Pastoral practices of ethical negotiation: community nurses and implementation of patient self-management

Health policy that aims for patients to take greater responsibility for self‐managing their long‐term condition has had increasing global significance. Sociologists, drawing on Foucault's governmentality theory, have explored the way in which ‘responsibilised’ identities are constructed for patients, encouraging them to make well‐informed and self‐sufficient decisions about their health, as well as how health professionals, acting as ‘pastors’, attempt to shape these desirable patient subjectivities. This paper draws on ethnographic data collected within a community‐based integrated care (CBIC) service in England to explore how community nurses were encouraged to seek out and eliminate ‘waste’ by discharging patients to self‐management. Building on Waring and Martin’s model of pastoral practices, this paper demonstrates how nurses engaged in pastoral ‘practices of ethical negotiation’ when trying to reconcile sometimes competing discourses of ‘waste watching’ and their professional values of care. This was enacted collectively when community nurses shifted their gaze outwardly from ‘technologies of the self’ to others on their team, demarcating appropriate practice for nurses more broadly through ‘technologies of the collective’. This paper contributes to governmentality studies by demonstrating the ongoing work required by professional communities to render themselves ethical within the modern neoliberal state.