‘Teach, reduce and discharge’
Community nurses’ textual production of ‘independence’ and the coordination of discharge from home care services
Keywords:school health supports, children with diabetes, institutional ethnography, home care, healthcare restructuring
Over the past three decades, the Canadian healthcare system has undergone significant reform and restructuring. As a result, healthcare and healthcare costs are relocated from hospitals to the community (McGregor, 2001). Text-based technology is increasingly used to standardize care and contain healthcare spending. This paper examines an example of a text-based technology used in the School Health Support Services programme for students with diabetes in Ontario, Canada. Using institutional ethnography, the inquiry starts with parents’ concerns regarding the premature termination of nursing care for their children with diabetes at school. The exploration shows how these parents’ concerns are hooked into the institutional work of assessment for service discharge conducted by the Community Care Access Centre (CCAC) care coordinators. The analysis shows how the institutional category of ‘independence’ coordinates the service discharge work of the CCAC care coordinators with that of the nursing work of community nurses at school. The activation of the category of ‘independence’ by the nurses mediates their work, orienting their focus away from providing direct nursing care, and towards transferring primary care to children with diabetes. Children doing diabetes self-care work at school is then written up in nursing texts to stand in for children’s ability to manage diabetes ‘independently’. The textual production of ‘independence’ enables the next institutional course of action, that is, the discharge of children from nursing services at school. In this process, children with diabetes are drawn into doing the discharge work that ultimately serves the cost-containment interests of the institution. This institutional process also functions to obscure important actualities: It obscures how children’s ‘independence’ is co-created on a daily basis with their parents and relies on their parents’ work, and it discounts the significance of children with diabetes coming to their own embodied and emotional readiness for diabetes self-care.
Armstrong, P., Amaratunga, C., Bernier, J., Grant, K., Pederson, A., & Willson, K. (2001). Exposing Privatization: Women and health care reform in Canada. Garamond Press: Aurora, Canada.
Aronson, J., & Neysmith, S. (2006). Obscuring the costs of home care: Restructuring at work. Work, employment and society, 20(1): 27–45.
Aronson, J., Denton, M., & Zeytinoglu, I. (2004). Market-Modelled Home Care in Ontario: Deteriorating Working Conditions and Dwindling Community Capacity. Canadian Public Policy, 30(1), 111-125.
Browne, P. L. (2000). Unsafe practices: Restructuring and privatization in Ontario health care. Canadian centre for policy alternatives.
Darville, R. (2014). Literacy work and the adult literacy regime. In A. I. Griffith & D. E. Smith (Eds.), Under new public management: Institutional ethnographies of changing front-line work (pp. 25-57). University of Toronto Press.
Delamater, A. M. (2009). Psychological care of children and adolescents with diabetes. Pediatric Diabetes, 10(Suppl. 12), 175-184.
Diabetes Control and Complications Trial Research Group (1994). Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. Journal of Pediatrics, 125, 177–188.
Follansbee, D. (1989). Assuming responsibility for diabetes management: What age? What price? The Diabetes Educator, 15(4), 347-352.
Griffith, A. I., & Smith, D. E. (2014). Under new public management: Institutional ethnographies of changing front-line work. University of Toronto Press.
Hanas, R. (2011). Type 1 diabetes: In Children, adolescents and young adults. Fourth edition. Bookwell, Juva: Finland.
Helgeson, V. S., Reynolds, K. A., Siminerio, D., Escobar, O., & Becker, D. (2008). Parent and adolescent distribution of responsibility for diabetes self-care: Links to health outcomes. Journal of Pediatric Psychology, 33(5), 497-508.
McGregor, S. (2001). Neoliberalism and health care. International Journal of Consumer Studies, 25, 82-89.
Peter, E., Spalding, K., Kenny, N., Conrad, P., McKeever, P., & Macfarlane A. (2007). Neither seen nor heard: Children and homecare policy in Canada. Social Science & Medicine, 64, 1624–1635.
Piette, J. D. (2010). Moving beyond the notion of ‘self’ care. Chronic Illness 6(1), 3-6.
Ponder, S. W., & McMahon, K. L. (2015). Sugar Surfing: How to manage Type 1 diabetes in a modern world. Mediself Press.
Randalla, G. E., & Williams, A. P. (2006). Exploring limits to market-based reform: Managed competition and rehabilitation home care services in Ontario. Social Science & Medicine 62, 1594–1604.
Scheiner, G. (2004). Think like a pancreas: A practical guide to managing diabetes with insulin. Da Capo Press.
Smith, D. E., & Turner, S. M. (2014). Incorporating texts into institutional ethnographies. University of Toronto Press.
Smith, D. E. (2006). Incorporating text into ethnographic practice. In D. E. Smith (Ed.), Institutional Ethnography as practice (pp. 65-88). Rowman & Littlefield Publishers, Inc.
Smith, D. E. (2005). Institutional Ethnography: A sociology for people. Altamira Press: A division of Rowman & Littlefield Publishers, Inc.
Smith, D. E. (1990). The conceptual practices of power: A feminist sociology of knowledge. Northeastern University Press.
Smith, D. E. (1987). The everyday world as problematic: A feminist sociology. University of Toronto Press.
Turner, S. M. (2014). Reading practices in decision processes. In D. E. Smith & S. M. Turner (Eds.), Incorporating texts into institutional ethnographies (pp. 197-224). University of Toronto Press. Format APA.
Turner, S. M. (2006). Mapping institutions as work and texts. In D. E. Smith. (Ed.), Institutional Ethnography as practice (pp. 139-161), Rowman & Littlefield Publishers, Inc.
Turner, S. M. (2003). Municipal planning, land development and environmental intervention: An institutional ethnography. PhD dissertation, University of Toronto.
Watt, L. (2015). (Un)safe at school: Parent’s work of securing nursing care and coordinating School Health Support Services for children with diabetes in Ontario schools. Journal of Sociology and Social Welfare,42(1), 103-126.
Wherrett, D., Huot, D., Mitchell, B., & Pacaud, D. (2013). Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Type 1 diabetes in Children and Adolescents. Canadian Journal of Diabetes, 37 (suppl. 1): S153-S162.