The ‘well‐run’ system and its antimonies

Abstract

An aim of all of the management of healthcare systems is the smooth provision of services. A great deal of effort is put into ensuring processes will obtain this ideal--the well-run system. The central argument in this paper is that these processes result in a system that perpetrates violence and coercion on its clients and workers. This violence is structural and personalizing in its effects. Moreover, time and effort is taken away from the actual work of the system for its management. Under such managerialist control, the idea of chaos and the need to ensure order are used to fuel an apparatus that takes the focus from other aspects of the system such as the power relations that keep the system as it is. In such an ordering, the clinical audit is promoted as a method to ensure order by keeping ahead of, or removing the potential for chaos. In using Žižek's ideas about violence it is possible to identify how efforts and attempts to correct the system are doomed to fail just as they hide how nurses' enrolment in the service of the system leads to alienation and subjectification. A central aim of this paper is to rethink how power and implicit violence are practised in such processes. To overcome the inherent violence of the audit culture, this paper suggests an interruption of audit cultures with a promotion of more radical positions for nursing practice and clinically based research. The hope is to recalculate and interrupt how nurses are to operate in the management structures that organize healthcare.

Chapter Two: Privileging Practices: Manifesto for “New Nursing Studies”

“…What interests Rudge is hown urses have been drawn into this preoccupationw ith productivity, (cost)effectiveness and efficiency, and more specifically,toaccept and work hardfor what has come to countasproductivityinhealthcare settings, aconcept lifted from the manufacturing sector.Notable is the ease with which economic discourses and industrial processes are incorporated into care practices, valued by nurses as ameans to recapture consistencyand reliability in an increasingly turbulentw ork environment, albeit without the sources of this turbulence-austeritymeasures and changing workforce characteristics -either named or addressed. But, as Rudge observed, the appearance of as mooth running system is all important: "the ward sails likeaswan (all surface beauty and serenity) while the tools (those ugly legs) work frantically under the water" (p.208;see also Rudge, 2011). In this, nursing is an objecttobemanipulated like anyother -limited, determinantand bound tightly to anarrowconception of "good"practice.…”

Discourses and practices in institutionalised nursing in South Africa: Challenges for care

“…In professional nursing, conditions of governmentality and surveillance are intensified through the pervasive audit and selfassessment culture dictated by institutional bureaucracies in an attempt to ensure accountability (Rudge 2011). A study of the effect of this on nurses at a KwaZulu-Natal hospital illustrates how 'audit culture makes use of entrenched workplace hierarchies, rather than challenging or changing them', while simultaneously 'creating an illusion that [staff] have greater responsibility and autonomy than in fact they do', resulting in 'a logic whereby the responsibility for any apparent "failure" to fulfil these and other initiatives falls on individual nurses' (Hull 2012: 619, 626).…”

Beat the clock! Wait times and the production of ‘quality’ in emergency departments

“…This happens within a powerful ruling discourse that inserts the interests of politics, government, and economics into health care delivery and, more specifically, into nurses' work. In the larger context of health care reform, the infiltration of business values, economic rationalism, and corporate accounting practices is rampant and there is ongoing pressure to commodify health care (Armstrong et al ., ; Weiss et al ., ; Shannon & French, ; Rankin & Campbell, ; Rudge, ). While most reports suggest that health care is benefiting from the application of ‘waste reduction thinking’ that is the cornerstone of ‘lean’ initiatives (de Koning et al ., ; Shiver, ; Ng et al ., ), there is some indication that the corporate models being introduced into health care resource allocation and efficiency have significantly disrupted the culture of health care resulting in negative effects for patients and health professionals (Varcoe, ; Weiss et al ., ; Shannon & French, ; Storch, ).…”

“…The sense of ‘urgency and imminent chaos’ (Rudge, , p. 168) that is produced through the waiting crisis creates a demand for narrowly targeted solutions aimed at moving people in and out more quickly to solve the problem and reduce the wait. Rudge () argues that the preeminent ideal of a ‘well run system’ (p. 167) ensures that attention is focused on aspects that ensure order, such as the use of audit tools and mechanisms of counting to avert chaos and insecurity. The solutions that support the ‘smooth operation’ of the system presume that the system itself does not need fixing (Rudge, , p. 172).…”