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Reviews / Comptes Rendus

Dana Beth Weinberg, Code Green: Money-Driven Hospitals and the Dismantling of Nursing (Ithaca and London: Cornell University Press 2003)

A SENSE OF CRISIS has been palpable in nursing in North America since the 1990s. Cost containment, restructuring, and institutional mergers have all contributed to an unstable environment with considerable costs for nursing, including job losses, intensified work loads, and the loss of professional autonomy and power. This engaging study describes the "dismantling" of a prized nursing professional model known as primary care nursing, during restructuring at Beth Israel Hospital in Boston in the late 1990s. This was not just any hospital, Beth Israel was a renowned Harvard teaching facility, the first in the country to establish a patient's bill of rights, and "one of the best hospitals in the world to be a nurse." (2) It set the gold standard in terms of the respect and power it gave nursing, and was known as a so-called "magnet hospital" because of its record in attracting and retaining nurses. It had adopted primary nursing care in 1974, a model which privileged the role of nurses in organizing and providing care for patients.

In 1996, under enormous competitive and financial pressures (intensified by cuts to health spending in the 1997 Balanced Budget Act), Beth Israel became another participant in the "merger mania" then sweeping American health care institutions. It joined with nearby New England Deaconess Hospital to form Beth Israel Deaconess Medical Centre (BIDMC), part of the even larger CareGroup health care corporation. The merger was fraught with power struggles and culture clashes between personnel at the two hospitals. In the case of nursing, the reasons for the clash were plain. Beth Israel's management style had been consensus-based, relying upon debate and experience to make decisions. By contrast, Deaconess had adopted Total Quality Management (TQM) during a restructuring exercise in the early 1990s, and had a data-driven decision-making style. At that time, Deaconess had also introduced patient care technicians to perform some nursing tasks, in order to decrease their nursing budget. This had generated enough discontent to spur a unionizing drive by the Massachusetts Nurses' Association in 1993, which was defeated by a two-thirds margin. Weinberg argues that the introduction of patient assistants was not a new concept, but essentially a return to the "team nursing" concept of the 1940s and 1950s — a way to divide up nursing labour, and delegate those tasks requiring the least skill to cheaper nursing assistants. Primary nursing care, the model employed at Beth Israel, had developed as an explicit rejection of team nursing as detrimental to both nursing professionalism and patient care.

The institutional merger was meant to eliminate redundancies, increase efficiency, and allow the two hospitals to claw their way out of their financial imbroglios. Yet after a year, BIDMC was haemorrhaging money, losing a million dollars a week. Its response was to launch a restructuring initiative, known as "Genesis" (or, "Genocide" as staff called it). Primary nursing at BIDMC was fundamentally undermined by Genesis, which introduced an expanded role for nursing assistants, the majority of whom were nursing students. This too was reminiscent of the 1940s, when student labour was essential to the expansion of hospital care.

Beth Israel nurses were understandably unhappy about this. The primary nursing model held significant benefits for nurses, including opportunities for career advancement and a role in the power structure. Nurses throughout the hospital reported only to nurses, and the head of the nursing department was a hospital vice-president. Nursing was recognized as a clinical discipline in its own right, that determined its own practice. This was particularly important in relationships nurses had with physicians. Nursing leadership was committed to equality with doctors. Beth Israel had clearly created an environment in which academically-oriented and ambitious women in nursing could make use of their skills and abilities, and gain both status and power. Restructuring decimated this power base.

What primary nursing meant for bedside nurses is more ambiguous, and Weinberg might have looked more directly at the downsides of the model. Primary nursing put pressure on bedside nurses to sacrifice self-interest to the goals of nursing professionalism. For example, primary care stressed the continuity of patient care, which was to be achieved by a nurse taking full responsibility for each patient's needs over a 24 hour period. Few tasks were delegated, nurses routinely stayed past the end of their shifts to finish their work, and they rarely took breaks. When they did, they were discouraged from leaving the unit, in case they were needed. Weinberg points out that nursing management at Beth Israel preferred to view themselves as "mentors" rather than managers, and to downplay their power over bedside nurses. What happened when conflicts occurred between management and frontline nurses? In Weinberg's account, there apparently were none.

In this context, it is disturbing but not surprising to learn that the response of bedside nurses to increased workload and decreased autonomy at the restructured BIDMC was further self-sacrifice, rather than collective action. As Weinberg herself notes, "nurses have been socialized by nursing schools, hospitals, and professional organizations to feel personally responsible for the care and comfort of their patients." (152) Nurses told Weinberg in surveys, focus groups, and interviews conducted in 1999 that they felt stressed, unsafe, overworked, and unhappy about the inferior quality of patient care they had time to deliver. One nurse testified that "I don't like the feeling of walking into a patient's room and saying, 'Here are your medications for the morning.' And I'm thinking in my head, 'Don't talk. Just take the pills. I've got five people today.'" (145) Yet their form of resistance to unwelcome changes in the workplace was highly individualized: fantasies of quitting nursing, refusing to give up high standards for their patient care (often at their own expense), and opting to work part-time rather than full-time. Although a significant proportion of nurses (one in four) reported to Weinberg that they were contemplating leaving their jobs, she presents no data on employee turnover that would suggest that nurses were in fact doing so. One reason must be the relatively high compensation nurses enjoy relative to other female-dominated occupations. Salaries, which were not rolled back as a result of budget cuts, were not a source of complaint.

The greatest difficulty facing Weinberg, and other critics of hospital restructuring, is to establish that what has happened to nursing practice threatens the safety and recovery of patients. Code Green doesn't provide any data on measures such as medication errors, complications, falls, and so on. Administrators at BIDMC argue that standards of care remain high, and that patients are satisfied. An inpatient survey, they argue, found 85% patient satisfaction. If you ask nurses, however, as Weinberg did, quality is deteriorating, and the emotional and psychological aspect of healing ignored. Do patients in North American hospitals even expect emotional care from overstretched staff in hospitals anymore? Certainly, their experience of illness cannot be more pleasant for its lack. Unfortunately, health care providers and patients seem to have lowered their expectations of institutional care. In the process, nursing has become a less appealing career for women, and the seeds of a nursing shortage are sown.

This is not a book about solutions, as much as it is a very convincing cautionary tale. It offers little hope that nurses themselves will organize to demand changes to their work environment, and does not explicitly argue that they should. Weinberg does not comment on the failure of unionism among nurses in the US, or the barriers to organization, including the opposition of nursing leadership. Sadly, bedside nurses at BIDMC have had a hard time getting support from the nursing élite, some of whom argue, with administration, that nursing has changed and the old-style nurses must simply adapt. Although there is plenty of blame to go around here, Weinberg clearly reveals the gap between bedside and élite nurses, and shows how dangerous this has become for the future of nursing.


Esyllt Jones Arbeiter Ring Publishing

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