Consecuencias de la desigualdad en el acceso a la información

(sometimes bordering on abusive) and who established a hierarchy based on power over others, created a culture that was based on the institutional model of care. Within these two homes, there was maladaptive organizational functioning of leadership and the staff. Overall, there was

conflict between departments, and most staff members were afraid of the formal leaders. Staff would not perform tasks that were not “approved of” by management (those that were focused on tasks and routines versus based on resident choice) for fear of retribution. One NA described an incident where she was “written up” and almost fired for not complying with an order from management.

Our home is impeccably clean...very clean. So, what they do is....on one day a week, each wing...so that is three days a week....they close off the wings with the steel doors, right after breakfast...and the residents are not allowed to go back to their rooms until they have cleaned that entire area. I was supposed to comply with that and I was supposed to be on board with all of them. When I saw what it did to them [residents]...how it confused them. I said “Leave those doors open. Let them go to their rooms.” Management said that what I did caused a safety issue…it escalated to me being written up and escalated to them calling labour relations in. I was very close to losing my job (NA, low sustainability home, retrospective study).

Other staff members expressed that this type of incident was not an isolated event and they “had learned” to “get used to it because that is the way it is.”

Within these two homes, there was a significant amount of inter-departmental conflict. Most of these conflicts were over issues that would improve the quality of life of the residents. The leaders in these two homes tended to support the departments that were proposing ideas where order, routine, and cleanliness were the most important rather than the direct caregivers (NAs and nurses) who were advocating for the residents. The same NA above described an incident where she tried to help a resident to go to her room for a nap in the afternoon.

When talking to labour relations, I said, “Do I have to check with housekeeping whether I can put a person to bed?” Basically, management said yes. And I thought “that is all wrong. It is me caregiving for that resident. If that resident needs something, I should be

124

able to judge that, not some housekeeper.” But see, they are in tight with housekeeping, so they want them to be elevated. Who is suffering here? Not me, but my resident is. And that is where I see GPA falling down all together. We do not have support. When we think a resident has a need and we implement it against their policy, we do not have support for that (NA, low sustainability home, retrospective study).

The leaders in the two low sustainability homes did not support the GPA program. The leaders in the prospective study home did not attend the initial GPA training course while the leaders in the retrospective did, however, the leaders in the low sustainability homes did not consider this program a priority. It was viewed as “one more thing to do” in a list of other initiatives that the health region was mandating. After the first GPA training session within the retrospective low sustainability home, the GPA Coaches and participants held a brain storming session to make changes to the LTC home physical environment so that there would be areas within the home that could be used by residents with dementia (e.g., reminiscence area and snack area). They created an action plan, budget, and assigned different duties to staff members to get the ideas off the ground. Staff at this training session were excited and enthusiastic about the changes that they could make for their residents. When they approached the formal leaders, it was “shot down because it wasn’t feasible” and would be “too much work” for other members within the LTC home (i.e., maintenance, housekeeping, and dietary). According to an RN in this low sustainability home, “We had all sorts of ideas. We had it all laid out kinda thing. All

excited. Everybody was all pumped. Then we called in the leaders. And then it just kinda got shot down. I heard GPA sessions after this did not go well. One was stopped early because of the conflict in the room.” Once the ideas were dismissed, staff members stated that the enthusiasm and creativity that the GPA program and Coaches inspired in the staff died, along with the GPA program. Staff members continued to provide institutionalized care because it was how the leadership wanted things done.

Within the institutional model culture of care in the low sustainability homes,

management of responsive behaviours was not in alignment with the GPA program. The GPA course taught staff to identify the reasons behind a behaviour and create a care plan to help minimize the behaviours. Within these two homes, non-pharmacological management of

responsive behaviours was not the usual practice of the staff. Instead, residents were more likely to be physically restrained and medication management used to manage the behaviours. Triggers

125

to the behaviours were rarely identified, and if they were, anti-psychotic or anti-anxiety medications were used first. For example, in the low sustainability home in the prospective study, a resident was found in a female co-resident room. The next day, the nursing staff left a note in the physician’s order book. “Please review Mr. C. as there has been an increase in wandering and inappropriate behaviours to residents.” At the next physician’s rounds, a prescription for Ativan was given to manage the behaviours. A week later, the following chart note was left by a nurse “…resident disruptive. Smirking at writer. Writer ignored behaviour, on doctor’s list for intervention to subdue this behaviour.” As a result, an antipsychotic medication was started. There was no trigger identified to the wandering behaviours and staff did not explore other medical, physical, or emotional issues that may be causing these behaviours to occur. The anti-psychotic was increased over 6 months and a second one was added one month prior to the end of the study. In the same home, a staff member was observed restraining a resident who was constantly urinating in co-resident rooms. She placed the resident in a reclining chair with a lap table because they did not have enough staff members to watch him or clean up after him. Another resident was given an anti-anxiety medication to help manage aggressive behaviours when staff were not able to transfer him to the toilet.

3.3.3.1.2 Low sustainability homes negative opinion leaders. Within this study, an