Results: Institutional Logics of Institutional Care

From the literature and the ethnographic findings, three “institutional logics” were identified as most salient in care homes; these can be described as home, medical institution, and business logics. The logic of the home, which aligns closely with the logic of person-centred care, is associated with the private sphere; familial relationships; independence and freedom from bureaucratic control; and norms of care and reciprocity. Care homes with skilled nursing are also medical institutions, however, and therefore associated with norms and practices related to physical health and, perhaps secondarily, mental health; bodily comfort and cleanliness; and, also, consistent documentation and quality control. Although these medical practices are certainly not antithetical to the home logic, neither do they entirely correspond to the latter’s emphasis on flexible, individualized patterns of daily life and the development of meaningful, sustained, and reciprocal personal relationships. An important difference between these two, broadly speaking, is that the medical logic is informed by the medical model of disability, with the biological basis of infirmity/impairment as the point of departure, whereas the social model of disability, which focuses on the enabling or disabling effects of the individual’s surroundings, has more salience in the home (Williams and Busby 2000).

Finally, whether public, private, or non-profit, nursing homes also operate according to a business logic—influenced by the logics of the state and market—in order to provide an acceptable standard of service using the resources available and according to external accountability mechanisms. Managing the workforce to deliver this service with optimum efficiency and effectiveness is paramount, and the impact for workers is an emphasis on fulfilling job descriptions, demonstrating competence in recognized job skills, meeting targets, and so on.

Broadly speaking, direct-care staff at both Richardson’s and Forest Lodge shared a similar responsibility for reconciling, through their “sayings and doings” (Nicolini 2011), the different priorities that each logic entailed, for example, with regards to balancing autonomy against safety, medical needs against individual choices, and group or organizational needs against individual preferences. However, notable differences were observed across the two care settings. In the following sections, two individual and highly abridged stories are described to illustrate the different “dementia experiences” produced through different instantiations of institutional logics. It must be emphasized that, because this research study focused on staff rather than residents, these stories are neither clinically precise nor subjectively informed; they are invoked exclusively to highlight logics and practices rather than individual experiences or outcomes.

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