Introduction

Morality is frequently equated with conduct and character of individuals, but when a group of community health nurses interprets market-driven health care by saying, “We can't be nurses anymore,” they are sending a warning sign that corporatization is forcefully introducing a contradictory morality into health care at the institutional level. The nurses, whose encounter with corporatization I will describe, worked at a home care agency affiliate of an integrated health system (IHS). An ethnographic analysis of the institutional content of their moral problems more generally offers insight into the moral dimensions of changing values and structures in health care.

Less than 18 percent of the 2.5 million nurses in the United States are employed in home care. So the turbulent work world of community health nurses over the last decade is largely invisible to most people. In the early 1990s, it was widely believed that home care would strategically bridge hospital and community-based care by facilitating earlier discharge of patients and controlling rising hospital costs. By 1997, an estimated 60 percent of acute hospital IHSs had home care affiliates, but within a span of five years strategic thinking had changed. Concerns about financial risk from declining Medicare reimbursement led many IHSs to sell or close their home care agency affiliates.

The nurses in this study, like all nurses, are expected to act responsibly and to do the right thing for patients despite the chaos occurring all around them. Nursing practice expresses values central to health care and tends to closely approach the core of how we understand deeply important matters, such as caring, comforting, quality of life, suffering, and death. Because of the close association between nursing and human experiences in health care, Jameton argued that the ethical problems of nursing are fundamental to understanding the broad ethical issues of health care institutions. Thus, it is reasonable to conclude that one way changing health care structures can be assessed from a moral perspective is through an examination of the institutional content of nurses’ moral problems.