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INSTITUTIONALIZED ELDER ABUSE:
Jason S. Ulsperger Department of Behavioral Sciences Witherspoon Hall 347 Arkansas Tech University Russellville, AR 72801
J. David Knottnerus Department of SociologyCLB 006 Oklahoma State University Stillwater, OK 74078david.knottnerus@okstate.edu
In Beyond Sociology’s Tower of Babel, Bernard Phillips (2001) describes the foundation of the Web and Part/Whole Approach using the concept of bureaucracy to explain problems with sociology and the scientific method. His description is not only important in illustrating faults in research methods and the hyper-specialization of sociology, but also in highlighting problems of bureaucracy. Bureaucratic organizations are a crucial part of society. Daily, we deal with organizations that focus on employment, education, government operation, product consumption, and many other facets of life. This is of little surprise for many sociologists. Max Weber (1921/1968) predicted organizational growth years ago. He anticipated the rise of organizations characterized by impersonal interaction, written rules, and clearly defined hierarchy. He indicated that as society grew more complex, social life would be impossible without bureaucratic organizations. However, as Phillips (2001) indicates with his assessment of the profession of sociology, bureaucratization is now a fundamental problem (for other social scientists addressing the role of bureaucracy in modern society see Merton 1936, 1940; Gouldner 1954, 1957; Blau 1955; Etzioni 1961; Blau and Scott 1963; Simon 1985; Friedland and Alford 1991; Powell and DiMaggio 1991; Meyer and Rowan 1991; Rabe and Ermann 1995; Lee and Ermann 1999; Vaughn 1992, 1999; Ritzer 2000). Acknowledging the importance of the Web and Part/Whole Approach, this chapter proposes that work bureaucratic rituals are an important part of social life for nursing home employees. Using 40 autobiographies, biographies, and research monographs to examine everyday life in nursing homes, it reviews various symbolic themes expressed through work rituals. The themes involve general concepts related to the fundamental problem of bureaucracy. Employing structural ritualization theory, it suggests that certain ritualized practices that express bureaucratic themes influence the behaviors of nursing home employees and contribute to the unintended maltreatment of residents. In turn, this chapter focuses on several research questions. How did bureaucracy come to have an influence on nursing homes? Does bureaucracy influence for-profit and nonprofit nursing homes in different ways? How do aspects of bureaucracy lead to the poor treatment and more specifically the physical neglect of residents? Can we consider alternative patterns of interaction that have the ability to counter bureaucracy and lower resident neglect? The Bureaucratization of U.S. Nursing Homes
According to the Web and Part/Whole Approach, it is important to consider circumstances leading to the development of a problem. To understand how bureaucracy facilitates physical neglect in both for-profit and nonprofit nursing homes, it is relevant to reflect on multiple factors. This includes historical aspects of nursing homes, legal developments, and organizational variation. The modern nursing home industry has roots in early colonial life. In colonial times, public policy followed the tradition of English poor laws. It left the care of dependent elderly people in the hands of community governments (Hawes and Phillips 1986). For the aged, this meant one of the only forms of public support was from poor farms which also provided care for the poor, sick, mentally ill, and lawbreakers (Dunlop 1979; Vladeck 1980; Holstein and Cole 1996). In the early 20th century, a move against institutionalization for the dependent old occurred culminating with the establishment of the 1935 Social Security Act (Canterbury 1938; Moore 1939; Achenbaum 1978; Vladeck 1980; Mitchell 2000). Politicians labeled a program in the first title of the act Old Age Assistance (OAA). Eligible recipients received no more than $30 per month. Because of scandals involving poor farms, regulations prohibited the institutionalized elderly from getting payments. However, there was not an adequate system to check the use of the funds so recipients would use the money for institutional care anyway. This led to an increase in what we now know as nursing homes (Hawes and Phillips 1986). Many welcomed the use of organizations specifically caring for the dependent old. However, from the start people were discontent with nursing home conditions. From the 1930s to the 1960s, stories of physical and financial abuse leaked to the public. Policy makers seemed to ignore them (Lidz, Fischer, and Arnold 1992). Grant money from OAA continued to feed a growing for-profit nursing home industry. People promoted the application of medicinal aid to care for the aged and soon the elderly were no longer cared for in informal, family-type environments. They were cared for in formal institutions promoting rules, hierarchical structure, and medical services. During this time, facilities started looking less like “homes” and more like hospitals. With OAA funding going straight to institutions, people receiving the funding were no longer directly involved. Lobby groups, such as the American Nursing Home Administration, gained power fighting for government funding increases and regulations favoring their facilities (Hawes and Phillips 1986; Giacalone 2001). Soon, direct payments and construction loans attracted people concerned with profit making, not care taking. Many of the names connected to the for-profit industry during the heyday of OAA funding used shady business practices to generate revenue. Sources indicate some even had ties to the Mafia (Mendelson 1974). Regardless, lobby groups convinced policy makers to push in more money. National expenditures for elder care increased. Estimates indicate they were nearly $33 million in 1940, and $187 million by 1950. By 1965, they were $1.3 billion (Giacalone 2001). In the early stages of nursing home growth, the federal government was only paying 10 percent of expenses. By the 1960s, they paid 22 percent (Hawes and Phillips 1986). The 1960s began with the passage of the Kerr-Mills Act. It replaced OAA with Medical Assistance for the Aged (MAA). It allowed states to control the criteria for government assistance. It also removed the federal government’s responsibility to match state funds. By 1965, MAA money provided support for over half of nursing home residents (Lidz et al. 1992). The establishment of MAA was important, but the 1965 amendments to the Social Security Act continue to be the most relevant policies for nursing home funding. They fostered Medicare and Medicaid. Medicare provides some money for the elderly in nursing homes, but if an aged person enters a nursing facility, the use of Medicare is limited. It is only for acute care, and only covers up to 100 days of nursing home services. Depending on geographic region and services needed nursing home costs can reach up to $60,000 per year. Without extra funding, 30 percent of the elderly entering nursing homes are in poverty within three months (Rosen and Wilbur 1992; Riekse and Holstege 1996). That impoverishment leads to Medicaid eligibility. Medicaid coverage includes the old poor. It is the primary funding for nursing homes. While Medicare only pays 2 percent of the total dollars spent on nursing home care, Medicaid covers 40 to 60 percent of nursing home expenditures (Giacalone 2001). In the years following the passage of the 1965 measures, the industry rapidly expanded. In 1969, 879,091 nursing homes existed, and by 1980, there were nearly 1.5 million (Hawes and Phillips 1986). Following the Social Security Act of 1965, policy makers estimated that few facilities could meet the minimum standards. The government decided to give facilities funds if they were in substantial compliance, rather than full compliance. When a state survey agency found violations, nursing homes only had to present them with a plan for corrections. This made it easy for owners seeking profit to cut operating costs, with care subsequently suffering. Through the late 1960s and 1970s, people became increasingly concerned with quality of care particularly in for-profit facilities. Individuals and corporate entities own for-profit nursing homes, as opposed to nonprofit government and religious sponsored facilities. The main objective of the former is revenue generation. Research indicates for-profit facilities focus more on administrative services, give less personal attention to residents, receive more complaints, have fewer staff members per patient, and spend less per resident (see Holmberg and Anderson 1968; Winn 1974; Caswell and Cleverley 1978; Brooks and Hoffman 1978; Koetting 1980; Moden 1982; Weisbrod and Schlesinger 1983; Elwell 1984; Hawes and Phillips 1986; Lemke and Moose 1986; Jenkins and Braithwaite 1993; Ulsperger and Ulsperger 2001). However, some analysts contend ownership does not predict quality of care (Holmberg and Anderson 1968; Winn 1974; Gottesman 1974). Factors of facility size and location may carry more weight (see Hawes and Phillips 1986). While researchers in the 1970s and 1980s continued to debate the superiority of certain types of facilities, costs skyrocketed. In the mid to late 1980s, the cost of care in nursing homes reached an unprecedented level. Both for-profit and nonprofit homes had trouble keeping pace. The average annual expenditure on one resident went from $5,100 in 1970, to $23,300 in 1985. By 1990, the average was $30,000 (Giacalone 2001). Poor care continued, and states raised nursing home standards; however, the standards put many smaller facilities out of business. Small facilities closed because they could not logistically meet new requirements. The bureaucratic demands also created a need for specialization. With requirements for activities, food, rehabilitation, and the preservation of resident records, facilities needed specific departments. Certification for workers became a requirement. Nursing home care became more complicated as nursing homes grew in size (Miller and Berry 1979; Johnson and Grant 1985; Harrington and Grant 1985). The bureaucratic logic in long-term care was in full swing. In reaction to substandard nursing home care and pressure from advocacy groups such as the National Citizens’ Coalition for Nursing Home Reform, the Omnibus Budget Reconciliation Act of 1987 (also known as the Nursing Home Reform Act) was passed. Policy makers designed it to decrease levels of inept care (Filinson 1995). It continues to have a large impact. The new requirements included quality of life issues, regulation of activities, privacy rights, visiting rights, and discharge rights (Riekse and Holstege 1996). The new guidelines also established the formal right for residents to be free from threats and actual neglect and abuse. This includes mental and physical neglect and abuse relating to corporal punishment, the use of drugs or physical restraints to control residents, and involuntary isolation (Mooney and Greenway1996). Regardless, as the elderly population in the U.S. grows, problems such as physical neglect still occur in for-profit and nonprofit nursing homes. In addition, bureaucratization in nursing homes appears to be as prevalent as ever (Foner 1994, 1995). Structural Ritualization Theory and the Web and Part/Whole Approach Structural ritualization theory (SRT) focuses on the fundamental role rituals play in everyday social life and the structuring of social events. They help provide symbolic meaning to our actions, give direction to human behavior, and create a sense of stability. According to the theory, ritualization involves interaction sequences that occur in multiple contexts including secular, sacred, formal, and informal settings (Knottnerus 1997). Various social scientists emphasizes the importance of rituals (e.g., Warner 1959; Durkheim 1912/1965; Goffman 1967; Turner 1967; Douglas 1970; Etzioni 2000; Collins 2004). Some of this work focuses on cultural and cognitive dimensions of organizations and institutional dynamics (e.g., Powell and DiMaggio 1991). All of it is relevant to SRT because it builds upon past work by providing formal definitions for rituals. According to the theory, ritualized symbolic practices (RSPs) are an important dimension of social behavior. They help structure group dynamics. RSPs are standardized, schema-driven actions. Schema refers to a cognitive framework. RSPs, therefore, involve regularly engaged in actions that take on meaning and express symbolic meanings. They help to produce patterns of action and relationships. In its original form, SRT emphasizes the processes by which RSPs in larger social environments influence embedded groups. These are groups nested in a larger social environment (e.g., a work group or office in a corporate or governmental organization). Over time, dominant ritualized practices in the larger milieu shape the cognitive schemas that guide the actions of actors in embedded groups. They become part of the cognitive script that guides their taken-for-granted, ritualized behavior. The theory argues that four factors are essential to ritualization and the structural reproduction process. They include repetitiveness, salience, homologousness, and resources. Repetitiveness involves the “relative frequency with which a RSP is performed” (Knottnerus 1997:262). The idea here is that the repetition of RSPs varies. Great differences may exist in the degree to which RSPs occur in different social settings or domains of interaction. For example, in one area within an organization such as a cafeteria, actors may never engage in a specific RSP. In another, such as a boss’s office, people may repeatedly engage in it. Salience involves the “degree to which a RSP is perceived to be central to an act, action sequence, or bundle of interrelated acts” (Knottnerus 1997:262). This involves the prominence of a RSP, which too can vary. In other words, actors’ perceptions of ritualized practices can differ in the extent to which they stand out. Homologousness implies a “degree of perceived similarity among different RSPs” (Knottnerus 1997:263). It is possible that different RSPs exist in a social setting. However, they may or may not be similar in meaning and form. The more they are alike, the more likely they strengthen each other. This enhances the impact of RSPs. Finally, resources are “materials needed to engage in RSPs which are available to actors” (Knottnerus 1997:264). The greater the availability of resources, the more likely an individual will participate in a RSP. Resources include nonhuman materials such as money, time, clothes or uniforms, and physical items (e.g., musical instruments, furniture, buildings). They also include human traits such as intellectual capacity, interaction skills, physical strength, and cognitive/perceptual abilities. Rank is another important concept in the theory. It involves “the relative standing of a RSP in terms of its dominance” or importance (Knottnerus 1997:266). According to the theory, rank is a function of repetitiveness, salience, homologousness, and resources. A RSP ranks high if it is repeated often, is quite visible, is similar to other RSPs, and people have resources to take part in it. When a RSP in a wider social environment has high rank, it is more likely it will appear in an embedded group. In other words, a RSP with high rank will have a greater impact on the thoughts and behaviors of people nested in a larger social environment. Structural ritualization theory parallels many aspects of the Web and Part/Whole Approach. The Web and Part/Whole Approach recommends scholars refocus on Mills’ (1959) idea of the sociological imagination and Gouldner’s (1970) thoughts on reflexive sociology. The sociological focus on grand theory and abstracted empiricism fail to generate significant questions about society. Moreover, many sociologists fail to view their own beliefs in the way they view the beliefs of others. In turn, the Web and Part/Whole Approach considers both basic assumptions that shape methods as well as theoretical consequences. Specifically, the approach calls for defining and linking a specific problem to other fundamental problems, moving up language’s ladder of abstraction by using high-level ideas for understanding, moving down language’s ladder of abstraction in obtaining facts, and integrating knowledge from specialized fields (Kincaid 1996; Scheff 1997; Phillips 2001; Phillips, Kincaid, and Scheff 2002; Scheff 2006; Phillips and Johnston forthcoming). In regard to defining and linking fundamental social problems, researchers have used SRT to examine an array of sociological topics in different historical periods and milieus. This includes the development of aggression in ancient civilizations (Knottnerus and Berry 2002), hierarchal distinctions on slave plantations (Knottnerus 1999), social identity for immigrants (Guan and Knottnerus 1999; Knottnerus and LoConto 2003; Guan and Knottnerus 2006), and educational issues (Knottnerus and Van de Poel-Knottnerus 1999; Van de Poel-Knottnerus and Knottnerus 2002; Wu and Knottnerus 2005, forthcoming). Other social issues SRT examines include corporate crime (Ulsperger and Knottnerus 2006; Knottnerus, Ulsperger, Cummins, and Osteen 2006), social inequality (Varner and Knottnerus 2002; Mitra and Knottnerus 2004), and responses to natural disasters (Thornburg, Knottnerus, and Webb forthcoming). Research also exists on interaction in experimental task groups and deritualization (Sell, Knottnerus, Ellison, and Mundt 2000; Knottnerus 2002, 2005). In terms of moving up the conceptual ladder of abstraction, SRT relies on the basic concept of ritual. However, as previously discussed, it does not merely utilize rituals in the ordinary sociological sense. It systematically focuses on specific aspects of ritual behavior - repetitiveness, salience, homologousness, and resources. This allows researchers to use a clearly defined theory of rituals. It also provides researchers the ability to move down the ladder of abstraction, simplify complex interaction, collect concrete measures in a variety of social environments, and draw basic conclusions. Furthermore, SRT allows researchers to move up and down the ladder of abstraction by examining how social structure produces everyday rituals and how everyday rituals reinforce social structure. Finally, both SRT and the Web and Part/Whole Approach emphasize the need for theory integration and cooperative efforts aimed at theory development and synthesis, which also implies openness to using various research methods. This chapter uses SRT to examine a new social problem dealing with the dynamics operating in a particular kind of social organization. Addressing the fundamental problem of bureaucracy, it examines everyday taken-for-granted work rituals that facilitate the maltreatment of residents in for-profit and nonprofit nursing homes. The rank of RSPs of bureaucracy and physical neglect are assessed using measures of repetitiveness and salience. Guided by the Web and Part/Whole Approach, it also provides practical suggestions for policies that would facilitate alternative RSPs which would replace or offset existing RSPs involving physical maltreatment. Methodology This research follows a tradition of using documents to qualitatively analyze social settings (see Thomas and Znaniecki 1918; Allport 1942; Dilthey 1962; Geertz 1973; Bogdan and Taylor 1975; Glassner and Corzine 1982; White 1986; Griswold 1992; Manning and Cullum-Swan 1994; Marshall and Rossman 1995; King 1998). More precisely we employ a literary ethnography, which involves a six-stage process of text analysis. Researchers use literary documents, often autobiographical in nature, to explore common themes. Similar to the typical content analysis, the steps include: identifying a scope of sources, reading and interpreting the documents, identifying textual themes, classifying textual themes, developing a set of analytic constructs, and rereading documents for contextual confirmation. These steps focus on thick descriptions. Descriptions generate themes that represent a portrait of actors’ experiences (Van de Poel-Knottnerus and Knottnerus 1994; Knottnerus and Van de Poel-Knottnerus 1999). The Literary Ethnography and the Web and Part/Whole Approach We believe the literary ethnography reflects important aspects of the Web and Part/Whole Approach. It helps identify a problem, but also further conceptualize issues contributing to the problem with its intense reading of personal documents reflecting actors’ perspectives on everyday life. It also helps researchers move up and down the ladder of abstraction. As noted, with a literary ethnography it is important to apply textual themes to analytic constructs. This allows researchers to identify an abstract concept (such as bureaucracy), read first hand accounts of a social environment, and see how abstract concepts are applicable to concrete situations (such as instances of neglect). Once those applications are established, a literary ethnography allows researchers to test particular ideas, reevaluate them, and move back up the ladder of abstraction through the contextual confirmation process. In addition, the Web and Part/Whole Approach concerns itself with the literature inside and outside of sociology that deepens research. As with this project, researchers have the ability to use non-sociological accounts of daily life and documents involving sociological observations of a specific milieu. Analyzing Rituals of Bureaucracy In this study, we used 40 autobiographies, biographies, and research monographs to analyze the bureaucratic rituals of employees in nursing homes (see Appendix). These sources of data are from 1963 to 2000: the time when the federal government first introduced nursing home regulations. Twenty sources focused on for-profit homes while 20 focused on nonprofit facilities. Reading revealed several textual themes. We grouped themes and then applied them to analytic constructs of bureaucracy. Following Weber’s (1921/1968) work, we defined bureaucracy as “any aspect of the social environment and its processes that involve the notation of staff separation and hierarchy, rules, documentation, and efficiency.” These points made up our bureaucratic subdivisions (see Table 1). Staff separation and hierarchy involved ritualized distinctions between levels of employees. Rules involved references to official regulations about the way to do something. Documentation rituals concerned references to recording any aspect of nursing home life in written form. Efficiency involved any demand to behave quickly and effectively. Insert Table 1 here An open category of “other” was also used to identify emerging themes that evolved after our initial reading and classification process. To gauge variation of bureaucratic ritualized symbolic practices in for-profit and nonprofit sources, we used structural ritualization theory to analyze their “rank” using factors of repetitiveness and salience. Analyzing Rituals of Physical Neglect Following our review of bureaucratic rituals, we focused on rituals of physical neglect in for-profit and nonprofit sources. We again followed the steps of the literary ethnography. To categorize specific rituals of physical neglect, we included any act leading to medical dereliction, personal negligence, environmental negligence, or bodily harm (see Table 2). Medical dereliction involved the failure to deliver medicine and services that have the capacity to help or heal resident ailments. This included situations in which staff used pharmaceutical drugs for no other reason than to control a patient’s behavior. Personal negligence concerned any references to staff failing to provide adequate upkeep of tangible features of residents such as clothing and personal hygiene needs. Environmental negligence included staff members failing to adequately maintain regions such as living areas, recreational rooms, kitchens, and grounds outside of the facility. This includes aspects of cleanliness. The category of bodily harm involved actual physical abuse of residents by staff members. This also included the overuse of physical restraints to control residents. Insert Table 2 here
As with the analysis of bureaucratic rituals, an “other” category emerged through our rereading and contextual confirmation. Our analysis of rituals of physical neglect also utilized SRT to analyze “rank” using repetitiveness and salience. A Note on Reflexivity In line with the Web and Part/Whole Approach emphasis on reflexivity, it is important to note that both researchers have first hand experience with nursing homes. This involves family members who lived in them, years of volunteer service, and limited employment. There is little doubt exposure to everyday life in nursing homes helped shape our concerns and approach to this project. Regardless, we see strength in this. While developing the research, these experiences helped us shape, reflect upon, and authenticate various aspects of the project. Findings: Rituals of Bureaucracy and Physical NeglectOur results from the literary ethnography focus on ritualized symbolic practices of bureaucracy and physical neglect. In regard to bureaucracy, we discuss four subdivisions of rituals involving staff separation and hierarchy, rules, documentation, and efficiency. We also consider the impact on four subdivisions of rituals involving physical neglect: medical dereliction, personal negligence, environmental negligence, and bodily harm.BureaucratizationAs Table 1 shows, there are 2,076 references to bureaucracy. The sources discuss rituals of staff separation and hierarchy 716 times (accounting for 34.5 % of bureaucracy references). References to rituals of rules occur 522 times (25.1 %) and documentation 490 times (23.6 %). References to efficiency rituals occur 241 times (11.6 %). Finally, the “other” subdivision has 107 references (5.2 %).Staff separation and hierarchy involves ritualistic dividing lines between levels of staff. It also involves any reference by authors to staff and residents in terms of order of importance. Table 1 shows 716 references to RSPs of staff separation and hierarchy. Of those, 297 references to staff separation and hierarchy appear in for-profit sources. This comprises 41.5 % of the references to this subdivision. In terms of nonprofit sources, 419 references appear, which accounts for 58.5 % of the references. RSPs of staff separation and hierarchy are salient in both for-profit and nonprofit sources. Discussions usually involve work duties. For instance, in one for-profit facility, residents look forward to coffee which is served by the activity director. The source notes that sometimes residents confined to their rooms want aides to bring it to them while aides resist. However, the text indicates aides feel bringing coffee to residents is exclusively the activity director’s responsibility (Kayser-Jones 1981). In another for-profit source, strict lines exist between workers. Administrators have luxurious air-conditioned and heated offices. Diamond explains when he worked in a nursing home he would see administrators get off the elevator coming to the floor and make a “sudden leap from 70 degrees to over 90” (1992:49). On the division between nursing staff he explains, “There were numerous distinctions among the ranks of the nursing staff: different training and income, different racial, ethnic, and age groups” (Diamond 1992:156). Similar points are made in nonprofit sources. For example, Shield describes, “Several implicit hierarchies - medical, administrative, nursing, and social service – operate within the bureaucracy…” (1988:93). RSPs involving rules concern any reference to official regulations about the way to do something. This includes internal rules of a facility. It also includes references to rituals concerning government regulations. As shown in Table 1, 522 references to rules appear in the sources. For instance, Foner suggests nursing homes are under a “tyranny” of rules and regulations (1995:231). This is true for for-profit and nonprofit sources. However, Table 1 shows more references in nonprofit sources. In for-profit facilities, 202 references appear (38.7 %), while in nonprofit facilities, 320 references to rules are found (61.3 %). In regard to RSPs and rank, rules are a prominent force in nursing homes. However, they have a larger influence on ritualized action in nonprofit facilities. In relation to the salience of rituals of rules in for-profit facilities, Fontana points out that idea of “rules above compassion” dominates nursing homes (1978:130). In this study, formal rules regulate what many would consider routine. Sources point to ritualistic rules for everything from feeding to personal care. Laws even require staff to help residents bathe. One resident told Howsden (1981), “I feel so strangled here. So many rules and regulations that don’t make any sense” (1981:144). Of course, rules are salient in nonprofit descriptions as well. In one literary account, Michael Fisher, an 82-year-old resident in a nonprofit facility, discusses his dislike of all the “rules and regulations” (O’Brien 1989:83). Foner (1994:68) states: … resentments ran especially high because, in an effort to upgrade the facility, the new administrator was tightening enforcement of existing rules and adding new ones. A seemingly endless onslaught of new rules affected even the smallest details of work life. One day aides could wear jewelry to work; the next, after a memo went out, only watches, engagement and wedding rings, and small earrings were allowed.
In this study, facilities also emphasize informal rules. In one for-profit home, an aide comments on a staff member violating an informal rule. The violator scalded a senile resident with hot bath water. Implying the scalding was intentional, the aide says the person should have known that “crazy patients are not punished for cursing aides” (Stannard 1973:338). In this study, nonprofit sources have more references involving rituals of rules, but salience appears high in both for-profit and nonprofit sources which indicate their high rank. Documentation rituals concern references to the recording of any aspect of nursing home life in written form. This includes activities of paperwork fulfilling legal requirements based on government regulation. In the sources, 490 references to this subdivision appear. As shown in Table 1, the references in for-profit and nonprofit sources have a similar pattern. In for-profit sources, 243 references appear (49.6 %) while in nonprofit sources, 247 are found (50.4 percent %). Rituals of documentation are salient in for-profit and nonprofit sources. One for-profit administrator comments “there is so much of it there is little time left to do anything else” (Farmer 1996:20). Someone explains later that “An abundance of tedious paperwork and documentation is the norm and not the exception” (Farmer 1996:97). Our findings suggest documentation rituals consume nursing staff. They shape the way nurses think, speak, and provide care. Diamond (1992:160) states: Staff continually cursed at being overwhelmed with paperwork.
As Howsden notes, “written documentation provides a medical rationale” for dealing with patients (1981:89). The RSP of writing things down shapes the way staff members view residents. Diamond explains that a nurse made it clear to him that documentation is a primary objective. Expressing his displeasure with the facility’s focus on writing so much down, the nurse once pointed to a sign posted in the nursing home reading “If It’s Not Charted, It Didn’t Happen” (1992:131). Documentation rituals shape actions in nonprofit church facilities as well. One account from Gubrium (1975:144) explains:
Efficiency rituals involve any demands to behave quickly and effectively. As shown in Table 1, 241 references to RSPs of efficiency appear in the sources. There are 116 references to efficiency appearing in the for-profit sources. This makes up 48.1 % of references. In nonprofit sources, 125 references appear accounting for 51.9 %. It seems that the emphasis on efficiency is similar in both for-profit and nonprofit settings. In terms of salience, for-profit and nonprofit facilities emphasize efficiency rituals. Large amounts of staff stress exist due to the “pressure of time” (Diamond 1992:79). For example, in a for-profit facility, Fontana (1978:130) notes: There was usually a minimal number of aides on the ward, andin order to meet administrative demands the aides wouldaccomplish their daily assignments as quickly as possible…The patient was scrubbed, washed, turned over, rinsed – and theaides were ready for the next patient. Feeding the patientsfollowed the same course. In the rushed meal hour, food wasshoved down open mouths or splattered on closed mouths asthe aides carried on without missing a beat. The aides brokethe rules concerning good care, but it mattered little to themsince the goal of efficiency was seemingly more important.
Similar accounts exist for nonprofit facilities. A good worker is not a worker who cares for residents, but one that executes tasks quickly. Foner (1994:60) states: Ms. James was typically the first nursing aide in the day room atlunchtime getting residents ready to eat. She was a fast worker. She finished her “bed and body” work early and was punctilious about getting her paper work done neatly and on time… Ms. James’ attitude toward dressing, bathing, and feeding patients was much the same as her attitude toward her other chores. She was determined to get them all done quickly, whether patients liked it or not. Residents in her view had no choice but to take prescribed medicines, eat so they would not lose weight or be forced to go on tube feeding, or “do a BM” so they would not get impacted. She had no tolerance for patients’ resistance, which slowed her down… In fact, Ms. James was proud that she could get patients to eat and “do a BM” so they would not get impacted. I overheard her explain, indeed justify, her approach to one of the therapists: “Schmidt eats for me, but if anyone hears me they’re gonna get me for patient abuse…”
In describing Ms. James, Foner (1994:60) notes that she once explained: I say “You eat” and I’m a big woman and I have a loud voice… Now Bernice Grossman, one day I was feeding her, saying eat, if you don’t eat, I’m gonna…
As mentioned, this analysis was open to emerging themes not discovered in the early phases of the literary ethnography. In the category of other, a common theme emerged concerning ritualistic meetings. Since this theme emerged during the analysis, our data in this subdivision do not cover all references to RSPs as other categories do. Ritualized meetings involve staff members and/or family assembling. As Table 1 shows, from the time we started counting, the sources reference meetings 107 times. In for-profit sources, 38 appear making up 35.5 % of references. In nonprofit sources, 69 are found making up 64.5 %. Ritualized meetings are salient in the nonprofit sources though examples for meetings exist in for-profit sources as well. One type showing up on a consistent basis is staff meetings which involve drafting a resident care plan. Savishinsky (1991:42) describes what occurs: Upon admission to the home, a new resident was discussed at Thursday Review. This was a regular staff meeting at which “care plans” were developed and periodically reviewed for each person living in the institution. The plan specified, for example, which treatment modalities a resident would be getting, such as PT (physical therapy), OT (occupational therapy), or ST (speech therapy); it indicated what foods and medications were to be administered; and it identified treatment goals which, if achieved, would allow a person to leave the facility for either a lower level of care or her own home. The latter details constituted a “discharge plan.”
Another type of meeting involves in-services. These are often required meetings for lower level staffs’ continuing education. Foner (1994:72-73) describes the disruption they create: During my research, aides had to attend an average of three or four in-service sessions a month, each lasting about half an hour. Five of the “in-services” given annually - on fire safety, needs of the elderly, patients’ rights, body mechanics and infection control are mandated… Others, on such topics as rehabilitation nursing, behavioral problems, and accidents and incidents, were designed by the nursing home to review and bring up to date the nursing aides’ job skills and to teach them more about patients’ special problems. Aides, administrators felt, needed re-training in even the most elementary tasks as well as instruction when added responsibilities such as filling out a new form, were introduced. Aides did not like in-services. In their view, the session taught things they already knew and did every day, interfered with getting their work done… One aide told me that in-services were the most difficult aspect of her job. “When you have too many meetings in a day, they take you from your direct work and take your time away from the patient and slow you up.” In fact, conscientious and caring aides were often the most vocal in their resentment of in-services, for they wanted to spend their time doing a good job for their residents.
Physical Neglect The physical neglect category involves references to RSPs of medical dereliction, personal negligence, environmental negligence, and bodily harm. As shown in Table 2, 541 acts of abuse involving physical neglect appear in the texts.The most references are to RSPs of medical dereliction. In the documents, 119 references appear (22 %) in this category. Statements about personal negligence rituals appear 111 times (20.5 %). Rituals of environmental negligence appear 99 times (18.3 %), and rituals of bodily harm occur 97 times (17.9 %). The open subdivision has 115 references (21.3 %). Rituals of medical dereliction include the failure to deliver medicine and services that have the capacity to help or heal residents’ ailments. This includes the use of pharmaceutical drugs, such as Thorazine, for no other reason than to control a patient’s behavior. In these situations, residents do not need medication. Staff members still use it in order to keep annoying patients from disrupting work. Table 2 shows 119 references to RSPs of medical dereliction appear. In for-profit sources, 78 references are found (65.5 %) while in nonprofit sources 41 references appear (34.5 %). For-profit sources reveal the salience of rituals of medical dereliction. For instance, references indicate that doctors working for the organization sometimes fail to provide medical care. Kayser-Jones (1981:76) explains: The nurse in charge of Unit B said that on some occasions when she had suggested glasses or a hearing aide for a patient, the doctor had rejected this suggestion with, “Oh well, she’s old anyhow.” Mr. Franklin, a patient, said, “There are too many patients here whom the doctors have rejected or turned away.”
In relation to nursing staff, Kayser-Jones (1981:77) notes: … at Pacific Manor the lack of medical care and concern for medical needs was frequently a subject for discussion both with patients and the nursing staff. Inattention to patients’ needs at Pacific Manor causes anxiety, stress, and fear among patients…
The lack of medical attention in for-profit facilities revolves around monetary issues. For example, Diamond reports that the administrator in the facility he worked at was not spending money on the medical needs of residents. In turn, he notes that aides often brought medical supplies from home. One of the better aides complained to him one day, “Damn… I forgot to bring those Epsom salts. Now Violet is not going to be able to soak her foot” (Diamond 1992:151). Regardless, staff members sometimes ritualistically overmedicate. As mentioned earlier, they overmedicate residents that cause disruptions to the bureaucratic demands of the workday. Fontana (1978:128) points out that workers label resident behavior deviant even when medications to control them cause the initial problem: The center exhibited many forms of deviance, which were perpetrated by individual members of the organization but were really done for and normalized in the name of the organization. The goal of the center, a typical one in this respect, was to provide a smooth-running schedule and flow of work, minimizing disturbances and avoiding trouble. What constituted disturbances and trouble was defined by the staff. Hence many deviant acts perpetrated by patients on other patients or by staff members were handled to minimize their hindrance to the running of the organization. Often these acts were normalized in order to avoid stopping the center’s smoothly flowing machine. Therefore if Maria, a wiry old patient, fell heavily to the ground after having been pumped full of Thorazine, the incident was dismissed as the result of an obfuscated mind and deteriorated body.
This practice is not limited to for-profit facilities. Gubrium (1975:148) states: Early in the day shift, it is not unusual for various aides on the floor to pass the nurses’ station and ask, “Did Max get his shot today?” or “I hope you remembered to give Emma her Thorazine. I have a lot of work to do, you know.” When the nurses forget to sedate such patients, concerned aides repeatedly remind them of it early in their shifts. Nurses usually oblige them if they claim to be busy, “just to get her [an aide] off my back so we can all get our work done.” When they do not, aides may threaten to do nothing until their request is granted… As one floor nurse stated to several aides just before leaving for her break, “Well, I guess I can take my break now. Everyone’s sedated.”
Gubrium (1975:148-49) also explains that the power to label residents as deviant lies in the hands of staff members who often abuse this power: Patients and residents do not necessarily enter the Manor withphysician’s orders for tranquilizers. However, when aidesdefine them as “troublemakers,” they get tranquilizers shortlyafter. Tranquilizers are mostly prescribed “PRN,” which meansthat they may be administered as needed at the discretion of thefloor nurses. In practice, however, the discretion involved isthat of the aide, who asks for, or reminds a floor nurse of “herneed” for, a sedative. From start to finish, the prescriptionand administration of tranquilizers is controlled indirectly byaides.
Evidence indicates rituals of medical dereliction are more prevalent in for-profit facilities. However, nonprofit facilities engage in the nonuse and abuse of medications as well. Data shows that staff members in both types of facilities ritually overused medications to control residents labeled as problems. Personal negligence concerns any references to staff RSPs, which fail to provide sufficient upkeep of tangible features of residents (e.g., clothing and personal cleanliness). Table 2 shows that 111 references are made to personal negligence. In for-profit sources, 76 references appear (68.5 %) while 35 references (31.5 %) are found in nonprofit sources. As with RSPs of medical dereliction, the for-profit sources have more counts of personal negligence. In fact, references to personal negligence in for-profit sources are twice the number for nonprofit sources. Rituals of personal negligence seem less salient compared to medical dereliction. Nevertheless, in for-profit sources, accounts clearly demonstrate how busy aides often fail to properly clean or clothe residents. Laird (1979:99) elaborates: Florence had a daffodil-yellow dress which didn’t entirely satisfy her. One day she said, “I believe I’ll give this to Annie. The color will be becoming to her.” No sooner than done, and a few days later Annie wore it. But to our disappointment, the aide had put it on her backwards.
It would be easy to assume that putting on a dress backwards would be a mistake and not intentional personal negligence. However, this is not the case as Kayser-Jones (1981:46) explains: … many residents at Pacific Manor do not have personal clothing, and what is provided for them is ill-fitting, un-pressed, and inappropriate. The available clothing (contributed by charitable organizations or left behind by previous patients) is stuffed in large cardboard boxes; no attempt is made to keep it neat or pressed. When someone needs a shirt or dress, attendants pull out whatever they can find; if the appropriate piece of attire is not available, a substitute is made. Mrs. White, an attractive 78-year-old woman who normally sat in a wheelchair clad in a sweater and slip, had to wear a bathrobe tied backwards around her waist to simulate a skirt when the therapist came to help her walk. To lack underclothes or to have clothes put on backwards is also dehumanizing for the elderly. Robes often are put on this way, staff informed me, to decrease the amount of work involved in changing an incontinent patient and to decrease the amount of laundry. If robes are put on backwards and not tucked under, they are not soiled when patients are incontinent.
In regard to RSPs involving personal negligence, Gubrium (1975) stresses that staff members make the lack of hygienic care routine. They turn actions other people find repugnant into something normal. In this study, nonprofit sources reveal how personal negligence can even be a punishment if a resident upsets a staff member. Shield states “… staff retribution can result when residents are too demanding. In subtle and not so subtle ways, staff members neglect or delay doing things” (1988:159). In this study, personal negligence RSPs, similar to bureaucratic RSPs, speed up the process of care. However, they also dehumanize residents. Environmental negligence rituals include staff members failing to maintain and keep clean domains of interaction such as living areas, recreational rooms, kitchens, and grounds outside of the facility. As Table 2 indicates, 99 references to this category appear. For-profit sources contain 74 references (74.7 %) while nonprofit sources account for 25 references (25.3 %). Environmental negligence is salient in the for-profit, but not nonprofit sources. In the for-profit sources, the theme of environmental negligence is especially strong. Gubrium (1993:170) provides one such account from a former nursing home surveyor turned resident:I think that cleanliness is a problem. I think here roaches are a problem. We are having a roach war here, okay? They are trying to kill the roaches. I myself am not a roach person. I don’t like them. I used to write out nursing homes for roaches all over. And this place has probably got as good roaches as I have ever run into… I mean, I was sitting with Harry [another resident] last night talking and one of them walks up the back of my dresser. I do not keep loose food in my room, okay? An experienced surveyor knows this. We have got a really, truly serious, bad roach problem. No examples pertaining to environmental negligence and pests exist in the nonprofit sources. Though environmental negligence references appear less and are not as intense in nonprofit sources, examples still exist. They involve staff not cleaning messes in resident rooms as described by Henry (1963:404): Mr. Unger sat in his wheelchair by the foot of his bed. He wasdressed and wore a black corduroy cap. He was holding a urinal inhis lap like a spitoon, and the neck of it was bloody… Next to himsat Mr. Butler, dressed, in a chair… A bedpan with dried feces satuncovered in front of Mr. Butler’s bedside table on the floor.
In for-profit and nonprofit facilities, this type of physical neglect leaves residents feeling less than human. Henry (1963:405) states that it communicates to residents that “they all have become junk” not worthy of well kept surroundings. Bodily harm rituals include physical abuse by staff members directed toward residents (including the overuse of physical restraints to control residents). Table 2 shows that 97 references to this subdivision appear. Again, we see more for-profit than nonprofit references. In for-profit sources, 70 appear (72.2 %) while nonprofit sources have 27 (27.8 %). Regardless of repetitiveness, rituals of bodily harm are salient in both types. As previously discussed, Stannard (1973) suggests staff in for-profit facilities sometimes give scalding hot baths to residents as a form of punishment when they create problems. Other for-profit sources suggest that staff may tie residents up with restraints when they disrupt schedules. Paterniti (2000:106) provides one account: Out of frustration and a perceived need to keep Scott restrained, aides frequently tied a square knot in the nylon vest restraint that secured Scott in a reclining Gerry chair. Some even remarked, “If you’re a mechanic, let’s see you get yourself out of this one!” On one occasion, an aide locked Scott, tied to a chair, in the janitors’ closet. The aide entertained himself by keeping records of how long it took Scott to work his way out of the restraints and to the door of the closet. Ironically, additional work to this staff member’s schedule, generated under his own control, seemed to present no obstacle to his work timetable.
Henry (1963) sees restraint use as a form of psychological terrorism. Residents experience discomfort and pain when tied down. The threat of restraint use is a deterrent for what the staff members see as deviant behavior – any act disrupting the routines of the institution. Diamond (1992) links this to bureaucratic and profit issues. Specifically, he notes goals of cost cutting as seen in the following account (Diamond (1992:182): Mary Ryan, like many others, spent all day in the day room, secured to her chair with a restraining vest. “How’y doin’ today, Mary?” I once asked in passing. She answered the question with a question. “Why do I have to sit here with this thing on?” I responded automatically with the trained answer, “That’s so you won’t fall. You know that.” “Oh, get away from me,” she reacted with disgust. “I don’t trust anybody in white anymore.” Stunned by her rejection, and not completely confident of my own answer, I passed the question on to Beulah Feders, the LPN in charge. “Beulah, why does she have to wear that thing all the time?” Beulah accompanied her quick comeback with a chuckle. “That’s so they don’t have to hire any more of you.”
Regardless of profit, nonprofit sources have accounts of this ritualized behavior as well. Tisdale’s conversation with a staff member describes one worker’s opinion on bodily harm, “Some are kind, some are cruel… They kick me, I kick them” (1987:109). However, not all staff members have the same perspective on bodily harm. Shield (1988:76) describes the attitude of one physical therapist working in a nonprofit facility: She is telling me about the time one of the residents came to physical therapy and had a bruise that, to the physical therapist, looked suspicious. She was sticking her neck out, she knew, by reporting it, but she decided to act. She phoned the charge nurse on the resident’s floor and reported it. She also wrote it up. Though she knew she was inviting employee resentment and anger by her actions, she felt it was important to be a resident’s advocate and agent for change in this way. She was letting employees on the floor know she was not going to avoid difficult issues and help cover things up.
Such actions by physical therapists are rare in the literature. As previously mentioned, lower level staff members sometimes normalize neglect. However, physical therapists are in a unique position. Physical therapists are not administrative staff, but are not floor staff either. Stannard (1973) explains that in nursing homes, administrative staff members, far removed from resident domains of interaction, seldom actually see neglectful and abusive behavior. They, like the lower staff, develop a culture of accounts to deal with repetitive cases of abuse. As with lower staff, this allows them to normalize maltreatment with specific vocabularies of motive (for more see Mills 1940). Stannard’s (1973) work indicates the physical therapist he observed lacked successful socialization to the organization’s culture. Her attitude shows that people use different RSPs when dealing with residents in specific locations. In that regard, Shield (1988) describes the physical therapy room as a unique social setting which exhibits a different atmosphere. When residents are there they joke, smile, laugh, and flirt with one another. Again, this analysis was open to emerging themes. In the case of physical neglect, common themes emerged after several phases of the literary ethnography were completed. In the “other” category, we noted themes dealing with limited supplies and inappropriate architecture. Such conditions (and related behaviors) also hinder good care. Keep in mind, we started counting references to this “other” category long after the literary ethnography started and numbers for them do not include all references in the texts. Table 1 indicates 115 references in the open category which includes both limited supplies and inappropriate architecture. For-profit sources have 83 references (72.2 %) while nonprofit sources have 32 references (27.8 %). References to the absence of limited supplies only appear in for-profit documents. The cost cutting mentality may explain this phenomenon. References to inappropriate architecture exist, but do not appear salient, in the for-profit or nonprofit sources. Although, examples do exist (Bennett 1980:65-6): A four-foot passageway at the foot of the beds is unreasonably small. It does not allow patients to go by one another without some risk… a patient ambulating in this passageway tripped over another’s foot, fell down, and fractured his hip.
Staff abuse does not always cause bodily harm. Residents do things to hurt themselves. However, the inappropriate architecture does not help as O’Brien (1989:216) notes: Many Bethany Manor residents described both falls and the fear of falling. Mrs. Cavanaugh, a five-year resident, reminisced, “I have had 14 falls since I have been here. The first day I was here I went downstairs to breakfast in the main dining room and I used the walker. After breakfast I came back to the elevator, and before I could get on, the door closed on me and knocked me down in the elevator. I didn’t break anything but I skinned all my side.”
While inappropriate architecture cannot be considered a RSP it does influence the way people move around in nursing homes. It creates a situation where simple tasks like getting out of bed or going to another floor of the building are hard to do if not dangerous. Such conditions also send a symbolic message to residents that their physical needs are not important. SummaryThis research indicates everyday life in nursing homes is quite bureaucratic in nature. More precisely, it shows how the presence of bureaucratic ritualized symbolic practices facilitates the maltreatment and physical neglect of residents. The sources in this study reveal multiple kinds of bureaucratic RSPs. Most commentary concerns ritualistic staff separation and hierarchy, with more references appearing in nonprofit nursing home sources. However, both for-profit and nonprofit documents vividly discuss rituals of staff separation and hierarchy, i.e., they are quite salient. We believe this has a social psychological effect on individuals working in nursing homes. Workers tend to perform duties if it is specifically their responsibility. With a high degree of separation between staff members, different organizational units within nursing homes develop their own norms. For example, employees at lower levels of the organization sometimes accept neglect and abuse. They see it as an appropriate punishment if a resident disrupts their work routine. New aides who socialize with other aides learn to neutralize abuse if residents violate institutional rituals of staff work (for more on this process in terms of crime and deviance see Sutherland 1940; Sykes and Matza 1957). Top staff may see neglect or abuse as deviant, or may avoid dealing with it because it does not occur in their domains of interaction. Regardless, social cohesion created by staff separation leads aides to cover up neglect or abuse when carried out by one of their own. This implies that staff separation in for-profit and nonprofit nursing homes facilitates maltreatment. Many references to rituals of rules also exist. Again, more of the references are from nonprofit sources. However, RSPs of rules are salient in both for-profit and nonprofit settings. Many of these actions involve formal requirements created by government regulation. However, informal ritualized rules also exist for resident care. Various sources suggest that the abuse of certain residents may be legitimated depending on whether a person is senile or not. Like staff separation, these informal ritualistic practices unintentionally promote maltreatment. Fewer references are made to rituals of documentation and efficiency. Nevertheless, similarities exist in for-profit and nonprofit sources in terms of repetitiveness and salience. In relation to documentation, work rituals involving paperwork even influence church operated facilities. This creates a situation where staff members stop thinking they work with people. Documentation of most if not all aspects of the job ritualistically turns residents into objects of work. For example, when residents have bowel movements, aides record it in a “defecation book” (Gubrium 1975:138). A personal act turns into a quantitative measurement. Aides count human excrement like factory workers count the number of parts falling from a conveyer belt. With humans and their behavior turned into objects of ritualistic documentation, impersonalization and maltreatment are more likely. Moreover, the emphasis on efficiency does not help. A prominent goal of nursing homes is for workers to complete their duties as rapidly as possible. Both for-profit and nonprofit accounts indicate that it does not matter how a job is done as long as it is done, and is done quickly. In addition to these points, ritualistic meetings unintentionally lead to poor care. In line with the new institutionalism perspective (see Meyer and Rowan 1991), nursing homes value meetings. Meetings may not even have relevance to the organization. However, modern organizations think they have to act like organizations. Meetings are a part of this. This ceremonial legitimation of organizations has negative consequences for nursing homes. Repeated references to ritualized symbolic practices of staff separation, rules, and meetings indicate bureaucratic RSPs drive nonprofit facilities. However, these RSPs are highly salient in both for-profit and nonprofit sources. Repetitiveness and salience provide evidence of bureaucratic RSPs having a high rank in all types of nursing homes. As mentioned earlier in this chapter, for-profit facilities may promote poor quality of care with profit motives. However, any nursing home unintentionally promotes poor care if a bureaucratic logic supporting RSPs of staff separation, rules, documentation, efficiency, and meetings dictates its interaction patterns. In regard to RSPs of physical neglect, more references exist in for-profit sources. RSPs of physical neglect are highly salient in most of the subdivisions in both for-profit and nonprofit texts. In terms of RSPs of medical dereliction, doctors often fail to provide medical care to residents when they need it. Staff members in nursing homes also ritualistically fail to provide adequate care in certain situations. Sources indicate this failure involves issues connected to money in for-profit homes. Some facilities simply do not purchase medical products. Aides sometimes even bring what they need from home to care for residents. This study also indicates for-profit and nonprofit staff members ritualistically overuse medications. This occurs when staff members want to control residents who keep them from efficiently carrying out work duties. As a symbol of power, aides ritualistically tie residents down, even when they do not need it, in order to get them out of the way. Moreover, staff members ritualistically label residents deviant to justify restraint use. In terms of RSPs involving personal negligence, the data indicates that busy aides sometimes fail to clean residents properly. They even intentionally fail to dress them properly because improper dress speeds up the fulfillment of work duties. Aides in nonprofit facilities sometimes ritualistically neglect the personal care of residents to punish them if they are too demanding. In terms of environmental negligence, cleanliness is an issue as well. Accounts in for-profit sources describe pest control problems. Accounts in nonprofit sources also describe the ritualistic failure to adequately clean rooms. This sends a symbolic message to residents that they are not worthy of good care. In terms of bodily harm rituals, references to explicit physical abuse exist in for-profit and nonprofit documents. Staff members sometimes justify the physical abuse of residents with an eye for an eye mentality. They claim residents abuse them, so they ritualistically get revenge. Aides and nurses sometimes give scalding hot baths, unnecessarily restrain, and even lock up residents to control or punish them. These punishments are for behavior that disrupts the flow of the workday. At the same time, for-profit sources indicate restraint use is also an effective means of cost control. A small staff can easily handle many residents if they tie them down. Finally, inappropriate architecture is an important issue. Spatial conditions of nursing homes influence patterns of resident behavior that possibly promote bodily harm. In sum, evidence suggests bureaucratic RSPs shape the cognitive frameworks of nursing home workers leading to the reproduction of RSPs involving the maltreatment of residents. Policy Recommendations: Transforming Maltreatment and Physical Neglect Structural ritualization theory discusses not only structural reproduction, but also ritual change (Knottnerus 1997). In relation to the Web and Part/Whole’s emphasis on the practical application of research, ritualized practices can involve innovative processes, which lead to novel social structures. Transformative structural ritualization is concerned with how new ritualized behaviors may emerge in social settings. One type of ritual change would involve the deliberate encouragement and activation of new ritualized symbolic practices in organizations to lessen the impact of bureaucratic rituals and neglect. With this in mind, we suggest the following: Recognize and downplay bureaucracy. Facilities should take steps toward open discussions about bureaucratic constraints. For instance, executive directors could conduct an initial meeting to orient new staff on concepts of bureaucracy; then carry out a needs assessment to identify bureaucratic problems and ritualized bureaucratic behaviors that could be reduced within the constraints of state and federal guidelines. Limit specific job / specific task mentality. Directors of facilities should emphasize to all staff that if a resident is in need with a minor problem any employee should help. Moreover, if a worker does not have the correct training to help with a serious issue, he or she should make it a priority to find someone who does have it. Such efforts would promote more personalized rituals which facilitate the well-being of residents. Integrate Meetings. If certain meetings are short or issues they deal with are not of immediate importance, consolidate meetings and in-service training sessions. Also, do not schedule in-services during times when care taking should be occurring. Simulation exercises. Have all staff members go through simulation exercises involving short stints as “mock residents.” Require all employees to be tied down to a bed, fed, and inadequately dressed. Such exercises would sensitize staff to the importance of ritualized behaviors explicitly focused on the human needs of residents. Revise wage standards. Increase lower level staff pay, but also provide extra funds when staff members perform in a way that encourages emotional support. In other words, introduce positive sanctions that would encourage ritualized activities that enhance the quality of life of residents. Clothing Design. To create a middle ground between dress and efficiency, it might be possible to design clothing conducive to the bureaucratic necessity of working quickly. To prevent residents from sitting around with a gown on backwards and open in the front, the industry could work with fashion experts to design clothing that looks presentable and socially acceptable. However, have them design it in a way where employees can perform necessary work tasks with residents in a dignified way. Increase upper-level staff and resident interaction. To lower objectification, facilities should create measures for top staff to communicate with residents. Make it a requirement that they spend time during the workday visiting with residents. In other words promote in various ways ritualized behaviors that heighten social involvement and contact between upper-level (and lower-level) staff and residents. Preventative Architectural Design. Too often, nursing homes resemble hospitals or are designed with a bureaucratic or medical rationale in mind. Designers could start considering how the layout of a facility negatively influences resident wellbeing and then consider the relevance of design on the ritualized behaviors of employees. Policy recommendations and measures such as these would represent a first step toward the development of alternative ritualized practices that would foster the physical, emotional, and mental health of nursing home residents. Because these recommendations are grounded in theory and research, the presentation of which has been facilitated by the Web and Part/Whole approach, we are optimistic about the prospects of lowering resident neglect in such settings. However, because bureaucratic RSPs are ingrained in multiple organizations in modern society, it will not be an easy battle. While Weber’s (1921/1968) work suggests the need for individuals to stand up to the negative impact of bureaucracy, it also implies bureaucratic arrangements and behavior are among the hardest social conditions to alter once established.
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