This is a summary of the main points that I thought were of importance from the doctoral thesis by Luisa Patrizia Toffoli RN MN Sydney Nursing School The University of Sydney April 2011
It is only possible to capture a few fragments of this 370 page thesis here but I try to use Toffoli’s own words and the phrases she quotes from others in order to reflect the nature of the effort she made and the significance of her findings. It was embarked on because of Dr Toffoli’s own experiences while nursing. It provided the material for 8 presentations or publications.
The thesis is built around Foucault’s concepts and Toffoli gives a good description of Foucault’s theoretical insights and the terms he uses.
- discourse, “a group of statements that share the same formative system”, so that matters “are rendered in a particular conceptual form and made amenable to intervention and regulation”.
- governmentality - broadly, “the deliberate shaping of the way we act”.
- Power but a rather different sort of power. This power enables discourses and is intimately associated with knowledge so that “power is needed for the production of knowledge and knowledge is needed for the exercise of power”. It also represses “other possible discourses and other forms of knowledge”. It is a means of control that enters into the lives of individuals and their identity so that they regulate themselves. It sets “boundaries/limits that permit something, and not other things, to be said; what is permissible to say - -.” And language plays a crucial role.
In her analysis Toffoli explores how changes at “the macro-level of governance play out at the micro-level of the ward”. She found that nurses started talking, like their managers, about “nursing hours” rather than “nursing patients”. She explores the contradictions and tensions “between the spheres of business management and nursing; and the situation for nurses in private health because these organisations produce a certain type of care within a competitive business environment”. She talks of “how the business of private healthcare governs nurses’ souls”. These discourses “govern the manner in which nurses conduct their work in this hospital”.
The multitude of texts examined translate health policy from the macro level to the micro level, “which takes nurses beyond that of nurses as ‘employees’ to that of an ‘expert’ nurse whose skill and experience combine to manage the cost of nursing care time for the hospital”. The “dominance of business and economic discourses” puts time management at the centre of nurses’ practice.
The thesis argues that “an ethos of enterprise or business operates” where marketing presents nursing care as its defining feature so ensuring that nurses are responsible for the health of the hospital as well as the experience of the patient - “effectively enrolling them in the hospital’s aims and mission”. But there are “uneasy tensions between the business management of the hospital and nursing”, particularly around nurse labour costs and how nurses are induced to keep these costs down.
An extensive literature review looks at the many ways in which nurses and nursing are conceptualized by numbers, as shortages and a multitude of other attributes. This leaves “the care of the sick dependent upon how those numbers are distributed rather than on nursing knowledge(s) about such care”. The “desire for rendering nurses’ work countable and thereby visible dominates the professional literature and is an example of governmentality at work”. Workload measurements “equate nurses’ ‘worth’ to the delivery of healthcare with working time” and “a process of reducing nursing work to a number – the nursing working hour” and creates ways of thinking.
CHAPTER 3 THE STUDY
This chapter of the thesis describes the ethnographic research technique which is about ‘how things work”, what they are up to, and how the nurses work is “managed not only by management but by the nurses themselves”. It is to “problematise what is taken for granted” and to identify what is hidden in the exchanges of ordinary people on an ordinary day.
The study was conducted in a small, not-for-profit, acute care, metropolitan private hospital which did not have an emergency department, full intensive care facilities or a resident medical officer on site so it would not have provided much acute care or managed many critically ill patients. It would have transferred these to nearby large public and private hospitals which it cooperated closely with. It was “very much a local hospital with a strong, valued, community presence in the area as well as a close-knit culture”. The vast bulk of the nurses worked part time and all were initially registered nurses.
Note: This would have been a relatively low pressure nursing environment, one where a mission of care could survive. Peer pressure to do so would have been strong. There were no on-site doctors employed by the hospital. As a surgeon I would not have used it for major or high risk surgery but the ambience would have been less stressful and more comfortable for patients.
My own study of the hospital sector in the USA showed that as in aged care the pressure to be profitable would be less in not-for-profit than in share market or particularly private equity owned hospitals or even in larger not-for-profits. But, as in the USA, market pressures have steadily driven not-for-profits to operate more like for-profits so the distinction may not be as great as it once was. It would be interesting to see a similar study to this in a private equity owned hospital but they would not welcome this. It would be even more interesting to set this against actual measurements of performance in care, and contrast that with patient satisfaction, in each setting.
There were many ethical issues and it is interesting that a hospital executive had very different ideas about research believing that the organization had ownership of the data and of the outcomes. This led to the research being temporarily terminated while this issue was resolved by the university.
CHAPTER 4 TAKING CARE OF BUSINESS
This chapter describes the neoliberal changes made to health care as well as the regulatory framework (regulatory capitalism) and managerial language that has radically changed health care. There is comment on the way “liberal modes of rule shift power from reliance on truth claims of expert knowledges to those found in “calculative regimes” that are built around writing things down and audits. The structure of the industry is described.
The attitude and matters discussed in discourse are then looked at. Greater nursing intensity ie. having more patients to look after, is reflected in statements like “I’m working harder than I’ve ever worked in my whole career”. There is the perception of long time staff that care is not what it was some years ago and that staff are not as good. But in practice this is set aside in order to identify with management’s language of ‘excellence’ and ‘5 star’ care, and then making the patients experience the 5 star care that they expect but which they don’t understand is not nursing care. They spoke of “the difficulties in maintaining ‘excellent nursing care’ as constituted now within a managerialist discourse”.
In the discourse Toffoli found “a shift from cost to the hospital being solely the domain of insurers and administrators to the nurses on the wards” also being responsible. There is “continual reference to the hospital’s business in nurses’ talk as they work to move patients through the system”. The reason that they think this way is revealed by “the context in which this hospital operates; a very competitive environment”. Nurses “are continually translating patient care requirements in terms of what that care may entail for both patients and the organization”. When asked how nursing had changed they spoke of “changes to how nurses thought about their work, with nurses working on the wards now thinking about the ‘budget’”.
Describing how patients had changed “They want value for money, so their expectations are so different” compared to when they were “very grateful for any care and really appreciative of time”. Now nurse managers and staff continuously focus on the hours per resident per day. Patients might expect to be staying in hospital ‘until I am better’ but for nurses “patients are ‘covered for this amount of time’ under DRG funding classifications”. Although it may be necessary to keep them longer the nursing time is not organized for this.
The final conclusion of this chapter was that nurses were “acutely aware of their relationship with private health funding” which is of course exactly what the management would want. While “talk is imbued with management concepts of quality and excellence of service delivery” the object is “focused on the costs of care” and “nurses work for the viability of the organization”. While residents ‘see private healthcare as’5-star’ against the usual care of the public healthcare system”, nurses “caught in this misperception and the contradictions of ‘care’ - - - enact a concern for economical and timely care beyond mere nursing professionalism”.
Comment: My impression reading this is that there is compartmentalization between the care they used to know and what they do now and that most nurses now identify actively with the managerial requirements and quite willingly cooperate with inconvenient rostering. When questioned directly some had criticisms of the past while others flipped to the other compartment and saw it as being better in the past. This is what you would expect in a spectrum of conversion as a new culture replaced an old one.
Caring relationship: The comments about patients illustrate the way the relationship between patients and nurses have changed to become much more structured and formal – perhaps less empathic - ‘caring for’ rather than ‘caring about’. Marketing and a changing world view have turned patients into customers and they have internalized this. It is evident that this has resulted in a change in power and that this impacts on the relationship.
Patients are now customers whose expectations must be met. They expect this and are no longer grateful in the same way. It is the expectations that the market has created rather than the care they need that is important for nurses and these are not the same thing. We need to set this against Professor Fine’s work between 2012 and 2015, particularly of the nature and relationships of care, and the negotiations around power and dominance.
This chapter is summarized as “the objects of nurses’ talk lay with/in business discourses where the hospital’s viability was viewed as crucial within a competitive private healthcare market. What was being problematised for nurses in the studied hospital was not nursing as a profession in shortage, as figured in the literature, but nursing as business, as reflected in their enrolment in, and use of, managerial concepts of quality and excellence”.
CHAPTER 5 NURSES’ BUSINESS: (RE)DEFINING THE JOB
This chapter addresses “the constitution of nursing subjectivity focusing on nurses’ job descriptions as they translate and articulate programs of governance in the political rationality of private healthcare”. It looks at how nurses are enrolled “in power relations that promote care for the risk to the business through keeping doctors, as customers, satisfied - - - a level of expertise that includes having business acumen”.
They were employees and their responsibility was to the employer on whose account they provided “excellent care” as specified in their job descriptions which ensured that “the hospital’s reputation and status within the private health market/industry (are) paramount”. They are expected to reach professional competency standards but also a “greater level of clinical expertise - - - as well as a degree of business management insight” so that “care is timely, planned and expert”. The “employer’s authoritative voice is evident throughout” and is “infused with words that guarantee that nurses’ work is about ensuring the ongoing performance of the hospital’s business” with an emphasis on “quality and how nurses’ work will enhance the hospital’s profile both internally and externally”.
They are required to give attention to length of stay benchmarks agreed to by the hospital with “health insurance partners”. Care is “well and truly located within managerialist discourses where nurses’ work is as much about achieving organisational goals in line with private sector peers and health insurance partners as it is about achieving patient outcomes”. They are constantly reminded of the hospital’s financial position “via forums held regularly by the hospital executive” and because nursing costs were responsible for most cost blowouts. Nurses felt they were being held responsible so that they came away “from these meetings feeling like it’s your personal fault”.
Nurses were under pressure and “held accountable for their working time using administrative strategies” to the extent that “their ‘nursing hours’ feature daily in their conversations”. It was a part of their “business mentality” as they were urged “to tighten up” so “shifting of responsibility of managing these ‘hours’ to the nurses on the ward”. The focus was to “maximise outcomes and minimise costs but to maintain service quality in the most economical way”.
Rather than management, it became “nurses’ business to manage their working time for the benefit of the organization”. The “cost of nurses to the organisation shapes how the organisation is managed” and threatens its financial viability.
Doctors who bring the patients are seen as the customers who bring in the money and in this regard documents are “heavily tilted toward business-oriented discourses of marketing and customer-service”. “Nurses’ work is as much about promoting the hospital’s image, reputation, and services as it is about care”
Nurses working time is central to the “enterprise bargain and the hospital’s interest was in making this ‘flexible’ in order to allow it to be used more efficiently and so meet demand”. In this regard it is nurses’ expertise “that is drawn upon to manage the nursing budget”. Patterns of thought (subjectivity) include the idea of “an ‘expert’ nurse whose skill and experience combine to manage the cost of nursing care time for the hospital - - managing the cost of that time accruing to nurses across all levels of the organisation”.
CHAPTER 6 TIME AT WORK
This chapter looks at the “centrality of the concept of time to the organisation of nurses’ work - - the responsibility for responding to the hospital business imperatives becomes the nurses’ responsibility through ensuring the flexible delivery of their work”. To do so it examines how the measurement of nurses work is reduced to “their working time or nursing hours” and they come “to describe their work within discourses of business management and the ‘reality’ of private health and the market in which this hospital operates”. They “manage these market and/or business concerns daily in their work”.
Concepts of quality pervade Mission statements with terms like ‘first choice, premier personalised care, teamwork, sustainable excellence etc.’ These are tied to ‘business excellence’ and preserving the hospital’s “prestige in the community”.
The chapter looks at the way management focuses on the flexibility of the workforce, a concept “central to modern economies” and how this impacts on thinking and behavior. This relates to managing the size, skills and flexible use of skill levels. It comes down to “numerical flexibility” adjusting working time.
Employee flexibility is considered as an advantage for staff and we see “the promotion of flexibility as ‘family friendly’, and the idea that some form of ‘work-life balance’ can be achieved”. The system does not always work that way as in practice it “comes at a cost in terms of work-life balance” as attempts to balance the budget lead to “unachievable workloads” making nurses too “absolutely exhausted to have a life afterwards”.
At one stage the dominance of doctors as customer was being challenged by the hospital as it advertised itself to the public in an attempt to induce them to select the hospital and then choose one of the doctors who attended - called “top providers”.
Note: It is interesting that in psychiatry in the USA in the late 1980’s many hospitals used this and other strategies to take control of patient recruitment and admission. They then allocate the patients to doctors of their choice. This gave them the power to control doctors and the treatment they ordered by making those who complied rich and those who did not starve. They used this power to orchestrate a massive fraud of insured patients, many of whom were harmed.
Legal requirements in providing care played an important role in what nurses thought about and how they managed the flexibility of their nursing hours. For example the geography of the hospital and the wards became important because the need to closely monitor one or two residents at one location could limit the ability of an underworked nurse to assist overworked nurses elsewhere. This can stretch the nursing budget so “the design of the facility or ‘the place’ is important for meeting the hospital’s business goals”.
The paper also looks at the issues that are no longer discussed stating “in other words, ‘nursing sensitive outcomes’ and/or time involved in achieving those outcomes, are now ‘no longer discussed’ - - how that old-fashioned proper care was being delivered was being re-written as I observed and talked with the nursing staff”. As one nurse indicated “things are slowly slipping by ... that we don’t do any more.” Core business statements “hold remnants of particular conceptualisations about nursing; what nursing is or should be, and what was, for many, what they went into nursing to do”.
In summary “the nurses’ work is re- conceptualised through economic and business management discourses” resulting in “new ways of understanding care through a number of technologies and practices.” Nurses “account, and are accountable to the hospital for, business outcomes”. Nurses’ “working time became a concept central to the organisation of nursing work when the economic and business discourses of private health dominated nurses’ talk”.
CHAPTER 7 PRIVATE HEALTH: INTANGIBLE NURSING CARE?
This chapter examines the business management discourse about “how nurses are enrolled in the interests of the business through ‘text based practices of accountability’. These texts exemplify the governmental rationalities in play to “make up” private healthcare. The multiple discourses - clinical, business, and economic – “set up a number of contradictory positions for nurses in providing such a thing as ‘excellent care’ within calculations of ‘nursing hours’ - - - - tension between the clinical and economic”. This leads to nurses “(re)constituting ‘care’ in the interests of ‘the business’ or firm”.
Nurses admit that “everything is dollar driven” but still maintain the belief that “it is the quality of the nursing care delivered at the hospital that will distinguish this hospital from its competitors” – exposing the competing priorities because good care needs expensive time. But customer satisfaction depends on their perception of the care and whether the company delivered it or better still exceeded it. This contrasts with the reporting of nursing care primarily as a cost impacting company viability in annual reports.
The “perceived quality of care and the hospital’s continued financial viability is emphasised in each year’s ‘Annual Review’”. The “contradictions for nursing exist between the clinical care and business of private health”. This is not captured in measurements but nurses do, “consciously, knowingly, and actively - - - invest in the business, and there is a strong sense of ownership and pride in the organisation and indeed of the work that they do.” So despite the tension with “what they can actually deliver, and although they struggle to work at this hospital at times, nurses choose to do so”. But “nursing is answerable to the organisation’s business concerns – it is a clear expectation”.
The article examines the hierarchical organizational charts showing the authority structure and reporting lines of the hospital. These charts changed frequently and this caused insecurity among staff. In spite of a nurse shortages there was a history of redundancy and staff reductions with many good staff being made redundant so “their positions/jobs were not necessarily secure; that they could be made redundant at any time”. They were “determined by the economic value or cost of nurses to the hospital as co-producers in the business” so they had a “vested interest in ensuring the viability of the firm - - - keeping the hospital within budget”. There was considerable anxiety when the ‘Quality Manager’ was not a nurse and when Theatre and Maternity were reporting to the Director of Support Services, who was not a clinician but a Human Resources person.
The hospital shaped nurses’ employment/work. What the hospital did, and the committees it appointed were governed by, documented requirements from multiple external bodies. But nurses also felt responsible and anxious, one describing workloads that are “you know out of, out of acceptable, or you know limits that will in fact place them in a situation where potentially they could make an error which has a significant impact on their professional life.”
In conclusion “the hospital uses care as a business strategy”. It is “an ‘ethos of enterprise’ of business, that enrolls nurses within the private sector in the strategic goals of the firm through their shared goal of delivering quality care”. Nurses “sense of job insecurity, ‘as measured by the fear of job loss’ rather than job stability, has nurses working and working hard to ensure the future of the firm”.
“Nursing’s traditional values and care are commodified – but this work is not acknowledged”. There is an uneasy tension between the hospital’s business management and nurses, particularly around cost and importantly around reducing nurse labour costs.
CHAPTER 8 SORTING THEMSELVES OUT
This chapter “considers the ways in which nurses organise themselves in light of the prominence of business management and marketing discourses”. The nursing manager knows that “no matter how Marcello works the figures, his calculations show he is unable to come in within budget; his nursing hours will always be over” yet his job depends on doing so. “Governing by numbers‟ rules managerial thinking. To keep costs down the skill’s mix was changed. Registered nurses were replaced with enrolled nurses (ENs) to reach an 80/20 mix called a “Business Improvement Initiative” but in some situations there were more ENs than RNs.
Another strategy was to reduce handover time in the rostering and clearly insufficient time was allowed for this. A number of other strategies were described. They all put pressure on the nurses.
Examples are given to show how “managers think about reducing labour costs through rescheduling work to increase productive hours and/or reduce overtime by tightening their control of nurses’ working time”. The “re-introduction of enrolled and graduate nurses and an increasing use of agency staff had implications for the organisation of work” and how the nurses coped. Instead of having ‘total patient care themselves’ RNs now had to supervise and be responsible for what others did - a ‘buddy’ system.
Another unpopular strategy was when nurses were asked to ‘babysit’ another nurses patients until more staff came on. This markedly increased workload. Nurses found that they could not complete their work in the time leaving it undone. The “flexibility needed for the hospital’s efficiency and productivity demands led to work intensification for nurses; intensification due to constant interruption of their working time due to fluctuating patient occupancy and/or nursing hours - - - patients’ individual needs are easily subordinated to organisational goals”. It was the “hospital’s flexibility practices that ordered nurses’ work and increased the work intensity for nurses who remained committed to the caring ethos of the profession as well as the hospital’s mission”.
Nurses “order ward life through nursing handover as they classify or ‘grade’ patients and their care”. Because of the rostering “handover was a practice that occurred throughout the day and night, and also served as a source of industrial regulation - - - change of shift handover is regarded as pivotal for the continuity of patient care”. It is used as “a dominant organising strategy”. Nurses “constantly handled their handover sheets and blue folders during the course of the day as they sorted themselves out”. The sheets “highlights how time governs nurses’ work.” Each nurses sheet was individual and reflected that nurses working patterns.
Conclusions: “Attempts to reduce nurses’ working time, or ‘nursing hours’ at an industrial level by reducing the wasting of time in ‘handover’ have led to the demise of the ritualised handover practice of giving a ‘report’”. But their need is apparent as they “resurface in other more distributed and less centred locations and practices”. Nurses respond to the cost cutting of management and cope by “changing understandings of care delivery modes” and “(re)configure the nursing hour”. When handover is restricted “the requirement for handover seeps into other moments”.
Note: Not explicitly mentioned in all this is the lack of redundancy in the staffing system and so the difficulty in responding to unexpected developments. Illness is by its nature highly unpredictable and without the capacity to adapt rapidly to a crisis without leaving other patients unattended failures in care are really inevitable.
CHAPTER 9 CONCLUSION
This thesis examines “the kind of thinking or mentalities that nurses working in this sector draw upon”. This shows that “discourses of business management or enterprise are far more extensive in nursing in the private healthcare sector than currently reported”. Nurses’ talk “lay with the business of managing care with regard to their working time ‘nursing’ hours”. The neoliberal governance is “premised on minimal state intervention to protect the ‘free’ market and individual choice”. This ultimately 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”. This makes “the profession and individual nurses responsible for the workforce problem facing the healthcare system and their workplaces”. Nursing becomes “a risk to the ‘firm’s’ financial viability; a risk that shifts the burden of care to nursing and sees individual nurses and the profession as a whole take responsibility for the hospital’s financial problems, and more broadly those of the healthcare system – in this case, private health – in accounting for their work.”
The discourses of business management and marketing led to nurses identifying with the need to embrace ‘flexibility’ to “re-organise and re-conceptualise care in times of financial constraint”. We saw “the constant adjustment of the contours of nurses’ working time, as and when required by the hospital”. Efficiency in managing the budget resulted in work intensification for nurses and this put pressure on the caring work they did. The neoliberal mantra of giving choice to make employment family friendly saw nurses “working hard in the interests of the firm”.
At the same time the nurses “drew upon management concepts of ‘excellence’ and ‘quality’ alongside a discourse of ‘flexibility’. Understandings changed from ‘those of service and dedication’ to ‘those of competition, quality and customer demand’. Business mentality governed nurses’ work and saw them “taking up the hospital’s business concerns as their own”. Their nursing care is “marketed as a defining feature of the quality and differentiation of this organization”.
Management addressed budget issues by “changing staff skill mix, limiting handover time, and in its financial accounting practices” by focusing on ‘nursing hours’. The strategies used by nurses in order to provide this care in the face of this included baby-sitting, buddying up and informal handover practices, when the need for flexible rostering made formal handover impracticable. Nurses structured their time to “create and construct their working time - - to manage to ‘care’ for their patients” within the constraints imposed by management.
Nurses are not ‘passive dupes’. “Such practices are undertaken mindfully and in line with an ethics of care”. This is shown by their efforts to maintain what “they see as ‘qualities’ of private care”
The full 370 page thesis is available here