Managing home nursing care: visibility, accountability and exclusion

© 2001 Blackwell Science Ltd

Nursing Inquiry

2001;

8

(3): 141–150

F e a t u r e

Blackwell Science, Ltd

Managing home nursing care:visibility, accountability and exclusion

Mary Ellen

Purkis*

School of Nursing, University of Victoria, Victoria, BC, Canada

Accepted for publication 20 February 2001

PURKIS ME.

Nursing Inquiry

2001;

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: 141–150

Managing home nursing care: visibility, accountability and exclusion

The paper examines managerial practices shaping contemporary home nursing care. Foucault’s writings on governmentalityare used to appraise managerial and nursing practices understood as exemplars of forms of government of people’s health.An ethnographic study of organizational practices shaping contemporary home nursing care reveals that the everyday workof managers involves making particular forms of nursing practice visible. Through careful scripting of these visible forms ofpractice, managers and nurses together work to exclude the local knowledge of patients and of nurses regarding experiencesof living with chronic illness. Recommendations are offered for managers and nurses who seek to develop more autonomousroles for nurses: roles that require the inclusion of people’s own knowledge of how they live at home with their chronic illness.

Key words:

ethnography, Foucault, governmentality, home-care, management of nursing practice.

This paper explores the problematic ground that ariseswhen ‘nursing’ and ‘politics’ come together. Most often,when nurses write about politics in relation to their practice,they represent themselves as innovative political leaders oractivists (e.g. Antrobus and Kitson 1999; Beaton and McKay1999; Stahl 1999). Nurses as political actors are portrayed assomewhat marginal persons, held at a distance by their moreconservative, apolitical colleagues. Political nurses areportrayed as struggling against these odds to raise levels ofconsciousness about a wide range of social problems.

There is no doubt that in nursings’ recent as well asremote past, nurses who measure up to these definitions of‘politically active leaders’ have indeed been influential infostering an image of nurses as trustworthy women whooften disregard their own interests for the betterment ofothers (Moore 1988). Such images are extremely powerfulin shaping relationships among nurses

within

the profession.

They can be used to great effect in socializing new recruitsand, in a time when retention and recruitment becomes anoverwhelming obsession, they can be used to cajole nurses toremain in the workforce or to return to it after an absence.

These socializing efforts might all be deemed to repres-ent a ‘positive’ face of politics in nursing. The powerdeployed through such use of politically charged imagescan be seen as overwhelmingly good. But this positive facerepresents a very particular way of constructing nursings’relationship to power. The construction favored by nurses isone in which some nurses actively engage in political actionand target the effects of such action on problems widelyagreed upon as deserving of active intervention: problemssuch as a global shortage of nurses, medical domination overnursing practice, scientific domination over nursing research,and so on. This construction of nursings’ relationship withpolitics treats power as something separate from the everydayactivities of nurses. Power is portrayed as ‘dangerous’: onlysome nurses have the acumen to engage it for positive good.

But this construction of power denies a vast amount ofcontemporary theorizing on the topic. It supports highlyproblematic hierarchical understandings of change innursing (Copnell 1998) and it promotes simplistic andevangelical responses from nurses on matters of health

—

matters that have always been political (Foucault 1984).

Correspondence: Mary Ellen Purkis, School of Nursing, University of Victoria,PO Box 1700, Victoria, BC, Canada, V8W 2Y2.E-mail: <[email protected]>

*

An earlier version of this paper was presented at the conference, ‘The Ethosof Welfare: Metamorphoses and Variations of Governmentality’, 31 August–2 September 2000 at the Faculty Social and Political Sciences, University ofHelsinki, Finland.

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Drawing on materials arising out of a field study ofhome-care nursing practice, the paper locates the actions ofhome-care nurses and home-care managers as explicitlypolitical. The analysis of those actions draws from Foucault’swritings on governmentality (1991) as well as a commentaryon that work by Burchell (1991). The aim is to set out aground that will stimulate debate within the discipline ofnursing that enables a more sophisticated examination ofnursing practice as a form of government of people’s health.Such a debate could be aimed at examining the effects ofnursing in the everyday and enabling the development ofstrategies for

collective

action to improve access to relevantforms of health-care. As such, the paper also touches oncontemporary theorizing on citizenship.

DELIMITING THE TARGET OF NURSING CARE DELIVERED IN THE HOME

In the summer of 1995, I negotiated access to two healthcareunits in western Canada. The purpose of my presence was togather field notes for an ethnographic study of home-carepractices. At the time, nurses working within communitysettings were engaged in a nearly daily battle to fend off pro-vincial government accountants keen to reduce deficits inthe face of major cuts in federal health and social spending.I spent time with managers of home-care nursing services,with nurses themselves as they made their way through theirassigned workload, with patients receiving services fromthose nurses and with allied healthcare workers who workedalongside those nurses. I observed the practices engagedin by each of these groups and I interviewed nurses andmanagers.

Early in the fieldwork, I asked nurses to talk to me abouthow their work had changed during their careers as home-care nurses. One nurse told me that when she first beganworking as a home-care nurse, some 20 years previously,washing an elderly woman’s hair once a week was deemed alegitimate nursing treatment. This is certainly no longer thecase. Now, the majority of a home-care nurse’s work consistsof providing specific treatments for people who are oftenquite unwell returning home from hospital still recoveringfrom significant surgical or medical events.

The space between these two forms of ‘legitimate’practice (from routine hair dressing services to subcriticalnursing intervention) is vast. Perhaps most problematically,home-care nurses have been positioned as mediators betweenthe general public and a healthcare system that raises thebar on nearly a daily basis regarding decisions about whosesituation is

serious enough

to require hospitalization. Nolonger can hair washing be legitimated as a ‘nursing treat-

ment’. What was previously regarded as pleasant workwhere nurses could get to know their patients and to do soduring highly desirable work hours (Monday–Friday, 8 a.m.to 4 p.m.), home-care managers are now demanding thattheir employees act in very different ways. Now home-carenurses must have recent experience working in hospital,must develop skills such as undertaking complex surgicaldressings under less than ideal (i.e. hospital) conditions andbe motivated by work in which high turnover in one’s patientcase load is encouraged. Many of the nurses who haveexperienced these changes have undertaken the difficultwork of disengaging long-term elderly patients from theexpectation that they might receive a visit from a nurse on aweekly or a biweekly basis. To the extent that nurses are ableto achieve the workload targets set by their managers, theiractions in this latter regard are clearly powerful.

The accomplishment of such a shift in practice signalsthe home as an interesting site

theoretically

as well as practi-cally. The home can be studied as a location for professionalpractice that is amenable to the governing (cf. Foucault1991) of nurses by their managers and of citizens by thosesame managed nurses. Burchell (1991) raises an interestingquestion based on his reading of Foucault’s writings ongovernmentality that seems appropriate within the revisedcontext of practice described above: ‘What kind of subjectivityis involved ... when individuals obediently perform theirassigned tasks and conduct themselves in prescribed ways?What kinds of reason do governments offer the individualsfor doing what they are told?’ (Burchell 1991, 119).

That is, what kind of subjectivity is involved when nursesact to discontinue service to chronically ill patients who havebeen part of a nurse’s workload for many months or years?and what sort of subjectivity is involved when patients whohave been receiving weekly nursing services suddenly, andapparently willingly, take up self-care strategies such aswound management with only minimal encouragementfrom a nurse who has been visiting and doing that samewound care for the past three or four months?

I am interested in home-care nursing practice as a formof practice that can be examined as a governing interface.My initial aim upon analyzing the field notes had been to tryto alert nurses to the effects of their actions in the home(Purkis 2000). My supposition was that if they could see howmorally problematic the terrain of their work was, nurseswould be inclined to develop alternative forms of practice.However, in this paper and, following Burchell’s (1991)writings on the ‘system of natural liberty’, I want to questionboth the utility and the possibility of engaging in suchconsciousness-raising. The question for me becomesone that challenges the assumption that, if they ‘knew’ what

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they were being co-opted to take part in, they would ceaseparticipating in these practices of exclusion. I wondernow, to what extent is the invisibility of their governing aprecondition of their home-care nursing practice?

SUBJECTS OF GOVERNMENT

Burchell argues, in line with Foucault, that the actions ofpersons, in this case, nurses and patients, can be consideredas a relation between individuals and the political order,whereby individual nurses and patients are objectified ascertain kinds of subjects through the ways they are targetedby political power.

Nurses and their managers have taken up explanationsoffered to them about the budget cuts that have forced aprofound reconceptualization of home-based nursingservices. One nurse describes her own relationship to thesebudget cuts:

Nurse: Well the reason we had cut backs was so that wecould become under budget. We were over budget beforeand (Central Office) always covered it. So the reason we’vehad cut backs is because we are now running on budget. SoI’ve had all my hours cut back so it has affected me in a veryreal way.

Interviewer: And you did that by creating part-timepositions?

Nurse: That’s how we decided to do it because we wereworking with one and a half or two FTE’s [full-time equival-ents] over what we were suppose to be so that was our cutback. That all came out of part timers.

Interviewer: Not a particularly happy time?

Nurse: Oh, it’s okay. I mean I’m fine with it. I’m fine withsummer, the summer is just fine and money wise we’refine, my husband and I, but there are people out therethat aren’t. and for the summer it’s fine but I know comeSeptember I know I’m going to be itching for somethingelse. I’ve always gone to school and I’ve always been verybusy with that and now I’m not going to have school thisSeptember and my kids are going to go off to school and myhusband is going to go off to work everyday and I’m goingto be working one to two days a week and it’s just not goingto be enough. So that’s why I’m looking for something else.

Being a part-time worker meant that when cuts to thebudget were required, this nurse was affected more so thanher full-time colleagues. The cuts to part-time nurses’ shiftswere applied ‘fairly’ across all the part-time nurses but, asthis nurse indicates, such fairness is experienced unequally.For her, because her husband also works, the reduction inpay is not punitive to her family. However, there are nurseswho may be sole wage earners for their families for whomsuch a reduction would mean a significant change in thefamily’s circumstances. For this nurse, the change is said toaffect her identity as a worker. Over the summer when her

children are out of school, the flexibility of working onlytwo days a week means she has more time to supervise herchildren at home. However, once they are back in schoolin the autumn, she does not see herself being happy withbeing a homemaker. She is looking for ‘something else’. This‘something else’ may be in nursing

—

or not. For managerskeen to retain their staff in this time of nurse shortage, thisstatement should be read as significant. The cuts wereapplied ‘fairly’ but they clearly indicate to this nurse that herservices are not valued

—

she is expendable. Her relation-ship with the organization that originally hired her has beenaffected. She may go elsewhere to find more satisfying work.

But it is not just nurses who experience this effect ofpolitical power. Patients experience it too and they experi-ence it

through

the work of the nurse. For, as Burchell argues,

(w)hen we are governed, when our behaviour is managed,directed or conducted by others, we do not become thepassive objects of a physical determination. To governindividuals is to get them to act and to align their particularwills with ends imposed on them through constrainingand facilitating models of possible actions. Governmentpresupposes and requires the activity and freedom of thegoverned (Burchell 1991, 119).

The paradoxical point raised here by Burchell, that ‘govern-ment presupposes and requires the activity and freedomof the governed’, represents a central plank in Foucault’swritings on governmentality. Foucault describes govern-mentality as a collective movement, the aim of which is anordering of society to support forms of productivity. Govern-mentality recognizes the problems inherent in relying onsovereign power to achieve levels of productivity demandedby contemporary forms of a global capitalism. Drawing onpolitical writings from the 18th century, Burchell sketchesthe manner in which this problem was tackled

—

and theeffects that has had in separating politics from ethics. In orderto establish a new grounding for community-based care, thisseparation must be acknowledged and reintegrated in acritical and respectful form of home-care nursing practice.

In the examples that follow, the techniques of govern-ment used to enable shifts in home-care nurses’ interestsin certain patient groups will be illustrated as they wereobserved to occur within the context of a staff meetingbetween home-care nurses and their unit manager. A meth-odological point is worth raising here. The excerpts drawnon in the following analysis represent one staff meetingobserved during the longer period of fieldwork in one ofthe two health centers participating in the study. In theseexcerpts, it is argued that the home-care manager can beread as ‘a particular kind of emergent effect’ (Callon andLaw 1995, 484). My time in the health center was too short


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to determine the longitudinal effect of the meeting Iobserved and report below. But I want to argue against aversion of power that can only be determined by longitudinaleffects. To make this argument, I draw on social theoristssuch as Callon and Law (1995) who argue that agency, ratherthan being understood as an essential property housed inhuman bodies, is instead, ‘an emergent property’ (484).They go on to explain:

… [the]

possibility

that agency is an emergent property. Thatto be an agent like a managing director is a form of actionwhich derives from an arrangement. That,

by themselves

,things don’t act. Indeed, that there are no things ‘by them-selves’. That, instead, there are relations, relations which(sometimes) make things (Callon and Law 1995, 484–5,emphasis in original).

So, in what follows, I illustrate how the home-caremanager seeks to govern the nurses who work for her. I amnot arguing that she

has

the power to make them work in thisnew way. Rather, I want to illustrate the relations throughwhich she might be making a new form of home-care nursing.

Through examination of the dialogue between managerand staff, it will be possible to further examine the questionof subjectivity posed above (Burchell 1991): what sorts ofsubjectivities are operating in the accomplishment of shiftsin understandings of what home-care nursing consists of?What can explain the extent to which significant numbersof patients can come to be displaced as no longer legitimaterecipients of care from those who are deemed legitimaterecipients of a particular sort of nursing care?

CENTERS OF INTERESTS

In order to explicate these subjectivities, it is necessary tofirst explore the notion of ‘interest’ both as Burchell (1991)uses it in his historical studies of ‘natural liberty’, but also thenotion of interest as it has been extended by Bruno Latour(1987). Burchell (1991) locates his examination of interestin the works of David Hume who distinguished two forms ofopinion

—

a juridical opinion of principle and a subjectiveopinion of interest. According to Hume, individuals willsurrender, exchange or transfer their ‘natural rights’ in orderto become legal subjects. Interests, however, are different.

Interests are never exchanged or surrendered

. As the ‘irreducibleexpression of felt preferences’ (Burchell 1991, 130), interestsare only ever ‘adjusted’ so that they align in a system ofconduct and behavior with other individuals’ conduct andbehavior

—

all the better to satisfy one’s own interests.In a complementary way, Latimer (1999) draws on

Latour (1987) to similarly distinguish two broad ways ofthinking about interests. The first is where interests are

thought of as lying behind people, motivating their actions.In this sense, interests are understood as calculated andindividuals are represented as having full knowledge ofsituations. That is, fully understanding the situation theyface, individuals can calculate a particular stance that willenable them to capitalize on other interests operating in thesituation. The second way of conceptualizing interests delin-eated by Latimer is a more unusual understanding. It arisesout of Latour’s (1987) critical studies of science. Latimer seesin Latour a way of preserving the notion of ‘concern’ withinan understanding of interests. Here, persons are thought ofas having only ‘partial’ knowledge of situations. Without

fully

knowing the consequences of our actions, our present con-cerns lead us to align our interests with others whom we canidentify with, choosing particular courses of action over others.

As Burchell (1991) tackles this same issue, he claims that:

In the ‘scheme of actions’ that results from the actions ofisolated subjects of interest, the economic positivity andrationality of each individual’s calculated actions

—

‘theproduction of ‘an end which was no part of his intention’

—

is possible

only

if the ultimate conditions and effects ofthe individual’s actions escape his or anyone’s knowledgeand will (133).

This condition of the apprehension of one’s participationin the formulation of interests would seem to radically under-cut the possibility of consciousness-raising at this level ofaction. Beyond mere calculation, individuals can be under-stood as being caught up in processes that may result inthem working

against

their own interests. Instead, as oppor-tunities for expressing our concerns for ourselves as well asothers, we can become enrolled (cf. Latour 1987) in theinterests of others and our concerns are

translated

(cf. Callon1986) into the accomplishment of dominant interests.

So, having had her hours recently cut, and having indi-cated that such treatment has altered her relationship to heremployer in that she may begin looking for another job,what is it that ‘interests’ this nurse in her continued engage-ment in the work of home-care nursing? In an interview afterobserving her in her day-to-day work, she told me that:

The approach that I use is always a very caring approach inmy particular job because we are going into their home,I try to be very courteous and it’s their home, I’m a guestthere. I’m there to help them and I’ll help them as much asI can but I always let them know that this is their home. SoI try to be a polite and courteous person and I go with theattitude that ‘I’m here to teach you to look after yourself ’.Basically that’s what I feel my role is: ‘I’m here to teach youhow to best take care of yourself, I’m here to be a resourcefor you, tell you about what is out in the community thatmight be helpful to you. I’m here as an advocate on yourpart, between you and your doctor or you and whoever elseneeds to be (involved)’. That’s the approach that I take.




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The nurse lays out a number of subject positions here:she is a caring nurse; a polite and courteous guest in apatient’s home; she is a teacher; an advocate; a resourceperson. She is now talking of her work in quite a differentway. This segment of interview transcript was selected asa contrast to the earlier segment. Now the nurse is fully

—

almost evangelically

—

engaged in her work!But this ‘good work’ has to be carried out under very

particular circumstances in each home. Being a guest insomeone’s home is highly problematic when you onlyhave 15 minutes to spend (because you still have four morepeople to see before the end of the day and overtime payhas been severely cut back). Negotiating a highly delimitedform of nursing care as representative of high qualitycommunity health services is an extremely difficult task. Theprofessional rhetoric espoused by this nurse above, on itsown, would seem to be insufficient to the task. How can itbe explained to a patient who has been having a home-carenurse visit on a weekly basis to cleanse and dress a persistentleg ulcer that s/he no longer requires nursing services? Theseeds for ‘translations’ are embedded in the statementsmade by the nurse above. But at a staff meeting called by aunit manager and attended by nine full- and part-time staff,the grounds for translation were laid out more clearly for thenurses working at the health unit.

Governing ‘difference’ in the work of home-care nursing

The issue of difference in the way nurses conduct themselvesin homes served as an important point of translation. In rais-ing the possibility that nurses were enacting their practicedifferently from one another, managers also signaled thatpractice conducted in the relatively invisible location ofindividual homes in the community was, nonetheless,visible for the purposes of managing nursing services. Andto the extent that differences could be rendered visible,‘adjustments’ were being called for.

The context of the following field notes was a staff meet-ing. The local health unit manager was chairing the meet-ing. She was relatively new in the job, perhaps three monthsor so. However, like any other manager, she was accountablefor expenditures on home nursing services. Her conversa-tion with the nurses on this particular day reveals an interest-ing strategy aimed at ‘problematizing’ (Foucault 1984)nursing practice. The way the problem was formulated wasthat it had become apparent to her as a manager that nurseswere applying the rules of eligibility for home nursingservices in an uneven fashion and she wished for them towork towards greater standardization in applying those rules.

The meeting began with the manager ‘reminding’ her staffof the reasons for this particular meeting. What is interestingin this reminder is how the manager offers a ground uponwhich she asks nurses to translate their interests into her owninterests for fiscal accountability:

Manager: We said we’d try and do more frequent casereviews. When we had our meeting in March, back in Marchwhen we figured out ... if we did, whatever, those of you whowere there remember it and everyone else got copies of it.We said we’d follow up on it.

Here the manager ‘reorients’ her staff to a conversationthat she apparently had with them a few months back.At that meeting, there was an agreement that staff and man-agers would meet on a more regular basis to conduct whatare being called here ‘case reviews’, and are later referredto as ‘case conferences’. The purpose of the reviews is notdetailed here. What seems more important for the manageris to remind her staff that this conversation happened, that

together

they agreed on a course of action that was not fullydetailed at the time and that there had been a promise to‘follow up’ on that conversation. Through this strategy, shereminds them that she is a ‘good’ manager: she heard theirrequests for more frequent case reviews and she is followingup on a promise made. The case reviews will also, apparently,render nurses’ practice visible, which serves an importantpurpose for her, enabling the supervision of rules governingpatient access to home nursing services. The managercontinues:

We said there were four things we said we’d do. One wascase conferences more regularly, and I have in the rotationscheduled those in and scheduled people on. So we don’tsort of, a week ahead try and get everybody in. I’ve sched-uled them regularly. Now, I have to see if we have enoughmoney to do it.

Not only has the manager heard something nurses wereasking for but she has gone further and scheduled thesemeetings well in advance in a way that means nurses cannow more easily participate as a part of their everyday work.This benefit is contrasted to existing practices of having toscramble at the last minute to pull together enough peopleto ‘do’ a case conference. It seems that previous ways ofmanaging such conferences resulted in a rather haphazardmeeting schedule. The manager, in this way, signals thesignificance of these conferences for nurses (or at least thatnurses ought to consider them as significant) as well asreflecting their significance by scheduling them in advanceand finding the money to enable the nurses to attend them.

Having established her credentials as a ‘good’ manager,she then sets out to remind her staff of some other aspectsof these meetings that they had previously discussed:


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Manager: So the case conferences, one of the reasons Iremember, and maybe you can refresh my memory, is oneof the things we said sort of divided us was sometimes wehave different views of how we do nursing and our differentnursing practice. I don’t know who brought that up [Sandy]I think it was. Do you remember that? We talked about that.

We can see here the ground presented by the manager assomething likely to be of ‘interest’ to nurses

—

a groundupon which they can translate their interests. Differencesamong nurses were identified at the last meeting. The caseconferences are meant to help nurses ‘learn’ from oneanother

—

to standardize their approach to practice. Nurseswill be ‘interested’ in reducing possibilities that they mightbecome the individual targets of ‘practising differently’. Inorder not to be singled out, nurses will, I argue, seek to

blendin

with the standard forms of practices as far as possible.In this meeting, these nurses are being called upon to

‘change their relation to government’ (Burchell 1991, 146).In so doing, they are being asked to change their relation-ship to themselves. and as Burchell rightly points out, ‘it isthen that we become aware of the ways in which the politicalpower of state impinges on our individual lives, that we

feel

it’ (Burchell 1991, 146).So, my earlier attempts to ‘alert’ nurses to the effects of

their actions were coming much too late. By the time I ‘saw’it in their actions, they had already ‘felt’ it and had madeadjustments in their changed and changing relations withthose who govern their actions. Such techniques of govern-ment are invisible in important ways and it is my argumentthat such invisibility underpins the effectiveness of thestrategies aimed at reducing the availability of professionalnursing services to a larger and increasingly debilitatedpopulation of citizens. But, while the relationship to govern-ment remains invisible, other aspects of their practice are alltoo visible:

Manager: So, what I had done when I first came in ... thenurses, I think you were there [June and Sandy and Linda]and I sat down. We were looking at some of the chronicpeople because they had said [previous manager] theyhad a real problem with mismanagement of chronicpatients, so we were sitting and we were talking about a wayof looking at them. Do you remember that [June]?

June: Yes I do.

Manager: Do you think it would be helpful to review whatwe were talking about then for other people?

Here, individual nurses are singled out as having contributedin specific and important ways to the construction of the‘problem’ that draws these nurses together in this meeting.The manager gets nurses to ‘confirm’ her understanding ofthe source of the problem (‘our differences were dividingus’) as well as the outcomes of those problems (the mis-

management of chronic patients). The manager can evenget one of the staff to take her place in this ‘teaching’ sessionto ‘review what we were talking about’ for those staff nowpresent who were unable to attend previous meetings. Thestaff nurse seems very willing to take up this teaching role:

June: I do. [We talked about] making contracts with clientswhen we bring them on the program, regarding ... like we’llsee them for two months and we’ll actively treat these, andthen after two months we’ll reassess that and teach themhow to do their own care once they become chronic, andhaving the really clear guidelines so that when we initiallymake that first visit, that we can lay it out for them so theyunderstand what the plan of action is. I think that was reallyhelpful because it was something that we haven’t done inthe past with chronic ... We’ve gone on continuing, like Mrs[Brown], to see her for 3 years:

Manager: Um hmm. Eight hundred and ninety-five visits.

The accuracy of this calculation of the number of visitsmade to Mrs Brown is not challenged by any of the staffmembers

—

and perhaps the number is not all that import-ant in itself. The significant point in the context of thepresent discussion is that counting numbers of visits issignaled to staff as being

possible

. The population of chronicallyill patients is thus rendered

visible

in a very particular way.‘Becoming chronic’ takes on a peculiar character in this

segment. Becoming chronic does not require reference to amedical diagnosis but rather, an ongoing (and incalculable)need for nursing service. According to nurse June, a patient‘becomes chronic’ at the end of the contracted period ofservice. Nursing services have already been constituted as avaluable and limited resource earlier in the meeting. And so,as ‘heavy users’ of nursing time chronic patients are consti-tuted as ‘the problem’ to be addressed. Without mentioninganything about the particulars of Mrs Brown’s living circum-stances or the reasons for the nurses’ visits, the assumptioncarries that this extraordinary number of visits has comeabout through ‘mismanagement’ of Mrs Brown as a chronicpatient. In addition, ‘looking’ at her differently could rectifysuch ‘mismanagement’. The manager takes up the conver-sation again and begins to instruct the nurses how to ‘shift’their therapeutic gaze:

Manager: Do you remember when we talked a little bitabout shifting how we think about the care from ‘the care’to ‘the person’? Do you remember we talked about what isit the person can’t do, so that we can figure out how to helpthem manage their own care? Does that, I may have torepeat that. But what we look at is ...

June: How we can better help them to do, to provide theirown care. What do

they

need?

Manager: Right. For those unable to manage, just what is it?So what can’t the person manage? Rather than what is it

wehave to

do for them?




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So here we see the intersection of interests laid bare.Drawing on contemporary professional nursing rhetoric of‘individualized care’ (May 1992), the manager suggests thatnurses need to ‘shift’ the focus of their attention off of ‘thecare’

they

deem necessary to provide and turn it, instead, to‘the person’. The implication is that this shift will be betterfor the person too. Within a society that values individual-ism, patients are being portrayed here as the hapless victimsof overbearing nurses. This equates to ‘mismanagement’. Ifnurses were instead to ascertain what

specifically

the patientis ‘unable to manage’, this now individualized problemcould form the basis of a ‘contract’ with the patient. A teach-ing plan could be formulated to move the patient into aposition where he/she would, over a short period of time,become ‘able to manage’ independently. The nurse coulddocument the successful outcome of her contracted workwith the patient. The patient could continue on his or herlife independently.

Everyone

would, clearly, be better off!

‘Superintending the industry of private people’

It is significant to note what aspect of nurses’ work withpeople in their homes becomes visible in the precedingdialogue. The issue of ‘chronic illness’ serves as a focus of‘the problem.’ This suggests that the population of potentialpatients seeking home nursing service are divisible into,at least, ‘the chronically ill’ and ‘others’. The ‘others’ areapparently not problematic. It is my own speculation thatthese ‘others’ are quickly being constituted by senior healthservices managers as those persons eligible for ‘hospital inthe home’ programs where length of service required fromhome-care nurses can be quite tightly predicted.

Against these people who might be discharged fromhospital following some form of surgery, it is the populationof chronically ill people who present a problem for themanager. The issue of ‘mismanagement’ is an interestingone too. It seems that ‘mismanagement’ becomes visible,not through some technique of examining nurses’ practiceor by patient ‘outcome’, but instead, through the number ofvisits made to patients. There is a link, however, to nurses’practices. The preceding discussion takes place in a carefullystaged manner. The manager has had some discussions withsome nurses. She ‘knows’, or perhaps can just anticipate,that there are divisions amongst staff in terms of their valuesfor conducting themselves as home-care nurses. Raising thespectre of ‘differences among us’, the manager can makeuse of these to ask nurses to ‘adjust’ themselves

—

not to solveinternal problems but to solve external problems such as theproblem of ‘the mismanaged chronically ill’. Focusing onexternal problems, the manager successfully establishes a

ground upon which nurses can translate their own interests.That is, just as Burchell sets out, engaging in practice thatone can individually take pride in (i.e. practice that is‘unique’) is not an ‘interest’ that nurses will surrender.Instead of demanding this, the manager skilfully offersnurses a point of translation (cf. Callon 1986). Nurses needto leave their ‘old’ ways behind and take up the ‘new’ waysof modern nursing where persons are the center of attention

—

not the care a particular nurse might think is good care.Having affected such a translation in her staff, the managerneed not be domineering in her requests that those staffchange their ways. They will do this themselves as ‘active andfree’ subjects of government.

According to Burchell (1991), one the of the tenets ofliberalism embedded in the writings of Adam Smith is that:

(n)o sovereign, no ‘single person, ... council or senate’ can‘safely be trusted’ with authority over the pursuit of privateinterest, because there is no ‘human knowledge or wisdom’sufficient for performing the duty of ‘superintending theindustry of private people, and of directing it towards theemployments most suitable to the interest of the society’(133–4).

From her position in the health unit, far away fromthe day-to-day work carried out by home-care nurses, themanager understands that she can never know in any sortof

complete

way what nurses are spending their time on. But,as the preceding dialogue illustrates, she has at her disposalthe means of calculating numbers of visits made by nurses.With that capacity comes an

assumption

that there might bean appropriate number of visits to be made. It is an assump-tion only. The manager is operating in a remarkably similarfield of political theory as that set out by the Physiocratsin Burchell’s study of 18th century civil society. There, the‘sovereign’s despotic imposition of regulations’ is understoodas both futile and harmful:

Not only is the attempt to govern reality in this way un-necessary, since reality contains intrinsic mechanisms of itsown self-regulation, but it is harmful because it is likely toproduce effects other than those desired (Burchell 1991, 126).

The manager’s careful staging of the discussion on changingpractice suggests she is aware there are regulations operatingon her ability to continue to act as manager in this context.She

could

overpower the nurses. But collectively they could resisther power, thus rendering her ‘ineffective’ in the eyes of hersuperiors. Instead the manager draws, not on some essentialagency inherent to her self as a manager, but rather the

rela-tions

available to her in the health unit (time sheets, staffschedules, daily work sheets, computerized patient records)through which she

performs agency

(Callon and Law 1995, 485)and in so doing, she asks the nurses to ‘come along’ with her.


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Albeit that she operates within a fragile world of permis-sions (cf. Munro 1998), the suggestion that there mightbe a correct number of visits for nurses to work towardsoperates on staff nurses as subjects of forms of disciplineat two complementary levels. The first is at the level ofmanagement, the other, at the level of professional conduct.The premise operating here is that if chronically ill patientsare being managed well, fewer visits will be required. And ifthe nurse is conducting herself in a manner in keeping withcontemporary conventions, she will focus on the person ina particular way that facilitates her making it ‘clear’ to thepatient from the outset why fewer visits are not only betterfor her, but better for him too.

These citizens are being asked to do their part to ‘savethe public healthcare system’ by making fewer demandsupon it or by paying privately for the ‘luxury’ of home-basedcare. While the problem of ‘the chronically ill’ is certainlymade visible through the accounting mechanisms availableto the manager within the health unit, the point of transla-tion upon which the manager asks the nurses to shift theirpractice, that of ‘differences amongst us’, remains com-pletely invisible. Home-care nurses work in relative isolationin the community. What goes on behind closed doors ismuch less accessible to the manager’s gaze than what goeson behind the curtains within the hospital. Raising the pos-sibility of ‘differences amongst us’ enables each individualnurse to ‘come on board’, to

translate

her individual interestsinto a new way of practising, without demanding any agree-ment on what it is that ‘divides us’ in the first place.

NURSING, POLITICS AND CITIZENSHIP

What does this analysis provide for a more robust discussionof nursing’s relationship to politics? Most concerning per-haps in the preceding dialogue are the ways in which shiftsrequired by managers to tackle the problem of the ‘chroni-cally ill’ serve to exclude, or at least limit, significant num-bers of the citizenry from having legitimate access to homenursing services. These exclusions rest on particular condi-tions that are necessary for their full operation. Firstamongst these conditions are a widely acknowledged set ofrisk criteria, which have helped nurses frame their interac-tions with community patients for many years now. On thebasis of these risks, it was previously possible for nurses toenter people’s homes to ensure cleanliness and safety (Bloorand McIntosh 1990), colonizing forms of everyday life inways that sought to ensure a disciplined care of the self.

More recently though, with the knowledge of how theserisks are productive of categories such as ‘the chronically ill’sitting just behind us, nurses have encountered a more

generalized undermining of that opportunity to extend dis-cipline into private homes (Purkis 1993). Now nurses talkabout the ‘right’ of citizens to live at risk. So, while they con-tinue to ‘assess’ clients in the community on measures ofrisk for any number of diseases or injuries, their inalienableright to act on the basis of those assessed risks has beendrawn back onto themselves as they now monitor eachother (Rose 1996) for the ‘differences that may divide us’.The availability of risk discourse alongside the difficultiesof acting upon those assessed risks leaves nurses in a positionto exclude those at the ‘margins’ of their work. The point ofthe meeting between the manager and her staff appearsto be to enable nurses to ‘see’ how those who fall into thecategory of ‘the chronically ill’ can now be excluded fromaccessing long-term supportive nursing service. The crucialissue here is one that is formulated by Mezzadra (2000):

In this battleground, demarcated by the neo-liberaloffensive against the Welfare State and by the globalisationprocesses, the lacerations in the social co-operation andcitizenship have not yet been recomposed. On the contrary,they have been ‘transcripted’ in terms of exclusion (164).

The need to standardize access to home-care services can beunderstood as an effect of globalization. Living so close tothe insatiable appetite of the American for-profit healthcareindustry (Fuller 1998), home-care managers are constantlybeing encouraged to get their staff to work more efficientlyin order to resist the insurgence of private industry into therealm of what is currently a public health service. However,in the absence of a debate about the extent to which thesefears are in fact altering views of citizenship, it seems likelythat, as Mezzadra claims, citizenship has not yet been‘recomposed’. Instead, it has been translated on the basisof exclusions

—

exclusions that are enacted and made ‘real’in daily practice by nurses.

How to resist this inexorable movement? One widelydispersed resource is that of ‘local knowledge’ (cf. Foucault1979). The local knowledge of home-care nurses is muchmore minute, personal and detailed than that relied uponby their manager to shift their gaze away from their ownforms of practical knowledge (what nurses can do forpatients

—

to provide comfort, forms of independence andso on) towards a regulated and abstract form of what theperson cannot manage him or herself. This latter knowledgeis highly professionalized

—

and presumably already col-onized by managerial interests around the control of costs.To the extent that it can be pre-established that a manwith, for example, chronic obstructive lung disease, recentlydischarged from yet one more period of hospitalization,needs to be ‘taught’ how to use his inhaler at appropriatemoments, such teaching can become the ‘limit’ of nursing




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149

intervention. Inappropriate use of the inhaler becomes thatwhich is predicted (post hoc) as the cause of the hospitaliza-tion. Two or three teaching sessions can then be ‘ordered’ asan appropriate

—

and time limited

—

response on the partof the nurse. Other, less time-specific issues of the experienceof living with a chronic breathing condition are excludedfrom the interested gaze of the nurse. Instead, these inter-ests are returned to the person who, having received histraining in the use of his inhaler, is left to ‘live at risk’. Butall of this can be applied ‘generally’ to the situation of thisman

—

or any other.

Local knowledge

of his situation, that is,knowledge obtained by the nurse through several visits tothis man during which he talks about deep sadnesses andregrets he lives with, reveals a state of depression and a seriesof choices that suggest he is trying, in many small ways, toend his life. Learning to use his inhaler will be a time-limitedintervention. It will not touch on his life-distress.

Mezzadra (2000) suggests an alternative view of citizen-ship that speaks to the possibilities inherent in nurses’ localknowledge of their patients’ everyday living situations. Hesuggests that:

citizenship should be rethought both as a problem and acategory of movement: a ground on which the several con-temporary instances clash and gather which refuse exclu-sion and which claim new rights and imagine new forms ofcomposition and mediation between them (165).

Home-care nursing practice might be reconceptualizedas a political practice; a political practice that addresses

problems

encountered by people as their life concerns aremore and more excluded as legitimately requiring supportand assistance within the context of their home. These prob-lems can be said to arise out of the ways in which people are

moved

between private and public spaces by nursing andmanagerialist technologies. This requires a little furtherexplication.

The argument developed in this paper is that the homebecomes politicized when it becomes a

public

workspacewhere nurses enact practices of exclusion (that is, makingdecisions about eligibility for service) emerging throughon-going managerial interests in efficiency. This politicalcharacter of home nursing care must be acknowledgedbecause its motility in one moment being private and thenext public, is all too easily discounted as important. In thehome as a politicized public work space

and

a private livingspace nurses might seek to reintegrate ethics into their prac-tices in ways that refuse exclusions (by nurses or by patients)on the basis of local knowledge. Because, as Foucault (1976/1980) argues, ‘it is through the re-appearance of this know-ledge, of these local popular knowledges, these disqualifiedknowledges, that criticism performs its work’ (82).

Currently the work of the home-care manager involvesinstructing nurses how to ‘move’ patients from being‘mismanaged problems’ to being responsible users of a con-strained resource. But nurses have knowledge of people’scircumstances of everyday living that could ‘clash and gather’with the experiences of struggling to live independent liveswhile confronting the effects of chronic illness on a dailybasis.

The local knowledge of nurses represents a ground uponwhich a refusal of exclusion could be enacted. Such a refusalrelies on nurses’

acknowledgement

of the legitimacy of theirlocal knowledge, and of their development of

systems forrecording this knowledge

that resist managerialist demandsfor standardization (Purkis 1999). These are significant andachievable means available to nurses to respond to theirexperience of

feeling

the ways in which ‘the political power ofstate impinges on (their) individual lives’ (Burchell 1991,146). In so doing, nurses can begin to acknowledge andreintegrate the political with the ethical in a critical andrespectful home nursing practice.

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Managing home nursing care: visibility, accountability and exclusion

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