As hospital budgets become ever more squeezed, administrators and policy makers are increasingly looking for ways to achieve more efficient and less expensive means to keep things running. Housekeeping services are an interesting component of health care. When things function well, no one notices. When the place is dirty, suddenly everyone is complaining. This invisibility extends to the workers as well, often poorly paid immigrants cleaning up bodily fluids and worse, with little say and a clear place at the bottom of the health care worker hierarchy. And, perhaps most importantly, they are mostly women.
As part of the Action for Health Project, Nicki Kahnamoui looked at how cleaning services were outsourced in one of Canada’s largest health care facilities. Kahnamoui took all of this into account as she spoke with not only the people busy mopping but also others within the hospital. She thinks that outsourcing—and as we know it’s certainly not just happening in health care—can create as many problems as it solves. But perhaps the most distressing concern is that by undermining the value of cleaning work and its contribution to overall patient care, there is an artificial divide that occurs, where cleaners are no longer part of the team. They come and go all over the building, never being in one place long enough to get to know the staff, the patients, or the routines.
Housekeeping services are more than just esthetics. Infections can (and do) become life-threatening, and a dirty environment is dangerous, to say nothing of demoralizing. Privatizing this important component may reduce costs as people are forced into situations with much lower salaries. They operate at the beck and call of a centralized administration system and perhaps that is more efficient. But a hospital is not a factory plant, where one assembly line can become replaced by another. Hospitals are not in the business of making cars, they are in the business of patient care. Kahnamoui finds that privatization of cleaning services, as one of the components of patient care, has the potential to impact the functioning of the whole system. And hospitals are more than the sum of its parts as she so eloquently puts it.
Cost savings are achieved by paying people less (a lot less). Whether that’s what we want in our society is perhaps a bigger question than even Kahnamoui can answer. She does outline a long and impressive list of reasons why this is happening. Right wing ideologies, international policies that are impacting everyone (think globalization), and the separation of distribution and production. Everyone it seems wants less government involvement, more productivity, more fiscal accountability, less expensive services. That’s all fine, but there are other costs, harder to quantify.
As a result of outsourcing, there is now minimal direct communication among the nursing staff and housekeeping. In the new privatized system a call is made to a central agency that pages the cleaner. The system itself doesn’t always work as calls remain unanswered, nurses are placed on hold, and perhaps end up just doing the task themselves because it’s easier and faster. Even when someone appears, it’s not necessarily someone that’s been there before, since people are no longer part of the ward team where they can learn the routines, get to know people, interact with patients and staff and generally improve the team effort of helping people become well again.
This fragmentation has a human cost as well. Nurses don’t like having to deal with a supervisor rather than the person standing in front of them. They feel sorry for the underpaid, overworked cleaning staff, who are of course mostly female doing work that many of us would shun. And the workers themselves resent being treated as stupid automatons, arriving like a robot with a broom ready to sweep up. It is simply assumed by everyone that you don’t need any intelligence to scrub toilets. Their place on the bottom rung of the hospital hierarchy is assumed. And it’s even easier to do now that you don’t really know the person anyway. It’s a different one every day. Their work is invisible and they themselves are invisible.
In a complex hospital system where things never quite go according to plan—let’s face it, sick people are unpredictable—Kahnamoui argues that more flexibility and a softening of the rigid boundaries on who does what, when, and for how long could go a long way towards meeting everyone’s needs. Everyone needs to feel valued and respected for the part they play in health care. But more importantly, it’s just common sense that a safe, hygienic environment where good communication among all team members is the norm would go a long way towards patient care. It really is what patients want and deserve.
Note: The Action for Health project was run within a team created by Dr Ellen Balka in order to facilitate research in many different areas. Working within that group was research assistant Nicki Kahnamoui who developed her master’s degree thesis looking at how cleaning services were outsourced in one of Canada’s largest health care facilities.
If you have a comment or question about this, or any of the columns in the Action for Health Project series, email firstname.lastname@example.org
What is a feminist approach towards research?
What is striking in Kahnamoui’s research is the value she places on having everyone’s voice heard, including the lowly cleaners themselves. This emphasis on issues of gender and power, respect for marginalized and oppressed groups, as well as an awareness of the researcher’s own (often privileged) place in the scheme of things is the hallmark of a feminist approach in research. Traditionally, researchers as experts have spent too much time and effort analyzing other people’s roles and functions, often completely overlooking and silencing those very people who might have the most to contribute towards an understanding of what’s really happening. In a feminist approach every effort is made to overcome this.