Introduction

Through ethnographic research and in-depth interviews sociologist Theresa Morris, through her book, Health Care in Crisis: Hospitals, Nurses, and the Consequences of Policy Change (New York University Press, 2018)  gives us an inside look at a hospital in transition through the eyes of the nurses who work there. Morris followed nurses in an obstetric unit at a hospital in New England for three years, during a time of immense state and national policy changes. These changes directly affected the way these nurses were required to do their job. Morris gained an intimate insight into exactly how these changes made the nurses' jobs more challenging and less rewarding. She provides an astute and perceptive look at not only these nurses but also the broader context that influenced the decisions that worsened both their working conditions and their ability to spend time caring for their patients.

Setting the scene

In part one, Morris takes the reader deep into the obstetrical unit of Fuller Hospital (pseudonym) with a tour of the physical and policy landscape in the very first chapter. She then paints a picture of a day in the life of an OB nurse there which involves navigating hospital policy, best practices, professional politics, patient needs, and so much more. Fuller is in flux during this period, moving from a 100-year history of non-profit hospital status to a for-profit model at a time when state and national policies are placing increasing demands for documentation, payment, and service. The hospital is dealing with a potential financial crisis, and the nurses' jobs are changing because of policies put in place to attempt to deal with this crunch.

Listening to the voices

Part two of the book is dedicated to in-depth descriptive portraits of individual nurses that Morris divides into two basic categories based on their essential outlook to how their job should be performed: patient-oriented nurses and process-oriented nurses. She neither venerates nor vilifies either category, rather uses her writing and keen ethnographic observations to elucidate the ways that these two very different approaches affect how these nurses do their job. Morris examines how they deal with the policy changes that require nurses to spend more time documenting and less time at their patients’ bedside. It is through these nurse portraits divided into before and after the changes that we see the unsettling effects of policy changes that cost the hospital much time and money and truly seem to have negative effects on both the nurses’ job satisfaction and patients’ experiences.

Analysis

In the final section of the book, Morris lays out the philosophical argument and discussion from a political economy and resource dependency theory perspective. Morris is specifically interested in looking at all levels of the issue and drawing a picture of how resources influence decision-making processes. She explains how national and state policy decisions seemingly force executive decisions at the hospital level and lead directly to changes for nursing practice generally and how they interact with patients specifically. Morris untangles the complicated web of how policy connects to practice and builds directly on the stories of individual nurses to make her case.

My take

As a doula and childbirth educator, I find this book fascinating especially for the insight it gives into how the nursing practice changes with sweeping policy reform. Morris really plunges you into the world of these nurses and helps you see the immense pressures they are under even before the policy changes of the Affordable Care Act and state legislature. Her documentation is so descriptive that when she writes about the individual nurse approaches on either side of the changes, I felt as if I was there with them and just as frustrated. For anyone thinking about how to change policy to help improve not only outcomes but also process, this book is essential reading. Morris does an outstanding job of bringing the voices from the floor of the hospital and speaking directly to the executives and policymakers that are making these decisions and deftly explains how if we are going to improve health care, especially in obstetrics, the nurses' voices are vital to include in the discussion.

A brief interview with Theresa Morris

I spoke to Dr. Morris, and she would like to leave this audience with the takeaway that nurse to patient ratios matter. She states that we know from the existing data that payroll is the biggest expense for many hospitals and that non-profit hospitals continue to have better nurse to patient ratios and lower cesarean rates. Dr. Morris recognizes that not everybody has a choice on where to birth. We should be sharing this information with people who do have a choice, so they can make an intentional decision. It is known that the characteristics of the hospital are important for all kinds of outcomes and experiences. In her study, both patient and process-oriented nurses had less time to spend at the bedside performing patient care after the policy changes, and we know that makes a difference in how they practice. This reduction in time made the process-oriented nurses even less supportive of patients with birth plans and doulas because they further disrupted the already strained time that needs to be devoted for hospital protocols.

Dr. Morris emphasizes that families should be able to decide what they want regardless of protocols. Morris believes it is our right and privilege as humans to not only become aware of these issues but also to know that we have the ability to make decisions about our care. She encourages families to seek out information and resources and to get in a room with other people just as passionate about these issues not only for the energy but also to help ask great questions and to build a movement in their local area. Morris practices what she preaches; she runs a local ICAN chapter in College Station, TX.

This book builds on Morris’ previous work, including her book Cut It Out: The C-Section Epidemic in America. I highly recommend Health Care in Crisis: Hospitals, Nurses, and the Consequences of Policy Change if you are looking to better understand the varying pressures put on nurses within changing hospital and healthcare systems. Dr. Morris clearly has an interest in improving birth and her ethnographic research on individuals within the system highlights critical areas at all levels that need to be considered when not only dealing with change but each person within that system and how their lives are directly impacted from the very top of policy decisions.

About Hillary Melchiors

Hillary Melchiors PhD, MPH, LCCE, CD(DONA) is a medical anthropologist, childbirth educator, birth doula, and writer in Evansville, Indiana. She received her PhD in Medical Anthropology and Masters in Public Health from Case Western Reserve University and has practiced as a birth doula since 2014 when she founded the Doula Group of Evansville. She has served as a leader of the Evansville Birth Network and member of the Southwest Indiana Breastfeeding Coalition, as well as serving on the DONA International Advocacy Committee. You can follow her on Twitter: @HillaryMelch and contact her through her website - Doula Group of Evansville.

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