web viewlupin battersby, ma ... coding that resulted from reading the transcripts and coding units...

From familiar faces to family 1

RUNNING HEAD: FROM FAMILIAR FACES TO FAMILY

From familiar faces to family: Staff and resident relationships in long-term care

Sarah L. Canham, PhD*, Postdoctoral Research Fellow, Simon Fraser University, Gerontology Research Centre, 2800 - 515 W. Hastings St., Vancouver, BC, Canada V6B 5K3, [email protected], 778-782-9876

Lupin Battersby, MA, Research Associate, Simon Fraser University, Gerontology Research Centre, 2800 - 515 W. Hastings St., Vancouver, BC, Canada V6B 5K3, [email protected]

Mei Lan Fang, MPH, Research Associate, Simon Fraser University, Gerontology Research Centre, 2800 - 515 W. Hastings St., Vancouver, BC, Canada V6B 5K3, [email protected] Judith Sixsmith, PhD, Professor of Public Health Improvement and Implementation, University of Northampton, Boughton Green Road, Northampton, UK NN2 7AL, [email protected]

Ryan Woolrych, PhD, Assistant Professor, Heriot-Watt University, School of the Built Environment, William Arrol Building Room G.11, Edinburgh, UK EH14 4AS, [email protected]

Andrew Sixsmith, PhD, Director, Simon Fraser University, Gerontology Research Centre, 2800 - 515 W. Hastings St., Vancouver, BC, Canada V6B 5K3, [email protected]

*Corresponding author

Funding statement: Baptist Housing supported this work.Acknowledgement: We are grateful to all of the research participants who shared their experiences, perceptions, and time.Conflict of interest: No conflict of interest has been declared by the author(s).

mailto:[email protected]








Abstract

Objectives: Long-term care (LTC) facilities are increasingly intent on creating a

“homelike” atmosphere for residents. While residential staff are integral to the

construction of a home within LTC settings, their perceptions have been relatively absent

from the literature.

Methods: Thirty-two LTC staff participants were interviewed about their experiences and

perceptions of the physical environment and conceptualizations of home; and thematic

analyses were conducted.

Results: An overarching category—interpersonal relationships—emerged from our

analyses emphasizing the importance of relationships in creating a homelike environment

within institutional settings. Sub-themes that inform our understanding include: 1) Staff

members’ perceptions of home; 2) “Their second home”: Adjustment to and familiarity in

LTC; and 3) “We become family”: Relationality makes a home.

Discussion: The study provides evidence to inform current policies and practices in LTC:

specifically, enough time and space should be given to residents and staff to create and

maintain personal relationships in order to make residential care homelike.

Keywords:

Caregiving, Interpersonal relationships, Nursing homes, Gerontology



In recent decades, long-term care (LTC) facilities have shifted away from

institutional settings with emphasis on medicalization and efficiency and have moved

toward environments structured under tenets of person-centered models (Angelelli, 2006;

Koren, 2010). Person-centered approaches intend to create a “homelike” atmosphere for

residents through integrating practices and key design features that support patients,

family, and staff, and prioritize patient choice, independence, and quality of life (Koren,

2010).

“Home” has been conceptualized as the emotional, cognitive, behavioral, and social

bonds a person has to a particular place (Cooney, 2012). One framework for

understanding the complexity of the meaning of “home” describes three experiential

modes of home (Sixsmith, 1986): 1) the personal home, which captures feelings of both

belonging and self-identity; 2) the social home, which emphasizes the relationships one

has with others in the home as well as the opportunity to entertain; and 3) the physical

home (i.e., the built environment), which includes the architecture, comforts, and

resources afforded by the structural home. These modes are indivisible and dynamic

aspects of home that are assigned different meanings and emphasis by different people

(Sixsmith, 1986). Valuable parallels may be drawn between this tripartite model of home

and person-centered approaches in LTC settings. The emphasis on looking at the

integration of the physical, personal, and social environment has been notably absent

from previous work in this area (Wahl, 2001).

The person-centered framework emphasizes aspects of the ‘personal home’ that

include the ability for residents to sustain high levels of self-direction, autonomy, dignity,


choice, and privacy and to engage in meaningful activities (Angelelli, 2006; Verbeek, van

Rossum, Zwakhalen, Kempen, & Hamers, 2009). Similarly, the ‘social home’ reflected in

person-centered frameworks includes increased levels of empowerment, motivation, and

job satisfaction among caregivers (Koren, 2010; Verbeek et al., 2010), reduced burden on

family members (Verbeek et al., 2010), consistent assignment of staff to residents

(Koren, 2010), and residents feeling a sense of warmth, friendliness, and community

(Cooney, 2012). Lastly, researchers and designers have emphasized the importance of the

built environment, the ‘physical home’, in person-centered developments. The goal of

environmental design in person-centered approaches is to increase residents’ sense of

home by adjusting residential layout, décor, and features; by excluding institutional-like

features (e.g., nursing stations); and by focusing on shared spaces (e.g., dining and

gathering areas) (Cooney, 2012).

Prior research has questioned whether institutions can be considered “home”

(Wahl, 2001), especially from the perspective of LTC residents (Groger, 1995; Molony,

2010). However, considerations of LTC staff have been largely absent. This is surprising,

since staff contribute substantially to life within LTC settings, including to the creation

and maintenance of homelike features for residents; thus, their voices must be prioritized.

In this paper, we present data from interviews with staff from two institutionally

designed LTC facilities, Holly Oak and Juniper Fields (pseudonyms). Holly Oak and

Juniper Fields were outdated LTC facilities located in the downtown core of a city in

Western Canada. Holly Oak, home to approximately 80 residents, was originally built in

1906 and redeveloped in the early 1970s into a residential care facility. Juniper Fields,

built in the early 1970s as an institutional care facility, was home to 147 residents. Both


facilities had long hallways, small single-occupancy bedrooms, shared bathing rooms,

and centrally located nursing stations. Dimensions of Holly Oak and Juniper Fields that

were found unsuitable for the residents’ complex level of care included: small doorways

difficult for wheelchairs to navigate, noisy dining areas, a single communal bathing room

on each floor, old carpeting, uneven flooring, poor air quality, and unreliable plumbing.

Our research objective was to explore meanings and experiences of “home” from

the perspective of paid staff members. We focus on staff reports of their everyday work

experiences to better understand how formal providers describe the physical aspects of

their workspace and the influence of this space on creating a homelike environment.

Methods

Design

This semi-structured interview study was conducted with LTC staff in order to

explore their perceptions and experiences of the physical environment, care provision,

and conceptions of home. Accounts characterized by depth and richness were elicited

through semi-structured interviews. Ethics approval was obtained from [blinded for

review] and pseudonyms are used to anonymize the research facilities and participants.

Participants

A purposive sample of staff participants who were working on one of three data

collection days was recruited from Holly Oak and Juniper Fields. In addition, the

research team conducted one interview by telephone for a staff member who was

unavailable for in-person data collection. In order to collect a variety of staff reports, the


thirty-two participants included 18 residential care aides; 1 activities coordinator; 5

licensed practical nurses; 3 registered nurses; and 5 management staff members, all

whom held continuing part-time, full-time, or casual positions. Three participants were

male; and the length of employment tenure ranged from two to over 25 years. All

participants provided written consent to participate and no financial remuneration was

provided.

Data collection

Semi-structured in-depth interviews, which lasted 23 to 53 minutes, were

conducted between June and September 2014. Participants described, in their own terms,

1) their experiences working in an institutionalized care setting and providing care to

residents; and 2) perceptions of whether the LTC setting was homelike.

Our interview guide was informed by consultations with residents’ family members

and staff members prior to the initiation of the in-depth interviews, as well as previous

environmental gerontology research and extant literature. Example questions included:

How would you describe your workspace? How do the physical aspects of the work

environment affect care provided? How does the environment impact your relationship

with residents? How does the environment contribute to or reduce feelings of “home”?

In-depth probing questions (Kvale, 2008) were used to provide further insight into

perceptions of the environment and conceptualizations of home.

The semi-structured, open-ended interview questions enabled informants to provide

detailed reports that were expressively rich and gave strength to the data. The structure of

the interviews enabled conversations to progress naturally and to focus on the dimensions


important to informants. Interviews were complemented by detailed memos,

observations, and impressions maintained by the researchers (Mischler, 1986) and were

audio-recorded and transcribed. Transcripts were de-identified to ensure anonymity and

entered into the Nvivoqsr (2012) qualitative software program where data were coded and

managed.

Data analysis

Two trained qualitative researchers independently conducted thematic analyses

(Braun & Clarke, 2006; Patton, 2002) of the data to organize and identify emergent

themes and patterns in participants’ experiences and perceptions of working in an

institutionalized care setting, care processes, and whether the LTC setting was homelike.

Analysis began with an initial read-through of each transcript for general and potential

meanings. An initial coding framework was created, based on initial low-level coding

that resulted from reading the transcripts and coding units of text as themes by labeling

these units with a word or phrase closely related to the participant’s account (Boyatzis,

1998). Through an iterative process of reading and rereading the text, the codes were

subject to constant comparative analysis to further refine the interpretation and definition

of themes, the coding framework, and the patterns and relationships across codes (Braun

& Clarke, 2006; Boeije, 2002; Glaser & Strauss, 1967). The result was a detailed coding

framework with which both researchers agreed.

Findings


Three key themes emerged that captured the nature of home in LTC. The three

themes build on the tripartite model of home, with each of the modes captured through

the broader category of interpersonal relationships. The themes include: 1) Staff

members’ perceptions of home; 2) “Their second home”: Adjustment to and familiarity in

LTC; and 3) “We become family”: Relationality makes a home.

Staff members’ perceptions of home

There was a range of staff perceptions as to whether residents considered the LTC

residence to be home or homelike. Table 1 displays factors that participants reported as

enabling or disabling a homelike feeling for residents. Some staff participants felt that

there were fundamental limitations to creating a homelike environment in the LTC

settings, which were described as too institutional and facility-like; some staff reported

that residents did not consider the residence in which they lived as their home. As Amy

stated,

This is just where they are staying—they have a room here, an apartment here. It’s not home—home is happy and nice with your family and this isn’t your family. It’s kind of sad, actually, but I’m not going to sugar coat it.

The difference between a “place to stay” and a “home” was made clear here. The

sadness and emptiness implied in the phrase “just where they are staying” was associated

in this staff member’s mind with the negative connotations of institutionalization and

contrasted with the happiness ideally experienced at home.

Staff indicated that the routinized nature of the care (organized around a schedule

of bathing, toileting, medication delivery, and meal times), communal tub room, limited

space to sit and socialize, inability to access outdoor space, and residents’ lack of choice


in moving into the LTC facility detracted from residents’ experience of the LTC setting

as home. This emphasis on the physical experience of home indicates the importance of

the physical mode of home in the tripartite model.

These reports contrasted with statements that the LTC residence was thought of as

“home” by residents. As Michelle reported, residents have “some of their own

belongings, they get to know the staff almost like family at times, and pretty much

everything that they need is in the care home.” Previous research has also found that LTC

residents create a sense of home through the personalization of their environments with

personal belongings, furniture, and memorabilia, which have the ability to convert

residents’ rooms into familiar spaces and reinforce residents’ self-identity through their

memories (Falk, Wijk, Persson, & Falk, 2012). In such reports, the personal experiences

of home are emphasized. Place attachment and sense of belonging have long been

associated with a feeling of being at home in later life (Chaudhury & Rowles, 2005;

Rubinstein & Parmelee, 1992).

Staff participants also reported that the caring “faces” residents saw every day, and

the strong relationships built with staff, promoted a sense of home, for both staff and

residents. In essence, the personal and social dimensions of the care home were

considered to be of greater consequence than the outdated and unaccommodating

physical dimensions of the LTC settings. As Joy stated, “It’s not more on the physical

things; it’s more on the relationships with the worker and the residents.” Another

participant, Marcy, agreed, “As far as the team—I just think everybody that works here

just loves the residents so much. We’re not here because of the building.” Here, the

emphasis is on the social experience of home.


The key feature enabling participants to feel the residences were homelike was

interpersonal relationships between staff and residents. That is, though the physical

environment was important to some extent, it was relationships and persons with whom

residents interacted on a daily basis that defined home. Reportedly, the issues that staff

and residents have with the physical environment are offset by the perceived sense of

community with one another. As Lesley stated, “You know, it’s an older building, but

I’ve worked in older buildings and I’ve worked in brand spanking new buildings and it’s

not necessarily the environment that makes the place, it’s the people in the place”.

Personal, social, and physical aspects of the LTC setting interacted to create a sense of

home, with the personal and social modes of home mitigating the negative experience of

the physical environment.

Staff also reported that residents began to feel more at home once they became used

to the environment, had lived in the LTC residence for a while, and had developed

relationships with other residents and staff. Thus, similar to findings by Bonifas and

colleagues (2014) the design of the environment does not exclusively determine whether

a LTC setting can feel homelike. Rather, the environment can be supportive of staff and

residents in acclimating to the space and building relationships, thus creating a sense of

home. The ways in which a LTC setting can become a resident’s “home” will be further

discussed in the context of adjusting to and feeling familiar in LTC and building

relationships in this setting.

“Their second home”: Adjustment to and familiarity in LTC


According to participants, some residents disliked the LTC environment when they

first transitioned into the residence. However, once they adjusted, they often began to feel

more at home. In this way, the personal mode is emphasized, suggesting that a sense of

belonging is important to feeling at home. As Marcy stated, “A lot of them [residents]

have gotten used to it; it’s kind of like their second home.” This concept of a “second

home”, also noted in work with Chinese elders living in nursing homes (Lee, Wu, &

Mackenzie, 2002) or thought of as a “home-away-from home” among nurses working in

residential care settings (Tuckett et al., 2009), suggests a recognition of “homelike”

features experienced amidst non-“home” environments and highlights that the division

between “home” and “non-home” may be too simplistic to capture more nuanced

experiences.

Participants acknowledged that some residents may feel abandoned or a sense of

loss when they first enter the LTC residence. As Jill suggested, because new residents are

away from their family, community, and social engagements within community, they

have a difficult time adjusting to the LTC setting. Similar reports are reflected in previous

literature that has found nursing home residents to feel emotional and personal losses as

well as a sense of abandonment (Brandburg, Symes, Mastel-Smith, Hersch, & Walsh,

2013; Fiveash, 1998; Nay, 1995).

Participants reported, however, that in time residents do adjust to the LTC

environment and to everyday routines, and begin to develop relationships within the care

setting that promote a sense of familiarity and meaning. Joy stated, “They’ve been here

for a long time so they’re comfortable, they’re used to it, it’s their home. They think it’s

their home.” Similarly, Anne reported:


[Residents’] first reaction, it’s funny, when they first come here because of the building and everything, it’s not their home. The first thing is, ‘I don't like it here, it’s not home.’ But I’ve seen, once they’ve got adjusted, it’s almost like it doesn't matter—for me too—the building doesn’t matter anymore. It’s the faces and the people around you that matter most.

As residents become used to the other residents and staff in their environment—

those with whom they eat meals or see in the morning—family-like ties are developed.

Anne stated,

It’s almost like us is her world now. It’s kind of sad for the daughter to feel that, but the residents—because of the faces, the familiarity, and our approach with them—it’s their world now, it’s their family; doesn’t matter what building.

Joy reported that residents care for one another and notice the loss of other

residents. For instance, in the dining room, residents know those with whom they sit and,

in some cases, residents look after one another because they have known each other for a

long time. According to Joy, when a resident is gone, to the hospital or elsewhere, other

residents feel a sense of “emptiness”; and when residents return from the hospital, Joy

reported that residents are so relieved to be back and say, “It’s so nice to be home”. Such

data suggest the importance of a sense of belonging on the personal dimensions of home

as well as the mitigating role of social dimensions of home, particularly in LTC.

Previous research has explored experiences of adjusting to life in nursing homes.

Lee and colleagues (2002) examined the process of adjustment for Chinese elders newly

admitted to a nursing home and suggested a series of four stages through which new

residents adjust to their new setting: orienting (i.e., gathering information and settling in),

normalizing (i.e., finding ways to maintain a lifestyle similar to the one lived prior to

admission), rationalizing (i.e., coming to terms with living a reestablished life in the

nursing home), and stabilizing (i.e., accepting nursing home life and finding connection


with the nursing home). Though we did not explicitly examine notions of adjustment to

life in a LTC setting, the theme of adjustment to and familiarity in LTC, which emerged

from our data, is consistent with Lee and colleagues’ findings.

“We become family”: Relationality makes a home

After adjustment to life in a LTC setting and finding continuity in interactions and

contact with other residents and staff, staff reported that interpersonal bonds were

formed. As Pat stated, “Basically the residents just see the staff day-in and day-out and

there’s a bond there.” This suggestion of having a bond with residents implies feelings of

attachment and affection, emotions often experienced by people who spend significant

time together. Similarly, Barb reported her preference for being in a steady care

relationship in which she was consistently assigned to care for the same residents as

opposed to the former care model whereby staff made care rotations on a quarterly basis:

“I like it this way [having consistent assignment] because you really have a good

relationship with the resident; they’re comfortable, and they know who to expect.”

Knowing one’s co-workers and working with other staff who know the residents

was cited as less stressful than rotation for residents and staff. As Anne stated, “It’s

always good if you have the regular care aides that work with you because they know the

resident.” Jamie agreed, reporting that when residents “see all regular staff members on…

it is a calmer environment. When someone [i.e., a casual staff person] comes on that

doesn’t know the ropes and is nervous, they bring their anxiety to the floor.” As a care

aide, Carey described this experience and the difficulty she had in learning resident

preferences after moving from one floor to another: Carey put a bib on a resident on her


new floor who ripped the bib off and yelled, “I don’t wear that!” And with another

resident, Carey asked whether they had any kids, to which the resident replied, “No! I

didn’t have any kids; don’t you know I don't have a family.” Carey reported on the

significance of staff knowing intimate details about their residents in order to avoid

irritating residents or triggering any behavioral problems.

When residents are admitted to LTC settings, their former relationships with family

members, friends, and neighbors may weaken; but often, new relationships will develop

over time within the LTC environment (Bitzan & Kruzich, 1990). Such relationships and

connectedness often flourish through story sharing between residents, family members,

and staff, a process shown to enhance interpersonal relationships in care settings and

personalize care for residents (Brown Wilson, 2008; Heliker & Nguyen, 2010). Knowing

residents’ preferences enables LTC staff to build relationships with residents, have fun,

and find satisfaction in their jobs (Hung, Chaudhury, & Rust, 2015). Further,

understanding residents’ needs and emotions and working together in a reciprocal

partnership with residents to manage day-to-day life has been reported by care providers

to improve care delivery and meet resident needs (McGilton & Boscart ,2007).

Some participants reported viewing residents as family and that the feeling was

mutual. Chris stated, “I started looking at them like family members rather than as

patients.” Beth stated, “You build a family kind of thing…you see them all the time, they

see you all the time, they already know you more than their family.” Carey, too, agreed:

I think we become family. I’ve seen many instances where the residents won’t even sit up, stand up for the family and they’ll have to come to us and say, “Can I get my mum?” Then the staff will say to the resident, “Come on honey, get up” and the resident will get up.


Participants also identified their co-workers—with whom they had developed long-

term working relationships—as family. Barb reported, “This is a nice place to work; we

are just like a family here.” Dana, who also described positive co-worker relationships

stated, “It’s not so much like going to work, it’s more like a different family in a way.”

Anne agreed: “I really like our group here, it’s like a family. It’s almost like your second

family.” The social dimension of experiencing home is emphasized in this theme;

relationships emerged as an integral component to the personal, social, and physical

experiences of home being fostered in the LTC environment.

Using “family” as a metaphor for caring relationships between staff and residents

has been reported previously by care aides in other LTC settings (Berdes & Eckert, 2007;

Bowers, Esmond, & Jacobson, 2000; Moss, Moss, Rubinstein, & Black, 2003). Earlier

research has defined close relationships between staff and residents as when care

providers “feel connected” to residents, “know the resident”, and experience

“reciprocity” with residents (McGilton & Boscart, 2007). Care aides have distinguished

between performing “caring tasks” with all residents as required by their profession and

“affective care” in which certain residents come to be seen and treated as family and

provided with emotional care (Berdes & Eckert, 2007). The nature and quality of

relationships between staff and residents has been found to be an important determinant

to care outcomes and quality (Bowers, Esmond, & Jacobson, 2000; Bowers, Fibich, &

Jacobson, 2001), as well as to resident quality of life and physical and psychosocial well-

being (McGilton & Boscart, 2007; Nussbaum, 1991). Such understandings are valuable

in the context of the current study, which found that a sense of home is facilitated within

LTC settings through interpersonal relationships and adjustment to the environment.


Discussion

This paper describes three themes that emerged from a study exploring perceptions

of “home” among staff members of two residential LTC settings in Western Canada.

Despite working and living in an institutional LTC setting that was designed using an

institutional and medicalized model of care, staff participants reported that some residents

feel a sense of home because of adjustment to the LTC setting, familiarity with persons in

the environment, and relationship continuity. These findings build on earlier research

which suggested that social and organizational features of an institution influence

whether residents feel at home (Wahl, 2001) and highlighted the importance of making

considerations beyond the physical attributes of LTC environments to include personal

and social aspects of home (e.g., consistent assignment; Koren, 2010). While some

residents may never feel at home in a LTC setting, regardless of relationship continuity or

their period of adjustment, others may come to feel at home if good relationships are

built.

For some residents, the LTC residence may be seen as their “second home” and the

residents and staff in this setting as their “second family”. Thus, achieving a sense of

home in LTC settings will be an individual experience that develops over time and efforts

to make LTC residences homelike need to remain flexible to the individuality of residents

living in these settings. As the concepts “second home” and “second family” imply, even

institutional environments can offer people a sense of home. That is, while LTC

environments may be seeking to replace one’s “first home” or “real home”, this may not

be a reasonable goal. Second homes and second families may be just as conducive to


creating attachment to place as previous homes and original families. Potentially, the

division that researchers and housing developers have created between what may be

considered home or not home is too simplistic. Indeed, locations in which people feel

safe and where their needs are being met may be considered home (Brandburg, Symes,

Mastel-Smith, Hersch, & Walsh, 2013) and even a workplace could similarly be

conceived of as one’s “second home”. Future research should continue to explore these

more nuanced experiences of “being at home” among staff and residents in other LTC

settings.

Participants highlighted the importance of interpersonal relationships within LTC

settings, which captures the essence of Sixsmith’s (1986) tripartite model of “home”: the

personal home captures feelings of both belonging and self-identity; the social home

emphasizes the relationships one has with others in the home; and the physical home

provides the context for social connectedness. In building upon Sixsmith’s concept of the

social home and relationships within, it is essential to recognize that the social home is

not static, but includes a series of social connections, which vary in their nature and

quality (Morgan, 1996). For instance, as elders move from their homes where they live

with family and intimate others into LTC homes where they live with other residents and

staff, aspects of the social home become increasingly complex and the nature and quality

of relationships can shift significantly. As both staff and resident relationships and co-

worker relationships develop and evolve over time within LTC settings, strengthened

bonds will have positive residual effects on residents’ adjustment to their new homes. As

Morgan (1996) suggests, someone who performs actions typically attributed to those of

kin can result in familial feelings, regardless of relationship status. These aspects of


relationality (see Roseneil & Ketokivi, 2015) builds upon the basic assertions of the

social home within the tripartite model and deserve further investigation. Thus,

incorporating the perceptions of LTC staff into our current models of what it means to

feel at home in institutional settings is key to resident environmental well-being.

Previous research has also demonstrated the importance of personal relationships

between residents, staff, and family members and has suggested that the development of

relationships often occurs within the context of care provision (Brown Wilson, 2008;

Brown Wilson, Davies, & Nolan, 2009). Brown Wilson (2008) provided a typology of

potential relationships in LTC settings: 1) pragmatic relationships, which emphasize the

instrumental aspects of caring and care tasks; 2) personal and responsive relationships,

which emphasize understanding the residents as a person with particular needs, that are

developed through conversations with residents and family; and 3) reciprocal

relationships, which emphasize the role and needs of all residents, staff, and family

members in creating a sense of community within the home, featuring negotiation and

compromise within a context of trust. While relationships and meaningful experiences for

both residents and care providers will vary across care settings and changing faces,

personal relationships that are responsive and reciprocal deliver the most positive

experiences for all stakeholders (Brown Wilson, 2008).

Among the barriers to building meaningful relationships in LTC settings,

researchers have identified both organizational barriers, such as workload, lack of

consistent resident assignment, time restraints, and staff turnover or inadequate staffing,

as well as resident characteristics, including frailty, cognitive status, the inability to

communicate, and duration of residence status (Bitzan & Kruzich, 1990; Bowers,


Esmond, & Jacobson, 2000; Koren, 2010; McGilton & Boscart, 2007). Such barriers

should be taken into consideration to foster relationships and a sense of community

within LTC settings.

One limitation of the current study is that data were obtained from a sub-sample of

voluntary staff participants who had time during their work schedules to participate in in-

depth interviews, and thus may not be comparable to data collected in other

circumstances or settings. However, the primary goal of this research was to provide a

breadth of insight into the experiences and perceptions of participants by asking in-depth

questions to access what was most salient to them. Additionally, these findings confirm

reports of previous research and provide further evidence that LTC settings that want to

increase a sense of “home” in their communities should facilitate familiarity and the

development of family-like relationships between staff and residents.

Future research should build upon these findings and more fully examine

relationships between residents and carers in order to inform care practices in LTC. For

instance, as residents transition from one care setting to another, what impact does staff

discontinuity have on frail, older adults? Similarly, what impact does this discontinuity

and high patient turnover have on staff? Also, perceptions of care providers, residents,

and family members should be explored separately as each may define and value close

care provider–resident relationships differently (McGilton & Boscart, 2007). Moreover,

since relationships fall across a continuum, examining the impact of relationships on

quality of life and care across this spectrum is an important next step for research.

Determining whether staff-resident relationships vary across gender, socioeconomic, and


ethnocultural groups would also improve our understandings of and ability to facilitate

familiarity and relationship-building within LTC settings.

Conclusion

As LTC settings transition away from institutional models of care toward new

models of care and housing, staff and resident conceptions of home must be made. In

LTC settings where funds are unavailable to modify the physical environment, improved

health and well-being outcomes can be found in promoting familiarity and interpersonal

relationships. Beyond the physical space, it is the people in a space who can facilitate a

sense of familiarity and family, and thus home. Participants articulated that relationships,

familiarity, and sense of family within the LTC environment were most important to the

experience of care provision. These data can inform the LTC agenda in terms of ensuring

residents are provided with everyday relational supports that facilitate a sense of being

“home” or with family while residing in LTC. Such findings are also important for policy

makers and health authorities pressured with improving healthcare outcomes, while

containing costs. Emphasis should be placed on the value of fostering supportive

relationships between residents and their formal staff.


References

Angelelli, J. (2006). Promising models for transforming long-term care. The

Gerontologist, 46(4), 428–430. doi: 10.1093/geront/46.4.428

Berdes, C., & Ekert, J. M. (2007). The language of caring: Nurse’s aides’ use of family

metaphors conveys affective care. The Gerontologist, 47(3), 340–349. doi:

10.1093/geront/47.3.340

Bitzan, J. E., & Kruzich, J. M. (1990). Interpersonal relationships of nursing home

residents. The Gerontologist, 30, 385–390. doi: 10.1093/geront/30.3.385

Boeije, H. (2002). A purposeful approach to the constant comparative method in the

analysis of qualitative interviews. Quality & Quantity, 36, 391–409. doi:

10.1023/A:1020909529486

Bonifas, R. P., Simons, K., Biel, B., & Kramer, C. (2014). Aging and place in long-term

care settings: Influences on social relationships. Journal of Aging & Health,

26(8), 1320-1339.

Bowers, B. J., Esmond, S., & Jacobson, N. (2000) The relationship between staffing and

quality in long-term care facilities: Exploring the views of nurse aides. Journal of

Nursing Care Quality, 14, 55–64. doi: 10.1097/00001786-200007000-00009

Bowers, B. J., Fibich, B., & Jacobson, N. (2001) Care-as-service, care-as-relating, care-

as-comfort: Understanding nursing home residents’ definitions of quality. The

Gerontologist, 41(4), 539–545. doi: 10.1093/geront/41.4.539

Boyatzis, R.E. (1998). Transforming qualitative information: Thematic analysis and code

development. Thousand Oaks: SAGE Publications.

Brandburg, G. L., Symes, L., Mastel-Smith, B. Hersch, G. & Walsh, T. (2013). Resident


strategies for making a life in a nursing home: A qualitative study. Journal of

Advanced Nursing, 69(4), 862–874. doi: 10.1111/j.1365- 2648.2012.06075.x

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative

Research in Psychology, 3, 77-101. doi: 10.1191/1478088706qp063oa

Brown Wilson, C. (2008). Using relationships to develop practice that values the

contribution of older people, families and staff. International Journal of Older

People Nursing, 3, 274–277. doi: 10.1111/j.1748-3743.2008.00140.x

Brown Wilson, C., Davies, S., & Nolan, M. (2009). Developing personal relationships in

care homes: Realising the contributions of staff, residents and family members.

Ageing & Society, 29, 1041–1063. doi: 10.1017/S0144686X0900840X

Chaudhury, H., & Rowles, G. D. (2005). Between the shores of recollection and

imagination: Self, aging, and home. In G. D. Rowles and H. Chaudhury (Eds.),

Home and Identity in Late Life: International Perspectives, p. 3-20. New York:

Springer.

Clarke, P., & Nieuwenhuijsen, E. R. (2009). Environments for healthy ageing: A critical

review. Maturitas, 64(1), 14-19.

Cooney, A. (2012). ‘Finding home’: A grounded theory on how older people ‘find home’

in long-term care settings. International Journal of Older People Nursing, 7(3),

188-199. DOI: 10.1111/j.1748-3743.2011.00278.x

Day, K., Carreon, D., & Stump, C. (2000). The therapeutic design of environments for

people with dementia: a review of the empirical research. Gerontologist, 40, 397–

416. doi: 10.1093/geront/40.4.397

Falk, H., Wijk, H., Persson, L-O., & Falk, K. (2012). A sense of home in residential care.


Scandinavian Journal of Caring Sciences, 27, 999–1009. doi: 10.1111/scs.12011

Fiveash, B. (1998). The experience of nursing home life. International Journal of

Nursing Practice, 4, 166–174. DOI: 10.1046/j.1440-172X.1998.00062.x

Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory. Chicago:

Aldine.

Groger, L. (1995). A nursing home can be a home. Journal of Aging Studies, 9(2), 137-

153. doi:10.1016/0890-4065(95)90008-X

Heliker, D., & Nguyen, H. T. (2010). Story sharing: Enhancing nurse aide-resident

relationships in long-term care. Research in Gerontological Nursing, 3(4), 240–

252. doi: 10.3928/19404921-20100303-01

Hung, L., Chaudhury, H., & Rust, T. (2015). The effect of dining room physical

environmental renovations on person-centered care practice and residents’ dining

experiences in long-term care facilities. Journal of Applied Gerontology, 1–23.

doi: 10.1177/0733464815574094

Iwarsson, S., Wahl, H-W., Nygren, C., Oswald, F., Sixsmith, A., Sixsmith, J., Szeman,

Z., & Tomsone, S. (2007). Importance of the home environment for healthy

aging: Conceptual and methodological background of the European ENABLE–

AGE Project. The Gerontologist, 47(1), 78–84. doi: 10.1093/geront/47.1.78

Koren, M. J. (2010). Person-centered care for nursing home residents: The culture-

change movement. Health Affairs, 29, 1–6. doi: 10.1377/hlthaff.2009.0966

Kvale, S. (2008). Doing interviews. Thousand Oaks, CA: Sage Publications.

Lee, D. T. F., Wu, J., & Mackenzie, A. E. (2002). The cultural context of adjusting to

nursing home life: Chinese elders’ perspectives. The Gerontologist, 42(5), 667–


675. doi: 10.1093/geront/42.5.667

McGilton, K. S., & Boscart, V. M. (2007). Close care provider–resident relationships in

long-term care environments. Journal of Clinical Nursing, 16, 2149–2157. doi:

10.1111/j.1365-2702.2006.01636.x

Mischler, E. (1986). Research interviewing: Context and narrative. Cambridge, MA:

Harvard University Press.

Molony, S. L. (2010). The meaning of home: A qualitative metasynthesis. Research in

Gerontological Nursing, 3(4), 291-307.

Morgan, D. (1996) Family Connections: An Introduction to Family Studies. Cambridge:

Polity.

Moss, M. S., Moss, S. Z., Rubinstein, R. L., & Black, H. K. (2003). The metaphor of

“family” in staff communication about dying and death. Journal of Gerontology:

Social Sciences, 58B(9), 290–296. doi: 10.1093/geronb/58.5.S290

Nay, R. (1995). Nursing home residents’ perceptions of relocation. Journal of Clinical

Nursing, 4, 319–325. DOI: 10.1111/j.1365-2702.1995.tb00030.x

Nussbaum, J. F. (1991). Communication, language and the institutionalized elderly.

Aging and Society, 11, 149–160. doi: 10.1017/S0144686X00003986

NVivo qualitative data analysis software. (2012). QSR International Pty Ltd., Version 10.

Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). Thousand

Oaks, CA: Sage.

Roseneil, S., & Ketokivi, K. (2015). Relational persons and relational processes:

Developing the notion of relationality for the sociology of personal life. Sociology

[epub ahead of print]. doi: 10.1177/0038038514561295


Rubinstein, R. L., & Parmelee, P. A. (1992). Attachment to place and the representation

of the life course by the elderly. In: I. Altman and S. M. Low (Eds.), Place

Attachment: Human Behavior and Environment (vol. 12), 139-163. New York:

Plenum Press.

Sixsmith, J. (1986). The meaning of home: An exploratory study of environmental

experience. Journal of Environmental Psychology, 6, 281–298.

doi:10.1016/S0272-4944(86)80002-0

Tuckett, A., Hughes, K., Gilmour, J., Hegney, D., Huntington, A., & Turner, C. (2009).

Caring in residential aged‐care. Qualitative findings from an e‐cohort sub‐study.

Journal of Clinical Nursing, 18(18), 2604-2612.

Verbeek, H., van Rossum, E., Zwakhalen, S. M., Kempen, G. I., & Hamers, J. P. (2009).

Small, homelike care environments for older people with dementia: a literature

review. International Psychogeriatrics, 21(2), 252. doi:

10.1017/S104161020800820X

Verbeek, H., Zwakhalen, S. M., van Rossum, E., Ambergen, T., Kempen, G. I., &

Hamers, J. P. (2010). Dementia care redesigned: Effects of small-scale living

facilities on residents, their family caregivers, and staff. Journal of the American

Medical Directors Association, 11(9), 662–670. doi: 10.1016/j.jamda.2010.08.001

Wahl, H-W. (2001). Environmental influences on aging and behavior. In Handbook of

the Psychology of Aging, 5th edition (Eds. J. E. Birren & K. W. Schaie, p. 215-

237). San Diego: Academic Press.


Table 1. Perception of factors that enable or disable a homelike feeling in LTC

Enable HomelikePersonalization and personal belongingsInterpersonal relationships – e.g., getting to know staff as family, feeling a

sense of communityEnough time has passed to enable adjustment to the residenceFeelings of familiarity

Disable HomelikeRoutinized careInstitutional design – e.g., communal tub, lack of spaceLack of choice in moving to the LTC residenceResidents’ cognitive impairment

web viewlupin battersby, ma ... coding that resulted from reading the transcripts and coding units...

Documents