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CHAPTER 7 - CONSTRAINED AGENCY: THE SOCIAL STRUCTURE OF NURSES' WORK
(By: Colleen Varcoe & Patricia Rodney)
Thoughts & Comments
Share your initial thoughts or comments here about the readings, or any questions you might have about the material. Remember, everyone in the class has access to this site and can answer any questions posted.
(added by Shuai Yue)
I believe that the topic of constrained agency is very relevant to nursing practice today. I have seen many examples of practice in healthcare institutions where corporate ideology and ideologies of scarcity has an impact on policies. For instance, I had a conversation with a nurse who was working in the post anaesthetic care unit (PACU) of one of the largest hospital in Canada, and he was telling me how there are only 13 beds in PACU, and there will often be a log jam of patients in the operating room because they have no where to go. As a results, policies are changed to try to make things go "faster". One example is in the case of malignant hyperthermia, a severe condition that affects some patients after they have been given general anaesthetics. Usually policies will state how many hours that patients with MH are supposed to be monitored after surgery. However, the nurse has seen patients being discharged from PACU just to open up space, which puts the patients at risk. Thus, the issues discussed in this chapter is very relevant to clinical practice today.
(added by Shuai Yue)
This chapter really opened my eyes to the machinery that is keeping our healthcare system operating the way it is currently. I think it is important for all nurses to realize that accepting these ideologies contributes to their perpetuation, to the satisfaction of the corporate leaders. It is scary to think that we are forced to sacrifice our professional standards for the sake of corporate efficiencies. The more "efficient" they want the system to become, the larger our sacrifices become. It was disheartening to be faced with the fact that much of the nursing we are taught to provide, the holistic aspects that require time, are impossible to provide in today's healthcare system. Through all the disheartenment though, the authors of the chapter are encouraging in suggesting that nurses are able to reverse this 'ideology of scarcity' and can contribute to changing their practice within a more effective health care system. - Trista Simmons
Create a list of important terms that emerged in the readings and their meanings/definitions below!
o Cost containment measures such as setting a predetermined level or number of activities to be performed within a specific program during a specified time frame for ex a number of particular organ transplants or surgeries over a one-year period
o The well being of aggregates (communities and society) no just individuals, some notion of the well being of communities and society, if arrived at through participatory democratic processes, can provide a moral horizon for work in ethics and public policy
o Ideological and structural constraints to agency within nursing such that nurses are unable to act upon their professional responsibilities and accountability
o The taken for granted beliefs, attitudes and assumptions that bring a business model to health care
o The processes that happen between people as individuals and as groups within organization and society and that confer meaning and significance, the health care system has its own culture
o Cost containment measures such as bed closures, staff lay offs, and reduction in the length of hospital stay
o The effort involved in dealing with other peoples feeling and emotions and in the case of nursing, dealing with the fears and worries of ill patients and their families and promoting the emotional well being of patients
o the economic social and political transformation of the world, such that capital flows around the world to serve the interests of an economically dominant elite
A set of beliefs, attitudes, and assumptions about the world that justify or explain “what is”. Ideologies are no in and of themselves good or bad; when unexamined, however, they can lead to unanticipated consequences
Ideology of scarcity
a perception about the state of the economy, fiscal realities, the availability of funds, and budgetary deficits, such that current levels of care are no longer affordable; a view popularized by the media, corporate elite, management elite, and other (Bolaria & Dickinson, 2009) - By Haley Rice
o The actions through which people fulfill their moral responsibility and accountability and deal with ethical problems
o A situation that occurs when nurses( or other moral agents) are unable to translate their moral choices into moral action because of constraints in the organizational context; the aftermath can include anger, frustration, guilt and powerlessness
o Administrative policies, procedures, and practices, such as allotted labour time and performance evaluation, that set the parameters within which labour is performed
By; Krystina Zelem
It is the tendency of nurse to resist to the constraints in their work place in order to provide the higher quality of care for patients.
Ideology of Scarcity
— "a perception about the state of the economy, fiscal realities, the availability of funds, and budgetary deficits, such that current levels of care are no longer affordable; a view popularized by the media, corporate elite, management elite, and others" (Bolaria & Dickinson, p.141, 2009). (By: Neile Baboushkin).
Moral agency: the action through which people fulfill their moral responsibility and accountability and deal with ethical problems (Rodney, 1997; Rodney, Brown, & Liaschenko, 2004).
Moral distress: a situation that occurs when nurses (or other moral agents) are unable to translate their moral choices into moral action because of constraints in the organizational context; the aftermath can include anger frustration, guilt, and powerlessness (Bolaria & Dickinson, p.141, 2009).
Nurses work that cannot be captured, countered or recorded rather it is the being there, emotional labour and support that is required to meet the patients health care needs (Bloaria & Dickinson, 2009, p. 129-129).
A Delaine Lloyd
What major themes emerged in Chapter 7? How were these discussed? Why are they important?
A major theme discussed within Chapter 7 is the link between corporate ideology and the ideology of scarcity. Corporatism has led to constraints that has had a direct impact on nursing. These effects include more work, more uncertainty and less control how nursing time is spent (Bolaria & Dickinson, 2009). These constraints in turn has led to the ideology of scarcity. Nurses have begun to see resources as scare and unattainable in their day to day work. Nurses have adjusted their work from the pressures of corporatism along with developing a new mindset. Corporate ideas have dominated the thinking of the health care system (Bolaria & Dickinson, 2009). The ideology of scarcity is ever present in the news and social media, bombarding the thoughts of the public and health care professionals regarding weight times and wait lists.
A major theme that emerged in this chapter was the topic of constrained agency. Nurses work as moral agents which means they 'fulfill their moral responsibility and accountability and deal with ethical problems' (Bolaria & Dickinson, 2009). Nurses experience a great deal of moral distress day to day and this is often compounded by constraints and cutbacks in the workplace. As Bolaria and Dickinson (2009) discovered in their studies, the amounts confused patients that are being physically restrained and dependent elders that are being rapidly force fed as dramatically increased due the inadequate staffing levels. In the current corporate culture of health care, the well-being of nurses, patients, families, and communities are being threatened (Bolaria & Dickinson, 2009).
Another major theme that emerged was efficiency in the health care system. Bolaria and Dickinson (2009) state, “in response to cost constraint measures and messages about the inevitability of scarcity in health care, and with at least a partial acceptance of those messages, nurses’ work is organized to maximize their ‘efficiency’” (p. 128). Policies and procedures are put into place to reduce costs of every aspect of the health care system. As Campbell (1994) states, being efficient does not account for ‘indeterminate work’ as they plan for staffing based on minimized and standardized estimates of patient’s needs, it does not reflect the needs of ‘real’ patients. The theme of efficiency works towards reducing costs without considering how the change will impact both patients and nurses. If a facility cannot meet the goals of efficiency, it increases the risk of sanctions for managers, units, and staff, including staff layoffs, and/or replacement of registered nurses with less prepared staff (Bolaria & Dickinson, 2009).
Time restriction of nurses was another main theme that emerged throughout chapter 7 by Bolaria and Dickson (2009). The cost constraints of the health care system has lead to nurse-patient time restriction. Thus the patient is not receiving the best possible care as the nurse is doing what is needed at that point in time. Bolaria and Dickson (2009) discussed how patients emotional needs are not attended to due to other higher priorities and time constraint. Many nurses stated that they were worried they were going to miss something as they were cut short with the time they had with their patients (Bolaria & Dickson, 2009). Many nurses end up staying past their shift to complete tasks or finish patient care without receiving overtime (Bolaria & Dickson, 2009). With the lack of autonomy of nurses they are forced to follow the rules and policies set by the health care facility to promote efficiency. The battle then exists for the nurses to provide good care for the patients and balance personal costs such as excessive workloads, frustration, anxiety, and self-blame about the care they are able to give.
Physical and moral constraints at workplace, job satisfaction of nurses and their influence on patients’ outcome were other main themes that emerged throughout chapter 7 by Bolaria and Dickson (2009). The present day corporate ideology of scarcity and consequent financial restraints put most of the hospitals under pressure and force them to cut their operating budgets. That gruesome reality leads to some radical money-saving measures - the necessity to shorten patient average hospital length of stay, as well as results in the increase in physical and emotional work demands for already over-worked and under-staffed nursing personnel.
A situation, when a health care institution is unable to provide adequate staffing resources, can lead to not only nurses’ poor self-rated health and low job satisfaction, but also can endanger patients’ safety and outcomes as a result of the need to speed up the caring process to meet length of stay deadlines. As an example, West et al. (2014) asserted, that the staffing level of the nursing workforce had the profound effect on ICU patients’ outcomes by increasing their chances of surviving in ICU and for up to a month after admission to hospital.
Also, as a consequence, a higher work pace can increase chances for committing medication errors or for violating of standards of health care (Cho et al., 2014).
Cho, S., Park, M., Jeon, S., Chang, H., & Hong, H. (2014). Average Hospital Length of Stay, Nurses' Work Demands, and Their Health and Job Outcomes. Journal of Nursing Scholarship, 46(3), 199-206.
West, E., Barron, D. N., Harrison, D., Rafferty, A., Rowan, K., & Sanderson, C. (2014). Nurse staffing, medical staffing and mortality in Intensive Care: An observational study. International Journal of Nursing Studies, 51(5), 781-794.
A major theme of chapter 7 includes the ways in which corporate ideologies have an impact on the organization, delivery and implementation of health care and further how this constrains nursing practice (Bolaria & Dickinson, 2009). This has resulted in streamlined nursing care that focuses on the “efficiency” of nurses work and neglect the intermediate work that is core component of nursing. Highlighting the influence of these ideologies, challenges nurses to gain an understanding of the limitations of their practice, outcomes of their decisions, and to gain an awareness of how these issues can be addressed. Bolaria and Dickinson (2009) suggest collective refusal and action, questioning ideologies, and increased collaboration with professional organizations and units is needed for nurses to maintain and gain back the control and autonomy that is needed to provide the client centered care they desire and are accustomed to. Nursing is more then just “efficiency” rather is grounded in the ideologies of “health, social justice and the common good” (Bolaria & Dickinson, 2009, p. 138).
A Delaine Lloyd
A theme that I found interesting in chapter 7 was the idea that nurses are disposable. As mentioned by Bolaria & Dickinson (2009), there are four different ways nurses sacrifice themselves for the system. Firstly, the intellectual and emotional labour that nurses endure. Nurses can become so rushed and stressed that they may miss things, or not be able to attend to a patient's emotional needs, because they only have the time to focus on the physical. Nurses are not given the time to "think through" their care (Bolaria & Dickinson, 2007). Secondly, nurses personal times are frequently ignored. In some cases, nurses must stay later to complete all their tasks, and often do not claim overtime, essentially giving up their personal time to complete their work. Lastly, the well-being of nurses has been known to suffer, just so they can try to do their jobs at the best of their ability. There can be guilt and fatigue, physical, emotional and physiological exhaustion.
- Brittney Illman
A major theme discussed in Chapter 7 is ‘Responsible Subversion. Responsible subversions, or Rule Bending, are behaviours in nursing in which the nurse intentionally violates the nursing practice standards, and he/she do so because they believe they are acting in the best interest of the client. Rule bending is due to a system-nurse conflict which impedes the goals of nursing care (Collins, 2012). Although there are cases in which rule bending can be perceivably exempted, rule bending presents a string of dilemmas including violation of ethics and standards of practice, and potential harm for the client. Furthermore, rule bending has become a socialized behaviour that nurses or health care teams drift away from acceptable standard of performance (Collins, 2012). As a result, the normalization of deviance is an increasing problem because it ignores and hides practice problems that require revision or improvement by the appropriate governing body.
Collins, S. E. (2012). Rule Bending by Nurses: Environmental and Personal Drivers. Journal Of Nursing Law, 15(1), 14-26. doi:10.1891/1073-74126.96.36.199
To go along with the theme of 'efficiency' in the health care system, Varcoe & Rodney (2009) weave in the concept of 'effectiveness.' They propose that the "form of efficiency that must be sought is one that takes into account effectiveness (Varcoe & Rodney, 2009, p. 139)." To provide care that is both efficient and effective, effectiveness would have to be valued and understood. efficiencies must not be allowed to get in the way of strategies toward effectiveness, and both efficiency and effectiveness must be measured (Varcoe & Rodney, 2009). In order to provide effective nursing care, nurses must have sufficient control over their practice to implement care that has been shown to be effective (Varcoe & Rodney, 2009). If nurses continue to be forced to practice under the current "efficient" system, they will never have the control they need to provide the effective care that they so desire to provide. - Trista Simmons
A major theme discussed in chapter 7 is the pervasiveness of corporate idealism in the Canadian healthcare system. Corporate idealism threatens the principles of universality and accessibility of the Canadian health act. Corporate idealism has transformed healthcare into a business that serves the interests of a corporate group rather than towards a common good. The effects of corporate idealism creates greater inequity against an already impoverished, marginalized group of people. the pervasiveness of corporate idealism Is evident in media through reports of long wait times and wait lists. Nurses also perpetuate the idea of scarcity through their behaviours; nurses have adopted a way of working more "efficiently" to compensate for scare resources. Ultimately, corporate idealism negatively affects nurses and patient care. Increased nurse workloads results in burnout and creates moral distress for nurses who are unable to provide patients according through their moral compass. Patients are affected by not receiving quality care as a result of increased pressure to reduce length of stay.
- Harold quinto
This section provides key points from Chapter 7. These are the "take aways" that you should understand from the reading.
Using critical reflection in your reading, consider the following questions:
What are the main arguments?
Are the arguments supported?
What are the underlying assumptions?
How do they fit with your assumptions?
(added by Shuai Yue)
In Chapter 7, Colleen Varcoe and Patricia Rodney talked about the consequences of resource "scarcity" in the Canadian healthcare system in the context of "corporate ideologies". The authors referred to these as "corporate casualties", which include key players such as healthcare professionals, patients, families and the community. Particularly, they noted the concept of "disposable nurses" in the Canadian healthcare system, as demonstrated in four difference ways:
1. clinical judgements and intellectual knowledge are take for granted.
2. nurses' emotional labour, those that come with dealing with emotional needs of the patients, are compromised
3. nurses' personal time is treated as disposable, that they are often working for free, "donating" their time to healthcare
4. nurses' well-being is compromised when they are exposed to excessive workloads, stress, anxiety and frustration.
(Bolaria & Dickson, 2009)
(added by Shuai Yue)
I found the idea of nurses' "indeterminate work", and the inability of current systems to capture and measure it, extremely interesting (p. 129). This notion is coupled in the text with the observation that the systems in place that do measure work done and inform the administrative/managerial decisions related to this work are reliant on decreasingly visible and increasingly ubiquitous technologies. This has essentially backed nurses into a corner in terms of defending the reality of their indeterminate (and determinate) work. Nurses find themselves increasingly in the position that methods of quantifying and qualifying the work they do, do not actually capture or reflect the reality. This presents a massive problem for matching administrative decisions to clinical realities since the decisions are being based on a skewed and tech-only representation of what nurses are doing and facing. In the end we are left to wonder how nursing will deal with the ever-increasing presence and use of technology in healthcare and what facets of nursing will benefit from the evolution of health technology and which would be better off under the control of a more humanized entity. How do we reconcile these concerns from the bedside to the boardroom? — Matthew Colussi
Bolaria, S., & Dickinson, H. (2009). Health, Illness, and Health Care In Canada . Toronto: Nelson.
"You'd like more staff and you'd like more participation but in reality there isn't the money, you aren't going to get the staff, so don't spend the time whining and sniveling, its not going to be there. Just do the best you can with what you have." (Bolaria & Dickinson, 2009)
The author uses this quote exemplify the effects of corporatization and the theory of scarcity.
“Nurses commitments to their patients and their own families, and their difficulty in meeting these commitments exact significant personal costs,” (Bolaria & Dickinson, 2009)
The author describes the fourth “disposability” of the nurses well-being, exemplifying the great sacrifices the nurses are expected to make, as a direct result of the corporatization.
Bolaria, S., & Dickinson, H. (2009). Health, Illness, and Health Care In Canada . Toronto: Nelson.
A quote that I underlined while reading this chapter was the one the authors provided from John Raulston Saul: "Canada operates on myths…rather than memory and has lost sight of its commitment to the common good that characterized the development of Canada as a nation (Raulston Saul, 1997, as cited in Varcoe & Rodney, 2009, p. 125)." This is a very striking quote as it shines a spotlight on the current problem with health care in Canada. The authors exert that such myths contribute to the powerful influence that unexamined ideas have on perpetuating current practices. Varcoe & Rodney (2009, p. 125) state that, "in health care, Canada has allowed its commitment to the common good to be replaced by corporatism." This is a bitter sentiment, but one that we must share in order to examine new ideas. - Trista Simmons
"Nurses providing direct care are treated as if they are disposable in at least four ways. Their intellectual and emotional labour, their personal time, and their well-being are too often often sacrificed for the efficiency of the system" (Varcoe & Rodney, 2009, p. 131).
I found this perspective of the authors to be very thought-provoking. There is much truth to these words, although I think it may be more true in some institutions compared to others. An important quality of many nurses is that of altruism or even self-sacrifice, in the context of helping their patients. However, when nurses are undervalued by an organization or institution for which they work, I think that this becomes a problem and something that nurses are not, and should not, be willing to overlook. I think that nurses will do a lot if they feel that their work is appreciated, but when they are treated in a disposable manner, the quality of care they provide suffers, not just due to time and other organizational restraints but because of a decrease in motivation. This is an important issue to address, even within a corporate ideology.
- Judy Van
Share an interesting quote or perspective that the author's present in the readings here. You can post your thoughts/opinions/perspectives here or ask critical-thinking questions to uncover the deeper meaning behind these perspectives.
Post potential quiz questions here or quiz each other to help you study for the upcoming Week 6 Quiz!
1. What are the relationships between disvaluing of women and women's work in general and the disvaluing of the emotional labour of nursing?
2. What examples of responsible subversion have you observed? What were the consequences?
3. List the rhetoric currently in vogue in health care. What are the latest "buzz words" or popular areas of concern? What ideas, images, and assumptions underlie this language?
4. Imagine some situations in which you and the people you work with could constructively challenge the corporate ideology. Provide some examples of how you would achieve this.
5. What major contributions of nursing care are neglected if a nurse is practicing under the "efficiency" requirements of corporate ideology?
6. What are some of the ways in which nurses can stand up against corporate ideology and streamlined care?
7. What are the impacts of corporate ideology on nurses? Patients?
8. What implications does moral distress have on nurses?
9. Do nurses accept the 'ideology of scarcity' or are they too busy providing care to do anything about it?
10. What are the dangers of replacing nurses with a less expensive care provider?
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