Ebook: How nurses practise health care reform: An institutional ethnography

The Canadian public service sector, particularly health care, has been undergoing restructuring following trends set in what many are calling “the new public management”. This institutional ethnography addresses questions surrounding nurses' participation in Canadian health care reform, tracking the lived actualities of nursing work, organized within widespread practices of hospital management. It critically examines the use of a proliferating set of managerial technologies (standardized programs for bed utilization, care-pathways, patient-centred-care and integrated programs) that are expected to improve efficiency and provide more accountability. Using participant observations, textual analysis, and interviews, it explicates the contemporary social organization of nurses' knowledge and action. Central to this analysis is the understanding that managerial undertakings in restructured hospitals are massively textual and information based. The analysis turns on careful empirical exploration of who knows what, and how different forms of knowledge are generated and employed. The texts being introduced into nurses' work appear merely to improve efficiency, yet these efficiency methods are not neutral. The argument made is that nursing work and patient care are deleteriously affected through nurses' interaction with textual tools designed to serve the business-orientation that is central to the restructured approach. Nurses are coached and monitored in their restructured activities by a corps of front-line-nurse-leaders, previously known as head-nurses, whose work has been formally restructured to subordinate clinical expertise to organizational demands. A nursing discourse that blends managerial and nursing ideas and goals supports their rationalization of workplace strategies that organize them to address their patients as objects of an organizational order—worked up into texts—for text-based, managerially-relevant action.

An important, if troubling, finding is that the text-based hyper reality, upon which restructuring is based, builds apparently factual knowledge about what is going on in hospitals that may be at odds with on-the-ground actualities. The study offers insights into how the new expectations and regulatory practices to which nurses are being held produce serious contradictions for nurses, patients and the nursing profession.