Structural properties impinge on agents in the form of constraints and enablements (Archer, 2003
). They shape the situations in which agents find themselves such that some courses of action are impeded, and others are facilitated (Archer, 2003
). For PSWs, structural emergent properties arose in the form of Ministry standards of care and institutional policies that structured day-to-day organizational care delivery. Bureaucratic rules have been noted to discourage the initiative and spontaneity of PSWs (Foner, 1994
), and to devalue the supportive emotional labour PSWs provide (Diamond, 1992
). Yet our findings suggest that the internal conversations undertaken by PSWs exerted causal powers as evidenced by their abilities to perceive, negotiate, reluctantly comply with, or selectively resist provincial and institutional regulations, and to thereby shape point-of-care decisions in accordance with their own deliberations concerning quality care. Thus contrary to the presumption that PSWs simply comply with care and treatment plans developed by regulated health professionals (Health Professions Regulatory Advisory Council, 2006
, p. 10), our findings suggest that dementia care is significantly influenced by what PSWs do and how they do it. This underscores the importance of PSW caregiving work, the nature of their clinical decision-making, and the implications for resident outcomes (Anderson et al., 2005
; Diamond, 1992
; Henderson & Vesperi, 1995
; Janes et al., 2008
; Kontos & Naglie, 2009
). Extending an exploration of PSW caregiving work to include other factors that might influence decision-making, such as cultural origins, is an important direction for future inquiry as this would broaden our understanding of the complexity of care dynamics.
The slippage between official rules and actual practice in US long-term care has been explored by Lopez (2006
) and Foner (1994)
. Lopez identified rule-breaking as necessary since “no level of staffing supported by the current federal reimbursement system would allow nurse aides to actually live up to official care standards” (2007
, p. 241). Lopez found rule-breaking to often compromise quality of care, with managers colluding with unsafe care to avoid citations. For example, supervisors recognized that PSW compliance with the rule that residents be monitored on the toilet would increase the amount of time residents waited for call lights to be answered – and these records were subject to review by state inspectors. Foner (1994)
viewed rule-breaking by PSWs as defiance against nursing home management. Like Lopez, she argued rule breaking had negative consequences for resident care.
In contrast to these studies, our findings suggest that rule-breaking was pursued by PSWs as a strategy to individualize care
since full compliance with rules constrained their ability to do so. In addition, in contrast to overt routinization of “unofficial rules” (Lopez, 2007
, p. 227), we found that rule-breaking was contextualized rather than routinized. The agential powers of PSWs were themselves contingent upon covert, reflective evaluation vis-à-vis the internal conversation of supervisors who responded by disciplining some violations of PSWs and ignoring others. Supervisors’ decision to discipline violations or ignore them was the outcome of their own internal deliberations concerning resident interests, their own priorities, and the disparity between provincial and institutional regulations and quality care. Where supervisors shared PSW reasoning that rules compromised quality care, PSWs were not disciplined. The choice to collude with the violation of rules was further contingent upon how supervisors interpreted the intentions of PSWs. For example, tone and body language were considered when determining whether terms of endearment constituted “abuse”. Where policies and regulations were enforced and violations disciplined, supervisors acted in the interests of maintaining order with regards to the scheduling of care activities in the facilities, and to preempt sanctions by the Ministry. Supervisors were keenly aware that institutional violations are reported publicly and thus can adversely affect future admissions (Foner, 1994
). Findings of violations lead to orders for correction and re-inspections to verify compliance, and pose the threat of temporary suspension of patient admissions, or even the suspension or revocation of the facility’s license to operate (Ontario Ministry of Health and Long-Term Care, 2002
At no point during interviews or focus groups with supervisors was it suggested that they believed PSWs were aware of supervisors’ complicity regarding rule breaking. Similarly at no point during PSW interviews or focus group discussions was it suggested that they were aware of supervisors’ complicity; this perpetuated PSWs’ erroneous belief that violations went undisciplined because they were not detected - and likely fueled further rule-breaking. This suggests that successful rejection of structural impingements (i.e. rules and regulations) were contingent on often unseen and asynchronous decision-making of PSWs and supervisors. Ultimately, despite congruence between the care logic of PSW rule-breaking and the complicity of supervisors, the covert nature of their respective efforts failed to effect change at either the institutional or provincial levels. This is because PSW rule violation and supervisor complicity remained non-dialogic, thus undermining the potential for their combined reflexive capabilities to transform the legislative landscape of long-term care.
This study is the first to demonstrate the contingent nature of decision-making in long-term care. It reveals not only the strong contribution that PSW rule-breaking makes to the delivery of quality care, but also the supportive role that supervisors play in the continuance of these provincial and institutional violations. With each reflexive deliberation, PSWs and supervisors could choose to act otherwise, and by so doing, influence the nature and quality of care activities. This illuminates a new dynamic in long-term care that significantly shapes the way that care is delivered. Further research is necessary to evaluate the applicability of our findings to other long-term care settings.
Long-term care is fundamentally a multidimensional construct (Mor, Zin, Angelelli, & Miller, 2004
). A critical realist lens addresses this multidimensionality by highlighting the irreducibility of care either to the regulatory regimes that influence the content and delivery of care, or to the experience, knowledge and reflective deliberations of PSWs or supervisors that oversee PSW care. Critical realism is a perspective that invokes the complexity of the “messy” interrelationship between agential and structural factors capturing both causal mechanisms and their contingency in dementia care. This, in turn, has implications for knowledge translation research that seeks to embed interventions in long-term care settings for the purpose of improving quality of care. As Kontos and Poland argue (2009)
, using critical realism to elucidate the complexity of the conditions of practice would help to successfully embed interventions in settings, thereby ensuring greater impact and sustainability. It would also inform evaluation efforts in terms of analysis of how the interconnection of structural, agential, and intervention elements facilitate and/or impede action or inaction related to research uptake (Clegg, 2005
; Kontos & Poland, 2009
At a time when evidence-based decision-making is reshaping clinical and policy reasoning and practice, it is imperative that research contribute to the generation of theoretical explanation that can inform decisions by health care managers and policy makers (Mykhalovskiy et al., 2008
). By illuminating the causal generative mechanisms of care practices, including inspector subjectivity, and supervisory complicity with PSW rule breaking, critical realism has the potential to generate knowledge that will challenge ill-fitting policies that constrain humanistic care. Critical realism, taken up in future research in long term care, can significantly inform the cumulative and systematic development of knowledge informing the areas of public policy applications and program interventions.