A Major Collaborative Research Initiative funded by the
Social Sciences and Humanities Research Council of Canada
The Paradox of Regulation
Albert Banerjee, PhD
CIHR Postdoctoral Research Fellow
Pat Armstrong, PhD
Distinguished Research Professor of Sociology
Presentation at “ Do Regulations Make it Harder to Care?”,
Toronto, Canada, May 28, 2013
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Policy level regulations, set the conditions for
care (e.g., ownership, funding levels,
minimum staffing levels, required training,
etc).
Local level regulations specify the process of
care (e.g., a Resident’s Bill of Rights, Family
councils, how and when and how feeding is
to be done, etc.)
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Relational care recognises that care is
provided in and through relationships
between people.
Furthermore, care is always situated, located
within institutions processes and
organizational practices.
Care - understood relationally - is always
embedded, dynamic and as a result, often
unpredictable.
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A relational approach to accountability would expect
that policy and institutions would be accountable to
residents and those who immediately care for them.
Such relational forms of accountability would involve
ensuring adequate time to care, flexibility,
communication, resources as well as the power to
identify and resolve problems in a context
appropriate and timely matter.
The auditing approach to accountability: Objectives,
performance measurement, monitoring & reporting
(Powers, 2000, The Audit Society, Second thoughts)
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“We heard…seniors had missed their weekly bath due to staff
shortages” (274).
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“Staff who contacted us said they don’t always have time to
assist with thorough daily oral hygiene” (275).
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“Several of the residents require feeding at meal times…With
only two aides available this is difficult” (278).
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“Due to staffing levels, the residents are toileted at specific
times only, so for my mother … if she needs to go to the
bathroom outside of her times, she ends up going into the
diaper as she cannot possibly hold on” (275).
Source: BC Ombudsperson Report (2012), The
Best of Care
“It is surprising that neither the ministry nor the health authorities
have established standards on acceptable response times to call
bells.
Technology enabling the measurement of call-bell response times is
available, and some facilities are already using it.
Without objective data, it is difficult to determine the extent of the
problem. It would be useful for health authorities to collect objective
data about actual response times and use it to support the
development of appropriate standards and guidelines.
Once this is done, compliance with these standards can be
monitored”
Source: BC Ombudsperson Report (2012), The
Best of Care
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Increasing workload
Taking time away from care
Increasing paperwork
Supporting a culture of mistrust and
marginalization
Decoupling power from residents care
Transforming carework .
Routinization & defensive work
“Gosh forbid I walk down the hall and give somebody a drink without
checking the food and fluid binder! It creates all this dissociation
from what the whole intent is, which is to give the residents what
they would really enjoy having for their tea or anything else. It
creates this whole disciplinary approach to documentation.
....
So instead of sitting there for 20 minutes and having just a nice chat
over tea, they’ve got to sit there doing the busy work of
documenting...That’s part of the problem I have with the Act
because I’m constrained by these things to not create what would be
seen as a normal living circumstance for someone because you feel
like you’re in a lab and people are, you know, everything you do,
everything you do! has got to be written down.”
-LTRC RN
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Lesson 1: Not all regulations are the same
Lesson 2: The conditions of work are the
conditions of care
Lesson 3: Respond to problems with
inadequate staffing by regulating minimum
staffing levels
Lesson 4: Developing public and non-profit
providers and approaches
Lesson 5: Policy level regulations are political
Cost to provide 3.36 direct
care hours per day
Solving the problem of call bell
response times
“It is surprising, therefore, that neither the
ministry nor the health authorities have
established standards on acceptable
response times to call bells.
Technology enabling the measurement of
call-bell response times is available, and
some facilities are already using it.
Without objective data, it is difficult to
determine the extent of the problem. It
would be useful for health authorities to
collect objective data about actual
response times and use it to support the
development of appropriate standards and
guidelines.
Once this is done, compliance with these
standards can be monitored.”
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The Fraser Health Authority said it
would need to invest an additional $79
million in staffing to achieve the
guideline.
The Interior Health Authority estimated
that it would cost $39 million to achieve
the guideline.
The Northern Health Authority said it
would require an additional $11.6 million
to meet the guideline.
The Vancouver Coastal Health
Authority said that it would cost
approximately $57 million.
NB: No information was obtained from
the Vancouver Island Health Authority.
Source: BC Ombudsperson Report (2012), The
Best of Care
For more information or to offer feedback
please contact:
Albert Banerjee
balbertb@yorku.ca