title: Dementia care at the intersection of regulation and reflexivity: a critical realist perspective.
abstract: OBJECTIVE
  To understand point-of-care decisions, and in particular rule breaking, by personal support workers (PSWs) regarding institutionalized elders with dementia within a context of legislative and organizational care mandates.
  
  
  METHODS
  Qualitative baseline data including focus groups and semi-structured interviews with PSWs (n = 26) and supervisors (n = 9) were collected during a 2-year, multi-method trial of a 12-week interprofessional arts-informed educational intervention in two Alzheimer support units and were analyzed using a critical realist approach.
  
  
  RESULTS
  PSW care decisions were the outcome of a discordant interrelationship between PSWs' reflective deliberations, and legislative and organizational care mandates. PSWs responded to discordance through rule breaking in order to provide individualized care. Unbeknownst to PSWs, rule breaking was contingent upon supervisors' case-by-case complicity as they strove to balance fears of regulatory citations with private assessment of the soundness of PSW logic.
  
  
  CONCLUSIONS
  Quality care emerges at the intersection of policies governing long-term care, PSW rule breaking, and the supportive but undisclosed role supervisors play in these violations. Understanding this complexity has important implications for initiatives to improve care practices and to challenge legislation and policies that impede dementia care.
authors.affiliation: Toronto Rehabilitation Institute, Toronto, Ontario, Canada. kontos.pia@torontorehab.on.ca
authors.forename: Pia C
authors.initials: PC
authors.lastname: Kontos
authors.forename: Karen-Lee
authors.initials: KL
authors.lastname: Miller
authors.forename: Gail J
authors.initials: GJ
authors.lastname: Mitchell
authors.forename: Cheryl A
authors.initials: CA
authors.lastname: Cott
mesh_terms: D000328:Adult; D003695:Delivery of Health Care / Q000331:legislation & jurisprudence*; D003704:Dementia / Q000175:diagnosis* / Q000628:therapy*; D005260:Female; D017144:Focus Groups; D006282:Health Personnel; D006801:Humans; D007407:Interviews as Topic; D007878:Legislation as Topic; D008134:Long-Term Care / Q000331:legislation & jurisprudence*; D008297:Male; D008875:Middle Aged; D019095:Point-of-Care Systems; D011159:Population Surveillance; D011787:Quality of Health Care