From familiar faces to family1

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,,778-782-9876

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

Mei Lan Fang, MPH, Research Associate, Simon Fraser University, Gerontology Research Centre, 2800 - 515 W. Hastings St., Vancouver, BC, Canada V6B 5K3,

Judith Sixsmith, PhD, Professor of Public Health Improvement and Implementation, University of Northampton, Boughton Green Road, Northampton, UK NN2 7AL,

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

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

*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).

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

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-twoLTC staff participants were interviewed about their experiences and perceptions of the physical environmentand 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

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

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 staffcontribute 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 stafffrom 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 theirperceptions 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 5management 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 conductedbetween 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 frameworkwith 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 sadnessand 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 reportscontrasted 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 everyday, 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 wereconsidered 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 enablingparticipants 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, becausenew 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 thathas found nursing homeresidents to feel emotional and personal losses as well asa 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: