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Competing logics and organizational failure: the structuring of California prison health care

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Content Running Head: COMPETING LOGICS AND ORGANIZATIONAL FAILURE i

Competing Logics and Organizational Failure:
The Structuring of California Prison Health Care

by

Jennifer Lee Heckman

_________________________________________________________________________________________________________

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
ANNENBERG SCHOOL FOR COMMUNICATION AND JOURNALISM

May 2013

COMPETING LOGICS AND ORGANIZATIONAL FAILURE

ii
Table of Contents

Dedication and Acknowledgements

iv
List of Tables and Figures

v
Abbreviations

vi
Abstract

1
Chapter 1: Introduction
Communication and Institutions
Dissertation Preview

2
3
5
Chapter 2: Literature Review
New Institutional Theory
Communicative and Behavioral Aspects of Institutions
The Role of Discourse in Institutions
Legitimacy and Institutional Change
Logics are Evident in Structuration
Organizational Field, Stakeholders and Change

9
10
15
21
25
28
33
Chapter 3: Methods
Qualitative Research
Data Collection
Data Analysis
Procedure

35
35
39
43

Chapter 4: Clashing Logics: Command and Control versus Care
Case Overview: Plata v. Schwarzenegger
The California Correctional Peace Officers Association: An Overview
San Quentin Prison
Correctional Officers: Practices and Logics
Medical Care Inside Prison Walls
Medical Technical Assistants Embody Conflicting Logics
Diabetic Care: Symbol of Logics, Practices and Systems
Custody or Care, Which Do You Want?

47
47
48
53
58
63
70
75
82
84
Chapter 5: Bureaucracy Reigns Supreme
Order to Show Cause Hearing
Coercive Pressure and Institutional Logics
Lack of Will
Care is Costly

84
93
100
102

COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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Chapter 6: Discussion and Conclusion
The Prison Response to Coercive Isomorphism: Care is Not a
Legitimate Driver for Change
Implications
Limitations and Future Research

103
103

117
122
Post Script: CDCR Update and Researcher’s Confessional Tale

References

124

126
Appendices
Interview Guide
Textual Analysis Protocol

142
144
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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Dedication and Acknowledgements

Dedication
To my husband, Pete, whose loving support has fueled so many of my triumphs,
including this one.

Acknowledgements
Abundant thanks to the members of my dissertation committee: Tom Hollihan, Tom
Goodnight and especially Colleen Keough for her feedback, brainstorming sessions, support
and years of friendship. I am also very thankful for Patti Riley’s service as my advisor;
thanks for helping me to never, never, never, give up. Becky Heino acted as my “dissertation
nag,” thanks for holding me accountable to deadlines and supporting me when I needed it.
And I am grateful for Rebecca Weintraub’s support and efforts to facilitate my research.
Special thanks to Dr. Jody Lewen, Executive Director of the Prison University
Project. Because she championed my research, I was able to jump into the corrections
world. For that, and more, I will always be grateful. Thanks are also due to the employees
of the California Department of Corrections and Rehabilitation, especially those who
participated in this research. Your jobs are difficult under the best of circumstances; I
applaud you for your courage in the face of daily challenges.
I thank my friends, especially Kim Stephens and Kari Conness. Kim performed four
jobs exceedingly well: trouble-shooter, colleague, cheerleader and dear friend. She was
always available to fulfill whichever of these roles I needed at the drop of a hat. Thanks,
Kim! I give warm thanks for Kari, my best friend for over twenty years, for her love,
encouragement, gentle counseling and diversionary phone calls.
Finally, I thank my family, my greatest blessing. I thank my father, Michael Roche,
for introducing me to the Plata case and prison health care. I’m truly grateful for his
stalwart support, encouragement and that he never grew tired of my seemingly endless
questions. I am grateful for my mom, Diane Roche, who taught me how a tender person
could be gritty and tenacious when called for. And my deepest, heartfelt thanks and
gratitude go to my husband, Pete, and daughter, Diane. They gave me a wealth of support,
encouragement, freedom, forgiveness and most importantly, love. Without them, I would
not be able to say what my daughter has longed to hear, “I’m done with my dis-ro-tation!”

COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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List of Tables and Figures
Tables
Table 1 Case Document Summary 42
Table 2 Thematic Term Definitions and Examples 87
Table 3 Textual Analysis Matrix: Perceptions of Care, Legitimacy and Logics 88

Figures
Figure 1 CCPOA Cycle of Influence 52
Figure 2 MTA Chain of Command 71
Figure 3 Functionality of Command and Control Logics 111
Figure 4 Perceived Structuration of Care 112

COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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Abbreviations
CCPOA California Correctional Peace Officers Association
CDC California Department of Corrections
CDCR California Department of Corrections and Rehabilitation
CO Correctional Officer
MTA Medical Technical Assistant
PLO Prison Law Office
YACA Youth and Adult Correctional Authority
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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Abstract

New institutional theory posits that organizations experiencing coercive isomorphic
pressures will change in order to maintain legitimacy. However, this may not always be the
case. Using a structurationist lens, this dissertation explores an organization’s failure to
change under coercive isomorphism. At the root of this failure lay conflicting logics about
the purpose and function of the institution. Specifically, this case study explores the Plata
v. Schwarzenegger class action lawsuit regarding prison inmates’ lack of access to adequate
medical care. Prison structuration reflected predominant institutional logics of command
and control, making it difficult for organizations to enact legitimate caring practices. Two
powerful stakeholders groups, prison workers and state bureaucrats, were key players in
the failed quest to improve prison health care. Namely, for correctional officers, care was
often associated with weakness or vulnerability. For the state, there was resistance to
subvert established bureaucratic practices to improve health care. Stakeholders dismissed
an identity of the prison as a site for medical excellence, even under the threat of a loss of
legitimacy. This research provides an opportunity to investigate how enacted logics
challenge coercive isomorphic pressures.
Keywords: new institutional theory, structuration, logics, legitimacy, organizational
culture, prison health care
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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Competing Logics and Organizational Failure: The Structuring
of California Prison Health Care

“Vision: With our partners, we protect the public from crime and victimization.”

“Mission: We enhance public safety through safe and secure incarceration of offenders,
effective parole supervision, and rehabilitative strategies to successfully reintegrate offenders
into our communities. ” – California Department of Corrections and Rehabilitation

Introduction
In the United States, there is a small class of people who are entitled to free medical
care. These individuals receive medically necessary treatments, prescriptions, physical
therapy, surgery, and dental care all paid for by the state at a cost of approximately $2
billion per year (Kiai & Stobo, 2010). Only about 1% of the population is entitled to this
benefit (Liptak, 2008). Who are these people? They are prisoners; wards of the state who
are entitled to health care under the eighth amendment of the United States constitution,
which bars cruel and unusual punishment.
However, in 2001, California’s prisoners filed a class action lawsuit claiming this
constitutional right was being violated. Inmates claimed they were suffering morbidity and
death due to inadequate care. The federal court agreed with this assessment and, as a
result, the California Department of Corrections (CDC) undertook efforts to provide
“constitutionally adequate medical care” within the prison system.
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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The state’s ongoing struggles to improve prison health care provides a unique
opportunity to analyze what happens when an institution is forced to instill practices
discordant with its perceived purpose. To better understand institutional change, it is
necessary to explore the theoretical aspects of this issue. According to new institutional
theory, institutions are socially constructed entities structured by taken for granted
routines, scripts, and logics, which are shaped by the institutions’ drive for legitimacy
(DiMaggio & Powell, 1983; Friedland & Alford, 1991; Jepperson & Meyer, 1991; Meyer &
Rowan, 1977). Legitimacy is determined by members of an institution’s community rather
than by the organization itself (Ashforth & Gibbs, 1990; Ruef & Scott, 1998). Accordingly,
organization members conceptualize their roles as supporting the legitimacy of the
institution and behave accordingly (Human & Provan, 2000). So while some may talk of
legitimacy in more global terms (the social legitimacy of imprisonment), in this study
legitimacy is conceived in terms of organization members’ perceptions of an institution
(what does it mean to be a prison in the United States).
The following sections illustrate the relationship between discourse and
institutions. Of particular importance for this research are institutional logics, which are
discussed at length. I then explain this study’s purpose and preview each dissertation
chapter.
Communication and Institutions
Discursive practices among institutional stakeholders illuminates the tension
between philosophy and practice. Communication processes are fundamental in the
construction of organizations (Kuhn, 2008; Putnam & Nicotera, 2009). The communication
process enables organizational activities and conversations about the meanings of those
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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activities. Communication also creates boundaries around people’s understanding of the
organizations they experience—the discourse that is used to describe the what, how and
whys of similar organizations. These conceptions of “like organizations” have been
aggregated over time and are now codified into institutional fields. Common examples of
institutions would be armies, churches, prisons, hospitals and universities.
We understand how these institutions are enacted due, in large part, to the logics
that guide them. The characteristics and logics of an institution—its defining mission—
separate it from other institutions and create distinctive discourses that delineates what it
means to be, for example, a member of the US Navy or part of the academy (McPhee & Zaug,
2000). What happens when institutions are folded into each other, or collide, is less well
understood. Many organizations do not have one simple mission but are instead
complicated by multiple goals, circumstances, economic materialities and shifting politics.
For example, what happens to a war-fighting army that discovers it needs to do community
building or what changes when higher education organizations become for-profit? Little
research has examined the discourse of these institutions.
Research also tells us that pressures from a powerful stakeholder, like the judicial
system, should result in organizational changes, however this did not occur here (DiMaggio
& Powell, 1991; Friedland & Alford, 1991; Lounsbury, 2007). Over a four-year period, the
CDC functioned under court mandate to improve correctional medicine, however change
was slow and ineffective. Consequently, the Federal Court challenged the legitimacy of
prison healthcare, and as an offshoot, the legitimacy of the prison as a place barring cruel
and unusual punishment. Ultimately, this challenge resulted in the CDC’s healthcare
operations being wrested from the state and placed in federal control.
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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These unexpected outcomes warrant further analysis. Therefore, the purpose of
this research project is to explore failed institutional change. This dissertation investigates
the failure of an organization to adapt to coercive isomorphic pressures and argues that
competing logics may impede an institution’s ability to change even when the institution is
faced with delegitimation
1
. In this study, the question is what is perceived to be legitimate
action and when? This case enables us to observe how organizational discourse, practices
and logics of institutional legitimacy aggregate and structure an institutional field.
Ultimately, this research attempts to contribute to the body of literature concerning
structuration processes within institutional change.
Dissertation Preview
Chapter 2 provides a framework for this research through reviews of relevant
theory and literature. I explore how conceptions of legitimacy at the institutional
(conceptual ideal of a prison) and organizational field (multiple prison organizations)
levels were made meaningful at the organization and actor levels. Because actions at
multiple levels recursively influence one another (Purdy & Gray, 2009), this study’s
theoretical foundations work together to appreciate multiple forces upon institution, field,
organization and actor. To assess how these layers interact, I rely on literatures from new
institutional theory, structuration, the communicative constitution of organizations and
culture.
Major new institutional theory writers include DiMaggio (1997), Powell (2007)
(DiMaggio & Powell, 1983, 1991), Meyer and Rowan (1977) and Scott (1995, 2003).

1
This research project regards health care reform for male prisoners. While female
inmates were covered under the Plata class action lawsuit, the majority of available data
regard male inmates.
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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Particularly relevant to my area of study are more recent efforts by new institutional
scholars who seek to reintroduce agency into institutional study; these works inform my
discussion of legitimacy and change (McPhee & Zaug, 2000; Phillips, Lawrence & Hardy,
2004; Schmidt, 2008). To help explain the relationship between legitimacy and change
entactment, I draw from literatures regarding institutional logics, the material and
symbolic practices which support institutional legitimacy (Friedland & Alford, 1991;
Lounsbury, 2006; Thornton, 2002; Thornton & Occasio, 1999, 2008). Logics influence
whether proposed changes are deemed to be legitimate in accordance with the institution’s
purpose. This study evaluates how institutional notions are evident in organizational
structuration. This study also extends the work of Riley (1983) and Witmer (1997) on the
structuring of cultural and sub-cultural decision-making in organizations by focusing more
attention on the key logics that produce and reproduce those cultural differences.
Therefore, to discuss how institutional legitimacy, organizational culture and change
coalesce, literatures from Giddens (1979), Riley (1983, 1993, 2001), Greenwood and
Hinings (1996), Oliver (1991, 1992) and Barley and Tolbert (1997) among others are used.
Together, this body of literature facilitates our understanding of how multiple legitimacies
at the organizational field level are instantiated in discourse and organizational practices.
Chapter 3 consists of the study’s methodology. First, details about the case study
are provided. Next, the data and methods are introduced. Data informing this research
came from fieldwork, interviews, court documents and media reports. Qualitative textual
analysis was employed to appreciate context and reveal important themes. Overall, these
data illustrate judgments of prison health care legitimacy in a system under duress.
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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Then, chapter 4 explores how organizational members and stakeholders structure,
and are structured by, the prison institution. In this chapter, interview and fieldwork data
portray legitimated practices within the prison system. First, to ground this discussion, the
legal case behind prison medical improvement efforts, Plata v. Schwarzenegger, is
explained. Then, the tension between custodial logics of command and control versus
caring logics and practices are scrutinized. This tension is explored via a discussion about
the California Correctional Peace Officer’s Association and San Quentin State Prison. These
organizations also illustrate conflict between logics of custody and care. The chapter
concludes with an in depth analysis of diabetes treatment as an exemplar of custodial logics
and structures as impediments to adequate care.
In Chapter 5, prison health care is examined according to various organizational
field stakeholders’ perspectives. This discussion is largely informed by court documents
and other texts, which reflect the macro-level difficulties institutionalizing prison health
care. To explore these issues, data from the Plata v. Schwarzenegger case files illustrate the
state’s hyper-concern with bureaucratic compliance. Bureaucratic practices inhibited
substantive, wide scale, health care improvements and again, reified existing prison logics.
The conflicting logics of incarceration and care are then discussed in terms of pain
management. Pain and its treatment demonstrate health care complexities, while a
system-wide unwillingness to fundamentally change underscores health care’s illegitimacy.
A summary about the cognitive and symbolic costs to improve care concludes the chapter.
The final chapter of the dissertation consists of the discussion about California’s
failure to substantively improve prison health care under coercive pressures. To custody
staff, care was equated with weakness. For the CDC, substantive care improvements
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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would have subverted existing bureaucratic process; thus bureaucratic compliance was
given primacy over inmates’ welfare. For most institutional stakeholders, care was not a
legitimate institutional practice. The implications for this research regard appreciation of
structuration in institutional change. While coercive forces are expected to render change
or failure, we see that ongoing enactment of legitimated logics greatly influence
institutional legitimacy. Further, this research illustrates the broadening of the
institutional discursive space whereby a myriad of institutional stakeholders negotiate
their power relationships. More broadly, a structurationist lens allows us to explore
greater complexity in institutional change.
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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Literature Review
California failed to make any meaningful improvements to its prison health care
system prior to having control wrested from the state and placed with a Federal overseer.
While resource issues contributed to this failure, another argument is that prison
legitimacy was a serious problem in this case. There were many parties invested in prison
health care improvements and each party held a particular vision of what constituted
legitimate prison medical care. Accordingly, when considering California’s prison health
care improvements, the question is, “who determines what is legitimate and when?”
The notion of legitimacy crises developed in this study challenges extant concepts
of the ways isomorphic pressures influence institutions and organizational change.
Legitimacy is conveyed communicatively (Putnam & Nicotera, 2009). They argue
legitimacy is “taken for granted through institutional claims that are instantiated in
communication systems” (p. 162). Examination of communication within and about an
organization provides insights into the meanings of an organization’s activities (Kuhn,
2008; McPhee & Zaug, 2000; Putnam & Nicotera, 2009). For example, a guiding question is
how is legitimacy perceived at various organizational levels? Further, how was prison
health care communicatively portrayed across organizational levels? To better understand
how conceptions of prison health care legitimacy were made meaningful at the
institutional, organizational field and actor levels, a communication analysis is employed.
Since actions at multiple levels recursively influence one another (Purdy & Gray,
2009), this study’s theoretical foundations work together to appreciate multiple forces
upon institution, field, organization and actor. To assess how these layers interact through
communicative means, I rely primarily on literatures from new institutional theory and
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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structuration. These literatures are used to generate research questions in the broad areas
of (1) institutional logics, (2) change and (3) legitimacy.
New Institutional Theory
Research leading to the formation of new institutional theory began, in part, out of
the desire to explore why institutions so resembled one another. DiMaggio & Powell
(1983) assert that most organizations in a field are quite homogeneous and that variance
among institutions is quite rare. As like organizations come together to form a field,
“…powerful forces emerge that lead them to become more similar to one another”
(DiMaggio & Powell, 1991, p. 65). As organizations become aware of like entities, a field of
practice forms that over time comes to set the expectations and behaviors that define the
institution.
Friedland and Alford (1991) conceive of institutions as the conglomeration of
individuals and organizations producing and re-producing meaning and structures to
organize reality. In order to support the institution’s identity, rules and norms are
appropriated and enforced. Organizational actors construct environments that support
these beliefs but in doing so, also constrain their ability to change later on (DiMaggio &
Powell, 1983).
Isomorphism and change. New institutional theory is concerned with institutional
similarity. Institutions often copy the formal and informal structures that have been
established by like bodies in the past, behavior that DiMaggio and Powell (1983) term
“isomorphism.” As organizations change to resemble one another for practical purposes,
over time structures take on a broader, more meaningful significance. For instance,
organizations may initially become isomorphic because to do so results in greater
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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efficiency (DiMaggio & Powell, 1983). Over time, however, the structures that were put in
place for practical purposes take on symbolic significance. So while there may be more
efficient ways of managing the organization, any change may challenge organizational
legitimacy. Therefore, organizations remain similar because it is symbolically significant to
do so, even if there are other, different, ways for the organization to function.
DiMaggio and Powell (1983) identify three types of isomorphism: coercive, mimetic
and normative; each is functionally distinct. For instance, normative isomorphism is often
concerned with the professions. Normative isomorphism is evident in two aspects of
professionalization: formal education and professional networks (DiMaggio & Powell,
1983, p. 71). Mimetic isomorphism tends to arise as a response to doubt; organizations in
a field model themselves after similar and successful entities when faced with uncertainty.
Coercive isomorphism results from pressures exerted upon an organization by other
organizations, institutions and by the environment in which the organization operates.
More generally, coercive isomorphism stems from regulatory and perceived pressure upon
an organization to have legitimacy (DiMaggio & Powell, 1983; Fligstein, 1997; Greening &
Gray, 1994; Haveman, 2000).
Because institutions tend to protect themselves from evaluation and inspection,
preferring instead to adjust activities informally (Meyer & Rowan, 1977), mimetic and
professional isomorphism have received more attention in the existing literature.
DiMaggio and Powell pay short shrift to coercive isomorphism, perhaps because new
institutional theory expects an organization encountering coercive isomorphic pressures to
change in order to maintain legitimacy.
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One of the consequences of isomorphism is that institutional stability is maintained,
especially when the institution is given status as a subunit of society rather than
considered as a separate unit (Meyer & Rowan, 1977). For instance, marriage is often both
a religious and legal activity that serves to symbolize love and provide recognition by the
state. The government funds prisons because they serve a social function as part of the
judicial system. Both these examples draw from institutions that are tightly coupled with
their environments. Because there is a perceived social benefit to be derived from the
institution, the institution is more tightly linked to its environment. Yet, these benefits may
be difficult to define in empirical terms.
Generally, institutions are not considered easily modified (DiMaggio & Powell,
1991). To make institutions even more intractable, legitimacy is so embedded within
institutions’ formal and informal structures, mandated changes are often anathema
(Greenwood & Hinings, 1996). Organizational ecologist would claim that inertia tends to
insulate institutions from change efforts, since change is more frequently associated with
organizational death (Hannan & Freeman, 1984). For new institutional theory, however,
inertia itself is not isomorphic. Rather, new institutionalism holds that organizational
change is associated with the granting or loss of legitimacy. Historically, an institution’s
impetus to change has been considered to be dependent upon field-level attributes:
likeness to other institutions, resource dependence, uncertainty and professionalization
(DiMaggio & Powell, 1983). Current research links institutional change to organizational
discourse, citing actors’ abilities to think and speak outside the institutions in which they
act (Schmidt, 2008). Yet, while contemporary new institutional scholars are using
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discourse as a vehicle to introduce change into systems, the costs of deviating from
institutionally sanctioned behaviors remains high (Phillips, Lawrence & Hardy, 2004).
Isomorphism legitimizes institutions. Organizational members’ roles and
behaviors, reporting relationships, hierarchies and bureaucracies, in some form, support
and legitimize an institution. In practice, organizational actors may follow taken for
granted routines, scripts and rules, while still seeking to serve their self-interests
(Friedland & Alford, 1991). In response to such self-serving behavior, institutions protect
themselves from the divergent interests of organizational members through the
development of explicit and tacit expectations (Friedland & Alford, 1991). Accordingly,
organizations structurally reflect their socially constructed reality (Meyer & Rowan, 1977).
Within new institutional theory, there is a great deal of pressure for institutions to
maintain legitimacy as legitimacy is equated with survival (Meyer & Rowan, 1977). As
greater numbers of organizations populate an institutional field, powerful forces emerge to
both support and constrain institutional actors. For example, once an institutional field
emerges, organizations within that field exert pressure upon one another and each
organization is compelled to adhere to legitimizing routines and scripts within the field.
The external environment also exerts pressures on institutions via legal requirements,
government mandates and societal expectations (Baum & Oliver, 1991). These pressures
provide further impetus for organizations to form clear identities and buttress themselves
against legitimacy challenges. In other words, the routines and beliefs of an organization
appear in both its formal and informal structures, which in turn influence the institutional
field in a myriad of ways.
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For example, Phillips, Lawrence and Hardy (2004) suggest that public accounting is
illustrative of stable routines and discourses. These practices converge to create a common
understanding of what goes on a balance sheet and how audits are conducted, making the
identification and punishment of financial reporting misdeeds easier. These pressures
constrain organizations to act in certain ways and not others. Ultimately, conformity with
institutional characteristics provides one of the mechanisms for organizational evaluation:
those that conform are legitimate; those that do not conform are denied legitimacy.
Institutions form linkages with their environments to guard against the threats
posed by environmental forces. Linked institutions are more likely to reap survival
advantages than their unlinked counterparts (Baum & Oliver, 1991). Linkages form, in
part, due to the meshing of institutional behaviors with the expectations of the larger
environment. Embedded institutions benefit from the relationships formed with their
environment; legal rules and social expectations tend to shore up embedded institutions.
These systems, however, may come into conflict, an occurrence that needs to be
more fully explored by current scholarly research. Research notes that actors within fields
are both constrained and constituted by the institutional logics to which they ascribe
(DiMaggio & Powell, 1991; Ingram & Clay, 2000). Taken for granted rules guide actors’
decisions and choices. However, research has yet to discern what occurs when the rules,
scripts and expectations—the very elements of institutional legitimacy—are challenged.
Specifically, research can expand to delve further into the consequences of competing
institutional logics when organizations of relatively equal power come into conflict. When
institutional logics clash under coercive isomorphic pressures, organizational scripts and
COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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structures might reflect new logics to preserve legitimacy. This dissertation seeks to
contribute to this discussion.
Communicative and Behavioral Aspects of Institutions
Through institutionalization, social processes take on a rule-like status within
organizations, compelling the myths of the institution to permeate actors’ thoughts and
behaviors (Meyer & Rowan, 1977). Meyer and Rowan (1977) claim that in an effort to
acquire legitimacy, institutions craft stories that correspond to the prevalent ideologies of
what the institution should do. Similarly, organizations in an institutional field are
communicatively constituted; communication creates patterns of actions and structure
thus constituting an organization (McPhee & Zaug, 2000; Putnam & Nicotera, 2009; Taylor
& Van Every, 2000). This assertion illustrates that the term “organization” is both a verb
and a noun; a process and an entity (Putnam & Nicotera, 2009). Organizations are created
through discourse (Cooren, 2004; Cooren & Putnam, 2004; Eisenberg & Riley, 2001;
McPhee & Zaug, 2000; Myrsiades, 1987; Putnam & Nicotera, 2009; Taylor & Van Every,
2000). Roles, policies, and practices are communicatively conveyed and serve to constitute
and reconstitute organizing processes. Or, more simply put, “an organization is realized in
the day-to-day interactions of its members” (Taylor & Van Every, 2000, p. 141).
Through these interactions communicative patterns emerge and people enact their
organizational culture (Conrad & Poole, 1997; McPhee & Zaug, 2000). Root metaphors, the
tacit interpretive frameworks that undergird an organizational member’s worldview, help
frame actors’ experiences (Smith & Eisenberg, 1987). For example, the California
Correctional Peace Officers Association (CCPOA), which represents all the state’s prison
custody staff, invokes the term “cop” rather than “guard” to describe members. The image
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of a “cop” brings to mind a trained law enforcement agent as opposed to a “guard,” who
was described by a CCPOA member as a “knuckle dragger with keys” (Anonymous,
personal communication, September 30, 2012). The terms employed by correctional staff
to describe themselves have significance. The only difference between a knuckle dragger
and an inmate may be who is standing on which side of the prison bars, whereas a cop is
authority embodied. Through communication, employees come to understand their role
and that of the organization.
These roles are continually reconstituted through discourses, both verbal and
textual, across time and space (Cooren, 2004; Giddens, 1984). Texts are especially relevant
to the structuring of organizations as the written form, such as policy and procedure
manuals or memos, are more durable than the spoken utterance (Cooren, 2004; Putnam &
Cooren, 2004). We can see how communication, behavior and legitimacy converge via
Zucker’s (1987) findings that legitimacy conceptions are present in an organization’s
written procedures and policies, which become meaningful in terms of members’ behaviors
and cognitions. These texts further define the practices and purposes of organizations.
Organizational identity is also manifest in mission statements, visible to both internal and
external constituents, further legitimizing an organization (Mohr & Guerra-Pearson, 2005).
In other words, the terms utilized by an organization to define it also serve to shape
perceptions of it.
Legitimacy as a guide for organizational practices. Baum and Oliver (1995)
found that “non-profit” childcare organizations were deemed more legitimate than similar
“for-profit” organizations. Ruef (2000) determined that the labels adopted by health care
institutions, such as “HMO” or “nursing home,” and the subsequent use of these terms in
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the media, resulted in an increase in the founding of these organizations. On the other
hand, the language used by an organization also serves to delineate what it is not (Polos,
Hannan & Carroll, 2002). For example, a “credit union” is not a “bank;” rather a “credit
union” is a financial cooperative with a mission to serve its member-stakeholders
(Merriam-Webster, 2010). The term “credit union” communicates different competencies
than does “bank;” the notion here is that credit unions are somehow more caring, more
community oriented than for-profit, faceless banks.
The prior example illustrates that the communication employed by organizations
serves many important purposes. Organizations manage their identities and hence their
legitimacy by controlling the language employed to define and describe them. Legitimacy
guides the formation and stabilization of organizational structures (DiMaggio & Powell,
1983; Haveman, 2000; Meyer & Rowan, 1977). Activities are given meaning according to
institutional scripts and the legitimacy of the institution is reproduced (Friedland & Alford,
1991; Schmidt, 2008).
Various sources of legitimacy coalesce. Haveman identified multiple levels of
institutional legitimacy: microlevel via “…routines, rules and scripts that guide the actions
of individuals and groups; mesolevel organizations and occupations, industries, and local
identities and regimes; and macrolevel norms, values, expectations, and codified patterns
of meaning and interpretation” (2000, p. 478). This conception of institutional legitimacy
reinforces the assessment of institutions as both material and symbolic entities (Meyer &
Rowan, 1977). The routinized behaviors and cognitions of organizational actors serve to
reify institutional structures and insulate the institution from misaligned demands that, if
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acted upon, may threaten legitimacy. This notion provides the underpinnings for the first
research question:
Research Question 1: How is constitutionally adequate medical care understood in a contested
environment of dueling logics?
For an organization to be legitimate it must look like what we believe organizations
in that particular institutional field look like; it must be normatively isomorphic.
Ultimately, an institution must measure up to conceptions of what the institution should
resemble and how it must behave: institutional actions must appear to be legitimate
(DiMaggio & Powell, 1983; Fligstein, 1997; Jepperson & Meyer, 1991; Lounsbury, 2007;
Meyer & Rowan, 1977; Phillips, et. al, 2004; Ruef & Scott, 1998).
One of the issues regarding improved medical care implementation concerns how
the parties involved perceived such care. For example, the federal court, state, and Prison
Law Office viewed constitutionally adequate medical care from a vantage point external to
the organization. Those directly involved with health care services within the prison, such
as medical workers and custody officers, also held beliefs of what constitutionally adequate
medical care meant. To better our understanding of how health care improvements failed
to take root, it is important to look at how the prison institution and health care
improvements were envisioned by the organizations and actors involved.
Logics lead the way. One tool to explore these viewpoints is the concept of
institutional logics. These logics are defined as, “a set of material practices and symbolic
constructions — which constitute [an institution’s] organizing principles and which is
available to organizations and individuals to elaborate” (Friedland and Alford, 1991, p.
248). Institutional logics “define the norms, values, and beliefs that structure the cognition
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of actors in organizations and provide a collective understanding of how strategic interests
and decisions are formulated” (Thornton, 2002, p. 82). Logics are to the institution what
sensemaking is to the individual. For Weick (1988, 1993), sensemaking consists of our
efforts to create order and retrospectively make sense of what we have experienced.
Similarly, logics are a higher level of legitimating structures. A variety of institutions, such
as churches, hospitals or universities might operate based upon the rules of an overarching
logic. Like characteristics deemed legitimate for individual institutions (i.e., church), logics
embody a set of guidelines that constrain and prescribe appropriate behavior for many
different types of institutions (i.e., religion).
For example, Friedland and Alford (1991) cite the institutional logic of the state as
“…rationalization and the regulation of human activity by legal and bureaucratic
hierarchies” whereas the logic of democracy is “…participation and the extension of
popular control over human activity” (p. 248). These logics are seamlessly absorbed into
the life and work of institutional members, shaping cognitions and scripting what
behaviors are permitted, thus re-defining and re-enforcing institutional legitimacy
(DiMaggio & Powell, 1991; Fligstien, 1997; Selznick, 1996).
Not only are institutional logics symbolic, they are also apparent in organizational
structure (Friedland & Alford, 1991). Dominant institutional logics are adopted, become
normative and assume a taken for granted status in the actor’s daily life and work
(Friedland & Alford, 1991). Generally, organizational beliefs lead to a reification of
institutional logics. Thus the organizational myths that arise from these understandings
have cognitive importance and structural presence. For instance, the structures
surrounding medical care are just part of a larger symbolic system that generates and
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reinforces the ideals of the prison institution. Within the CDC, an inmate must make a
written request to receive medical treatment. This request, which has been granted,
denied or ignored, reinforces the notion of the prison as a place of incarceration and
control. Due to the linkage between institutional logics and perceptions of legitimacy,
members will defend their organizational beliefs when challenged (Ashforth & Gibbs, 1990;
Friedland & Alford, 1991). Logics influence which organizational issues are deemed
problematic and which are not (Thornton, 2002). Accordingly, organizational stakeholders
may have differing notions of what comprises constitutionally adequate medical care. The
likelihood of conflicting perceptions about constitutionally adequate medical care leads to
the next research question:
Research Question 1a: Is there a working definition of constitutionally adequate medical care
that is generally agreed upon or are the systems of meaning for the CDC and the federal
justice system separate and at odds?
Overall, institutional logics provide the lens through which actors contemplate
organizational problems and their solutions (Thornton & Ocasio, 1999, 2008). Another
consideration regards the diversity of various stakeholder groups’ logics. A stakeholder is
anyone who “can affect or is affected by the achievement of the organizations’ objectives”
(Freeman, 1984, p. 46). Within a prison organization, for example, a sample of
stakeholders would be employees, law enforcement, legislators, bureaucrats, victims’
rights organizations and inmates. For this particular study, one way to better understand
stakeholder logics is to consider definitions of “constitutionally adequate medical care.” If
the problem of constitutionally adequate medical care was commonly understood, tackling
the issue initially would have been easier as stakeholder groups would, at a minimum, have
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held similar understandings of what constitutionally adequate medical care entailed.
Determining how stakeholder groups understood inmate medical care may provide
insights into the reasons for the implosion of the change endeavors.
The Role of Discourse in Institutions
Research Question 1b: What are the communicative contradictions in the enactment of
constitutionally adequate medical care in the CDC?
Institutionalization arises within the systems of communication as actors share
cognitions and agree upon definitions of reality (Berger & Luckmann, 1966; Phillips, et. al,
2004). New institutional theory appreciates that as common meanings develop and gain
legitimacy, these shared cognitions take on a rule-like status; consequently institutions are
buffered from constant change (DiMaggio & Powell, 1983; Meyer & Rowan, 1977; Scott,
1995). Through discourse, institutions, organizations and actors recreate structures and
legitimating practices. Discourses are “collections of communicative actions” that
demonstrate both structural and social patterns; they constitute organizational actors and
define organizational reality (Heracleous and Barrett, 2001; Heracleous, 2002; Putnam &
Nicotera, 2009). Barrett, Thomas and Hocevar (1995) claim,
“it is through patterns of discourse that relational bonds are formed; that action and
structure are created, transformed, and maintained; and that values and beliefs are
reinforced or challenged. The process is recursive: interpretive repertoires are
extended to include various practices. At the same time, these practices augment
and alter the interpretive code” (p. 367).
Interpretative repertoires may extend to include various practices, however, the
efficacy with which these extensions occur varies. While communication is necessary for
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organizing, communication itself does not guarantee quality outcomes (Putnam & Nicotera,
2009). For instance, Heracleous (2002), in his study of the Asian National Police force,
found that the lack of talk about cultural and structural barriers to organizational change
significantly decreased the implementation of planned changes.
Heracleous’ study focused on the role of actors within an institutionalized field of
practice, thus addressing the criticism that new institutional theory places too much
emphasis on structural pressures. New institutional theory has been faulted for being too
static and failing to consider a more “dynamic, agent-centered approach to institutional
change” (Schmidt, 2008, p. 305). In response, various scholars have proposed bringing the
agent back into institutional and organizational change; the primary vehicle for this move
is discourse (Lammers & Barbour, 2006; Lounsbury, 2007; Phillips, et. al, 2004; Schmidt,
2008). Discursive institutionalism appreciates that actors are constrained by institutions
but are able, through discourse, to imagine, speak and act outside of the institutions that
constrain them (Schmidt, 2008).
However, it is impossible to separate institutional practices and the discourses that
comprise them. Discourses and texts “secure and maintain legitimacy” and make it easier
for organizations to “signal to internal and external members of the organization that their
activities are legitimate” (Phillips, et.al., 2004, p. 642). When new practices are introduced
into an organization, members will assess them in terms of their past experiences and
knowledge about the organizations’ legitimacy (Putnam & Cooren, 2004; Taylor & Van
Every, 2000; Schmidt, 2008). “Discourses make certain ways of thinking and acting
possible, and others impossible or costly” (Phillips, et. al., 2004, p. 638). It then seems
natural to inquire: what are the discursive contradictions that make certain ways of
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thinking and acting impossible? Geertz (1973) advocates that researchers uncover the
conceptual structures that inform subjects’ acts. Examination of the communicative
contradictions within the context of CDC medical improvement requires consideration of
how discourses were interpreted in terms of content, members’ logics and notions of
legitimacy.
Research Question 2: How do conflicting institutional logics influence the CDC’s change
efforts?
Specifically, this research question examines how change efforts are supported or
opposed via institutional logics. Exploration of conflicting institutional logics enhances our
understanding of how multiple logics are negotiated. We know normative logics provide
tenacious behavioral prescriptions. Research has demonstrated that when an individual
deviates from an established norm, other organization members may believe they have the
right to not only correct the divergent behavior but also ensure that such a deviation does
not occur again in the future (Knight & Ensminger, 1998). Consequently, institutional
changes may be met with disdain, especially if such changes contradict prevalent
institutional logics.
Because norms shape expectations about what people will do, some scholars argue
that change to an institution requires changing the logic about the institution (Knight &
Ensminger, 1998; Meyer & Rowan, 1977; Rao, 1994; Thornton, 2002). To support this
viewpoint, Romanelli and Tushman (1994) argue that organizational patterns are
established at founding and become further embedded during institutionalization.
Members support these organizational patterns, and consequently, they may resist even
small organizational changes. Lounsbury (2006), however, challenges the idea that a
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change in dominant logics is a necessary prerequisite for institutional change. He found
that social pressures were sufficient to cause varying practice instantiation in money
management firms. This finding is significant as Lounsbury notes that conflicting logics,
rather than an outright change to them, provided the impetus to change institutionalized
practices. Thus, there is some question about the role of logics in institutional change.
Specifically, more needs to be known about constituents’ conflicting logics and their
consequence for institutional legitimacy.
Previous research also suggests that there is a great deal of complexity involved in
coercive isomorphic pressures. Because diverse stakeholders grant legitimacy, no one
group may be able to instill institutional change. In other words, when powerful
stakeholders’ conceptions of legitimacy diverge, coercive isomorphic pressures may not be
sufficient to induce change. For example, in Seattle, teachers at Garfield High School
refused to administer mandated academic assessment exams, stating the test was not
aligned to the state’s academic standards and that “teaching to the test” took away
“valuable” instruction time (Wolfgang, 2013). For these teachers, standardized exams are
not legitimate measures of educational progress. The school’s superintendent threatened
to suspend the teachers for 10-days. Yet in the face of pressures to comply with state
mandated exams, these teachers received widespread support from the National Education
Association, the American Federation of Teachers and parents. These national unions
supported the teachers’ refusals to administer what they viewed to be an illegitimate test.
Parental support illustrates grass roots efforts to change educational assessments.
Together, these actions reflect a larger national debate about the legitimacy of nationally
mandated standardized testing under the Bush-era No Child Left Behind legislation.
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More broadly, one reason why an organization may shirk coercive isomorphic
pressures is related to Zucker’s (1987) claim that an organization’s compliance with a
mandated change is linked to its ability to control its own boundaries, resources and
environmental penetration. Change tends to be costly not only in terms of material
resources but also in terms organizational members’ cognitions (Barnett & Hansen, 1996;
DiMaggio, 1997; Phillips, et. al, 2004). Isolated and decoupled institutions may resist
external change initiatives. Internally, institutional logics may be used to assess proposed
changes and organizational members may question whether legitimacy is enhanced or
sullied by change efforts.
One reason actors may defend current practices is that they cannot conceptualize
valid alternatives. This bounded-rationality describes actors’ penchant to conceive of
certain patterns of action while leaving other options not only unviable but also
unimaginable (DiMaggio & Powell, 1983; Meyer & Rowan, 1977; Williamson, 1981). Thus,
those who propose changes must have the ability to enforce compliance (Knight &
Ensminger, 1998).
Legitimacy and Institutional Change
Research Question 3: How is health care legitimacy determined?
Suchman defines legitimacy as “…a generalized perception or assumption that the
actions of an entity are desirable, proper, or appropriate within some socially constructed
system of norms, values, beliefs and definitions” (1995, p. 574). One source of legitimacy
stems from institutions’ relationships with outside agencies and other institutions. Citing
Scott (2001), Huegens and Lander (2009) define organizational legitimacy as the
normative support an organization garners based on “its alignment with prevailing cultural
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norms as well as relevant rules and laws” (p. 63). For instance, an organization’s
relationship with its environment as well as an institution’s own identity are sources of
legitimacy (Ashforth & Gibbs, 1990; Human & Provan, 2000; Ruef & Scott, 1998). A stickier
notion is that of moral legitimacy, where an organization is deemed to be doing “the right”
things (Suchman, 1995), especially when the version of what is “right” varies across
stakeholders.
Overall, it can be said that legitimacy comes from an institution’s conformity to
rules and structures deemed appropriate by the environment (Ruef & Scott, 1998; Meyer &
Scott, 1983; Suchman, 1995). Community members may grant or withhold legitimacy,
making organizations interdependent with the environment in which they operate
(Stephens & Thomas, 2010). Indeed, as institutions become valued, such as “education” or
“prison,” they are legitimated as a subunit of society and thus buffered from failure (Meyer
& Rowan, 1977, p. 49).
Meyer and Rowan (1977) go on to claim that state institutions may very well persist
even when threatened by another agency because the institution is tightly coupled with
societal structures. For example, a school may be seen as legitimate because its rules,
resources and practices are those that we collectively agree a “school” should possess
whether or not it effectively educates students (Meyer & Rowan, 1977). As long as the
organization complies with the rules and practices that are associated with constituents’
notion of “school” it will be thought of as such. If the school does not conform to these
beliefs, it will be considered illegitimate and forces may seek to bring the school back into
compliance with institutional norms. These forces may be typically isomorphic; however,
how organizations respond to institutionalized pressures may vary (Heugens & Lander,
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2009). For example, the “school” organization has the option to conform to the
constituents’ notions of legitimate structures and practices for a “school” or it may try to
challenge these values and norms and institutionalize new practices. The overarching
argument is that perceived legitimacy becomes more important than the institutional
outcomes. Chapter four will explore stakeholders’ conflicting notions of prison legitimacy
and how logics were enacted.
Two significant sources of legitimacy are the state and society, each of which may
exert pressure for institutions to adhere to legitimated activities (DiMaggio & Powell, 1983;
Tolbert & Zucker, 1983; Oliver, 1992). However, organizations within an institutional field
may be called to reassess previously legitimate practices if continuing those practices
results in disincentives (Oliver, 1992). Because power is not distributed equally among
institutional stakeholders, when one stakeholder claims an institution is illegitimate,
institutional failure is not guaranteed. An area to observe is what occurs when a large
stakeholder group calls legitimacy into question and how organizations respond.
Accordingly, the following two research questions are posed:
Research Question 3a: What occurs when there are differing notions of legitimacy?
Research Question 3b: Who is able to determine what is legitimate?
Institutions conform to ideals held by various constituent groups. These groups
often have different interests regarding an institution’s purpose. Each constituent group’s
beliefs are relevant in two ways. First, these notions will shape how an institution is
perceived. Next, they will also influence how the related organizations are critiqued. For
instance, institutionalized practices, deemed by “organization members to possess
intrinsic worth or legitimacy beyond [their] technical requirements,” (Oliver, 1992, p. 571)
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may come into question. Belief systems arguably become the most critical aspect of
organizational assessment as they provide the terms by which organizations are assessed
(Ruef & Scott, 1998). Specifically, organizations are critiqued by how they align with
prevalent cultural rules, norms and values, which in turn mandate particular structures
and procedures.
When previously legitimated practices are called into question, an organization may
respond in a variety of ways. An organization may choose to deinstitutionalize the newly
illegitimate practices and structures. Or, actors may protect practices and structures they
deem to be legitimate even in the face of conflicting assessments (DiMaggio & Powell, 1983;
Oliver, 1992). Of course, the ability to buck coercive isomorphic pressures will be related
to resources and the institutions’ social role.
Logics are Evident in Structuration
Research Question 4: What do enacted logics tell us about legitimacy conflicts?
Logics operate at multiple levels: institutionalization gives rise to them,
organizational structures and practices support them and actors rely on them to function
effectively within an institutional system. Logics cross the divide between institutions and
actors. Logics are enacted as rituals, which express institutional myths and also
demonstrate one’s position in the world (Friedland & Alford, 1991; Lounsbury, 2006;
Meyer & Rowan, 1977). Logics also can be seen conceptually as a duality—they are
instantiated as practices that embody institutional structures and they also recreate those
structures. Duality of structure is a key component of Giddens’ structuration theory (1979;
1984). Structuration facilitates investigations of the ways organizational actors interact
with multiple logics due to the recursive relationship between human agency and
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structures. For instance, a dominant institutional logic will be present in the organizational
structures that support it, yet through agency, organizational members may enact or
challenge dominant practices. Within a prison, for example, the dominant logic is that of
command and control. However, actors within these structures may enact more care-
focused practices, such a talking with a suicidal inmate rather than exerting physical
control over him. With structuration theory, we have a means to more fully understand
how logics impact work life.
Structuration. Structuration appreciates agency within institutions and recognizes
the complexity inherent in any social system. At the heart of structuration theory is the
idea that structures both constrain and enable social action. Logics and structures function
in relation to one another. Logics’ material practices and symbolic constructions
(Friedland & Alford, 1991) are apparent in structures, which are the rules and resources
used by people engaged in a system (Poole & McPhee, 2005). Logics and structures
together support and create the norms, values, practices and purpose of institutions.
For Giddens, institutions and actions meet. Institutions provide rules, which
become encoded in actors’ interpretative schemes and consequently appear in action
(Barley & Tolbert, 1997; Giddens, 1979, 1984). As organizational members interact, these
interactions both produce practices and reproduce systems and structures (Heracleous &
Hendry, 2000; Poole & McPhee, 2005). Over time, these interactions serve to maintain or
modify institutions (Barley & Tolbert, 1997; Riley, 1983).
The same can be said of logics. Through discourse, institutional beliefs and material
practices are recreated and modified. As organizational actors carry out their daily work
activities, they will draw on the dominant institutional logics they deem meaningful to their
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work (Friedland & Alford, 1991). However, there are multiple logics available for actors to
draw from at any given time (Dacin, Goodstein & Scott, 2002; Lounsbury, 2006).
Accordingly, organizational members have some agency to determine which logics are
relevant given the situation at hand.
Which logics are relevant is dependant upon the structuration processes evident in
organizational life. An individual’s perceptions about organizational practices and
institutional legitimacy will impact logics’ salience as well. For instance, the cognitive
aspect of logics is apparent in what Giddens calls practical consciousness, the ways actors
know how to act but are unable to explicitly describe. As Friedland and Alford (1991)
write, “dominant institutional logics are imported in such a way as to become invisible
assumptions” (p. 240).
One facet of structuration theory particularly relevant to logics’ influence comes
from Poole and McPhee’s (2005) discussion of organizational identification and personal
identity, which explores the relationship between organizations and the individuals who
comprise them. Organizational identification and personal identity work recursively to
form and perpetuate organizational ties (Scott, Corman & Cheney, 1998). The authors
contend that people appropriate identities that fit particular situations (Poole & McPhee,
2005; Scott, et.al, 1998). In turn, situations warrant certain normative practices (Friedland
& Alford, 1991). For instance, a prison custody officer beginning his workday may assume
a “command and control” identity and practices. However, this affinity is situational; a
“command and control” presence would be an inappropriate when the officer is home with
his family. Which is to say, identities and practices help define what organizational
members are and what they are not. People’s positions in structures and the resources that
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are available to them highly determine their cognitions, interests and perceptions of
legitimate ways to act (Fligstein, 1997). Thus, how organizational members interact with
logics may vary depending upon how norms, agency, structures and organizational
purpose are enacted.
Research Question 4a: When logics conflict, what occurs?
One possible insight into how conflicting logics are negotiated concerns ontological
security (Giddens, 1979; 1984), which regards an actor’s unconscious need for
“psychological sheltering from anxiety, guilt, and doubt about the uncertainty of the world”
(Banks & Riley, 1993, p. 172). Ontological security is often realized through routines and
taken for grantedness. As logics are enacted in legitimated ways, a sense of ontological
security is realized. Consequently, actors will likely assess new practices in light of current
legitimated structures. Thus, if we return to our correctional officer, asking him to enact
“caring” practices may challenge his sense of ontological security in light of his “command
and control” presence. What occurs when these logics conflict warrants further
investigation.
Should there be sufficient power and resources to initiate practice changes, their
authentic adoption may be difficult to demand. Kostova and Roth (2002) describe
ceremonial adoption, which occurs when practices, deemed to be illegitimate by actors,
are mandated by external forces. The new practices are formally adopted by the
organization but fail to be normatively or cognitively accepted. The authors explain that
authentic adoption occurs when behavioral and attitudinal components work together
allowing new practices to be appropriated and cognitively valued (p. 216). Ultimately,
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resistance to change is likely when the organization is normatively embedded within its
institutional context (Greenwood & Hinings, 1996).
Research Question 5: What accounts are given for the failure of the mandated changes and
are there instances of ceremonial adoption?
Ultimately, the CDC failed to sufficiently instill a “constitutionally adequate”
standard of medical care even though the court allowed five years for the system to do so.
This failure resulted in the prison health care system being placed under the control of a
Federal receiver who was given powers to appropriate funds, implement and enforce new
practices, policies, and procedures. In a way, the receiver was akin to a new sheriff riding
into a corrupt wild-west burg proclaiming, “I’m gonna clean up this town!” This trope
illustrates the receiver’s purpose: to right the wrongs of CDC health care. However, while
the placement of the receiver demonstrates CDC’s failure to change, it does not provide
insights as to why, after years of effort, constitutionally adequate medical care failed to take
root.
Another issue that warrants consideration regards the nature of change.
Institutional change is both material and symbolic; it involves varying interests and powers
(Friedland & Alford, 1991). DiMaggio and Powell (1991) argue that when institutional
change occurs, it is likely to be “episodic and dramatic” as the result of legitimacy problems
(p. 11). However, Oliver (1992) challenges this notion. She claims institutionalized
behaviors may dissipate, be rejected or replaced. This deinstitutionalization is defined as
“the process by which the legitimacy of an established or institutionalized organizational
practice erodes or discontinues…deinstitutionalization refers to the delegitimation of an
established organizational practice or procedure” (Oliver, 1992 p. 564).
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For this study, I focus on literature that illuminates why health care improvement
endeavors may have failed in order to examine whether appropriate health care measures
were ever institutionalized and then eroded due to constraints or conflicts or whether they
were only ceremoniously adopted and the practices were never fully embedded. In
particular, I focus on two distinct groups who impacted CDC change efforts: institutional
and organizational field stakeholders and organizational actors responsible for
instantiating new practices.
Organizational Field, Stakeholders and Change
As I have discussed, there are multiple stakeholders who grant institutional
legitimacy. Accordingly, these groups are affected when institutions face change.
Organizations that embody old institutional structures tend to be resistant to change
pressures until a new logic is introduced; then pressures to change increase as the old
forms become delegitimated (Thornton, 2002). Stakeholders’ ability to influence changes
will vary depending on their power (Greenwood & Hinings, 1996; Knight & Ensminger,
1998; Zucker, 1987). More specifically, stakeholders’ ability to influence changes will vary
depending upon their perceived power. For instance, Kostova & Roth (2002) found that
state regulatory pressures had a negative impact on practice adoption as employees
equated mandates with coercion. Since an external agent dictated changes, the changes’
legitimacy was questioned. This finding illustrates that while change may be advocated
from stakeholders in an organizational field, the implementation of those practices is
subject to those responsible for carrying them out.
Actors and change. Greenwood & Hinings (1996) argue, “radical change will occur
only if interests become associated with a competitive or reformative pattern of value
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commitment” (p. 1036). In other words, prevailing norms are assessed and new practices
are considered in terms of their legitimacy (Dacin et. al., 2002). Knight and Ensminger
(1998) claim that if social actors want to instill a new practice they must “re-coordinate
social expectations” by focusing actors’ attention on the desired norm rather than the
status quo (p. 120). They go on to say that to re-coordinate social expectations, reformers
must have the means to reassure early adopters that the practice will be adopted
throughout the group as well as have the ability to deploy sufficient sanctions to make the
old practices costly. Ultimately, it is a challenge for a new norm to displace the status quo
(Hannan & Freeman, 1984; Ingram & Clay, 2000; Knight & Ensminger, 1998; Nee, 1998).
Change is difficult, but not impossible. Fligstien (1997) proposes that social skills
can be employed to achieve new practice adoption. Specifically, he claims that when
reformers understand opportunities, constraints and the groups’ collective meanings this
knowledge can be harnessed to attain cooperation towards new norm adoption. For
Fligstien, reformers are not individual actors but a collective motivated by similar interests.
When members of the reform-oriented group interact with other stakeholders, imaginings
of new structures are conveyed through discourse. Through social interaction, change
becomes possible.
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Methods
This research consists of a qualitative case study. Yin (2003) recommends case
study research under three conditions: the primary research questions asked are how and
why, the issue of study is a contemporary one, and the researcher has no control over
behavioral events. Due to the nature of this research project, a case study is the best means
to explore prison health care legitimacy and institutional logics.
For instance, qualitative case study research allows the “exploration of a
phenomena in its context utilizing a variety of data sources” (Baxter & Jack, 2008, p. 544).
More specifically, case studies are well suited to appreciate contextual influences on
organizations (Baxter & Jack, 2008; Yin, 2003). Prison health care reform is complex in
terms of functional change and moral belief systems. Accordingly, the context within which
reform occurred is a critical research component. As an example, consider California’s
inmate population: it is older than the national average (Petersilia, 2006), thus there is
increased demand for medical services as inmates age. However, there is palpable tension
surrounding an inmate’s right to health care especially when free citizens enjoy no such
right. A case study approach appreciates the complexities surrounding prison health care.
Various data sources contributed to the explorations of legitimacy issues and logics,
including interviews, observation, and archival data. In this chapter, qualitative research is
argued to be the best approach to study prison health care legitimacy. Next follows a
discussion about data collection, including participant recruitment. The chapter concludes
with a discussion of the data analysis protocol.
Qualitative Research
Denzin and Lincoln (2003) stress qualitative research as the best means to research
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the social construction of reality because qualitative approaches “…stress how social
experience is created and given meaning” (p. 13). Discourse is the primary means for
understanding how people understand the social world. Accordingly, the preponderance of
data from this case study comes from discursive sources: interviews and archival
documents. For example, via an interpretive constructionist approach, interviews enable
further exploration of prison medicine’s “cultural arena” (Rubin & Rubin, 2003). This
research project takes an inductive approach, whereby themes and practices emerge from
observation and analysis.
Qualitative data “are a source of well-grounded, rich descriptions and explanations
of processes in identifiable local contexts” (Miles & Huberman, 1994, p.1). Since
“organizations are fundamentally systems of ‘talk,’” social discourse provides insights into
the structures and practices in organizational life (Ventrensca & Mohr, 2005). Qualitative
research facilitates the emergence of themes through multiple readings of a text, thus
allowing the researcher to develop a thorough, well-rounded understanding of the content
under study (Mason, 2002). Because this research is based on descriptions of actions and
narratives, it is critical that words are recognized as being about doing; in order to embrace
that perspective, qualitative inquiry and its focus on social practices and context is most
appropriate (Schwandt, 2003).
The purpose of this research project is to understand how diverse stakeholders
perceived health care legitimacy under coercive isomorphic pressures. Dacin, et al. (2002)
praise Zilber’s (2002) case study approach to institutional change, claiming that the use of
interviews and participant observation allowed data to emerge that would have otherwise
gone unnoticed had the focus been on macro level structures and practices. Similar to
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Zilber’s approach, various sources of evidence contribute to my analysis, including:
documents, interviews, direct observation and physical artifacts. Through thematic textual
analysis, in concert with observation and fieldwork data, I explored perceptions of prison
health care reform and developed a greater understanding why health care improvements
failed.
Because my research regards stakeholders’ perceptions of health care legitimacy, I
needed to determine which stakeholder groups where instrumental to prison health care
reform efforts. Pettigrew, Woodman and Cameron (2001) state that to sufficiently study
organizational change, researchers must pay attention to context and levels of analysis.
Through analysis of stakeholder perspectives at multiple levels, the data demonstrate how
legitimacy was envisioned and enacted throughout the change process.
Accordingly, at the individual level, I interviewed CDCR employees with varying job
classifications and responsibilities. For instance, I interviewed correctional officers,
physicians and a lone medical manager. While I sought to interview health care managers
and key decision makers in the Receiver’s office to gain insights into the organizational
level of analysis, I was asked to end my study. Thus, my organizational level research
consists primarily of reviews of internal memos and policies. Finally, I assessed the
environmental level through interviews with subject-matter experts and stakeholders,
internal and external corrections reports, and court records.
Institutional review board constraints. Inmates are a protected class when it
comes to research; they are considered to be vulnerable subjects. Conducting research
within a prison system and not involving inmates seemed to fall into an odd gray area for
institutional review board (IRB) approval. The default response was that this study should
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have IRB approval for dealing with inmates, even though prisoners were not the focus. For
instance, the CDCR, after learning of my project, referred me to the state’s IRB department,
even though I explicitly informed them I was studying the prison organization. In
hindsight, I believe this step was made to try to shut down my project, especially in light of
an email the receiver’s office sent to prison medical staff advising them not to participate in
my research.
Other small, but important, stumbling blocks came from my own university’s IRB
department. Any human subjects research at a prison needs to have the prison’s approval,
which I certainly was not likely to get due to the organization’s apparent fear that I would
made the CDCR look incompetent. Consequently, I was not able to get human subjects
research approval. This decision by my university’s IRB seems short sighted, again,
because my inquiry was about a prison organization, which, quite frankly, could benefit
from more inquiry and academic assessment.
Another IRB issue regards one of my prison visits: I had an opportunity to chat with
prisoners. They were interested in my research and we talked; I was not interviewing
inmates. They seemed happy to know someone was taking a rather roundabout interest in
them. During these brief chats, I learned information I would have liked to include in this
dissertation project. The information was fairly generic, but interesting nonetheless, and I
sought retroactive IRB approval to use it. After a few meetings both with and without my
participation, my request was denied because of inmates’ protected status. As a result, I am
unable to use the data I gathered from inmates. This data censoring is particularly
unfortunate because inmates are the clients of a broken system; their experiences with it
round out the tale. While I certainly understand and respect the need to protect inmates
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from unethical research, I believe my project presented an unplanned opportunity for
prisoners to give voice about an issue that deeply affects them. It is unfortunate that there
is not a means within IRB to recognize that, sometimes, a prisoner is just a person with an
opinion.
Data Collection
The CDCR agreed to initiate prison health care improvements in July 2002. This
process began via a legal action called a joint consent agreement, whereby the CDC agreed
to implement comprehensive medical reforms in all prisons (Stipulation for Injunctive
Relief, 2002). It was at this time the CDC officially acknowledged that all was not right with
the state’s prison health care system. Improvements were to first be rolled out to seven of
the CDC’s 33 prisons. The first rollout cycle was to be completed in 2003 (Stipulation for
Injunctive Relief, 2002).
Observation. I visited three CDCR prisons and spent a total of five days on site.
Prisons are not identified in order to protect everyone’s confidentiality. Gaining access to a
prison is a complicated process; in order to be allowed on site I needed to have a sponsor at
each facility and underwent government background checks. Movement within the prison
is tightly controlled and therefore impacted what I was able to experience.
Of the three prisons, two were among the worst health care offenders and the third
was able to adapt to health care changes more easily. I was able to tour health care
facilities at two of the three prisons. At all these sites, I acted as an observer and was able
to note the physical artifacts and structures that are unique to the prison workplace. As a
method, observation is particularly valuable for this research project as the prison itself
has communicative significance. After each visit, I immediately audio-recorded my field
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notes since I was unable to bring any recording or photographic equipment inside the
prison. The recordings were then transcribed and analyzed.
Interviews. The purpose of a qualitative research interview is to “understand
themes of the lived daily world from the subjects’ own perspectives” (Kvale & Brinkmann,
2009, p. 24). We do not construct our understanding in a vacuum; rather we do so “against
a backdrop of shared understandings, practices, language and so forth” (Denzin & Lincoln,
2003, p. 305). Interviews are excellent tools to describe social processes and change
(Rubin & Rubin, 2005), thus knowledge can come from understanding other’s experiences.
An interviewer’s goal is to establish an ethical rapport, where the interviewee feels safe to
share events, stories and experiences freely (Kvale & Brinkmann, 2009). Accordingly, I
utilized a semi-structured interview approach, where I sought to balance my needs for in
depth information and the subject’s need to engage in dialogue (Appendix A - Interview
Guide). Tailoring interview questions to each respondent has been recognized to enhance
respondents’ coherence and depth (Weiss, 1994). Furthermore, each interview
contributed to my knowledge about CDC health care, which led me to refine my questions
and explore new ideas or gather more in-depth information. Prior to any interview,
however, subjects were informed, verbally and/or via email, that I was a student
conducting research and that if they chose to speak with me, their contributions would be
anonymous. Those who chose to participate gave verbal consent; if consent was withheld, I
did not proceed with the interview.
I interviewed a variety of stakeholder groups, including correctional officers (COs),
medical technical associates (MTAs) who are correctional officers and nurses, physicians,
and subject matter experts. Interviews took place on the phone or in person. Most
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interviews lasted about 40-minutes to an hour. Each interview was recorded, or, if the
interviewee withheld permission, notes were taken. Recordings were then transcribed and
notes were typed and reviewed. A few subjects were contacted for follow-up discussions
so I could clarify and explore ideas more thoroughly. In total, I conducted 21 interviews,
which resulted in 198 pages of transcriptions and notes.
Initially, I employed systematic sampling of health care workers from a 2004 CDC
employee directory. However, after sending out 18 interview requests to CDC email
addresses, I was contacted by the receiver’s office and asked to stop. My requests to
interview members of the Receiver’s staff also were denied. Consequently, I no longer
contacted CDCR employees through their work email and adapted my method to
convenience and snowball sampling. One limitation is that subject recruitment was not
random. However, due to the prison organizations’ insularity, snowball sampling was the
best method to find participants willing to speak openly and honestly.
Due in large part to access constraints, I interviewed four physicians and one
physician-manager. Later, I learned from an interview subject that the receiver’s office
sent an email to medical staff advising them not to participate in my research.
Interestingly, four medical managers contacted me, two of whom scolded me for trying to
conduct research without official CDCR backing. However, I had much greater success
interviewing correctional officers and medical technical associates, who are culturally and
operationally significant stakeholder groups. I attended the California Correctional Peace
Officer’s Association convention in Reno, Nevada over three days. While there, I was
introduced to many COs from prisons all over the state, some of whom were very
forthcoming with their opinions about and experiences with prison health care.
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Documents. The court documents from the Plata v. Schwarzenegger case are vast
and diverse. The case file, prior to the Receivership, includes over 300 distinct documents.
Of these, approximately 100 have been deemed relevant to my study. Table 1 summarizes
these documents:
Table 1: Case Document Summary

Court orders Settlement agreements
Arguments and motions from each party
Letters (inmates, physicians, lawyers,
prison leadership, court experts)
Vested parties’ formal statements Court expert reports
Joint case management conference
minutes
Forms, policies, procedures
Transcripts Press articles

The breadth of documentation serves to provide multiple perspectives of the prison
institution as medical provider. Archival research has a demonstrated ability to appreciate
an organization’s social connectivity, as was illustrated in Baum and Oliver’s (1991) work
on childcare centers (Ventrensca & Mohr, 2005). For this study in particular, documents,
arguments and motions put forth by the state and the inmate Plaintiffs (represented by the
Prison Law Office, or PLO) are thought to embody the values, beliefs and roles of the prison
institution and thus correspond to the institutional logics ascribed to by each party. Of
particular interest are the court hearings’ transcripts, which demonstrate the prevailing
organizational identity held by the parties through the messages employed in their
respective legal arguments.
To convey its position, the state provided testimonies and documentation
illustrating the prison system’s compliance with orders to provide inmates with
appropriate medical care (Stipulation for Injunctive Relief, 2002). The texts are especially
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useful because each party’s perspective is argued before the court. In a legal case, both
parties have a vested interest in having their side prevail. Arguably, to succeed, each side
puts forth their best arguments in the hopes of shaping the ruling judicial body’s
perceptions.
Case data details. The court data consisted of 86 case documents and 739
transcript pages. Approximately 60% of the transcript contents were devoted to the
plaintiffs’ inquiries, 30% for the defense and the remaining 10% regarded court business
and reference materials. Of the 11 witnesses called, all but one was called to testify by the
plaintiffs. Almost 40% of the transcript contents were testimonies by the medical experts.
The medical experts, who were appointed by the Court to oversee the state’s compliance
with prison medical care improvement, were jointly chosen by the plaintiffs and defense.
Of the three experts, two were physicians with extensive correctional medicine and
management experience and one was a nurse practitioner with 40-years experience in
prison nursing and administration. The additional testimonial content came primarily
from upper management in the Youth and Adult Correctional Agency (YACA) regarding
issues of organized labor, human resources, information technology and funding.
Data Analysis
The primary method of data assessment was qualitative textual analysis. This was
the chosen method because textual analysis is consistent with a constructionist
perspective: everything from the document’s creation, intention, and reception by multiple
audiences is taken into consideration (Newman, 2006; Prior, 2003). Second, the protocol
develops as the meanings and patterns of the content emerge over time (Altheide, 1996;
Boeije, 2002; Glaser, 1965).
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Creswell’s (1998) Data Analysis and Representation and the constant comparative
method informed the analysis protocol (Boeije, 2002; Glaser, 1965). Creswell discusses
qualitative data analysis as a process that spirals, looping back upon itself and building,
such that the researcher is immersed in the material multiple times. Part of the spiral
process involves reflecting, classifying and interpreting the data numerous times. The
process is similar to the constant comparative method, wherein coding and analysis follows
explicit comparative procedures with an aim to generate and suggest “properties and
hypotheses about a general phenomena,” (Glaser, 1965, p. 438) via comparing and
contrasting incidents, establishing and refining categories, and (re)assessing themes until
categories are saturated (Boeije, 2002; Creswell, 1998). In case study research, Creswell
recommends using categorical aggregates: collecting instances from the data with the hope
that pertinent meanings will emerge (154). Ultimately, the researcher develops what
Creswell defines as “naturalistic generalizations” from the data, which are the insights that
apply to the case, otherwise known as categories.
Procedures
The procedures are based on those outlined by Altheide (1996) and Boeije’s (2002)
steps for constant comparison. Specifically, the data were assessed as individual cases, as
members of a group and across groups. Boeije (2002) advises researchers evaluate how
comparisons differ in terms of data, aim, questions asked and results (p. 395). For
example, in her work studying couples coping with Multiple Sclerosis (Boeije et. al, 1999),
the aim of comparing interviews from different groups is used to validate a subject’s story
as well as enrich information. Accordingly, for this project, themes inductively generated
from the analysis protocol were evaluated across subjects.
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One of the initial steps involved data reduction via determinations about relevant
groups. Miles and Huberman (1994) claim that data reduction “sharpens, sorts, focuses,
discards, and organizes data in such a way that ‘final’ conclusions can be drawn and
verified,” occurred (p. 11). Although actual discourse may not always be so cleanly
articulated, the process of data reduction exposes the overlaps and relationships between
practices, concepts and terms. Accordingly, groups were established by treating each
institutional stakeholder as a separate case (Yin, 1984). Relevant groups consisted of
custody officers, medical technical assistants, physicians, managers, court experts,
bureaucrats, the prison law office, and other stakeholders.
Once groups were established, data were analyzed as individual cases and as part of
a case group. So, for example, a custody worker’s interview was analyzed first as a distinct
case and next, as part of the custody group’s data. Reviewing, comparing and contrasting
data in this manner allowed me to appreciate the distinctions particular to each case as
well as patterns within groups (Leonardi, 2007). Next, cases were compared across
groups. Relationships among these groups were explored, as were contrasting details.
This iterative process led to the emergence of pertinent themes, which were identified and
further refined over subsequent comparisons. Altheide (1996) advises drafting a
preliminary protocol after becoming familiar with the documents under analysis, then
revising the protocol as additional themes emerge over the course of multiple readings. To
help discern thematic content, terms that were central to themes were identified (see
Appendix B –Textual Analysis).
Operationally, the following procedures were employed to conduct the textual
analysis:
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(A) Read texts and began initial development of themes through open coding
(B) Reviewed themes in terms of categories
(C) Assessed categories against a sample of texts from various time periods
and sources (individual, group and across-group comparisons)
(D) Revised and tested categories on a different sample of texts
(E) Coded texts according to identified themes and categories
(F) Revisited texts and reviewed them in their entirety to allow for the
emergence of new themes and the refinement of existing categories after
which coding continued

Through these procedures, I coded all interview, court and field data. Categories such as
harm, incompetence, and control emerged. These themes demonstrate the issues facing
the CDC health care system and the structuring of prison health care practices.

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Clashing Logics: Command and Control versus Care
The prison system provides an interesting forum to explore legitimacy conflicts in
institutional change. The focus of this chapter is to explore how various organizational
actors and levels interacted in light of Plata mandates. In this chapter, I explore how
conflicting logics influenced roles within the organization. A means to ground this
discussion is through analysis of different group’s perceptions of health care legitimacy.
This chapter is organized in the following manner. First, I provide a brief overview
of the court case, Plata v. Schwarzenegger, whereby inmates challenged California’s prison
health care quality. Next, I discuss the most formidable player in California’s prison
system: the California Correctional Peace Officer’s Association. This union, and its tough-
on-crime worldview, significantly influences all prison matters, from legitimate logics to
the state’s incarceration practices. Finally, an analysis of San Quentin allows me to explore
organizational workers’ logics via assessment of how policies and procedures were
communicatively framed and enacted (Eisenberg & Riley, 2001; Pacanowsky & O’Donnell-
Trujillo, 1982). Specifically, San Quentin’s history, custody’s dominance, strict reporting
relationships and downward communication mechanisms all reinforce command and
control logics. In this case, multiple logics competed for primacy and rather than
encourage practice variation (Friedland & Alford, 1991), existing custodial practices were
further entrenched.
Case Overview: Plata v. Schwarzenegger
In order to improve medical care to a constitutionally adequate level, the CDC and
plaintiffs’ attorneys entered into a joint consent decree. The court supervised agreement
provided the impetus for both parties to negotiate and implement changes to prevent what
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had been determined to be an excessive number of preventable inmate deaths in California
state prisons (Stipulation for Injunctive Relief, 2002). Over the intervening four years, the
CDC made varied and largely ineffective efforts to improve medical care. The results were
paltry (Udesky, 2005).
Four years later, under the impression that inmates were still dying unnecessarily,
Judge Thelton E. Henderson placed the CDC’s health care function under a federal
receivership. Via the receivership, an agent of the court was put in control of prison health
care function. The receiver’s role was to carry out court orders and thus better manage the
prison system’s Health Care Services division. The receiver has the power to appropriate
state funds outside legislative channels, hire and fire employees and generally impose
actions that substantively improve inmate health care. One important aspect of the
receivership was that, through it, material resources to improve medical care were
provided outside legislative channels. These same resources were largely absent during
the joint consent decree period. So, while the absence of material resources was certainly a
large contributing factor for inadequate medical care improvements, another issue regards
how stakeholders perceived care. For California’s inmates in particular, corrections
officers’ views about medical care were especially significant, since custody staff enabled or
restricted inmates’ access to care. For many stakeholders, instantiating caring practices
was not only inappropriate, but also potentially dangerous.
The California Correctional Peace Officers Association: An Overview
The CDCR employs almost 69,000 staff, making it the largest state employer. Of
that, approximately 40% are peace officers including correctional officers and parole
agents (California Department of Corrections and Rehabilitation, 2011). These corrections
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workers are represented by the California Correctional Peace Officers Association (CCPOA),
which was founded at San Quentin prison in 1957. A co-worker’s suicide triggered the
union’s founding; officers were also concerned about low pay and poor working conditions
(Page, 2011). The CCPOA’s mission is “to represent the men and women who walk the
toughest beat in the state.” And they do it well. The CCPOA has been recognized as the
“most successful correctional union in the nation” (Petersilia, 2006, p.2). For example,
compensation for CCPOA members is about 60% more than correctional officers in other
states (Petersilia, 2006). Also, previous contracts granted represented corrections workers
90% salary pensions as early as age 50, which was more generous than agreements for the
state’s teachers, nurses and firefighters (“Fading,” 2010).
Yearly, the union receives $23 million from membership dues (Petersilia, 2006),
which has helped the CCPOA build a formidable power base in California’s politics. The
results are two-fold. First, the union has atypical managerial influence into prison
operations, as most prison managers ascend from CO ranks. Second, the union’s political
power contributes to California’s high prison population and recidivism rates through their
support of tough-on-crime legislation and elected officials who support that agenda (Page,
2011). The result is the CCPOA’s influence both inside prisons and in California’s politics
enhances the legitimacy of custody practices. To better understand how the care logic is
perceived inside California’s prisons, it is helpful to explore the CCPOA’s influence and
values.
The CCPOA has negotiated lucrative employment contracts and secured control over
certain performance management practices previously exercised by management. Page
(2011) claims “a primary purpose of the CCPOA is to enhance its members’ autonomy and
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control over workplace decisions” (p. 162). One example concerns work assignments.
70% of assignments are determined by post and bid, a process whereby officers with the
most seniority receive more attractive positions. Typically, work assignments are in
management’s purview (Benson & Delshon, 2004). By largely surrendering management’s
ability to assign work as they see fit, the state has negotiated away a significant portion of
management’s control. Furthermore, these settlements practically and symbolically
convey that management’s control of the prison organization is tenuous. In fact, a federal
report claimed “the Corrections Department, in part because the powerful correctional
officers union has usurped some management authority, has a pervasive ‘code of silence’
that protects wrongdoers, and punishes those who try to expose malfeasance” (Delshon,
2004). As management’s authority is subverted, the custody officer’s organizational
leverage increases. Culturally, the CCPOA has great influence upon which practices are
deemed to be appropriate within the prison’s walls.
Another facet of CCPOA’s influence concerns California politics. The CCPOA has the
financial wherewithal to be a significant player. For instance, in 2005, the CCPOA and its
political action committees spent over three million dollars for political purposes
(Carrasco, 2006). For gubernatorial elections, the CCPOA asks each candidate 13 questions
regarding California’s prison system and tough-on-crime legislation (“Fading,” 2010).
Whoever satisfactorily answers these questions receives significant financial support: in
2006’s election, the union spent $5 million on broadcast advertising for their preferred
candidate (Furillo, 2006). The CCPOA actively supports candidates and legislation, which
benefit their members. Tough-on-crime legislators enact tough-on-crime laws. Or, in other
words, the best way to ensure there are jobs for prison guards is to make sure there are
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people who need guarding.
Tough-on-crime and the three strikes law. In 1994, the “three strikes and you’re
out” ballot measure was passed. Sponsored by the CCPOA, it enhanced sentencing laws and
required that anyone convicted of a third felony receive a 25-years to life minimum
sentence. According to the CDCR, the intent of the law “is to reduce crime by targeting
serious, repeat offenders for long-term incarceration” (2011, p. 24). However, many
inmates are serving these long sentences for non-serious and nonviolent offenses. 50% of
incarcerations are for drug or property crimes (California Department of Corrections and
Rehabilitation, 2011).
The legacy of three strikes has been rampant inmate-population growth. At their
highest, prison population levels were 200% to 300% capacity (Green, 2010). Additional
tough-on-crime laws ensured even minor parole violators returned to prison. For example,
in California, 65% of released inmates return to custody within three years (CDCR, 2011;
Petersilia, 2006). California has one of the highest recidivism rates in the country, which
consequently influences correctional worker’s perceptions about the value of reform
programs.
According to Page (2011, p. 135) the CCPOA fosters a belief system that “criminals
are largely unredeemable” and therefore the incapacitation of prisoners is the main
purpose of incarceration. It is the correctional officer’s duty to “protect the good people of
the world from the bad people” (“Fading,” 2010). So, while the union’s “New Directions
Blueprint for Prison Reform” recognizes “the important role rehabilitation can and should
have” in corrections (2010, p. 10), the publication also recommends an additional 16,000
inmate beds be added to the current system. Reform is not in the CCPOA’s best interests
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since fewer inmates equal fewer custody staff. Thus, negative orientations toward reform
programs are reflected by custody officers.
CCPOA’s broad influence. The CCPOA’s primary concern is, understandably, its
own wellbeing. The best way to advance this agenda is through tough-on-crime legislation.
And their efforts have been quite successful. In light of the state’s struggles to minimize
overcrowding, the union has an interest to maintain these tough-on-crime laws. To do so,
the CCPOA relies largely on outside groups. For example, Page (2011) discusses the
penchant for the CCPOA to sponsor crime victim’s groups. In the public sphere, these
groups’ messages of suffering and harm are more persuasive than union pitches which
come across as self-serving. These victim’s groups advocate punishment and harsh
sentencing laws, which are in line with our society’s general adherence to a crime and
punishment belief system (Freeman, 1999). No politician has ever been reelected on a
platform for prison improvement. Thus, we come full circle. The CCPOA supports
politicians who enact tough-on-crime laws. Ultimately, these laws, together with high
recidivism rates, result in higher inmate populations who require oversight by greater
numbers of correctional officers (see Figure 1: The CCPOA Cycle of Influence).
Figure 1: CCPOA Cycle of Influence

CCPOA
Politicians
Legislation
Tough-on-
Crime Laws
High Inmate
Populations
More
Correctional
Officers
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It is important to understand the mission and values of the CCPOA because its
members are the very heart of the prison organization. Hierarchically, CCPOA values
persist as most prison management is promoted from custody officer ranks. So, for
security and cultural reasons, custodial practices are the correctional worker’s primary
concern; legitimate practices follow accordingly. The result is that as meanings and
practices are enacted, the corrections-focused culture is entrenched within the prison. To
explore the culture of custody and how meanings are enacted by prison workers, I turn to
San Quentin prison. San Quentin was chosen by the court to be the first prison to roll out
health care improvements. Since much of the initial effort to improve medical care was
focused on San Quentin, the prison acts as a site that embodies the practices, logics and
problems facing a prison system trying to implement change.
San Quentin Prison
2

In a 1985 investigative piece, the Sacramento Bee published accounts of San Quentin
custody officers suffering from daily inmate attacks and an “unresponsive and almost
uncaring prison bureaucracy” (Mecoy & Pollock, 1985). The investigation also found
evidence of custody officers who engaged in theft, drug trafficking, inmate abuses and
ignored prisoner-patient’s medical needs. Over the decades, San Quentin has been pulled
between two powerful forces: an unresponsive and removed prison bureaucratic system
and a culture of complacency. The resultant legacy has been difficult to change and
resonates still.
History. San Quentin, the first California prison, was built in 1852 on acreage

2
As mentioned previously, the prisons I visited are not identified. Discussion of San
Quentin prison is emblematic of the issues facing the prison system as a whole and not an
admission that research was conducted on site. San Quentin was also the first “rollout”
prison for improved health care practices.
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overlooking the beautiful Marin coast (Johnson, 2011). Inmates who previously had been
kept on prison ships constructed San Quentin State Prison; these 68 men and women were
the first to be incarcerated at the new facility (Reed, 2001). As of February 2013, San
Quentin State Prison housed 3,971 inmates, which is 128% of the prison’s capacity
(“Weekly report,” 2013).
Since its establishment 160 years ago, San Quentin prison has been home to some of
the state’s worst offenders; Sirhan Sirhan, Charles Manson, and Richard Ramirez, more
commonly known as “The Night Stalker,” have all been incarcerated there. Richard Allen
Davis, whose lengthy criminal record and murder of 12-year old Polly Klass powered
support for California’s three strikes law, awaits death by lethal injection at San Quentin
(Egelko, 2009). San Quentin is the only state prison that conducts executions; thus the
condemned call San Quentin home.
Possibly in spite of its residents, San Quentin has, in the past, provided inmate
reform programs and quality medical care. However, the overall quality of San Quentin’s
rehabilitation and health care efforts, and even its physical edifice, has crumbled under the
strain of political and cultural challenges. In this section, I provide background information
on San Quentin as a site that represents the “worst of the worst” (“Evidentiary Hearing,”
2005) of California state prisons. In terms of the enactment of caring practices, it is
important to note how the purpose of imprisonment changed in the late 1960s.
Furthermore, I discuss how the CCPOA shaped the organizational culture and structure of
today’s state prison system.
San Quentin: 1960s-1990s. In his 1973 book The Politics of Punishment: A Critical
Analysis of Prisons in America, Wright discusses San Quentin prison in depth. Citing new
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employee pamphlets from the late 1960s, Wright asserts that many prisoners enjoyed
relative “freedom of movement” and were able to move around the cellblock
unaccompanied by guards. Inmates engaged in work assignments and educational
programs. San Quentin also maintained an accredited 150-bed hospital on site; other
prisons sent their more serious or surgical cases there. However, these organizational
highlights were short-lived. Prison organizations, in general, maintain rigid control
functions and a militaristic operating culture (Clear, Cole & Reisig, 2011) rather than
embrace an organizational structure and culture necessary for care logics to survive.
During the reform-era in California prisons (1940s-1960s), prison guards were
reclassified as correctional officers. COs were tasked to aid the convict with his
rehabilitation; the goal was the inmate would learn how to eventually become a valued
member of society (Page, 2011). However, the reclassification did little to change the
meaningworld of officers. Page asserts COs “saw treatment workers as naive foreigners
who bought into softhearted sociological theories about crime that excused criminal
behavior” (2011, p. 19). The logics of care and custody came to loggerheads.
Custody’s general orientation to reform. When asked about reform programs,
most COs held adverse views. Many officers voiced displeasure with the volunteer-based
and privately funded education programs provided to inmates. One officer said, “I have to
pay for college. You have to pay. And these guys get to go for nothing.” Similar sentiments
were consistent across custody subjects. However, other officers saw the value in
education, but largely these were officers who had worked with the program’s volunteers.
Reform programs provide inmates with an opportunity to develop skills and an identity
other than that of a convict. Further, one CO who supervised inmate participation in these
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programs reported being treated more respectfully by participating prisoners. Program
participation is a privilege, thus good behavior is required to maintain that privilege.
However, reform programs continue to be cut from the prison system’s budget year after
year after year (California Department of Corrections and Rehabilitation, 2011). Without
contact with reform-oriented activities, COs have little if any experiential framework to
challenge the notion that inmates are, and always will be, unredeemable.
Custody-centered perceptions and practices heavily influence the legitimacy and
availability of programs for inmates. For example, COs enable inmates’ program
attendance since all inmate movement occurs under custody’s control. Volunteer staff
explained that without officer acceptance or buy in, the ability of inmates to attend
programs may be compromised. Gates may be locked; required officers may not be
present. This is to say that some form of permission is needed from those holding the keys.
In these ways, and others, command-and-control values are enacted and structure officers’
work-lives. Overall, notions of reform and rehabilitation are disconnected from the
mission of the CCPOA and consequently, the officers working within the prison system.
Reform through conformity, command and control. With the end of
indeterminate sentencing (the system under which inmates’ release was determined by a
parole board) in 1977, California essentially dropped its goal of rehabilitation (Freeman,
1999). Inmate programs for education and job training steadily decreased and the
preoccupation with incarceration as punishment became more and more entrenched.
Structuration is evident in these early days of a system becoming more and more punitive.
For instance, Wright discussed a San Quentin officer-training program. During the course,
the officer stated, “We are here to teach conformity” (Wright, 1973, p. 74). Conformity and
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supplication to the prison’s rules and habits were meant to teach convicts to do the same in
society. Conformity was the vehicle for rehabilitation. Yet there is additional significance
to these words. First, “proper conduct” was defined and determined solely by the
institution. Second, the “teachers” were the corrections officers who commanded the daily
activities of inmates. The shared values and practices of incarceration served to create a
framework whereby reform was not cognitively valued (Eisenberg & Riley, 2001).
Educational groups and job training programs were no longer considered to be a legitimate
means of reform as reform in itself held no legitimacy.
Culturally, the prison organization became more rigid during the 60s and 70s due to
a variety of factors. First, as the rehabilitation goal declined in importance, so did the
humanizing of convicts. Second, prison violence increased as groups such as the Black
Panther party advocated revolution by any means necessary (Page, 2011). And finally, the
judicial system began to intervene in prison operations, as was evident in the legislature’s
1968 passage of the “Convict Bill of Rights” which extended prisoners’ rights and
resurrected them from being “civilly dead” (Page, 2011, p. 24). Consequently, prison
workers grew more cohesive in the face of physical threats and outsider intervention.
Custody is king. Custody’s primacy is conveyed early on in an employee’s tenure.
For example, an old San Quentin employee orientation handbook advised new guards to
Never show the slightest uncertainty as to the course of your action. You must be a
leader in the strongest sense of the word; must know and show your authority.
Never show that you have been angered personally. To be effective, discipline must
be sure and impersonal. (Wright, 1973, p. 76).
Similar behavior is advised today as a means to ensure order and maintain officer safety
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(Anonymous, 2012; Owen, 1988). However, such recommendations have unintended
consequences for prison workplace culture. “Certainty” can become inflexibility at best and
entrenchment at worst, limiting an organization’s ability to adapt and grow. “Authority” is
given primary importance and exercised without forethought. Rigidity is essentially
advocated by prison leadership leading to increased organizational insularity. The prison
organization’s purpose appears through worker’s practices, discourses and shared
understandings (Putnam & Cooren, 2004; Putnam & Nicotera, 2009). The result is a
culture of custody that permeates throughout every facet of the prison environment.
In the 1970s, as violence increased, inmate mobility and privileges decreased
(Owen, 1988). Prison gangs began to pose serious threats to security, and in response,
security practices burgeoned. The corrections culture became more and more inflexible
over the next twenty years. Freeman (1999) asserts that the CO culture values group
solidarity as a means of protection from violent, unpredictable inmates and management
who cannot understand what it is truly like to be an officer. Put simply, incapacitation is
the main purpose of incarceration and legitimate practices flow accordingly.
Correctional Officers: Practices and Logics
Correctional officers are unique in that even the most junior-level employee is a
manager; it is their responsibility to control all aspects of inmate life (Cressley, 1969). How
officers enact this responsibility is largely based on tenure and orientation to the work
(Owen, 1988). Some officers may be “badge heavy,” or overly concerned with personal
authority while others may be “old timers” whose work performance is based on taken for
granted social structures and prison culture (Owen, 1988). What is consistent across
orientations is a worldview that inmates are always trying to get away with something.
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Inmate scams: From vino to violence. One officer described her job
metaphorically as an actor in a play. She went on to explain that she had a role to play and
the inmates had one as well; as long as both parties accepted these roles, she claimed
“everything turns out ok.” This officer’s description is an example social control, defined as
“…a product of relations among human beings, acting and reacting within the institutional
context of the prison” (Owen, 1988, p. 5). Owen’s research describes how prison workers
define their roles and in turn become agents of the institution. For example, social control
enactment is portrayed through correctional officers’ stories about inmates’ varied and
often creative efforts to “try to get away with things.”
Infractions varied from the mundane to the dangerous. For example, nonviolent
rule violations regularly surround commodities. Inmates often make “pruno,” or prison
wine, from fruits, ketchup and sugar. A pack of cigarettes (smoking was banned in 2005),
can be sold for up to $125 inside the cellblock (North County Times, 2007). I was also told
of an inmate who smuggled seven hamburgers up his sleeve; his intention was to sell them
but he was caught because he could not bend his arm. Other infractions are potentially
deadly. Shivs, or sharp, pointed implements, are a constant threat to inmate and officer
safety. Toothbrush handles, Plexiglas and metal utensils can be sharpened into weapons.
Inmates have also been known to swap out disposable razor blades with silver chewing
gum wrappers. The switch is made so the disposable razor looks as though it has not been
tampered with; correctional officers must check each razor to ensure it is still intact.
Razors are often embedded in a melted toothbrush handles to make slashing tools (Reed,
2001).
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The violent/nonviolent nature of inmate rule violations infuses the COs job with
uncertainty. A means to manage this uncertainty is through a command and control
orientation. The culture of custody exists in large part to convey to officers that they are as
safe as possible within an unsafe environment. The underlying social structure is for
officers to constantly question “what is this prisoner trying to get away with at this
particular moment?”
One officer discussed that as long as the inmates did not try to subvert the rules “to
her face,” she accepted their role as one where misbehavior was appropriate. Mutual
respect came from recognizing and respecting inmate and officer roles. She described an
activity called fishing, where inmates tie strings together and make long fishing lines.
When locked within their cells, inmates attach an item to the line and throw it to another
inmate in the cellblock. Her version of respect was that this activity would stop when she
approached. Inmates would yell “Hot water!” when a CO began walking the block. This
warning signaled the COs presence and fishing, for the time being, would cease. When I
asked her why she didn’t put a stop to such activities, since “fishing” is against the rules,
she said, “If I wrote up every infraction, I’d spend all day doing paperwork.” Officers “learn
to ignore certain inmate behaviors and overly restrictive prison rules in order to make
their jobs manageable” (Freeman, 1999, p. 61). Further, these tacitly negotiated
agreements between custody and prisoner illustrate structuration processes as members
engage in social practices which (re)produce the prison’s social order (Owen, 1988).
Command and control as a means of protection. The most pervasive element of
correctional officers’ work culture is the command and control orientation to their jobs
(Page, 2011). The correctional officers I interviewed held very negative views of inmate
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medical care. Most felt that all inmates deserved to receive mental health care. Their
reasons are understandable. First, approximately 60% of prisoners have mental illness or
substance abuse problems (Taylor, 2007). Second, mentally ill inmates are unstable and
possibly violent. During one of my prison visits, I spoke with a CO who had just returned
from an inmate suicide attempt. The prisoner was found cutting his wrists. “He was really
going for it too, not just scratching,” the CO claimed.
Suicide attempts provide an interesting example of CO sensemaking, whereby
meaning is attached to experience (Weick, 1979). The CO’s statement demonstrates
custody’s assumptions that fundamentally, prisoners are liars. Even suicidal acts are
evaluated in terms of being genuine or “trying to get away with something.” Furthermore,
it is important to understand how the suicide attempt was stopped. Rather than physically
engage the inmate, who was in possession of an item that could be used as a weapon, the
officers pepper-sprayed him. This intervention is significant as there is no space for caring
practices, such as talk or touch, to occur because of possible threats to an officer’s safety.
Every single activity within the prison is evaluated in terms of safety and security. Force
and control are a COs most readily available and legitimate tools. These practices
contribute to custody’s negative views toward physical health care as well. Most COs
stated that the inmates currently receive too much medical care, which costs the taxpayers
too much to deliver.
Command and control logics mask feelings of inferiority. Multiple logics
contribute to this perspective. First and foremost, correctional officers are tough. “Cops,”
as they choose to refer to themselves, are officers charged to maintain a secure prison
environment. Multiple meanings are attached to self-identifying as a “cop.” COs view
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themselves as law enforcement officers, responsible for carrying out legal judgments
against those who have wronged society. Thus, there is a significant moral aspect to their
job. However, in my research I found that the moral high ground of the correctional officer
is much less significant than their views of themselves as the underdogs of the criminal
justice system.
Correctional officers face physical harm and mental stresses most could not
imagine. A nonprofit’s research study claimed 31% percent of correctional workers
experience post-traumatic stress disorder (Lennard, 2012). One officer stated that every
day he left his home, he felt unsure if he would see it again. On the job, the threat of
physical harm is there, but more pervasive is the threat of humiliation. Forms of
humiliation run the gamut. An officer may find himself “gassed,” which occurs when
inmates throw cups of urine and feces at officers. Or, if deadly force is used on the job, an
officer will find herself automatically under criminal investigation. The notion that an
officer would be found guilty of a crime is one that undermines the validity of custody
work. And occasionally, COs are ridiculed in the press as overpaid guards who are not very
different than their charges.
I believe these practices and logics have led California’s correctional officers to
experience a pervasive sense of inferiority. Officers may invoke the language “cop” to
describe themselves, but there is an essence of fraud underlying the usage. Correctional
officers often wanted to be police, sheriff, or highway patrol officers but did not have the
skills, education or qualifications to warrant such positions. What is left for these law
enforcement-enamored individuals is to guard those convicted of crimes. While an
important and necessary job function, it is a far cry from apprehending a criminal and
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participating on the front end of the criminal justice system.
As such, the CCPOA has become a powerful advocate for California’s correctional
officers, securing wages and benefits far better than those for correctional workers in other
states. CCPOA rhetoric underscores the CO as the officer who is brave enough to walk the
law enforcement’s toughest beat. To further buoy their status, correctional officers
culturally reinforce paramilitaristic organizational structures.
The command and control culture is the most powerful legitimating force within the
prison organization. Because of the nature of correctional officers’ work and the threats
they face daily, command and control ensures safety. But it is also a scapegoat for choosing
procedures over what is morally right. And it is a means for dehumanizing the inmates COs
guard. An insightful MTA spoke of why COs tended to have negative views of inmate
medical care. He replied that officers look at every situation from the standpoint of “I am in
charge. I am in control. I am not being manipulated.” To provide care is a possible way to
be duped. If an inmate is a malingerer and a correctional officer provides care, not only
does the inmate learn of the officers’ “weakness” his coworkers do as well. Weakness can
be exploited. Weakness is not to be abided.
Medical Care Inside Prison Walls
The custody-is-king organizational culture severely inhibits caring practices. In fact,
medical care was little more than an afterthought, as historically inmates were categorized
as “slaves of the state” until the 1940s (Woodbury, 1982). And, as previously mentioned,
inmates’ constitutional right to medical care was not court mandated until 1976 (Taylor,
2007). For almost 125-years, San Quentin was not required to provide inmate health care.
There is a history of rampant medical understaffing, poor records management,
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incompetent treatment and a subordination of health care to custody as evidenced by
numerous lawsuits filed by inmates and investigative reports (Sward & Wallace, 1994).
One could argue that the problems with medical care at San Quentin take root in the
physical building. There were virtually no private spaces for medical assessments
(“Evidentiary Hearing,” 2005). Often, exam rooms were repurposed storage closets. These
spaces were often filthy and had no means of sanitation. A physician treating patients had
no way to wash his hands. The message that came though was “San Quentin does not value
inmate health care.”
This perspective was reflected by the physicians who worked there. One of the
complaints during the Plata trial was that there was no evidence of push-back
(“Evidentiary Hearing,” 2005). Physicians did not clamor for clean places to examine
patients; much less request drastically improved facilities. Doctors did not make formal
complaints that correctional officers often overrode medical decisions with custody
concerns, even though that was found to be the case (Plata v. Schwarzenegger, 2005).
Medical staff was trained to keep their mouths shut. Custody staff overrode medical
decisions; custodial practices were deemed more important than health care delivery. The
medical chain-of-command reported to the Warden; health care provision was subject to
custody approval.
The primacy of custody may explain, in part, why Plata experts found San Quentin’s
physicians to be insensitive to the convict’s medical needs at best and incompetent at
worst. To be an accepted member of the prison organization, certain custodial worldviews
were necessary. For example, consider the case of one inmate who suffered from high
blood pressure and diabetes was given a drug cocktail that was contraindicated for his
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illnesses over a nine-month period (“Evidentiary Hearing,” 2005). Overtime, the inmate
grew more ill, and while the staff was aware of his deteriorating condition, he still did not
receive appropriate medical intervention. While it was recommended that this patient see
an outside physician, the appointment never came to pass. The inmate was found
unconscious in his cell and died. There are hundreds of cases such as this, illustrative of
poor medical treatment, lack of management oversight, failure to follow up on patient care,
indifference and prison health care structural failures (Sward & Wallace, 1994).
Court experts found medical staff to be so entrenched in the imprisonment logic of
their workplace that improvement seemed futile. One witness testified, “…the staff had
become so accustomed to [the sad state of care they] just think that’s just the way it is”
(“Evidentiary Hearing,” 2005). Another witness expressed his belief that medical staff at
San Quentin was functioning under two predominant worldviews. First, staff believed the
prisons’ systems were broken. Compounding this perspective, system breakdown was so
dire that staff were unsure how to fix things. Second, many prison workers felt that court
intervention into prison medical care was temporary. The idea was to grin and bear it; that
eventually, the court would leave and things would return to the dysfunctional normal, so
“in a sense, why bother” making changes (“Evidentiary Hearing,” 2005).
Contributing to the failed state of affairs were the belief systems at work. In a 1994
investigative series, the San Francisco Chronicle claimed that poor inmate medical care was
linked to beliefs held by many corrections officers: “…that sick prisoners get what they
deserve” (Sward & Wallace, 1994, p. 2). Even mentally ill inmates were often thought to be
phonies and were subsequently punished (Wallace & Sward, 1994, p. 1), as was illustrated
by the particularly odd case of an inmate being written up for a rule violation after he had
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committed suicide. The authors also state that while these recompense beliefs may be
callous, they merely reflect the sentiments of society at large. For instance, budget
allocations for prison health care were paltry, mainly because expenditures for health care
and rehabilitation programs are not attractive to elected officials’ constituents. Prison
health care’s structural failure can be attributed, in large part, to lack of adequate
resources. Yet, resource problems and are also linked to the primacy of custody.
Bad management: A prescription for failure. Working with convicts is not
prestigious; at best it may be considered generous. Zigmond (2007) describes prison
health care worker’s motivations:
For some who work in correctional facilities, they see it as a calling to treat a
population that many would choose to ignore. For other clinicians and
health care staff, it offers an opportunity to work somewhat regular hours
and avoid the hassle of third-party payers (p. 2).
These sentiments were echoed in my interviews. One physician, who began her
prison career after the receiver increased salaries, told me she treated the same people
whether they were out on the street or incarcerated; she was drawn to aid this
underserved, typically poor, population. Others, however, were satisfied to have a job with
civil servant benefits and none of the administrative headaches that typically accompany
private practice.
However, a barrier to entry to prison health care regarded public perception.
Generally, physicians felt they would experience social ramifications if they worked at a
prison (“Evidentiary Hearing,” 2005). The assumption was that prison medicine was the
last vestige for the washed up doc. Prior to the receivership, low salaries and unseemly
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working conditions made hiring and retaining quality medical practitioners problematic.
Nursing and physician shortages were rampant throughout the prison system. The same
can also be said for medical management staff.
During the Plata hearings it was revealed that management was problematic. At the
state’s prisons, there was often a lack of medical-managerial oversight, or, if there were
supervisors, these individuals were often unqualified. Further, convoluted chains-of-
command made it nearly impossible to provide cohesive care for inmates. For instance,
subjects and court data reported nursing supervisors did not speak to scheduling
supervisors. MTAs, nurses and office technicians failed to work together. Even under the
receivership, a physician reported to me that the nursing supervisor “never met the
majority of the physicians.” The lack of effective supervision and management silos made
resolution of these issues difficult. In a report, the medical experts claimed, “Because of
differing chains of command between the disciplines, and because of the nurse supervisory
deficiencies, no one is truly responsible and accountable for the implementation of the
[health care] policies” (Medical Experts Report, 2005, p. 2).
The physicians I interviewed expressed poor views of management. One physician
said she did not know what her boss did all day, except go out to lunch because of the
takeout boxes that were left behind. Subjects all bemoaned a lack of effective supervision;
which was most evident by a lack of “management by walking around” practices. I found
this complaint to be especially interesting since a retired Chief Medical Officer discussed
the management training courses he attended in Sacramento. The courses promoted
management-by-walking-around practices; the message from CDCR leadership was that
these practices were expected. However, this expectation was largely unfulfilled, according
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to subjects. One physician claimed management’s job was to forward policy memos from
CDCR headquarters. Another claimed, “I have been [here] for four and a half years, and I
have yet to have an evaluation,” as a means to illustrate a lack of the most basic
management functions.
Downward communication and no feedback mechanisms. There was an
expressed sense that the physicians and nurses were working together, without
management support, to get their job done. Respondents claimed it was unique to see,
much less meet, a new Chief Medical Executive or Chief Executive Officer. Communication
flowed down on top of medical staff, as was evidenced by new metrics or policies and
procedures, but no mechanism existed to provide feedback up the chain of command. This
frustration with poor to nonexistent feedback loops manifested itself in a few ways.
For example, physicians expressed desires to keep their heads down and do their
jobs. This aspiration is important for a few reasons. First, prison doctors overwhelmingly
believed they were the objects of criticism (similar to their CO coworkers). Physicians also
felt their jobs had high likelihood of being interrupted by “more important” custody related
issues. Finally, doctors all voiced exasperation with the administrative systems they were
forced to use. Post-receiver, metrics were instituted and closely monitored. Physicians
were given checklists as a means to ensure constitutionally adequate medical care was
delivered. However, physicians’ resentment toward the checklists and protocols was
apparent. One physician complained that if an inmate had a history of heart problems, she
had to listen to his heart at each appointment. Her resentment of this protocol was
grounded in the idea that outsiders believed this step to be indicative of good medical care.
She stated that the mandate to listen to his heart might not be medically necessary in all
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situations. Further, the mere act of listening to a heart would not make her a good doctor.
Rather, this particular protocol was indicative of bureaucrats, rather than physicians,
making medical decisions. She said,
…it’s lawyer driven, and lawsuit driven, and it’s not based on any evidence at all, so
we have to do things that we have not been trained to do…And I don’t know who
made [the metrics]. Because they don’t seem to be very medically trained. Some of
the people in Sacramento, I’m sure they must be licensed, but I have to tell you,
having interacted with them, they are some dim bulbs.
Physician’s discretion was removed. While discussing care and management, one
doctor’s statement reflected common themes,
…there’s no content to those [inmate medical] visits. It’s all entirely just hitting the
markers that CDCR has set up for us to do, what they have decided are markers of
good care, but it has nothing to do with the care that’s being provided…you could
check all those boxes and have a set of vitals and maybe not even have had a real
visit. You could fake your way through it. So I think there’s an element of that that’s
taking place now. My administration, I don’t even know how many people are above
me, honestly. I don’t understand the structure…they keep shifting the initials.
Physicians expressed exasperation that no one had defined “constitutionally
adequate medical care” which they were responsible to provide. Doctors believed that
bureaucrats and lawyers in Sacramento, rather than practicing physicians in the field,
created disconnected metrics system. Further, these metrics discursively structured
physician’s agency (Cooren, 2004), demonstrating they were not to be trusted.
Understandably, doctors were insulted by the implication they were incompetent or
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untrustworthy.
However, when I asked subjects if they had communicated their dissatisfaction up
the chain of command, none had. Most expressed they had not had the opportunity or
means to provide feedback to CDCR. And while each had feedback to give, none were
willing to take unconventional paths to communicate up the hierarchy. Thus, these
physicians recreated custodial norms’ primacy by failing to become the discursive agents of
change they believed were necessary (Schmidt, 2008). The institutional context
communicated, even after federal intervention, that physicians’ services were necessary
but still illegitimate (Putnam & Nicotera, 2009).
These physicians took ownership of their own work, but failed to see themselves as
an important part of a prison health care system. Subjects portrayed themselves as lone
doctors providing quality care in spite of the CDCR. Doctors felt unappreciated by the
system. For some, they saw themselves as educated and trained physicians who chose to
take these valuable skills and treat patients who society has cast aside. The values that
drove these doctors to provide quality care were internally motivated; imposed metrics
and mandates insulted them. Overall, the pervasiveness of command and control logics
distracted from and were a hindrance to quality medical care.
Medical Technical Assistants Embody Conflicting Logics
A particular custody officer job classification, the medical technical assistant (MTA),
is required to continually negotiate between custody and care logics. Even the MTA’s job
description muddles custody and care: “In lieu of Correctional Officers in a correctional
facility in instances where medical skills are required of custodial officers in addition to
their responsibilities for the custody and supervision of inmates” (California State
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Personnel Board, 2012). These employees are particularly interesting because they
embody conflicting logics at work. MTAs, while correctional officers, are also licensed
vocational nurses.
Structurally, MTAs had few ties to health care. While responsible for ensuring
inmates received medical treatment, these employees were essentially unsupervised by
health care managers (“Evidentiary Hearing,” 2005, p. 282). Rather, MTAs reported to
correctional staff. Specifically, MTAs reported directly to a supervising MTA who then
reported to a Health Program Coordinator, also a peace officer. The Health Program
Coordinator reported to the Director of Nursing, however these positions were largely
vacant during the Plata case. Thus, the MTA’s chain of command was strictly through
custody; a place where the care logic was viewed cautiously if not rejected outright (see
Figure 2). In other words, the organization’s structure had communicative significance
(Putnam & Nicotera, 2009).
Figure 2: MTA Chain of Command

This reporting relationship and dual role conflict is especially relevant during times
of ambiguity. All MTAs claimed to give care when care was warranted. One said, “If he’s
got it comin’ to him, I’m gonna give it to him.” For this MTA, “got it comin’” meant a
Reports to
Custody
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prescription or test or health aid that had been authorized by a physician. However, the
question remains, what occurs in the space between an inmate request for care and a
physician’s orders? In this critical juncture, the MTA was truly the gatekeeper the court
claimed he was.
Yet what is largely overlooked in this ambiguous space is the personal integrity of
the MTA. While it would be unlikely for a subject to state otherwise, all MTAs interviewed
were very adamant that they were nurses first and custody staff a distant second. The
forcefulness behind these identity claims reveal a class of custody worker that has had to
fight to be a legitimate arm of a command and control organizational culture.
COs’ opinions of MTAs: “You’re just an inmate lover.” COs tended to hold
negative perspectives about their MTA coworkers. I argue this was the case because care
logics are in direct conflict with a command and control orientation. Problematic was the
lack of MTA conformity with custodial practices and culture; this complicated the ability of
COs to consider MTAs as group members (Erez & Earley, 1993). Namely, officers
complained that MTAs were unreliable when it came to custody crises. Multiple CO
subjects claimed that MTAs would not get involved when violence erupted at the prison. In
fact, one MTA admitted, as a group, they had bad reputations for not participating in violent
custody actions. For example, an MTA explained that she “refused to get [her] kicks in”
while COs were beating on a violent, yet restrained, inmate. Most MTAs told similar,
although less violent, tales. It was as though each had been hazed by the fraternal order of
custody officers; tested to see if the MTA was a cop or something other. However, MTAs
clearly stated their duty was as a nurse first and foremost.
In court proceedings, MTAs were labeled as “gatekeepers” who were able to provide
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or deny inmate medical care. And while the nature of the position is a conflicted one, the
MTAs I spoke with consistently described incidents of invoking the care logic in situations
where the custody logic could easily come to the forefront. For instance, cell extractions
are commonly violent. When an inmate must exit his cell and refuses, custody often will
force him out. During an extraction, an MTA claimed, “everyone gets hurt. The inmate gets
injured. We get injured. It’s just bad.” However, cell extractions were commonly instigated
by COs; a symbol of command and control at work. For MTAs however, forceful cell
extractions were sometimes necessary (custody logic) but never the first option (care
logic). An MTA explained the logics of his job:
We’re the cops of the prison. We have to maintain order also as well. I always had
pepper spray to carry my whole time with Department of Correction and not once
did I ever have to use it. I mean to me, that’s a pretty good deal because I have the
protective equipment that I could use, but I’ve always been able to talk. I use my
communication skills to talk to [inmates] because that’s, most of the time, that’s all
they want. They just want someone to hear what their problem is…I’m able to
communicate that and talk to them and try and resolve the issue just by using my
mouth.
MTAs consistently reported that talk, rather than force, was their best tool for dealing with
inmates. However, there is a cost to the MTAs for employing caring practices within the
prison institution: their CO coworkers often criticized their practices, using derogatory
names like “inmate lover” or “a hug-a-thug.”
While interview data significantly demonstrates MTAs mainly enacted caring
practices, court documents reveal another perspective. MTAs were found liable for part of
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the prison’s failure to treat sick inmates. Case materials portray instances where MTAs
impeded inmate medical care. Procedurally, MTAs were the ones who made it possible for
inmates to receive care as they were the ones who received inmates’ sick slip requests.
Court records claim that one prison had a backlog of over 300 sick requests; MTAs were
also present at inmate medical appointments. Physicians spoke of MTAs interjecting
themselves into medical treatment. For instance, a few physicians told of instances where
an MTA would say things like “That’s too much” or “He doesn’t need that.”
These interjections are significant because of their dual purpose. Rather than being
an admonishment about care being given, often times such statements were made in an
attempt to educate the new prison physician, both in terms of legitimate practices and
acceptable logics. One doctor claimed he relied on MTAs to “learn the ropes.” For instance,
newer medical staff may be unaware that medical equipment is social capital in the prison.
An inmate who claims his bad back necessitates sleeping on the bottom bunk may be trying
to up his social standing. In prison, the lower bunk is a symbol of higher status (Zigmond,
2007). Or, an inmate may claim to require a wheelchair, which would give him the ability
to get to the front of the cafeteria line, as well as perhaps build a case to receive Social
Security disability benefits upon release. Again, these MTA-voiced admonishments fall
along a spectrum of motives: at one end is an educational purpose; at the other is the
notion that illness is retribution. Reflected within these statements is the stable belief that
an inmate will always try to get away with something.
Because the organization failed to manage MTAs effectively, the position was one of
individual integrity and shifting identity triggers. Discretion is something that the MTA
position provided; however that discretion was easily abused as no checks were built into
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the system to both manage inmate malingers and yet ensure those truly in need were
treated. While among inmates in the cellblock or yard, MTAs would be the caring presence
within that environment. However, during medical appointments, MTAs would be the
custody presence, ensuring that adequate care, and only adequate care, was delivered to
the prisoner. What is interesting to explore is the fulcrum: what occurs when the situation
is not clearly one where custody or care logics are triggered? Which scripts are enacted?
At this critical junction, two factors have significant relevance: the personal discretion of
the MTA and the organizational structure.
Diabetic Care: Symbol of Logics, Practices and Systems.
One of the most predominant diseases inside California’s prison is diabetes. Studies
have found that hypertension and diabetes are the top two reasons inmates are
hospitalized (Resch et al., 2007). And, as the inmate population ages, chronic diseases like
diabetes have become more commonplace (Fernandez, 2012). Diabetes treatment and care
is a significant issue for California’s prison system. Accordingly, an in-depth look into
diabetes is an excellent way to illustrate logics, practices and system-wide challenges to
quality health care.
A day in the life of inmate diabetes care. One of the issues raised in the Plata v.
Schwarzenegger case regarded diabetic blood sugar testing. Specifically, the court cited
poor diabetes treatment to illustrate the general lack of will to improve medical care.
Diabetics are supposed to test their blood sugar before eating; food ingestion prior to the
test skews the results. For diabetic inmates at San Quentin, blood testing did not occur
before breakfast (“Evidentiary Hearing,” 2005, p. 398). This example is fascinating because
while many health care problems seemed to have been related to larger resource issues,
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the “simple” change to administer a finger-prick blood sugar test should have occurred
easily. Thus, during my research I focused on this particular failing as illustrative of care
logics not taking root within the prison. What follows are some of the issues impacting the
effective delivery of diabetes care, which also illustrate prison logics and structures.
Challenges begin with breakfast. San Quentin assured the court that inmate blood
sugar testing would occur before breakfast; however, after one year, the status quo
remained in place. To understand some of the difficulties establishing this practice, it is
necessary to consider how custodial practices impact care. Inmates are not allowed to
independently manage their diabetes. Health care staff must conduct all blood tests and
insulin shots. Custody is the intermediary between health care staff and inmate treatment.
As an outsider looking in, two seemingly simple solutions come to mind: get care to the
inmate or get the inmate to the care, earlier.
Morning is a hectic time at the prison. Inmates eat breakfast at 6:15 a.m. CO shift
change is at 6:00 a.m. So, first thing in the morning officers hit the ground running to get
inmates out of the cells and to the cafeteria on time. Health care staff did not engage with
inmate patients without custody facilitation. Practices dictated that inmates would have to
be transported to medical for blood testing. However, no custody officers were assigned to
perform that function (“Evidentiary Hearing,” 2005, p. 399).
Inmate movement is tightly controlled.
What cannot be overstated are the challenges moving inmates, which is tightly
coordinated. When inmates transition between locations en masse, gangs and racial
tensions must be accounted for. Prisoner traffic is often orchestrated so that different
groups do not cross paths as this may result in violent situations. Individual movement is
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also restricted and scheduled. For example, each inmate’s daily activities are scheduled on
a ducat. At one prison visit, my guide stopped an inmate and requested his ducat (failing to
produce the ducat when asked is a rule violation). After patting a few pockets to locate the
precious schedule, the inmate handed over a small rectangular piece of paper. On it were
his scheduled activities for the day, including work assignment, location, and schedule, an
AA meeting and time he was allowed to visit the chapel. The degree of scheduling and
oversight is astonishing in light of the sheer number of inmates within California’s prisons,
which currently stands at over 123,000 (“Weekly report,” 2013). And yet this form of
control is understandable considering each prisoner must be safe and secured. To ensure
this end, COs oversee all inmate movement. Freeing up custody staff to transport
individual diabetic patients to medical was likely thought to be too disruptive to security,
safety and schedules. Rather, the existing practices were more valued than the proper
medical protocol.
For instance, cell unlocks are scheduled for specific times of day and early release is
discordant. But if that were to occur, having staff available to transport an inmate, at, for
example, 5:45 a.m., was also problematic. The 6:00 a.m. shift change is set in stone. When I
asked, hypothetically, if the warden could mandate a change to the shift-start time for
certain officers so that inmate blood sugar testing would occur before breakfast, I was
informed that, yes a warden could make that decision, but the impact of that change would
have to be negotiated with the CCPOA. Thus, the union’s influence into personnel
management is reflected here. Further, since all prison activity is so tightly scheduled and
monitored, moving breakfast’s start time has a ripple effect to inmates’ work, class and
other treatment schedules. These are some of the obstacles for getting the diabetic inmate
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to medical care before breakfast. What are reflected are legitimated and entrenched
structures and practices; diabetes management is not seen to be a valid change driver.
Care must be dictated. The other seemingly simple solution would be to get
medical treatment to the inmate. Since custody staff were seemingly unavailable to
support diabetic inmates’ blood sugar testing, one could assume that medical staff could be
ordered to conduct the tests prior to breakfast; however, even these changes were not
implemented because of transport and security issues. Again, medical treatment
necessitates custody’s involvement. So, even if a physician were available to conduct a
finger-prick test for an inmate who was still in his cell, the court found such treatment to be
insufficient for a constitutionally adequate standard (“Evidentiary Hearing,” 2005).
When COs were asked why diabetic testing could not change, most placed blame on
Sacramento for not dictating a new process. When asked, “Wouldn’t San Quentin want the
autonomy to manage its own practices?” COs tended to skirt the question. Rather, replies
referred to the organizational hierarchy. For instance, some claimed they were not aware
of if or how this problem was communicated to the warden. Some thought that perhaps
“messages got stuck within the department.” The knee-jerk response was to blame the CDC
for not making care happen. Interestingly, though no unsurprisingly, no COs discussed the
processes they would take to ensure testing occurred. Processes must be explicit and flow
down through the hierarchy; there is no empowerment within custodial practices.
Diabetic testing continued to occur after breakfast for one year after San Quentin
was told to change the practice (after that time the court ordered the receivership). While
the systems made it difficult to adequately test diabetic inmates’ blood sugar levels, a lack
of will certainly reinforced the legitimacy of the status quo. Other CDC prisons tested blood
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sugar prior to chow; thus if San Quentin management had chosen to benchmark another
facility, they perhaps could have discovered ways to instill the mandated change.
As a system, the prison cannot adapt to individual needs. As such, diabetic
inmates were herded, after breakfast, to a central diabetes testing location. One inmate
reported, “To get your insulin shot or your pills, you had to stand in line for an hour, hour
and a half in the rain, if it was raining” (Noyes, 2011), which is problematic for continuity of
care. Inmates cannot be forced to control their disease, thus disincentives make it less
likely that inmates will effectively manage their diabetes. When inmates ignore their
health, the consequence results in higher medical costs. For instance, one study
demonstrated that diabetic inmate patients took 14% of medical beds (Resch et al., 2007).
These inmates were hospitalized because they required more than one finger-prick blood
test per day. That was the primary medical reason; two or more finger prick tests per day
necessitated a hospital stay because it could not be guaranteed that the inmate would
receive the test otherwise. It appears that because of entrenched custodial practices, the
only way to ensure adequate blood sugar testing was to hospitalize the inmate.
Other support systems for effective diabetes management were also absent.
Diabetic inmates may be unable to receive special diets appropriate for diabetes
management (Noyes, 2011). Generally, prison meals provide cheap nourishment, which
means breakfast may be powdered eggs and pancakes. According to the Legislative
Analyst’s Office, California spends about $1.35 per prisoner meal (“Criminal justice,” 2009).
A diet high in protein, complex carbohydrates, and fresh vegetables is costly and not
readily available. Furthermore, the one place were inmates are allowed to exercise choice
is at the prison canteen. Prison canteens function like little mini-marts where inmates can
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purchase candy, cookies, sodas and other snacks. Diabetic inmates are supposed to use
discretion in their eating habits. According to one physician, most do not.
Generally, inmates, like free citizens, cannot be forced to manage their illnesses.
There is an exception, though. In 1984, courts ruled that inmates could be medicated by
force, but only if the inmate was deemed dangerous or incompetent (Savage, 1990).
According to the state, since the penal coded “vests ‘the responsibility for the care, custody,
treatment, training, discipline and employment of persons confined’” in prisons, the CDC
has the responsibility to treat inmates even if doing so goes against their explicit wishes
(Office of Administrative Hearings, n.d.). Yet these “responsibilities” must be balanced
against an inmate’s civil rights, so medication by force typically involves court-ordered
administration of psychiatric drugs.
Diabetes care does not meet the standard for treatment by force; therefore if an
inmate chooses not to take care of his illness, it is his right to do just that. And many make
that choice. Diabetes management classes are not widely available, so unless educated by
medical staff, the diabetic inmate may not be aware of how or why to manage his diabetes.
Proper nutrition, exercise and continuity of treatment are largely up to an inmate’s
discretion. However, research has demonstrated that a lack of social support hampers
diabetes self-care behaviors (Snoek, 2002). Overall, systems are not in place to support
proper diabetes treatment. The result is that many inmates ignore their disease.
Dialysis difficulties: transport, expense and mismanagement. Over time,
uncontrolled diabetes can lead to kidney failure. When kidneys can no longer filter waste
and excess fluid from the blood, dialysis is required (Nordqvist, 2009). Dialysis for inmates
illustrates other system failings. Prior to the receivership, most dialysis patients were
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taken to outside medical facilities. Dialysis was largely unavailable within prisons, even
though there was significant demand for this treatment. Additionally, an inmate taken to
dialysis would be accompanied by two COs, a necessary but expensive security measure.
However, it still remained difficult to ensure treatment. Court records indicate that
many dialysis providers refused to treat inmates because the CDC did not pay for services
rendered. Consequently, inmates would often be hospitalized at outside facilities, under
guard, or not receive the care they were constitutionally guaranteed.
Do inmates deserve care?
These practices, however, merely reflect our social beliefs that prisoners get what
they deserve. A particularly interesting article by KPBS (2010) about the California
Medical Facility, the largest prison hospital in the state, illustrated many of the tensions
surrounding inmate medical care. Portrayed in it were: an inmate, serving a life sentence
for murder, who was recovering from cataract surgery, and a hospice patient, dying from
prostate cancer, who was incarcerated for child molestation. And while the article
represented the social conflict about providing violent criminals medical care, the most
interesting aspect of the article were the readers’ comments. There were three. One was a
father’s cry for better care for his diabetic-inmate son. The second was a statement
blaming the CCPOA for a lack of compassionate release programs. The third, in response to
the father’s plea for help, simply asked, “Why is he in prison?” Or in other words, “Does he
deserve to suffer?”
Poor diabetes treatment demonstrates logics enacted. The constraints upon
effective diabetes treatment demonstrate prison logics at work. First, inmates cannot treat
their own diabetes. While this may seem a frivolous rule, in actuality the tools of treatment
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(alcohol prep pads, needles, drugs, disposal canisters) may be used in inappropriate ways:
as weapons or as currency to appropriate other contraband. Second, San Quentin’s
custodial practices were entrenched to such a great extent that finding the extra time and
staff to ensure effective diabetes care was virtually impossible; care was illegitimate when
considered in light of custodial practices. Third, diabetes management practices were not a
part of the system: treatment, nutrition, exercise and education were not easily obtained.
Finally, when the secondary diseases associated with diabetes appeared, the reactive
organization often failed to ensure care was delivered in an effective and fiscally prudent
manner. The diabetic patient is an inmate first and foremost, dehumanized so that
adherence to bureaucratic systems is more important than an individual’s rights to
constitutionally adequate medical care.
Custody or Care, Which Do You Want?
Custodial and caring practices mix like oil and water. Pour them together and shake
the bottle hard enough, it may appear the two are blending, but they never truly will. From
the perspective of custody staff, caring practices were anathema to effective and safe prison
operations. To medical practitioners, the sheer magnitude of the command and control
culture made it difficult to provide adequate care, much less practice the “art” of medicine.
And for those stuck in the middle, the MTAs, the care and custodial aspects of their jobs
were a source of ridicule, confusion and personal fortitude.
In this case, caring practices could not break through custodial structures and logics.
This is particularly evident in how San Quentin failed to improve its diabetes treatment
practices. Overall, how care was, or rather was not, enacted tells us something about
agency. This case indicates that agency, to some degree, depends upon the extent to which
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organizational members are committed to a new or old system of legitimation. Logics offer
ways to work, communicate and negotiate (Barbour, 2010). In times of change, new logics
must provide legitimate ways for conducting these activities. For the majority of prison
workers, namely custody staff, caring logics did not mesh with embedded prison legitimacy
concepts. Caring practices were also impeded by existing organizational structures. And,
as will be explored further in the next chapter, the state’s bureaucratic systems further
obstructed care. As such, health care improvements were not widely adopted throughout
prison organizations.
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Bureaucracy Reigns Supreme
California’s prison workers felt especially disconnected from the part of the CDC’s
mission to employ “rehabilitative strategies to successfully reintegrate offenders into our
communities.” From actor-level custodial practices to legislated budget cuts for
rehabilitative programs, few things signaled to prison employees that “care” was one of
their job functions. To further my discussion of prison health care legitimacy, I now
consider the prison system and its bureaucratic structures. Specifically, this chapter
focuses on the Plata v. Schwarzenegger class action lawsuit and various system and
institutional stakeholder constraints to provide constitutionally adequate care prison
health care.
This chapter proceeds in the following manner: first is a discussion about the Plata
case’s texts. Here, it is argued that court documents portray divergent stakeholder logics.
To further support this claim, a summary of the textual analysis findings is offered. Based
upon these data, I contend that, for the state, legitimate health care improvement could
only occur according to existing bureaucratic structures. Namely, bureaucratic compliance
was more important than unnecessary inmate deaths. To illustrate how logics conflict, a
discussion about pain management conveys “adequate” health care’s complexity while the
lack of will to improve medical care demonstrates structural and cognitive constraints for
health care’s legitimacy. The chapter concludes with a brief summary about the cognitive
and symbolic costs to enact prison health care.
Order to Show Cause Hearing
A year after the joint consent decree, the court approved a joint stipulation
agreement between the state and inmate-plaintiffs. In this agreement, the state promised
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to draft “policies and procedures to implement systemic prison medical improvements”
(“Joint Case,” July 15, 2002, p. 1). The state’s purported goal was to improve heath care in
four areas: primary care physician assignment, chronic care policies and procedures
implementation, and triage and sick-call systems reforms. At that time, state attorney Joe
Applebaum claimed the state “really strives to mirror the private sector and to furnish care
in line with the community standard” (“Evidentiary Hearing,” 2002, p. 16). The state not
only failed to meet community standards, it also failed to meet legally minimal ones.
Immediately prior to the CDCR receivership in 2005, federal judge Thelton E.
Henderson held an Order to Show Cause hearing (“Evidentiary Hearing,” 2005). The
purpose of the hearing was for the state to demonstrate two things. First, that the CDC had
made sufficient changes to assure inmates received constitutionally adequate medical care.
Second, a receivership, which would remove prison health care control from the CDC and
place it with a federally appointed entity, was unnecessary.
In this case, both the State of California and plaintiffs (represented by the Prison
Law Office or PLO) structured their arguments to demonstrate compliance, or lack thereof,
with previously established court orders. The communication employed by each side
demonstrated how they conceived of court compliance, as well as illustrated broader, more
meaningful conceptions of the prison institution. The case’s documents and testimonial
records are thought to embody the prison institution’s values, beliefs and roles.
Accordingly, the communication corresponds to the institutional logics ascribed to by each
party. More specifically, the court transcripts from the Order to Show Cause hearing are an
excellent source to investigate institutional logics and legitimacy because the language and
stories employed are indicative of the prevailing organizational identity.
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Hearing transcripts portray incompetence and bureaucracy. Initial close
readings of the court transcripts produced the following thematic areas: patient harm,
physician incompetence, performance management issues and activities, bureaucracy,
facilities and functional aspects of medical care. Table 2 provides definitions and examples
for each category.

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Table 2: Thematic Term Definitions and Examples
Category term
Term
denotes
issues of
Sample of words
in category
Sentence example from
transcript
Patient harm
Inmate
suffering,
cruel and
unusual
punishment
Death, suffer,
cruelty, morbidity,
mortality
“…the guy ended up dying of
an overwhelming infection,
that again, this doctor didn’t
pick up the clues…”
Physician
incompetence
Poor medical
practitioners
and
incompetence
Unqualified,
incompetent, bad
doctor, problem
doctor
“Getting rid of bad doctors.”
Performance
management
Qualifications
of medical
care
providers,
performance
evaluation
criteria and
compensation
requirements
Board certified,
standard of care,
competent,
compensation,
salary
“… the CDC doesn’t have
anywhere near the number of
competent physicians it needs
to properly provide adequate
care, correct?”
Bureaucracy
Organizationa
l structure,
policies and
procedures.
Bureaucracy,
institution,
protocol,
documentation,
(non-medical)
procedures,
staffing, vacancies
“My opinion is that they have
not adequately implemented
the policies and procedures
that they were require to
implement…”
Facilities Physical space
Exam room,
overcrowding
“…barely enough room for an
exam table and to be able to
turn around in the room…”
Functional
medical care
Items related
to but not
responsible
for patient
care.
Risk, sanitation,
records, schedule
“…there should be a review of
the record to make sure that
these chronic medications are
continued.”

Transcript thematic analysis identified bureaucracy, performance management and harm
to prisoner patients as the three predominant themes. Textual analysis yielded two main
results. First, the prevalence of these themes varied according to party in that the primary
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concerns of the state were employment issues as opposed to the PLO’s concern with harm
to prisoners.
3
Second, and most meaningful, were the discursive choices used by opposing
parties to discuss prison bureaucracy (see Table 3). This section (1) demonstrates how the
defendant’s and plaintiff’s arguments reveal competing institutional logics of bureaucracy
and inmate wellbeing and (2) conveys the prison’s response to coercive isomorphic
pressure and the subsequent challenge to its legitimacy.
Table 3: Textual Analysis Matrix: Perceptions of Care, Legitimacy and Logics
State of California
Defense
Prison Law Office
Plaintiffs
Constitutionally
adequate
medical care is
Proceeding within the
boundaries of our established
policies, procedures and laws.
Nonexistent. Bureaucracy and
lack of will make any
significant and lasting change
unlikely.
Legitimacy is Bureaucratic compliance Inmate welfare
Impact of
institutional
logics
Unable to conceive of change
outside of bureaucratic
structures, thus compliance
with court mandates is
difficult if not impossible.
Since inmate welfare is not a
driving institutional logic, the
federal government must take
control of the prison system
and force necessary changes.

Again, the Order to Show Cause hearing was intended to demonstrate that the
appointment of a federal receiver, who would ensure constitutionally adequate prison
medical care, was not necessary. To do this, the state employed arguments demonstrating
bureaucratic compliance. Their opening statement supports this view:
Defendants also believe they are making meaningful progress toward the provision
of constitutionally adequate health care on a system-wide basis, although
admittedly, it is taking longer than had been initially hoped and planned. This has

3
Textual analysis occurred through a lens of organizational interpretation. Discourse was
interpreted as it related to the function, performance and structure of prison medical care.
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been due largely to various obstacles and barriers, many of which are California
state law and California constitutional requirements that are beyond the defendants’
immediate control (“Evidentiary Hearing,” 2002, p. 5).
Bureaucracy as guiding institutional logic. In the years prior to the Order to
Show Cause hearing, the state and inmate-plaintiff’s attorneys met periodically to negotiate
healthcare improvements. However, as the years passed and progress was slow, the PLO
filed court motions demonstrating the state’s failure to make meaningful changes. The
following excerpt act as an exemplar of medical care conflicts:
PLO: The policies fail to provide for necessary heart disease screening.
State: (citing policy manual) Volume 4, Chapter 2. Health Screening – Reception
Center. “A…RN/MTA/LPT shall obtain blood pressure, pulse and weight…”
(“Defendants’ Response,” 2002, p. 3)
The PLO sought the “spirit” of the policy rather than a specific policy reference. The
broader concern was how the policies would be implemented. The state, however,
consistently cited procedures rather than demonstrate how those procedures were
enacted. This difference, between the actual provision of care versus the policy dictating it,
illustrates the dividing line between the state and PLO’s vision of health care legitimacy.
Forms solve problems? During the Order to Show Cause hearing, witnesses
described improvements made to the prison health care system. When doing so, witness’s
responses reflected a bureaucratic institutional logic, particularly in the realm of
performance management and staffing. For instance, one of the improvements the state
took to ensure improved medical records management was to establish a new medical
form for nurses to use when inmates first came to a new prison facility. Compliance with
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form utilization was given greater importance than the form’s ultimate purpose: to
improve medical care. The discussion between State’s Attorney Jerrold Schaefer and one of
the court’s appointed experts, nurse Madeline LaMarre demonstrates the state’s view of
process improvement:
Schaefer: [Each transferred inmate has a medical form.] Then there would be a
nurse that would receive the form at [the receiving] institution. Is that process
working?
LaMarre: There are some significant problems, it has gotten started…[but in one
instance] 25% of the [medical] records did not [transfer with the inmate to the new
facility]…medications didn’t come…medical problems that should have been
addressed the day of arrival [but were not]…So while the process has begun in that
staff are using the forms, all the mechanisms that should take place accompanying
that are not.
Schaefer: Okay. Is it your testimony, nevertheless, that the forms are being used
and are being used correctly?
LaMarre: Not always, but –
Schaefer: In those instances?
LaMarre: In those cases, the [nurses] are making the effort to fill them out correctly.
Schaefer: I have no further questions of this witness (“Evidentiary Hearing,” 2005, p.
332).
This exchange exemplifies a belief held by the state prison organization: improving medical
care necessitates generating new bureaucratic processes and procedures, rather than
assessing those systems’ outcomes. This frame of reference is reflected in Governor
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Schwarzenegger’s reorganization plan whereby YACA was dissolved and the CDCR was
instated. The Governor’s “Reorganization Plan 2” states, “…the state still operates a system
in which heads of individual correctional institutions have almost complete control over
operations” (2002, p. 3). Attempts to curb this power resulted in consolidation of certain
functions and, consequently, the addition of another bureaucratic layer. For instance,
procurement and facilities management were placed at the agency level, removing the
ability of each institution to oversee these functions. Responsiveness and prison-
institution flexibility were further compromised. Furthermore, from a system perspective,
the problems with procurement largely remained: any purchase over $2000 required a bid
by three suppliers each time the order was placed. Court experts determined this
requirement made it difficult for prisons to maintain a provision of adequate medical
supplies. Yet these systems were seen as necessary constraints and, according to the state,
prison health care improvement would have to occur within them.
Plaintiffs’ messages of suffering, morbidity and death. Overall, the state argued
that obedience with bureaucratic systems was the best indicator of prison health care
improvement. However, by taking this approach, the state failed to demonstrate
compliance with the court’s mandate to actually improve medical care. Furthermore, this
focus undermined any perception that California was even capable of envisioning the prison
as a medical provider. Rather, medical care seemed to be a tertiary concern, subordinate to
custody and process foci.
Plaintiff’s attorneys addressed medical care in all together different terms.
Arguably, plaintiff’s statements utilized more pathos to greater effect. Medical issues were
framed in terms of patient suffering; suffering that needed to stop regardless of
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bureaucratic systems. The opening statement of the PLO set the tone for the plaintiffs’
approach:
In California’s prisons, cancer is ignored and untreated…in California prisons, the
sickest patients are at times locked away in secluded filthy rooms, sometimes
without even a bed…In California’s prisons, investigations into one [inmate] death
takes so long that two years go by before the same doctor’s put on administrative
leave after two more questionable deaths by his care…In California, being sent to
prison for a few years has turned into a death sentence for far too many people
(“Evidentiary Hearing,” 2005, p. 18).
Clearly, the state and PLO envisioned medical care in competing manners. Defense
descriptions of improvement processes were pitted against plaintiffs’ claims of physician
malpractice and inept medical care. So, while the state discussed newly established
performance management systems and bureaucratic red tape, plaintiff’s council repeatedly
told tales of inmate harm. One witness spoke of an instance of malpractice if not cruelty.
According to Dr. Michael Puisis, a court appointed medical expert, there had been a case:
Where a patient had been in a fight in the yard and was injured, was brought to the
health care unit, and due to injuries the inmate sustained, he was paralyzed in his
legs from a fracture in his neck. [The fracture] was unknown to the staff at the time,
but it was known that he couldn’t move his legs…The physician did not believe that
the inmate couldn’t move his legs. And the physician took a needle and stuck the
inmate in his legs and the inmate didn’t move his legs. And the doctor said the
inmate was faking it. When a patient has a neck injury, the neck is customarily
immobilized by medics and often attached to a hard wooden board so that the neck
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can’t be moved, because if this was a fracture of the neck, the neck should not be
moved because the spinal cord could be injured if a fracture fragment moved into it
and cause irreparable harm. In this case the physician, with a [patient with] a
suspected neck injury, took the head of the patient and turned it side to side and
said, ‘See, he can move his neck,’ thereby permanently paralyzing the patient, if he
wasn’t already paralyzed (“Evidentiary Hearing,” 2005, p. 74.).
While the example above is an extreme instance, it was not a unique occurrence.
The State of California is responsible for approximately 64 preventable inmate deaths per
year (“Evidentiary Hearing,” 2005). Consequently, this data informed the plaintiffs’
approach to the case. Attorneys and witnesses spoke of morbidity and mortality; one
account went so far as to claim an incompetent physician killed a patient in his care
(“Evidentiary Hearing,” 2005).
Coercive Pressure and Institutional Logics
Bureaucratic terms were most often invoked by plaintiffs’ attorneys to demonstrate
the absurdity of the state’s strict adherence to policies and procedures when people under
state care were dying. The state bureaucracy was compared to Alice in Wonderland and a
Franz Kafka novel, metaphors for a surreal system that was difficult to navigate. Plaintiffs
also illustrated that the state’s improvement efforts yielded questionable results. The
following exchange between PLO attorney Steve Fama and the CDC acting Deputy Director
of Health Services Division, Renee Kanan, illustrates the state’s blindness to the impact of
its bureaucracy:
Fama: …didn’t the state recently eliminate the process by which the CDC could
obtain services though an informal solicitation process or sole-source contracting?
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Kanan: Yes. The Department of General Services did issue what they call a
management memorandum.
Fama: And the state now requires for all medical service contracts that there be
specific permission for a noncompetitive bid solicitation that is granted by the
Department of General Services or that the contract be obtained by means of the
normal competitive bid process, right?
Kanan: Yes.
Fama: And either of these methods add time to the already time-consuming and
complicated process of obtaining necessary services for medical care, right?
Kanan: Yes (“Evidentiary Hearing,” 2005, p. 571).
This exchange portrays the state’s most common fix-it effort: to create another
bureaucratic process. The state could not demonstrate that substantive actions to improve
care were being taken; the texts indicate that the state had trouble even imagining how to
do so.
Even though the prison was ordered to implement credentialing programs, quality
assessments and medical staff hiring practices, these actions were largely insufficient or
failed to occur. One of the issues plaguing the CDC was difficulty attracting quality medical
staff. More often than not, prisons are located in less than desirable areas. So, the CDC was
already at a disadvantage because it was asking highly educated physicians to work at less
than ideal locales.
The CDC also suffered because it offered well below-market salaries to physicians
and nurses. In 2003, an internist’s average salary was $158,000 per year (Dorsey, 2003),
whereas the CDC offered physicians about $130,000. Similarly, a state nursing salary
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survey conducted in 2005 found that in the central California coast, CDC nursing salaries
lagged by 23% (Labor Relations Division, 2005). Put another way, the CDC offered medical
professionals below market salaries to treat convicted felons at often-remote locations.
Consequently, staff who accepted such terms was often subpar.
However, institutional logics were also at the root hiring failures. For instance, the
state claimed it could not bypass established processes for hiring and recruiting. So while
the state was under court order to immediately hire more medical staff, the process for
doing so thwarted any such efforts.
For example, the trouble the state experienced trying to hire a regional nursing
director exemplified system-wide problems as well as prominent institutional logics. As
laid out in the hearing, the process for hiring a regional nursing director began with the
CDC’s establishment of a civil service job classification. The new job classification of
regional nursing director would report directly to the governor. This action was necessary
to circumvent California’s Department of Personnel Administration (DPA), the state’s de
facto employer. Circumvention was necessary because the process to establish a nursing
director job classification under the DPA would not be timely, nor would the salary be
sufficient. So, the CDC began the process of creating a new job classification, essentially
avoiding one bureaucratic system in favor of another. Six months into the effort, there still
were no nursing director hires.
Hiring issues represent two institutional logics. First of all, no one involved with
hiring processes could imagine how to simply hire a qualified worker. Various
bureaucratic systems were cited as barriers, from the necessity of potential employees to
take exams, to salary compaction and locus of control issues. Second, state employees
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involved with hiring decisions had a different conception of a reasonable length of time for
such activities to render results. Time was regarded in terms of how long it typically takes
to complete an activity within the bounds of the existing system; whereas time for the court
was defined in terms of the number of inmate deaths that would occur in the interim.
The nursing directorship further illustrates some of the institutional logic issues
described. At this point in the case, it had already been established that nursing
management oversight was integral to improving medical care in state prisons. And while
not a single regional nursing director had been hired, neither had the management function
been filled by some other means. After stating all the reasons why hiring had not occurred,
PLO attorney Steve Fama questioned the state’s Deputy Director for Human Resources,
YACA, Sandra Duveneck, to determine if nurses could be contracted, rather than hired
outright, to fill the nursing director positions in the interim. Ms. Duveneck stated:
I doubt it. We would have to go through a process, a contract process, with the
Department of General Services, another control agency. And you cannot contract
out for services unless it’s an emergency, if state workers could do the work
(“Evidentiary Hearing,” 2005, p. 452).
But it had already been established at this point that no existing state worker had
been identified to fulfill the role (i.e., appointed as an acting regional nursing director), nor
could a currently qualified state worker take the job, because the job classification had yet
to be established.
Thus, the existing bureaucracy worked against its own interests. Through this
example, we see that the ultimate purpose of these systems was to ensure checks and
balances in California’s employment practices. These systems look good at the meso-level.
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However, down in the trenches, often the systems that were designed to help only served
to harm. For instance, investigations into physician malpractice occurred, were found to
have merit and doctors were fired. But during the appeal process, many terminations were
overturned by the Department of Personnel (“Amended Joint Status,” 2005). Physicians
were often reinstated but kept away from patients. Management learned their personnel
decisions may not be respected by the state, and thus the motivation to remove poor
performers dwindled. Or, medical managers did not have the skills or training to manage
staff effectively. Poor management practices were purported to be the reason one
physician’s malpractices were linked to three unnecessary inmate deaths before he was
terminated (“Evidentiary Hearing,” 2005).
What is also telling about Ms. Duveneck’s statement is her perception of the larger
issue: adequate medical care for California’s inmates. At the conclusion of the exchange
between the attorney and witness Duveneck, she stated that the lack of medical staff in
state prisons would not constitute “an emergency” under state guidelines. Accordingly, it
would be at least one to six months before staff could be appropriated. In response, Judge
Henderson exclaimed:
…take one month, which is 30 days, to six months, which is 180 days, we would
have 3 to 18 people dying. I can’t think – and I just want everyone here to start
thinking about it – I can’t think of a bigger emergency (“Evidentiary Hearing,” 2005,
p. 457).
Yet emergency or no, the representatives of the state could not give inmate medical
care primacy over bureaucratic compliance. A number of statements confirm this
perspective. Court appointed expert witnesses (medical professionals with experience in
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the management, administration and delivery of prison medical care) railed against the idea
that acting in accordance with existing laws and structures were of primary importance to
the state. Expert witness, Dr. Puisis claimed,
Well, you are assuming that laws were written by God. Laws are not written by God,
they are written by people, legislatures, who can be influenced and talked to. It
happens every day. Laws are written every day. Why can’t [those involved] see that
a law doesn’t make any sense and try to modify it? Has there been any attempt to do
that for Plata related to some of the staffing issues that are simply absurd?
(“Evidentiary Hearing,” 2005, p. 213)
Yet absurdity is in the eye of the beholder. Witness statements also served to
illustrate bounded rationality of those working in the prison system. There was one
medical case where a prisoner, who, critically ill with HIV and meningitis, required
emergency hospitalization. However, even though that inmate was too weak to walk under
his own strength “…that hospitalization [was] delayed because [the inmate] was made to go
back to his housing unit to change his shoes” prior to passing through one of the prison’s
gates (“Evidentiary Hearing,” 2005, p. 353). According to prison policies, inmates are only
allowed to wear certain types of footwear when being transferred outside of the prison
walls.
Pain treatment must be negotiated among logics of care and punishment.
Many of the issues regarding constitutionally adequate inmate medical care are easily
understood. Inmates with HIV/AIDS should be identified early and receive consistent and
appropriate treatment. Prisoners who require follow up care should receive it. However,
there are areas where the meaning of constitutionally adequate medical care must be
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negotiated. Take pain management as an example. One of the complaints in the Plata case
was that the CDC failed “…to provide protocols for chronic pain management” (“Stipulation
for Injunctive Relief,” 2002, p. 29). In response, the CDC cited policy statements devoted to
inmate pain management. The policy regarded Correctional Treatment Centers (CTC) as
the resource for inmates who required consistent health care services. The CTC’s purpose
is “to provide patients with inpatient services consistent with their needs that are
necessary to protect life, prevent significant illness or disability, or to alleviate significant
pain” (“Defendants’ Response,” 2002, p. 5). So, while the CTC’s purpose is clearly stated,
determination of “significant pain” is not.
The notion of pain illustrates conflicting logics of prison medicine. Pain is not
measured objectively and inmates have been known to employ drug-seeking behavior.
Further, narcotics are contraband when taken outside the medical setting and into the
jailhouse walls. COs often discard all medication when searching an inmate’s cell for
contraband. Pills may be used as currency, for example, and purchase items or services
that constitute inmate rule violations. Therefore, effective pain management comes under
close scrutiny. Does the inmate suffer from a recognized condition that warrants pain
management, or is he lying to obtain a valuable good? Further, who defines “pain”? Due to
the nature of the population seeking treatment, the procedural response is to deny
narcotics and try to manage pain with over the counter medications; however the conflict
is constant: an inmate patient states he is in pain, how will that condition be treated? More
significantly, how will the person in pain be treated: as prisoner or a patient? From a
medical standpoint, the inmate may be given painkillers to “alleviate significant pain”
according to policy. However, from a custody perspective, it may be more acceptable to
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deny such treatment since getting high on narcotics is not the best way for a convict to do
time.
Lack of Will
While there is no shortage of medical policies and procedures, the core problem is
inadequate adherence to those same health care policies and procedures. For example, an
inmate requires a follow up appointment. However, there are a variety of reasons he may
never get that appointment due to organizational, custodial and inmate constraints.
Organizationally, the follow-up appointment process may not have been followed, as
structurally, nurses were not responsible or often involved with inmate appointment
scheduling. During the experts’ prison visits, they noted considerable tension between
nursing staff and schedulers. On the custody side, if an appointment is made, officers may
not be available to transport the inmate to his appointment. Also, the inmate population is
difficult to treat: inmates may refuse to attend medical appointments and also refuse to
sign the form, which documents the refusal of care.
The prior example certainly does not account for all lapses in care. One instance
cited by the PLO was that it took an inmate eight months to receive a MRI scan (“Defense
Response,” 2002). The CDC response was that an inmate would be seen every 30 days until
the test was performed, or, if the inmate’s condition became worse, the physician could
mark the test as “urgent.” While the state always offered a procedural response, what it
could not demonstrate was the drive to get the job done.
Specifically, various court experts who had been working to assist and evaluate the
state’s improvement efforts over the previous four-year period repeatedly claimed that
there seemed to be a lack of will within the prison organization to change. Computer
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information systems were implemented within corrections departments across most of the
state’s prisons, however medical departments were left out; no one seemed to know why.
San Quentin officials promised to hire janitorial services to clean “filthy and unsanitary”
medical care areas, but failed to follow through (“Joint Status Conference,” May 19, 2005).
Tales were told of doctors ordering emergency CT scans, only to have the orders go
through a clerk for approval, a process outside the health services department that often
took three weeks. Even the state’s own audit found “layers of bureaucracy between
managers and functions blur lines of responsibility. Accountability is conspicuously
absent…” (Schwarzenegger, 2005, p. 5). Court expert Dr. Joe Goldenson stated that in his
opinion:
…there was a lack of will [to change]. What was really sort of shocking, amazing to
me, was that if – and I’ve been in the situation when I first started working at the jail
in San Francisco there was a consent decree. And if – well, the judge never visited
the facility, but I mean, things came up that we had to fix, and we fixed them. I know
if the judge came to the jail and said, “This really bothers me,” you know, I would fix
that immediately. I mean, a natural response is even if you have multiple problems,
you really want to fix the thinking that the judge or the court is saying really bothers
them (“Evidentiary Hearing.” 2005, p. 405).
Instead, Dr. Goldenson claimed that he was not seeing results. The state had failed to
implement multiple items that were deemed critical to adequate medical care, such as a
program to treat chronically ill inmates. Additionally, Dr. Goldenson expressed frustration
that there was no evidence of even gradual steps towards the creation of such a program,
such as a method to identify and track people with chronic illness.
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To him, there was little indication of forward movement. Nurses refused to carry
out physician’s orders and no one knew why; typically a nurse would only refuse to carry
out an order if he knew it was harmful to the patient. However, there was no evidence to
support that was the reason for noncompliance. Improved management oversight was
supposed to be established, yet a nursing supervisor reported he never went out to the
clinics where his employees worked. Rather, he relied on his staff to inform him how
things were going. On the custody side, staff overrode physician’s orders at one extreme or
were pulled off Plata-related duties at the other. Amidst this chaos, at some point, a San
Quentin physician had to wonder, “How can I deliver constitutionally adequate medical
care from a broom closet?”
Care is Costly
Overall, the CDC was a floundering non-system, one that tried desperately to
manage its day-to-day activities but was incapable of a larger organizational perspective.
In hindsight, it appears that the state’s arguments merely sought to delay the inevitable
receivership for as long as possible. Health care was never embraced as a legitimate
institutional practice. Rather, care was always a disruptive force to custodial practices,
command and control logics, and established bureaucratic systems. Not only was it simpler
for organizational actors to adhere to the status quo, caring practices threatened
organization members’ ontological security. For custody staff, caring practices introduced
vulnerability into a difficult, and at times dangerous, job. For state bureaucrats, care was
legitimate only when established according to existing structures. The cognitive and
symbolic costs, not to mention the material ones, were just too high for care to be
thoroughly and completely enacted in the prison system.
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Discussion and Conclusion
In this dissertation, I have examined perceptions and practices surrounding
California’s prison health care improvement efforts. Internal and external stakeholders
and organizational factors must be considered in order to develop a full understanding as
to why California failed to sufficiently improve its prison medical care under coercive
isomorphic pressures. Overall, command and control logics permeate prison culture and
operations, making it very difficult for caring practices to be incorporated as a legitimate
prison function. For custody staff, care is not only illegitimate but is also threatening; for
state bureaucrats, care is legitimated when instantiated according to existing laws and
procedures. These challenges to prison health care legitimacy significantly contributed to
California’s failure to substantively improve inmate care for many years. To explore this
failure, I used the theoretical foundations of new institutional theory and structuration.
In this chapter, I discuss my research question findings and pertinent theory. The
discussion section is organized thematically around the concepts of logics and legitimacy.
Next, I offer the dissertation’s practical and theoretical contributions. Finally, I conclude
with the study’s limitations and suggestions for future research.
The Prison Response to Coercive Isomorphism: Care is Not a Legitimate Driver for
Change
At face value, we might assume that the prison’s inability to change was due to
inertia. However, when we introduce the idea of competing institutional logics, we see that
failure to change was related to differing perceptions of legitimacy from multiple
constituents. Stakeholders such as the CDC, federal judiciary, CCPOA and prison workers
all held varying notions of constitutionally adequate health care.
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Within prison organizations, practices remained largely stable because there was no
context for health care improvements to be legitimately instantiated. Generally, interview
and court data suggest that prison health care improvements were deemed illegitimate
within the dominant organizational structures. Custody, both practically and cognitively,
drove all aspects of prison operations. Since care begins not with doctors or nurses, but
custody officers who make it possible for inmates to receive care, CO support of health care
improvements was critical.
For instance, COs largely equated caring practices with weakness. To veer away
from command and control logics and practices threatened CO’s security and identity
(RQ4). This response is understandable when considered in light of custody’s fundamental
belief that inmates are always trying to get away with something. Custodial logics provide
a means for COs to protect themselves from being scammed or physically harmed. For
custody staff then, caring practices provided an opportunity for inmate’s to exploit them.
For medical staff, “appropriate care” tended to be congruent with command and control
practices. A normative concern about medical care was that it provided a means for
inmates to be unduly rewarded. For example, within the prison, medicine is monetary
capital, assistance devices, like canes, can become weapons and special accommodations,
such as being assigned a lower bunk, increase social status. Since these outcomes benefit
prisoners, to be legitimate, health care must be controlled. In the command and control
workplace, there was no space for improved care to take root.
Further, coercive pressures from the federal government were insufficient to
guarantee meaningful health care improvements. Most of the prison’s institutional
stakeholders found no advantage to improved inmate medical care. Prisons were given
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mandates but no clear roadmap for how to instate them. Further, these new policies failed
to account for how care could mesh with prison culture. Resources, which could support
improvement efforts, were lacking. In general, caring practices were disruptive to
legitimate command and control oriented prison operations. Accordingly, such efforts
were often ignored. What is especially interesting about this case is that ultimately,
stakeholders’ prevailing institutional logics negated the federal judiciary’s coercive power
(RQ4a). This is an unexpected outcome, which illustrates some of the limits of coercive
isomorphism. In particular, results point toward entrenched bureaucratic processes and a
dominant custody culture as the primary material and symbolic practices which hindered
health care logics’ taking root within the prison system (RQ5).
A root problem was that no one effectively challenged the primacy of custody over
care. Medical staff was relegated to positions subservient to custody, both organizationally
and practically. Operationally, COs were present at inmate medical appointments and often
voiced opinions about the care provided to the prisoner. Doctors reported that custody
would say, “He doesn’t need that,” to educate doctors about appropriate health care.
Health care’s illegitimacy was further buoyed by organizational field stakeholder’s notions
of the prison as a place of punishment. Guaranteed, high-quality inmate health care feels
like an imprisonment perk rather than a constitutional right. However, while most prison
workers agreed that inmates deserved medical care; what they disagreed with was the
extent and enactment of that care. So, even though the CDC management and the courts
insisted that care improvements be enacted in prisons, at most institutions they were not.
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While the court’s primary concern was unnecessary inmate deaths, the CDC did not
take the steps necessary to stop them. Rather, the CDC relied on its authoritative power to
enact health care reform through new policies, which failed miserably. This underscores
Canary and McPhee’s (2009) claim that, “Simply distributing policy texts will not work any
more than will top-down mandates to implement policy provisions that fly in the face of
current system practices” (p. 181). The authors assert that to be effective, policy
communication must include the effective assessment of systems and institutional
contexts; this did not occur. An added complexity was that policies could not overcome
other fundamental problems: the prison system was unable to hire or fire staff
expeditiously, increase wages, order needed equipment, adequately perform medical tests
or find appropriate spaces for medical treatment. To fulfill each of these needs quickly, the
CDC would need to subvert the existing bureaucracy, which was difficult for bureaucrats to
imagine. Overall, the state’s almost pathological compliance with systems demonstrated its
own guiding logic: bureaucratic compliance was more important than prisoner’s lives.
Organizationally, the changes proposed by CDC leadership challenged the logics of
appropriate prison activities. The predominance of downward communication and the
reported lack of feedback loops limited organization members’ participation in meaningful
communication about how to enact improved health care practices. Largely, results
indicate that existing organizational structures were deemed more legitimate than care-
focused ones. These ideas about health care improvements under coercive isomorphic
pressures are discussed in greater detail in terms of logics and legitimacy.
Logics. As we know, institutional logics not only guide an organization’s
operational role, they also influence the salience of organizational issues across
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hierarchical levels (Thornton, 2002). Logics act as the tipping point between institution
and action; they provide the basis for legitimate scripts, practices and interpretations
(Barley & Tolbert, 1997). Logics’ functionality are particularly relevant when I consider
their role in the CDC’s change efforts (RQ 2). For the California state prison system, health
care improvement logics did not motivate the prison organization to pick up the mantle of
meaningful changes. This failure begins with the communicative significance of the
ideological term “constitutionally adequate medical care.” Constitutionally adequate
medical care was never defined by the courts, thus involved parties determined what it
meant for themselves (RQs 1, 1a and 1b). Accordingly, each stakeholder group structured
their activities around their perceptions of “appropriate” constitutionally adequate care.
Appropriateness, which informs what is considered to be reasonable action (Townley,
2002), was determined through assessments of the ways care meshed with existing logics
and structures. In part, because communication among stakeholders was poor, lacking or
just plain absent, CDC officials and prison workers failed to determine ways care could be
legitimately instantiated.
Structurally, prison as a place of incarceration is deeply embedded. Consequently,
communication among various stakeholders reflected this reality and served a constitutive
function (Putnam & Nicotera, 2009). The structurational process indicates that deep
discursive structures unconsciously informed interpretive schemes of appropriateness,
actions and perceptions of legitimacy (Giddens, 1984; Heracleous & Hendry, 2000). For
instance, even COs who acknowledged the deplorable state of prison medicine often could
not envision how to demonstrate care in a way congruous with existing prison structures
and custodial identity. Communication between custody and medical staff often took the
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form of COs trying to “educate” doctors as to what appropriate care was. Such activity was
procedurally invalid but appropriate in terms of prison logics. Custody and medical staff
discourses were a means for meanings, identity and consequences of policies to be
explored (Canary & McPhee, 2009). In this case, organizational discourses supported
command and control structures, even when the consequence was preventable inmate
deaths.
Absent meaningful discourse challenging extant notions of prison legitimacy, most
institutional constituents maintained their view of the prison organization as normative.
Actors negotiated among the interests of two ideologically different constituent camps: the
federal government and other organizational field stakeholders. All of these entities grant
legitimacy, so in a way, it is understandable for actors to privilege the legitimacy form that
most closely aligns with legitimated practices and logics. In other words, since health care
legitimacy as conceived of by the federal government conflicted with predominant
institutional logics, prison organizations’ established and legitimated structures were
consistently reproduced (RQ 4a). The duality of structure and agency is evident in this
example; social action recreated prison structures and influenced how work was
legitimately performed.
This outcome is consistent with new institutional theorists’ claims that creation of
and adherence to legitimated processes is a common reaction to isomorphic pressures
(DiMaggio & Powell, 1991; Elsbach, 1994; Meyer & Rowan, 1977; Oliver, 1991; Zucker,
1987). In response to coercive isomorphic pressures, the state sought to demonstrate
rational and institutionally legitimate activities. The creation of new policies, procedures
and even an organizational name change (the CDC added “and Rehabilitation” to its title
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just prior to the receivership) were intended to signal a transformation in institutional
logics and indicate compliance with federal mandates. Instead, these texts served to direct
attention away from task performance and represented ceremonial adoption of health care
practices (Kostova & Roth, 2002): policies served to legitimate health care improvements
to external constituents, but were not meaningfully put into practice system-wide. For
example, there were instances of nurses using new health care intake forms, but the forms’
intent, to improve medical care, went unrealized. Further, physicians complained that new
documentation requirements seemed to be authored by lawyers and “dim bulbs” at CDC
headquarters rather than sufficiently trained medical staff. Consequently, doctors largely
considered forms to be worthless for truly improved health care practices. These examples
illustrate that policies were drafted but not consistently and meaningfully enacted. Canary
and McPhee (2009) claim that policies “bind organizational and social actors across time
and space as they relate to each other, to activities, and to institutions” (149). Yet, in these
organizations, policies gain that power through explicit implementation instructions. New
practices were rolled out without these specific directions; in organizations that struggled
with “trained incapacity” the result was inaction.
Further, resources did not accompany new policies and procedures. Previous
research has demonstrated that resources are necessary to support new institutional logics
(Greenwood & Suddaby, 2006; Oliver, 1991; Purdy & Gray, 2009). However, these
resources were absent as a powerful constituent, the state legislature, would not
appropriate additional funds for the prison. Increasing the spending on prison services
was a political non-starter; officials are typically not reelected because they embrace prison
reform. Thus, the CDC and prison management were tasked to reform health care without
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monetary support. The difficulty of this task was compounded by the lack of open
communication to facilitate meaningful practice adoption. In terms of social capital,
support from the CCPOA was both critical and absent. Due in large part to the absence of
material resources and constituent support, custodial logics were maintained and health
care logics were constrained (Lawrence, Hardy & Phillips, 2002; Purdy & Gray, 2009).
More significantly, proposed changes were incongruous with extant institutional
structures, especially in light of custody’s cultural impact and actors’ perceptions of
legitimate practices. Logics symbolically grounded, materially constrained and socially
reinforced institutional legitimacy. For this case, logics were significantly influenced by the
dominance of custody, command and control as the valid operational orientation.
Accordingly, custody logics were encoded into workers’ activities and interpretive
schemes. For instance, an inmate who seeks medical attention is more likely to be viewed
as lying rather than actually being sick. This perception was reified through discussions
about health care consequences. For instance, COs consistently told stories of inmates’
medical system abuses. A favorite story concerned an inmate who received an organ
transplant but refused to take anti-rejection medication and consequently died. This
cautionary tale demonstrated that even while imprisoned, inmates could still harm society.
In this example, a prisoner stole and wasted a vital organ that could have saved the life of a
“deserving citizen.”
Custody’s logics are heavily imbued with the retribution role of imprisonment,
highlighting complex moral issues. When the prisoner is taken out of the prison context,
we see an ill human being in need of care and our response follows accordingly. Behind
the prison walls, however, the ill human being has also harmed society and is being
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punished for it. Culturally, our penchant is to weigh the inmate’s suffering against the
social harm he caused and ask, “Is the suffering justified?” While the court system turns a
blind eye to this question, as a society, we do not. Further, these considerations become
more complicated for prison workers in light of logics that guide appropriate prison
activities. Often, the result is the dehumanization of the prisoner. By dehumanizing the
inmate, the “cop” maintains command and control; it is preferred to ignore the sick inmate
than show compassion to the undeserving. The rejection of caring logics and practices
supports Fligstein’s (1997) claim that structures and resources significantly influence
actor’s cognitions and perceptions of legitimate activities. Figure 3 portrays how command
and control logics support legitimated prison work while figure 4 demonstrates how a
caring logic disrupts prison structuration.
Figure 3: Functionality of Command and Control Logics

Command & Control

Power
Authority
Physical
Security
Ontological Security
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Figure 4: Perceived Structuration of Care

Consequently, organizational actors had few supportive generative mechanisms to
accept and appropriate caring logics (RQ 4). Greenwood, Suddaby and Hinings (2002)
suggest actors must theorize about new norms and practices both morally and practically.
In other words, discussions such as “how do we incorporate care in a way true to our
identity?” may have supported the enactment of new health care policies (Barrett, Thomas
& Hocevar, 1995; Canary & McPhee, 2009). However, deep discursive structuring practices
and a rigid hierarchical organization impeded this form of interaction. The deeply
embedded custody logic and bounded rationality severely impacted actors’ ability to
imagine health care improvements outside existing structures. The impact of these logics
are evident in the following example: one prison had a 300 sick-slip backlog; at this facility,
an officer reported not taking extra steps to ensure medical treatment for a truly ill inmate
for fear that taking such action would first, not render results, and second, portray her as
soft and thus open a channel for additional bothersome or nuisance requests. Overall,
results indicate that health care logics were deemed illegitimate drivers for prison system
Authority
Ontological Security

Weakness
Exploitation
Harm
Command Control
CARE
Power
Physical
Security
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changes.
If we say health care is important, why isn’t it? In terms of the accounts given for
the failure of the mandated changes (RQ 5), the results suggest actors adhered to existing
structures; these recursively reinforced identities and the prison’s legitimacy. The root
metaphor that deeply influences prison work(ers) is “we are less than.” Guards are not
cops, and although they call themselves as such, the term rings hollow. Prison docs are
relegated to treat the less-than of society either by choice or circumstance; consequently,
medical staff members are viewed suspiciously for caring for those society locked away. In
a way, prison workers are doing their time just like their charges; the majority of
interviewed subjects reported, without prompting, how many years they had until
retirement. To balance this “less than” worldview, the command and control logic provides
a sense of power, righteousness and security.
Accordingly, structuration theory indicates that health care was legitimate only
when subservient to command and control. Bounded rationality and sedimentation
reinforced existing structures (DiMaggio & Powell, 1983; Meyer & Rowan, 1977; Poole &
McPhee, 2005; Williamson, 1981). Results demonstrate that medical improvements were
undermined by security concerns and a shame-based organizational culture. Medical
providers reiterated that view.
Because of the primacy given to custodial practices, what health care improvements
there were seemed to be largely a result of individual discretion. Individual actors chose to
instantiate care, some stating they eschewed common (read: harmful) custodial practices
in favor of more caring behaviors such as talk and follow through on inmate-patient’s
needs. MTAs, for example, reported enacting caring practices, which were triggered by
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their nurse identities rather than their custody role. The organizational subculture of MTA
workers was at odds with the dominant culture. Many MTA’s conveyed a more care-
focused orientation by telling tales of situations where they refrained from engaging in
violence against inmates, such as pepper-spraying a suicidal inmate or kicking a prisoner
during a cell extraction. In the prison environment, caring practices are sometimes most
evident by the absence of violence – a disruption of the routine.
Many prison workers sought to provide some level of care within the constraints of
a broken system. The MTA subculture of care-over-custody was appropriated to varying
degrees by other custody staff depending upon their role and organizational tenure. For
example, “old timers,” those with at least 4-5 years on the job, tended to be less “badge-
heavy,” an orientation described by Owen (1988) as a hyper concern with personal
authority. As COs became more instantiated in prison’s social system, taken for
grantedness increased as did common sense approaches to prison work (Owen, 1988).
Within this space arose opportunities for custody to exhibit care in a way congruous with
their worldview, if they chose to do so at all. Systemically, however, custody’s ontological
security was based upon their command and control orientation, which, in turn, influenced
actors’ bounded rationality (Geertz, 1973; Giddens, 1984). For COs as a whole, caring
logics were synonymous with weakness. Normatively and cognitively, care logics were
rejected.
Legitimacy. Since the prison system was largely considered normative, legitimacy
threats did not have pragmatic resonance (Ruef & Scott, 1998; Suchman, 1995). External
pressures from legislative bodies and society supported adherence to legitimated
organizational activities (DiMaggio & Powell, 1983; Oliver, 1992; Scott, 1987).
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Structuration allows us to look at legitimacy challenges and how those challenges are made
meaningful across time and space. In this case, the expectations of what an “effective”
prison institution is and does were steadfast during the lawsuit crisis. Accordingly, daily
practices remained largely stable and thus contributed to structuration of the prison. The
routinized behaviors of organizational actors further supported institutional legitimacy.
For instance, the highly scheduled prison day of unlocks, meals, lock-ups, ducats and work
remained entrenched. Consequently, there was little space for legitimate health care
improvements in this highly structured environment.
A powerful stakeholder (the federal court) envisaged legitimacy differently.
However, this lone stakeholder was not quite powerful enough to overcome other
stakeholders’ perceptions of normative legitimacy. As such, this case demonstrates that
legitimacy was determined based upon stakeholder’s logics (RQ3 and 3a). Results
illustrate that existing organizational structures maintained legitimacy, even when
challenged by coercive isomorphic pressures from the federal judiciary (RQ 3b). We can
observe how legitimacy was maintained in two ways. First, actions at the individual level
reproduced higher-level structures. Day-to-day prison work changed little to facilitate
improved care. Second, the organizational field structured activities based on dominant
notions of prison legitimacy. Supportive resources were absent from the state; bureaucrats
were unwilling to circumvent established protocols and challenge laws to fundamentally
improve care. Rather, new policies were drafted and rolled out to California’s prisons, but
these were not normatively legitimate. Custodial and health care policies did not mesh.
Consequently, custodial policy knowledge was a resource for generating legitimate reasons
for inaction (Canary & McPhee, 2009). So, while the court system felt the prison should not
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be a site of unnecessary inmate death, the state and organizational members demonstrated
that prison health care was only legitimate if provided within established bureaucratic and
custodial structures. In this case, we see the myths of the prison reflected, rather than the
new demands for the institution (Meyer & Rowan, 1977).
Delegitimation of practices involves challenges to “taken for grantedness,” which
often resembles the deterioration of consensus about the value of an activity (Oliver, 1991).
Since the operational status quo was valued above health care improvement mandates, an
appropriate challenge to legitimated practices never manifested. Organizationally, health
care improvements were deemed illegitimate for a variety of reasons. First, the cognitive
costs of incorporating caring logics were too high for organizational members. Caring
practices, as mentioned, undermined the COs ontological security. Since the CDC failed to
define when and how an inmate’s civil rights were violated, actors were left to make such
determinations, if they made them at all. Second, even small-scale changes, such as San
Quentin’s quest to implement appropriate diabetes blood sugar testing, were negated as
too disruptive to entrenched prison structures and operations. Further, the micro-level
scripts of command and control were legitimated in terms of macro-social expectations and
norms of what it means to be a prison. In other words, the prison was legitimate as a place
of punishment and control, thus the activities it conducted followed accordingly. At the
micro, macro and social levels, health care excellence did not fit in with widely held
expectations for legitimate prison operations. Rather, legitimacy was structured via
paramilitary organizational operations and pervasive control mechanisms. Isomorphic
pressures from the majority of institutional stakeholders privileged extant prison practices.
Overall, looking at isomorphism and the various sources of legitimacy highlights the
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divergent and complex constraints under which organizations operate, further enhancing
our understanding of isomorphic pressures and organizational change.
Implications
The theoretical contributions of this research lie in several domains but revolve
around the exploration of prison organization structuration and coercive isomorphism in
institutional change. More specifically, within new institutional theory, coercive
isomorphic pressures are expected to result in institutional change or failure. However, in
this research project, coercive isomorphic pressures were insufficient to warrant large-
scale institutional change. Through a structurationsist lens, we appreciate the duality of
structures, as they are reproduced across time and space to significantly impede the
prisons system’s ability to significantly improve health care. In the following sections, I
discuss practical implications of merging new institutional theory concepts with
structuration, theory building as well as suggestions for future research.
Practical implications. Because coercive isomorphic pressures come from both
external organizations upon which the institution is dependent and from widespread
cultural expectations (DiMaggio & Powell, 1991), organizations may view these sources,
and the pressures that come from them, differently. Structuration appreciates how these
pressures are made meaningful through action and recursively structure the organization
and actors who inhabit this discursive arena. So, in this particular case, the actual
structuring of legitimacy as an element of the culture is made apparent, rather than simply
being a variable in a system as is the case in many new institutional theory research
projects.
At a macro level, we see the prisons’ organizational field determined the pressures
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from the judiciary to be illegitimate in light of the prison system’s purpose. Practically
speaking, no efforts were taken to communicate ways care could be instantiated in a
custodial-focused culture. So, while the powerful federal stakeholder viewed prison health
care to be illegitimate, the majority of other stakeholders paid lip service to this
perspective and consequently, meaningful changes were not instantiated until the health
care function was taken over by the court’s receiver. The prison institution recognized a
benefit from noncompliance: by delaying an inevitable take over, no stakeholder truly had
to risk their legitimacy, whether they were custodial workers, organizational field
stakeholders or government bureaucrats. A benefit for noncompliance is not typically an
outcome according to new institutionalism. At the most basic level, the threat of
institutional failure was not a significant motivator for change. Failure itself was
meaningless; since closing prisons was not an option, the organizational field ignored the
judiciary’s conception of prison legitimacy and instead maintained the old structures.
Sedimented custodial practices were reproduced as meaning systems failed to incorporate
care as a valid institutional logic.
Organizational discourses reflected the dominant institutional logic: prison is a
place of punishment. The routines and habits that support this notion made it practically
impossible for the prison to morph into a rehabilitory institution concerned with inmate
welfare. Throughout the prison system, medical care was structurally and politically
subordinate to custody, which further communicated the primacy of incarceration and
care’s inferiority. For instance, organizationally the warden occupies the highest position
in the prison management hierarchy. The highest medical management position directly
reports to the warden, rather than being a peer-to-peer reporting relationship. While such
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reporting relationships are consistent with traditional organization theory, functionally,
this reporting hierarchy was problematic in instances of warden interference with medical
decisions. Further, it seems that no one in the upper hierarchical echelons wanted to
communicate with prison staff about ways care could be legitimately instantiated. Under
such circumstances, organizational actors often rely on local understanding to inform their
actions (Canary & McPhee, 2009), thus underscoring existing practices and logics.
Another problem was that communication across prisons was not culturally valued.
For instance, at San Quentin, management failed to benchmark best practices from other
CDC prisons that provided a higher standard of diabetes care. Failures to communicate
openly about prison health care reforms throughout the organizational hierarchy illustrate
deep discursive structures of fear about any kind of assessment or evaluation. Open
communication was perceived as a means to discover failure and open doors to retribution,
rather than as a productive, supportive tool for health care reform. Systemically,
bureaucratic controls within the CDC morphed into controlling, dysfunctional, power
wielding systems. This study briefly touches on the notion that administrators can block
any organizational change effort by citing procedural and legal requirements.
Theory building. This study contributes to our understanding of structuration in
institutional change. In particular, my research contributes to our appreciation of
structuration’s influence on agency, the complexity of coercive isomorphic pressures and a
broadening of an institution’s discursive space. Here, I discuss each of these ideas in turn.
Structuration, logics and institutional agency. Since new institutional theory
typically takes a macro-level approach to the study of institutional change, structuration
provides a means for to “dissolve” the micro/macro theoretical divide and consider the
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actor within the institutional system. For instance, structuration enables us to explore how
institutional logics are enacted. Since logics are material practices and symbolic
constructions that constitute organizing (Friedland & Alford, 1991), they provide a
blueprint for legitimate institutional activities. Structuration provides a lens through
which we can better interpret this blueprint through examination of domination,
legitimation and signification (Barley and Tolbert, 1997). Or, in other words, structuration
enables us to consider multiple logics’ enactment via resources, norms and interpretive
schemes.
Specifically, logics influence which resources, norms and interpretive schemes are
deemed legitimate in certain activity systems. Individuals’ interpretive frameworks
contribute to the duality of structure; as organizational members enact root metaphors, the
institutional system and the actors who comprise it are reproduced. The work by Canary
and McPhee (2009) is also extended as this study reconceptualizes agency as the ability to
reframe legitimate organizational practices within the language game of institutional policy
conflicts. Because structuration appreciates social interaction, we are able to see how
small actions are reproduced and reverberate through larger organizational structures. In
this way, structurational processes provide a means to examine agency in institutional
change.
Coercive isomorphic pressures are complex. Coercive isomorphic pressures are
expected to result in successful institutional change or failure. However, this case
demonstrates an instance where coercive isomorphism alone was an insufficient change
agent. The institutional pressures upon prison organizations were contradictory;
organizational actors determined which practices were legitimate based largely upon their
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logics rather than the practices deemed legitimate by a powerful stakeholder.
Structuration adds to our understanding of the ways agency functions under coercive
isomorphic pressures; specifically, via a structurationst lens, where the negation of
coercive isomorphic power is observed. Structuration brings in a vocabulary that
appreciates structure's duality and the sedimentation of existing practices. Through the
duality of structure, actors re/produced existing logics and structures; and newly imposed
logics were dismissed as illegitimate and disruptive to the organization’s purpose and
function. Structuration allows for agency to either modify or reproduce existing structures,
thus providing a vantage point to witness, and analyze, actors’ negation of coercive
isomorphic pressures.
Broadening an institution’s discursive space. New institutional theory would
have us view institutional stakeholders as distinct agents. So, in this case, the court, state
and prison organizations would be isolated entities, which exert influence upon the prison
institution. Structuration allows us to appreciate that prison stakeholders are functioning
within a much larger discursive space. Taking a structurationist approach, Poole and
McPhee claim, “meaning systems and communication practices can give unequal power to
some and make that power seem legitimate” (2005, p. 177), an exchange that occurs
through social interaction. So, while new institutional theory assumes this process, it does
not provide a mechanism for how it occurs. Structuration illustrates a more fluid
relationship among institutional stakeholders where power is negotiated. Legitimation,
domination and signification illuminate not only institutional structuration (Barley &
Tolber, 1997; Giddens, 1979, 1984) but also a complex array of institutional stakeholders.
Because these stakeholders engage via social action carried out by institutional agents,
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unequal power is more apparent. And, more importantly, how that unequal power is
enacted is visible through discourse and structuring processes.
Limitations and Future Research
There are several limitations that should be recognized, however, many pose the
opportunity for future research. First, as with any qualitative study, these results are
limited; this case study research explored data from a particular institutional field.
However, qualitative inquiry allowed me to develop an in-depth understanding of prison
health care legitimacy from the perspective of various organizational actors. Because my
interpretations of these data are filtered through my own understandings, additional
studies based on my research may be useful to support and further explore my claims.
Other qualitative inquires into this subject would be assisted by greater access to
prison staff and state bureaucrats. Because of the insular nature of prison organizations, I
was viewed as an outsider and, at times, a threat. Additional research would benefit from
access to a larger and more diverse sample of institutional actors.
Another limitation is that a portion of my interview data consisted of subjects
looking back upon their experiences; a receiver was placed in control of California’s prison
health care in 2006. Thus, my subjects’ recollections about the time prior to the
receivership are drawn from memory and recollections of events change over time. Future
research into coercive isomorphic pressures would benefit from longitudinal studies begun
at the nascence of a mandated institutional change.
Future research. Typically, forces that threaten legitimacy are related to
organizational survival (Meyer & Rowan, 1977; Oliver, 1991). However, this case
demonstrates that failure took a different form; legitimacy and organizational failure were
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decoupled in the eyes of some constituents. While this may be a rare occurrence, an area
where we may see these ideas resonate within the market is during a banking crisis. In
these organizations, what does failure mean? Recently, the U.S. government has bailed out
multiple gargantuan financial institutions because it was believed that the failure of these
entities would be too harmful to society. For example, an examination of the rescue of
insurance monolith AIG may be particularly fruitful. Because AIG was tightly coupled with
the globe’s financial system, it was rescued from failure when ordinarily, market pressures
would have resulted in the firm’s failure. However, AIG was rescued because the
consequences of its failure were determined to be too dire. In 2009, AIG was deemed “too
big to fail” and consequently was bailed out by United States’ taxpayers to the tune of $170
billion (Saporito, 2009). Future research would do well to explore what failure means in a
dire context. It would be interesting to explore what occurs when management’s
legitimacy is publicly lost but the organization itself is considered too embedded within the
environment to fail outright. Exploration of banking crises may illustrate how large, tightly
coupled firms respond to isomorphism when managers of those firms apparently believe
the legitimacy of those pressures is in question.
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Post Script: CDCR Update and the Researcher’s Confessional Tale
In 2006, the federal court appointed a receiver to control California’s prison health
care. Through the receivership, the CDCR was able to substantively improve prison health
care and cut the number of unnecessary inmate deaths. Most of these improvements are
linked to additional resources. For example, new health care facilities have been built
while old ones have been improved. The receiver was also able to circumvent California’s
Department of Personnel Administration and raise physicians’ salaries by approximately
20% in an effort to attract quality primary care providers and fill the substantial vacancy
rate (Sillen, 2007). However, improved health care carries a hefty price tag: according to
the California’s Legislative Analyst’s Office (2010) it costs over $16,000 per inmate per year
to provide California’s version of “constitutionally adequate” health care. Still, in 2011 the
U.S. Supreme Court ordered the CDCR reduce prison overcrowding by 30,000 inmates, in
part, because prisoners would not otherwise receive adequate medical care.
At a press conference in January 2013, governor Jerry Brown proclaimed, “The
prison emergency is over in California” and accused additional federal requests for prison
improvements as “nit-picking” (Medina, 2013). In reference to continued federal control,
Brown declared, “We’ve got it. Enough already” (Brown, 2013). He went on to claim that
any additional improvement efforts were essentially attempts to “gold-plate a prison
system,” rhetoric surely geared to impassion California’s taxpayers who are footing the bill.
The receiver, Clark Kelso disagreed, claiming that progress had been made but that the
“constitutional threshold” baring cruel and unusual punishment had not been crossed (St.
John, 2013).
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Governor Brown summed up the essential problem, the one with no end in sight
regardless of this case’s outcome: “Everybody wants to send people to prison. No one
wants to pay for it.” At the time of this writing, the receivership has been in place for
almost seven years and there is no end, yet, in sight.
Fieldwork Reflections
While studying California’s prison health care crisis has been incredibly interesting,
it has also been a difficult undertaking. As I discussed in the methods chapter, there were
significant IRB constraints surrounding the study of prison organizations. While I will not
revisit these issues, I do want to recognize the constraints came from the prison
organizations. The automatic response was to shut out the research study; it was as
though nothing positive could possibly be gained from the research. What is most
disheartening is the high level of fear that appeared in response to inquiries (which makes
me even more grateful to those who did participate). I empathize with these employees.
They go to work each day constantly concerned that they will be reprimanded for some
real or imagined infraction. There is so much to be learned from this project, and there is
much to share, but the CDCR is not yet open to dialogue. Perhaps this will someday change.
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Appendix A
Interview Guide

These interview questions are designed to illicit respondents’ institutional logics, which are
understood to be beliefs that shape cognitions and actions. More specifically, these
questions seek to uncover logics of practice, and thus inform the research agenda to
understand how the taken-for-granted work practices ultimately inform notions of
organizational legitimacy.

Questions are designed to portray the taken-for-granted through the use of story and
metaphor in three areas: areas of practices, rules, and conflict.

General questions
 Tell me about what you do everyday.
 How do inmates get treatment? What happens when treatment is turned down?
Refused?
 How does the concept of security affect your job practices?
 What happens when a new policy/warden comes into play?
 What’s different about dealing with healthcare in a prison?
 What is the most different aspect of working in a prison as opposed, to say, working
in a commercial (more open? Less risky?) environment?
o To do your job most effectively, who do you rely on? What other positions do
you have confidence in?
 What’s different about dealing with rules here?
 How does change happen?
 What are the stories that were told to you when you first came to work here?
 What stories would you tell a new employee to convey what is important?
 How do concerns spread?
 What are the situations that arouse emotions?

Prison and Healthcare Management
 What change did you make that you are most proud of?
 What was difficult to do and you succeeded in doing it?
 Does the location of your practice, i.e., “a prison,” alter your professional identity?

Medical workers
 You work in a culture that views many medical complaints as a stratagem. How do
you teach people to tell the difference so someone doesn’t die of a burst appendix,
for example?

COMPETING LOGICS AND ORGANIZATIONAL FAILURE

143

Advocacy groups
 In terms of prison medical care, what change needs to occur that has yet to be
accomplished?
 During the Plata hearings prior to the implementation of the receiver, what was the
most pressing concern for prison reform?

Custody personnel
 Tell me of a time when an inmate needed medical attention?
o Went well? One that didn’t go well?
 What does it mean to be an MTA? Tell me about your responsibilities.
 What procedures do you find most helpful in terms of how you do your job?
o What practices have you learned that aren’t explicitly in the prison’s policies
and procedures? Things that make it easier to do your job as an MTA?
 Tell me about a time when your custody responsibilities and medical care
responsibilities have been at odds? What happened? As you thought about what to
do, what professional practices influence your thinking?

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Appendix B
Textual Analysis

COMPETING LOGICS AND ORGANIZATIONAL FAILURE

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Asset Metadata

Creator Heckman, Jennifer Lee (author)

Core Title Competing logics and organizational failure: the structuring of California prison health care

School Annenberg School for Communication

Degree Doctor of Philosophy

Degree Program Communication

Publication Date 05/06/2013

Defense Date 02/25/2013

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag legitimacy,logics,new institutional theory,OAI-PMH Harvest,organizational culture,prison health care,structuration

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Advisor Riley, Patricia (committee chair), Goodnight, Gerald Thomas (committee member), Hollihan, Thomas (committee member), Keough, Collen M. (committee member)

Creator Email jennifer.l.heckman@gmail.com,jheckman@usc.edu

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