare – governmentality at work. It examines the hierarchical organizational charts showing authority structure and reporting lines.

The multiple discourses - clinical, business, and economic create contradictory situations for nurses where they are expected to provide ‘excellent care’ within calculations of ‘nursing hours’ that focus on the economic aspects rather than the care.  That makes this very difficult.

When funding is tight there is restructuring and jobs are lost.  Even though there is a shortage of nurses they all feel at risk of losing their job so putting more pressure on them to protect the business.

While admitting that ‘everything is dollar driven’ they still believe that “it is the quality of the nursing care delivered at the hospital that will distinguish this hospital from its competitors” – but good care needs expensive time so this is difficult.

The important point here is that nurses actively invest in the business. They have a sense of ownership and pride in what they do. Even though traditional values and care are commodified and their work is not acknowledged they want to work there.

CHAPTER 8 SORTING THEMSELVES OUT: This chapter looks at the way the nurses organise themselves and their time to accommodate to the situation they find themselves in. It is a context where managers govern by numbers. At one stage costs were kept down by replacing registered nurses with enrolled nurses – called a ‘Business Improvement Initiative’. Hours were saved by reducing handover. Rosters were split up and fragmented so that time could be used more flexibly with more staff at expected busy times.  There was little allowance for the frequent unpredictability of clinical care.

A variety of strategies were adopted by nurses to cope with the difficulties, by handing over informally, by ‘babysiting’ other nurses patients in gaps between nurses being rostered on, by developing a “buddy system” where a registered nurse would supervise an enrolled or new nurse. All this led to work intensification - a situation where patients’ individual needs were easily subordinated to organisational goals. With no redundancy in the system it was difficult to respond to unexpected developments.

CHAPTER 9 CONCLUSION: The thesis reveals the thinking that nurses working in this situation draw on. It describes the way neoliberal government policy finds its way into care as “one of nursing’s ‘grammars of living’, as the means through which the hospital’s business concerns become those of nurses” and makes them responsible for the hospital’s financial problems and so for the healthcare system. They came to identify with what their managers wanted and the business concerns became their own. Understandings changed from ‘those of service and dedication’ to ‘those of competition, quality and customer demand’. Nurses identified with concepts of ‘excellence’ and ‘quality’ alongside a discourse of ‘flexibility’ which made that difficult.

If you would like to explore this in more depth I have made a longer (nine A4 pages) summary on another page. Link to 9 page summary.

Or to read the full thesis link to it here

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Comment on this study of nursing hours

Readily apparent but not specifically addressed in Toffoli’s thesis is the extent to which this nonprofit hospital had drifted in its approach to care and now adopted the same approach and strategies as many for-profits. The focus of the whole organization had shifted and it no longer represents what many of us once considered nonprofits to be. To survive in a competitive marketplace it had no choice.

This was a fascinating study but inevitably it was limited in scope in that it was not pinned to objective measures such as missed care or any other measures of failed care. The nature of the research and the need for hospital approval to undertake the study made it impossible to comment on the actual standards of care observed. We can only wonder at how successful the nurses were in maintaining nursing standards. Were they able to to build the sort of caring relationships with patients that Professor Fine describes. Could they provide both emotional empathic care and the actual physical care as they tried to meet the management rhetoric of 5–star and exceptional care. There were clearly tensions and conflicts between market expectations and the mission of care that brought most of these nurses into the profession.

Foucault’s theories provide a wonderful insight into the way pressures build up in social systems and how these cause people to change the way they think and then behave in quite different ways to those that they had previously. This doctoral thesis illustrates this very well.

Authenticity: This study raises the issue of authenticity and how we understand that term. Were these nurses expressing a new authenticity or were they escaping their professional authenticity and embracing inauthenticity in order to prosper and belong to the business culture and community in this hospital. If so and if care was suffering as a result (and I am not claiming that it was) then what strategies did they use to accomplish this and be professionally inauthentic. To remain employed and to identify with what they were doing they would have had to use some sort of psychological strategy.

My interest is in dysfunctional systems and we can readily see from this study how embracing an ideology can cause harm when Foucault’s insights are applied.   On the earlier web page Conflicting Cultures I look at the difficulty we have in handling conflicting cultures (or discourses), particularly when one is dominant and not suited to the activities involved. I wrote about the responses including conversion, justification and rationalization as well as other alternative responses. We can readily see some of these at play here as nurses embrace conflicting paradigms in order to build lives in the new context created by neoliberal policies that pay only lip service to their nursing tradition and values. Although some nurses had some reservations and others who could not compromise their traditions might have left, those interviewed were to a large extent converts. Given the nature and intent of the study this would be expected.

Strategies described on the 'Conflicting Cultures' web page include justification (or rationalization) and compartmentalisation. On the web page, Culturopathy: A for-profit example, I explore additional paradigms including 'willful blindness' and philosopher Jean-Paul Sartre’s more difficult to understand concept of ‘bad faith’. He describes how we lie to ourselves as a means of escaping authenticity in order to meet our existential needs when being authentic would require us to do otherwise. He indicates that participants are aware of what is happening and sometimes talk about it but when it comes to what they need to do to build lives they lie to themselves.

If care was being compromised in this hospital (and we don’t know that) then it is easy to see this as happening here.
Whatever concepts we use to understand the psychological strategies used for handling this situation, in each instance core contradictions are neutralized. The new views expressed and the actions taken remain legitimate for the participant. They are genuine within themselves in their actions although to others with knowledge they can appear as illogical and deceptive – no longer authentic.

Foucault and society: What Foucault describes is essential for the maintenance of a structured society but, if we acknowledge our weakness for ideology and the psychological strategies we so readily apply are recognized, then we can understand how things can go very wrong and people can be harmed.

We can argue that Foucault describes the way strong pressures are generated and the other concepts I wrote about earlier describe the strategies we all use to comply with these pressures.  They are neither good nor bad.  That depends on the context - the when, how and why.

US examples: The pressures that are generated are very powerful. We might think that doctors with their strong principles and professional associations would be immune but in the USA they succumbed to these pressures on multiple occasions. The market and the managers were more powerful than their medical associations and they dominated. In 1996 I wrote a detailed article about the way many US doctors abandoned their responsibility to their patients and by conniving in their company’s practices and serving their economic demands they harmed their patients. While I did not know about Foucault and his theories at the time the way these forces operated in that situation should be clear if the details of that quite long article are examined.

Australia is not immune: Forewarned Australian doctors united behind their associations to resist similar pressures in 1998 and their associations hopefully remain strong. But the ACCC reported exactly the same sort of thing happening in audiology to a house of representatives inquiry on 23 March 2017. Audiologists have been put under immense pressure to make the most profit they could when selling expensive hearing aids to the vulnerable whether the consumer needed it or not. Some resigned instead and others who refused were probably pushed. As in the US case there were large rewards and it was difficult to refuse. The ACC indicated that “commissions, incentives and interest on targets are quite pervasive in the industry”. “Significant pressure” was exerted on the audiologists. In the business sector these practices are considered to be “a normal part of business” in a “a market economy” and industry wide. They are doing “what they do elsewhere”.

Being suscpetible and being made susceptible: We can also understand how people with inheritable characteristics that limit reflectiveness and empathy (successful sociopaths) can prosper and succeed in these situations, why marketing emotionally or otherwise appealing ideas can be so successful and how the use of incentives and disincentive strategies, can augment the processes at play and reinforce conversion to new patterns of thinking whether desirable or dysfunctional.  I have written more about sociopaths and the use of incentives on another page and there are extracts from the Hansard of the audiology inquiry.

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Money and resources are not bottomless pits and some form of rationing has always been necessary. Under the welfare state where resources were stretched for maximum benefit and the most needy were prioritized this could be justified and accepted.

The problem with the neoliberal agenda and its belief in the utility of markets is that pressures in the system all too often cause care is rationed in order to generate larger and larger profits and not to provide more or better care. Success in the marketplace depends on making more profit and in aged care that profit comes from reducing nursing costs.  These normally comprise one third to three quarters of the cost of running a nursing home so this is vitally important. Market listed companies boast to their shareholders that they have made more money by treating more high acuity residents who pay better while at the same time reducing the costs of staffing.

Because we don’t measure outcomes and failures in care and depend on a flawed regulatory system operators can get away with this. Studies of missed care and the reasons for this are therefore of interest. Missed care is a global problem in countries with similar aged care systems.

Most of these studies have been done in hospitals but our low aged care staffing levels by international standards, the few studies that have been done in aged care and the accounts of nurses who speak out all indicate that this is a major problem in aged care. The neoliberal argument that the market fixes any problems itself simply does not hold up.

Studies of missed care in hospitals

What nurses miss most: International Network for the Study of Rationalized Nursing Care-Multi-study results Eileen Willis et al Conference Paper June 2014

The paper reviews the various strategies to reduce the costs of care in hospitals. These have increased the intensification of the care provided by nurses and the frequency that required care is not given ie missed, something that has become a global problem. Care is of necessity rationed.

An internationally tested questionnaire was modified and completed by 289 nurses. When care has to be rationed “priority is given to clinical and basic nursing care over tasks which may be less immediately important for patient well-being”. The reasons for missed care included a rise in patient volume or acuity, heavy admission and discharge activity, inadequate numbers of staff, an urgent patient situation and inadequate number of assistive and/or clerical personnel. Increasing throughput and greater acuity causes “nurses to take short cuts, ration certain tasks, or omit them all together” and there is a risk of not providing optimum care.

Work intensification as missed care, Eileen Willis, Julie Henderson, Patti Hamilton, Luisa Toffoli, Ian Blackman, Leah Couzner & Claire Verrall (2015): Labour & Industry: a journal of the social and economic relations of work, DOI: 10.1080/10301763.2015.1060811

This is an extension of the previous paper with a larger number of responses and more detail

Understanding Missed Nursing Care Using Institutional Ethnography: The Ruling Relations of Post New Public Management. Willis E, Henderson J, Blackman I, Verrall C and Hamilton P. Austin J Nurs Health Care. 2015;2(3): 1022.

This is another study of missed care this time in a tertiary public hospital. This paper is a criticism of the New Public Management (NPN), which is based on the introduction of competitive market-like strategies that see nursing labour as the major drain on costs. The new scientific approaches used lead to missed care. Twenty five nurses were interviewed. The authors argue that the New Public Management alters the way care is provided and results in missed care.

Priced to care: Factors underpinning missed care Harvey C et al Journal of Industrial Relations · April 2016 DOI: 10.1177/0022185616638096

Staff shortages, stress and working conditions are not new problems in nursing and as a result “care is missed, rationed or left undone”. The authors use a critical discourse analysis (CDA) to study this in hospitals. CDA is interested in “social organisation and the interplay of people’s activities within it, the focus being on how they construe and internalise such activity”.

Management techniques and care: The paper indicates that “care is routinely missed in today’s budget driven health care milieu, and it has a roll on effect on nurses, organisations and above all, patients.” New public management techniques (NPM) are designed to contain costs. They include “performance incentives and the tying of financial bonuses to meeting performance indicators” which “increases indirect control of nursing work through policies established external to the institution”.

The importance of the actual care given is not realized because “quantity, related to how much care costs, has become more important than the quality of care delivered.”  This is a particular problem because nursing care follows a moral compass and is built on emotional responses so is not easily measured. Clinical pathways become prescriptive and impede the provision of individualized care. As a consequence “nurses’ perceptions of care requirements are at odds with the performance targets set out for care delivery.”

Power: Power is integral to institutions and most important is “the power ‘behind the discourse’, because it is how ‘people with power shape orders of discourse as well as the social order in general’”.

The study: In the study 354 nurses completed the MISSCARE survey and 21 registered nurses were interviewed. What began as a study of missed care ended as a study of the way nurses experienced the policies through which they were managed. What emerged were the conflicts that arose between management that was task oriented and policy driven in ways that undermined and challenged nurses professional identities and roles.

Nurses colluded in hiding their difficulties by adopting the language and thinking of management because “to not do so would ‘result in a painful, psychological disequilibrium’.” The nurses “who care the most are stressed out by their inability to be the nurses they want to be due to lack of time”.

Argument: The paper argues that “financial constraints have contributed to the establishment of policies and performance incentives which direct nursing practice from a distance through monitoring service outcomes” . These have “eliminated individualised patient care” and “failed to recognise the art and science of nursing, and care as core nursing work”. Nurses have taken on new roles and in doing so “unconsciously justified slippage in care” and internalized missed care by taking on “the terminology of the governing dialogue”.

This was “a result of tension that is created between organisational expectations and the concept of caring” which is in turn consequent on the “clash of values structures and ideologies that are at play in current western health care systems”.

Conclusion: In their conclusion the authors indicate that what started as a study of missed care “emerged as tensions in practice between professional identity and organisational commodity. Missed care became a symptom of tension, implied through nurses’ inability to manage the daily expectations imposed upon them by their own need to provide care, in the face of organisational directives that controlled what and how to care based on a financial value rather than a care value.”

Comment: I discuss ‘incentivisation’ in its various forms on another page. It has been one of the major vehicles driving dysfunction and health care fraud in the USA.

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Studies of missed care and poor staffing in nursing homes

Missed care in residential aged care in Australia: An exploratory study. Henderson, J., et al. Collegian (2016),

This paper reviews the extensive international and local literature on missed care in hospitals and discusses when this is better called rationing because it is not the nurses fault. Rationing is not knew. “What is new is its increasing prevalence given the intensity of patient throughput and the subsequent pressure on nursing labour”. In aged care, studies have been done in Switzerland and Canada. In some the problem was infrequent care that impacted on the standards of care.

In Australia the 2011 Productivity Commission report saw a growth “of private-for-profit ownership of residential aged care to 36% in 2012 and a change in the skill mix of the workforce delivering direct care away from registered and enrolled nurses to unlicensed personal care workers in an attempt to achieve cost saving on wages.”

The paper describes a survey of missed care similar to those used elsewhere of 922 nursing carers in nursing homes across 3 states (NSW, Victoria and South Australia). All tasks were missed at least part of the time but the most often missed were “responding to calls bells; toileting residents within 5 min of a request and ambulating with residents”. At the trained nursing level important clinical tasks like glucose monitoring and IV line care were less likely to be missed than “wound care, medication management and vital signs”

The reasons for this were found to be

  • inadequate number of staff,
  • unexpected rise in patient volume or acuity,
  • urgent patient situation,
  • inadequate number of assistive staff, and
  • heavy discharge and admission activity.

The “study demonstrated that current staffing levels are not sufficient to complete all tasks”. Between 2014 and 2915 staffing levels had fallen from 3.05 to 2.84 hours per resident per day. The literature on minimum staffing levels suggested 4.55 to 4.85 was needed. Registered nurse numbers were falling and “education standards for PCAs are poorly regulated”. The paper concluded that staffing levels, resident acuity and skill mix were identified as major reasons for missed care”.

Nurses' perceptions of the impact of the aged care reform on services for residents in multi-purpose services and residential aged care facilities in rural Australia by Julie Henderson, Eileen Willis, Lily Xiao, Claire Verrall June 2016 Abstract only seen

Aim: To understand nurses' perceptions of the impact of the aged care reform on care and services for residents in multi-purpose services (MPS) and residential aged care facilities (RACF) in rural South Australia.

Methods: An interpretative study using semi-structured interviews. Participants comprised registered and enrolled nurses working with aged care residents in rural South Australia. Eleven nurses were interviewed, of these seven worked in MPS and four in RACF.

Results: Data were analysed for similarities and differences in participants' experiences of care delivery between MPS and RACF. Common issues were identified relating to funding and resource shortfalls, staffing levels, skill mix and knowledge deficits. Funding and staffing shortfalls in MPS were related by participants to the lower priority given to aged care in allocating resources within MPS. Nurses in these services identified limited specialist knowledge of aged care and care deficits around basic nursing care. Nurses in RACF identified funding and staffing shortfalls arising from empty beds due to the introduction of the accommodation payment. Dependence upon care workers was associated with care deficits in complex care such as pain management, medication review and wound care.

Conclusion: Further research is needed into the impact of recent reforms on the capacity to deliver quality aged care in rural regions

National Aged Care Staffing and Skills Mix Project Report 2016 Report for ANMF prepared by researchers Flinders and South Australia universities.

Background: This report was a response to problems in staffing identified by the 2011 Productivity Commmission and the absence of any definition in Australia of what adequate staffing was. It “considers both staffing levels and skills mix for Residential Aged Care”. An earlier assessment of 200 residents had shown needs for staffing levels of between 2.5 and 5 hours per care/day. The average needed was 4.3 compared with only 2.84 found by a recent Bentley’s survey. The skills distribution needed was RN’s 30%, EN’s 20% and PCWs 50%.

The study: In the study a number of strategies were adopted including a MISSCARE survey of 3,206 participants and an evaluation by 102 experts. Only 8.2% of respondents to the MISSCARE survey thought that staffing was always adequate. All “nursing services and personal care interventions were missed at least some of the time”. Inadequate staff numbers was the main reason given. It found that staff:resident ratios were highest in government, lower in for-profit and lowest in not-for-profit facilities but in this instance the variable of distance was not considered so this result, which is at odds with international data should be questioned until properly evaluated. A number of factors increased the time needed to provide care. The focus groups considered the current skills mix to be inadequate. Facilities with fixed staff:resident ratios missed less care.

Recommendations: The study recommended a changed methodology for assessing staffing in nursing homes. It recommended that “the average of 4.30 (RCHPD) or 4 hours and eighteen minutes of care per day, with a skills mix requirement of RN 30% (1.29hrs), EN 20% (0.86 hrs) and Personal Care Worker 50% (2.15 hrs) is the evidence based minimum care requirement and skills mix to ensure safe residential and restorative care.

Comment: This is remarkably similar to the average total 4.17 hrs, with RNs 2.08 and equivalents to ENs 0.66 hrs and PCWs 2.43 hrs recommended as a safe average level in the USA. These have been extensively validated since they were adopted by the Centre for Medicare and Medicaid after extensive research during the 1990s.

Aged Care Crisis (ACC) second supplementary submission 302.2 (November 2016) to the reconvened Senate Community Affairs References Committee review into the Future of Australia’s aged care sector workforce

During 2016 staffing levels for nursing finally became available for a number of aged care facilities in Australia and it became possible to relate what has been happening in Australia to the vast amount of information in the USA where both staffing data and data about failures in care have been collected from all 15,000 Medicare and Medicaid registered nursing homes then published and regularly analysed since the mid 1990s. Their recommended staffing levels are based on extensive research and since about 2000 they have been very similar to those now recommended by the nursing study above. ACC submission number 302.2 analysing and comparing the data between our two countries can be downloaded from the senate web site.

The analysis shows that in Australia the skills levels of staff have been falling as providers employ cheaper less trained nurses. Our residents on average receive less than half the care from registered and enrolled nurses than US residents receive. Overall Australian residents receive more than an hour less nursing care per resident per day than in the USA. We fall a well short of levels that the USA consider put most residents at risk of harm.

Studies done in the USA show the close relationship between staffing and failures in care. Multiple studies in the USA show that the more profit focused the owner of the nursing homes are (eg Private equity and market listed companies), the lower the staffing levels and the greater the number of failures in care. There is insufficient data in Australia to repeat these studies but studies of sanctions, and an evaluation of accreditation results that takes into account the geographic distribution of providers and the impact of distance on accreditation performance suggests that we are not different.

ACC does not argue for the US system as there are many problems there but we should learn from their mistakes.

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On these pages we have looked at imagining the life of the other in order to develop empathy – essentially engaging our emotions with the lives of others. We have contrasted ‘patient centred’ with ‘task focused’ care, as well as ‘caring about’ versus ‘caring for’.

It is not only the pressures in the profit before care working environment that can inhibit imagination. Education itself focuses on knowledge, evidence and critical evaluation and may not prepare students for future empathic relationships. Two articles look at what might be done about this in education.

Imagining what it is like for others

In defence of a pedagogy of the heart: theory and practice in the use of imaginal knowledge in Higher Education Research and Development Willis E and Leiman T August 2013 DOI: 10.1080/07294360.2012.706747

The authors talk about 'imaginal knowledge', as opposed to evidence-based and critical pedagogy. Imaginal knowledge “illuminates the imagination and moves the heart towards humanistic action”. The authors try to integrate this with courses based on evidence based knowledge.  They discuss managing the emotions that result.

Evidence based knowledge alone can leave students confused about the authenticity of their choices and they fail to develop a “philosophy of meaning”. The paper explores our nature to explain this and the role of “imaginal insight into shared human experiences” in addressing the problems. They are the “unifying narratives that illuminate for humans a way of being in the world”. The use of students own stories and their ‘myths’, as well as simulated situations that evoke emotion are explored.

Interrogating education of the heart. Willis E, Abery E and Leiman T The International Journal of the First Year in Higher Education ISSN: 1838-2959 Volume 4, Issue 1, pp. 21-32 April 2013

This paper reports on a group of students who engaged in this process.  It describes some of the problems and students feelings about it. They students found the - - “portrayals of the lived experience insightful for developing their own theory of care, but this was tempered by feelings of insecurity in completing these forms of assessment in the competitive environment where grades are important for achieving transfer to their program of choice”.

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We have a large component of immigrants and visa holders providing services, many from non-English speaking cultures.  More males are becoming nurses and we fall a long way behind in providing palliative care for patients who don’t have cancer.  We need more staff for this. Papers address some of these issues


Factors affecting the integration of immigrant nurses into the nursing workforce: A double hermeneutic study by Xiao l, Willis E and Jeffers L. International journal of nursing studies · August 2013 DOI: 10.1016/j.ijnurstu.2013.08.005 · Source: PubMed

The study looks at the multiple difficulties immigrant nurses have in integrating into nursing care in Australia with “cultural clashes, interpersonal conflicts, communication problems, prejudiced attitudes and discrimination towards immigrant nurses”. Unsuitable social structures (policies and resources) impeded integration. There were inadequate rules and resources. The authors found that “learning from each other in multicultural teams and positive intergroup interaction in promoting intercultural understanding are enablers contributing to immigrant nurses’ adaptation and workforce integration”.

Time and the Labour Process: The Construction of Masculinities in Nursing Eileen M Willis published in Current Research in Industrial Relations, Volume 2 p 297 (2015)

A study of how males adapt to a nursing career and the sort of care they focus on. The study indicates that “At the heart of the labour process in nursing is the performance of dirty work and emotional labour. The time male nurses spend on these activities provides insight into how they construct nursing work”. Interestingly the study revealed that men “spend less time on the domestic tasks and more on the emotional but this is done, not by trivialising women’s work, or suggesting that female nurses are too fussy but by seeing themselves as going to the heart of the problem” which leaves “the female nurses with little to complain about”.

Palliative care in aged care facilities for residents with a non-cancer disease: Results of a survey of aged care facilities in South Australia. Ian Maddocks, Deborah Parker, Margaret Brown Eileen M Willis Australasian Journal on Ageing · June 2005 DOI: 10.1111/j.1741-6612.2005.00085.x · Source: OAI

This paper explores guidelines for assessing who needs palliative care. It documents that in the United Kingdom, New Zealand, and Australia only 3–16% of hospice patients in 2003 had a non-cancer diagnosis. It is estimated that 50% of non-cancer deaths would benefit from palliative care and this is the percentage who received it in the USA in 2002.

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