Web viewLupin Battersby, MA ... coding that resulted from reading the transcripts and coding units...
Transcript of 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).
From familiar faces to family 2
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-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
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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,
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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
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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
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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
From familiar faces to family 7
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
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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
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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.
From familiar faces to family 10
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
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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:
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[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
From familiar faces to family 13
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
From familiar faces to family 14
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.
From familiar faces to family 15
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.
From familiar faces to family 16
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
From familiar faces to family 17
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
From familiar faces to family 18
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,
From familiar faces to family 19
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
From familiar faces to family 20
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.
From familiar faces to family 21
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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