Listening to the Whispers: Re-thinking Ethics in Healthcare

2. Corporatization and the Institutional Aspectsof Morality in Home Care

2 Corporatization and the Institutional Aspects of Morality in Home Care tobie h. olsan When I approached the community health nurses1 at the Riverside Home Care Agency2 about participating in an ethnographic analysis of the institutional aspects of morality in home care, they interpreted my work as being a study about “the other stuff.” They were referring to the workplace domain as they understood it, namely, business principles, bureaucracies, formal rules, regulations, expectations, and work group relationships. The other stuff was distinct from, but intertwined with, “patient care,” a second domain in the nurses’ work world. Caregiving, professional obligations, and relationships with patients were included in patient care, as was the nurses’ agentive capacity for professional judgment and nursing practice. Put another way, when I asked a case manager whom I will call Eva, “What does it mean to be a nurse at the Riverside Home Care Agency?” she responded, “That’s too generic a question. You’ve got to be more speci fic. What do you mean? Is it the organization or is it the community health part of it, or what?” Eva’s questions, like the two workplace domains, patient care, and the other stuff, demonstrate the moral force of institutions in healthcare. Institutions classify thinking, acting, and systems of social relations (Douglas , 1986), and as such they construct moral problems and influence moral judgments and actions in a work group. Institutions are defined here sociologically as a legitimized social grouping and the associated 10 history, values, purpose, roles, rules, relationships, and moral comportment of members of the group. Examples include a work group, profession , managed care organization, and government entity. Institutional arrangements define, shape, and reshape the picture of morality that occurs in them (Wolgast, 1992), yet the sociocultural study of moral life in the workplace is largely unaccounted for in the bioethics literature. Bioethics primarily connotes medical ethics and philosophical analysis from abstract principles to gain insights into questions about what should be in healthcare. The entire body of work in bioethics has little to say about what is, including the particulars of experience in organizations and the relationship of persons to other structures in the workplace. Descriptive ethics offers a corrective approach and is a good fit with this research , which is concerned about morality and culture. Morality is part of culture (Jameton, 1990), and the moral aspects of market-driven healthcare cannot be adequately understood without examining the social dimensions of the workplace (Potter, 1999). When institutions are in a state of flux, the upheaval from change and uncertainty can be accompanied by competing conceptions of persons and work. Ethnographic analysis exposes those conflicts and brings the institutional aspects of the dilemmas they generate into view. The aim in this chapter is to raise awareness of the role institutions play in morality by naming and describing dilemmas the nurses encountered at Riverside during a change in governance from the public to the private sector. In the sections that follow, the larger ethnographic study about morality in market-driven healthcare, from which the workplace dilemmas were derived, is described. Analytic concepts from personhood theory that guided fieldwork and analysis are explained next. Examples of the dilemmas appearing in the nurses’ work life are excerpted from their reflective work narratives. A discussion of the implications of the nurses’ encounter with corporatization for healthcare reform concludes the chapter. Riverside Home Care Agency The larger ethnographic study was conducted with a group of community health nurses at the Riverside Home Care Agency. The rich history of Corporatization and Aspects of Morality in Home Care 11 Riverside is too detailed to recount here, but briefly, the life cycle of the organization largely reflects the shape of public health during the 19th and 20th centuries. Riverside was established as a Public Health Bureau in the late 19th century during urbanization and the proliferation of community-based public health services for immigrants and the poor. Around 1950, Riverside was restructured as a public health home care agency to provide illness care to patients discharged from hospitals. Throughout the 1970s public health nursing included a mix of preventive health services and illness-focused care. Working at a distance from mainstream acute care secured in a safety net of public funding throughout the 1980s, the nurses at Riverside were initially protected from the corporate transformation of healthcare occurring at that time. But eventually , the...