Cutting from the Bottom: Reform and Hospital Work Under the Influence of New Public Management

Health care research predominantly analyzes the role of pharmaceuticals and physicians. Less focus is given to the majority of workers who are essential to the health care system. While often ignored, the non-physician work force has a large impact on health care financing and health care outcomes. Their work and the context they work in needs to be analyzed to provide a fuller understanding of health care systems. This dissertation is an attempt to fill this gap in health research. Hospital work exists in a complicated political context. Hospitals in Canada are privately operated, non-profit corporations that are publicly funded directly by provincial governments and indirectly by the federal government. Both levels of government have attempted to constrain health care spending in the last few decades, and much of this reduction was aimed at non-physician hospital workers and services. This dissertation utilized theories from public administration and sociology to contextualize hospital work within large political shifts and how they have impacted hospital work. These theories guided the literature review, the interview schedule, and the analysis and interpretation of the data. This dissertation examined the impact of health care reform on hospital work. Semi-structured interviews were utilized to ask hospital workers about their work, work-life balance, and how hospital work has changed over their careers. In total, 20 hospital workers were interviewed, including 10 nurses and 10 non-nurse workers. Interviews ranged from 30 to 65 minutes. Most respondents were from hospitals downtown Toronto, with the remaining working in hospitals within the Greater Toronto Area. This dissertation found that successive waves of health care reform have negatively impacted hospital work. Workers indicated various ways that the changing political and economic climate has impacted their lives and their ability to perform their work at a high level. In general, workers cited lowered autonomy, increased automation and documentation, and increased managerial control over their work. Workers also reported work intensification and high rates of injury. Workers pointed to budget cuts and a shift in accountability down to the workers to explain why these changes had occurred.