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The influence of information exchange processes on the provision of person-centred care in residential… Caspar, Sienna 2014

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THE INFLUENCE OF INFORMATION EXCHANGE PROCESSES ON THE PROVISION OF PERSON-CENTRED CARE IN RESIDENTIAL CARE FACILITIES  by Sienna Caspar  BSc, University of South Alabama, 1990 MA, Simon Fraser University, 2008  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Interdisciplinary Studies)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  April 2014  ? Sienna Caspar, 2014ii Abstract Purpose: The movement away from task-oriented care toward the consistent provision of person-centred care (i.e., care based on residents? needs and preferences) is widely recognized as the goal of the residential care culture change movement. The purpose of this study was to explore why the attainment of this goal has remained elusive for many residential care facilities (RCFs), despite significant effort to alter practice.  Methods: I conducted an institutional ethnography to explore the textually mediated work processes that influence the day-to-day work practices of front-line care staff in RCFs. The social organization of RCFs was explored through the observation of resident care attendants? (RCAs') practices and the interaction of those practices with institutional texts. The data were derived from three RCFs and included 104 hours of naturalistic observation, 76 in-depth interviews, and document analysis.  Results: Practical access to institutional texts containing care-related information was dependent on job classification. Regulated healthcare professionals (e.g., RNs) frequently accessed these texts to exchange information. Although RCAs provided 80% of the care to residents, in all sites studied, they lacked practical access to the institutional texts that contained important information relevant to the residents? individualized care needs and preferences (e.g., assessments, care plans, social histories). The RCAs primarily received and shared information orally; however, the organizational systems in the facilities studied mandated the written exchange of information and did not formally support an oral exchange. Consequently, the oral exchange of care information was largely dependent upon the quality of the RCAs' working relationships with one another and especially with management. iii Implications: Access to detailed knowledge of residents? needs and preferences is fundamental to the provision of person-centred care. The transfer of this knowledge to and between front-line care staff is dependent upon the quality of the relationships managers develop with and among RCAs. Initiatives aimed at building supportive and collaborative work teams are essential to the inclusion of RCAs in the care planning process and to the attainment of the goal of person-centred care.  iv Preface This dissertation is original, unpublished, independent work by the author, S. Caspar. The fieldwork reported in Chapters 5-8 was covered by UBC Research Ethics Board?Certificate number H11-03536 and Vancouver Island Health Authority Health Research Ethics Board?Certificate number H2012-16.  v Table of Contents Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iv Table of Contents .......................................................................................................................... v List of Tables .............................................................................................................................. xiii List of Figures ............................................................................................................................. xiv Acknowledgements ..................................................................................................................... xv Dedication ................................................................................................................................... xvi Chapter 1: Introduction ............................................................................................................... 1 Discovering a Problematic .......................................................................................................... 3 Professional. ............................................................................................................................ 4 Researcher. .............................................................................................................................. 5 Family caregiver. .................................................................................................................... 6 The story behind this study. ................................................................................................ 6 The Problematic and My Standpoint ........................................................................................ 11 Purpose and Significance of This Study ................................................................................... 12 Overview of the Chapters ......................................................................................................... 13 Chapter 2: Review of the Literature ......................................................................................... 16 How Has Person-Centred Care Been Conceptualized? ............................................................ 16 What's in a Name? .................................................................................................................... 18 Attempts at Clarifying the Meaning of the Concept ?Person-Centred? ................................... 20 How Has Person-Centred Care Been Implemented? ................................................................ 23 How is Person-Centred Care Experienced? .............................................................................. 28 vi How Have Person-Centred Care Interventions Been Studied? ................................................. 29 Intervention Format and Duration ............................................................................................ 43 Intervention Factors .................................................................................................................. 44 Predisposing factors. ............................................................................................................. 45 Enabling factors. ................................................................................................................... 45 Reinforcing factors................................................................................................................ 47 Goals and Outcomes ................................................................................................................. 49 Methodological Quality: Sample Size, Follow-Up, Level of Evidence, and Risk of Bias ....... 51 Intervention Effectiveness ........................................................................................................ 53 Summary and Reflections ......................................................................................................... 54 Chapter 3: Methodology............................................................................................................. 57 Conceptual Framework: Institutional Ethnography .................................................................. 58 Institutional Ethnography: Central Concepts ............................................................................ 59 Standpoint. ............................................................................................................................ 60 Social relations. ..................................................................................................................... 60 Replicable texts. .................................................................................................................... 61 Textually mediated work practices. ...................................................................................... 61 Disjuncture. ........................................................................................................................... 61 Ruling relations. .................................................................................................................... 62 Objectives, Research Questions, and Aims .............................................................................. 62 Study Rationale ......................................................................................................................... 64 Investigative Methods ............................................................................................................... 65 Phase One.................................................................................................................................. 68 vii Naturalistic observations. ...................................................................................................... 68 In-depth interviews. .............................................................................................................. 69 Textual analysis. ................................................................................................................... 70 Phase Two ................................................................................................................................. 70 Data Collection: Setting and Sample ........................................................................................ 71 Setting. .................................................................................................................................. 72 Facility #1. ........................................................................................................................ 73 Facility #2. ........................................................................................................................ 74 Facility #3. ........................................................................................................................ 75 Sample................................................................................................................................... 75 Data Analysis ............................................................................................................................ 77 Ensuring Scientific Quality ....................................................................................................... 79 Ethical Considerations .............................................................................................................. 83 Ethics review. ........................................................................................................................ 86 Chapter 4: The Context of Living or Working in a Residential Care Facility ..................... 89 The Macro-Level Context: An Historical Overview of Residential Care Regulations  in Canada .................................................................................................................................. 89 Meso-Level Context: How Quality is Regulated and Measured in Residential Care  Facilities .................................................................................................................................... 92 Regulating quality in residential care. .................................................................................. 93 Measuring quality in residential care. ................................................................................... 98 Micro-Level Context: Regulations to Determine Who Lives and Works in RCFs in BC ...... 103 Who lives in RCFs?the complex care admission requirement. ........................................ 103 viii Employees of residential care facilities: The nursing staff mix. ......................................... 106 Summary and Reflections ....................................................................................................... 109 Chapter 5: The Influence of Everyday Texts on the Provision of Person-Centred Care: Exploring the Embodied Work Experience of RCAs ............................................................ 111 Beginning the Work Shift: Three Reports?So Much to Learn, So Little Time .................... 111 Unofficial Oral Reports........................................................................................................... 112 Oral Report.............................................................................................................................. 116 A new admission: Two sides to the coin. ........................................................................... 120 We're working short. ........................................................................................................... 122 Written Report ........................................................................................................................ 124 24-hour observation sheets. ................................................................................................ 124 Communication books. ....................................................................................................... 126 The lists: Baths and bowel care. ......................................................................................... 127 During the Shift: Resources, Residents? Care, Risk, Personal Competence and Resilience .. 128 The activities of daily living (ADL) care plan. ................................................................... 130 Tips for care sheets. ............................................................................................................ 139 Care risk symbols: Purple dots, ladybugs, stoplights and incident reports. ........................ 142 Purple dots, ladybugs, and stoplights. ............................................................................. 144 Incident reports. .............................................................................................................. 151 Personal competence: Values, beliefs, experiences and skills. ........................................... 155 Relationships and resilience: We're in this together. .......................................................... 158 The End of Shift: Providing Information to the LPNs and RNs?Oral Report and Written Records of Care....................................................................................................................... 161 ix Oral report. .......................................................................................................................... 162 Giving up and keeping silent. ............................................................................................. 170 Written records of care provision. ...................................................................................... 170 Daily flow sheets............................................................................................................. 171 RAI-MDSv2.0 observation sheets: Seven-day, fourteen-day, and behavioural records. 173 Summary ................................................................................................................................. 176 Chapter 6: The Influence of Institutional-Level Texts on the Provision of Person-Centred Care in Residential Care Facilities .......................................................................................... 178 Pre-Admission Reports and Admission Assessments ............................................................ 185 RAI-MDSv2.0: Admission, Quarterly, and Change of Condition Assessments .................... 189 Care Plans ............................................................................................................................... 191 Admission and Annual Care Conferences .............................................................................. 196 The Institutional-Level Texts That Contained Individualized Personal Information ............. 206 Social history assessment. ................................................................................................... 206 Recreation assessment. ....................................................................................................... 214 Missing Links Between Assessments, Care Conferences, Care Plans, and ADL Care Plans 216 Summary and Reflections ....................................................................................................... 217 Chapter 7: The Influence of Information Exchange between Management and the Care Team: Essential Gates of Communication ............................................................................. 220 We Need to Talk: Written Versus Oral Communication With Management ......................... 221 Informal Gates of Communication ......................................................................................... 228 Formal Two-Way Gates .......................................................................................................... 234 Successful formal two-way gates........................................................................................ 235 x A workload committee. ................................................................................................... 235 Workplace injury prevention teams. ............................................................................... 236 Unsuccessful formal two-way gates. .................................................................................. 238 Injury prevention program. ............................................................................................. 238 Team huddles. ................................................................................................................. 239 Summary and Reflections ....................................................................................................... 243 Chapter 8: Boss Texts: Explicating the Ruling Relations That Influence the Provision of Person-Centred Care in Residential Care Facilities .............................................................. 246 Access to Organizational Information: Exploring the Boss Texts That Influence Gates of Communication Between Management and Care Staff Members .......................................... 247 Some positive aspects of regionalized health care in BC. .................................................. 248 A disjuncture: Disempowered managers. ........................................................................... 249 A second disjuncture: Whose side of the fence are you on? ............................................... 254 Access to Care-Related Information: Exploring the Boss Texts That Influence Gates of Information Relevant to Residents? Care ................................................................................ 260 Access to Residential Care Policy?Complex care. ........................................................... 261 The positive aspects of the Access to Residential Care Policy. ...................................... 263 A disjuncture: It is people on paper. ............................................................................... 265 A second disjuncture: The fallacy of choice. .................................................................. 270 A third disjuncture: Time is of the essence. .................................................................... 274 A fourth disjuncture: Welcome to your new home?please sign here. .......................... 276 The RAI-MDSv2.0: Home and community care classification tools project. .................... 281 The positive aspects of RAI-MDSv2.0 assessment instrument. ..................................... 282 xi A disjuncture: Who is using these data? ......................................................................... 283 A second disjuncture: Why are we really doing this? ..................................................... 293 Summary and Reflections ....................................................................................................... 297 Chapter 9: Conclusion: How the Social Organization of Care Influences the Provision of Person-Centred Care in Residential Care Facilities .............................................................. 299 A Synthesis of the Research Findings .................................................................................... 300 Research question #1: What are the primary institutional texts that influence RCAs? day-to-day care work. ..................................................................................................................... 302 Research question #2: How do textually mediated work processes influence the provision of person-centred care? ........................................................................................................... 304 The first appropriate bed policy. ..................................................................................... 306 The RAI-MDS v2.0. ....................................................................................................... 306 Research question #3: How is the work of RCAs socially organized in RCFs? ................ 307 Concluding Remarks and Implications ................................................................................... 308 Discussion: The Empowerment Pyramid for Person-Centred Care ....................................... 309 Empowered leaders. ............................................................................................................ 310 Responsiveness. .............................................................................................................. 311 Recognition. .................................................................................................................... 312 Respect? ........................................................................................................................ 313 Trust? ................................................................................................................................ 313 Reciprocity. ......................................................................................................................... 314 Resilience. ........................................................................................................................... 316 Quality of work-life leading to quality of care. .................................................................. 317 xii Theoretical Implications: Why Leaders Need Access to Structural Empowerment and RCAs Need to Experience Self Determination ................................................................................. 319 Structural empowerment. .................................................................................................... 319 Self-determination theory. .................................................................................................. 321 Policy Implications: To Whom Are You Responding? .......................................................... 325 Limitations and Future Directions .......................................................................................... 327 Summary and Reflection......................................................................................................... 328 References .................................................................................................................................. 330 Appendices ................................................................................................................................. 371 Appendix A: Study Information Sheet and Consent............................................................... 371 Appendix B: Letter of Initial Contact ..................................................................................... 374 Appendix C: Study Information Document ............................................................................ 375 Appendix D: Proxy Consent For Participant Observation ...................................................... 378 Appendix E: Participant Observation Consent Form: Resident ............................................. 379 Appendix F: Regional Daily Care Record .............................................................................. 380 Appendix G: RAI-MDS 7 Day Tracking ................................................................................ 384  xiii List of Tables Table 1.1: Population Aged 85 Years or Older as a Percentage of All Individuals Over the Age of 65. Data Source: Statistics Canada, 2006. ..................................................................................... 1 Table 2.1: Review of Person-Centred Care Practice Intervention Studies ................................... 35 Table 2.2: Number and Frequency of Included Studies by Country (N = 38).............................. 43 Table 3.1: Phase One?The Number of Study Participants by Facility ....................................... 77 Table 3.2: Phase Two: Part A?The Number of Study Participants by Facility .......................... 77 Table 3.3: Phase Two: Part B?The Number of Study Participants by Sector ............................ 77 Table 4.1: Contextual Factors of the Study RCFS ...................................................................... 106  xiv List of Figures  Figure 3.1: Research Process Map ................................................................................................ 67 Figure 5.1: ADL Care Plan Cycle ............................................................................................... 138 Figure 6.1: Facility #1-Information Exchange Map ................................................................... 181 Figure 6.2: Facility #2-Information Exchange Map ................................................................... 182 Figure 6.3: Facility #3-Information Exchange Map ................................................................... 183 Figure 9.1: Empowerment Pyramid for Person-Centred Care .................................................... 310   xv Acknowledgements I offer my enduring gratitude to each of my committee members--thank you for your support of my work in this field. I owe particular thanks to my co-supervisors Dr. Pamela Ratner and Dr. Alison Phinney. My heartfelt thanks to both of you for your amazing mentorship and guidance. I was continually aware of how privileged I was to have the opportunity to learn from you.  I thank Dr. Dorothy Smith for enlarging my vision of science and Dr. Karen MacKinnon for introducing me to such a powerful method of inquiry.  This study would not have been possible without the financial support of the Joseph-Armand Bombardier Canada Graduate Scholarship and the Alzheimer Society of Canada. These awards enabled me to commit essential time, energy, and resources to this study.  Special thanks are owed to my wonderful family and friends. To Mom, Ken, Dad, Micki, Heather, Vivian and Lorraine thank you for always being there. I am blessed with an amazing support system!  Finally, profound gratitude is extended to my sons Grant and Rylan-you cheered me on during my successes and held me up during the trying times. Thank you for generously honouring my need to try to make a difference. I could not have done this without your support!  xvi Dedication To the women and men who care for people living in residential care facilities. 1 Chapter 1: Introduction Canada, along with most of the Western world, is experiencing the effects of population aging, defined as the extent to which a population?s age structure is distributed in the older cohorts as a consequence of longer life expectancy and lower fertility rates (McPherson, 2004). According to Statistics Canada (2012), it is expected that by the year 2031 the number of people over 64 years of age in Canada will increase from 13% to 25% of the population. Given this rapid increase, the number of older adults living in residential care facilities (RCFs) can also be expected to rise dramatically. This is especially likely since the population over 84 years is the fastest growing age group in Canada (see Table 1.1) and it is this group that is most likely to require long-term, residential care1. Table 1.1: Population Aged 85 Years or Older as a Percentage of All Individuals Over the Age of 65. Data Source: Statistics Canada, 2006.                                                    1 The prevalence of living in RCFs increases with age. Among the age group of 65 to 69 years, about 1% lived in RCFs in 2011; among the age group of 85 years or older, the percentage was 29.6% (Statistics Canada, 2012). 5.04.44.74.85.87.98.29.010.212.412.214.316.311.613.59.60246810121416181921 1931 1941 1951 1961 1971 1981 1991 1996 1998 2016 2021 2026 2031 2036 2041%2 It is estimated that approximately 25% of elderly individuals in Canada will reside in an RCF at some point during their lives (Conn, 2002). According to the Rising Tide report (Alzheimer Society, 2010), the demand for RCF beds is based on the projected prevalence and severity of dementia. These projections suggest that the number of people who will require care in an RCF could quadruple, to 690,000 by the year 2038 (Alzheimer Society, 2010). It is widely recognized that the care of older adults who have dementia can be especially challenging to RCF staff members due to the behavioural and psychological symptoms of dementia (Cassidy & Sheikh, 2002). Consequently, not only is the number of people who require care going to increase, but the complexity of the care they require is likely to increase dramatically as well.  Concurrent with these trends, projections suggest that there will be a significant reduction in the number of available formal care providers (i.e., registered nurses, licensed practical nurses, and resident care attendants) for RCFs (Stone, 2001).2 This is further compounded by high turnover rates caused by resident care attendants? (RCAs) dissatisfaction with the workplace (Bowers, Esmond, & Jacobson, 2003) and high levels of stress and burnout due to the physical and emotional demands of their work (Cohen-Mansfield, 1997). The combination of higher prevalence rates of dementia and diminishing availability of formal caregivers is likely to cause the work within RCFs to become even more physically and emotional demanding.  Within this context of diminishing and strained resources, there is, simultaneously, increasing importance being placed upon the provision of "person-centred care" in RCFs. A                                                   2 Demand for nurses is much higher than nursing schools can accommodate and is expected to increase by 2 to 3 percent each year through at least to 2025. It is proposed that this increase in demand is mainly due to the aging baby boomer population (Stone, 2001). 3 central tenet of person-centred care is that it is individualized, based on the care recipient?s unique needs, preferences, and life history (Fazio, 2008). Accordingly, the provision of this type of care is largely dependent upon caregivers' access to individualized information about the person to whom they are providing care. The attainment of the goal of increasing the provision of person-centred care is considered by many to be essential to both the quality of care and quality of life of people residing in RCFs, especially those who have Alzheimer disease or a related dementia (Brooker, 2007; Fazio, 2008; Kitwood, 1997; Talerico, O'Brien, & Swafford, 2003). Unfortunately, a review of the literature indicates that meaningful improvements in the provision of person-centred care in RCFs have been largely unrealized, despite significant effort (Doty, Koren, & Sturla, 2008; Miller, Miller, Jung, Sterns, Clark, 2010). In light of these developments, there is a need for a better understanding of how the social organization of care in RCFs may facilitate or hinder the delivery of high quality, person-centred care. Discovering a Problematic  Dorothy Smith (1987), a Canadian sociologist who is widely recognized as a pioneer of institutional ethnography (IE), described a ?problematic? as a place to begin an investigation. She said that a problematic develops from a sense that something troublesome, interesting, and worthy of study is going on. Thus, every IE investigation begins with issues, concerns, or problems that are real for people and that are situated in their relationships with an institutional order. My experiences and observations (on both a professional and personal level) of what happens to the individualized information required for person-centred care in institutional healthcare settings led to my sense that something troublesome and interesting was going on. I entered into this study with three distinct, yet intertwined, experiences that shaped my research questions as well as the lens through which I approached this study?these include my 4 experiences and observations as: a professional, a researcher, and a family caregiver. My exploration of these experiences also serves as an acknowledgement of both my motivations and my assumptions as I entered into this research. Professional. I have worked as a certified therapeutic recreation specialist (CTRS) in RCFs for over 20 years. During my first position as a CTRS in a RCF, I witnessed physical and psychological abuse of residents with dementia (e.g., a resident being tied to her chair because she was damaging the newly installed wallpaper due her attempts to "pick" the pretty flowers in the design, a resident being yelled at and vigorously shaken because she had spilled juice on newly install carpet). Although I reported what I had witnessed to the State regulatory agency, I found that very little was actually done to ensure that instances such as these would no longer occur in this RCF. It was this experience that created the foundation for my passionate determination to make changes to the quality of care provided for, and quality of life of, residents in RCFs.  After 12 years of clinical experience in RCFs, I furthered my education and became a dementia care specialist and consultant. In this role, I trained staff members in RCFs about the best practices in dementia care. These trainings were based on the care philosophy of person-centred care. Subsequent to these trainings, I returned to the RCFs to assist care staff members in implementing what they had learned. What I found was that very little, if any, of the information I had imparted resulted in practice changes within the facilities. I ultimately came to believe that it was not the individuals within the facilities that resisted the change; instead, I felt it was the organizational systems within which they worked that prevented the change from occurring. I viewed these organizational systems as being based primarily on the medical model, which 5 places inordinate emphasis on the timely completion of tasks, adherence to routines, and objective medical outcomes.  It is noteworthy that the field of therapeutic recreation is based on a holistic approach to wellness and asserts that ?health? is significantly more than the absence of illness (Stumbo & Peterson, 2004). As a CTRS, I believe that a person?s spiritual, emotional, cognitive and physical needs must all be met for an individual to be deemed ?healthy.? I have never believed that I ?fit? well in healthcare settings wherein the medical model is firmly established. My views and values as a CTRS, combined with my experience as a consultant, have made me very aware of the limitations of the medical model.  Researcher. For my master?s thesis, I examined the relationship between RCAs' access to structural empowerment (i.e., support, information, formal power, informal power, and resources) and their reported ability to provide individualized, person-centred care to residents in RCFs. My findings suggested that support, especially in the form of rewards and recognition for a job well done, seemed to be particularly salient to RCAs. In addition, access to informal power, as measured by the quality of relationships in the workplace, appeared directly related to both RCAs? quality of work life and the quality of the care they provided (Caspar & O'Rourke, 2008). Thus, I entered into this current study with the supposition that feeling appreciated and recognized for their work, combined with the quality of their workplace relationships, were two factors that determined whether RCAs felt able to provide person-centred care in RCFs.  Prior to conducting this study, my assumptions and values as a researcher were fairly entrenched in a quantitative inquiry paradigm. Consequently, making the decision to conduct a qualitative research study was not an easy one. I often felt as though I was learning a new language in a foreign land. As a researcher, I am committed to ensuring that my work is relevant 6 and applicable to the ?real world,? for ?real people,? doing ?real work.? I am less interested in examining how and why we come to know things and more concerned about determining whether what we claim to know (i.e., research findings) is helpful to people. When choosing my research method, I admittedly spent little time deciphering and exploring the ontological and epistemological aspects of my selected method; instead, my primary focus was on whether this method could produce evidence that would be useful to the people that I am trying to serve as a researcher (i.e., the residents and staff of RCFs).  Family caregiver. My personal experience as a family caregiver of a terminally ill spouse with dementia was extremely influential in the development of my research questions. It is for this reason that it is important to introduce this study with an account of that experience.  The story behind this study. When I admitted my husband, John, to a palliative care unit, I believed that he had weeks, perhaps days, to live. The idea that he might have months to live had never crossed my mind. Yet, his body seemed unwilling to succumb to the cancer that was prematurely ending his life. Believing that he had little time left to live, it seemed reasonable and appropriate (and even just) that I be the one to provide most of his care. For the previous six weeks, I had been available 22 hours a day?stealing just two hours each day, during the evening meal, so that I could be with my children and thank my mother again and again for ?being there? for them.  During those six weeks, I watched John?s dementia set in as a result of the cancer having spread to his brain via his cerebral spinal fluid. Because I was there, and knew him so well, I was able to make subtle, yet important, adaptations in my caregiving, which were required because of his ever-changing needs. These were the adaptations that enabled him to take his pills orally, even when he could no longer understand what they were for or why he needed to take them?7 even when he had trouble seeing them or picking them up and putting them into his mouth. His vision was impaired because of the cancer, so he needed an overhead light to see the pills; he needed the pills put into a cardboard bowl so that he could scoop them up because his fine motor skills were also impaired; he needed no more than three pills at a time placed into the bowl; he needed a cup of water with a lid and a straw; he needed step-by-step directions to take them; he needed to be reminded to swallow after taking each of his 12 pills. Based on these needs, our ?pill taking ritual? was developed; it was repeated four times a day and it enabled John to take his pills orally. This was an important ability because his skin integrity was poor and his shoulders and thighs had several injections sites that had formed lumps; it was, therefore, preferable to administer his medications orally rather than by injection. I knew this, so I ensured that I was always present when John took his medications.  This was my role and my routine for six weeks. It worked well until my children?s school year began?causing me to be pulled between my responsibilities as John?s caregiver and my responsibilities as a mother. There were now going to be times when it would be impossible for me to be there when John was given his medications. In anticipation of this, I talked to his nurse and discussed with her, in detail, what John needed to take his medications. She watched as I demonstrated our routine and assured me that all would be fine when I was not there. The next day I had to be away and I returned to his room to find his medications in a small paper cup on his bedside table, their delivery had occurred two hours before my return. I found his assigned nurse. She was not the one I had talked with the day before; this nurse had no awareness that John needed any assistance in taking his medications. The knowledge and information that I had shared had not been transferred to the nurse who was next assigned to John?s care. My heart sank and my anger rose. I knew of this problem, referred to as ?inter-shift communication 8 breakdown,? for I had watched it occur over and over again during the 21 years I had worked as a recreation therapist in RCFs. Until that moment, however, I had never experienced it from the vantage point of a family member.  Determined to ensure that this situation did not occur again, I sat down and thought of all that I knew about providing care to John, which now needed to be known, understood and replicated by the nursing staff when I was not there. I prioritized it by importance and recorded it in point form so that it would be relatively easy to read. I then discussed it with his nurse and had it posted in his room, on his medication sheet, and in his chart. On this one-page note, I described how to help John with his toileting and his medications and, most important, about the fact that he was lactose intolerant. I had already discussed this with the dietician and he was on a special diet. Still, there were snacks on the unit and to be extra cautious I wrote in capital letters that he had to be given a lactose pill immediately before eating anything that had lactose in it.  Having worked in RCFs, I knew what to write and I knew where to put it to ensure that it would be read by the staff. I believed I had covered all the bases and that things would now go more smoothly when I could not be on the unit. Three days later, I had to attend an evening school function for my oldest son and my communication plan was put to the test. After having been away from the unit for four hours, I returned to find John eating custard. I immediately asked for his nurse. She was on a break. I asked for her to be interrupted so that I could find out if John had been given a lactose pill. The answer was ?No,? the nurse had not given it to him. She said she was sorry, but was unaware that he was lactose intolerant.  ?Perhaps I should write it in his chart,? said the nurse.  ?It is written there,? I said.  ?Perhaps we should post it in his room?? said the nurse.  9 ?It is posted in his room,? I said.  The information was available; still it had not been read nor applied. The result was seven hours of uncontrolled and painful diarrhoea. I cleaned him, I had always been the one to clean him?. he preferred it that way, and because he did, so did I. We both preferred it because I knew him, I understood him, and I knew how to make his experience of being cared for the best that it could possibly be. It was because of this that, even though the dementia caused him not to know who I was, he trusted me and he knew that it was simply ?better? when I was there.  To me, this is what person-centred care is about. It is about knowing a person such that trust is established between the caregiver and the care recipient. The ultimate result of this care is safety, security, and comfort for both the care recipient and the care giver. Consequently, I believe that the provision of person-centred care is impossible without an understanding of the unique needs, wishes, and routines of the care recipient. Furthermore, if this information is not available, gets lost, or is not applied, the goal of providing person-centred care cannot be realized. My experiences on the palliative care unit combined with my observations as both a CTRS and a consultant in RCFs affirmed my belief that we are a long way from being able to ensure that person-centred care is consistently provided in the majority of institutional healthcare environments.  I do not share this story or this belief as a condemnation of the nursing profession or of the quality of care provided to John while he was on the palliative care unit?far from it. The nurses were dedicated, caring, thoughtful, and skilled. I often referred to them as ?angels walking on this earth.? None of these nurses purposefully neglected or harmed John, yet, more than once during the three months that John and I were on the palliative care unit, instances occurred that put him at risk. Each of these instances occurred because the staff did not access or apply 10 information that would have enabled them to provide the individualized care that he required. I had watched this type of breakdown in communication occur in RCFs and I had always believed that it was due to one of two problems?lack of adequate staffing or lack of adequately trained staff.  However, these hypotheses did not hold in the palliative care unit. These were skilled, educated registered nurses (RNs) with specialized training in palliative care. These were nurses working on a unit with enviable staffing ratios?4 to 5 patients to 1 RN, whereas in RCFs, the ratios are often closer to 100 residents to 1 RN. And yet, what I was experiencing as a family member was what I had watched occur over and over again while I was a CTRS working in RCFs. Family members would inform care staff members of the individualized needs and wishes of their loved one? ?My mother needs her feet elevated whenever she is sitting otherwise her feet swell and it is very painful for her.?  ?My husband was poor when he was growing up. They only took sponge baths with a bucket in the backyard. Now that he has Alzheimer?s disease he doesn?t recognize what a shower is and he is afraid of it. He needs to have a bath basin and a sponge and then he won?t fight with you over bathing.? ?My mother will not eat her food if you serve her too much. She is afraid if she touches it no one will eat the leftovers, so she will not eat anything unless you serve her a smaller portion.? ?If you distract my sister by singing to her she will let you give her the insulin shot. That is the only way I could do it while I was caring for her.?  I believe the transfer and application of this personal information is what enables the provision of person-centred care in healthcare settings of any kind, but most especially, in RCFs. 11 Yet, my experience indicates that this information most often does not get transferred or it is inconsistently applied to the benefit of the residents living in RCFs.  Some may question my introduction of a study based in RCFs with the story of an experience that occurred in a palliative care unit. It is important to note that the similarities between RCFs and palliative care units are many (e.g., family involvement, a holistic approach to care, admissions with the understanding that discharge is unlikely, and attempts at creating a ?homelike? environment). In fact, due to the recent changes to admission policies to RCFs within British Columbia, which require newly admitted residents to have highly acute and complex care needs (British Columbia Ministry of Health, [BCMOH], 2009), some have recently asserted that RCFs may soon need to be re-classified as ?Palliative Care Units for the Aged? (Schulz, 2011). This is the effect of a significant increase in the acuity of residents? care needs, which has led to a reduction in their length of stay as the result of higher mortality rates (Canadian Healthcare Association, 2009). Furthermore, and perhaps most important, palliative care units and RCFs have a goal of providing person-centred care that includes family members as part of the care team, and both institutions continue to fall short of attaining that goal.  The Problematic and My Standpoint My experiences on the palliative care unit with John combined with my years of experience working in RCFs create a strong foundation from which to develop my problematic for this study. Smith (2006) asserts that the problematic forms the foundation for research questions that cannot be fully explained by studying experiences. The questions I pondered as I developed the problematic related to person-centred care in RCFs, included the following: 1. How is information pertaining to the personal needs, wishes and routines of residents in RCFs obtained?  12 2. Where is this information stored and how is it transferred between care staff members?  3. What are care staff members? beliefs about this information?  4. How and why does this information get lost, when it does?  5. Why is personalized information not consistently applied so as to enable person-centred care?  6. What processes in RCFs enable or impede the translation and application of this information?  Smith (2006) argued that before researchers attempt to explore a problematic, they must take a ?standpoint.? Consistent with institutional ethnography, a standpoint is considered to be the sum of experiences of everyday practice embedded in an institutional order. Accordingly, the taking of a standpoint anchors one?s research in the experiences and concerns of a particular group of people. In this study, I took the standpoint of RCAs?the front-line formal, unregulated caregivers in RCFs. RCAs (also referred to as nursing assistants, nurses? aides, health care assistants, care aides, healthcare aides, and personal support workers) provide the majority of direct resident care and thus play a central role in determining whether person-centred care is provided in RCFs (Kane, 1994).  Purpose and Significance of This Study A review of the literature revealed that, compared with other healthcare services, research about residential care services, processes, and outcomes is sparse. In addition, of the research that is conducted in healthcare institutions, very little focuses on, or includes, unregulated healthcare staff members. For example, when I reviewed the literature about interdisciplinary collaboration, team decision making, team building, and communication in healthcare 13 institutions, I found that the studies focused almost exclusively on regulated healthcare professionals (e.g., registered nurses, licensed practical nurses), with little or no mention of attendants, assistants, or aides as members of the healthcare team (e.g., Lemieux-Charles & McGuire, 2006; Manser, 2009). Thus, a purpose of this study was to give voice to unregulated care staff members and to recognize them as members of the healthcare team in RCFs.  It is my hope that this study will contribute to the advancement of knowledge by developing a more complex understanding of how institutional processes and social relations shape RCAs' experiences and influence their access to information and their ability to provide person-centred care. More than that, however, I hope that this study produces knowledge that can be applied to generate a much needed culture change in RCFs.  Overview of the Chapters The subsequent chapter, a review of the literature, explores how person-centred care has been conceptualized, experienced, and studied. This chapter attempts to review what we know about person-centred care from the perspectives of both the providers and the recipients of care in RCFs.  The third chapter provides an overview of the conceptual framework for the study and introduces the reader to institutional ethnography as a method for scientific enquiry. In this chapter, I describe the study setting and sample and detail the specific investigative and analytic methods I used to study the social organization of care in RCFs.  The fourth chapter, "The Context of Living or Working in a Residential Care Facility," describes the complex regulatory framework that governs RCFs in British Columbia (BC). I first discuss macro-level contextual factors by providing an historical overview of residential care regulations in Canada. At the meso-level, I explore current provincial and regional regulations 14 that govern the three study RCFs (Facilities #1, #2, and #3). Finally, at the micro-level, I discuss the regulations that determine who lives and works in these institutions.  The fifth chapter, "The Influence of Everyday Texts on the Provision of Person-Centred Care: Exploring the Embodied Work Experience of RCAs," describes the embodied work experience of RCAs with a specific emphasis on the exchange of information that occurs during three phases of a work shift: at the beginning of the shift (i.e., before the provision of care commences), during the shift (i.e., while care is provided), and at the end of the shift (i.e., after the provision of care). Chapter Six, "The Influence of Institutional-Level Texts on the Provision of Person-Centred Care in Residential Care Facilities," introduces information exchange ?maps? that I created to represent the flow of residents? care information between RCAs and the other members of the healthcare team. The maps, specific to each facility, include ?every day? texts and institutional-level texts and demonstrate the interconnectedness and directionality of the information flow between them.  Chapter Seven, "The Influence of Information Exchange between Management and the Care Team: Essential Gates of Communication," breaks from the original trajectory laid out for this institutional ethnography. In this chapter, I first explore the use of written versus oral information exchange between management and the care staff members. Next, I discuss how informal, open communication influences organizational trust in the workplace. Finally, I close the chapter by examining the differences found between successful and unsuccessful formal, two-way communication exchanges between management and the RCAs.  Chapter Eight, "Boss Texts: Explicating the Ruling Relations that Influence the Provision of Person-Centred Care in Residential Care Facilities," examines the boss texts that influence 15 RCAs' access to information and that directly or indirectly influence their ability to provide person-centred care. In an attempt to present a balanced perspective, I discuss both the positive outcomes as well as some of the unintended consequences that result from the activation of selected boss texts.  The concluding chapter presents a synthesis of the research findings followed by a discussion of the link discovered between the presence of empowered leaders in RCFs and RCAs' quality of work-life and care?a link that is essential to the provision of person-centred care. I examine both the theoretical and policy implications of the findings, and conclude by addressing the study?s limitations and considering some future directions and research.  16 Chapter 2: Review of the Literature The purpose of this study was to develop a more comprehensive understanding of how institutional processes and social relations shape resident care attendants? (RCAs?) experiences and influence their ability to provide person-centred care. It was deemed essential to begin with a review of what is known about person-centred care. In this chapter, I first explore how person-centred care has been conceptualized and implemented. Next I discuss the small body of literature examining how person-centred care has been experienced by both the recipients and providers of care. I conclude the chapter with an examination of the ways in which person-centred care has been studied and present the systematic literature review I conducted of intervention studies aimed at increasing the provision of person-centred care practices in residential care facilities (RCFs).  How Has Person-Centred Care Been Conceptualized? Person-centred care has been described as a care philosophy in which a positive relationship is established that respects care recipients? preferences and life histories, honours their identities, enables their engagement in meaningful activities, and encourages an overall sense of well-being (Fazio, 2008). The person-centred care approach originated from the work of Carl Rogers, a psychotherapist who developed the "client-centred approach" to psychotherapy in the 1950s (Kirschenbaum, 2004). An important aspect of the client-centred approach is the therapeutic benefit of positive interpersonal interactions. The conditions that influence positive change include having a therapist who provides unconditional positive regard, is empathetic, and is genuine or congruent within the client-therapist relationship. The term person-centred evolved from the work of Rogers and his colleagues at the Center for Studies of the Person in the 1970s (Kirschenbaum, 2004).  17 The person-centred approach was later adopted and applied to dementia care in RCFs as described in Dementia Reconsidered: The Person Comes First by Tom Kitwood (1997). In his book, Kitwood discussed a philosophical approach to formal caregiving that uses residents? unique personal preferences and needs to guide their care practices, thus enabling the individualization of care plans and care routines (Boise & White, 2004). A central feature of person-centred care is the recognition that all human life, including people with dementia, is grounded in relationships, and that people with dementia need an enriched social environment that fosters opportunities for personal growth while compensating for their impairment (Brooker, 2007).  By adopting the term "person-centred", Kitwood (1997) forced the discussion of who or what is a "person" into the context of dementia care. This was critical with respect to Western societal values that imply that to be a person is to be capable of conscious thought, and to possess autonomy, agency, rationality, and self-awareness (Brooker, 2007), which results in the pervasive assumption that a loss of self and personhood occurs for all persons with advanced dementia (Kontos & Naglie, 2007). Kitwood (1997) challenged these assumptions by viewing personhood as a status (or standing) that could be bestowed upon one human being by others in the context of social relationships. Central to this idea is that these social relationships are based on recognition, respect, and trust and that all human beings have value as "persons" regardless of their cognitive abilities.  In emphasizing the value of all persons, person-centred care also acknowledges the personhood of direct care staff, the respect for whom is believed to be as crucial as for those with dementia (Kitwood, 1995). Although Kitwood?s (1997) book focused primarily on persons with 18 dementia, it is important to note that person-centred care is a model that is assumed to benefit RCF residents who do not have cognitive deficits.  What's in a Name? Attempting to conduct a thorough search for literature about person-centred care proved to be somewhat challenging because the key elements and philosophy of person-centred care have been described with the application of a broad-spectrum of terms (e.g., individualized care, resident-directed care, consumer-directed care, patient-centred care, relationship-centred care, self-directed care). Some authors have asserted that these terms share connotations and definitions that are philosophically congruent with the term person-centred care and that the variance merely depends upon the context in which care is provided (e.g., hospitals and acute care settings tend to use the term patient-centred care, whereas RCFs tend to use resident-centred or resident-focused care) (see Morgan & Yoder, 2012). Others have argued that there exist subtle but important conceptual differences in the terms (Edvarsson, Winblad, & Sandman, 2008; Talerico, O'Brien, & Swafford, 2003). Specifically, some researchers have contended that using such terms as patient-centred or resident-centred results in the individual with dementia continuing to be defined in terms of their status within a healthcare institution (i.e., patient or resident), as opposed to being a unique person (Brooker, 2007; Talerico et al., 2003).  Similarly, it is argued that use of the term "individualized care" as opposed to person-centred care narrows the frame of reference such that care needs are determined and met with potentially little attention to the lived experience of the care recipient (Brooker, 2004). For example, Brooker (2004) maintained that it is possible to conduct a detailed assessment and to develop an individualized care plan based solely on goals determined from the care providers' perspective, without prioritizing preferences and routines that the care recipient considers 19 important. She provided an example of a resident in a long-term care facility with an individualized care plan that detailed how frequently the resident was required to use the toilet so as to remain continent. Yet the fact that the resident was someone who believed that her quality of life was largely dependent upon the ability to make and drink a cup of tea every afternoon may not have been considered in the plan of care. Consequently, the resident remained defined by her status as a patient with continence needs, while the need to continue a life-long activity of making and drinking afternoon tea was disregarded (Brooker, 2007). Brooker contended that a person-centred care approach ensures that care is individualized, whereas care that is individualized does not necessarily translate into person-centred care.  Another important distinction deserving mention is found with the term ?patient-focused care.? The similarity between this term and those used to describe a person-centred care philosophy has produced some confusion and even inappropriate interchange of the terms; therefore, it is important to differentiate this term from the rest. Briefly, patient-focused care originated in acute care hospital settings in an effort to improve the efficiency and effectiveness of service delivery while being more responsive to patients? concerns. It is a model of care delivery established for self-contained units staffed by multi-disciplinary caregivers who are supposed to be trained to provide up to 80% of what patients need while in their rooms. The key components of patient-focused care are consistent with the initiatives implemented for continuous quality improvement?these being interdisciplinary teams working together to accomplish needed changes in care delivery with a primary focus on the elimination of any care delivery process that is deemed unnecessary, redundant, or does not add ?value to the end-product? of patient care (Kerfoot & LeClair, 1991). 20  In British Columbia, patient-focused care has been used as a model for reforming staffing ratios through changing job descriptions and care routines, and has been referred to as a ?hospital staffing redesign or reengineering model? (Talerico, O'Brien & Swafford, 2003). The difference here is that patient-focused care is based on care recipients? needs as well as cost containment and organizational reforms, whereas person-centred care is almost solely focused on the care recipients? needs.  Attempts at Clarifying the Meaning of the Concept ?Person-Centred? The use of "person-centred" terminology is frequent in both the literature and in practice and has come to denote quality care; however, consensus has yet to be achieved on the exact meaning of the concept (Edvarsson, Winblad, & Sandman, 2008; Passalacqua & Harwood, 2012; Packer, 2000; Talerico, O'Brien, & Swafford, 2003). Literature reviews and concept analyses have been conducted to clarify the meaning of person-centred care (Hughes, Bagley, Reilly, Burns, & Challis, 2008; McCormack, 2004). Many assert, however, that the concept of person-centred care remains vague and abstract, is viewed through various lenses, and means different things to different people in different contexts (Brooker, 2004; Edvardsson, Fetherstonhaugh, & Nay, 2010; Hughes et al., 2008; Nolan, Ryan, Enderby, & Reid, 2002). This is likely the result of person-centred care being viewed as both a value-based philosophical approach as well as a practice-based framework.  Rockwell (2012) asserted that person-centred care "best describes a practice philosophy, rather than a practice model?it suggests values and best practices to employ when working with residents of care facilities, but it does not provide prescriptive techniques or problem-solving procedures" (p. 234). Entwistle and Watt (2013) concurred with Rockwell and emphasized that even subtle differences in the ways in which care providers think about "person-centred care" 21 have important implications for how they understand the value and ethical significance of their interactions with the people for whom they provide care.  Other authors have been more pragmatic and view person-centred care primarily as a set of caregiving techniques focused on individualized care approaches. According to Boise and White (2004), RCFs that profess to deliver person-centred care should be implementing nursing routines and care practices that are individualized to each resident?s unique preferences. These include enabling residents to prepare for sleep when they like, eat what and when they prefer, bathe or shower according to their personal needs and preferences, celebrate life events consistent with their personal lifelong traditions, and interact with friends and family members in ways that are meaningful and important (Boise & White, 2004).  Walker, Porter, and Gruman (1999) argued that individualized care plans developed on the basis of person-centred care should focus on the specific needs of the individual by: (a) ensuring that each resident is treated as an autonomous adult; (b) encouraging independence; (c) enabling freedom of movement; and (d) giving residents the right to make decisions regarding their daily lives. Some authors have published frameworks that detail the care approaches considered to be consistent with the person-centred care philosophy. For example, Brooker (2004) reviewed the existing literature about person-centred dementia care and identified four essential elements of a person-centred care approach: (a) valuing and respecting people with dementia and those who care for them; (b) regarding individuals with dementia as complete people; (c) looking at the world from the perspective of the person with dementia; and (d) creating a positive social environment.  Talerico, O'Brien, and Swafford (2003) presented seven key components of person-centred care: (a) knowing the person as an individual; (b) providing care that is meaningful to the person 22 in ways that respect his/her values, preferences, and needs; (c) viewing residents as bio-psycho-social beings; (d) enabling the development of consistent and trusting caregiving relationships; (e) emphasizing freedom of choice and individually-defined risk taking; (f) promoting emotional and physical comfort; and (g) involving residents? families, friends, and social networks in care decisions. McCormack (2004) used a relational perspective and defined person-centred care as an approach to practice that is established through the formation and fostering of therapeutic relationships. According to McCormack, this approach is based on three key values: (a) respect for persons; (b) the individual right to self-determination; and (c) mutual respect and understanding. A criticism of person-centred care is the tendency to focus only on the person with dementia and to neglect the experiences of the family and formal care providers (Nolan, Davis, Brown, Keady, & Nolan, 2004; Nolan, Ryan, Enderby, & Reid, 2002). Nolan et al. (2002) argued that person-centred care fails to "fully capture the interdependencies and reciprocities that underpin caring relationships"(p. 203). This criticism led to the emergence of a relationship-centred model of dementia care based on the "Senses Framework" (Nolan et al., 2004; Ryan, Nolan, Reid, & Enderby, 2008). This approach is guided by the belief that all parties involved in care (i.e., the person with dementia as well as the family members and care staff) should experience relationships that promote a sense of security, belonging, continuity, purpose, achievement, and significance.  More recently, other authors have claimed that person-centred care is shrouded in well-intended but often paternalistic approaches that place "patients" or "clients" at the centre of care decisions, but rarely, if ever, actively involve them in decision making (Dupuis et al., 2012). These criticisms have resulted in a more recent movement focusing on "authentic-partnerships." 23 Dupuis et al. (2012) supported the socio-critical or partnership approach in dementia care, which views all knowledge perspectives as equally valued, including the expertise of persons with dementia (Clarke, 1999). Thus, they have challenged researchers and practitioners alike to consistently and actively include persons with dementia in any attempt to improve the quality of their care or life.  This review demonstrates the challenges inherent in attempting to achieve a universally agreed upon operational definition of person-centred care. It also underscores why it is important to continue the dialogue on this complex topic, which is important to both the quality of care and life of individuals who reside in RCFs, the vast majority of whom have dementia.  Although the complexity of the topic needs to be appreciated, a pragmatic approach, aimed at simplifying the term, may be useful. Based on this review, I offer that person-centred care can be said to have three components?each of equal importance. First, care providers must know and value the needs, concerns, and preferences of their care recipients. Second, care providers must be able (based on their skills, abilities, and experiences) and enabled (based on their access to information, resources, and support) to adjust their care practices so as to meet the care recipients' needs, address their concerns, and honour their preferences as consistently as possible. Third, a reciprocal relationship between care givers and care recipients (based on mutual trust and respect) must be formed, acknowledged, and supported. Simplifying the concept to these three components may make it more useful for caregivers attempting to implement it in the everyday practice of care and more measureable for researchers attempting to study it. How Has Person-Centred Care Been Implemented? The movement away from care that is provider driven and task oriented (i.e., care that is based on consistent adherence to care providers? routines and focused on cost effectiveness and 24 the timely completion of tasks) to the consistent provision of person-centred care within RCFs is widely recognized as the universal goal of a ?culture change movement? in the developed world. According to Rahman and Schnelle (2008), "culture change" is a process associated with the transformation of RCFs that goes "beyond superficial changes to an inevitable re-examination of attitudes and behaviour, and a slow and comprehensive set of fundamental reforms" (p. 142). Culture includes both implicit and explicit contracts that dictate what is expected of members and defines the rewards or sanctions associated with compliance or non-compliance (del Bueno & Vincent, 1986). Cultural norms have been found to be more effective in influencing behaviour than are formal control systems, such as written policies and procedures or supervisory monitoring (Gibson & Barsade, 2003). Thus, culture change encompasses system-wide changes in practice that occur as a result of both intrinsic and extrinsic motivation.  The culture change movement began in earnest in North America following the first Institute of Medicine (IOM) (1986) report on improving the quality of care in nursing homes. The authors of the IOM report wrote that ?whenever possible, facility staff and management should honour consumer preferences? (p. 172). A year later, the US Omnibus Budget Reconciliation Act (OBRA) of 1987 introduced numerous changes to USA federal nursing home regulations, requiring nursing homes to adopt a more social-behavioural treatment model for residents (Morford, 1988).  However, ten years after those regulatory changes were implemented in the US, it was clear that they had not led to a more humanistic culture in RCFs (Flesner, 2009). Subsequent to the regulatory changes, grassroots organizations were formed, such as the Pioneer Network (a national group formed to serve as an umbrella organization for the culture change movement) and numerous models of care were developed and implemented across North America (e.g., 25 Eden Alternative (Thomas, 2003), Gentle Care (Jones, 1995), and Wellspring (Stone et al., 2002))?each with the primary purpose of facilitating the provision of person-centred care in RCFs.  Unfortunately, the empirical base for this movement has been weak and the goals have, for the most part, continued to be largely unrealized (Rahman& Schnell, 2008). For example, in 2007, a survey of nursing homes in the US was conducted to examine the penetration of the culture change movement at the national level, and to measure the extent to which nursing homes had adopted culture change principles and practised resident-centred care (Doty, Koren, & Sturla, 2008). A representative sample of 1,435 nursing homes was surveyed between February and June 2007. For the survey, the phrase ?culture change for resident-directed care? was defined as occurring in an organization that had home or work environments in which: (a) care and all resident-related activities were decided by the resident; (b) the living environment was designed to be a home, rather than an institution; (c) close relationships existed between residents, family members, and the community; (d) work was organized to support and allow all staff members to respond to residents? needs and desires; (e) management allowed collaborative and group decision making; and (f) processes and measures were used for continuous quality improvement.  The survey examined whether the sampled nursing homes had adopted practices that made care provision more ?resident directed,? that engendered a work environment that fostered staff autonomy and decentralized decision making, and that altered the physical environment to make their facilities look and function like a home, rather than a hospital. The researchers found that only 5% of the sampled nursing homes reported that the definition of culture change for resident-directed care ?completely? described their facility. Forty-three percent of the facilities (categorized as ?traditional nursing homes?) stated that their respective nursing homes met the 26 ?culture change? criteria ?not at all? or only ?in a few respects,? and that their leadership was only ?somewhat,? ?not very,? or ?not at all? committed to the adoption of culture change. The results of this survey indicated that, although some improvements had been realized, most of the culture change initiatives had yet to penetrate the culture and care of the sampled RCFs. Unfortunately, the literature is fraught with examples of failed attempts at successful implementation and sustained person-centred care delivery. Possible reasons for the failures have included observations that the concept of person-centred care is ill-defined (Brooker, 2004; Nolan, Davies, & Brown, 2006), is too idealistic and thus unworkable on a day-to-day basis (Packer, 2000), conflicts with practice and process realities, which tend to deny the diversity of residents (Ray, 1999), contradicts traditional models of service delivery, and is unsustainable because of issues related to staffing levels and resources (Dowling, Manthorpe, & Crowley, 2007). The failure to implement person-centred care has been found repeatedly in facilities that have not successfully redressed pre-existing organizational and staffing problems (Hagenow, 2003; Scalzi, Evans, Barstow, & Hostvedt, 2006; Talerico, O'Brien, & Swafford, 2003).  Studies that have examined the factors that support the successful implementation of culture change models indicate that good leadership, stable management, strong teamwork, efficient communication systems, and an investment in staff training and education about culture change are requisites for change (Barba, Tesh, & Courts, 2002; Steiner, Eppelheimer, & De Vries, 2004). Resistance from senior leadership is the most frequently cited barrier to adopting culture change, followed by the perceived cost and concerns about compliance with regulatory requirements, which often demand increased conformity to prescribed routines rather than flexible care practices (Miller, Miller, Jung, Sterns, Clark, & Mor, 2010).  27 Crandall, White, Schuldheis, and Talerico (2007) and Rosemond (2009) explored factors that helped or hindered the implementation of person-centred care in RCFs. Of interest, contrary to commonly held beliefs and her hypotheses, Rosemond (2009) found that implementation effectiveness was not associated with the presence of financial resources, management support, organizational stability, or the amount of time and training offered to workers to learn about person-centred care. Instead, she found that the factors positively associated with implementation effectiveness included the way in which leaders communicated with RCAs about the intervention and whether the intervention fostered smooth operations in the daily routines of the RCAs. Crandall, White, Schuldheis, and Talerico (2007) reported that the most striking differences between facilities that were most successful in implementing person-centred care and those that were unsuccessful were related to institutionalized practice changes. More specifically, those facilities that made changes to the institutional documents and texts associated with care delivery (e.g., changes in mission statements, policies and procedures, job descriptions, and training materials) were the most successful in implementing and sustaining person-centred care. This finding was replicated by Hill (2004), who identified procedural barriers within an institution itself and governmental policies and regulations as two major barriers in the implementation of person-centred care.  Examples of regulations that can be barriers to the implementation of person-centred care include, but are not limited to, the following: (a) fire safety regulations that promote uncluttered spaces yet counter efforts to create homelike environments (e.g., not allowing art created on paper to be placed on the walls); (b) regulations that specify that every resident must have a private room and do not allow RCFs to accommodate residents who, because of the opportunity for socialization and a sense of security, prefer to have a roommate; and (c) regulations that 28 require a defined breakfast and lunch schedule throughout the week do not allow RCFs to accommodate residents who prefer to eat brunch except on weekends or holidays (Residential Care Regulation, 2012). How is Person-Centred Care Experienced? Edvardsson, Fetherstonhaugh, and Nay (2010) conducted one of the few studies aimed at exploring person-centred care as it is understood by people with dementia, family members, and RCF staff. Their findings indicated that these stakeholders viewed the core feature of person-centred care to be the promotion of a continuation of self and normality. Five content categories emerged as contributing to the promotion of a continuation of self and normality: knowing the person, welcoming the family, providing meaningful activities, being in a personalized environment, and experiencing flexibility and continuity.  There is a dearth of studies aimed at evaluating person-centred care as experienced by residents in RCFs?the majority of whom have dementia (Rosenzweir, 2010), their family members, or RCF care staff members. Researchers have focussed on more generalized issues, such as the "quality of care." When questioned about the quality of the care provided, RCAs tend to focus on the quality of the relationships formed between residents and themselves and on how care is delivered, rather than on specific clinical outcomes (i.e., outcomes primarily associated with residents? physical health) (Bowers, Esmond, & Jacobson, 2000). Furthermore, they deem relationships to be the central determinant of both quality of life and quality of care (Deutschman, 2001; McGilton, 2002; Schirm, Albanese, & Garland, 1999; Wagner & Colling, 1993). Finally, they recognize that the indicators of quality of care include positive outcomes for the residents as well as for themselves (Deutschman, 2001), and often state that providing person-centred care by being able to do the ?extras? (e.g., sitting and talking with a resident 29 about his or her past, taking extra time to put makeup on a resident) is what ?really? matters (Deutschman, 2001; Schirm et al., 1999).  From the residents? perspective, high quality care is based almost exclusively on having considerate, respectful RCAs with supportive attitudes, who are kind and ?nice? while providing care (Deutschman, 1999; Grau, Chandler, & Saunders, 1995; Tellis-Nayak & Tellis-Nayak, 1989). Residents also deem the relationship between themselves and the care staff to be a central determinant of high quality care and life. According to Grau et al. (1995), the greater their perception of having a positive relationship with staff members, the less residents view themselves as objects receiving care. Thus, an important determinant of residents? quality of life is their interpersonal relationships, yet their relationships are often neglected as a significant assessment element. An exception to this was a recent study of Coleman and Medvene (2013) that found the strongest effect of a person-centred care intervention to be an improvement in residents? reported ?relationship closeness? with the RCAs.  How Have Person-Centred Care Interventions Been Studied? The majority of published articles related to person-centred care are descriptive or anecdotal in nature; however, a review of the literature demonstrates a continued effort by researchers to find ways to rigorously study person-centred care interventions. The lack of a universally accepted operational definition of person-centred care is likely associated with the struggles researchers have experienced in studying the outcomes associated with its implementation. For example, Brownie and Nancarrow (2013) recently conducted a systematic review of the effects of person-centred care on residents and staff in RCFs and concluded that the complexity of the interventions and range of outcomes examined made it difficult to form accurate conclusions about the impact of person-centred care interventions.  30 Given these complexities, I conducted a comprehensive review of the literature to gain insight into how person-centred care has been studied and to understand more fully the factors that influence the effectiveness of interventions aimed at improving the provision of person-centred care practices in RCFs. My aim was to describe interventions targeting both residents? and care staff?s behaviour and to assess their effectiveness. The strategy to identify relevant studies included searching the following electronic indexes and databases: Academic Search Complete, AgeLine, CINAHL, MEDLINE, PsycINFO, PubMED, and SocINDEX; undertaking manual searches of journals and the bibliographies of retrieved articles; and acquiring information from experts in the field. Key words used in the search included long-term care, nursing home, outcomes, quality of care, quality of life, intervention, person centred care, resident centred care. Articles meeting the following criteria were chosen for inclusion: 1. The setting was in a nursing home, long-term care (LTC) facility, RCF, or special care unit, 2. The population of interest was RCF care staff members or residents of RCFs, 3. A primary focus of the intervention was aimed at improving the provision of person-centred care practices, 4. There was evident evaluation of the intervention with empirical data provided, 5. The study was published in an English-language journal, and 6. The publication date was between 1985 and 2013. For example, MEDLINE, Academic Search Complete, CINAHL, and PsycINFO were first searched with the key words, person-centred care, nursing home, AND intervention; limitations of publications dated between 1985 and 2013 and those published in English were placed on the search. This search yielded 11 citations. Three duplicated citations were removed. The abstracts 31 of the remaining eight references were reviewed for relevance. Of these, four were excluded because they provided only preliminary results, did not provide empirical data relevant to an intervention designed to increase the provision of person-centred care practices in RCFs, or were reviews of previously published intervention studies. The remaining four studies received a full review. In addition, a subsequent search of each retained article?s reference list was conducted. This process was repeated several times with different databases and different key words until 38 studies were found that met the inclusion criteria set out for this review.  Table 2.1 presents the selected studies summarized by intervention focus, study (author and country), the goal or intended outcomes, intervention format, sample, implementation factors, the outcomes or impact, follow-up, level of evidence, risk of bias, and effectiveness rating. The stated goals and intended outcomes of the selected studies were stratified by target population: residents or staff. The residents? outcomes were classified into three categories:  1. Behaviour (e.g., decreased agitation, decreased physical aggression), 2. Health status (e.g., functional status, infection rate, fall rates), and 3. Quality of Life?outcomes based on residents? perceived sense of emotional, social, and spiritual wellbeing, including safety, physical comfort, enjoyment, meaningful activity, relationships, and dignity.  The staff outcomes were classified into five categories:  1.  Attitudes (e.g., beliefs and values regarding person-centred care practices, aging, or dementia-related behaviour), 2. Knowledge (e.g., increased knowledge of Alzheimer?s disease and related disorders and person-centred care practices), 32 3. Quality of Care?change in actual care practices related to physical and cognitive health and well-being of the residents, 4. Quality of Life?changes in actual care practices related to the social, emotional, and spiritual health or well-being of the residents (e.g., providing choices, improved communication, or developing relationships), and 5. Quality of Work Life?changes in the quality of work life (e.g., team building, leadership, support, empowerment/autonomy, overall quality of work-life, safety and security, or reward and recognition). The format of the program or intervention (e.g., lecture, group discussions, practice sessions, videos, on-site consultation, or written materials) was described to better understand the types of formats frequently used in practice change interventions in RCFs and to determine whether specific formats are associated with intervention effectiveness. The intervention factors (i.e., the features within the intervention developed specifically to produce, enable and reinforce changes in behaviour related to care practices) were categorized with the classification system developed by Green and Krueter (2005), and included the following:  1. Predisposing factors: The creation of a shared vision that provides the foundation for change in practice. Effectively communicating and disseminating information designed to modify staff members? knowledge, beliefs or attitudes (e.g., lectures, written information, group work, didactic training, experiential learning, video presentations, role-playing, or computerized learning), 2. Enabling factors: Conditions and resources within the environment developed to allow or enable staff members to implement new skills (e.g., modified work 33 schedules, practice opportunities, changes to policy or treatment guidelines, development of new treatment protocols, or access to appropriate resources), and 3. Reinforcing factors: Mechanisms that reinforce the implementation of new skills or practices (e.g., providing cues or reminders, improved peer support, timely and appropriate feedback, timely and consistent follow-up, and rewards and recognition for a job well done).  The interventions were then further classified into types: Type I = predisposing factors only, Type II = predisposing plus enabling factors, Type III = predisposing plus reinforcing factors, and Type IV = predisposing, enabling, and reinforcing factors (Davis, O'Brien, Freemantle, Wolf, Mazmanian & Taylor-Vaisey, 1992).  The quality of the published evidence was categorized as evidence generated from properly randomized control trials (RCT), quasi-experimental designs (i.e., well-designed controlled trials without randomization) (QE), and descriptive case studies or case reports (DCS).  The Cochrane Collaboration?s tool for assessing risk of bias (Higgins et al., 2011) was used to evaluate risks related to five key domains (i.e., selection, performance, detection, attrition, and reporting bias) for each of the studies. Risk of bias was classified as follows: 1 = low risk of bias in all key domains with plausible bias unlikely to seriously alter the results; 2 = unclear risk of bias for one or more key domains with plausible bias that raises some doubt about the results; 3 = high risk of bias for one or more key domains with plausible bias that seriously weakens confidence in the results.  Finally, the effectiveness of each study was evaluated based on a combined overview of the sample size, effect size, outcomes and impact, level of evidence, and the risk of bias. The effectiveness was rated based on the following descriptions: A = good evidence to support 34 recommendations of effectiveness, B = fair evidence to support recommendation of effectiveness, C = insufficient evidence to recommend for or against the effectiveness, D = fair evidence to support recommendation of ineffectiveness, and E = good evidence to support recommendation of ineffectiveness. 35 Table 2.1: Review of Person-Centred Care Practice Intervention Studies Intervention Focus Study  (Country) Goals/Intended Outcomes Intervention Type and Format Sample Implementation factors Outcomes and Impact  Follow-Up Level of Evidence Risk of Bias Effectiveness Rating Resident Staff Predisposing Enabling Reinforcing Resident Staff Behaviour Health Quality of Life Attitude Knowledge Behaviour Quality of work life Behaviour  Health Quality of Life Attitude Knowledge Behaviour Quality of work life Quality of Care Quality of Life Quality of Care Quality of Life Person-centred Care Ashburner at al., 2004 (UK)     X X X  TYPE IV Unspecified format  46 nursing staff 21 residents Information sharing Collecting and sharing residents life histories with care staff Weekly team supervision meeting with staff  Action learning set for managers     1. Improved 2. Improved 3. Improved  #1, 2, & 3 sustained at 36 months DCS (2)  (B) ADL and psychosocial intervention Beck et al., 2002 (USA) X  X      TYPE I Specific staff were hired and trained as ?Project Nurse Assistants? Time and length of training unspecified 143 residents Care staff unspecified Information sharing   1. Not Improved  2. Mixed      No change at 1 and 2 months RCT (2) (E)  Eden Alternative Bergman-Evens 2004 (USA)   X      Type IV unspecified Assumed Standardized Eden training provided to care staff members with managerial support 33 Residents Unspecified Information Sharing  Unspecified Managerial Support Unspecified Follow-up team meetings   1. Improved      #1 sustained at 12 months QE (2) (A) R.E.L.A.T.E. Boettcher et al., 2004 (USA)     X  X X TYPE III 9 sessions (unspecified length): Lecture with experiential techniques and practice homework between sessions 50 Residents 38 RNs, 46 Nursing assistants,  Information sharing  On the job coaching & supportive mentoring      1. Not reported  2. Improved 3. Not Reported # 2 sustained at 2 months DCS (3) (C) 36 Intervention Focus Study  (Country) Goals/Intended Outcomes Intervention Type and Format Sample Implementation factors Outcomes and Impact  Follow-Up Level of Evidence Risk of Bias Effectiveness Rating Resident Staff Predisposing Enabling Reinforcing Resident Staff Behaviour Health Quality of Life Attitude Knowledge Behaviour Quality of work life Behaviour  Health Quality of Life Attitude Knowledge Behaviour Quality of work life Quality of Care Quality of Life Quality of Care Quality of Life Leadership Vs. Renovation Bond & Fiedler, 1999 (USA)   X X  X X X TYPE I  10 Bi-weekly sessions over 5 months: Lecture with goal settings and behaviour modelling  65 RNs, nursing assistants, admin, RT, support staff Information Sharing     1. Not reported 2. Not reported   3. Not Improved 4. Not Improved 5. Not Improved #1, 2, 3, No change at 6 months QE (2) (E) Integrated Care Boumans, et al., 2008 (Netherlands       X  X TYPE II ?specialized training? unspecified 226 care staff unspecified Vision Setting Information Sharing Working Groups created Demand-oriented working        1. Improved Not Improved No follow-up QE (1) (D) Perfecting Patient Care (PPC) Castle & Bost, 2009 (USA)  X    X  X TYPE IV 1.Team Leaders attended 5-day university training on TPS 2. Care staff attended a 4-hr session: Lecture Residents Family members All levels of care staff in the LTC facility Number is unspecified Information Sharing Process redesign through application of TPS (Toyota Production System) Consistent follow-up with care staffs? proposed initiatives for improved care practices  1. Improved    2. Improved  3. Mixed #1,2,3, sustained at 12 months DCS (2) (A) Beliefs and values re: aging Chandler et al., 1986 (USA)    X X    TYPE I  Five 60-min training sessions: lecture with video, groups activities, discussion and games 101 RNs, LPNs and nurse assistants Information sharing      1. Not improved 2. Not improved    No follow-up RCT (2) (E) Dementia care Chartock et al., 1988 (USA)    X X  X X TYPE I Twenty eight 2-hr sessions: Lecture with group activities 206 nurses and support staff Information Sharing      1. Mixed 2. Mixed  3. Mixed 4. Mixed No follow-up DCS (3) (C) 37 Intervention Focus Study  (Country) Goals/Intended Outcomes Intervention Type and Format Sample Implementation factors Outcomes and Impact  Follow-Up Level of Evidence Risk of Bias Effectiveness Rating Resident Staff Predisposing Enabling Reinforcing Resident Staff Behaviour Health Quality of Life Attitude Knowledge Behaviour Quality of work life Behaviour  Health Quality of Life Attitude Knowledge Behaviour Quality of work life Quality of Care Quality of Life Quality of Care Quality of Life Person-centred care Vs. D-CMap Chenoweth et al., 2009 (AUS) AND Jeon, et al., 2012. X X X X    X TYPE IV  2-day training on PCC Vs. 2-day training on dementia care mapping: Lecture 289 residents 194 Care staff for PCC training 2 staff per site trained in Dem Care mapping Information sharing Review of resident?s life history Develop individual care plans for residents for DCM Hands-on practice to implement PCC Follow-up phone support 1. Improved 2. Not improved 3. Not improved 4. Not improved    5. Improved #1 sustained at 4 months #5 sustained at 15 months RTC (1) (C) ERIC Emotional Response D-C Chrzescijan-ski et al., 2010 (AUS) X   X     TYPE I  One 40-min video Hands-0n skill application 43 Residents 85 care staff unspecified Information sharing   1. Decrease in frequency of aggression but not intensity   2. Not Improved     #1 Not sustained at 6 weeks. DCS  (2) (D) Eden Alternative Coleman et al. 2002 (USA)  X       TYPE IV unspecified Assumed Standardized Eden training provided to care staff members with managerial support 170 Residents Unspecified Information sharing Unspecified Managerial Support Unspecified Follow-up team meetings  1. Not Improved       No change at 12 months QE (1) (E) Person-centred Care Coogle et al., 2006 (USA)        X TYPE I  Six 8-hr  Train the trainer sessions for selected staff: Lecture One 12-hr and one 5-hr workshop for all staff: Lecture 53 RNs, Nursing Assistants, LPNs Information Sharing          1. Mixed #1 sustained at 12 months DCS (2) (C) 38 Intervention Focus Study  (Country) Goals/Intended Outcomes Intervention Type and Format Sample Implementation factors Outcomes and Impact  Follow-Up Level of Evidence Risk of Bias Effectiveness Rating Resident Staff Predisposing Enabling Reinforcing Resident Staff Behaviour Health Quality of Life Attitude Knowledge Behaviour Quality of work life Behaviour  Health Quality of Life Attitude Knowledge Behaviour Quality of work life Quality of Care Quality of Life Quality of Care Quality of Life Individual care plans & clinical Edberg & Hallberg, 2001 (Sweden) X        TYPE IV 2-day training session: Lecture  22 residents ?all staff? number unspecified RNs, LPNs, and nursing assistants Information sharing Individualized care plans Systematic clinical supervision 2-hr every other week focussing on particular patients and staff?s reactions and feelings 1. Improved        #1 sustained at 6 and 12 months QE (2) (A) Emotion-oriented care Finnema et al., 2005 (Netherl-ands) X  X     X TYPE IV Two half-day sessions: Lecture 194 residents 124 RNs & nursing assistants Information sharing Individual care plans for each residents An ?adviser? was selected from the nursing staff who received additional training and support  1. Not Improved  2. Mixed     3. Mixed sustained at 7 months RCT (2) (D) Person-centred care Fossey et al., 2006 (UK) X X X      TYPE I Didactic training, skills modelling, supervision of groups and individuals Care staff unspecified 346 residents Information sharing   1. Not improved 2. Improved 3. Not Improved      #2 sustained at 12 months RCT (1) (D) Caring  Journey Gaspard et al., 2009 (Canada)    X X X X X TYPE I  3-day workshop: lecture with group activities Not reported Information sharing     1. Not Reported  2. Improved 3. Not Reported 4. Not Reported 5. Mixed No follow-up DCS (3) (C) CARIE: Behaviour Management Goodridge et al., 1997 (Canada) X  x X X X x x TYPE I 1-day workshop: lecture 126 care aides Information sharing   1. Not Improved  2. Not reported 3. Mixed 4. Not Improved 5. Improved 6. Mixed 7. Mixed #3, 5, 6, & 7 sustained at 8 weeks DCS (2) (C) CARES: Internet  training Hobday et al., 2010 (USA)     X    TYPE I Interactive internet training program Unspecified length 40 nursing assistants Information sharing       1. Improved    No follow-up DCS (3) (C) 39 Intervention Focus Study  (Country) Goals/Intended Outcomes Intervention Type and Format Sample Implementation factors Outcomes and Impact  Follow-Up Level of Evidence Risk of Bias Effectiveness Rating Resident Staff Predisposing Enabling Reinforcing Resident Staff Behaviour Health Quality of Life Attitude Knowledge Behaviour Quality of work life Behaviour  Health Quality of Life Attitude Knowledge Behaviour Quality of work life Quality of Care Quality of Life Quality of Care Quality of Life Green house model Kane et al., 2007  (USA)   X   X   TYPE IV unspecified Assumed Standardized combined Eden and Green House model training provided to care staff members with managerial support 120 Residents Information Sharing  Revised care routines and job descriptions Unspecified Follow-up team meetings   1. Improved    2. Improved   #1 & 2 sustained at 24 months QE (2)  (A) R.E.L.A.T.E. AD training Kemeny et al., 2006 (USA)     X    TYPE I  5-week long formal training interventions and informal coaching sessions. Length of time unspecified: Lecture, role plays, simulations 77 RNs and nurse assistants Information sharing and coaching sessions       1. Unable to report as no baseline measures were provided    No follow-up DCS (3) (C) The use of drama to improve PCC Kontos et al., 2010 (Canada)    X X    TYPE I Dramatized vignettes, role playing, critical reflection 24 nursing staff Information Sharing      1. Unable to report as no baseline measures were provided 2. Unable to report as no baseline measures were provided    No Follow-up DCS (3) (C) Best Practice Dementia Care Kuske et al., 2009 (GER)   X X  X X X X TYPE I Thirteen 1-hr training session over 13 weeks: Lecture, group work and video-scenarios Relaxation Training 96 caregivers unspecified 210 Residents Information Sharing    1. Mixed 2. Not Reported  3. Improved 4. Mixed 5. Not Reported 6. Mixed # 1, 3, 4, 6, Not sustained at 6 months RTC (2) (D) 40 Intervention Focus Study  (Country) Goals/Intended Outcomes Intervention Type and Format Sample Implementation factors Outcomes and Impact  Follow-Up Level of Evidence Risk of Bias Effectiveness Rating Resident Staff Predisposing Enabling Reinforcing Resident Staff Behaviour Health Quality of Life Attitude Knowledge Behaviour Quality of work life Behaviour  Health Quality of Life Attitude Knowledge Behaviour Quality of work life Quality of Care Quality of Life Quality of Care Quality of Life Person-centred care dying Linn et al., 1989 (USA)   X X   X  TYPE I Education program unspecified 306 residents staff unspecified Information sharing      1. Improved 2. Improved   3. Improved  #1, 2, & 3 sustained at 3 months RCT (1) (A) Best practice in Dementia Care Lintern et al., 2000 (UK)   X X X X X  TYPE IV 2-day training for management 2-day training for care staff: Lecture, group work, role-lay, interactive discussion 44 residents 34 nursing assistants Phase One: Information sharing Phase Two and Three: Established supervision protocol. Development of induction procedures Developed care planning practices Established a key worker system Phase Two and Three: Follow-up and on-going training based on participant feedback   Phase one: 1. Not improved  Phase 2 & 3: 1. Improved Phase one: 2. Improved  Phase 2 & 3: 2. Improved Phase one: 3. Improved  Phase 2 &3: 3. Improved Phase one: 4. Not Improved  Phase 2 & 3: 4. Improved Phase one: 5.Not improved  Phase 2 & 3: 5. Improved  #1, 2, 3, 4, & 5 sustained at 2 years DCS (2) (B) Emotional Communication Magai et al., 2002 (USA) X  X     X TYPE I  Ten 1-hr sessions over 2 weeks: lecture and experiential sessions 91 residents 31 care staff Information sharing   1. Not Improved  2. Mixed     3. Improved #2 & 3 Not sustained at 3 months RCT (2) (D) REPC: Relationship Enhancing program McGilton et al., 2003 (Canada)    X   X  TYPE IV Eight 20 min sessions over 7 months: Lecture and experiential Learning  40 RNs, LPNs, Nursing Assistants, Unit Managers  Information sharing Changes to Staff Assignments Education Booklet, Monthly Newsletter   1. Improved    2. Improved  No follow-up QE (1) (A) Dementia Care Peterson, et al., 2002, (USA)     X   X TYPE I Length and time not specified: Lecture, video, role-play. 72 RNs, LPNs, and nursing assistants Information sharing       1. Improved   2. Not improved #1 sustained at 2 months DCS (3) (C) 41 Intervention Focus Study  (Country) Goals/Intended Outcomes Intervention Type and Format Sample Implementation factors Outcomes and Impact  Follow-Up Level of Evidence Risk of Bias Effectiveness Rating Resident Staff Predisposing Enabling Reinforcing Resident Staff Behaviour Health Quality of Life Attitude Knowledge Behaviour Quality of work life Behaviour  Health Quality of Life Attitude Knowledge Behaviour Quality of work life Quality of Care Quality of Life Quality of Care Quality of Life Partners in Caregiving Pillemer et al., 2003 (USA)    X    X TYPE I  One 7-hr workshop 655 RNs, LPNs, and nursing assistants Information sharing       1. Improved    2. Improved #1 & 2 sustained at 6 months RCT (1) (A) FOCUSED Dementia Care Ripich et al., 1995 (USA)    X X    TYPE III Six weekly 2-hr group sessions: lecture, role playing, clinical assignments, videotape vignettes 17 nursing assistants Information sharing  Weekly consultation with staff. FOCUSED cards with reminders on principles taught in the program.    1. Improved 2. Improved    No follow-up DCS (2) (B) Eden Alternative Robinson & Rosher 2005 (USA)    X  X   Type IV  Eden training in-services provided to all care staff members with managerial support 1 nursing home number not specified  Unspecified Information sharing Unspecified Managerial Support Unspecified Follow-up team meetings   1. Improved   2. Improved   #1 and 2 sustained at 24 months DCS (3) (B) Best Practice Dementia care Schonfeld et al., 1999 (USA)     X    TYPE I  Two 8-hr session one week apart:  provided in one of three options: Classroom Train-the-trainer Facility-based learning  135 care staff Information sharing       1. Improved    # 1 sustained at 3 months DCS (3) (C) Emotion-Oriented care (Validation) Schrijnemae-kers et al., 2002 Netherlands X       X TYPE II  6-day training program: lecture, didactic training, Role-playing, video. 8 caregivers (not specified) 151 Residents Information sharing Supervisor meetings to support the implementation of the intervention  1. Not Improved       2. Not Improved #1 No change at 3, 6, or 12 months RCT (2) (E) 42 Intervention Focus Study  (Country) Goals/Intended Outcomes Intervention Type and Format Sample Implementation factors Outcomes and Impact  Follow-Up Level of Evidence Risk of Bias Effectiveness Rating Resident Staff Predisposing Enabling Reinforcing Resident Staff Behaviour Health Quality of Life Attitude Knowledge Behaviour Quality of work life Behaviour  Health Quality of Life Attitude Knowledge Behaviour Quality of work life Quality of Care Quality of Life Quality of Care Quality of Life Bathing without a Battle Sloane et al, 2004 (USA) X X   X    TYPE II Didactic training with hands-on supervision 73 Residents 37 nursing assistants Information sharing Changed bathing routines  1. Improved 2.  Improved   3. Not reported    No follow-up RCT (1) (A)  Relation-related Care Testad et al., 2010 (Norway) X X    X   TYPE III  2-day education session and monthly group guidance for 6 months 145 Residents 197 RNs, LPNs, and Care Assistants  Information Sharing  Monthly Group guidance sessions for 6 months 1. Improved 2. Not improved    3. Improved   #1 sustained at 6 months #3 not sustained at 6 or  12 months RCT (2) (B) Abilities-focused care Wells et al., 2000 (Canada) X X X    X X TYPE IV Five 20-30 min education sessions: Lecture, role play, games 40 residents 44 care staff Information sharing Random observations of care staff to ensure and reinforce use of newly learned skills  20-30 min long Reinforcement sessions every 2 weeks for 3 months and then monthly until completion of study  1.Improved  2. Improved 3. Improved    4. Improved 5. Not improved # 1,2,3, &4 sustained at 3 & 6 months QE (1) (A) Team work and Individualized CP Wilkinson, 1999 (USA) X       X TYPE IV 1-day workshop: lecture, role play, and exercises 40 residents 32 RNs LPNs nursing assistants Information sharing Hired an advanced practice psychiatric nurse to work 10-hr shifts to teach and role model Did follow-up training based on unit needs assessment 1.Not improved       2.Not reported #1 sustained at 11 months DCS (2) (E) Foundations of Dementia Care Zimmerman et al., 2010 (USA)    X X X  X TYPE I  6-sessions Unspecified length 491 direct care staff 171 supervisors Information Sharing     1. Not Reported 2.Not Reported 3. Mixed 4. Not Reported  5. Decreased # 3 partially sustained at 3 months # 5 sustained at 3 months RCT (2) (E)  43 Thirty-eight studies met the selection criteria. Studies from eight countries were included in this review and the majority of the studies were conducted in the USA (see Table 2.2). More than one half of the studies (n = 22, 58%) were published in the last ten years (between 2003 and 2013); the remaining were published during the 17-year period between 1985 and 2002. Table 2.2: Number and Frequency of Included Studies by Country (N = 38) Country n Relative frequency United States of America 22 58% Canada 5 11% United Kingdom 3 8% Netherlands 3 8% Australia 2 5% Sweden 1 .03% Norway 1 .03% Germany 1 .03%  Intervention Format and Duration Previous reviews of education initiatives in RCFs have found that lecture or didactic methods of instruction alone are unlikely to be successful in producing the desired changes in behaviour (Aylward, Stolee, Keat, & Johncox, 2003; Kuske, Hanns, Luck, Angermeyer, Behrens, & Riedel-Heller, 2007; Nolan et al., 2008). The majority of the studies in this review used multiple teaching methods for their interventions. The most common was lecture in combination with role-play, group work, experiential learning, and written material offered as a supplementary resource. One group of researchers reported specifically on staff members? learning preferences and styles (Kemeny, Boetther, DeShon, & Stevens, 2006). According to Kemeny et al. (2006), RCAs often have impoverished educational experiences leading to a lack of confidence with traditional passive approaches to learning such as class-room style teaching (Bova and Kroth (2001) as cited in Kemeny et al. (2006)). Thus, Kemeny et al. (2006) 44 emphasized the importance of creative, experiential learning for RCAs. Smith, Buckwalter, Garand, Mitchell, Albanese, and Kreiter (1994) made a similar argument when they suggested that how an educational initiative is delivered is as, if not more, important than the content.  Several published accounts did not report the duration of the intervention or the exact duration of each aspect of the intervention (i.e., education sessions vs. hands-on follow up and support). Of those that did, the duration of the interventions ranged from one 40-minute session to a 48-hour training initiative. An overview of the studies indicated that the duration of the educational portion of the interventions was not predictive of their effectiveness (i.e., one intervention provided 42 hours of staff training and received an effectiveness rating of ?E? while another provided only 12 hours of training and received an effectiveness rating of ?A?). The reported duration of ongoing support following the initial training intervention ranged from a 3-week hands-on phase to 24 months of follow-up support. Unlike the duration of the initial training session, the duration and depth of follow-up support seemed to be predictive of effectiveness. This observation is discussed in more detail within the review of the intervention factors, set out below.  Intervention Factors According to the literature, it is essential to involve staff members as fully as possible in the design, content, delivery, and evaluation of practice change initiatives and to create a consensus among them as to the need for education, practice change, and the desired goals and outcomes (Burgio, Stevens, Burgio, Roth, Paul, & Gerstle, 2002; Nolan et al., 2008). The practice of including staff members in the development stage of an intervention is said to improve their sense of ownership and to help to establish the appropriateness and relevance of the intended program (Nolan et al., 2008). Of interest, this review of the literature found that this 45 practice is not the norm in intervention studies conducted in RCFs. Of the studies reviewed, only four indicated that they sought input from staff members and administrators about their training needs and the appropriate focus and content of the intervention (Castle & Bost, 2009; Kemeny, Boetther, DeShon, & Stevens, 2006; McGilton, O'Brien-Pallas, Darlington, Evans, Wynn, & Pringle, 2003; Wilkinson, 1999).  Predisposing factors.  One half of the studies, 19 in total, were classified as Type I; they evaluated predisposing intervention factors alone. Each of these studies relied solely on information sharing as their implementation strategy to produce change. It is widely recognized that providing education alone is rarely effective in producing actual change in practice (Aylward, Stolee, Keat, & Johncox, 2003; Kuske, Hanns, Luck, Angermeyer, Behrens, & Riedel-Heller, 2007; Nolan et al., 2008). One of the studies demonstrated that improvements in staff knowledge or attitudes did not lead to improvements in care practices (Lintern, 2000). Of the studies classified as Type I, only two received an effectiveness rating of A (Linn & Stein, 1989; Pillemer et al., 2008) and none received a rating of B. Thus, the results of this review lend further support to the assertion that educational interventions classified as Type I are largely ineffective in producing change in the care practices provided in RCFs. According to Green and Kreuter (2005), the creation of a shared vision is included as a predisposing factor. Only one of the studies indicated that they incorporated vision setting as part of their initiative (Boumans, Berkhout, Vijgen, Nijhuis, & Vasse, 2008).  Enabling factors. Eight of the studies were classified as Type II (interventions that included both predisposing and enabling factors for implementation). Of these, only one received an effectiveness rating of A (Sloane et al., 2004) and none received an effectiveness rating of B. Over one half of the studies (n = 23) did not include any enabling factors within their 46 interventions. This finding is consistent with previous reviews of continuing education studies in RCFs. For instance, Aylward, Stolee, Keat, and Johncox (2003) found that in nearly three quarters of the 48 studies they reviewed,3 new information was presented to staff members with no strategies in place to support the transfer of new knowledge into practice.  Enabling factors include conditions and resources within the environment that are developed to allow or enable staff members to implement new skills. Thus, administrative commitment to assist and enable the translation of learning into practice would be considered an important enabling factor. Of the studies reviewed, only three discussed the ways in which they addressed, ensured, and measured administrative support for the initiative (Lintern, 2000; McGilton, O'Brien-Pallas, Darlington, Evans, Wynn, & Pringle, 2003; Wilkinson, 1999). This is an interesting finding because the literature consistently notes that lack of administrative support likely explains the failure of education, training, and practice change initiatives (Aylward, Stolee, Keat, & Johncox, 2003; Campbell & Knight, 1991; McCabe, Davison, & George, 2007; Nolan et al., 2008). Of note, only one study provided a two-day training course that specifically targeted leadership skills and support from management and senior staff, and subsequently created a development plan to address enabling factors prior to providing education to the direct care staff (Lintern, 2000).  The most common enabling factor examined in the relevant studies was the development and implementation of care plans for residents (n = 5). It should be noted that individualized care plans are now considered a basic standard of practice in RCFs; however, the creation of care                                                   3 The large number of studies reviewed by these authors relative to those reviewed here resulted from their review not being limited to intervention studies specifically aimed at increasing the provision of person-centred care. 47 plans does not necessarily ensure that they will be used or implemented in day-to-day practice. This may be why so many of the studies that used this as the primary enabling factor did not produce observable change in behaviour or outcomes. Thus, unless other enabling and reinforcing factors are in place, the development of care plans is not sufficient in creating sustained changes in RCF care practices.  It is noteworthy that care staff members' access to the care plans was not addressed in any of these studies. Rather, they seemed to assume that the information contained within the residents? care plans would be accessed and applied in the day-to-day care practices of the healthcare staff. This presumption, and the consequent lack of attention to how residents? individualized care information is accessed and exchanged among professional care staff members, is pervasive in the literature.  Reinforcing factors. Reinforcing factors are the mechanisms that reinforce and encourage the implementation of new skills and care practices. In total, 16 (42%) of the studies included reinforcing factors as part of their interventions. Of these, three were classified as Type III (predisposing and reinforcing only) and 13 were classified as Type IV (predisposing, enabling, and reinforcing factors). A review of these studies indicated that the presence of reinforcing factors is significantly related to the effectiveness of the intervention. For example, 11 of the 14 studies that received an effectiveness rating of A (good evidence to support recommendation of effectiveness) or B (fair evidence to support recommendation of effectiveness) included reinforcing factors as part of the intervention.  The reinforcing factors described in these interventions included such things as "on the job coaching," "hands-on practice," "supportive mentoring," "increased supervision," and "team meetings." These factors all indicate that resources in the form of direct human involvement and 48 interaction were provided to the RCAs as they worked to implement the newly learned skills and care practices. Given the influence that reinforcing factors exert on the success of care practice interventions, the importance of these types of supports for RCAs should not be underestimated.  Of interest, staff motivation systems via rewards or recognition for intervention implementation were not used in any of the studies. This finding is noteworthy because motivational factors, such as recognition and a sense of achievement, have been found to be important to RCAs? perceived empowerment and quality of work life (Caspar & O'Rourke, 2008; Pennington, Scott, & Magilvy, 2003). Further to this, Scalzi, Evans, Barstow, and Hostvedt (2006), who reviewed barriers and enablers to changing organizational culture in nursing homes, found that few, if any, incentives and rewards were linked to the implementation of quality of life or person-centred care practices. Rather, incentives in RCFs were often linked to competing or conflicting goals, such as performance-based outcomes related to the medical model?which places more emphasis on regulatory compliance than on meeting residents? individualized needs. Regulatory compliance can cause residents to be treated according to their diagnostic or functional status, with funding and staffing determined in relation to such status (as opposed to their individualized needs) (Ronch, 2004). Thus, regulatory compliance can reinforce the continued dominance of the acute care medical model in RCFs. As a result, the staffing remains hierarchically organized, highly scheduled, and predominantly focused on clinical tasks and the documentation of medically related objectives (e.g., medications, task completion, illness, and disease) (Diamond, 2009; Gnaedinger, 2003). Unless reinforcing factors such as motivation, recognition, and incentives are part of the intervention, the highly structured day-to-day care practices and routines may be in direct conflict with the successful implementation of any intervention aimed at increasing the provision of person-centred care.  49 Goals and Outcomes The majority of the studies (77%) had multiple goals and intended outcomes related to the interventions. Only five of the studies had goals that focussed solely on residents? outcomes and 14 of the studies focussed solely on staff outcomes. The remaining 19 studies focussed on outcomes for both residents and care staff. It is noteworthy that the outcomes of interventions associated with person-centred care are typically evaluated using criteria based on caregivers? or researchers? perspectives and not the care recipients?. Thus, there is growing concern that standardized measures for assessing outcomes may not address those that are significant for the person with dementia (Bamford & Bruce, 2000; O'Connor et al., 2007). The outcomes of these intervention studies should be viewed with this caveat in mind.  Of the studies reviewed, 13 had goals related to changes in residents? behaviour, five of which (38%) reported significant improvement following the intervention. The most common goals were related to residents? behaviour, particularly decreased agitation or aggression. Only eight of the studies had goals related to changes in the residents? health status; of these, four reported significant improvements following the intervention, indicating a 50% success rate. A total of 13 studies had goals related to the residents? quality of life, and about one half of them (n = 7) reported improvements.  When reviewing the goals of the care staff, 13 studies examined care staff members? attitudes and only four of them reported significant improvements following the intervention. Staff attitudes were most often measured using instruments designed by the researchers and specifically focussed on the intervention goals. Changes in care staff members? knowledge was a cited goal in 15 of the studies reviewed and nine (60%) of these studies reported improvements 50 as outcomes. The most frequent method used to measure changes in the care staff?s knowledge was a simple pre- and post- pen and pencil test.  Twelve of the studies included goals pertaining to the care staff?s behaviour related to the residents? quality of life, seven of which reported improvements as outcomes. All of the studies that reported improvements in the care staff?s behaviour related to the residents? quality of life also reported that the improvements were sustained for two months or more following the intervention. Of interest, only 11 studies included improvements in the care staff?s provision of quality care. Of these studies, seven reported improvements in the quality of care as an outcome.  Finally, 17 of the studies indicated that improvement in the quality of the work life of the care staff was a goal of the intervention. Of these, only two studies indicated that improvements were successfully realized as a result of the intervention. Quality of work life was most often measured in relation to absenteeism, intent to leave, and turnover rates (a significant consideration in most RCFs in the USA). In addition, some studies included measures related to care staff members? experiences of physical and verbal assault while on the job. Others measured quality of work life via questionnaires related to perceptions of job satisfaction. Thus, it is important to note that this outcome was measured in a variety of ways, some being highly objective while others being primarily subjective in nature.  It should be noted that many studies reported intervention goals that were not evaluated or not reported. For instance, in five of the 13 studies that specified improved quality of life as a goal of the intervention, the authors did not measure or report any outcomes related to quality of life (Bond & Fiedler, 1999; Gaspard, Garm, Harriman, & Scheffler, 2009; Goodridge et al., 1997; Kuske et al., 2009; Zimmerman et al., 2010). Other authors evaluated interventions designed to address residents? behaviour, such as agitation and aggression and reported 51 significant improvements in the staff?s attitudes and knowledge related to these issues, but they did not measure actual change in the residents? behaviour (Kemeny, Boetther, DeShon, & Stevens, 2006; Schonfeld et al., 1999). It is unclear why these goals were not measured or reported as outcomes by the authors of these studies. Methodological issues such as these may be due to the unique challenges presented to researchers conducting studies in RCFs; however, they also raise questions about the possibility of bias due to incomplete or selective reporting.  Methodological Quality: Sample Size, Follow-Up, Level of Evidence, and Risk of Bias Other reviewers of the literature about interventions conducted in RCFs designed to improve care practices have noted serious weaknesses in the methodological approaches of the research (Aylward, Stolee, Keat, & Johncox, 2003; Kuske, Hanns, Luck, Angermeyer, Behrens, & Riedel-Heller, 2007; Nolan et al., 2008). These have included concerns regarding small sample sizes, lack of control groups, lack of randomization, low response rates, high attrition rates, and other threats to validity such as the use of self-reports. Because of these concerns, the reviewers have concluded that the reported impact of the various interventions needs to be interpreted with caution. Thus, previous reviews have led to calls for more scientifically rigorous methodology to evaluate interventions (Aylward et al., 2003; Kuske et al., 2007; Nolan et al., 2008).  The sample sizes of the studies included in this review ranged from 8 to 662 in the care staff samples and from 19 to 346 in the resident samples. However, it should be noted that the majority of the publications that reported their sample size had generally small samples of fewer than 150 staff and residents.  Most of studies included in this review conducted a follow-up evaluation (n = 29). The majority of those (n = 19) conducted follow-up evaluations at six months or more after the 52 completion of the intervention. The remaining studies (n = 9) conducted follow-up evaluations between one and five months after the intervention. Of the studies that reported follow-up evaluations, the majority (n = 21) reported some aspect of the outcomes being sustained. Thirteen of these studies reported sustained changes to residents? outcomes. It should also be noted that previous reviews of intervention studies in RCFs have found that close to two thirds of the studies did not conduct follow-up evaluations and only one study was found that reported sustained changes to residents? behaviour (Aylward, Stolee, Keat, & Johncox, 2003). Thus, findings from this review indicate a significant and positive trend in the use of follow-up evaluations in intervention research in RCFs as well as a significant trend in sustained positive outcomes for residents.  Within this current review, 13 (34%) of the studies applied a randomized controlled trial (RCT) methodology, eight (21%) used a quasi-experimental design, and 17 (44%) used a descriptive case study design. Positive trends in methodology were also found when evaluating the risk of bias. Sixty-six percent of the studies that received a rating of ?1? (indicating a low risk of bias) were conducted between 2003 and 2013. Despite this pattern, however, there is still a need for significant improvement in this area. Of the studies reviewed, only nine (23%) were evaluated as having a low risk of bias, whereas 21 (54%) were evaluated as having a plausible risk of bias, which was high enough to raise doubts about the reported results. Finally, eight (21%) of the studies were assessed as having a high enough risk of bias to seriously weaken confidence in the reported results.  The current review found that most intervention studies conducted in RCFs have relied on the same person or persons to lead the intervention and to collect the data. When this was not the case, the studies relied on the often under-trained and overworked staff members to collect the 53 relevant data, many of whom participated in the intervention. This practice leads to serious concerns regarding the risk of bias. Of the studies reviewed, only four ensured that the individuals who collected the data were blind to the intervention (Chenoweth et al., 2009; Fossey et al., 2006; McGilton, O'Brien-Pallas, Darlington, Evans, Wynn, & Pringle, 2003; Sloane et al., 2004; Testad, Ballard, Br?nnick, & Aarsland, 2010). Thus, lack of blinding of outcome assessors was a major source of potential bias in the studies reviewed. Two other sources of potential bias were related to incomplete outcome data or selective outcome reporting. Of the studies reviewed, six did not report findings related to variables that were stated to be outcome goals of the intervention. Minimizing the risk of bias is an area in need of significant improvement in intervention research conducted in RCFs. Without this, the ability to truly claim the effectiveness of an intervention is seriously weakened.  Intervention Effectiveness In all, nine (23%) studies in this review received an effectiveness rating of ?A? (i.e., good evidence to support recommendations of effectiveness), six of which were published between 2003 and 2013. In addition, five (13%) studies received an effectiveness rating of ?B? (i.e., fair evidence to support a recommendation of effectiveness), three of which were published between 2003 and 2013. Thus, although there are some positive signs in intervention effectiveness, many published studies reported outcomes with either insufficient evidence to recommend for or against effectiveness (n = 10; 26%) or fair (n = 6; 15%) or good (n = 8; 21%) evidence to support a recommendation of ineffectiveness.  There were two primary features of the interventions that significantly affected their effectiveness ratings. One was a methodological feature, which affected the measure of the effectiveness, while the other was a substantive feature, which  affected the actual intervention 54 effectiveness. The methodological feature was an increased risk of bias due to the study designs. Specifically, researchers who relied upon care staff members to obtain the data for their studies should have taken additional measures to ensure that the practice did not confound the outcomes. For example, Wilkinson (1999), who conducted a study about an intervention to reduce residents? agitation and aggression, used staff members who participated in the intervention to obtain the outcome data. Part of the intervention was increasing the staff members? awareness of agitation and aggression and to encourage the documentation of the presence of this behaviour. Thus, after the intervention, the researchers found an increase in the very behaviours they were attempting to decrease. They noted that this increase was likely the result of staff members? increased awareness and reporting of the behaviours after the intervention. There were significant threats to the validity of the baseline measures, which in turn rendered the outcome assessments unreliable, thus making it impossible to accurately rate the effectiveness of the intervention.  The second feature that significantly affected the effectiveness rating of an intervention was the presence of reinforcing factors. This is perhaps one of the most noteworthy findings of this review because it indicates that, with the presence of effective enabling and reinforcing factors, interventions aimed at improving the provision of person-centred care in RCFs are, in fact, both feasible and sustainable. Summary and Reflections The literature is fraught with examples of failed attempts at successful implementation and sustained person-centred care delivery on RCFs. This review provides some explanation as to why meaningful improvements in the provision of these care practices in RCFs have been largely unrealized, despite significant effort.  55 There are three key factors that need to be addressed for changes to occur in the care practices in RCFs related to quality of life and quality of care. First, information designed to modify care staff members' knowledge, skills, beliefs or attitudes must be effectively communicated and disseminated (i.e., predisposing factors). Second, conditions and resources must be developed within the RCFs to enable staff members to implement new skills (i.e., enabling factors). Third, mechanisms must be in place to support the implementation of new skills or practices (i.e., reinforcing factors). Unfortunately, the majority of researchers attempting to change practice have not ensured that all of these factors were addressed. This is an important consideration given the amount of research published regarding the lack of change to care practices during the course of the last decade (Commonwealth Fund, 2007; Corazzini et al., 2010; Hill, Kolanowski, Milone-Nuzzo, & Yevchak, 2011). Before practice can be changed or innovative approaches implemented, the institution must be able to support the changes with sufficient resources. For example, care plans developed based on person-centred care practices are believed to produce positive results for the recipients of care. However, to consistently implement the highly individualized care prescribed in these care plans, RCFs must have sufficient resources. These resources could include such things as: (a) appropriate staffing levels, (b) appropriate levels of staff education and training, (c) appropriate access to individualized information regarding each resident?s history, needs, strengths, and interests, and (d) the ability to schedule staff so as to create and maintain consistent, trusting caregiving relationships.  It would be beyond the scope of a single doctoral study to attempt to address all of the resources required to provide person-centred care. The aim in this study was to focus on care staff members' access to individualized information regarding each resident's history, needs, 56 strengths, and interests. Studies that take into account care staff members' access to residents? individualized care information have not been undertaken. I aimed to address this gap by exploring how the social organization of care enables or impedes care-related information exchange within RCFs. 57 Chapter 3: Methodology Nadler and Tushman?s (1988) congruence model indicates that the most important determinant of successful implementation of practice changes in institutions is achieving the correct balance between the desired change and the environmental and social realities. Organizations will be effective only to the degree that their "internal components"?the way tasks are organized, the informal ways that people relate to each other, the formal structure, policies, and procedures, and the characteristics of an organization?s employees?are congruent (Nadler & Tushman, 1988).  Institutional ethnography (IE), as a method of inquiry, provides a practical and effective means by which to examine the congruence (or lack thereof) of the "internal components" in an institution. According to Smith (1987), institutional standardizing tools, which she referred to as replicable texts (i.e., any document, record, form, report, or page that is written, drawn, or otherwise reproducible) provide the visible representations of the "internal components" of an institution. Smith (1987) asserted that workers in any institution are organized?through institutional standardizing tools?to treat similar situations in the same way. A powerful way in which the organizational culture of RCFs either supports or hinders the implementation of person-centred care is through these institutional standardizing tools. Thus, I selected the methods described within an IE to provide a conceptual framework for this study.  Describing the methodological and analytical processes of IE is not a simple endeavour. According to Smith (2005), the emphasis of IE "is always on research as discovery rather than, say, the testing of hypotheses or the exploration of theory as analysis of the empirical" (p. 2). It is for this reason that Smith (2005) referred to IE as a "method of inquiry" rather than a "methodology." DeVault and McCoy (2002) acknowledged that it is difficult to fully explain the 58 methodological and analytical processes of IE because investigations themselves are rarely planned completely in advance and the steps of the researcher are dependent on the nature of the inquiry. According to Smith (2005), ?Each next step builds from what has been discovered and invades more extended dimensions of the institutional regime. The mapping of social relations expands from and includes the original site so that the larger organization that enters into and shapes it become visible? (p. 35). Thus, in following IE as a method of inquiry, I began with the particular experiences of the resident care attendants (RCAs) working in residential care facilities (RCFs) and then proceeded inductively to explore the social relations that governed them.  In this chapter, I present the research design, process, and methods. I begin with a description of the conceptual framework of IE and describe how I applied this method of inquiry to the investigation of the social processes that influence care provision in RCFs. I then present my research objectives, questions, and aims, followed by the study rationale. Following this, I detail the data collection and investigative methods. I conclude the chapter with a description of some ethical considerations.  Conceptual Framework: Institutional Ethnography IE was developed by Canadian sociologist, Dorothy Smith (1977) in response to her experiences as a woman in academia in the 1950s. Smith?s method has its roots in both Marxism and feminism. That people are driven and affected by powers above them, and of import, that these dynamics are usually invisible to them are key concepts in Marxist theory. Marx emphasized the importance of understanding the experiences of ?real people? to understand the ?whole picture? of what is happening from a sociological perspective (Smith, 1977). IE also draws from feminist perspectives in its concern with the ways in which the social category of gender exploits, oppresses, or marginalizes women and their experiences (Smith, 1977).  59 As a young academic in the 1950s, Smith found that the theories and abstractions within the sociological literature and research did not capture nor accurately represent her experiences as a working, single mother of two young children. In response to this lack of representation, Smith concluded that human experience needed to be examined in a new way?by talking about and examining everyday experiences rather than by examining abstract theories. She emphasized that IE is not a qualitative research methodology, but an alternative sociology that serves exploration and discovery, rather than theorizing. Accordingly, IE researchers learn from people?s everyday knowledge of their lives and doings; they do not impose pre-formulated interpretations (Smith, 2005). According to Smith, discussing everyday experiences becomes a means of discovering new knowledge. She described this new form of knowledge as ?embodied knowing"?the knowledge that comes from the expert, who is the person living the experience.  In the text The Everyday World as Problematic: A Feminist Sociology, Smith (1987) articulated a new way of doing sociological research. Her new perspectives allowed her to see that many social relations, and, in particular, people?s formal roles, are mediated by texts, forms and reports (Campbell & Gregor, 2008). A concrete example of this was how her mothering was affected by professors? tenure track requirements outlined in university policies. The discovery that texts and power relations profoundly affected people's everyday experiences formed the foundation for Smith?s future work.  Institutional Ethnography: Central Concepts IE begins with an exploration of the lived experiences of people directly involved in an institutional setting; however, the individuals are not the direct objects of investigation. Rather, it is the organizational processes that have generalizing effects on the people?s activities and 60 experiences that are under examination. The researcher's purpose in an IE is not to generalize about the participants, but to discover and describe the social processes that shape their activities.  Several key concepts within IE require both a definition and a description of how they relate to one another. The researcher begins an IE by identifying an experience worthy of investigation and then selects a "standpoint" from which to observe the "social relations" that permeate and influence the identified experience. The social relations are explored through a detailed examination of the study participants' embodied experiences. The focus of this exploration is to uncover the "textually-mediated work practices" that occur in response to the activation of "replicable texts" that coordinate their activities. The ultimate purpose of IE is to discover "disjunctures" and to subsequently explicate the "ruling relations" that influence the day-to-day practices of the study participants. Each of the key terms presented in the above description of IE is defined below. Standpoint. Taking a standpoint explicitly notes the place from which an IE researcher ?looks out? and acknowledges the way that an inquiry is ?situated? vis-?-vis other ?knowers? and other ?ways of knowing? (Cambell & Gregor, 2008). It anchors the research to the concerns and experiences of a particular group of people (DeVault & McCoy, 2002).  Social relations. According to Smith (2005), social relations are activities and practices through which people?s lives are socially organized. It is within social relations that we find the interplay of people?s ordinary activities being concerted and coordinated purposefully by something beyond their own motivations and intentions. These social relations occur as people carry out their activities within a social organization (Cambell & Gregor, 2008). Furthermore, one?s activity or work is said to affect the experience of another and it is this flow of activity or work that further constitutes the social relations. Thus, within IE, the term social relations is 61 often used as a technical term to describe the complex practices that coordinate people?s actions, often without their conscious knowledge.  Replicable texts. Smith (personal communication, May 3, 2011) described replicable texts as concrete forms of works, numbers, or images that exist in a materially replicable form. She said that it is the ?activation? of these texts by people that enables the texts to coordinate the social organization of institutions. Thus, within IE, a social organization is explored through the actual practices of individuals and the interaction of those practices with material objects, particularly replicable texts. Smith declared that it is not sufficient to use texts as sources of information about organizations; rather, they are to be observed and gathered as they enter into people?s local practices and to be examined as they co-ordinate people?s activities.  Textually mediated work practices. According to Campbell and Gregor (2008), a text has the power to hold people to acting in particular ways, although they may not recognize how their actions are being shaped by the texts when they meet face-to-face and relate to each other as individuals. In this way, the texts "mediate" the actual work practices. It is the relatively fixed and replicable character of texts "that can be stored, transferred, copied, produced in bulk, and distributed widely, allowing them to be activated by users at different times and in different places? (Smith, 2006, p. 34) that enables them to influence the social organization of individuals and groups within an institution.  Disjuncture. A disjuncture has been described as that moment of disquiet between the actuality of a person?s experience and the actionable institutional realities (Smith, 2005). Within an IE investigation, a disjuncture is believed to be imposed by regulatory frames, such as laws, policies, and other regulatory forms, that govern the structure or organization of the replicable texts used by the workers within an institution. The aim of IE investigations is not to study or 62 map out an institution in its totality; rather, it is to explicate pieces of actual work practices within a specific institution in ways that reveal points of disjuncture with governing processes and practices (Cambell & Gregor, 2008). Of significance, this mode of inquiry enables researchers and study participants to not only discover disjunctures, but to uncover solutions to address them (Pence, 2001). Ruling relations. The ruling relations, determined by the distribution of power within a social structure, are the complex set of rules by which society is organized (Smith, 1990). These formal rules may or may not be fully known by the individuals within a local setting (or institution), but they ultimately affect their work activities or experiences. The rules are ?translocal? in that they are developed outside the local setting. Smith (1990) maintained that, in contemporary society, ruling is organized through a construction of knowledge that relies on the complex forms of reporting, noting, accounting, and recording particular aspects of people?s work and lives.  Objectives, Research Questions, and Aims The objective of this study was to improve our understanding of how the social organization of residential care within RCFs supports or inhibits the exchange of residents? care information and thus, the provision of person-centred care. Following the framework of an IE investigation, it was assumed that, to achieve the objective, an understanding was required of the ruling relations that guided the everyday care practices of the RCAs in relation to organizational demands and priorities, as reflected in the institutional texts found within the RCFs.  Methodologically, IE proceeds inductively, moving from the particular experiences of workers in their everyday work to the general analysis of the social relations that govern them. Hence, this study was divided into two phases: Phase 1, in which I explored how RCAs 63 experienced working in RCFs and Phase 2, in which I explored the social and institutional processes that shaped the RCAs? experiences and how these processes affected their access to information and their ability to provide person-centred care (see Figure 3.1, p. Error! Bookmark not defined.). RCAs need to be in compliance with multiple regulations, guidelines, policies, and expectations while simultaneously considering the dynamic and unique needs of their residents. Thus, the provision of person-centred care must be accomplished within a highly regulated and complex healthcare system. In this study, I investigated the textually-mediated work processes within selected RCFs, thereby revealing points of disjuncture between the actual, embodied work practices of the RCAs and the governing processes that influenced them. I accomplished this through an exploration of the actual day-to-day care practices of selected RCAs and a detailed analysis of the influence that the replicable texts exerted on those care practices.  The research questions that guided this study were:  1. What are the primary institutional texts that influence RCAs in their day-to-day work? 2. How do textually mediated work processes influence the provision of person-centred care in RCFs? And 3. How is the work of RCAs socially organized in RCFs?  The specific aims of the study were to:  ? Systematically gather and analyze the replicable texts that influenced the day-to-day care practices within the study RCFs. This analysis included those texts that were actually used in the day-to-day care practices (e.g., daily flow sheets) and extended to texts that regulated or influenced the standards of care at the facility from the provincial and 64 national levels (e.g., care plans at the facility level, laws at the provincial level, accreditation standards at the national level).  ? Create a map that details how replicable texts containing residents? care information are made actionable by RCAs in RCFs.  ? Assess the relationship between the replicable texts in the RCFs and the provision of person-centred care to determine the following:  o How is information pertaining to the provision of person-centred care obtained in the RCFs (e.g., personal histories, needs, preferences, and routines of residents)?  o Where is this information stored? On what texts, if any, is it stored?  o Who has consistent and practical access to this information?  o How is this information transferred between care staff members?  o What organizational processes within the RCFs enable or impede both the translation and application of this information in day-to-day care practices? ? Develop specific knowledge that could be used to make recommendations for change and that could be linked directly to the creation of new standardizing practices, such as new rules, policies, procedures, forms, and training. Study Rationale The rationale for this study was based, in part, on my personal experience with replicable texts that contained language and information supportive of person-centred care within RCFs yet which remained largely inaccessible to the RCAs. For example, language explicitly supportive of person-centred care was most often found in institutional-level texts and boss texts (e.g., mission statements, public relations brochures, the Resident?s Bill of Rights). Yet, these texts were rarely, if ever, referred to during the course of the day-to-day work of RCAs. Instead, they were created, 65 reviewed, and revised by personnel who were often furthest away from the provision of direct care (e.g., policy makers, administrators). Another grouping of texts, which were specifically associated with the provision of person-centred care, were texts that contained residents? personalized information (e.g., social histories, care plans). However, my experiences led me to believe that these texts were often found only in the residents? charts, which were also rarely, if ever, referred to during the course of the day-to-day care practices of the RCAs.  Investigative Methods DeVault and McCoy (2002) described the procedures of research within IE as: (a) identifying an experience, (b) examining the processes or texts that affect the experience, and (c) investigating how those processes affect the activities within the experience. To accomplish these procedures, IE researchers are encouraged to draw on a variety of investigative and analytic methods. These include, but are not limited to, classic ethnographic field techniques, such as interviewing key informants, undertaking observations, and writing detailed field notes (Campbell & Gregor, 2008). It is important to note that within IE, these interviews and observations are specifically focused on how the experience of the subject is socially organized by institutional processes, rather than the customary sociological interest in studying groups of people (MacKinnon, 2005). Thus, a unique feature of IE is the exploration of what is referred to as the "translocal" level (i.e., what is beyond everyday experiences and not necessarily visible to the individual).  I began with ?local? observations and interviews of the RCAs. During my observation periods, I focused intently on the RCAs' observable activities with replicable texts during a regular work-shift. Once I was confident that I had achieved an understanding of the everyday practice of residential care provided in the RCFs, I shifted my focus to the ?translocal? level by 66 examining which and how institutional texts and, subsequently, boss texts affected the actual everyday provision of the residents? care (see Figure 3.1). Everyday experiences and interactions within the RCFs were captured using three primary investigative methods: (a) naturalistic observations, (b) in-depth interviews, and (c) textual analysis. As expected in an IE investigation, these primary methods of data collection were interconnected, and the data collected from one source informed the data collected from the others (Townsend, 1996).  67 Figure 3.1: Research Process Map            Naturalistic Observation in RCFs-field notes  Observe documentary practices and collect forms  In-depth Interviews Phase 1: How do RCAs experience work in RCFs?  Data Analysis ? describe RCAs' everyday work experiences ? create information access and exchange map Phase 2: What social and institutional practices shape the RCA?s experiences?  How do institutional and social practices affect RCAs' access to information and ability to provide person-centred care?  Interviews with RNs, LPNs, and team leaders Interviews with management & support staff Interviews with  residents and family members Expand the information access and exchange map by ?tracing up? the institutional-level and boss texts. Analyse how these factors influence information exchange and the provision of person-centred care within RCFs. Interviews with regional and provincial-level senior administrators and regulators.  How do these factors structure RCAs' work and what are the possibilities for change?  68 Phase One Naturalistic observations. The majority of the RCAs recruited for this study were first ?shadowed? or followed as they performed their daily work routines within the RCFs. Each observation began at the start of the RCA?s work-shift and concluded at the next team's start-of-shift meeting following the end of the participating RCA?s shift. Each RCA was observed only during the course of one of her regular work-shifts. Observations in IE are not treated as sources of data about the object being observed, but as a point of entry into the working of the institution of interest (Hammersley & Atkinson, 1995). Thus, the focus of these observations was to create a chronological account of the work of RCAs within their ?everyday, every shift? work. This chronological account created a story of what they did via a detailed description of the particulars of their work. It informed my understanding of the RCAs? work practices in their lived, embodied work-life. Specific emphasis was placed on information exchanges and on detailing all the texts that were used, or referred to, during the course of the RCAs? work-shifts.  To respect the rights and privacy of the residents, no residents were observed when personal care was provided behind a privacy screen (e.g., bathing, toileting). However, notes were taken during those times regarding the activities that the RCAs were engaged in. Thus, although I did not observe the RCAs actually bathe residents, I was able to take notes about the work that was occurring. For example, I was able to note that the RCA was providing a resident a bath, how long it took to accomplish the activity, what preparation went into the work activity, what occurred following the activity, what texts, if any, influenced the activity (e.g., was there a text that detailed the resident?s preferences regarding whether she took a bath or a shower and what time of day she preferred to be bathed?), and if available, whether the RCA accessed that text. Detailed field notes were written for each of the naturalistic observations of the RCAs 69 (Emmerson, Fretz, & Shaw, 1995) and included any questions that arose from the observations. Thus, my notes and observations guided the subsequent interviews and observations. In-depth interviews. Following the naturalistic observations, each of the RCAs was asked to participate in an in-depth interview. Permission was sought from the participants to tape record and transcribe the interviews. The interviews lasted approximately one hour and took place in a private location in the facility where the RCAs worked. The focus of these interviews was to ask the RCAs to fill in the gaps of what was observed so that I could further learn about "how things worked" within an RCF. It was during these interviews that I was able to further explore what had occurred when the RCA provided personal care to a resident, which I did not observe out of respect for the resident?s rights and privacy.  It is important to note that within IE, interviews are not structured, rather they are said to be more like ?talking to people? (DeVault & McCoy, 2002). According to Smith (2005), adhering strictly to an interview script limits the institutional ethnographer to what she or he has already anticipated and hence forestalls the process of discovery. Thus, the interviews all began with general questions such as, "With as much detail as you can, describe a regular work-day." "What makes a good day?" and "What makes a bad day?" The interviews then proceeded with questions specific to the exchange of information and the provision of person-centred care, such as: ?When a resident is first admitted, how do you learn how to provide care to them?" Following the IE method of inquiry, all other questions evolved out of the course of the conversations and interviews as they would normally arise (Smith, 2006). Each interview informed the ones that followed; thus, the interviews and the subsequent interview questions were iterative in nature. The focus of these interviews was to identify the ?institutional work process that shape[d] the informants? everyday work? (DeVault & McCoy, 2002, p. 755).  70 Textual analysis. During Phase One of the study, blank copies of the texts that were used or referred to during the naturalistic observations and interviews were obtained and analyzed for content related to the individualized care preferences and needs of the residents. I grouped these texts into the category of ?everyday texts??those texts that were found in the everyday practice of the RCAs (e.g., residents? bathing lists). During Phase Two, I categorized the texts into one of two groupings: (a) ?institutional-level texts??those texts that had the potential to mediate the work of the RCAs and were developed at the facility level (e.g., the residents? assessments and care plans) and (b) ?boss texts?? those texts that were translocal in that they were developed outside of the local institution and implemented across multiple healthcare institutions (e.g., laws, regulations, and standards of practice). All of these replicable texts were considered because they coordinated, or attempted to coordinate, the care staff members? actions that were integral to the RCFs; thus, they were investigated as the visible traces of the institutionalized social relations that governed the actual work practices.  I identified the everyday texts during the observations and interviews completed during Phase One by taking note of the texts that guided and informed the RCAs? daily care practices. The institutional-level texts and boss texts were identified through four sources: (a) observations of practice with the associated everyday texts, (b) my personal knowledge, (c) the search of web sites of relevant regulatory bodies with public domain search engines, and (d) the interviews conducted during Phases One and Two.  Phase Two The focus of Phase Two was to explore and describe how social relations were organized within and beyond the local setting. Phase Two began with interviews of the facilities? RNs and LPNs and then the support staff (e.g., maintenance, dietary staff, administrative assistants, 71 recreation staff), managers, residents, and residents' family members. The purpose of interviewing people other than the RCAs stimulated discovery of how what was done, in the context of the work, was guided or ruled by relations not always known or understood by the participants (Campbell & Gregor, 2008). Thus, the focus of these interviews was to understand how the organizational linkages and social relations between these groups supported or hindered the RCAs? access to information and ability to provide person-centred care. The questions for these interviews were not pre-determined and were derived specifically from the previous observations and interviews conducted with the RCAs.  I concluded Phase Two by conducting interviews with the senior administrators and regulators at the regional level. The focus of these interviews was to address the development, implementation, and use of the institutional-level texts found within the RCFs and the boss texts that influenced the daily care practices. My intention was to inform the study participants of the findings and to engage in a discussion of the possibility for change in the institutional work processes and texts that could positively influence the RCAs? access to information and ability to provide person-centred care.  Data Collection: Setting and Sample Campbell and Gregor (2008) suggested that sample size be decided by the type of data to be gathered. Several criteria, namely, the methodology, the complexity of the phenomenon under study, and the experience of the researcher should guide the decision of sample size in qualitative research (Sandelowski, 1995). Because IE follows the natural shape of everyday practices, the number of data sources (e.g., informants, documents) should emerge out of the research process rather than be predetermined in an a priori research design. Streubert-Speziale and Carpenter 72 (2003) suggested that participants be selected on the basis of their in-depth and particular knowledge about the experience under study.  In an IE, data collection continues until sufficient data have been collected to record how everyday practice actually works within an institutional framework (Townsend, 1996). Thus, the data collection process for this study began broadly to describe accurately the everyday work world of RCAs and gradually narrowed until no new variations or contradictions emerged in the observed practice. Data were collected over seven months.  Setting. The study was conducted in three RCFs located in British Columbia (BC), Canada. These RCFs were selected based on several features: (a) the facilities were home to between 120 and 150 residents; thus, they were similar in size to many RCFs within BC; (b) the facilities were home to residents who were assessed as having complex care needs and thus required the presence of skilled nurses 24 hours a day, 7 days a week; (c) the facilities were similar to the majority of RCFs within BC in their staffing mix (e.g., a registered nurse (RN) oversaw a licensed practical nurse (LPN) who was a team leader who oversaw the resident care attendants (RCAs)); (d) similar to the vast majority of RCFs in BC, the care staff were members of a union; (e) the facilities had implemented an explicit person-centred model of care; and (f) the facilities were located within reasonable proximity so that they were readily accessible for observations to take place during all shifts and for extended periods.  A key-differentiating feature among the three facilities was their ownership status. A substantial body of research has assessed the relationship between ownership status and quality of care in RCFs. A recent systematic review and meta-analysis by Comondore et al. (2009) concluded that, on average, not-for-profit facilities provide higher quality of care compared with for-profit facilities. However, their findings also suggested that while a positive association is 73 evident, it likely varies across situations and is potentially mediated by management philosophies and related work organization systems. It is because of these equivocal findings that the study facilities were purposefully selected to vary by ownership status. Facility #1 was a private-for-profit facility, Facility #2 was a private not-for profit facility, and Facility #3 was owned and operated by the government funded regional health authority. See Table 4.1 on page 106 for an overview of the contextual factors of the three participating RCFs.  Facility #1. Facility #1 was owned and operated by a private-for-profit provider of independent retirement living, long-term care, and home care in Canada and the United States. This firm was selected for two reasons. First, the site had recently developed a professional practice model based on their corporate mission of providing person-centred care. This practice model involved advocacy, empowerment, and respect for residents? autonomy, self-determination, and participation in decision-making. Second, at a chance meeting at a national conference on aging, senior members of the organization expressed interest in this research. Consequently, senior administrators from this corporation were contacted to seek their endorsement of the study. After multiple e-mails and phone meetings, these administrators agreed to have one of their facilities in BC participate in the study. A subsequent interview with the corporation's Provincial Director of Long Term Care Services was held. During this meeting, Facility #1 was selected for inclusion in the study based on the above-mentioned criteria.  Facility #1 provided complex care services to 131 residents, of whom 101 resided in publically subsidized units and 30 resided in private-pay units.4 The building was "older" and                                                   4 The difference between private-pay and publically subsidized beds is described in detail in Chapter 4, which describes the context of living or working in RCFs. 74 lacked physical design features that many RCFs in BC offered to residents (e.g., all private rooms, mechanical ceiling lifts built into the ceiling of each room to assist in lifts and transfers of physically impaired residents, small "neighbourhood" gathering areas). It housed residents in rooms that were private (i.e., one resident per room), semi-private (i.e., two residents per room), and 4-bed wards (i.e., four residents per room). The majority of the residents lived in semi-private rooms or 4-bed wards located on the lower level. The private pay rooms were all single dwelling rooms located on the second level. In this facility, the care staff members rotated to a new resident assignment list (i.e., a new group of residents to whom they would provide care) every six weeks. Facility #2. Facility #2 was a privately owned, not-for-profit facility. This facility was owned and operated by a well-known service organization. The goal of the service organization was to "support a culture of caring with compassion for the residents living in their facility." They also espoused a person-centred approach to care through the creation of "a warm, home-like atmosphere by grouping residents into small families of eight to twelve." Upon reading the research proposal, a senior administrator from the health authority recommended that I invite this facility to participate. I corresponded via e-mail with the executive director of the facility and then met with her to discuss the facility?s participation. She expressed interest in and support of the study and we subsequently pursued and obtained consent from the board of directors of the facility. This facility was home to about 125 residents, six of whom paid privately for their rooms. This facility was purpose built to provide specialized care to individuals with dementia who also had complex care needs. Every resident had a private room (i.e., one resident per room) and ceiling lifts were located in the rooms of those residents who required them. The care staff members were assigned to care for the same residents every shift they worked. This practice of 75 ?permanent resident assignment? is recognized by many as a "best practice" in dementia care (Castle, 2011). Facility #3. Facility #3 was owned and operated by the government funded regional health authority. It was home to approximately 150 residents and offered no private-pay rooms. The facility had several buildings, each of which was purposefully designed to meet particular care needs (e.g., small home-like units for ambulatory residents with dementia and larger hospital-like units for physically frail residents). Depending upon the building, the residents were housed in private, semi-private, and 4-bed wards. During my data collection, the care staff members in this facility were in the process of moving from permanent resident assignments to a rotation wherein they were assigned to different residents every three months.  Sample. The primary sampling strategy was purposive sampling. The study participants were composed of employees (i.e., RCAs, RNs, LPNs, support staff, and managers) who were employed on a casual or permanent, full- or part-time basis in one of the study RCFs, as well as family members, residents, and regional and provincial-level senior administrators, regulators, a member of a provincial advocacy group, and a researcher who utilized data from the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for research purposes.  The study RCAs were recruited during initial information meetings. Based on my past experience as an employee, consultant, and researcher in RCFs, I was acutely aware of how important issues related to trust in the researcher-participant relationship would be to this study. In acknowledging this, I gave much attention to how I would introduce this study to the staff during the recruitment meetings. I engaged a professional coach who assisted and challenged me as I explored this issue. As a result of this ongoing coaching, I developed an outline of my introduction to the study, which included messages of transparency and some vulnerability on 76 my part. This was important because, in effect, I was asking the RCAs to be transparent and vulnerable by participating. I believe my attention to these details was instrumental in recruiting sufficient numbers of participants. In all, 14 RCAs agreed to be ?shadowed? during their workday and to be subsequently interviewed; 4 RCAs agreed to be interviewed only. The 4 RCAs whom I interviewed, but did not shadow, were purposefully selected because they offered a unique perspective within their institution (i.e., they worked as casuals in multiple RCFs and in multiple units throughout RCFs, worked on units other than the ones in which I had conducted naturalistic observation, or actively participated in specific organizational programs such as a work-load committee). Attention was paid to recruiting RCAs who worked on all shifts during the 24-hour workday (e.g., day shift, evening shift, and night shift). At the completion of data collection, I had conducted 104 hours of naturalistic observation. RNs, LPNs, support staff, managers, residents, family members, senior administrators, regulators, a researcher, and RCF advocates were also recruited for in-depth interviews. The focus of these interviews was to understand how the organizational linkages and social relations between these groups of employees supported or hindered the RCAs? access to information and thus, their ability to provide person-centred care.  In all, I conducted 76 interviews. Following a description of the study requirements, informed and voluntary consent to be interviewed was obtained from each of the study participants. See Tables 3.1, 3.2, and 3.3 for details of the study participants stratified by study phase, facility, and sector.  77 Table 3.1: Phase One?The Number of Study Participants by Facility  Facility #1 Facility #2 Facility #3 Resident Care Attendant 8 6 4  Table 3.2: Phase Two: Part A?The Number of Study Participants by Facility Participant Group Facility #1 Facility #2 Facility #3 Executive Director 1 1 1 Social Worker 2 1 1 RAI-MDS Coordinator 2 1 1 Nursing Supervisor 1 1 2 Registered Nurse 2 2 1 Licensed Practical Nurse 2 2 1 Resident 3 1 2 Family Member 4 5 4 Maintenance Employee 0 1 0 Administrative Assistant 1 1 0 Food Services Employee 1 0 0 Recreation Employee 1 0 0  Table 3.3: Phase Two: Part B?The Number of Study Participants by Sector Sector/Title Number of participants Member of a provincial advocacy agency for RCFs 1 Union Representative 1 Senior Administrator 2 Regulator or Licensing Officer 3 Researcher 1 Retired Manager 1  Data Analysis Data analysis in IE is not clearly prescribed in the works written about the methodology. However, consistent with all IE studies is the requirement to analyze not only the participants? understandings and experiences, but to connect those experiences with a ruling system located outside the participants? everyday world. According to Smith (2005), the purpose of the analysis is not seeking patterns; rather, the purpose is to explicate how the work is socially organized. Thus, the goal of my data analysis was to obtain an accurate understanding of the relationships 78 between the everyday practice of care giving in the RCFs and of how the institutional priorities and mandates, as reflected in the institutional texts, influenced the RCAs? work. The data analysis began with the interviews that followed the observation periods; as each interview progressed I verified my understanding by reframing my questions and clarifying the responses (Campbell & Gregor, 2008; DeVault & McCoy, 2002).  Campbell and Gregor (2008) recommended using the following guiding query during the analysis phase of an IE study: ?What does it tell me about how this setting or event happens as it does?? (p. 85). Correspondingly, DeVault and McCoy (2002) described the researcher as one who is to ?find and describe social processes that have generalizing effects? (p. 753). They further proposed that selection of one strand is necessary because researchers often collect considerably more information than they can use in an analysis.  The data included in the analysis were derived from the field notes, recorded interviews, and documents obtained during Phases One and Two. Transcripts of the recorded interviews were produced verbatim. Microsoft Word? was used to manage and group the data from the interviews. The decisions regarding how the data were to be grouped were not predetermined. Rather, they evolved from a review of the observation notes, the transcribed interviews, and the process of creating information-exchange maps. The goal of IE is not to explain people or their attitudes, but to explicate the social processes within which people find themselves and which they reproduce and alter through their participation. Thus, I was encouraged to focus on the actual work processes and the forms of knowledge and co-ordination that went into the care of the residents of the study RCFs. The constant focal point of my analysis was discovering any gaps between what the RCAs experienced as a result of the institutional processes and the institutional goal of providing 79 person-centred care. Because I selected the standpoint of the RCAs, I made every effort to see the gaps from the RCAs? position and to see what parts of the gaps were produced by the institutional practices (i.e., a disjuncture).  Early on in the data analysis I created information-exchange "maps" that demonstrated the interconnectedness and directionality of the information flow between the RCAs and the other care staff. I conducted observations, interviews, and document reviews until I believed that I understood how the residents? care information was obtained, where it was stored, how it was accessed and by whom, and how it was transferred or shared by the various staff members. Having the data analysis grounded in these information-exchange maps provided an essential foundation from which to determine when the data collection and analysis were "complete." An IE study does not stop at the identification of issues that are problematic in the everyday work of people, but seeks to understand how these issues are governed by institutional priorities and mandates as reflected in the institutional texts. Accordingly, it is through the identification of the relationships between the texts and everyday practice that problems within the institution can be addressed with specific solutions for change. Consequently, I completed the analysis by creating a model that represented a conceptualized understanding of the factors that positively influenced the provision of person-centred care in the participating RCFs.  Ensuring Scientific Quality Several scholars have articulated ways of ensuring the scientific quality or rigor of qualitative research (Lincoln & Guba, 1985; Maxwell, 2012; Onwuegbuzie & Leech, 2007). Two broad types of threats to validity are often raised in relation to qualitative studies: (a) researcher bias?how the researcher?s values and expectations influence the conduct and conclusion of the study and (b) reactivity?the influence of the researcher on the setting or individuals studied 80 (Maxwell, 2012). According to Maxwell (2012), it is impossible to eliminate the influence of the researcher on the study and it is equally impossible to eliminate the researcher?s theories, beliefs, and perceptual ?lens? during the research process.  Consequently, the goal of a qualitative researcher should not be to attempt to eliminate these influences, but instead to understand them and to use them productively. For this reason, it was important for me to reflect on my ontological and epistemological approach to the research. I believe that the attainment of "universal truth" is impossible and that truth is culturally or socially constructed. I believe that knowledge is contextual, is subject to multiple interpretations, and is constructed through social interaction (Gergen, 1999). I also believe that knowledge depends on decreasing the influence of ideological biases. Thus, as I engaged in this research, the quality of the work and the utility of the results were largely dependent upon my ability to remain open while being fully immersed and engaged. I recognized early that a significant challenge was finding a balance between honouring and applying my prior knowledge and experiences (both on a professional and personal level) to enhance the research while simultaneously not letting any preconceived ideas obstruct the opportunity to learn something new or see something that I had not seen before. Once in the field, my aim was to put my preconceived ideas aside and be as open to learning from others who are positioned differently from myself as possible. Following the advice of Dorothy Smith (personal communication, May 3, 2011), I attempted to ensure a level of objectivity and openness by remaining steadfastly focused on the actual work that the RCAs did. During my interviews, I also worked diligently to ensure that it was the informants' ideas, thoughts, and experiences that guided the interviews and not my own. 81 Throughout this study, I reflected on what my possible biases were, how I should deal with them, and how I may have influenced what the participants said and did. I reflected on how these influences affected the validity of the conclusions I believed I could draw from the data. Hammersley and Atkinson (1995) called this process ?reflexivity??the ability of the researcher to reflect upon, examine, and explore the social process and contextual factors that influence the research relationship as well as the study participants? lives. According to Etherington (2007), reflexivity allows researchers to include our "selves" in the research by making transparent our values and beliefs that influence the research process. In this study, my reflexive work was made transparent through field notes, the more extensive writing that I engaged in at the end of each observation period and interview, and monthly meetings I held with my research supervisors to discuss my ongoing data collection and field experiences. In addition to reflexivity, the rigor of this study was assessed through the following validity tests: (a) the collection of ?rich? data, (b) evidence of credibility, and (c) the search for discrepant evidence or negative cases (Becker, 1970; Emerson, Fretz, & Shaw, 1995; Fonow & Cook, 1991; Lincoln & Guba, 1985; Wolcott, 1990). According to Becker (1970), ?rich? data are detailed and varied enough to provide a full and revealing picture of what is going on. This is clearly the goal of an IE investigation and was imperative to the rigor of this study.  To ensure that I obtained rich data, my observation periods included all of the shift types that the RCAs worked (e.g., day, afternoon, and night) and I observed the RCAs' shifts in their entirety, rather than observing a portion of them. Finally, I remained in the facilities and observed the start-of-shift reports and inter-shift communication immediately following each observation period. I interviewed each participant following the observation period so that I was able to clarify my observations and ?fill in the gaps? of anything that I may have missed or 82 misinterpreted. I repeated my shadowing of complete shifts and in-depth interviews until I believed that I had obtained a clear and detailed picture of what happened in the course of an RCA?s workday. In addition, I ensured ?rich data? by taking detailed, descriptive notes of the specific events that I observed (Emerson, Fretz, & Shaw, 1995) and by transcribing the interviews verbatim (Maxwell, 2012).  The notion of credibility refers to ensuring that study findings reflect the realities of the participants (Streubert-Speziale & Carpenter, 1995). For this IE study, it was important to address how the participants? realities were included and described accurately and thoroughly in the data. Thus, the credibility of the findings was sought in three ways: (a) through member checking?the process of ensuring that the participants had input into the interpretation of their experiences (Sandelowski, 1993), (b) auditability?the ability of others to trace the methods used in the study via a transparent ?decision trail? (Sandelowski, 1986), and (c) triangulation?ensuring that I had multiple points of view when gathering the data (Sandelowski, 2000).  I addressed member checking by sharing the emerging findings with, and soliciting feedback about the data and conclusions from, the participants throughout the data gathering and analysis stages. Member checking occurred with each participant. I did this with the intention of ruling out the possibility of misinterpreting the meaning of what the participants said or did, and to include their perspective about what was going on. In addition, I used member checking as a means of identifying my own biases and possible misunderstandings of what I had observed or heard (Maxwell, 2012). As noted by Hammersley and Atkinson (1995), however, participants? feedback is no more inherently valid than are their interview responses; therefore, both were taken as evidence of the validity of my accounts.  83 Auditability refers to the "decision trail" left by a researcher that allows others to trace the methods used (Sandelowski, 1986). A transparent decision trail was provided within my study design, my explanation of my methodological choices, and the information-exchange maps I created. Triangulation refers to the use of a variety of methods to collect information from a diverse group of individuals. Triangulation is used to reduce the risk of systematic biases. In this study, I addressed this issue in several ways. First, I used multiple methods to obtain the data: observations, interviews, and textual analyses. Second, I gathered data from diverse participants: RCAs, RNs, LPNs, support staff, residents, family members, managers, and senior administrators. Finally, I gathered and analyzed documents and texts created at three distinct levels: the everyday or local work environment, the institutional-level, and the relevant boss texts. According to Maxwell (2012), one way to test validity in qualitative research is by analyzing negative cases and discrepant data. He stressed that researchers ?need to rigorously examine both the supporting and the discrepant data to assess whether it is more plausible to retain or modify the conclusion, being aware of all of the pressures to ignore data that do not fit your conclusions? (p.112). I actively worked to ensure that I included and addressed divergent data in my analyses and asked my key informants for ongoing feedback so as to check my own biases and assumptions and to challenge any flaws in my logic or methods.  Ethical Considerations During the preliminary study information meetings (with small groups and one-to-one), all of the participants were informed that their participation was entirely voluntary. Before they decided whether they wished to participate, they were offered an information sheet that informed 84 them about the study, why the research was being done, and what was required of them, if they decided to participate (see Appendix A). They were also informed in writing and verbally that if they decided to take part in the study they were free to withdraw at any time without giving any reason for their decision. Furthermore, they were informed that if they did not wish to participate, they did not have to provide any reason for their decision, and their decision would in no way affect their employment status or relationship with management.  The confidentiality of the data collected during any research project is essential; therefore, numeric identifiers were used to replace the names of the participants and they were grouped into one of only six categories: RCA, Team Leader, Manager, Administrator (i.e., participants interviewed in Phase 2), Resident, and Family Member. In addition, all the participants were referred to as female (regardless of their gender) in the analysis and writing. All of the participants were asked to sign a consent form (see Appendix A). However, it is important to acknowledge that, as a result of spending considerable time in the three facilities, I engaged in informal discussions with RCAs who, although not active study participants, knew that I was a researcher and informally spoke with me (e.g., in the break room, while waiting for report, and in the hallways). I did not take notes of my conversations with, or observations of, these RCAs, who had not formally consented to participate. Consequently, although I acknowledge that the conversations I had with them informed my findings, I primarily relied on the data obtained from the study participants who had signed consent forms. All of the RCAs? interviews were scheduled during their regular workday. The interviews of all employees and residents of the three RCFs took place in private locations in their respective RCF. All other participants (e.g., family members, senior administrators, regulators) were contacted directly, and the times and locations of their interviews were set based on what 85 was most convenient to them. These interviews occurred in offices, coffee shops, and the participants' homes.  In designing this study, I was acutely aware that asking RCAs to leave their unit during their regular work-shift could result in negative consequences for the residents under their care and for their teammates who would have to "pick up the slack" and care for the residents in their absence. Thus, in an attempt to ensure the least amount of interference with the residents, families, and other care staff members, I paid the salaries of casual RCAs to cover the duties of the participating RCAs while they were engaged in the interviews. Because I could not afford to do the same for the participating regulated care staff, I scheduled their interviews to occur either immediately before or after a regularly scheduled work-shift; I gave them an honorarium for their participation equivalent to one and one half hours of work at their pay grade. The facility managers allowed the nursing leaders and other support staff to accommodate my interviews within their normal workday; thus, they were not given an honorarium nor replaced by a casual staff member. All of the RCAs who agreed to be observed during an entire work-shift and to participate in an interview were offered a $45 gift card as a "thank you" for their participation. Every study participant who agreed to participate in an interview alone was offered a $25 gift card.  The names of the residents of the facility and their identifying information (e.g., date of birth, room numbers) were not sought and no residents were selected for direct observation. Rather, my goal was to make general observations of "anonymous" residents during the RCA job shadowing. In addition, to respect the rights and privacy of the residents, I was not present when personal care was provided behind privacy curtains or closed doors (e.g., bathing rooms and toileting).  86 I recognized that it was important to ensure that, to the extent that they were able, residents with dementia understood that they were participating in research and were given the opportunity to agree or refuse to be observed. I accomplished this by obtaining signed consent from the resident (or designate) and also by seeking verbal assent?affirmative agreement to participate or, alternatively, respecting the resident?s expressed dissent or objection (Black, Rabins, Sugarman, & Karlawish, 2010). Recognizing the continual nature of naturalistic observation, obtaining assent was an ongoing process (Morse & Field, 1995). To address the ongoing nature of assent during the observation periods, I wore a nametag that identified my role as a researcher and I reminded the participants of who I was and why I was there. I spoke directly to the residents using language appropriate to their cognitive status while making observations of both their verbal and nonverbal responses to our conversations. I relied on my expertise as a dementia care specialist and recreation therapist to engage in these conversations and to assess the residents? apparent assent or dissent.  Ethics review. I was required to obtain ethics approval for this study from four ethics review boards or committees (i.e., the health authority ethics review board, the university behavioural research ethics board, and two facility-specific ethics review committees). Because I intended to observe RCAs interacting with residents with dementia, one of the ethics review boards designated the study as "high risk." Regardless of my efforts to ensure that the study would have minimal impact on the residents, the ethics board required that I obtain signed, informed consent from all of the residents whom I might observe in the facility (or their representative family members) prior to commencing the study. Obtaining signed consent from all residents or their family members was an arduous task. I accomplished this task by first mailing a study package, which I compiled and an administrative 87 assistant from the facilities addressed, to selected residents and all family members of the facility. This package contained the following items: (a) an information letter explaining the research aims and goals, (b) a detailed description of the data collection processes, (c) a consent form, and (d) a stamped self-addressed envelope to return the signed consent form (see Appendix B, C, D, and E). Following the mail out, I conducted several information meetings for the facility?s residents and their family members to recruit participants and to gain consent for the naturalistic observations.  The requirement of having to have informed, signed consent from every resident who may have been observed had the unintended consequence of placing a relatively heavy burden on the participating facilities. I required their assistance in determining which residents were cognitively able to provide informed consent and then in contacting the family members of the residents who were deemed not competent to sign their own consent forms.  The time consuming process of obtaining signed consent from all residents or their family members, in Facility #1, led to a change in the subsequent recruitment strategy. I obtained signed consent from only those residents whom I interviewed. To conduct my observations of the RCAs, I obtained ongoing verbal assent from every resident and requested signed consent only from family members.  In the second facility, I conducted naturalistic observations only of staff who worked in one small unit within the facility. I did so because I was then required to obtain signed consent from the family members of a limited number of residents who lived in the one unit (as opposed to the entire facility). In an attempt to address the possible bias that this recruitment strategy produced, I ensured that I interviewed an RCA who worked in another unit in this facility and also an RCA who worked on a casual basis on all units in the facility. Though this strategy 88 assisted in obtaining consent from family members, it was not until I had almost completed the data collection that I realized that the RCAs from this facility were at greater risk of being identified because the majority of the data obtained could have been traced to the one unit where they were permanently assigned. Thus, in Facility #3, I conducted naturalistic observations in two units. This approach better enabled me to protect the RCAs' anonymity, yet I was not required to obtain consent from 150 residents or family members.  The process of obtaining consent was the most challenging aspect of this study. The unintended outcomes of the ethics review process?a process that should have protected the study participants?was that some of them experienced unnecessary risks associated with the loss of anonymity. In an attempt to address this, I assigned some study participants more than one number (i.e., in the place of their name) when including their quotations. I was especially diligent in doing this when there was a possibility that a quotation could be traced to a particular facility.  89 Chapter 4: The Context of Living or Working in a Residential Care Facility The simplified, but accurate, goal of this institutional ethnography was to understand how information exchange is influenced by the way in which care work is socially organized in residential care facilities (RCF). I accomplished this through observing and interacting with people engaging in their everyday activities, which, when taken together, helped me to understand more fully ?how things work? in these institutions.  An understanding of ?how things work,? however, must begin with an examination of the context within which the work occurs. Consequently, I begin by describing the complex regulatory framework that governs RCFs in British Columbia (BC). The information presented here is derived from an extensive review of governmental policies, an overview of the relevant research literature, an analysis of selected participant interviews, and my personal clinical experience. I first discuss some macro-level contextual factors by providing an historical overview of residential care regulations in Canada. At the meso-level, I explore the current provincial and regional regulations that govern the three study facilities (Facilities #1, #2, and #3). Finally, at the micro-level, I discuss the regulations that determine who lives and works in these institutions.  The Macro-Level Context: An Historical Overview of Residential Care Regulations in Canada When attempting to better understand how the regulatory framework influences the quality of living or working in RCFs in BC, it is prudent to review the historical evolution of institutional living environments in Canada. Sadly, a review of this history reveals societal values that have been mostly oppressive and discriminatory against individuals who are unable to be productive members of the labour force.  90 Before the Great Depression, the only form of public support available to the destitute elderly was within institutional settings. The guiding principles of these institutions (called poor houses, work houses, or alms houses) were derived from the English Poor Laws?laws passed in the 1600s and later revised in the 1800s to ensure that conditions of life in these houses would be less pleasant than that experienced by the lowest working class citizens. Therefore, only the absolute essentials necessary for minimal maintenance of the individual were provided in any of these institutions (Forbes, Jackson, & Kraus, 1987). Unfortunately, until recently, it seems that the English Poor Law system exerted the greatest single influence on the evolution of residential care in Canada (Emodi, 1977). The governmental systems that invented poor houses were also eager to discourage people from using them, and a stigmatization attached to admission was not only intended, but also encouraged. Fear of the poor houses (based on the substandard and inhumane conditions within which residents were forced to live) was a ?pro-active? way to ensure that only those individuals who were truly incapable of labour were admitted. People in need were considered subjects of their own failure and were viewed as second-class citizens. The Puritan-based suspicion that moral degeneracy was the true cause of poverty enabled the grossly substandard living conditions experienced in these houses to remain for centuries (Forbes, Jackson, & Kraus, 1987). In Canada, the ?general mix? poor houses and work houses (single dwellings in which up to 200 people lived, including the poor, unwed mothers, mentally ill individuals, mentally impaired individuals, delinquents, and the infirm elderly) existed well into the twentieth century (Forbes et al., 1987).  This historical review of institutional living environments provides an important foundation from which to understand how the first measures of the quality of care provided 91 within RCFs were defined, measured, and regulated. The original inspectors of the poor houses primarily ensured that the management and bookkeeping of these establishments were in order. They frequently reported that the living conditions were substandard, but, in keeping with the ideologies of the Poor Laws, they did little to rectify the situations (Emodi, 1977). In Ontario, inspections of the poor houses were originally the responsibility of the Inspector of Prisons and Public Charities; in other provinces, the inspections were conducted by physicians or governmentally appointed persons (Forbes, Jackson, & Kraus, 1987).  In 1918, the American College of Surgeons (ACS), of which Canada was an active member, developed the Minimum Standards for Hospitals. The document filled just one page, yet at the time only 89 of 692 hospitals surveyed (12.9%) met the requirements for the minimum standards of care (Accreditation Canada, 2013). It was in the 1920s that the first ?private hospitals? were opened for the elderly. These facilities provided little more than food, shelter, and minimal nursing care and were often run by nurses forced to add to their income by opening their homes to patients (Forbes, Jackson, & Kraus, 1987). According to Emodi (1977), these hospitals provide the link between the earliest facilities and modern RCFs.  Between 1920 and 1970 much change occurred that would lead to significant improvements in the quality of care offered to Canadians living in RCFs. During this 50-year period, Canada opened long-term residential care public and private hospitals specifically for the elderly (1920s), implemented the Old Age Pension Act (1927), implemented the Homes for the Aged Act (1947), implemented the Canada Assistance Plan (1966) and, most important, implemented a national insurance program via the Hospital Insurance and Diagnostic Services Act (1957) and the Medical Care Act (1966). Each of these interventions had a dramatic impact on where, how, and how well the elderly were cared for (Forbes, Jackson, & Kraus, 1987).  92 However, it was not until 1978 that the accreditation of RCFs was implemented. Up to this time, no surveys specific to RCFs were developed; therefore, it may be safe to assume that residential care ?hospitals? would have been surveyed under the same standards developed for acute care settings (Accreditation Canada, 2013). It is no wonder then that original standards of care in RCFs were primarily focused on meeting basic biological needs, were clearly task oriented, and were based almost exclusively on objective medical and clinical outcomes. Critics of the medical model state that it ?justifies control as appropriate treatment for the good of the patient? (Lyman, 1989, p. 602). Furthermore, they contend that it creates a hierarchy of power within care environments and promotes care that is primarily custodial in nature ( Lyman, 1989; Lyman, 1990).  Meso-Level Context: How Quality is Regulated and Measured in Residential Care Facilities  The BC Ministry of Health (BCMOH) establishes province-wide goals, standards, and expectations for the delivery of care and services for seniors. This ministry is responsible for ensuring good governance and the continuous monitoring and evaluation of service delivery in BC?s RCFs. Though the BCMOH sets the standards and expectations for care, the actual delivery of services for seniors is the responsibility of BC?s regional health authorities.5                                                    5 In 2001, BCMOH restructured the administrative oversight of publicly-funded healthcare services by amalgamating the existing health authorities into six larger health authorities: five have geographic areas of responsibility (i.e., Vancouver Island, Fraser, Interior, Vancouver Coastal, and Northern) and one oversees specialized provincial health services (e.g., Children's Hospital, Women's Hospital, Cancer care).  93 Throughout BC, residential care services are provided in publicly owned and operated (not-for-profit) facilities, privately owned not-for-profit facilities, and privately owned for-profit facilities. Each type of facility was purposefully represented in this study. Facility #1 was a privately owned for-profit RCF, Facility #2 was a privately owned not-for-profit RCF; and Facility #3 was a publicly owned and operated RCF (see Table 4.1). Publicly subsidized residential care beds are funded, in part, by the BC Government and, in part, by the resident. According to the BCMOH, the cost of operating a RCF bed is about $6,000 per month, or $200 per day. Depending upon their incomes, subsidized residents contribute between $898 (15%) and $2,932 (49%) per month (BCMOH, 2013). This rate structure requires that people in subsidized beds pay up to 80% of their after-tax income, provided that they have at least $325 of their income remaining each month. Private for-profit and private not-for-profit facilities can offer both publicly subsidized as well as private-pay services. For example, in Facility #1, 29 of the 130 beds (22.3%) were private-pay beds, and in Facility #2, 6 of the 125 beds (4.8%) were private-pay.6 Accordingly, these privately owned facilities are referred to as "affiliated" or "contracted" facilities because they are contracted by the regional health authority to provide services to individuals entitled to publicly subsidized services. Regardless of the ownership status, all RCFs in BC are required to comply with the same standards of care.  Regulating quality in residential care. In BC, the RCFs that are located in the community are licensed and regulated under the Community Care and Assisted Living Act (CCALA). The residential care services that are provided in a public, extended care hospital or a private hospital are governed under the Hospital Act. Facilities that are licensed under either                                                   6 The total number of beds has been approximated to ensure anonymity of the participating RCFs. 94 legislative act may be publicly owned and operated or operated by private, non-profit or for-profit entities. Most RCFs (71%) in BC are licensed under the CCALA; however, over 100 RCFs (29%) continue to be regulated by the Hospital Act. Facilities #1 and #3 were governed under the Hospital Act and Facility #2 was governed under the CCALA.  According to the British Columbia Ombudsperson Public Report #47 (2012), the Hospital Act has changed very little in the past 50 years. At its inception, its principal focus was the regulation of public hospitals that provide acute care, rehabilitation and extended care services. Significantly, the Hospital Act has no mandatory standards of care or practice provisions for the operators who provide residential care services.  The CCALA, on the other hand, was created in 2002 to replace the Community Care Facility Act, and outlines extensive care standards specific to both residential care service provision and the physical environment within which it occurs. The CCALA also determines the responsibilities of the medical health officers, who are appointed under the Public Health Act and employed by the regional health authorities. Medical health officers are responsible for issuing licences, conducting routine inspections, investigating complaints, applying sanctions and issuing exemptions from the requirements of the CCALA. In practice, these powers are often delegated to licensing officers, who work for the regional health authorities. This process was described by a study participant from the licensing division of a health authority:  Administrator [04]: ...we have multiple, multiple policies and procedures for staff [licensing officers] to follow. We have a checklist that basically embodies the entire regulation that staff use when they go out to conduct inspections. ...there are requirements for the facilities to report to us any kind of allegations or concerns or not meeting their regulation on any kind of level.  95 However, the licensing officers have no authority to inspect or investigate complaints arising from the RCFs that are regulated under the Hospital Act. As a result, the standards and oversight mechanisms that apply to the RCFs licensed under the CCALA are more extensive and rigorous than those that apply to RCFs governed by the Hospital Act.  The BC Government recognized the need to harmonize these two regulations when they passed Section 12 of the CCALA, which would have placed private hospitals, extended care facilities, and public hospital continuing care facilities within the legislative framework of the CCALA. It is noteworthy that although Section 12 of the CCALA was passed on November 25, 2002, it has not yet been proclaimed and brought into force. According to the Ombudsperson (2012) report, the Ministry of Health identified several financial issues that needed to be addressed before the Government could proclaim and implement Section 12 of the Act. When I asked senior-level administrators whether they believed these RCFs would ever be brought under the legislative framework of the CCALA, they unanimously agreed that, because of the financial cost of implementing Section 12 of the Act, it was unlikely. Consequently, different regulatory standards, monitoring, and enforcement processes are in effect for BC?s RCFs. It is perhaps because of the differences in these regulatory standards that a province-wide investigation of residential care services by the BC Ombudsperson in 2008 reported that the RCFs varied widely in terms of their physical conditions, staffing levels, food services, service delivery models, and philosophical approaches to care. A primary focus of that investigation was the quality of care provided in BC?s RCFs. Two important new acts and one new regulation were developed and passed by the legislature and Ministry, respectively, following the Ombudsperson?s investigation: (a) the Patient Care Quality Review Board Act, 2008, (b) the 96 Health Statutes (Residents? Bill of Rights) Amendment Act, 2009, and (c) the Residential Care Regulation, 2009. On October 15, 2008, the Patient Care Quality Review Board Act (2008, c. 35) was passed. It requires each regional health authority to establish a Patient Care Quality Office to receive complaints about the delivery of services. The Act also requires each regional health authority to establish a Patient Care Quality Review Board. Patients and residents may complain to a review board if they are dissatisfied with the response of a Patient Care Quality Office or if they do not receive a response within 30 days. In November 2009, Bill 17, the Health Statutes (Residents? Bill of Rights) Amendment Act, 2009 was given royal assent. For the first time in BC?s history, it established the rights of seniors and other adults in all residential care facilities in BC. The Residents? Bill of Rights applies to all RCFs in which residential care services are provided, whether in extended care or private hospitals under the Hospital Act or RCFs that come under the CCALA.  The Residential Care Regulation (RCR) was passed on March 12, 2009 and came into force on October 1, 2009, repealing and replacing the Adult Care Regulations, as well as the residential aspects of the Child Care Licensing Regulation. The RCR establishes standards for physical requirements, including bedrooms, bathrooms, common areas, and work areas. The regulation also sets out requirements for admissions, the care provided, nutrition, medication management, the use of restraints and reportable incidents. The RCR includes a requirement for the licensee (RCF) to provide an opportunity for persons in their care, and their representatives and family members, to establish a resident and family council. The RCR also sets out records management requirements. 97 The new regulation requires that the dignity of persons in care be considered when determining care standards. In particular, the dignity of the individual is to be considered by operators (RCFs) when assessing the adequacy of privacy and of the furniture and equipment located in bedrooms and bathrooms. The regulation also specifies that staffing complements must be sufficient for individuals to receive care in a manner consistent with their dignity. However, measurable standards for ?dignity? and "sufficient staffing" have not been specified.  Complementing the introduction of this new regulation, family members and residents can now make complaints to the newly established BC Patient Safety and Quality Council (BCPSQC). In an effort to improve transparency and accountability, reports from the Council are available to the public.  The development and implementation of the Patient Care Quality Review Boards, the CRC, the BCPSQC, and the Residents? Bill of Rights place greater emphasis on ensuring that the quality of care provided and residents? quality of life are monitored and measured. However, it should be noted that there is currently no reliable or objective process in place to monitor and evaluate the degree to which residents? rights are respected. According to the study participants from the licensing division, such monitoring is done by residents? family members:  Administrator [04]: ?what we have noticed ? there?s been a huge increase in complaints actually ... like 100 more investigations in a year. ...we believe that it has a lot to do with the Resident[s?] Bill of Rights and people being more educated about what their rights are and families and members of the public are more inclined to speak up now. In addition to complying with these regulatory standards and processes, many RCFs voluntarily participate in a national accreditation process provided by Accreditation Canada, a not-for-profit, independent organization that provides health organizations with an external peer 98 review of the quality of their services based on established standards of excellence. These standards are developed, reviewed, and revised by Accreditation Canada and are based upon five elements of service excellence: clinical leadership, people, process, information, and performance. All three study facilities participated in this process and were accredited by Accreditation Canada. The accreditation process involves on-site surveys conducted by peer reviewers who are trained by Accreditation Canada. If the results of an accreditation survey indicate that the quality of service meets or exceeds the national standards, the accreditation process is repeated every three years. More frequent accreditation surveys indicate that a facility has areas in need of improvement. Because participation in the accreditation program is voluntary, it is independent of all governmental processes. Of note, there are no apparent links between the standards Accreditation Canada surveyors apply, the Residents? Bill of Rights from the Health Statutes Amendment Act, and the Residential Care Regulation that govern licensing officers? inspections.  Measuring quality in residential care. In reviewing the literature on the quality of care in RCFs, one finds that numerous definitions of the term ?quality? exist. A particularly well-cited example comes from the US Institute of Medicine (IOM, 1990): ?The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge? (p. 5). However, it also has been noted that operationalizing ?quality? from definitions such as this can be both problematic and challenging because they are extremely general and subjective (Castle & Ferguson, 2010). What, for example, is the "desired" health outcome and how are various types of health outcomes (i.e., physical, emotional, spiritual) operationalized and prioritized? Most researchers agree that the resulting measures cannot fully realize the quality concept (Castle & Ferguson, 2010). As a 99 result, quality indicators (a term used to describe a surrogate measure of quality), rather than quality measures (a term used to describe a measurement of actual quality), became prevalent in the relevant literature.  The most frequently used tool to measure quality of care in RCFs in North America is the Resident Assessment Instrument (RAI), of which the Minimum Data Set (MDS) is a major component (Rahman & Applebaum, 2009). In 2002, the BCMOH mandated the full implementation of the RAI-MDSv2.0 in every RCF in the province. The RAI-MDSv2.0 was developed by interRAI, an international research consortium that develops comprehensive assessment tools that are principally intended for older adult populations. InterRAI has developed 12 RAI tools designed for use in rehabilitation, home care, long-term residential care and other settings across the healthcare continuum. The RAI-MDSv2.0 is a standardized assessment tool that was developed specifically for individuals requiring long-term care in RCFs. It includes assessments at admission, on a quarterly basis, when significant changes in health status occur, and annually, for each resident. According to the literature, the RAI-MDSv2.0 was developed to improve individual care planning and the quality of care in RCFs (Morris et al., 1990). Additionally, it is said to provide a multidimensional view of residents' functional capacities, through which a profile of an RCF can be created.  The RAI consist of two primary components: the minimum data set (MDS) and the resident assessment protocols (RAPS). The MDS is a multidisciplinary summary assessment; consequently, the process of completing it should include specific input from the following multidisciplinary team members: nursing staff, dieticians, rehabilitation staff (e.g., physiotherapists, occupational therapists), social workers, and recreation managers or therapeutic 100 recreation specialists. Each of these multidisciplinary team members is typically required to fill out assessment sections of the MDS that are specific to their profession. In addition to providing a social, emotional, and recreational synopsis of a resident, the MDS includes measures of residents? functional status and health conditions related to pain, cognition, activities of daily living (i.e., self performance), health instability, depression, and the level of care provided (e.g., resources used to provide the required care).7 These represent the sections of the MDS for which nursing staff members are responsible.  The process for implementing the RAI-MDSv2.0 begins with an admission background form (often referred to as a pre-admission report, pre-admission assessment, or initial admission assessment). This form must be completed prior to, or at the time of, a resident's initial admission to the RCF. It contains demographic information as well as the resident?s customary or preferred routines. This form is a simple two-page document and is a precursor to the nine-page full assessment.  The RCF has up to 14 days following a resident's admission date to complete the full assessment. The full assessment consists of over 300 items and encompasses the following information: cognitive patterns, communication, hearing and vision, mood/ behaviour, psychosocial/well-being, physical functioning/structural problems, continence, disease diagnoses, health conditions, oral/nutritional status, oral/dental status, skin condition, activity pursuit patterns, medications, and special treatments and procedures. On the first day of this 14-day period, observation sheets are distributed to the resident care attendants (RCAs). These                                                   7 The RAI-MDSv2.0 is copyrighted; consequently, a sample of this document could not be included as an appendix. 101 observation sheets enable the RCAs to provide information to the LPNs or RNs, which will be used to complete the portions of the resident's full assessment.  The observation sheets were developed specifically for the RAI-MDSv2.0. They are intended to capture information related to residents' activities of daily living (e.g., mobility, dressing, eating, toilet use, hygiene, bathing). The relevant information is entered with numeric codes (i.e., 0 = no assistance to 4 = total assistance), which indicate what the residents are able to do for themselves, and how much assistance is provided. The document also captures information related to residents': (a) cognitive patterns (e.g., evidence of altered perception or awareness or of disorganized speech), (b) mood (e.g., self-deprecation or withdrawal), (c) behavioural symptoms (e.g., socially inappropriate behaviour or disruptive behaviour), (d) bowel and bladder control (e.g., incontinent of bowel), (e) problem conditions (e.g., complains or shows evidence of pain), (f) nutritional status (e.g., chewing problems or mouth pain), and (g) activity pursuit patterns (e.g., involved in activities most of the time). These items are selected with check marks to indicate that a described behaviour was observed by the staff (see Appendix F).  Once the RCAs have completed the observation sheets, an RN or LPN enters the recorded information directly into the MDS, which is managed with a computerized software package developed for the RAI (e.g., PointClickCare?, an electronic health record for long-term care, or GoldCare, a healthcare information management software package for community, residential and long-term care organizations). Once the MDS is complete it 'triggers' the resident assessment protocols (RAPs)?the second key component of the RAI system. The RAPs are triggered by specific items that have been coded in the MDS. Because the MDS is considered a "minimum data set" these RAPs are intended to highlight to care providers those areas that may require more detailed assessment (e.g., pain, depression, aggressive behaviour, social isolation). Once 102 completed, the MDSv2.0 software generates a CAP (Critical Assessment Protocol) for each resident, which highlights what items need to be included in a resident's formal care plan. It is this latter care plan that licensing officers and Accreditation Canada surveyors use when evaluating an RCF?s adherence to standards of care.  Administrator [04]: The legislation requires that a care plan be developed at the time of admission. It may be a short-term care plan, but it should be revised, as needed, depending on the care needs of the individual. It has to be reflexive so when we go in?at the time of routine inspection or the time of investigation, or for whatever reason?we look at the RAI, and it has to be there and it has to relate?it has to speak to what is required under the legislation. So, we?re looking for certain aspects of that care plan to exist at all. Right, and if it doesn?t, then we cite them and ask them to rectify. Once the admission full assessment has been completed and the subsequent care plan has been developed, the resident is placed on a fairly rigid schedule of quarterly and annual assessments. The quarterly assessment contains a subset of the MDS items (seven pages) and must be completed within 92 days following the last full or quarterly assessment. The annual full assessment must be completed within 366 days of the last full assessment. In addition to the scheduled annual and quarterly assessments, the RAI-MDSv2.0 contains a significant change in status full assessment, which must be completed by the fourteenth day following the determination that a significant change in the resident's condition has occurred. Prior to each of these assessments being completed, the RCAs are again required to complete the 7- or 14-day observation sheets (see Appendix G). The information in these observation sheets is used to assist the RNs and LPNs in completing each of the assessments. In addition to the information found on the observation sheets, the RNs and LPNs are expected to review information from a variety of sources to complete the assessment; these include the progress notes, physicians? 103 orders, and the resident's medications. All of the RAI-MDSv2.0 assessments and care plans are stored in the resident's electronic health record (EHR).  In addition to assisting with care planning, the RAI-MDSv2.0 includes outcomes scales for specific areas of concern that staff may have with a resident or a group of residents (e.g., the assessment results of the depressive rating scale, pain scale, self-performance hierarchy scale, pressure ulcer risk scale, aggressive behaviour scale, index of social engagement). This information is used to develop outcome indicators for the facility (e.g., rates of falls, depression, behavioural symptoms, urinary tract infections, decubitus ulcers, or bowel and bladder incontinence), which can be used to measure the quality of the care provided. Since the implementation of the RAI-MDSv2.0, the licensing officers depend heavily on it for their inspections:  Micro-Level Context: Regulations to Determine Who Lives and Works in RCFs in BC In addition to the multiple regulatory standards that govern care practices and processes there is a regulatory framework established in BC to govern who is admitted to live in RCFs and who is permitted to provide for their care.  Who lives in RCFs?the complex care admission requirement. Before 2002, the admission requirements for residential care in BC (previously called long-term care (LTC)), categorized residents? care needs as Intermediate Care 1, 2, 3 (IC1, IC2, or IC3), or Extended Care. Residents were classified according to these categories based on how independent they were in their activities of daily living (i.e., dressing, bathing, and eating) and on how independent they were in ambulation or mobility. In 2002, the BCMOH claimed that many residents assessed at the IC1, IC2, and IC3 levels, and even some at higher levels of dependence, did not require 24-hour nursing supervision; thus, these residents did not need to live in residential care facilities 104 (BCMOH, 2013). This decision was brought to force through the implementation of the BC Residential Care Access Policy in which it was mandated that only those people that require ?complex care? would be accommodated in RCFs. Accordingly, the BCMOH identified five groups of people considered to require ?complex care?: 1. Group A includes people who have severe behavioural problems (e.g., destructive, aggressive, or violent behaviour) exhibited on a continuous basis. 2. Group B includes people who, because of cognitive impairment, require total care for their activities of daily living and a secure environment for their protection.  3. Group C includes people who meet the criteria in Group B and who exhibit socially inappropriate behaviour (e.g., spitting, disrobing in public, urinating, or defecating in inappropriate places).  4. Group D includes people who are cognitively well, are physically very frail, and require professional nursing care for extensive daily nursing interventions (e.g., ostomy care, decubitus ulcer care, oxygen therapy, enteral feeding).  5. Group E includes people who are frail and have multiple disabilities and medical problems (e.g., clients who require palliative care with complicated pain management or clients who require continuous professional monitoring because of a psychiatric condition).  Under the Residential Care Access Policy, people who do not have complex care needs must continue to receive care at home or in a supportive living environment. As a result of this policy, only individuals who are extremely cognitively or physically frail or are demonstrating excessively disturbing behaviour are assessed to be appropriate for admission to RCFs. 105 Consequently, the complexity and burden of residents? care needs, and mortality rates, increased dramatically once the policy was implemented; yet funding rates, which are often the determining factor for staffing levels, staff education, and training requirements, and the nursing staff mix in RCFs, were not adjusted to accommodate this added complexity.  Furthermore, there are no clear guidelines for the government?s subsidy reimbursement rates to the RCFs and there seems to be a considerable discrepancy based on the ownership status of the facility. For example, in some regions, the owned and operated RCFs receive more funding to provide care to their residents compared with the affiliated or contracted RCFs. This discrepancy is based on the assumption that owned-and-operated RCFs would presumably care for residents with more complex needs; thus, historically the Government funded its owned and operated facilities at a higher funding rate. However, the implementation of the complex care admission requirement mandated that all RCFs care for residents with equally high complex care needs. Despite this new admission requirement, funding levels have not been made equitable between the owned-and-operated facilities and the affiliated facilities, as explained by an administrator from the Health Authority: Administrator [02]: And that [differences in reimbursement rates] was done I think [pause] a few years ago strategically or purposefully you know, because [the Health Authority] could assume greater levels of care, and we could put more resources at it. So we tended to place people with the most complex care needs in owned and operated sites. ...But once everyone became complex care, we needed to increase the level of care [everywhere] because now everyone is getting the most complex clients. But we still haven?t closed the gap [differences in funding levels]. So I would say if there is any distinction, and it?s often pointed out, that the funding and care levels tend to be higher in the owned-and-operated sites.   106 This discrepancy may be one of the reasons that affiliated RCFs tend to have lower staffing levels than do owned and operated RCFs, as was the case in the study facilities. See Table 4.1 for a summary of the contextual factors of the three participating facilities. Table 4.1: Contextual Factors of the Study RCFS Contextual Factor Facility #1 Facility #2 Facility #3 Ownership Status Private For Profit (Contracted) Private Not-for-Profit (Contracted) Public Not-for-profit (All owned and operated) Governing Regulation Hospital Act CCALA Hospital Act Accredited with Accreditation Canada Yes Yes Yes Number of Residents < 135 < 125 < 150 Number of Private-Pay-Residents 29 6 0 Staffing RN: Resident* Day/Eve/Night: 1:131  Day/Eve/Night: 1:122 Day/Eve/Night: 1:75 Staffing LPN: Resident* Day/Eve: 1:45 Night: 1:66 Day/Eve: 1:46 Night: 1: 62 Day/Eve: 1:36 Night: 1:50 Staffing RCA: Resident* Day 1:8  Eve: 1:11  Night: 1:27 Day 1:7 Eve 1:9 Night: 1:23 Day 1:6  Eve: 1:9 Night: 1:12  *These ratios are approximate because some units or neighbourhoods may have had different ratios within the facility.  Employees of residential care facilities: The nursing staff mix. Within RCFs, there are three general types of care staff employed: (a) registered nurses (RNs), who are regulated professionals who have completed a post-secondary diploma or baccalaureate degree in nursing (between two and four years of postsecondary education); (b) licensed practical nurses (LPNs), who are regulated professionals who have completed a diploma in nursing (ranging between one and two years of postsecondary education); and (c) RCAs, who are unregulated care staff who 107 have a certificate (ranging between three months and one year of training). Though there is variation among the Canadian provinces and among the facilities within each province, these formal caregivers usually work in teams (i.e., they are assigned to the same residents and unit (also referred to as a neighbourhood, floor, or wing) for a given shift or rotation). Most often LPNs are assigned as a team leader of these nursing teams, while being overseen by an RN.  In years past, the RNs were actively involved in the direct care provided to residents; however, their role has changed, and they now primarily complete managerial paperwork and have limited personal contact with residents (Anderson et al., 2005; McGregor et al., 2005; Rheaume, 2003). There is now an expectation that RNs will delegate significant portions of their past roles as direct care givers to other staff. In the three participating facilities, medication administration and quarterly and annual RAI-MDSv2.0 assessments were delegated to LPNs and almost all of the work related to residents? personal care was delegated to RCAs. The disparity between the amount of time RNs and RCAs spend with residents in the provision of direct nursing care is evidence of the delegation of all "bed and body care" to unregulated staff (Foner, 1994). Within the study facilities, the average staff to resident ratios for the RNs ranged from 1:75 to 1:131.  In all three of the facilities, LPNs were the care team leaders and were overseen by an RN. In addition, LPNs were responsible for the administration of medications to residents, documentation of residents? progress, completion of quarterly and annual MDS-RAIv2.0 assessments, attendance at care conferences, and provision of the start-of-shift report to the care team. This scope of practice for LPNs in RCFs is common throughout BC. These substantial changes to their responsibilities were a result of the Health Professions Council, Licensed Practical Nurses? Scope of Practice Preliminary Report (Epstein, Kazanjian, & MacAulay, 108 2000). This report proposed an expansion to the scope of practice for LPNs that would enable them to function in a broader capacity. Of interest, the regulation specifying the LPNs? scope of practice was not introduced until 2012. In the ensuing years, LPNs were permitted to carry out nursing functions that were consistent with their education, and were not specifically described. This lack of specificity over the past decade caused considerable confusion for many employers and employees in the sector. Notwithstanding this opacity, all nursing services provided by an LPN have always been required, except in an emergency, to be carried out under the direction of a physician or under the supervision of a RN who is providing services to the client (Epstein et al., 2000). The average staff to resident ratios for the LPNs within this study ranged from 1:36 during the day to as high as 1:66 in the evening.  RCAs usually work within a team assigned to a specific group of residents during a shift. Their work shifts are usually divided in a 24-hour period into three 8-hour periods: days?0700 to 1500 hours, evenings?1500-2300 hours, and nights?2300-0700 hours. They provide direct care to the residents, assisting them with all activities of daily living (e.g., dressing, bathing, eating, toileting). The staffing ratios for RCAs in this study ranged from 1:6 to 1:8 during the day shift and increased incrementally to 1:12 during evenings and 1:27 on nights. Researchers have estimated that RCAs provide between 80 percent and 90 percent of care to residents in LTC settings (Pennington, Scott, & Magilvy, 2003). There are no regulations associated with the staffing ratios of RCAs to residents in RCFs in BC. Significantly, when asked what most influences the quality of care provided by RCAs, one administrator (who is responsible for ensuring compliance with regulatory standards) stated that there are not enough RCAs to do the work:  Administrator[04]: It?s the numbers of them, the numbers. I think that they are overworked; I think they are run off their feet. I don?t think they have the time to provide 109 that, you know, the emotional, taking care of the whole person. I just don?t think that can happen.  A traditional hierarchical model was present in each of the participating RCFs, which ensured that the staff members with the highest education, salary, and position remained furthest from direct contact with the residents. As a result, the care staff members with the least amount of contact with residents had the most control in determining their care. Conversely, similar to other researchers, I found that the RCAs, who provided the majority of care for the residents, received the least amount of training, the lowest pay in health care, and were rarely consulted when decisions were being made about the care to be provided (Blair & Glaister, 2005; Kane, 1994; Stone, 2001; Stone & Yamada, 1998).  Summary and Reflections The regulatory framework that governs RCFs in British Columbia is extensive and complex. Historically, regulations governing RCFs have been based on the medical model, which encourages quality of care to be measured based on timely completion of tasks, consistent adherence to routines, and achievement of objective medical outcomes. Current regulations require that the dignity of persons in care be considered when determining care standards. However, the regulations fall short of specifying measurable standards that would help to ensure staffing is sufficient for residents to "receive care in a manner consistent with their dignity." Thus, a conspicuously absent regulation is one that governs the amount of staffing required to successfully accomplish the standards of practice laid out in these regulations.  This overview of the regulatory framework led me to ponder the possibility that the primary response to a perceived need for improved care practices in RCFs is the creation of more regulations. The depth and breadth of these regulations seem to directly or indirectly influence the quality of work-life and quality of care in the institutions. It is for this reason that I focussed 110 on the regulatory framework found in BC when describing the context of living or working in RCFs. This chapter provides the reader with a contextual foundation from which the everyday, embodied work experiences of RCAs can be more fully understood.  111 Chapter 5: The Influence of Everyday Texts on the Provision of Person-Centred Care: Exploring the Embodied Work Experience of RCAs  A central tenet of person-centred care is that it is provided with respect and deference to the care recipient?s unique needs, preferences, and life history (Fazio, 2008). Accordingly, the provision of this care is largely dependent upon caregivers' access to individualized information about the person to whom they are providing care. With this in mind, I began my data collection with the aim of mapping the work of resident care attendants (RCAs) over a 24-hour period to determine how institutional processes enable or impede the everyday, every-shift exchange of information related to residents' care needs. My initial focus was on what I referred to as ?everyday texts??those texts that are found in the everyday practice of RCAs. I was interested in identifying: (a) the information RCAs regularly access regarding residents? care needs, histories, and preferences; (b) where such information is stored; (c) how it is accessed; (d) how RCAs share such information; and (e) with whom they share it. This chapter describes the embodied work experience of the RCAs with a specific emphasis on the exchange of information that occurs during three phases of a work shift: at the beginning of the shift (i.e., before the provision of care commences), during the shift (i.e., while care is provided), and at the end of the shift (i.e., after the provision of care).  Beginning the Work Shift: Three Reports?So Much to Learn, So Little Time Upon arriving at the facility for the start of their work shift, the RCAs' first task was to receive information about what occurred during the previous two 8-hour shifts. This information was gathered, stored, and shared in two formats?through oral and written reports. Oral reports (referred to as ?start-of-shift reports?) are group meetings held with the RCAs so that they can receive information from the team leader (typically a licensed practical nurse (LPN) or registered 112 nurse (RN). The information deemed pertinent by a team leader is provided orally; it typically addresses the residents' status over the previous 24 hours and specific details regarding their care needs for the approaching shift (e.g., bowel care, appointments, preparations for laboratory testing, such as blood collection).  Written reports included the following: (a) 24-hour observation sheets?sheets used by and for the RCAs to share residents? care information, (b) communication books?notebooks that enabled the RCAs working different shifts to communicate, in writing, with one another, and (c) bath and bowel lists?lists that detailed the residents? care requirements regarding bathing and bowel care for the upcoming shift.  Facilities #1 and #3 both held start-of-shift report meetings at the beginning of the RCAs? shifts and also used communication books. In Facility #2, the start-of-shift report provided by team leaders to the RCAs had been stopped. None of the participants was able to explain why or when this had occurred. This facility exclusively relied on 24-hour observation sheets and a staff-to-staff communication book as the means by which the RCAs shared and received information with each other. All three facilities used bath and bowel lists. In addition to these communication formats, the RCAs of all three RCFs used ?unofficial oral reports? to receive and share information, as described below.  Unofficial Oral Reports   In almost all residential care facilities (RCFs), RCAs' work shifts formally begin with a start-of-shift report from a team leader (most often an LPN). In the facilities that I observed, many of the RCAs arrived before they were scheduled to commence work to receive an additional, unofficial oral report from the RCAs who were completing a shift and who had worked directly with the residents to whom they were assigned. Thus, they were able to receive 113 more details about what had occurred during the previous shift than what was shared during the start-of-shift report. This practice was described aptly by an RCA who consistently arrived for work 30 minutes early:  RCA [03]: When I read something on a piece of paper, it?s just quick and trying to be to the point, but the little stuff is missed, like how she [the resident] said, ?Ouch? when you turned her. ...and when I go to get her up, there could be a sore there or something like that. Or so-and-so?s legs were between the rails. Well, that?s not always written [on report] and then you go and look at her legs and they?re covered in bruises because it was just how she was turned and then she tried to turn at the same time and it just?. So, I like to know myself what?s going on in my section and who I?m dealing with that day.  Researcher: And you find that when you get the additional information that it really does add?   RCA [03]: Yeah, the actual hands-on stuff, not just what the RN or the LPN writes that they?re told?and half the time they forget because they?ve got umpteenth pills and turns and changes. And it just?gets lost in the mix.  Several of the RCAs mentioned the need to arrive early to receive an unofficial report because significant events, such as a patient?s fall, had been missed in the start-of-shift report. This was expressed by an RCA when I asked why she started early: RCA [02]: I wanna know how their day has gone, has?. That?s my first question, ?Has anybody had a fall?? ?because there?s been occasions we?ve come in and didn?t know?and gone, ?It didn?t say anything in report, why is so and so in bed? Oh my god, she?s had a fall? She?s got a?how come nobody told us??  Twice during my observations, information about a resident having fallen was not shared during a start-of-shift report; the distress and frustration this caused the RCAs was profound. It is easy to be critical of a team leader who misses something as important as a fall when giving a report. However, the LPNs, who typically serve as team leaders, reported that they too arrived to 114 work early to ensure that they had adequate time to gather the information required to give a comprehensive start-of-shift report. The multitude of sources that contained the information the LPNs were required to review before giving a start-of-shift report was explained by a study participant:  Team Leader [01]: I would come in in the morning and I would, of course, read the safety communication board?that indicates anybody who?s in infection control or care risk behaviours. Then I read the report from the evening before. If there is any incidences on the evening, then I would read what happened to the individual, the staff, and resident. Then I read the night shift report to see if anybody was awake. Then you plan. Then you look at the 24-hour date book that?s on each side of the nurses? station and list out: ?Oh, so and so has an appointment today at two o?clock.? ?I?m going to be calling the doctor regarding this particular individual because his ears need to be looked at and syringed.? ?Oh, by the way, can you leave this person in bed because the lab is coming to do blood work?? ?any kind of thing like that. And bowels? ?OK, make sure that they [the RCAs] are aware of who needs bowel work?that's very important.?  In addition to being able to read multiple sources of information, every interviewed LPN described the importance of arriving early to receive an oral report from the team leader who worked the previous shift. They did this to "fill in the blanks" and to know what they believed to be essential, additional details regarding critical incidents or residents? well-being. The gathering of this information took time and, similar to the RCAs, the institutional processes in the RCFs required that it be done on the LPNs? own time. One team leader explained what would happen if she did not come in early:  Team Leader [2]: ?I wouldn?t have time to research what happened the evening before, or the night before because I give report right at seven o?clock to the care aides. So then I?ve got to start because I?ve got 27 people to give meds [medications] to. ?if I don?t start early I?m going to be running behind for the rest of the day.   115 The majority of the interviewed RNs, LPNs, and RCAs believed that it was essential to arrive on the unit before their shifts officially began so that they could receive an unofficial oral report from the individuals who worked with their assigned residents on the previous shift. In all three facilities, there was no time formally allotted for the exchange of this information. It was done on unpaid time because it was deemed a necessary requirement for the successful and safe conduct of their work. One RN explained that this practice is considered an unwritten expectation of the job:  Manager [11]: It?s a bit of a frustration, but it is a professional expectation that as a courtesy to the person that you?re relieving you arrive with enough time that they don?t have to stay after their time to give you a report, so that?s just good manners, and professionalism, it?s also sort of an unwritten expectation of management as well.  It is worth noting that not everyone came in early to exchange information. If an RCA or LPN was a casual employee who had been scheduled to work immediately prior to the start of a shift (i.e., the casual staff member did not receive the call to work the shift until an hour before the shift began), then the oral exchange of information with staff from the previous shift would typically not occur. Similarly, staff members that demonstrated behaviour often associated with burnout (e.g., being verbally critical of management practices or taking longer rest breaks) did not arrive early to work.8 Rather, they expressed a determination not to give more to the institution than what was absolutely required. Similarly, the RCAs who worked at more than one facility and who scrambled to get from one facility to another to start a second work shift, what                                                   8 Burnout is a term used to describe a phenomenon observed in employees who suffer from long-term exhaustion and dimensions to the phenomenon: emotional exhaustion, cynicism, and inefficacy. Other researchers have argued that exhaustion is the cardinal feature (Kristensen, Borritz, Villadsen, & Christensen, 2005).  116 is called "a double" (i.e., back-to-back 8-hour shifts), simply were not able to start early. Working for more than one facility, to "make ends meet," was common among the RCAs interviewed. Approximately 40% of the RCAs who participated in this study held a second job. Consequently, these RCAs were rarely able to receive this unofficial oral report. In all three facilities, the institutional process in place did not enable the staff to overlap during the change of shift. Thus, not arriving ahead of when one?s shift officially was to commence resulted in staff members not being able to receive information that had been described as "essential" by the study participants. Oral Report After receiving their ?unofficial? report, the RCAs from Facilities #1 and #3 gathered in a designated area for the team leaders to provide a start-of-shift report. In Facility #1, the average length of the report for the day and evening shifts was less than 10 minutes and provided information for approximately 85 residents. In Facility #3, the report for the day shift was 15 to 20 minutes in length and provided information for approximately 75 residents. The evening shift report was shorter in duration, but was specific to the 12 residents for whom each team was responsible. In both of these facilities, the duration of the night shift report varied significantly and seemed to depend on the leadership style and focus of the team leader. However, the average time spent on the night shift reports was approximately 15 to 20 minutes.  After having completed a few observation periods in these facilities, I began to understand why the day-shift report meetings were so brief. This was explained by an RCA:  RCA [01]: By the time you get to your cart and, you know, it?s 7:15 [AM] if you?re lucky, and then you?ve got to make sure you?ve got your adequate supplies that you need and whatnot, and check your bath. And then you?re really probably not starting care until at least 20 after, if you?re lucky?20 after 7 [AM]. So, then you?ve got an hour and ten 117 minutes to get six people?at least six people washed! And that's only if you?ve got two people that are staying in bed or whatever. So, six people to get up and washed and hopefully get their teeth brushed and all that sort of stuff.   During the day shift, the RCAs had, on average, 15 minutes to provide morning care for each resident, which may have consisted of toileting or changing briefs (i.e., adult diapers), washing faces, hands, groins, and axillae, shaving, tooth brushing, dressing, and hair brushing. When the RCAs were assigned to care for eight residents, the workload dictated that at least two residents would remain in bed for their breakfast and forgo their full morning care until after they had eaten. Thus, it was because every minute counted that the RCAs anxiously watched the clock during the start-of-shift report. There was a tension between needing to hear the information provided during the day-shift report and needing to begin morning care:  RCA [07]: Everybody?s sort of there at 6:45 [AM] getting their carts ready. ?she [team leader] gives that report and we could be there 5, 10 after 7:00. ?by this time everybody?s kind of going, ?We?ve gotta get going! We?ve got to get that breakfast!?  Even though there was a pressure to complete the start-of-shift report quickly, many of the RCAs described the importance of receiving report for more residents than those they were about to care for:  RCA [05]: It?s always nice to sort of keep an ear out for the other sections on either side of you [because] I have to cover that area when my partners are on their break. ?If I can hear that something is going on or going to come up, like if I know that one of my partners? residents has been given bowel care in the morning and that?s why they?re fussing and on the bell so much, then I know: get over there, get them to the bathroom.   On average, less than one third of the residents were mentioned in a start-of-shift report. Given the extreme time limitation placed on this meeting, only information that was considered essential by the team leader was shared. This usually consisted of details pertaining to 118 appointments, infections, skin integrity, falls, sleeping patterns, bowel routines, and incidents of aggressive or agitated behaviour.  Although the start-of-shift report was one of the primary opportunities in which the RCAs would formally learn about a resident?s aggression, the information shared was usually limited. Typically, it was reported that "an aggressive incident occurred" and whether medication was given in response. The reports I heard did not contain a description of the actual behaviour (e.g., hitting, biting, kicking, scratching, or pinching), triggers for the behaviour, or any indication of a plan of care in response to the behaviour. The need for more information was expressed by a participant:  RCA [04]: If there?s a combative situation say, and they [the team leaders] will be like, ?Oh, an incident happened with so-and-so yesterday. We gave him some, some kind of medication?he?s now lying in bed, calm.? ?I [need] more details, like: What took place? What kind of medication he?s on, so I know how to?so that I'm not putting myself in danger, and maybe the resident.  During the day-shift oral reports, the RCAs rarely had time to share their perceptions or concerns regarding the residents. Because the evening and night shifts tended to begin relatively less rushed, the opportunity for two-way communication arose more frequently. The benefit of this was expressed by an RCA:  RCA [01]: I know in the evening shift they have a little bit more time to sit down and discuss through every single resident and go, ?OK, how?s this person been, how's that working?" Ours [day shift report] is kind of like, spit out what there is and go?because we just don?t have the time?  Researcher: For you to actually take that time to share information?  RCA [01]: Exactly, exactly, which is nice. I know there?s one nurse on evening shift and she sits down and she takes a good?15 minutes [for report] to go through every single 119 resident and say, ?OK, well, this person, they?ve been doing?? She gives her share. And then she asks for what we want or what we need to share, whatever, with them, about that, those residents. ?so we?re able to share or put in ideas for their care and stuff, which is nice because you have the time in the evenings to do that, at that time. But we don?t [on day shift].  I was particularly interested in speaking with this nurse who consistently took time to give and receive information during the reports that she led. During my interview with her, she explained why she always took the time to ensure that there was two-way dialogue between herself and the RCAs during report:  Team Leader [05]: We sit and we discuss issues. Like, I'll say, "This resident had a fall. How can we prevent what?s going on? Do we have to put a commode at their bedside?"?There might be several issues that are going on with different residents. And I try to answer all their [the RCAs?] questions. Because, in order for the RCAs to do their job, I need to give them information because that?s the only way we can be one team. And I need them to know what I know so I can depend on them. So they can give me the information back [that I need] so I can take care of the residents.   The majority of team leaders and RNs, however, did not take the time to engage in a two-way dialogue with the RCAs during their shift report meetings. In fact, during some night shifts (when the team leaders had the least amount of pressure on their time), some team leaders did not have report meetings and instead gave a written report sheet to the RCAs to read on their own. Thus, the quality and amount of information flow during report was influenced by both the leadership style of the team leader and by organizational constraints?namely time. In summary, because of the time pressures and leadership styles, the information shared in the start-of-shift reports was typically limited to the most basic information related to residents? care needs and concerns. In addition, the information most often flowed in one direction?from the team leaders 120 to the RCAs. It appeared to be especially problematic that these time constraints were present, and little information was communicated, when a new resident was admitted.  A new admission: Two sides to the coin. The start-of-shift report was the means by which the RC