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Nursing home regulation in most U. S. states is oriented more to compliance than to deterrent strategies. Voluntary compliance is surprisingly high. The major problem is not resistance to state commands but what Merton called ritualism-going along with institutionalized means for achieving regulatory goals while not attaining the goals themselves. The nature of state regulation has driven the American industry away from informal, intimate caring toward institutionalized care in larger nursing homes and toward the ascendancy of large corporate chains. These trends lead to the extraordinary disciplinary quality of U. S. nursing homes. Practices are regimented and documented from above-the federal government disciplines the states, state supervisors discipline inspectors, inspectors discipline nursing home operators, operators discipline nursing home staff, and staff discipline residents. Achieving quality of life and quality of care for residents requires substantial abandonment of this hierarchy of discipline in favor of local debate about outcomes in which residents and their advocates are empowered.
John Braithwaite (Fri,) studied this question.
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