Chapter 7 Textbook Notes

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HLTB03 Midterm Notes: Health, Illness, and Health Care in Canada
ΒΎ Driven by neo-liberalism and corporatization as part of economic globalization, several decades of Canadian health
ξ€ξ€‚ξ‚Œξ€žξ€ƒξ‚Œξ€ž(}ξ‚ŒuZξ€‚Γ€ξ€žξ€ƒΓ}ξ‚Œξ‚ξ€žvξ€žξ€šξ€ƒξ‚šZξ€žξ€ƒξ€}vξ€š]ξ‚š]}v}(vΒ΅ξ‚Œξ‚ξ€žξ‚[Á}ξ‚Œland thus the care nurses are able to provide.
ΒΎ They have the capacity to critically analyze and influence their conditions of work t in other words, they have agency,
albeit constrained.
ΒΎ dZ]Zξ€‚ξ‚‰ξ‚šξ€žξ‚Œξ€ƒξ€žΓ†ξ€‚u]vξ€žξ‚ξ€ƒξ‚šZξ€žξ€ƒξ€}vξ‚ξ€žξ‚‹Β΅ξ€žvξ€ξ€žξ‚ξ€ƒ(}ξ‚Œξ€ƒvΒ΅ξ‚Œξ‚ξ€žξ‚[Á}ξ‚Œl]vξ€ƒξ‚šZξ€žξ€ƒculture of health care characterized by a corporate
ΒΎ tξ€žξ€ƒΓ]oo}v]ξ€šξ€žξ‚Œξ€ƒZ}ÁvΒ΅ξ‚Œξ‚ξ€žξ‚[Á}ξ‚Œl]}ξ‚ŒPv]ΓŒξ€žξ€šξ€ƒΓ]ξ‚šZ]vξ€ƒξ‚ξ€ξ€‚ξ‚Œξ€]ξ‚šΓ‡ξ€ƒξ€‚vξ€šξ€ƒZ}ÁvΒ΅ξ‚Œξ‚ξ€žξ‚ξ€ƒξ‚‰ξ€‚ξ‚Œξ‚š]]ξ‚‰ξ€‚ξ‚šξ€žξ€ƒ]v}ξ‚Œξ‚‰}ξ‚Œξ€‚ξ‚šξ€žξ€ƒ]ξ€šξ€ž}o}PΓ‡X
ΒΎ Patterns of praξ€ξ‚š]ξ€ξ€žξ€ƒ(}ξ‚ξ‚šξ€žξ‚Œξ€ƒξ€‚ξ€ƒξ€ξ€žξ‚Œξ‚šξ€‚]vl]vξ€šξ€ƒ}(^ξ€ž((]]ξ€žvÇ_Ço]u]ξ‚š]vPvξ€šξ€ƒξ€šξ€žΓ€ξ€‚oΒ΅]vPξ€ƒξ‚šZξ€žξ€ƒξ€}ξ€šΓ‡ξ€ƒξ€ξ€‚ξ‚Œξ€žξ€ƒξ€‚vξ€šξ€ƒemotional labour
of nursing.
ΒΎ Nurses then donate unpaid time to limit moral distress they experience while working under such conditions.
ΒΎ This critical analysis of the culture of health care is offered in the spirit of building on the strengths of the current
ΒΎ This chapter builds on our programs of research, which include:
1. ξ€„ξ€ƒξ‚ξ‚šΒ΅ξ€šΓ‡ξ€ƒ}(vΒ΅ξ‚Œξ‚ξ€žξ‚[ξ€ƒξ€žvξ€‚ξ€ξ‚šuξ€žvξ‚šξ€ƒ}(ξ€ƒξ‚šZξ€ž]ξ‚Œξ€ƒu}ξ‚Œξ€‚oPξ€žvÇU}vξ€šΒ΅ξ€ξ‚šξ€žξ€šξ€ƒ]vξ€ƒξ‚šΓ}ξ€ƒξ€‚ξ€Β΅ξ‚šξ€žξ€ƒuξ€žξ€š]o¡v]ξ‚šξ‚ξ€ƒ]v two hospitals.
The study included over 200 hours of participant observation and 22 interviews with 11 nurses from acute
care and 3 from home care.
2. ξ€„ξ€ƒξ‚ξ‚šΒ΅ξ€šΓ‡ξ€ƒ}(vΒ΅ξ‚Œξ‚ξ€žξ‚[ξ€ƒξ‚‰ξ‚Œξ€‚ξ€ξ‚š]ξ€ξ€žξ€ƒ]vξ€ƒξ‚Œξ€žoξ€‚ξ‚š]}vξ€ƒξ‚š}À]}oξ€žvξ€ξ€žξ€ƒξ€‚P]vξ‚ξ‚šξ€ƒΓ}uξ€žvU}vξ€šΒ΅ξ€ξ‚šξ€žξ€šξ€ƒ]vξ€ƒξ‚šZξ€žξ€ƒξ€žuξ€žξ‚ŒPξ€žvÇ¡v]ξ‚šξ‚ξ€ƒ}(ξ€ƒξ‚šΓ}
hospitals and their communities. The study involved over 200 hours of participant observation, and
interviews with 45 participants, including nurses, social workers, physicians, clerks, and patients.
3. A study of the meaning of ethics and the enactment of ethical practice from the perspective of nurses (The
Ethics of Practice). This study involved interviews with 87 student, staff, and advanced practice nurses from
various practice settings in 19 focus groups.
4. A recent participatory action research study of nursing practice (Ethics in Action) conducted in an
Emergency Unit and a Medical Oncology Unit. This study involved three years of participant observation,
interviews, focus groups, meetings, workshops, and informal work within the two practice settings. At each
site, the research team included staff nurses and academic investigators working in partnership. Along with
qualitative data collection through focus groups and interviews, regular meetings with staff were conducted
at each site to discuss, debrief, and to plan for change. The research process supported staff to initiate
changes in their workplaces toward ethical practice.
ΒΎ Each of these studies used feminist and critical perspectives, and drew on the work of a number of diverse theorists.
ΒΎ Thus, this chapter draws on the four studies listed above as well as on meta-synthesis of the first two studies.
The Corporate Context of Contemporary Health Care
ΒΎ The Canadian health care system is increasingly shaped by globalization, in which capital flows around the world to
serve the interests of economically dominant elite.
ΒΎ While the espoused intent of the health care reforms occurring in Canada and other Western countries is to improve
the quality and accessibility of health care, the implementation of the reforms is fuelled by a powerful corporate
ΒΎ Cost constraints has to a significant extent, trumped the quality and accessibility of health care.
ΒΎ Economic trends in Canada, including budget deficits and restrictions in the role of the federal government in
maintaining the principles of medicare, put tremendous pressure on provincial and territorial governments to
economize on health spending.
ΒΎ ξ€’}vξ‚ξ€žξ‚‹Β΅ξ€žvξ‚šoΓ‡Uvξ€‚ξ€šξ€‚ξ€ƒZ}vξ‚š]vΒ΅ξ€žξ€šξ€ƒξ‚š}ξ€ƒξ€žΓ†ξ‚‰ξ€žξ‚Œ]ξ€žvξ€ξ€žξ€ƒ^o]uξ€‚ξ‚šξ€žξ€ƒ(}ξ‚Œξ€ƒξ€ZvPξ€žξ€ƒ]vξ€ƒξ‚šZξ€žξ€ƒ}ξ‚ŒPv]ΓŒξ€‚ξ‚š]}vvξ€šξ€ƒuvPξ€žuξ€žvξ‚šξ€ƒ}(
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HLTB03 Midterm Notes: Health, Illness, and Health Care in Canada
ΒΎ This climate has generated extensive cost constraint measures within health care. Thus, in the 1990s hospital units
and entire hospitals were close, community services shuffled, and health care staff moved around or dismissed at
unprecedented rates. Only recently has Canadian research begun to evaluate the impact of these changes.
ΒΎ Canadian data also portray increasing nursing workloads, with reduction in the quality of care and problems with
trust, commitment, and morale.
ΒΎ d}Pξ€žξ‚šZξ€žξ‚ŒUξ€ƒξ‚šZξ€žξ‚ξ€žξ€ƒξ‚ξ‚šΒ΅ξ€š]ξ€žξ‚ξ€ƒΓξ€‚ξ‚Œvξ€ƒξ‚šZξ€‚ξ‚šξ€ƒξ€‚ξ‚ξ€ƒξ‚šZξ€žξ€ƒξ€}vξ€š]ξ‚š]}v}(vΒ΅ξ‚Œξ‚ξ€žξ‚[Á}ξ‚Œlξ€ƒξ€šξ€žξ‚šξ€žξ‚Œ]}ξ‚Œξ€‚ξ‚šξ€žξ€ƒξ‚šZξ‚Œ}Β΅PZ¡o]ΓŒξ€‚ξ‚š]}v}(ξ€ƒξ‚šZξ€žξ€ƒ
workforce, increased workload, loss of clinical leadership, and shortages of skilled health care providers, morbidity
and mortality rises, and patient satisfaction is reduced.
ΒΎ Nurse satisfaction is also reduced, and there are now serious problems with nurse illness, injury, and attrition.
ΒΎ The impact of corporatized health care reform is not uniform across all citizens.
ΒΎ As cost savings in health care reform are achieved primarily through lower wages, poorer care, and a shift of costs and
responsibility to patients and their families, women, racialized people, those with debilitating conditions, those who
are impoverished, and those who are homeless are most affected.
ΒΎ Why had a corporate ideology, with its aforementioned problems, taken such hold in Canada? An ideology is a set of
ΒΎ A corporate ideology has taken hold in Canada and is largely taken for granted.
ΒΎ In health care, Canada has allowed its commitment to the common good to be replaced by corporatism. And, as
ΒΎ What has been taken for granted must be made visible if nurses and other health care providers are to work beyond
constraints to their ability to provide good and ethical care (in other words, constraints to their moral agency), and if
the nation is to move toward the more equitable health care system that most Canadians desire and all deserve.
Corporatism at the Level of Patient Care
ΒΎ Both the ideologies and the practices of the corporate culture of health care are played out at the level of direct
patient care.
ΒΎ The research cited earlier indicates that each cost constraint measure has a direct impact on nursing practice, creating
more work, more uncertainty, and less control over how nursing time is spent.
ΒΎ Wξ€žξ‚ŒZu}ξ‚ξ‚šξ€ƒ]u}ξ‚Œξ‚šξ€‚vξ‚šoΓ‡U^ξ‚Œξ€žξ€šξ€žξ‚]Pv_ξ€ƒξ‚ξ‚šξ‚Œξ€‚ξ‚šξ€žP]ξ€žξ‚U¡Zξ€ƒξ€‚ξ‚ξ€ƒξ‚šZ}ξ‚ξ€žξ€ƒξ€‚]uξ€žξ€šξ€ƒξ€‚ξ‚šξ€ƒξ‚Œξ€žξ€šΒ΅ξ€]vPξ€ƒξ‚šZξ€žξ€ƒoξ€žvPξ‚šZ}(Z}]tal stay, have
resulted in an increase in patient acuity and turnover, which in turn directly affect nursing workload.
ΒΎ Nurses find themselves caring for more acute patients and processing more patients more quickly.
ΒΎ Further, with less contact between direct care providers and management, nurses generally have less impact on
decision making. Moving nurses to unfamiliar patient care areas and replacing registered nurses with practical nurses
and/or care aides dilutes levels of skill, placing heavier responsibilities on the remaining staff.
An Ideology of Scarcity
ΒΎ Nurses participate in the corporate ideology and organize their work to maximize a certain kind of efficiency.
ΒΎ One of the most profound ways that the ideas and images of corporatism are enacted at this level is through an
ideology of scarcity.
ΒΎ Ideas and images of resources as scarce and unattainable abound in the day-to-day world of nursing practice. And
these ideas and images in turn drive practices that emphasize certain kinds of streamlining and efficiencies. So, for
example, nurses might put diapers on competent adults because they do not have time to assist them to the toilet,
justifying such practice as arising out of the necessity of scarce resources.
ΒΎ Nurses identified their attention to the nonphysical needs of patients as the aspect of care that suffered the most,
both during the provision of routine care and when patients experienced significant emotional crises.
ΒΎ Nurses talked about the ways they routinely curtailed their conversations and attention to the emotional needs of
patients and as researchers we observed nurses letting patients know that they were busy so that patients did not
expect to engage in conversation.
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