Slaps,Punches, Pinches—But not Violence: Boundary‐Work in Nursing Homes for the Elderly

This article presents an analysis of boundary work in the context of care for the elderly, where violence appears to be widespread but is still relatively unacknowledged. Talk about aggressive patients was formulated in a particular way among workers in a nursing home. Nursing home staff described how the elderly residents sometimes slapped, pinched, or hit them. Although staff members could describe these acts as intentional, although they could hold patients responsible, and although this violence could end in injuries, demarcations were made such that aggressive acts were constructed as somehow not really “violence.” As “violent” is an inherently exclusionary label, this downplaying can be seen as an effort to avoid pushing persons outside the boundary of normalcy and of continued acceptance. Placing the elderly's violence outside the boundaries of violence means that the elderly remain “care takers,” the staff “caregivers,” and the nursing home a “caring context.”     

Shaping social situations: A hidden aspect of care work in nursing homes

A significant aspect of care work in nursing homes involves dealing with emotional responses such as anxiety, fear, pain, depression and anger on the part of residents and their families. Previous care and nursing research on this topic centers around dyadic relationships and does not provide useful conceptualizations of how care workers actively deal with the social situations they encounter as part of their work. Drawing on ethnographic field work and interviews conducted in two Norwegian nursing homes, this article aims to describe and conceptualize a previously neglected aspect of good care work: the active shaping of social situations in order to lessen uneasy feelings of residents and their families. Three episodes of good work are described to illustrate how social situations can be shaped. Strategies include such actions as timing events, regulating one's presence, and composing social groups. The concluding section discusses some implications for nursing home management.     

Autonomy and Control in Everyday Life in Care of Older People in Nursing Homes

Self-control and autonomy are not guaranteed when people age and are in need of help from others, especially in institution-based housing. This occurs despite the fact that it is a generally accepted belief that care should be delivered with the greatest possible degree of independence and autonomy. This article discusses older people's experiences with and the opportunities for autonomy in institution-based housing. Through focus group interviews and observations, the daily lives of residents at two nursing homes in Sweden were studied through a comparative approach using the theoretical framework of organizational culture. Three themes emerged showing how autonomy was not a reality for the residents. The first theme revealed an ambivalent mission, indicating ambiguity as to whether the nursing home was a place to live in or a place in which to be cared for. The second theme was symbolic power, which encompassed the staff's power embedded in the organization. The third theme was the ageist approach to care, which was noted in the way staff considered the residents to be old people who were unable and unwilling to strive for autonomy. The three themes were embedded in the organizational culture and were created and recreated in the interaction between residents and staff. A key question for further research is how to change the culture to strengthen the residents’ autonomy.     

Staff-resident interaction in the nursing home: An ethnographic study of socio-economic disparities and community contexts

In recent years, nursing home (NH) researchers have paid increasing attention to socio-economic and racial/ethnic disparities in quality of care. Although there is growing evidence of disparities in resident health outcomes, less is known about the ways in which these differences manifest in care processes from a qualitative perspective. This paper addresses this gap by comparing staff-resident interactions in two urban, non-profit NHs, including roughly 50 staff participants in each facility. The researcher conducted ethnographic observation in one facility serving a white, middle class community and another serving low-income Black and Hispanic clients from an underserved neighborhood. Grounded theory methods generated three categories of interaction—activating, relating, and attending—which were performed differently in the two NHs. In the more affluent facility, staff interacted with residents in a dynamic fashion, adapting to residents’ responses, and they were relatively well equipped with resident-specific information when responding to individual concerns. In the safety-net facility, staff interacted with residents in a one-directional, “didactic” fashion, providing instruction without a mechanism for adapting to residents’ responses, and they were not as well equipped with resident-specific information. These differences reflected disparities between the two facilities in staff communication skills, underscoring the importance of workforce development to enhance the quality of staff-resident interaction and promote resident-centered care. This study raises further questions about the role of neighborhood contexts in shaping organizational processes that influence quality of life for NH residents. Moreover, the study offers a unique contribution to the NH literature by generating a typology of styles of interaction that can be used to develop a conceptual framework for understanding staff-resident interaction in the nursing home. Such a framework can inform efforts to improve residents’ quality of life.     

Non‐job work/unpaid caring: Gendered industrial relations in long‐term care

This article explores the operation of gender and industrial relations in long‐term care work or nursing home work, ‘from within’ the experience of the predominantly female workforce in seven unionized facilities in Canada. Drawing on qualitative case study data in non‐profit facilities, the article argues that the main industrial relations challenges facing long‐term care workers are that their workplace priorities do not fit within existing, gendered, industrial relations processes and institutions. This article starts from the experience of women and threads this experience through other layers of social organization such as: global and local policy directions including austerity, New Public Management, and social and healthcare funding; industrial relations mechanisms and policy; and workers’ formal [union] and informal efforts to represent their interests in the workplace. The strongest themes in the reported experience of the women include: manufacturing conditions for unpaid work; increasing management and state dependence on unpaid care work; fostering loose boundaries; and limiting respect and autonomy as aspects of care work. The article extends the feminist political economy by analysing the links between the policies noted above and frontline care work. Building on gendered organizational theory the article also introduces the concept of non‐job work and suggests a fourth industrial relations institution, namely the needs and gendered expectations of residents, families and workers themselves, operating within the liminal spaces in care work.     

Injustice and conflict in nursing homes: toward advocacy and exchange

This article examines the relational dynamics and patterns of conflict exhibited in the two interdependent parties in America's nursing homes. In the framework of the social exchange theory of structural power, it explains how the asymmetrical structure of dependence and control in nursing homes eliminates the possibility of fair bargaining—normal conflict—between staff and patients. In the absence of any opportunity for reciprocal rewards and punishment, patients tend to adopt submissive influence strategies, whereas staff members tend to neglect, exploit, or abuse difficult or resistant patients. The author examines the exchange dynamics of adversarial tactics and the prevalence of third-party conflict in the nursing home, and shows that a partisan, patient-directed ally could rebalance power and eliminate inequities in the nursing home environment.     

Weighing the relevant issues: obesity in nursing homes

The obesity epidemic has touched all segments of society and every health care sector including the nursing home industry. Understanding the issues related to the care of obese nursing home residents is important in light of this epidemic. Such issues include the difficulties related to access to nursing homes, the structural preparedness of nursing homes to care for obese patients, and the potential for staff injuries. Policies regarding strategies to improve nursing home access for obese patients, mitigate disparities in quality of care and health outcomes owing to obesity, and better prepare for the growing obesity epidemic are needed.     

“Would You Do That in Your Home?” Making Nursing Homes Home-like in Culture Change Implementation

Qualitative interviews with nursing home administrators reveal innovative and cost-conscious ways to physically modify facilities that help institute culture change practices. Telephone interviews were conducted following a national survey of nursing home nursing directors and administrators. In this cross-sectional snapshot of administrator experiences, motivations for making facilities more home-like and less institutional and creative responses to challenges are described. State and corporate support and regulator encouragement are noted that help their reform efforts. Administrators note that small steps to create a more home-like environment can result in a positive impact that minimizes disruption to existing care processes. They describe how they respond to challenges, such as the physical plant and high costs, and note how comparative shopping, cost-conscious physical improvements, and continuous involvement of staff and residents contribute to successful efforts. Their examples illustrate novel ways to humanize long-term care facilities that other nursing homes can emulate.     

‘IT'S TIME IT ENDED AND YET I HESITATE,I HESITATE TO END IT’: THE EMOTIONAL WORLD OF AN OLD PEOPLE'S HOME

Institutionalized responses to human care have been prone to developing unhelpful practices. Inquiries into malpractice often generate recommendations focusing on improving protocols or procedures, while neglecting the emotional experiences of both clients and staff. In this study, we aimed to address why and how complex and challenging emotions enter into care work. We explored the emotional world of a residential home for older people, using a psychosocial observational approach based on the Tavistock method. We have presented four themes: attacking–defending, living–dying, paralysis–movement and emptiness–fullness, which illustrate the complex existential challenges faced both by residents and staff in such a context. Our observations revealed how a range of defensive processes operated to protect the observer from experiencing painful feelings and emotions. Throughout the observation period an increasingly complex understanding developed of the emotional life of the home. This process was made possible by reflective supervision sessions. Our findings generate implications for the type of support that may be needed by care staff in such environments.     

The ties that bind? Social networks of nursing staff and staff's behaviour towards residents with dementia

This study investigated social networks of nursing staff and staff's behaviour towards residents with dementia. We focused on two types of networks: communication networks among staff, and networks between nursing staff and relatives/acquaintances of residents. Data was collected in 37 long-term care units in nursing- and residential homes in the Netherlands.     

THE SOCIAL DYNAMICS OF ELDER CARE: RITUALS OF BUREAUCRACY AND PHYSICAL NEGLECT IN NURSING HOMES

This research concerns nursing home rituals involving bureaucracy and physical neglect. It uses 40 ethnographies, biographies, and autobiographies to explore various symbolic themes expressed through everyday interaction in nursing homes. The themes involve bureaucratic concepts such as staff separation, rules, documentation, and efficiency. They also involve ideas of physical neglect, such as medical dereliction, personal negligence, environmental negligence, and bodily harm. Relying on structural ritualization theory, this work argues ritualized symbolic practices of bureaucracy unintentionally manufacture attitudes and acts of mercilessness for workers in both for-profit and nonprofit nursing homes. This aids in the development of rituals facilitating the physical maltreatment of residents.     

When Emotion Work is Doomed to Fail: Ideological and Structural Constraints on Emotion Management

This paper explores how workers try to manage their emotions under conditions that doom them to fail. The workers in question—floor instructors at a sheltered workshop for people with developmental disabilities—were expected to infuse clients with positive feelings about work and to help transform them into committed workers. But structural conditions—boring, poorly paid assembly work and long gaps between contract jobs—forced them to obtain clients' compliance through coercive and confrontational emotion management techniques that contradicted their ideological beliefs. The floor instructors sought to peacefully increase their control over clients through “preventive emotion management” but most often they experienced a loss of control, leading some of them to experience “burnout.” This paper defines burnout as “occupational emotional deviance” that workers experience when they cannot manage their own and other's emotions according to organizational expectations.     

Doing Gender,Paying Low: Gender,Class and Work–Life Balance in Aged Care

This article examines how interactions between the doing of gender and class at institutional and organizational levels perpetuate inequality for aged care workers. In particular, it investigates how managers ‘do gender’ and class in relation to their care workers' work–life balance and the unintended consequences of this for aged care workers. The research data comprised interviews with female managers and aged care workers from four case studies in residential aged care in New Zealand. We argue that despite best intentions, the consequences of managers' doing gender and class results in continuing low wages, poor work–life balance and disempowerment at work for aged care workers.     

Family Members' Reports of Non-Staff Abuse in Michigan Nursing Homes

Recent research showed that mistreatment of nursing home residents by other residents may be highly prevalent. The present study examined the issue from family members' perspectives. The data came from the 2005 and 2007 random-digit dial telephone surveys of Michigan households with a family member in long-term care. Based on family members' reports, about 10% of nursing home residents aged 60 and over were abused by non-staff in nursing homes (e.g., other residents and visitors) during the past 12 months. Family members were more likely to report non-staff abuse when the nursing home residents were younger, were female, had behavior problems, and had greater level of physical functioning. Family members who reported staff abuse were four times more likely to also report non-staff abuse.     

‘Doing Something Meaningful’: Gender and Public Service during Municipal Government Restructuring

Research on the gendered dimensions of workplace restructuring often focuses on management strategies and their structural consequences. Less attention is paid to employees’ gendered practices. In this article, we analyse material from in‐depth interviews with front‐line public‐sector employees following a major reorganization of their jobs and workplaces. Our study makes three contributions to theory and research on gender and organizational change. Firstly, it highlights the micro‐level dynamics at the heart of restructuring by showing how workers engaged with an ideal that was central to their understanding of public‐sector work — the public‐service ethic — which they believed was threatened. Secondly, it highlights the importance of gendered meanings and identities in shaping how workers engaged with the public service ethic. Thirdly, the study shows that front‐line employees did not passively accept management plans for change but struggled to resist or transform them in gendered strategies for dealing with organizational change.     

Examining the Nursing Home Physical Environment Through Policy-Driven Culture Change

A critical need exists to challenge approaches to nursing home care due to rigid organizational factors and hospital-like culture. It has been argued that resident care needs to move toward a person-centered approach by addressing the organizational, social, and physical environments in nursing home facilities, a process often known as culture change. In response to this need, the Centers for Medicare & Medicaid Services (CMS) has created funding for pay for performance (P4P) nursing home incentive programs to allow nursing home providers to receive CMS reimbursements for culture change in the facilities. Through care staff interviews, site observations, and a document review, this qualitative study assesses the impact of a Midwestern state P4P incentive program in three participating nursing homes. Using an environment and behavior (E-B) policy orientation framework, this study examines culture change through a focus on policy, the physical environment, place attachment, and social and psychological processes in the study settings.     

“Stuck in the Middle with You?” Supervisory Level and Anger about Work

Although sociologists have long been interested in the stratification of emotions, the occupational stratification of anger has been investigated in only a few general population studies. Through analyses of data representative of workers in Toronto, we evaluate the hypothesis that workplace hierarchical position, defined by supervisory level, has an inverted u‐shaped association with the frequency of anger about work. We also evaluate the more specific hypothesis that the difference in work‐related anger between front‐line supervisors and nonsupervisory workers will be relatively larger among workers in the commodified services sector than other sectors. Results are generally consistent with our hypotheses. We find that both front‐line supervisors in the commodified services sector, and secondary supervisors in all employment sectors, report more frequent anger about work than do nonsupervisory workers. In contrast, higher level supervisors report anger about work at about the same frequency as nonsupervisory workers. These associations are only slightly reduced by controls for work stress and stressors. We discuss how supervisory relations might explain differences in anger about work among workers at different levels in organizational hierarchies.