- Health Care in Crisis: Hospitals, Nurses, and the Consequences of Policy Change by Theresa Morris
By Theresa Morris
New York: NYU Press. 272 pages. 2018. https://nyupress.org/books/9781479827695/
In Health Care in Crisis: Hospitals, Nurses, and the Consequences of Policy Change, Theresa Morris offers a careful analysis of how the intimate interaction between nurse and patient is embedded in the social dynamics of the workplace, in the occasionally tense relations of authority between professions, in the hospital's budgetary constraints, and in the uncertainties of federal and state healthcare policy in the last decade. Morris' thoroughly detailed and highly readable ethnography provides a vivid account of how these forces shape nurses' work lives, with broad political and economic turmoil percolating down to the front lines of patient care. The book's rich empirical descriptions are jarring. Morris finds nurses struggling mightily to cope with work speedups, short staffing, the degradation of working conditions, and a loss of professional control—all of which, Morris suggests, detracts from nurses' ability to provide quality care for patients.
Health Care in Crisis is a very timely book. It captures the effect of a recent source of industrial turbulence: the Affordable Care Act (ACA), and the associated restructuring of payment systems for providers. The specific matter of adequate RN staffing, furthermore, is a longstanding object of political struggle for nurses, as hospital and nurses' associations continue to battle over mandated staffing ratios through legislation and collective bargaining (Aiken et al. 2010; Gordon, Buchanan, and Bretherton 2012; Livanos 2018). But while the book's topic is certainly of-the-moment, Health Care in Crisis finds a place in a long tradition of health care workplace ethnographies that have grappled with the effects of changes in health policy and hospital governance on the work dynamics of RNs and nurses' aides (Allen 2002; Brannon 1994; Clawson and Gerstel 2014; Foner 1995; Reich 2014; Weinberg 2003). One common theme in these texts is that of a crisis of professionalism, meaning, and work standards as the work of caring has become increasingly driven by pecuniary imperatives. It is a longstanding theme, but one which has arguably become more acute over time.
Through interviews and first-hand observations, the book examines one obstetrical ward in one New England community hospital from 2013 to 2016. Morris captures the experience of dozens of individual nurses before and after a failed acquisition by a for-profit hospital chain, and subsequent budgetary retrenchment. The empirical material in the book is divided into three parts. The first part offers a detailed profile of day-to-day work in the ward, with one chapter focusing on the functioning of the unit in the context of the hospital and its surrounding community, and another centering on the nurses' work process and work rules. This is a world dominated by nurses on a day-to-day basis; physicians, despite their professional control, are often absent from the world Morris depicts. The heart of the book is in its second section, which profiles some of the individual nurses that Morris interviewed and shadowed, comparing their work experience before and after the failed merger attempt. Part three takes a macrolevel view, embedding the transformation of the OB ward in broader shifts in state policy, federal policy, and industrial governance.
The core argument of the book is developed in the second section, which recounts the experience of individual nurses and how they manage the stresses of patients' childbirths. Rather than organize this analysis chronologically, Morris calls our attention to the differences between two types of nurses—"patient-oriented" nurses and "process-oriented" nurses—and how these types experienced the organizational transformation around them. Patient-oriented nurse spent more time with patients and were more attentive to their physical and emotional needs; they also actively resisted organizational change, "attempting to buffer patients from any negative effects" (Morris 2018:17). Process-oriented nurses, on the other hand, focused on following protocol and spent more time on documentation; these nurses embraced organizational imperatives in an effort to avoid individual liability. Both types of nurses were strained...