The ethics and politics of home care

Background: In the dominant health-care policy, commonly referred to as New Public Management, primary emphasis is placed on the reduction of costs in health care. This development threatens to increase inequality in society based on levels of health or impairment and on gender. Aim: The aim of this paper is therefore to raise awareness among nurses about the impact of New Public Management and explore how they might develop services that meet the diverse needs and wishes of those being served. Theoretical approach and method: Although this policy has been criticised by nurses, it has also been observed that they are key players in its realisation. This discussion paper explores the impact of different discourses upon the practice of home-nursing care. It was developed within the post-structural tradition, where discourses are considered of key importance in shaping practice. Discourses represent different viewpoints and interests, and determine what can be considered meaningful and possible. The empirical studies which form the base for many of the main arguments presented were identified through an extensive review of published ethnographic research of home care in the years 2000-2008. Results: A review of studies conducted in a number of countries both in North America and Europe showed that home-care services have in many ways been diminished. Clients and their caregivers experience insecurity and wish for more assistance. With New Public Management the focus has shifted from an ethical discourse to an economic one, although this shift has not been clearly articulated and critiqued. By understanding the impact of New Public Management, nurses can better focus their practice to meet the diverse needs of patients and their caregivers. Conclusion: In order to be able to respond to retrenchment in health services, nurses need to understand the complex ethical and political issues of New Public Management. A number of practices can be developed for working with patients and their families in such a way that their needs and wishes are respected.