Afraid to care; unable to care: A critical ethnography within a long-term care home

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Afraid to care; unable to care: A critical ethnography within a long-termcare home

Ryan DeForge a,!, Paula van Wyk b, Jodi Hall a, Alan Salmoni a,ba School of Health and Rehabilitation Sciences, University of Western Ontario, 1151 Richmond Street, Elborn College, London Ontario, Canada, N6A 3K7b School of Kinesiology, University of Western Ontario, 1151 Richmond Street, 3M Centre, London Ontario, Canada, N6A 3K7

a r t i c l e i n f o a b s t r a c t

Article history:Received 8 November 2010Received in revised form 22 March 2011Accepted 1 April 2011

This paper describes the findings of a critical ethnographic research study conducted in anurban long-term care home. While our intention was to learn more about the culture of care,specifically as it relates to mental health care provision, the participants in the studyconsistently spoke with us about (what we have labeled as) a culture of compliance. In acontext where new long-term care legislation is being implemented along with new,standardized resident assessment instruments, gaining a deeper understanding of the (un)intended consequences of government's efforts to ensure a high quality of care is of paramountimportance. This research demonstrates how policy-driven structural mechanisms can (re)produce conditions that result in frontline staff being afraid and unable to care, and thuscontributes to a better understanding of the lived experience of frontline long-term care staffwho find that their caregiving responsibilities are displaced by caregiving accountabilities.

© 2011 Elsevier Inc. All rights reserved.

Background

As the !nal dwelling for thousands of Canadians, long-term care homes constitute a key component of ourhealthcare system. In the province of Ontario, between75,000 and 80,000 people reside in approximately 600long-term care homes (Sharkey, 2008). By 2021, seniorswill account for 18% of the Canadian population, which willequate to nearly 7 million people (Health Canada, 1999).Projections for 2031 suggest that the number of seniors livingin long-term care will at least triple, and perhaps quadruple, are"ection of estimates that 24–38% of Canada's fastestgrowing population segment – those aged 85 or older – willlive in long-term care homes (Health Canada, 1999). As such,long-term care homes are, and certainly will continue to be,an integral and ubiquitous part of our healthcare system.

Yet home care policies – such as Ontario's newly legislatedLong-term Care Home Act (2007) – create complex relation-ships between long-term care supervisors and the frontline

caregivers they oversee. These relationships remain nebulous,replete with rule breaking that is sometimes condoned bysupervisors, and policy implications that (potentially) im-pede dementia care (Kontos, Miller, Mitchell, & Cott, 2010). Inaddition, recent research suggests that between 60 and 80% oflong-term care residents have some form of cognitiveimpairment (Berta, Laporte, & Valdmanis, 2004; OntarioHealth Coalition, 2008), and 91% suffer from some sort ofmental health issue in general (Grabowski, Aschbrenner,Rome, & Bartels, 2010). Therefore consideration of how long-term care policies may inadvertently impede care of residentsvia the relationships that are produced between various staffemployees, is warranted.

Undue harm

Several researchers have raised concerns about the qualityof care being offered to long-term care residents (Comondoreet al., 2009; Fahey, Montgomery, Barnes, & Protheroe, 2003;Kane, 2001; Schnelle et al., 2004). Among these studies,researchers have examined the impact of staff-to-residentratios (Comondore et al., 2009; Schnelle et al., 2004) wherein

Journal of Aging Studies 25 (2011) 415–426

! Corresponding author. Tel.: +1 519 850 2453; fax: +1 519 850 2469.E-mail address: [email protected] (R. DeForge).

0890-4065/$ – see front matter © 2011 Elsevier Inc. All rights reserved.doi:10.1016/j.jaging.2011.04.001

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lower ratios of staff per resident are associated with poorerquality of care. Fahey et al. (2003) cited poor monitoring ofchronic conditions and the overuse of inappropriate and/orunnecessary drugs as factors that contribute to poor quality ofcare. Kane (2001) pointed out how quality of life indicators(including security, comfort, meaningful activity, relation-ships, enjoyment, dignity, autonomy, privacy, individuality,and spiritual well-being) were considered only secondarily tohealth status as outcome measures. Consistent throughoutthese works was the !nding that compromised care wasattributed to policy decisions. Kontos et al. (2010) urgentlycalled on researchers to attend to the interrelationshipsbetween long-term care residents, practitioners, and socialstructures and policies. In exploring these intersections,Kontos et al. (2010) warned that we must be careful not toreduce care “either to the regulatory regimes that in"uencethe content and delivery of care, or to the experience,knowledge, and re"ective deliberations of [long-term careproviders, supervisors, and administrators]” (pg. 8).

With both political and personal agendas in play,understanding such interrelationships is both complex andof paramount importance. The government's efforts to ensureaccountable and transparent quality of care in long-term carehomes have yielded unintended consequences. Physicalviolence, for example, is an everyday occurrence in mostlong-term care homes: care providers describe the all-too-common occurrence of being punched, slapped, bitten, ortouched inappropriately by residents (Banerjee et al., 2008).Other researchers have documented the violence long-termcare residents have suffered at the hands of long-term carestaff (e.g., Post et al., 2010) or at the hands of other residents(e.g., Rosen, Pillemer, & Lachs, 2008). Banerjee et al. (2008)stated that “[l]ong-term care workers link violence withworking conditions. Having toomuch to do, working with toolittle time and too few resources places workers in dangeroussituations” (p. iv). They went on to suggest that “[w]orkingunder extreme conditions constitutes a form of violence initself — a structural violence that originates in large measurefrom the way long-term care work is organized and funded.”(See also Levin, Beauchamp, Misner, & Reynolds, 2003).

Consequently, the notion that policy creates harmfulworking (and in turn, living) conditions in long-term care,requires equal if not more attention than do reports ofphysical violence. Attending to the cause of the hardship ofproviding care rather than its symptoms (disruptive residentbehavior and physical violence) is particularly importantgiven that ‘as needed sedation’ of the long-term care residentis the all too commonly practiced treatment of the disruptive/aggressive behavior. Being overworked, short staffed, highlystressed, and feeling remorse about the treatment ofresidents can cause undue harm to both the staff andresidents of long-term care, and in light of an ever increasingproportion of residents who face both physical and mentalhealth challenges, the demands placed on long-term care staffare increased (Sharkey, 2008; Smith, 2004; Yu, Ravelo,Wagner, & Barnett, 2004). Caring for residents with amultitude of complex care needs, combined with resourceand staf!ng shortages and with legislated documentationrequirements, serves to create an immense demand on long-term care staff. Moreover, not only are they being asked tocare for seniors with increasingly complex medical and

mental health issues, they are doing so without suf!cienttraining, resources and support (Ersek, Kraybill, & Hansberry,1999; Grabowski et al., 2010). As a consequence of thesedemographic in"uences and structural/policy-related con-straints, long-term care home staff are subject to multiplestressors that undermine the highly interpersonal nature ofcaregiving (Goodridge, Johnston, & Thomson, 1997; Kontos,Miller, & Mitchell, 2009).

Purpose

The initial purpose of this research project was to criticallyexplore the mental healthcare needs of older adults (personsover the age of 65) seeking admission or recently admitted tolong-term care. While the larger project sought the perspec-tives of family caregivers, aging adults, community serviceproviders, and staff working within various occupationalroles of a long-term care home, we narrowed the focus of thispaper to explore from a critical perspective data collectedrelated to staffs' perceptions of the (un)met care needs ofresidents living in long term care homes. In doing so we seekto better understand the role that larger, socio-political/structural conditions play in reshaping staffs' relationshipswith residents (shaped as they often are by regulation andsurveillance). This critical analysis of staffs' experiences inproviding care served to explore the (un)intended conse-quences of healthcare policy that regulates care provisionthrough standardization. Below, we introduce critical eth-nography as the methodological research design that guidedour data collection, analysis and !ndings.

Ethical considerations

Ethics approval was obtained from the University ResearchEthics Board prior to data collection. Staff were noti!ed of theresearch and invited to participate through an email distributedby the administrator. Given thenature of the demands on staffs'time, often these focus groups were impromptu in thatresearchers would gather as many staff as were available atanygiven time, andconduct the focus group ina locationon ‘the"oor’ in a relatively private location of the participants'choosing.

Procedures

Methodology

This research was conducted using a critical ethnographicmethodology (Thomas, 1993). Like classical ethnography,critical ethnography shares an interest in understandingculture; however, critical ethnography can be conceptualizedas alternative or disruptive in that it is poised as openlyideological and interested in identifying how oppressivesituations are (re)produced and rei!ed within the culturesthey study (Koro-Ljungerg & Greckhamer, 2005). Culture wasalso seen not as a !xed entity with clearly de!nableboundaries, but as a space constantly in "ux, and as such,open for re-negotiation. Researchers conducting criticalethnographies locate themselves as a participant in theresearch, which includes emphasis on their own subjectivitythroughout the research process, particularly during the

416 R. DeForge et al. / Journal of Aging Studies 25 (2011) 415–426


critical acts of data collection, analysis, representation anddissemination (Koro-Ljungerg & Greckhamer, 2005). Re-searchers working in a critical tradition strive to create spacesfor critical dialog and to invite transformation of self and otherthrough the disruption of taken-for-granted assumptionsembedded within practices and policy (Kincheloe & McLaren,2002).

Theoretical framework

This work was guided by critical social theory in itsconcern formitigating suffering (Sayer, 2009). Understandingthe conditions that enable or preclude equitable powerdistribution, we assumed, would in turn assist us tocontribute to existing research and practice aimed at (re)creating conditions that canmitigate suffering and inequity inlong-term care. In developing the implications of thisresearch, Goffman's (1968) notion of ‘the total institution’remindedus that inmanyways, both theprovision and receiptof care occurs in a setting that is essentially cut off from therest of the world, where the activities of daily work and livingare tightly governed by formal rules. Our understanding ofsuch notions of governance comes into a sharper focus whenviewed through a Foucault (1991) lens of surveillancewherein through manifestations of self-surveillance, people(in this case, frontline care providers) give up their power toact as much as it is taken away from them. Such self-surveillance, Foucault contends, resulted from a shift of powerwherein the sovereign no longer exerted itself as having “theright to take life or let live” but aligned itself with a power to“ensure, maintain, or develop its life” (1990, p. 136, italics inoriginal). This new form of power over life is what Foucaultrefers to as ‘biopower’. Two separate yet connected de-velopments shifted this power over life: (1) a focus on thebody as a machine and subsequently treating the body interms of optimizing its ef!ciency and exploiting its ‘produc-tive’ capabilities — constituting an “anatomo-politics of thehuman body” (p. 139); and (2), as alluded to above, theregulation of the population through surveillance and “regu-latory controls: a biopolitics of the population” (p. 139).Disciplinary and regulatory controls therefore partnered toproduce the subjugation of individuals and entire populationsin the name of fostering life. Illustrations of the rationalitiesand techniques of biopower are evidenced through-out our!ndings section.

We also acknowledged the pervasive in"uence ofdiscourse, de!ned by Manias and Street (2001, p. 235) as“ways of forming knowledge that affect how we think, theway we act, and what we say and write.” Anyon (1994,p.120) too encourages the consideration of discourse:“human subjectivity is not at the center of meaning. Rather,subjectivity is constructed by the discourses that interpolateit.” Remaining cognizant and re"exive of these assumptionswas intended to infuse this research project with a morehumble, less authoritative research stance, while simulta-neously recognizing that research practices and processesare “heavily inscribed with habit and sedimented under-standings” (Lather, 1993, p.674). Therefore, the knowledgeclaims that we offer re"ect an appreciation of how languagewas used in shaping our understandings, in"uenced the

way we made sense of others' experiences, and informedour choices in representing the data.

Setting

This research took place in an urban, municipally-ownedlong-term care center in southwestern Ontario, Canada. Thefacility was home to 250 residents, most of whom lived insemi-private rooms. It included several separate care units, aswell as several common areas (cafeteria, main lobby, activityroom, etc.). Our interdisciplinary research team includedscholars in Health Sciences with backgrounds in counseling,caregiver burden, patient safety, organizational culture andgerontology, as well as community researchers with frontlineexpertise in working with people with mental health careissues in residential and clinical settings.

Methods

Our critical ethnography utilized methods that aimed torespect the intuitive base of healthcare practice so as to“ensure that our truth taxonomies capture, celebrate andpreserve the intuitive experience” of caregiving, which is sovaluable to both the care provider and the care-recipient(Winch, Creedy, & Chaboyer, 2002, p. 160). We believed itwas crucial to observe and dialog with the participants whowere most likely to possess explicit or implicit insider'sknowledge of the social context. With this in mind, weintentionally sought the perspectives of not only theleadership and administrative staff, but also nursing stafffrom day, evening, and night shifts. Therefore, this studyemployed ethnographic methods of participant observation(Dewalt & Dewalt, 2002), and in-depth focus groups andinterviews (Cook, 2005).

Dialogic data were collected using a semi-structuredinterview guide that invited participants to describe theirperceptions of if/how the needs of the residents living withmental health concerns were being met. As previouslymentioned, the initial purpose of this research project wasto critically explore the mental healthcare needs of olderadults seeking admission or recently admitted to long-termcare; however, concurrent data collection and analysisallowed us to hone in on particular recurrent themes withinthe staffs' data, which informed further focus to datacollection. For instance, we began inquiring about whatsupports (e.g. continuing education opportunities) staffreceived in providing for the increasingly complex careneeds of residents, and the perceived impacts policy had onproviding care to residents.

While conducting the focus groups, researchers paidparticular attention to how participants' experiencesappeared to converge or diverge within the group, andwatching and listening for how differing power dynamicswithin the group shaped the stories they shared (e.g. talkingover others, silencing through body language). In addition,!eld notes served to provide a rich, deep account ofobservations (Morse & Field, 1995). The focus groups wereall co-conducted by two members of the research team (RDand JH), a strategy that afforded added opportunity to buildrapport with participants, and to synergistically navigate theunfolding dialog. For example, one researcher could listen for

417R. DeForge et al. / Journal of Aging Studies 25 (2011) 415–426


emerging themes and the other could direct the dialog backto the interview guide as needed.

A total of six focus group interviews were conducted (seeTable 1). One was with seven members of the leadership andadministrative staff; one was with !ve members of theactivity staff; and the other four focus groups were withnursing staff (including registered nurses [n=2], registeredpractical nurses [n=3], and personal support workers[n=8]). The four focus groups with nursing staff took placeduring a day, an evening, and two night shifts. Additionally,participant observation data were collected throughout thecourse of 10 team meetings, which included the researchteam and members of the leadership team, as well as duringtimes before and after planned focus groups. All interviewdata were digitally recorded and transcribed, as were the !eldnotes the interviewers dictated after each visit to the setting.In total, 25 staff members participated in focus groups. Ofthese, 22 were female and 3 were male. While the length ofemployment at the home ranged from 2 weeks to 34 years,there was a clear difference in the number of years worked inthis particular home between the leadership team (none ofwhom had more than three years experience in theirrespective role) compared to the frontline staff (the activitystaff had an average of 17 years of experience; the nursingstaff had an average of 15 years of experience). The length ofthe focus groups ranged from 22 to 68 min.

Data analysis plan

Immediately after each focus group, all interview and !eldnote data were transcribed verbatim and reviewed by allmembers of the research team. Early analysis, informed byour !eld notes, focused on key phrases and themes thatemerged from the data (Lo"and & Lo"and, 1995). As commonthemes emerged, the research team participated in creatingan initial coding system. A second type of coding (focusedcoding) was then undertaken. The development of the codingsystem was discussed and reviewed during our research

team's bi-monthly meetings. This kind of simultaneous datacollection and interpretation made it possible to explore andexpand on themes from earlier focus groups and to reviseresearch questions in response to the priorities raised byresearch participants. While we consistently shared with staffthat the initial purpose of our study was to explore thechallenges related to providing care to residents with mentalhealth needs (and this was the starting point of all the focusgroups) staff quickly and consistently shifted emphasistoward regulatory, policy-related challenges they faced incare provision. Therefore, our subsequent lines of questioningand theorizations (while generally adhering to our initial dataanalysis plan) pursued this emergent !nding, a methodolog-ical choice we felt justi!ed in making given (i) the emergentnature of qualitative inquiry, (ii) ourmethodological choice ofethnography, which directs toward a better understanding ofa particular culture, and (iii) the potential for concernsregarding regulatory policies to affect the care provided toresidents.

Findings

Emerging themes

Our analysis of the data led us to two emergent themes:being ‘unable to care’ and ‘afraid to care.’ Although we presentparticipant data to substantiate these themes in a linearfashion, it is important to keep in mind the interconnectednature of our interpretations of the themes. For instance,feeling unable to care, at times, seemed to lead staff to feel asthough they were afraid to care; conversely, at other times,feeling afraid to care contributed to staff feeling as thoughthey were unable to care for their residents. Substantive datafrom each theme are presented below. A number of theexcerpts we include below re"ect the dialogic nature of ourdata collection methods, in that we sometimes include thequestions and responses of the researchers (RD and JH) so asto better contextualize participants' responses.

Table 1Demographic data.

The order focus groups were conducted: Focus group 1N=7(day shift)

Focus group 2N=2(evening shift)

Focus group 3N=2(night shift)

Focus group 4N=2(night shift)

Focus group 5N=7(day shift)

Focus group 6N=5(day shift)

GenderMale 1 1 – – – 1Female 6 1 2 2 7 4

Length of time of facilityb1 year 1 – – – – –

1–3 years 4 – – – – –

3–5 years – – – – 2 –

5–10 years – – – – – 1N10 years 1 2 2 1 5 4Missing 1 – – 1 – –

Position in home a

PSW – 2 2 – 4 –

RPN – – – 1 2 –

RN – – – 1 1 –

Management 7 – – – – –

Other – – – – – 5Duration of focus group 56 min 22 min 63 min 68 min 46 min 53 mina PSW: personal support worker; RPN: registered practical nurse; RN: registered nurse. ‘Management’ includes administrative staff. ‘Other’ includes activity

staff, dietary staff, and pastoral care.



On being ‘unable to care’

Given the broader, legislative context that shapes theprovision of long-term care in Ontario (e.g. implementationof the 2007 Ontario Long-term Care Act,) it was perhaps notsurprising that reactions to compliance issues were common.Signi!cantly, the nature of compliance issues seemed rathersimilar among the perspectives of frontline and administra-tive staff, albeit with differing experiences and subsequentconsequences of these policies between frontline andadministrative staff. From amanagement perspective, dealingwith compliance issues often entailed dealing with govern-ment of!cials and the power inherent in bureaucratic,authoritative positions. As one manager explained,

… there's these folks that come by who have quite a bit ofpower called compliance, they used to be called com-pliance advisors, so play on words. If I call my advisor andsay, I — because the manual is, is, very, how do you say,open to interpretation, so if I need to achieve A to B I havedifferent ways of going there. If I ask for advice, being theadvisor, they usually say, 'Well I can't advise you… I, youknow, this is what it [the policy manual] says'. She'll readverbatim what it says. They don't have, want to have, thatliability. They changed the model now, going moretowards compliance of!cers and if we are not compliantwith minimum standards, which are very challenging tomaintain, they can place us in a series of enforcement,they can place sanctions on us, and actually write ordersto have done in a certain time. Now that's Ministry ofHealth, not forgetting also though the power of theMinistry of Labor, where incredible — because as I've said,we have two vulnerable populations [frail seniors and/orseniors with mental health concerns] and again the addedburden of the mental health challenges that we aredealing with.

The frustration in feeling ill-supported by those who weresupposed to provide advisement with compliance issues(now replaced by of!cers enforcing standards that are“challenging to maintain”) was described as a consequenceof what we phrase as a ‘culture of compliance’ wherein thedaily taskwas to ensure all the proverbial baseswere covered.Moreover, the perception was that it was the responsibility ofthe home, not the Ministry of Health and Long-Term Care, to!gure out how to comply; the power of the Ministry lies in itsauthority to determine if compliance had been achieved.

From a front-line perspective, compliance was experi-enced in a somewhat similar fashion. In one of the focusgroups conducted with two personal support workers, thepervasiveness of compliance was described as follows:

… there seems to be all of this new compliance issues:compliance, compliance, compliance. And like you'reconstantly now on the edge of going, Oh gosh we'dbetter not do that because that's not what complianceagrees with, and If we get caught doing that, we're goingto be in big trouble. Right? That's been a real big strain —every move you make you think, Oh, you know, that wasokay to do before. Mind you I agree, we have to changewith the times, and if it's going to improve their life then

it's better or whatever, I'm all for it, but it's not a very nicework environment when you come and you feel likeyou're being breathed over… you know, what you'vedone for so long — but now you've got to be watching notjust the resident, you have to be constantly worryingabout what might happen from the other end. (PSW,night shift)

Clearly, in feeling like you're being “breathed over”, thereis a sense of surveillance. More notable though is the sensethat staff sometimes continued to practice in ways that wereacceptable to do before, and so it became a question ofwhether or not one wanted to risk ‘getting caught’. Such atenuous sentiment was framed, it seemed, by a kind ofacceptance or conformation with new regulations, butconstant concerns about getting in trouble seemed to create“not a very nice work environment”.

Concerns about getting in trouble were tied also to therequirement to adequately document daily care. As a PSWexplained,

… if the paperwork isn't answered, you didn't do your job.The paperwork is the priority. Like you think, if you comein here to work and there's two of us looking after 27people, and now it's not busy here by any means tonight,but in the day shift and in the other [evening] shift, if youthink if you have nine residents, !ne…— and you have toreally account for every "uid they drink, every bathroomtrip, like every little detail from their teeth to their hearingaid, you know people have different — and like, andcan you really be that on the ball— at the end of eight hoursto make sure you have documented everything for ninepeople properly?! Like that's an overwhelming load— youare already stretched out just thinking about that beforeyou even begin to try and document or even, you have thattask to perform !rst and then after you're so tiredmentallyfrom the job itself and all the stress, now you've got a putall this on paper. And so like that's a lot, isn't it? Becausegradually the paperwork has always built up and built up,and that's before we even moved to this building, there'smore now. And the workload was pretty heavy then. Andso in actual fact, what it really comes down to is that theresidents' care is really declining, big time. Because thepaperwork is getting the priority. (PSW, night shift)

To avoid such a work environment, many of the mostexperienced PSWs, those with 20+ years of experience, hadmigrated to full time nights rather than continue to besubjected to the stress and workload of day shifts:

The workload [on days] is insane, and then they broughtin the new, the RAI [resident assessment instrument, astandardized documentation tool], or whatever that'scalled before the funding — holy geez, I was here fromthree till four doing that, and I thought, This is nuts. Thisnight job came up, well I thought, I'll go for that — I don'tlike working nights, but for me to not have a stroke, it'sgood [laugh]. (PSW, night shift)

That several of the PSWs hadmade a choice to work nightsrather than days struck us as a rather creative way of working



around the rules: making such a signi!cant lifestyle change inlight of the work conditions of the long-term care homeserved to essentially remove those with the most experiencein caring for frail, older adults from sight. Rather than valuingand drawing on their experience, a culture of compliancemanifested conditions where experienced staff memberswere no longer able to care; they were literally driven intothe night.

Consistent with what other researchers have shown,PSWs felt their knowledge and input into care plans wereunder-valued (see Kontos et al., 2009). What appeared to beat odds often was the common sense approach of thefrontline caregivers with the legislated nature of caregiving.In a night shift focus group, we explored with participants theextent to which they felt able to have their practice concernsheard:

JH: Is there a role for you to say, “Hey so-and-so, I'mfeeling like this patient is getting too much meds!”…[heads shaking no] … so you don't have that kind of voiceto be able to say that? No? Okay.PSW: No we don't have that kind of voice. Some yearsago, I know we shouldn't go back in time, but I mean,people would go to bed, and there was always anunderstanding that people with Alzheimer's tend to beup at night time, I mean that that's one of the !rst cluesright? They start at home. I mean we were allowed to letthem be up and walk around, and if they wanted to sleepin in the morning and missed their breakfast, then wegive them a snack later or at nighttime or that kind ofthing… you kind of catered to their pattern. And now wehave the breakfast, and we have to have this, but youknow the Ministry [of Health and Long-term Care] justcame along and they said everybody has to get up forbreakfast. Okay, now: if you were up all night, do youthink that the Ministry has the right to tell you that youhave to get up now to go eat your breakfast? You knowlike wait a minute now: I should be able to say well listen,this man doesn't really remember that he was up all nightor whatever and I think that when he wakes up we'll feedhim then. (PSW, night shift).

Implied in the PSW's words are concerns about no longerbeing able to tailor or individualize care. Instead, standardizedwake times, bath times, snack times etc. meant that the long-term care residents received a kind of ‘one size!ts all’ care. Thatis, the insights about how to best provide care to residents thatcare providers gain daily from working directly with theresidents are ignored, often leaving staff feeling discounted.

The disconnect between management and frontline staff,especially night staff, is readily apparent at the intersectionbetween compliance, surveillance, and disruptive behaviors.In discussing some of the challenges inherent in caring forlong-term care residents with a variety of mental healthconcerns, a registered practice nurse (RPN) and a PSW sharedwith us the case of a female resident with a stress and anxietydisorder, describing the typical reaction of administrativestaff when something “drastic” occurs:

RPN: … yeah, some of them are afraid of her.PSW:Yeah theyareafraidofher, because she's veryexplosive.

RPN: And all you can do is document document document.And again, until something drastic happens, and then theywill still not do anything about it. It can be put in the doctor'sbook, they can be brought to management's attention, I just!nd that a lot of times it's not being dealt with bymanagement who do have some pull with the doctors —again, ‘How was your approach?’ You know what?!? Youguysneed to comeupherewhen this is goingon, youknow, italways happens, more so on evenings I think than on days.PSW:Yeah, andonevenings youhave less staff than youhaveon days. And it's busy.RD:What is this thing about ‘What is your approach?’What'sthat all about? And why is it —RPN: With a lot of them [residents], if you raise your voice,just the slightest little bit, it will trigger them. You have tokeep a calm tone of voice, oh yeah.PSW: If you go in like this, you know, kind of menacing, youhave towatchyour hands, youhave towatch everything, thatyour body language, because they'll just —RPN: Basically your body language, you have to watch that.JH: And so if there is a concern with the resident's behaviorand you raise that to management, the !rst questionthat comes out of their mouths is ‘Howwas your approach?’[Yep]… and what does that feel like?RPN: Very belittled. And that you don't know what you'redoing, and you don't knowhow to deal with it, and you don'twant to deal with them, you just want to complain kind of,basically, and that's just—PSW:Yeahbutyou'renot justdealingwithher [thedisruptiveresident], you're dealing with all these other people too, youknow someone else wants you for this or that and anotherthing, and she's carrying on like that— it's hard. It's very hard.And if you don't get help from the rest of the people you'reworking with, it's worse.RPN: If you don't have the backup from the management, itgets very very frustrating.PSW: And as I said you have to watch it because you have somany rules and regulations here: abuse abuse abuse, every-thing is abuse, you have to be careful. Usually you can justwalk away fromher, let her explode andwalk away fromher.Or tell her— she's in the dining room— she has to leave thedining room. Please. And she storms out and goes down for asmoke.

In caring for so many residents, the complexities of careprovision were experienced by frontline staff as a reduction totheir approach to residents. The reference to “somany rules andregulations” (and the implied assertion that to care for thewoman with the mood disorder runs the risk of being writtenup for being abusive) signi!es the extent to which the valuesand behaviors of management and frontline staff alike areshaped by a culture of compliance. As a result, tension anddivisions grewbetween the frontline staff and themanagementteam. Frustration began to grow, self-worth deteriorated, and,with frontline staff feeling unable to care, the resident with amood disorder (if she is not excluded from the dining room), isleft to ‘explode’.

Many factors contributed to staff feeling as though theywere unable to care: a lack of advisement from the Ministryof!cials who enforced regulations and the accompanyingfeeling of constantly being watched, the increased (paper)



workloads, and the apparent blame culture that attributedincidents with residents to the way in which frontline staffapproached an often unstable, resident. Each of theseconditions seemed to contribute to a workplace culture thatsuffered from low morale and high stress. In turn, theseconditions could have had deleterious effects on the residentsliving in long-term care. As both an antecedent and aconsequence of being unable to care in the ways staffunderstood to be in the best interest of residents, staff werealso left feeling afraid to care.

On being afraid to care

While our !ndings by no means suggest that long-termcare staff were purely or simply afraid (or unable) to care,several of the dialogic exchanges we had with staff re"ectedvarious fears: from fears of doing something wrong to fears ofexposing residents to (improbable) risks; from fears of beingphysically abused to fears of reporting such incidents. Theframing of being afraid to care is multifaceted. As the quotebelow from an RPN who works the night shift re"ects, a rootcause to which such fears could be attributed lies in thetension between complying and doing what they felt was‘right’:

There have been a lot of people who have come and goneand there's been a lot of things happening, and there's alot of people who come here and they're probably sounhappy with themselves they can't even perform thejob, and you know they're so scared of what they mightdo wrong… like they really aren't themselves! Like howdo you feel when you go to a job and you can't really dowhat you feel is right within your heart and what youthink the person deserves? (RPN, night shift)

Another illustration of how being afraid to caremanifestedwas shared with us by a PSW re"ecting on residents living onthe third "oor of the home, and their right/opportunity tobreathe some “fresh air”. In a focus group with day shiftnursing staff, we talked about the large balcony that wasaccessible from the third "oor dining room. Staff explainedthat it was ‘out of bounds’ because letting residents use thebalcony was too risky:

Now I had asked the RN in the spring when we were inthe dining room if it could be opened because when wewere on [another unit] it was allowed to be opened andthe Director of Care at the time said there was an issueabout bugs and "ies and so on … The issue was again, Noit can't be because it's a safety issue: what if somebodygot out, what if it was cold, what if they got a cold, what ifa "y came in …? (PSW, day shift)

In long-term care, simple pleasures like breathing fresh airwere often curtailed because of safety issues or fear ofliability.

While fears about safety issues preclude certain kinds ofcaring, the fragile mental stability of some of the home'sresidents also contributes to being afraid to care. In theexchange below, a PSW and an RPN !nish one story of theirexperiences of caring for another resident diagnosed with a

mood disorder, and then begin to speak with us about caringfor a woman with a brain injury:

PSW: What did I do the other day, I put something on herwalker, ohmyGod, she almostwent insane: “Get that off——ooh!” I took it off [laugh].RPN:… trying to think about who you're talking about?PSW: [Resident's name removed], over there. And then wehave somebodywith a brain injury, and she's terrible to dealwith, oh my God.RD: How so?PSW:Oh she's terrible – she just lights off – it doesn'tmatter,I mean she just explodes, she'll hit you, she's done that to allof us, she'd hit you, and swear, swear swear like a trooper,and I don't know, and you go into her room and if you justmove something, you know? And bathing her, but she'sterrible, just terrible. We wouldn't do it alone, you have tohave two people.RD: I'm interested in hearing one of those stories —PSW: and I know she has a brain injury, you have to take thatinto consideration, but man, it's hard to do sometimes.RD: What's that experience like, when you've had a shiftwhere you've been hit?PSW:Ohwell, you just carry on. Thatwas just natural for her.If shehits anRN, that's a different story, but if she just hits oneof us — yeah, it's true, I hate to say that but it's true.RD: What would the difference be?PSW: Oh! Phew! Write her up, get the doctor in, and andand… but with us oh, well you know, “What was yourapproach?” I hate that. “Howwas your approach?”…we getblamed all the time. She's terrible, you just have to — andwhenyou're newstaff, andyoudon't knowher, I got to knowher andknewher a little— I never had theproblemswithherafter that, but she can be very— and she likes to smoke, andshe's outside all the time… she's quite volatile, yeah, becareful. She's nasty with the other residents too. Rememberthat? She'd get in !ghts with them on the elevator [laughs].JH: And it just takes one person to change the dynamic of thewhole "oor. And people feel terrorized.PSW: Yep, and the other residents don'twant anything to dowith her.What are they going to do? There's noplacewe canput her. Thank God she smokes: she's outside a lot.

At least two things are remarkable about this exchange.One is that the resident's actions are naturalized (“That wasjust natural for her”), a sentiment that re"ects another,different kind of resignation wherein the future for thiswoman seems hopeless. Also remarkable though is theapparent contradiction in how different staff (a PSWcompared to a RN) were expected to deal with and respondto incidents of physical violence: the less powerful, lessvalued, and more poorly paid PSW felt blamed for an incidentthat might occur between her and the disruptive resident,whereas if the incident had occurred with or to a staffmember higher up on the staff hierarchy (i.e., a RN), anentirely different (and presumably more thorough) responsewould be initiated. Frontline PSWs reported being afraid:(i) of the potential violence that may erupt from a residentwith such a brain injury (or other “disruptive” pro!le), and(ii) of reporting any such violent incident for fear of beingblamed for taking the wrong approach.



Consequently, staff learned to work around such fears,even if doing so generated a secondary kind of risk or fear.Participants described to us their sense that the rules andregulations that work for some residents might not work forothers, and since one size did not !t all, nursing staff learnedhow to work around the rules and regulations:

…The best teaching you can have it's probably doing itevery day and what you learn from the experience of thejob and how to work around it. There is really no de!nitemethod, every resident is an individual, and everybody isan individual, so you really have to cater to people asindividuals. You know there's rules and there's regula-tions or whatever, but really when it comes down to it,what works for [one resident] might not work for[another]. (PSW, night shift)

An example of this kind of “work around” is describedbelow by a day shift RPN; notice how she and her colleagues“didn't do the management thing”:

Knitting, we had an issue … we were going to try toactivate [residents on the unit], and one lady asked, shewanted to knit. So we went through the proper channels,which I feel was a huge mistake because, ‘No, that's asafety issue. Someone could stab Joe in the eye with thoseknitting needles and Joe could be blind for the rest of his20 years of living.’ So Mrs. So and So can't knit and get herneeds met because there's a 10% risk. Meanwhile, the yearbefore we had let one lady, she was picking her !ngers,she knit the whole winter. We didn't do the managementthing, her daughter just brought knitting needles in sheknit the whole the winter. (RPN, day shift)

This is just one of many such workarounds. Othersincluded keeping doors to on-unit kitchen areas unlocked(rather than ‘safely’ locked); doing a one- instead of a two-person lift was another; walking away from a disruptiveresident instead of de-escalating the situation — each suchbehavior signi!ed a disruption of, or resistance to, the waycare was supposed to be provided. It is important to considerthough that workarounds can just as easily be detrimental toresidents' well-being. Consider this exchange from a focusgroup with day shift nursing and personal support work staff,whereinwe discuss how andwhy PRNs are administered, andwith what effect. (‘PRN’ signi!es that a medication is given ‘asneeded’). In this exchange, the staff discussed how they copedwith disruptive and/or agitated residents whose doctors hadwritten a PRN prescription for a sedative:

Registered Nurse (RN): … why should the residents get aPRN if it's the staff that's upset with it? That's not fair. Thatjust almost brings tears tomyeyes, because that happened acouple times: we come in and I cannot believe that theresidents have PRN because the staff [aren't coping].JH: And we've heard varying perspectives on the PRN. It'sactually a whole study in and of itself about how staff arefeelingabout this: fromdifferentmembers feelingas thoughthey [PRNs] are absolutely necessary and need to be givenbecause the residents are agitated, and then we've heardother people using the term ‘chemical restraints’, it's

abusive because it's being done for a whole bunch of otherreasons outside of that this resident actually needs it. But it'sabout, They don't want to eat at the time and so they'rebeing labeled as non-compliant, and then they're ‘agitated’because this dynamic going on — that really the staff ispushing for them [PRNs] and so again it sort of seems thatthis theme again comes up: about feeling frustrated aroundthe PRN being so widely used for what feel like issues thataren't related to the resident.RPN: She has a excellent point because I know some peoplewho are working at our site and they just giving out PRN'slike there is no tomorrow to prevent agitation. Who knowsif she's going to be agitated that evening, you know.PSW: And then they can't walk because they're drugged….RPN: And then they fall.RN: And they said that's the highest risk, you know, they aregoing to fall. That's, downstairs you know everybody is upwalkingandAlzheimer's— if somepeople are just givingoutPRN's like that there is a high risk of fall, very high risk. Andsometimes you know, they just push each other right,saying Hi and that's all she [a resident] needs. She's on the"oor with an injury, could be a fracture. They had anadmission down there, she was down there only for a weekand she fell after oneweek. And you know sometimes that'sall it takes: they had a PRN.

Data collected during a focus group with two night shiftPSWs provided evidence that some of the very reasons foradministering a PRN (e.g., to deal with disruptive nighttimebehaviors) were in fact produced by the very practice policiesin place within the long-term care home:

PSW2: The other thing is that people get up becausemaybethey're hungry, they might have to go to the toilet, theymight be in pain, but now, the RPN's have to give them aPRN.PSW 1: Yeah, that's the other thing.JH: What's that?PSW 1: Like a sedation. I guess somebody's up wandering,like before youwould automatically go, okay like toileting isthe !rst thing that you would offer the person, right? Makesure that they'rewarm— if they're cold theymight be up, orif they're too warm, they might be up, so you have to checkthose things. And thenwemight've offered them a snack, ormaybe they didn't enjoy supper, ormaybe they are agitated,bored —PSW 2: — or maybe they went to bed early and they'vealreadyhad enough sleep?But now, immediately, as soon asthey get up, they're going to be given a sedative.RD: To zonk them back out?PSW 2: Yup. There is no freedom in being in living to be an80-year-old, you've lost total control.JH: it makes that word ‘home’ feel…?PSW1: No but honestly, this is the truth,were notmaking itup.

In these two examples, the rationale for and practices ofadministering PRN sedatives/restraints serve to complicate theusual critique of chemical restraints as being an oppressivemeans to control care recipients and as having serious adverseconsequences (Sink, Holden, & Yaffe, 2005) by highlighting



how such drugs are not used in response to agitated behavior(or in any medical fashion) but are used to prevent agitation,even where there might not be any indication of its onset.Whether used to bene!t the residents themselves and/or tohelp the staff cope, our research !ndings demonstrated thatstaff often foundways towork around the conditions they facedeach day thatwere neither straightforward nor unproblematic.The ways in which staff behaved in light of their beliefs andperceptions ofwhatwas safe or not,whatwaspermitted or not,re"ects the tenuous balance between a valuing of the residents'care, a need to get tasks associated with their job done, andremaining safe (in terms of physical safety from aggressiveresidents, emotional safety from potentially reprehensible carepractices, and job security). To function in a work environmentwhere the staff was unable and afraid to care led to manyunanticipated consequences. Rules were sometimes brokenbecause a resident's quality of life was held above the policy-regulated practice. Rather than exclusively using themandatedapproach to providing care, staff often acted on their ownpractice-based logic, and catered their care based on knowingindividuals' unique preferences rather than treating residentsas mere occupants of an institution.

Discussion

As previously noted, the initial purpose of this criticalethnographic study was to explore the mental healthcareneeds of older adults (persons over the age of 65) seekingadmission or recently admitted to long-term care. In keepingwith an ethnographic methodology, we followed themes asthey emerged through data collection and analysis, and in thispaper we have focused on staff perceptions of (un)met careneeds. Our analysis led us to examine the intersectionbetween the accountabilities inherent in a culture ofcompliance and the responsibilities inherent in caring forolder adults in an institutional setting. Our !ndings describeda long-term care culture characterized by a frontline stafffeeling both unable and afraid to care: feeling unable to careat times led staff to feeling as though they were afraid to care;conversely, at other times, feeling afraid to care contributedto staff feeling as though they were unable to care for theirresidents.

Shifting blame

A signi!cant condition that contributed to such anatmosphere was the pervasiveness of the culture ofcompliance's capacity to create blame insofar as bothadministrative and frontline staff struggled to cope withfeelings of being monitored by their respective supervisors,a consequence of which was preclusion from being able andunafraid to provide compassionate, relational care to theresidents. Other authors have described how, by blamingmanagers, the government effectively avoids shoulderingaccountability at a time when the delivery of healthcare isbeing rationed (Bradshaw, 2002). Within this Ontario long-term care context, where the provincial government over-sees and funds healthcare, a similar end is achieved byway ofenacting a role of surveillance and sanction— a kind of ‘meetthese standards or else’ mentality that results in managersbeing blamed (and homes being sanctioned) when stan-

dards are not met. This seems to hold true even when long-term care home administrators report that the provincialgovernment continues to ration resources (Sharkey, 2008);it is the sanctioning and blaming that contributes to adminis-trative staff feeling as though they are afraid and unable tofoster a more compassionate care home, and as this researchhas shown, those feelings permeate to – and the blame shiftstoward – the frontline care providers.

Reason and colleagues describe how at the organizationallevel there are processes at work that (re)produce a culture ofregarding frontline workers “as both the primary cause ofmishaps and as the main target for remedial efforts” (Reason,Carthey, & de Leval, 2001, pg 22). Reason et al. (2001)explained how oftentimes, managers !nd it “relatively easy toidentify the proximal errors of the individuals at the sharpend and to consider these to be the “cause” of the mishap”(p. 22). Focusing on the last effort made to care for a personleaves no apparent reason to continue to investigate theadverse event. Moreover, (re)producing a culture of blameserved to minimize any institutional responsibility. “Thisresponse is especially compelling when the actions of theindividual in question are believed to deviate from someestablished protocol — a view that equates non-compliancewith guilt and overlooks the fact that any pre-programmedprocedure can be inappropriate in certain circumstances”(Reason et al., 2001, p. 22). Within the long-term carecontext, speci!c conditions that further (re)produce a cultureof blame include limited resources, overwhelmed leadership,and an educationally diverse workforce (Scott-Cawiezellet al., 2006). These researchers point out how such a culturalnuance “contributes greatly to the disconnection betweenseeking to learn and improve from potentially unsafe eventsand protecting one's job” (Vogelsmeier & Scott-Cawiezell,2007, p. 211). In the context of our research, a culture ofcompliance and disconnect seemed to be exacerbated by theconsiderable difference in the number of years of experience(working in this particular home) between frontline andmanagerial staff. Ceccato et al. (2009) reported that acrossOntario long-term care homes, the average turnover rateamong full time PSW staff was 7%, and 18% among part-timestaff. That the majority of participants in our sample werefull-time employees may account for their having so manyyears experience in this particular home; moreover, the factthat this was a municipally owned home may also havecontributed to the long lengths of employment among ourparticipants. While a limitation of our studymay be an under-representation of part-time staff, our data do not lead us tobelieve that newer frontline staff would have enjoyed a moreequitable, communicative relationship with managementthan the more seasoned frontline staff. Thus, an intersectionbetween/within a culture of blame, new(er) managementimplementing new accountability measures, and a veteranstaff accustomed to being able to relate to and care forresidents in ways that felt intuitive and tailored to individualneeds, could have led to the disconnect and frustrations withworking tasks, (unreasonable) expectations and compliance.

Workarounds

Consistent with previous !ndings, frontline staff in ourstudy engaged in ‘workarounds’ to circumvent the legislated



and standardized care expectations (Kontos et al., 2009,2010). Kontos et al. (2010) suggested that PSWs in long-termcare do indeed exert causal powers “as evidenced by theirabilities to perceive, negotiate, reluctantly comply with, orselectively resist provincial and institutional regulations, andthereby shape point-of-care decisions in accordance withtheir own deliberations concerning quality care” (p. 7). Thisresonated with our participants' stories of their own work-arounds, and research !ndings within an internal medicinesetting (Lingard et al., 2007). Lingard et al. (2007) character-ized the problem solving nature of workarounds as being “theresponse to a problem with a “quick !x” that supports short-term productivity but avoids addressing the underlying causeand allows problems to continuously re-circulate through thesystem” (p. 664). Moreover, they also described how, overtime, workarounds can erode organizational structures andrelationships: when there exists a ‘the way things are’ culture,which follows tacit, experiential rules rather than the explicit,formal rules of the ‘way things are intended to be’ culture, itcan be dif!cult to track problems and breakdowns in thesystem (Lingard et al., 2007, p. 664). As a result, a ‘work-around accretion’ phenomenon is produced, in which “layersof workarounds that further complicate, rather than resolve,the underlying system's problems that thwart effectiveinformation work” (Lingard et al., 2007, p. 665). Lingard etal. (2007) called the tension between the “quick wins” andthe layering of additional complications “functional dysfunc-tionality”: that is, an ability to simultaneously solve someproblems, ignore other ones, and create new ones. The datathat reveal how the PRN administration of sedatives isoftentimes a practice to prevent agitated behavior is apowerful illustration of how what appears to be a quick win(for staff) may contribute to the creation of much moresigni!cant problems (for residents and staff), such as anincreased risk of falls (let alone the unethical violation ofone's dignity). What must not be lost though is the notionthat such workarounds manifest as responses to structural/political conditions that render staff unable to provideadequate care to meet the individual needs of residents.

Implications

Similar to the staff experiences we learned about in thisstudy, other researchers have reported that while frontlineworkers in long-term care have described their work asrewarding, they have also stated they did not feel respected,listened to, or appreciated for the work they did (Bowers,Esmond, & Jacobson, 2003; Delle!eld, 2008). Frontline workershave also stressed the importance of managerial staff under-standing the experiences of PSWs, of being available to them,and of valuing and acknowledging their skills and knowledge(McGilton, Bowers, McKenzie-Green, Boscart, & Brown, 2009);so too have the care providers in this study.

The discussion on shifting blame (Bradshaw, 2002; Reasonet al., 2001) lends itself well to Goffman's (1968) notion ofactors playing a role, eachwith a particular script that instructsa particular way of being: the state (while rationing itsresources and instituting new measures of accountability)creates an atmosphere of surveillance and a culture ofcompliance for long-term care administrators, who then inturn project similar expectations of service and accountability

onto frontline staff, who in turn play out the role of carrying outset tasks, albeit while remaining unable and afraid to providethe kind of care they intuitively know is necessary. Such are theroles, it seems, within a ‘total institution’ (Goffman, 1968)wherein the activities of daily living are tightly governed bylayers upon layers of state- and facility-based rules. Theeffect ofbeing unable to care is an extension – a digression perhaps – ofDiamond's (1986) explication of the ‘invisibility of care’.Diamond detailed how the work of nurses' aids (i.e. PSWs) iswritten out of the chart because it is only the physical life ofresidents that is monitored and recorded. The caring work,which involves social relationsmanifest as touch, knowinghow‘to be’ with a person, and emotional labor, is all renderedinvisible. The contemporary digression is that oftentimes, staffmembers are precluded from even providing such caring workat all.

The exertion of power through mechanisms of surveil-lance and documentation, meanwhile, lends itself well toFoucault's (1991) notion of ‘the gaze.’ In his historicalaccounts of the wielding of power, Foucault demonstrateshow various members of society prepare themselves to besubjects of authority through subtle absorptions of theexercise of power into their collective, legitimated conscious-ness (Martin, 1998). As people become accustomed to theirposition within a social order (in this case, within the contextof long-term care) and to the mechanisms of surveillance,Foucault understood that they can be relied on to undertakeself-surveillance (Johnson, 1998), as evidenced in thisresearch by staff internalizing notions of ‘We'd better notdo that because that's not what compliance agrees with.’While this serves as another example of how power is givenup as much as it is taken away, Foucault's (1990) notion ofbiopower serves to remind us too of how long-term carerecipients have been rendered into docile bodies that are keptalive. The combination of disciplinary and regulatory controlexerted on staff subjugates not only their acts of caring, butthe lives of the care recipients as well, which Kontos (2005)describes in her call for a rethinking of person-centered care— a rethinking that espouses an appreciation of dementia carerecipients' embodied selfhood rather than a practice of caringfor bodies without minds.

The discussion of workarounds speaks to one way in whichfrontline staff seem to be able to empower themselves (insofarthat they seem to resist giving up all of their power), but herewe come to better understand the notion of being afraid to care,for indeed, the consequences of getting caught doing aworkaround are potentially severe, particularly as blameseems to roll down hierarchical structures to frontlineworkers,as discussed above. Lingard et al.'s (2007) notion of functionaldysfunctionality might then be further unpacked in light ofGoffman's description of the ‘morti!cation of self’, wherein aperson's original identity is stripped away: being afraid to carehas adramatic effect, itwould seem, on frontline staffmembers'interpersonal relationships (let alone their sense of self), aneffect we have characterized here as being unable to care. Anyresidual functionality (manifest as aworkaround) exists only asinvisible work, a phenomenon that has already been describedby Diamond (1986) as problematic, couched as it is within thecommodi!cation of care. In this respect, Diamond highlightshow daily care, particularly the social, interpersonal elementsof care, is ‘remade,’ as that which is documented is linked to



business constructs and measures and as the very discoursewithin the home becomes subsumed under that of long-termcare home management.

As such, we echo Diamond's assertion that frontline staffand care recipients themselves “be considered a vital voice in[long-term care] home research and political action. Theyknow a lot about how they would like their lives to bedifferent, and analysis of their situation can provide concretebases for change” (1986, p. 1293) and re-state this assertionas equally relevant today as it was 25 years ago. As do Kontoset al. (2010), we believe further investigation is necessary tobetter understand how PSWs can be more fully integratedinto care planning and be perceived and treated as valuablemembers of the care team. That which is rendered invisibleneeds to be made visible, and questions of where and whenthe ‘morti!cation’ of frontline staff can be prevented so as toprevent the morti!cation of care recipients remain vital topreserving the dignity and quality of life for both those livingand working in long-term care homes. To that end, thisresearch serves then as a call to soften ‘the gaze’ of top-downsurveillance by shifting it from issues of accountability toresponsibility for caring for those in need.

In closing

This paper contributes to a better understanding of thedif!culties long-termcare staff face on adaily basis by exploringhowandwhy frontline care providers in a long-termcare homeoften feel afraid and unable to care for their residents. That staff,as a consequence, report switching from day to night shifts soas to avoid being run off their feet and/or the hassles ofaccountability is remarkable insofar as it adds a layer of hiddencomplexity to the issue of staff turnover and provider–recipientcontinuity. Similarly, the accounts of why PRNs are adminis-tered so frequently (to prevent agitation, to help staff cope) areof great ethical concern and serve to complicate even furtherour understanding and objections to the (over)use of chemicalrestraints. Further research into this practice and into the‘migration to nights’ is certainly warranted. Most broadly, thispaper offers a resounding call to recognize and redress howpolicy-driven accountability mandates shape the caregiving/receiving experiences of long-term care staff and residents.Increasingly, it seems, responsibilities to care for others aredisplaced by measures of accountability, and that leaves manyfrontline long-term care providers afraid and unable to care.

Role of the funding source

Financial support for this research was provided by thelocal municipal government as a research contract to the lastauthor. The municipality played no role in the actual conductof the research.

Author 1 is supported by a Canadian Institutes of HealthResearch ‘Frederick Banting – Charles Best Canada GraduateScholarship’ – Doctoral Research Award.

Acknowledgments

The Long-term Care Home StaffThe authorswould like to acknowledge the critical role the

staff played in sharing their concerns and telling us their

stories. It was their expressed desire to make things betterthat motivated us to write this article. In addition, the long-term care facility's willingness to allow the interviewersaccess to the building and to the staff made data collectionpossible. We also recognize the !nancial support provided bythe municipality.

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Afraid to care; unable to care: A critical ethnography within a long-term care home

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