Making it Work: A Study of the Decision-Making Processes of Personal Support Workers in Long-Term Residential Care

This dissertation explores the decision-making processes of personal support workers (PSWs) in long-term residential care (LTRC). These workers are lowest in the LTRC labour hierarchy, performing the majority of "hands-on" care. Research has shown that PSWs have little input in formal care planning and organizational processes, but retain some limited control over how they work on a daily/nightly basis. Given this, my study asks: where can PSWs make decisions, what factors shape their capacity to decide and, when they can make decisions, what are the factors that these decisions respond to? I use a feminist political economy framework to answer these questions, and begin by examining broader social, political, economic, and historical features of the LTRC landscape on a global, national, and provincial level. Located on this landscape is “Riverside Home”, a multi-unit LTRC facility in a large urban city in Ontario. My analysis draws on data from a rapid ethnography conducted at this site, obtained through my participation as a student researcher on the project Re-Imagining Long-Term Residential Care: An International Study of Promising Practices. I use both observations of and interviews with personal support workers at Riverside Home, examining their daily/nightly experiences of care work including feeding residents, bathing/grooming, toileting/continence care, and clothing/laundry. My analysis demonstrates that PSWs experience a narrowed capacity to make decisions about care, and both regulations and restructuring have impacted their workload, work organization and working conditions. However, amidst this narrowed capacity to decide, PSWs make numerous important decisions throughout their daily/nightly care work, including adjusting the tempo of their work, prioritizing tasks, rearranging their workload, and coping with abuse. My findings demonstrate that PSW decision-making in LTRC is a complex social process shaped by and in response to social location (i.e. the intersecting variables of race, gender and class), work organization, regulations, LTRC (re)structuring, and models of care. By locating PSW decision-making within these multi-layered “nested” contexts, I demonstrate that the conditions of PSWs’ direct care work in LTRC are neither natural nor inevitable, and thus are transformable for the benefit of both workers and the residents they care for.