Ecology of a long-term health care institution: An institutional ethnographic inquiry
Arun Kumar Ph.D.
The use of scientific terms in social sciences and language studies is quite frequent, but such terms usually lose their original meaning when they are used by sociologists or linguists. Farmer (1996) uses weather as a metaphor for the organizational climate of nursing homes and compares meteorological features of climate systems to the physical features of nursing homes. Likewise, Cooper (1986) uses the biological concept of ecology to explore how writers interact to form systems. Environmentalism as a socio-political movement uses phrases like “deep ecology” and “ecological thought” in a very different context (McKenzie, 2002).
Ecology is the study of interrelationships between organisms, among organisms and their environment, whereas ecosystems are interacting systems that encompasses a community and its nonliving, physical environment (Raven and Berg, 2001). In this article I use the concept of ecology and ecosystem as a metaphor for a long-term nursing home environment, its employees as well as the hierarchical and lateral relationships among them. Like any biological ecosystem, the administrative system of functions in a nursing home environment is inherently dynamic in relation to their personnel. The employees and administrative structure of a nursing home are distinct at a given time. This model postulates dynamic interlocking systems which structures all activities within the nursing home. Like an evolving ecosystem, nursing home environments are well defined and are evolving constantly by the change in rules of governance in response to the changing need of society.
Institutional ethnography provides a methodology for sociological research. It begins with the issues and problems of people’s lives and develops inquiry from the standpoint of their experience in and of the actualities of their everyday living. Such an inquiry is not confined only to the description of local social organization or expressions of people’s own experiences, but most importantly it also includes the everyday world as a problem for investigation (DeVault 1999, p. 47). The aim of institutional ethnography is to create sociology for rather than of people. This is achieved by pulling the organization of the Ruling Relations (Smith 1999) – bureaucracy, text-mediated discourse, the state, the professions, and so on – into the actual sites of the people’s living where we must find them as local and temporarily situated activities (Smith 2002, p. 18-19). Institutional ethnography challenges the established scholarly way of validating knowledge and offers an alternative (Smith 1987). One way of describing research in institutional ethnography is to say that to understand our lives, or the lives of other people, we must find the actual determinations of those life conditions and ‘map them’. Institutional ethnographers believe that people and events are tied together in ways that makes sense of such abstractions of power, knowledge, capitalism, patriarchy, race, the economy, the state, policy, culture and so on (Campbell and Gregor 2002, p. 17). This work follows DeVault and McCoy’s (2002) discussions about how interviews are used in investigating ruling relations.
A higher level of longevity of the North American population coupled with relatively loose family bonds lead to old age social isolation and loneliness among large number of people. Health problems both physical as well as psychological among the elderly are a common occurrence in Canada and the USA. These circumstances have led to long-term health care becoming one of the fastest growing sectors of the economy since the 1960s (Grimaldi, 1982). Various aspects of long-term nursing homes have been studied by sociologists. Grimaldi (1982) studied the US policy of Medicaid Reimbursement of nursing home care and offered an overview of the financial aspects of nursing home industry in the USA. Diamond (1992) made an institutional ethnographic inquiry into the working environment of nursing aids and their relationship with management. He also studied the functioning of long-term nursing homes in the USA and compared his observations with other nursing homes in Canada and Europe. Farmer (1996) published an ethnographic study of a nursing home and probed its organization and functioning. He reviewed diverse literature on the sociological, psychological, economic, and linguistic study related to long-term health care institutions. The nursing profession has traditionally been a women’s profession. Like other professionals, nurses have constantly been required to update their expertise with the changing science and technology in the field of nursing. Cook-Gumprez and Hanna (1997) discuss some recent issues of professional practices and computer literacy among women nurses.
Personal experience – the beginning of this inquiry
An early morning telephone call from my wife on May 2, 2004, was very upsetting. She called me from her room in the Lama Extendicare, a long-term nursing home in Ottawa, to complain against a nursing aide who not only had left my wife in a urine-drenched bed for over three hours but was also rude in her behavior. This unfortunate episode made us extremely sad and angry. I decided to lodge a written complain to the director of nursing. My letter had a serious impact on this institution and a round table conference was convened within few days to discuss the irresponsible behavior of the nursing aid. The meeting was attended by the director of nursing, a social worker, my wife, son, and daughter besides me. During the hour-long discussion one of the proposals was to lay-off the irresponsible nursing aide because of her unprofessional behavior. Despite my anger, I did not agree with such a harsh punishment. Being a recent immigrant myself I was aware of the challenges of social adjustment and economic hardships faced by new immigrants in Canada, especially if they happened to be colored and come from poor countries. Mostly such immigrant families struggle to survive and work hard to find their ‘rightful place’ in the Canadian society. After some thought, I suggested that the concerned nursing aide be warned against her unprofessional attitude and be made aware of the consequences of repeating her unprofessional behavior. My family supported my point of view and ultimately it was decided that the nursing aide will be served a notice of warning but would not be fired from her job.
I had sincerely hoped that due to my written complaint not only the concerned nursing aide would learn a valuable lesson but hopefully this unfortunate episode would serve as an example for others to be better professionals as well. Since then, except for some minor issues, my wife is generally satisfied and happy with the care she gets at Lama Extendicare. Although we have not forgotten this event, I do wonder why a nursing aide would behave in an irresponsible and unprofessional manner. In this article, using institutional ethnographic method of inquiry, I have attempted to demonstrate the relationship between working practices and institutional context in Lama Extendicare. To achieve this goal, I studied the language of ordinary speech using interviews with various personnel and the texts of written materials as coordinators for organizing daily activities of nurses and nursing aids. The objective of this study is to see how people use language in organizing their attention and their actions as well as their coordination with others.
The Lama Extendicare in Ottawa is a long-term health care facility whose moto is “Health Care is our Business”. It is committed to delivering high quality, resident-oriented health care services in a cost-effective manner. The hallmarks of their care philosophy are dignity and respect, which guides their interactions with residents and their families, as well as with staff and business partners. They have established rigorous standards to ensure high quality physical, spiritual, social, emotional, and intellectual needs of the residents.
A day’s work of the director of nursing
To understand routine functioning of the Lama Extendicare, I interviewed the director of nursing to get the administrative perspective in institutional context from the top. I also interviewed a nursing aide to get the perspective from the working level as they are at the forefront of nursing care. Two simple questions were posed to the director of nursing - how do you begin your day at work and what do you do the whole day? The following statements in response to the questions provided a wealth of information that clearly demonstrates the daily activities conducted at the Lama Extendicare. These statements also show a relationship between working practices of this institution and the different levels of employees performing diverse tasks in running day-to-day activities of the institution. A whole range of textual materials was used in institutional context that cover medical, administrative, family concerns and recreational activities etc. The director’s answers are summarized as follows:
(1) Starting at 8.00 a.m., listen to all the telephone messages, priorities these messages and act accordingly. (2) Read and review the ‘Daily Care Flow Sheet’ of all residents of the past 24 hours on each floor. This sheet covers an exhaustive list of health care parameters to be completed by nursing aids at the end of their shifts. (3) Tour dining rooms at breakfast time and meet people, make sure that all is well. (4) Make sure that residents are clean and dressed appropriately. (5) Examine the rooms for cleanliness, comfort, and make it easier for the families of residents under palliative care, making sure that such residents and their families are at peace. (6) At 10.00 a.m. Interdisciplinary meeting: This is a very important meeting looking at daily routine issues. It is attended by the physician in-charge, the nursing in-charge, a pharmacist, a dietitian, the Recreation/Activity department, an occupational therapist, a physiotherapist, representatives from Support Services (housekeeping/ laundry/ maintenance/ hairdresser etc.), and resident representative. The minutes of the meeting are recorded in the Interdisciplinary Team Conference Record and the Interdisciplinary Resident Assessment-Physical Assessment. (7) Discuss reports on the floors, sick residents, family’s concerns, food and cleanliness. (8) Afternoon through Evening: Emotional support for the dyeing (signs and symptoms are evident) residents and their families. Dying residents are not aware of their dying condition, families understand, and professional help is provided. (9) Communicate with every resident on palliative care and address any complaint, understand their problems. (10) Reviewing files, admission, discharge, and other administrative duties. (11) Assessing workplace safety by using Ontario Government WSIP form 7 which deals with safety issues. (12) Networking with families and clarifications for their concerns or other types of public relations job.
The question of delegation of power for smooth governance of this institution further demonstrates relationship between working practices and institutional context.
The nursing director shows leadership in nursing care and attends to mainly difficult cases. He/ She delegates power for most minor and routine cases to be addressed by the nurse in-charge on different floors. Staff nurses are primarily responsible for clinical procedures, and they coordinate all kinds of care during their shift on their floor. Nursing staff and nursing aids are certified. They are also provided with training programs relevant to the services required at the nursing home. Nurses use a wide range of forms provided by the Lama Extendicare and the Ministry of Health, Government of Ontario. The policies and procedures are well defined in the Lama Extendicare and are implemented meticulously to avoid any possibility of litigation. All the work is done according to rules that follow from the administrative manual. There are rules for public/media relations, safety, different services, financial management, quality assurance, staff conduct, orientation process for new staff and code of conduct etc. Nursing aids are all certified as health care aid or personal support worker (PSW). They are educated and have completed grade 12 before they join a six-month long training program to get certified. Nursing aids are overwhelmingly women of multi-ethnic, multi-cultural, and diverse racial group of recent immigrants. After completing their shift, they fill ‘Daily Care Flow Sheet’ to record their work.
Funds for running the Lama Extendicare come primarily from the Ministry of Health, Government of Ontario. The Ministry uses a system called Case Mixed Index (CMI) to determine the funding requirements for each institution. Funding sources also come from the Ontario Government’s “Program Envelope Restorative System”. In addition to these sources of funds residents of the Lama Extendicare are also required to pay. Minimum Data Set (MDS) is an assessment tool for future funding estimations for long-term health care organizations. Every year Ontario Government inspects all long-term health care units for further funding.
A shift’s work of nursing aids and their perspectives
To investigate the functioning of the Lama Extendicare at the most important level of nursing care, I interviewed a nursing aid as they are fundamentally responsible for the real work of nursing care. I began by asking the same two questions which I had asked the director of nursing - how do you begin your day at work and what do you do the whole day? At this functional level, speech plays a very significant role as coordinators of all kinds of jobs unlike texts that played an important role as coordinators, in case of job of the director of nursing. The nursing aid’s response to the questions are summarized as follows:
(1) All the nursing aids usually have a ten-minute-long meeting at the beginning of their shifts where the Registered Nurse (RN) responsible for the floor briefs them verbally on important issues. (2) Then the nursing aid takes charge for their group of residents from the nursing aid of the previous shift. (3) They review the ‘Daily Care Flow Sheet’ for their group of patients which informs them about food intake during the past twenty-four hours, sleep pattern, sickness, personal hygiene, facial expressions etc. in addition to any other medical condition. (4) One nursing aid is usually responsible for ten to twenty residents depending on the level of care required for the patients. On the 3rd floor, a nursing aid takes care of twelve to thirteen residents because most residents on this floor require more help for their daily chores. (5) Throughout their shift, nursing aids have to fill out a chart called ‘Daily Care Plan’ detailing each resident’s general condition. For example, after each meal, report on whether a resident has finished his/her food plate, dessert, and soup. If he/she has finished all the food items required to eat give him/her a ‘1’ point on the chart. Any food item partially finished or not eaten at all is a ‘1/4’ deduction from ‘1’. Similarly other daily events are also tracked. (6) A Daily Care Plan for each patient is filled out during the shift that needs to be signed off by the nursing aid before the end of his/her shift. The plan is then passed on to the nursing aid responsible for that resident in the next shift. (7) A Daily Care Plan consists of patient information for each morning, day, and night shift for seven days – from one Wednesday to the next Wednesday. (8) In case of an accident or if a resident hurts himself/herself or someone else, the registered practicing nurse (RPN) of that shift writes a report on it and the nursing aid is held responsible for that and resident usually signs it.
The nursing hierarchy at the Lama Extendicare involves few levels of responsibility sharing. The director of nursing care usually is a senior registered nurse (RN). At times this position is held by a person from non-nursing background also. There is one registered nurse (RN) per floor. They are usually in-charge of all the patients on their floor. Their primary function is to report to the doctor on resident’s health issues and suggest and keep track of their daily medication. All the nursing aids and the registered practicing nurses (RPNs) work under a RN. To become a registered nurse, one requires a nursing degree – usually four years of college or university. Their primary function is to give daily medication to all patients on their floor. To become a registered practicing nurse, one requires a nursing diploma – usually two years of college. Nursing aids and RPNs report to RNs, who in turn reports to the director of nursing care. Nursing aids make up the staff that are most directly in contact with the residents and are responsible for their needs like food, sleep, hygiene, sickness etc.
There is a union of employees that includes RNs, RPNs, maintenance
staff and nursing aids. Although all such employees must sign contracts stating that they cannot strike under any circumstance. The union is quite active and takes care of their members’ concerns seriously with in the legal framework. Full time staff gets three weeks’ vacation after five years of service and four weeks after ten years. Part time employees get none of these benefits. Officially they get two fifteen-minute breaks and one-half hour lunch, although lunch time is unpaid. Nursing Aid workers can get one year leave without pay. These nursing aids are spread over three working shifts per day (morning, day, and night) plus one shift of workers that are off duty. Most of the nursing aids are immigrant women. There are very few men and all of them are black. Most of these people had their education from outside Canada.
The Lama Extendicare functions according to the rules laid down by the Ministry of Health, Ontario Government. Ministry inspects twice a year to check whether the Lama Extendicare is abiding by the laws. Depending on the reputation of the institution or due to complaints such checks could be even more frequent. Ministry inspectors usually ask nursing aids the most questions during inspections.
Since nursing aids work very closely with the residents and take care of their health and needs, it is quite natural to develop an emotional bond with residents. In this kind of work emotional labor is very high. They usually admit that they treat patients based on how ‘good’ or ‘nice’ they are. Cooperative patients are easier to take care of and thus bonding becomes obvious. Some patients are extremely hard to take care of because of sickness or behavior issues, such patients may get emotionally overlooked from time to time. Nursing aids feel that they should be paid higher salary because their job is both physically and emotionally demanding. They feel dissatisfied with their work and working conditions.
The institutional ethnographic sketch of the Lama Extendicare emphasizes the relations between working practices and institutional context. This study looks at how text mediated discourse is used by various levels of bureaucracy ranging from the Ministry of Health, Ontario Government to the Lama Extendicare. The study focuses on day-to-day working of its people, especially the nursing aids in this institution. It describes the hierarchical and lateral working relations among the employees and shows how different kinds of texts are used to successfully accomplish individual goals as well as overall goals of the Lama Extendicare. The delegation of duty and decision-making power in the nursing hierarchy is very significant in accomplishing daily chores.
The socioeconomic background of the nursing aids reflects Canada’s immigration policy and subsequent struggles of the new immigrants in the process of assimilation in the Canadian society. The fact that overwhelming majority of nursing aids are colored women, mostly educated and experienced recent immigrants from poorer countries accept this type of work. Most of them work in such physically and emotionally challenging environments despite low economic benefits because they have very limited options in their lives. During the past over two years I have repeatedly felt a sense of frustration among many nursing aids at the Lama Extendicare.
Literacy requirements constantly change and become more challenging for most professions and their working environments (Darville, 2002; Belfiore et al. 2004). In this regards nursing profession is not an exception (Cook-Gumprez & Hanna, 1997; Campbell, 1998). A great majority of immigrant women face cultural barriers placed in the Canadian education system. It puts an unfair demand for quick ‘Canadianization’ on educated or semi-educated, trained, or untrained colored female immigrants from poor countries. They find it difficult to cope with the educational requirements in terms of money, time and resources and thus fail to enhance their education. Most nursing aids would like to get further education and get promoted in the nursing hierarchy but are failed by the gatekeepers of the socioeconomic and educational systems (Castellano, 1997).
This study successfully relates to the ecological concept in describing working relationships among the nursing aids and nursing hierarchy in a long-term nursing home environment. The Lama Extendicare is seen as an evolving ecosystem that is an interacting system encompassing a certain community of disabled (both physically and mentally) human beings and its nonliving, physical environment. The constant changes observed in the Lama Extendicare ecosystem are influenced by much bigger and more complex ecosystem of its parent company. Growth and diversification of these ecosystems are controlled by similar set of environmental conditions (social, political, and economic) and thus are interrelated.
The interview with a nursing aid and the director of nursing brought out an interesting observation. At the nursing aid level speech plays a significant role as coordinators of all kinds of jobs but a variety of texts play an important role as coordinators for the job of the director of nursing.
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