Restructuring: A View from the Bedside

abstract:
this study reports on the thoughts and experiences of hospital staff nurses during the restructuring of the canadian healthcare system. the purpose is to bring nursing voices into the discussion about the effects of restructuring and the possible changes that nurses envision.

over the last decade we heard much about the need for deficit reduction as major cuts were made to social services (peterson and lupton 1996). the variety of organizational changes that resulted within the healthcare system are commonly referred to as "restructuring." beds and even entire hospitals were closed and patient care services reduced. nursing positions, as large budget items, became cost-cutting priorities. as a result, hospitals' shares of total expenditures are starting to slip, yet overall, healthcare costs continue to rise. drug costs and physicians' services seem largely responsible for the increase (canadian institute for health information 2000). for the nurses still in the system, workloads increased dramatically. another major outcome was an expanding "casualization" of labour, as caring work is now performed increasingly by part-time staff: a flexible "skill mix" of nurses and lesser-skilled/unskilled workers (huston 1996; prescott 1993).

the negative effects of restructuring on patient care and nurses' working conditions are now widely documented (baumann et al. 2001; burke 2001; spence laschinger et al. 2001). few researchers, however, reported on the perceptions of frontline nurses, who experienced the brunt of the changes. an exception are gail mitchell and mary ferguson-paré, both nurse executives in toronto hospitals. striving to understand the forces that affect nursing work life (ferguson-paré and mitchell 2001), they began to hold regular meetings with staff nurses to discuss nursing and human resources care. one primary concern identified in these meetings was the loss of crucial support networks. many nurses also stated they felt devalued and "not cared for." however, they expressed a strong desire to rebuild community among themselves.

as restructuring emanated from and was fuelled by managerial science, its aim was primarily to increase efficiency. therefore, it was centred around deficit reduction and the introduction of market principles into healthcare through "managed care" (goode 1995; lamb et al. 1991; peterson and lupton 1996; smith 1998; sturm 1998; wood et al. 1992). major shifts towards more "routinized patient care" took place through "care map" technologies (goode 1995) and "deskilling" (davies 1995). a care map, designed to increase efficiency, is a typical instrument through which care delivery is routinized and standardized. intermediate goals and outcome criteria are listed. workloads are broken down into specific tasks, centrally calculated and assigned to workers with varying levels of skills. as patients' collaboration is crucial, they too get a copy of the care map, to know what is expected of them.

routinized care supposedly allows any health worker to step easily into a situation and perform according to at least "minimum standards," an assumption that underpins the move towards increasing casualization (davies 1995). standards of care are necessary, of course. however, indiscriminately applied, they can result in a one-size-fits-all approach. conflicts arise when the care map's approach is too rigid, leading to a perceived lowering of standards (tovey and adams 1999), thereby causing moral distress to nurses (mitchell 2001). patients' individual differences always need to be accommodated, and patient goals should never become subordinate to institutional goals. within trusting relationships, nurses further patients' well-being precisely by considering their individualities and situations as whole, unique persons.

in the name of efficiency, jobs were casualized. this concept was carried to the extreme through city-wide staffing agencies as "just-in-time nursing" (gustafson 2000), dispatching nurses to wherever they were needed. therefore, over- or understaffing due to last-minute changes was thought to be minimized. however, the effect of this arrangement on nurses was hardly considered. for some time, new graduates were able to land only casual positions. they struggled with unfamiliarity, not only with their patients, but also with staff, hospital layout, charting and all institutional "routines." statistics show that the stressful working conditions took their toll. nurses who had sick benefits lost "a whopping 150 per cent more working time than the canadian average for all full-time employees" (fletcher 2000: 20). these figures leave out all those nurses who came to work sick or had no sick benefits, such as the casualized nurses. many left to work in the united states. as a nursing shortage and healthcare crisis loomed, it seemed important to explore the nursing perspective on this issue....