ABSTRACT Assertive Community Treatment (ACT) is considered the primary service-delivery vehicle for integrating individuals with severe mental illness into the community. Research on the model suggests that it has been helpful in aiding service users to achieve basic levels of integration including stabilized housing and maintaining financial and social security (Bond, Drake, Mueser & Latimer, 2001; Mueser, Bond, & Drake, 2001). However, critics of the model emphasize its limited success in enabling higher-order aspects of integration such as mainstream employment, recreation and socialization (Estroff, 1981; Gomory, 1998, 2001, 2002a, 2002b). These are fundamental criticisms given the significant investment in the model by policy makers. The rationale for the failure to promote higher-order integration typically rests on two central assumptions: a) service users are incapable of realizing full integration; and b) practitioners lack the training, skills, and philosophical base required to foster full integration. By focusing on the personal and professional characteristics of practitioners and service users, these views serve to obscure organizing structures operating at organizational, systemic, and social levels that encourage common ways of thinking about and carrying out community integration practice. The concern of this thesis is to explicate the impact of these organizing structures on the everyday practices engaged in by individual practitioners. In particular this thesis focuses on how practice becomes shaped by external structures that overrule both personal and professional values and intentions. The current study used the method of institutional ethnography to examine the impact of organizing structures of ACT in shaping how community integration practice is conceptualized, carried out, and accounted for on an everyday basis. The study findings are threefold. First, they suggest that organizing structures foster goals associated with protection as opposed to empowerment. Second, they reveal that organizing structures advance an individual-level focus over a social-level focus, prohibiting the community capacity building and environmental change necessary for fostering social autonomy and empowerment. Third, they show that organizing structures encourage practices discordant with integration, resulting in contradictory and therefore inconsistent attempts to facilitate higher-order aspects of integration. The power of these organizing structures is such that the personal and professional intentions of providers to facilitate broad community integration are consistently overruled within the context of everyday practice. The results of this study highlight the powerful role played by organizing structures in shaping community integration practice and provide an important theoretical model for planning, implementing, and evaluating models of service delivery for individuals with severe mental illness. / Thesis (Ph.D, Rehabilitation Science) -- Queen's University, 2007-09-27 15:10:26.391

Almost two decades after the end of apartheid, the higher education system in South Africa remains marked by inequity at both staff and student levels. Current research in this area focuses on measuring inequity but does little to explain why and how it persists. This research explores gender and race equity in South African universities using three critical case studies of the University of Kwa-Zulu Natal, the University of Pretoria, and the University of Cape Town. Using Dorothy Smith’s Institutional Ethnography, broadly conceived, this research examines the daily practices, processes and discourses that give rise to inequitable institutions. The case study of the University of Kwa-Zulu Natal revealed disjunctures between the push in commercialising universities, illustrated in the new managerialist approach and focus on research, on one hand, and the State’s goal to transform and redress, on the other. This tension was articulated in the incongruence between boss texts, such as the Employment Equity Act, and more local institutional texts that emphasised the employment of “productive” staff members. These competing national and institutional demands and pressures blunted the impact of equity policies and strategies. In the case study of the University of Pretoria, gender and racial inequity is maintained and reproduced through various practices and processes, some formal and others informal, both at institutional and individual levels. Students reproduced the racialism and racism that forms part of racial interaction in broader South African society. Despite having equity policies in place, there were significant enclaves of inequity, shown through the lack of female representation in some departments and in student politics, and importantly in the de facto segregation that continues in the student body. In the case study of the University of Cape Town, institutional structures and practices that both maintain and reproduce inequality were identified. In this instance, the formal arrangements and structures of the university were found to lead to the exclusion of and discrimination against certain groups of people. Examples of such institutional structures and processes include, but are not limited to: the concentration of power at middle management; the white-male domination in senior management; and the absence of an intersectional approach in equity policies and measures. Thus despite important progressive policies and ideals, the structural nature of the university served as one of the key obstacles to racial and gender equity. Together, the case studies carried out point to the objectified forms of consciousness and organisation that rely on and help create textual realities. The management of equity in South African institutions is characterised by disjunctures and competing interests and not necessarily by poor implementation, which has been suggested as the explanation by other researchers. The discourses of race, and gender that dominate South African society play an important role in informing how equity matters are managed and experienced at the local level. The local practices and realities of individual Universities should be understood as being framed and influenced by the ruling relations of higher education and the State.

This research investigates the work involved for social science graduate students (SSGS) in their development of an application for the Canadian Institutes of Health Research (CIHR). Central to CIHR’s mandate is the desire to “excel according to internationally accepted standards of scientific excellence” (CIHR, 2010, p. 3) which frames its epistemological stance around a traditional conception of science. Social scientists utilize a wide range of methodologies and work from a variety of epistemological positions. Some use very traditional "scientifically accepted" methodologies, which are most often quantitative. However, many social scientists use a wide range of qualitative methods to produce knowledge. This project describes how SSGS learn to make a CIHR application, navigate the application process, and negotiate its content, as well as other activities involved. It discusses the double subordination they face from both their supervisors and CIHR as well as the difficulties and challenges they encountered when making the application. By interviewing graduate social scientists, and through a textual analysis of their CIHR applications, I examine how social science graduate students know and describe their experience of developing their social science research project into a CIHR grant application. / Graduate

Several years ago a ten year child with a disability died from "severe malnutrition" according to a Coroners Service inquest jury. The inquest evidence shows that approximately one week prior to this child's death three health care providers conducted individual assessments of the child. Using institutional ethnography as a theoretical and methodological framework, the author conducts a textual analysis of the health care providers' documents generated during their provision of service to this child. Obtained as public documents from the Coroners Service, this data includes: the hospital form, the hospice society records and home care nursing records. / Graduate / 0566

This thesis is an exploration of the social construction and organization of community palliative care. The author's personal experience as the wife of a dying person is used to explicate the social relations of palliative care, through the feminist and constructivist methodology of institutional ethnography. The data analyzed includes a personal journal, working texts of the palliative care team (e.g. recording and reporting forms) obtained through Freedom of Information, and the Palliative Care at Home manual. / Graduate / 0452

While accountability measures are designed and promoted to increase trust among members of society in Canada, this study finds that accountability practices actually reduce trust and flexibility among people. This dissertation interrogates the concept of accountability as value-free and in the public interest in Canada. Using institutional ethnography as an approach to research, this study traces how accountability as a concept is defined through a set of performances described in texts that trickle down from the federal to the municipal level in Ontario. In particular, I examine how residents’ groups providing social services with a small grant from an Ontario municipality are required to go to great lengths to perform accountability according to dominant texts. This study overlays a mapping of the textual organization of accountability with the theories of civility and governmentality to demonstrate how white, middle-class, neoliberal values pervade decision-making about the allocation of public funds. The data demonstrate that while government accountability measures are designed with elected officials and government workers in mind, the practice of accountability gets enforced through the least socially powerful members of society, defined through racialized, gendered, and class distinctions. I conclude that while changes to reporting mechanisms could render the lives of more residents visible, ultimately the dominant focus on rules rather than relationships in Canada undermines real trust, and thus is the most vital site for change.

While accountability measures are designed and promoted to increase trust among members of society in Canada, this study finds that accountability practices actually reduce trust and flexibility among people. This dissertation interrogates the concept of accountability as value-free and in the public interest in Canada. Using institutional ethnography as an approach to research, this study traces how accountability as a concept is defined through a set of performances described in texts that trickle down from the federal to the municipal level in Ontario. In particular, I examine how residents’ groups providing social services with a small grant from an Ontario municipality are required to go to great lengths to perform accountability according to dominant texts. This study overlays a mapping of the textual organization of accountability with the theories of civility and governmentality to demonstrate how white, middle-class, neoliberal values pervade decision-making about the allocation of public funds. The data demonstrate that while government accountability measures are designed with elected officials and government workers in mind, the practice of accountability gets enforced through the least socially powerful members of society, defined through racialized, gendered, and class distinctions. I conclude that while changes to reporting mechanisms could render the lives of more residents visible, ultimately the dominant focus on rules rather than relationships in Canada undermines real trust, and thus is the most vital site for change.

Utilizing institutional ethnography and a critical analysis, this thesis explicates the textually-mediated process and ruling relations of performance measurement data collection in emergency homeless shelters. The thesis aimed to answer the query of whether the performance measurements collected by a set of programs, within a non-profit social service, adequately captured the full contribution of the work the staff did at their respective emergency shelter. Using literature, that has captured the experiences and insights of frontline workers who feel their work is inadequately captured, as a launch pad, this study spoke to informants who are directly involved in the creation of data collection tools and the reporting of the output and outcome performance measurements. How were these tools created? Who influences the development of the tools? Are some performance indicators (i.e. outputs, quality assurance, outcomes) measured more frequently or thoroughly than others? What are some of the barriers to measuring performance indicators? The study is based on five one-to-one semi-structured interviews, with informants working for a non-profit social service in Southern Ontario, and an analysis of the data collection tools used to compile performance measurements. The purpose of this research is to help social services, especially those that focus on addressing homelessness, improve the tools used to collect statistics on service so as to better articulate the breadth of work done by these services. / Thesis / Master of Social Work (MSW)

This study aims to understand the organization of Emergency Department (ED) nurses in Ontario after years of restructuring and cuts made to the healthcare system. The news is currently filled with ED closures across the country due to a shortage of nurses and high hospital occupancy. The recruitment and retention of nurses in the ED has proven extremely difficult due in part to the Ontario government's Bill 124 capping nurses' wage increases at 1%. This wage freeze is inscribed in a larger rationale present internationally advocating for efficiency and marketization of all spheres of life, healthcare included. Most of the literature published on the work of ED nurses refers to ideas of performance of flow. Using Institutional Ethnography (IE) as an approach and governmentality, more specifically neoliberalism, as a perspective, this study maps the ruling relations influencing the work of nurses in the ED. It also uncovers how the neoliberal discourse was not only internalized but applied by nurses in their work environment. The methodological approach and perspective used in this study highlight how a new rationale was implemented in the management and funding of healthcare, which then led to transforming the rationale of providing care in the ED. The ED now delivers care following a supply chain rationale employing technologies of governmentality such as Electronic Medical Records (EMR) to entice a specific conduct from nurses in order to meet the demands of the market. This new rationale, coupled with the implementation and sustaining of the technologies of governmentality, has come to completely transform what an ED nurse is nowadays. This new ED subject is responsible for most aspects of care, flow, and even her own training and security. The findings suggest that the use of algorithms based on best practices (such as medical directives) came to further erode the decisional power of nurses, resulting in "checkbox" practice.

My doctoral research begins from the standpoint of pregnant women and mothers living with HIV in Ontario, Canada and explores the concerns that women living with HIV have as they navigate healthcare during pregnancy, childbirth, and early postpartum. Moving beyond a description or abstracted theorization of women’s experiences, I have used institutional ethnography to explicate how women’s concerns are connected to and organized by ruling relations such as the ideological discourses that underpin the work practices of healthcare providers operating within healthcare institutions. This dissertation follows three “threads” that were discovered in the overall institutional ethnographic inquiry, and that form the basis of three manuscripts. The first thread (Chapter Three) focuses on HIV disclosure, which all women who participated in this research expressed as a concern, and uncovers how the issue of HIV disclosure is accounted for in healthcare providers’ work activities. In this analysis, I show how both the women’s and healthcare provider’s concerns about and actions related to HIV disclosure are connected to discourses such as “fear of contagion” and “AIDS hysteria” that continue to permeate public consciousness. The second thread (Chapter Four) focuses on the discourse of “risk” as organizing women’s experiences and healthcare providers’ work, which became visible through medications women were prescribed, the prenatal clinic appointment schedule women were expected to follow, and the medical interventions that were applied to women’s bodies during childbirth and early postpartum. In a third line of inquiry (Chapter Five), I outline how the current organization of “high-risk” maternity care that is delivered by specialists and is located in regional hospitals has particular implications for women’s pregnancy and motherhood experiences, especially for women who live at a distance from these services and/or find it challenging to attend appointments because of employment and familial responsibilities. This analysis shows how the discourses of “risk” and “safety” are differently known and enacted by women and their healthcare providers, and calls into question the classification of pregnancies of women living with HIV as “high-risk.” In following the three threads and tracking the territory of perinatal care for women living with HIV, I illuminate points of disjuncture between women’s and healthcare providers’ ways of knowing HIV in the context of pregnancy and childbirth, and identify possibilities for how healthcare practices can be augmented to respond to the concerns and challenge that women expressed. In the Conclusion chapter, I draw attention to the tensions between the meta-level ideological discourses of “HIV exceptionalism” and “HIV normalization” that run through Chapters Three, Four, and Five, and that are generalized across the HIV and maternity care services that women living with HIV encounter. I end this dissertation with my thoughts regarding implications for the organization of perinatal care for women living with HIV in Ontario. / Dissertation / Doctor of Philosophy (PhD) / In Ontario, the maternity care that women living with HIV receive during pregnancy, childbirth, and early postpartum (also known as the perinatal period) is located in “high-risk” clinical settings within regional, academic teaching hospitals. The organization of such care has important implications for women’s daily lives. This inquiry begins from the personal experiences of pregnant women and mothers living with HIV in Ontario and explores the concerns that women have as they navigate HIV and maternity care during the perinatal period. The inquiry shows how the troubles that women face are produced through institutional conditions and the routine practices of healthcare providers. This dissertation also examines how institutional arrangements related to reducing the risk of HIV to the fetus and infant, and lingering fears about HIV as “contagion,” shape women’s care experiences. Implications for the organization and delivery of perinatal care to women living with HIV is discussed.