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This thesis contributes to the feminist economics' literature on caring labour with an empirical study of aged care nursing. This study critiques the positivist paradigm of neoclassical economics and argues that the Cartesian dualisms deeply embedded in both neoclassical economics and medicine result in an undervaluing of caring labour. Data was collected from nurses and managers working in residential aged care facilities in metropolitan Adelaide. Qualitative methods are utilised to uncover the role of nursing culture, underpinned by notions of gender, embedded in aged care nurses' work. This study explores how dualistic constructs such as love versus money and public versus private have become central to nursing work and impact on the way nurses' work is valued in residential aged care. The feminist economics' concept of provisioning provides a framework in which nurses' work can be valued. This framework is used to present a matrix to illustrate how nurses' work crosses these dualisms and uses a 'web of meaning' as a conceptual device to explain the inter-connectedness of nurses' work. The feminist economics' concept of provisioning is used as a means of overcoming the limitations that a dualistic world view has imposed on understanding the complexities of paid caring work. The empirical evidence presented in this thesis shows that aged care nurses do both nursing work and training in unpaid time and are vulnerable to exploitation. The remuneration they are paid is inadequate when the difficulty of the work they do and the level of responsibility they take is recognised. Their work contains a strongly non-commodified element, where the development of two-way relationships between nurses and the people they care for, their relatives and friends, other staff and the wider community are important. A key conclusion is that nurses focus on the intrinsic rewards of their work, which are undermined because aged care nursing is under-resourced. In particular, nurses do not have enough time to be caring which impacts negatively on their job satisfaction and the level of care they can provide.

Population ageing has been posed as a problem for contemporary governing in relation to the allocation and consumption of finite health care resources, in particular acute hospital care. This thesis explores how nursing practice is a key resource in the management of this ???problem???. Employing Foucault???s concept of governmentality, nursing practice is examined as a form of social government that is central to the regulation of hospital care to older people. A governmentality approach enables consideration of the relationship between the macro political context of governing, as embodied in prevailing political rationalities, and their outworking beyond the arenas of formal government in the micro practices of nurses. Specifically, in this research, it reveals how contemporary entrepreneurial rationalities of governing work at a distance to discursively shape the local practices of nurses in the regulation of hospital care to older people. Discourse analysis of interview texts, literature and documents revealed how enterprise rationality was invested in the discourses circulating in the study site, highlighting the power relationships and subject positions available to registered nurses and outcomes produced in the regulation of hospital care to older people. The analysis details how registered nurses activated a range of technologies and practices as they engaged with enterprise discourses, constituting nursing practice as an activity aimed at making up older people as dischargeable subjects. It shows how enterprise is both a practice and way of thinking that directs us toward a particular truth of hospital, hence nursing, care of older people. The thesis illustrates how changes in the ways of governing hospitals have actively transformed the meaning and practice of nursing in the provision of hospital care to older people. It shows how the values and practices that make entrepreneurial modes of government possible penetrate each layer of an organisation and can create new mentalities or ways of thinking. This was evident in this research whereby an entrepreneurial mode of governance had re-imagined the social practice of nursing as a form of the economic, such that neither recovery, nor health, but discharge assumed pre-eminence as the focus and aim of hospital care for older people and hence the goal of nursing practice. These findings suggest that hospital care of older people has become a political and economic, rather than therapeutic concern. Furthermore, nursing interventions in the hospital care of older people have become administrative rather than therapeutic, with nursing practice focused on individual older people only insofar as they are constituted as part of a population at risk of delayed discharge. The thesis contends that nurses are implicated in the politics of health care in new and different ways amid entrepreneurial rationalities of governing that promote an ethos of risk management, individualism and responsibilisation in relation to health. It argues that the replacement of an ethos of nursing as care based on client need with an ethos of nursing as risk management substitutes the therapeutic intent and practices of nursing with the technical intent of managing risk. In so doing, the thesis illustrates dangers and possibilities arising from the re-framing of health care through entrepreneurial modes of governance. It enables a critically informed consideration of what kind of practice acute care nursing could be into the future and how nurses and others can take action to positively contribute to the futures of older people they provide care to. / Thesis (PhD)--University of South Australia, 2010

Doctor of Philosophy / Aim and significance: The aim of this research was to explore the phenomenon of Australian nursing home care from the perspective of those who provide and receive it. Its focus is on the processes of ‘quality care’ provision and the meanings and evaluations that care providers attach to their work. In other words, its purpose was to shed light on the practices based on a conceptualisation of care that is entwined with the mechanisms of ‘care’ production and identity creation, or what actually happens in the daily life of the complex social phenomenon that is a nursing home. A related aim was to add to understandings of clinical nursing competence and develop tools that will assist nurses to conceptualise and implement positive change in this setting. Background: The provision of care to our elderly has become a major concern with the ageing of the world population. This is occurring in the context of decline in the capacity of families to take on the responsibility of elder care, and of increasing commercialisation of medical care. Governments have responded by shifting their responsibilities from direct care provision to become auditors of the business of care provision that is supported by public funding. However poor care delivery has largely been hidden from the public gaze. Governments present themselves as having systems in place, creating the illusion of rational control; in reality, like the market economy, there is a ‘black box’ of unknown factors driven by human impulse. The aim of this study was to open up the black box of ‘quality care’ to direct observation, drawing insights from the literature on organisational culture and with a focus on the frontline worker and the construct of quality assurance. Specific research objectives were to: • Document the beliefs and attitudes of care providers towards elderly people in general and the needs of nursing home residents in particular • Elicit the range of meanings and evaluations that care providers attach to their work • Describe their constructions of ‘care’ and ‘quality of care’ and the organisational factors they believe to impact (positively and negatively) on their ability to provide it. • Through in-depth understanding of a particular setting, generate grounded theoretical insights into the phenomenon of quality of residential care that are more widely applicable Method: The study adopted a paradigmatic bricoleur approach, seeking to develop connections between a diverse range of methodologies. These included combinative ethnography, phenomenology, hermeneutics and traditional grounded theory. Conceptual insights were drawn from organisational studies, psychosocial nursing and coping theory. The research site was an Australian for-profit suburban nursing home. The student investigator conducted more than 500 hours of participant observation, recording extensive field notes which were analysed through the perspective of a hermeneutic middle way horizon that directed an augmented constant comparison traditional grounded theory approach. Additional data were collected through formal indepth interviews with six key stakeholders. Interviews were tape recorded, transcribed in full and analysed to reveal themes that were brought within a hermeneutic circle that spiralled recursively from the whole to the part and back to the whole. Findings: Eight key interrelated factors in the production of care within the nursing home were identified: internal and external accountability (the accreditation system); economic considerations; management and training; advocacy; characteristic of residents; care providers’ working conditions and environmental stressors; organisational culture; and the work/care styles of individual care providers. I have categorised the latter into two main types: ‘tortoises’ and ‘hares’. This typology is then used to generate a process-driven schematic diagram that tracks a hypothetical novice care provider through the process of learning how to produce ‘care’. Specifically, I found that nursing home ‘care’ is the outcome of a complex social process involving the interplay between resident, relative, care provider, proprietor, quality assessors and government within the phenomenon of the nursing home. Such care, indeed the phenomenon of the nursing home itself, is not a stable, controllable entity but is in a constant state of flux – what I refer to as a moral ecology. In their everyday practice, care providers devise a construction of ‘quality care’ that is more clearly grounded in their own worldviews and the development of the own identity than in the formal quality assurance system of standards, guidelines and evaluations. Conclusion: Understanding the ‘black box’ of processes that produce care is the key to identifying courses of action that will improve care outcomes. The study findings also question the validity, assumptions and significance of the accreditation system, which only identifies some of the component variables, disregarding both the complexity within the ‘black box’ and failing to acknowledge that the quality of care outcomes is overwhelmingly dependent on individual care providers.