Introduction
The ageing of the population is a global phenomenon, and the fastest growing age group is those aged 80 or more years (United Nations Organisation (UN) 2002), but the ways in which countries are approaching the provision of long-term care for an increasing number of frail older people vary considerably (Howse Reference Howse2007). The situation is further complicated by the different institutional arrangements in different countries, many of which stem from specific historical development paths and socio-demographic contexts, and the variable emphasis on shifting provision from the public sector to non-profit and private-sector providers, making generalisations questionable (Howse Reference Howse2007). Long-term care in the United Kingdom (UK), for example, has been a contested area of policy and practice for some time, with successive governments attempting to meet the needs of increasingly frail older people with finite resources (Netten, Darton and Williams Reference Netten, Darton and Williams2003). As a result, at a policy level the ‘care’ of older people is often considered primarily in financial terms and too often ignores the less tangible relational components of care provision (Daly Reference Daly2002). Although a growing body of literature suggests that the nature and quality of the relationships between care-givers and care-receivers are important determinants of both the experiences and outcomes of care (Minkler Reference Minkler1996; Brechin Reference Brechin, Brechin, Walmsley, Katz and Peace1998; Nolan, Grant and Keady Reference Nolan, Grant and Keady1996; Nolan et al. Reference Nolan, Lundh, Grant and Keady2003; McGilton and Boscart Reference McGilton and Boscart2007), relatively little is known about inter-personal relationships in long-term care environments such as care homes.
As the study reported here began, the National Service Framework for Older People (NSF) (Department for Health (DH) 2000), an initiative launched by the UK government to ensure nationally consistent standards of care for older people, was beginning to influence the long-term care choices available to older people in England. The NSF emphasised promoting independence through person-centred services, but the relevance of ‘independence’ as the primary goal of services for very frail older people has been increasingly called into question, and several have suggested that ‘interdependence’ is a more appropriate aim (Baldwin, Harris and Kelly Reference Baldwin, Harris and Kelly1993; Evans Reference Evans1999; Nolan, Davies and Grant Reference Nolan, Davies and Grant2001; Nolan et al. Reference Nolan, Lundh, Grant and Keady2003; Fine and Glendinning 2005). Interdependence encourages reciprocity and promotes mutual exchange in social relationships, which creates a sense of belonging and recognises the contribution that older people make to the social life of their community or residential setting (Godfrey, Townsend and Denby Reference Godfrey, Townsend and Denby2004). Promoting interdependence and personal relationships in a care home presents considerable challenges, however, not least because of the increasing frailty of the residents. Bebbington, Darton and Netten (Reference Bebbington, Darton and Netten2001) found that 79 per cent of all older people admitted to care homes had high levels of physical frailty, and 44 per cent had a degree of cognitive frailty. To compound these difficulties, people are becoming ever frailer by the time they enter a care home and the duration of residence is decreasing (Beringeer and Crawford Reference Beringeer and Crawford2003).
These factors create several potential barriers to the formation of personal relationships in care homes, although they are not yet fully understood. Despite different national arrangements for long-term care, studies in the United States (Pillemer et al. Reference Pillemer, Hegerman, Albright and Henderson1998), Canada (McGilton, O'Brien-Pallas and Pringle Reference McGilton, O'Brien-Pallas and Pringle2001), Australia (Kellett Reference Kellett1998), Sweden (Sandberg Reference Sandberg2001), and the United Kingdom (Davies Reference Davies, Nolan, Lundh, Grant and Keady2003; Davies and Nolan Reference Davies and Nolan2004) have identified common challenges in the relationships between care-home staff and family carers. This study seeks to raise our understanding of the nature of personal relationships in care homes from the perspectives of residents, staff and relatives. The findings point to ways in which the contributions of residents and their family members can support the development of positive relationships, whilst enabling staff to enhance the sense of community in the home and their job satisfaction and morale.
Literature review
A literature review was conducted to provide a context for the study and to help identify the key aspects of relationships in care homes that needed to be reflected in the data collection. The search was of publications in the English language between 1987 and 2002, and the search terms were: relationships, nursing homes, aged, aged care, older people, quality, residential care, and care homes. The electronic abstracting databases CINAHL, Medline, Social Science Citation Index and PsychInfo were used. Over 300 items were identified and their full bibliographic details entered into EndNote software.Footnote 1 The search was then widened incrementally by identifying potentially useful references in the articles, which were retrieved and also entered into EndNote. Articles were retrieved from North America, Australia and the Scandinavian countries as well as the United Kingdom.
The initial review of the literature found few studies that had considered the views of all stakeholders in care homes. Moreover, although many studies stressed the importance of relationships, this was rarely their main focus. A further classification was therefore required to reflect the themes relevant to relationships in care homes. This was achieved by sorting the items according to the reported inter-personal processes, which differentiated those that studied residents', family members' and staff members' relationships and their perspectives. The authors' recent thinking about relationship-centred care (Nolan et al. Reference Nolan, Brown, Davies, Nolan and Keady2006) and about creating community in care homes (Davies Reference Davies, Nolan, Lundh, Grant and Keady2003; Davies and Brown Wilson Reference Davies and Brown Wilson2007) were used as sensitising concepts, which generated three themes that captured what emerged to be important elements for residents, family members and staff:
• Being an individual
• Being involved, e.g. as in decision making
• Being partners, e.g. as in care delivery
Being an individual
Recognising the individuality of those who receive care has become an increasingly important principle of health and social care (Reed Reference Reed1992; Stanley and Reed Reference Reed, Cook and Stanley1999), and meeting individual needs is increasingly accepted by staff, residents and family members as central to good quality care (Rantz et al. Reference Rantz, Zwygart-Stauffacher, Popejoy, Grando, Mehr, Hicks, Conn, Wipke-Tevis, Porter, Bostick and Meridean1999). Individualised care is usually equated with ‘personalised’ care, and the phrase ‘being personal’ has been used in several interview studies to describe different types of care that involve residents, family members and staff (Deutschman Reference Deutschman2001; Gjerberg Reference Gjerberg1995; Jackson Reference Jackson1997). In these studies, being personal included paying attention to the small details of care (Jackson Reference Jackson1997; Gjergberg Reference Gjerberg1995) that is delivered by staff with a ‘good’ attitude (Deutschmann Reference Deutschman2001). A ‘good attitude’ has been equated by residents, family members and staff with staff being considerate and compassionate (Rantz et al. Reference Rantz, Zwygart-Stauffacher, Popejoy, Grando, Mehr, Hicks, Conn, Wipke-Tevis, Porter, Bostick and Meridean1999). This reflects the findings of Wilde et al. (Reference Wilde, Larsson, Larsson and Starrin1995) that older people recognise the importance of the interpersonal aspects of care. Grau, Chandler and Saunders (Reference Grau, Chandler and Saunders1995) also found that many residents described the quality of care in terms of their relationships with staff, with a good relationship connoting a good standard of care. Family members also valued their relationships with staff, particularly when staff delivered personal care in a way that ensured that their relative was recognised as a person of value and worth (Duncan and Morgan Reference Duncan and Morgan1994; Hertzberg, Ekman and Axelsson Reference Hertzberg, Ekman and Axelsson2001). Although the evidence from these studies suggests that residents, staff and family members see ‘being personal’ (including sensitivity, caring and respect) as integral to good quality care, how sensitivity and respect contribute to personal relationships was not clearly articulated.
Being involved
Maximising the extent to which the older residents of care homes are enabled and empowered to exercise choice has long been accepted as essential to their quality of life (Kane et al. Reference Kane, Caplan, Urv-Wong, Freeman, Aroska and Finch1997). Bringing this about presents various challenges, however, including the practical matters of organising meetings, ensuring everyone can hear, and sustaining participation (Mitchell and Koch Reference Mitchell and Koch1997; Raynes Reference Raynes1998; Reed, Cook and Stanley Reference Reed, Cook and Stanley1999). These challenges are likely to intensify as the levels of cognitive frailty rise, and need to be addressed if residents are to be fully involved in decisions that impact on their lives, especially as several studies have noted that often the perspectives of residents differ from those of care staff (Wilde et al. Reference Wilde, Larsson, Larsson and Starrin1995; Mattiasson and Andersson Reference Mattiasson and Andersson1997; Raynes Reference Raynes1998).
The degree and nature of family members' involvement in care homes is largely determined by the nature of their relationship with the older person prior to entry (Hertzberg and Ekman Reference Hertzberg and Ekman2000). For many family members, conserving a place in their relative's world is of great importance (Kellett Reference Kellett1998), and maintaining established rituals or routines provides family members with a sense of continuity (Kellett Reference Kellett1998). Such strategies are often used as a means of keeping the relationship special (Sandberg, Lundh and Nolan Reference Nolan, Davies and Grant2001). Family members also often work to ensure that the roles they adopt over time do not infringe on the domains of staff (Ryan and Scullion Reference Ryan and Scullion2000), which requires negotiation and the cultivation of positive relationships based on mutual respect (Seddon, Jones and Boyle Reference Seddon, Jones and Boyle2002). Family members' experiences with care homes are therefore often dependent upon good relationships with staff, but little is known about how these relationships are developed and sustained. Some recent work, however, has explored the ways in which residents, staff and family members work together as partners.
Being partners
Davies (Reference Davies2001a) described situations in which reciprocal relationships developed between residents and staff, as when staff spent break times with residents, which created a feeling of ‘community’ throughout the home. Other studies have reported that residents recognise that close relationships with staff imply sharing personal information and assisting staff during care provision, which amounts to a ‘care-as-relating’ model of delivery (Bowers, Fibich and Jacobson Reference Bowers, Fibich and Jacobson2001). Reciprocity for a resident is enhanced when she or he can share their past identities with the staff member, and when care is provided in a way consistent with these identities (Grasser Reference Grasser1996; Bowers, Fibich and Jacobson Reference Bowers, Fibich and Jacobson2001). A staff member may also share information about themselves with a resident, creating opportunities for the resident to offer advice in return: such relationships establish a reciprocal exchange (Bowers, Fibich and Jacobson Reference Bowers, Fibich and Jacobson2001; Davies Reference Davies2001a).
The literature also suggests that family members want to develop relationships within which staff value the resident's knowledge and the family member's involvement in the care (Duncan and Morgan Reference Duncan and Morgan1994). This increases a relative's sense of worth (Kellet Reference Kellett1998), encourages them to negotiate their role in the care home setting, and sustains their continuing contribution to their relative's care (Seddon, Jones and Boyle Reference Seddon, Jones and Boyle2002). Lindgren and Murphy (Reference Lindgren and Murphy2002) suggested that whilst the perspectives of staff and family members may differ, each knows the resident in a different way and can make a complementary contribution to her or his wellbeing. The most positive experiences described by family members are when they are able to work in partnership with staff, confident that their views and opinions are taken into account. Partnerships flourish when there is informal and regular communication between staff and family members, which reinforces their complementary roles in the life of the home (Davies Reference Davies2001a). The best relationships between staff and family therefore feature open communication and involvement in care decisions that lead to trusting relationships in which mutual roles are understood and negotiated openly (Sandberg, Nolan and Lundh Reference Sandberg, Nolan and Lundh2002). Although the cited studies attest to the importance of relationships between residents, staff and family members, few had such relationships as their focus, and even fewer explored the views of all participants simultaneously. Our study sought to do just that.
Methodology
The study reported here adopted a constructivist approach in which truth, rather than being seen as absolute, is conceived as comprising multiple social realities constructed by individuals at a specific time and place (Guba and Lincoln Reference Guba and Lincoln1989). The researcher becomes a ‘human instrument’, as only humans can grasp the meaning of interactions (Guba and Lincoln Reference Guba and Lincoln1989). Meanings, however, are dependent upon one's perspective and often require negotiation between those involved. This means that each participant may hold a different perspective on their relationships, influenced by the time, the context and by others with whom they share relationships. Constructivist research aims to understand and interpret these different meanings and creates joint accounts of shared events from each group's perspective, producing a joint construction (Rodwell Reference Rodwell1998). This is usually achieved through the development of a hermeneutic circle, which has been described as a circle of information created between participants to facilitate the sharing and negotiation of perspectives (Rodwell Reference Rodwell1998). A key feature of constructivist research is its emergent design, however, suggesting that inductive analysis is the method of choice as it is not possible to know what perspectives will emerge from a constructivist inquiry at the outset (Rodwell Reference Rodwell1998).
Three English care homes were purposively selected to reflect variation in terms of size, location and client group. Important characteristics of the three homes are summarised in Table 1. All residents, family members and staff were provided with verbal and written information about the study and invited to participate. As the research progressed during 2003–04, residents, family members and staff were purposively selected based on the different type and quality of their relationships within the home. Residents were approached following discussions with regular staff, and those who were able to communicate with the lead researcher (CBW) were invited to participate in a taped interview. For the residents with communication difficulties, their views were captured in field notes made during general conversations. As the study progressed, people who appeared to hold differing views were also approached to be involved after being identified through conversations or observations. This ensured that the breadth of views in each home was captured.Footnote 2
Table 1. Key features of the case study homes
Note: EMI was formerly used by commissioners or inspectors to refer to a category of residents and funded places, and has become well established in the vocabulary of care organisations and staff.
Data collection was by various methods including participant observation, interviews and focus groups (summarised in Table 2). The initial four to six visits to each home were used to gain an understanding of the physical and social dynamics of the home. During these visits, observations and conversations with residents, their family members and staff both helped to determine what they saw as important and also supported the development of rapport between the researcher and all participants, thereby facilitating the creation of a ‘hermeneutic circle’ in which all participants felt their voices were being represented. Participant observation in constructivist research involves weaving ‘looking, listening, watching and asking into the natural context of observation’ (Rodwell Reference Rodwell1998: 127). This was achieved by the lead researcher participating in various activities at each home, including offering to be of assistance at busy times of the day, e.g. helping take residents to the dining room, helping residents at meal times, fetching and carrying, and having conversations with residents when staff were busy elsewhere. In two of the three homes there appeared to be little interaction between staff and residents in communal spaces. In these homes, key staff were asked if the researcher (CBW) could work alongside them to participate in care routines. These observations were arranged with the staff and residents in advance and were confined to the residents who consented to be involved in the research that observed the care routines.
Table 2. Summary of the data collection methods in each home
Interviews are generally used when a researcher seeks to understand what people do, believe or think and they involve asking the informants to comment on their experiences (Gubrium and Holstein Reference Gubrium and Holstein2002). In this study, interviews supported the dialectic process of developing shared meanings between each of the participants and the researcher (CBW) (Guba and Lincoln Reference Guba and Lincoln1989). This was achieved through two types of interview: those that initiated general conversations about what was currently happening in each home (recorded as field notes); and semi-structured interviews that were pre-arranged, audio-recorded and transcribed. The focus of these interviews was influenced by the sensitising concepts from the literature and preliminary analysis of the field notes made during participant observations in each home. This provided participants with the opportunity to contribute to the developing construction by providing their perspective on what was being observed. Focus groups also provided opportunities for those who might not have felt comfortable being interviewed individually, to contribute to this process and were facilitated for all groups as desired (see Table 2). Data were recorded using field notes, audio-tape recordings, and a reflexive diary. As data were collected, transcription and coding were undertaken iteratively in each home.
Data analysis
In a constructivist study, there is an iterative relationship between data collection and analysis. As the data were read and re-read, units of meaning were located in the text and grouped under 18 headings that described how relationships were developed. From this process, six categories emerged which provided descriptors of actions contributing towards relationships. These categories were discussed with participants who were able to identify if these categories represented their experience. The process of member checking identified three themes that described the focus of activity (the task, the person or relationships) in each home, enabling the researcher (CBW) to review the data and to recognise the patterning of the three themes. From these, three different types of relationship emerged, and they are described in detail in the following section.
The findings
The analysis suggested that there were three types of relationships across the three homes, which we describe as:
Pragmatic: focused on the practical nature of caring, and developed primarily through communications directly concerned with care tasks.
Personal and responsive: focused on understanding the resident as a person, developed through communications that involved social conversations with both residents and their family members.
Reciprocal: featuring negotiation and compromise where the needs of staff, residents and family members were taken into account in the context of a trusting relationship.
The data from the three study homes suggested that different relationships predominated in each of the homes and that they were not mutually exclusive. Residents in all three homes demonstrated the ability to become involved in and influence these relationships irrespective of their physical and cognitive abilities, but few residents were able to articulate fully how they developed relationships. Instead, many spoke with the researcher (CBW) about daily activities and interactions with staff, and these conversations provided insights into how residents participated in the relationships with staff. Family members also spoke primarily about relationships in the context of care delivery. As the study progressed, it became evident that it was during care routines that residents and family members in all three homes actively contributed towards developing relationships with staff. The nature of these interactions largely determined the type of relationship that emerged.
Pragmatic relationships
Pragmatic relationships focused mainly upon the practical aspects of care giving, which usually dominated conversations between staff and residents or staff and family members. This was important because, for some residents, family members and staff, maintaining a focus on the tasks of care was equated with giving or receiving good care. Staff who worked in this way described their main aim as ‘getting the job done’. To do this to a high standard, however, they actively sought knowledge of each resident's individual preferences, likes and dislikes, which they tried to reflect in the care they provided. This approach contributed to the development of pragmatic relationships, which nevertheless sought actively to involve residents and relatives in care delivery.
Many of the staff who had a pragmatic approach described their main motivation for being in care work as doing ‘a good job’. For example, in Chestnut Lodge and Holyoake, some staff saw the rewards of such work in terms of a ‘job well done’. As Leon, a care worker at Holyoake said, ‘it's rewarding, very rewarding knowing that the residents, when I leave here at night they're well fed, clean, dry, comfortable until the next day when I come back in’. Others commented on the ways in which residents might help them by co-operating in the routines of care. As Sian, another Holyoake care worker said, ‘when I'm dressing John, I'll ask him to sit forward, put his arms up and that helps me to dress him and he's happy to do that as long as you tell him what you're doing’. Family members also made pro-active contributions to help staff get the job done, which might include keeping their relative's clothes tidy and in order, or helping with specific care routines as at meal times. The wife of a Holyoake resident said:
I'll say (to the staff), ‘Do you need any help with the teas, I've done a food hygiene course?’ Most of them say, ‘yes please’. I'll count out 12 cups and if only 11 come back, I know someone hasn't had a drink, so I can do that for them. Then there'll be 12 dishes and 12 spoons to wash so I do that and then I know everyone's had a meal.
The staff valued such contributions, and both they and the family members recognised that such assistance enabled the staff to provide high quality care for residents, whilst reassuring family members that care was being provided to the standard they wanted. Another resident's wife at Holyoake said, ‘I like him to be changed at 12, then I know he's been done. I don't know what time they do him in the morning because I'm not here, but I like him checked every few hours, so I make sure it's done’. This sentiment was echoed by some family members in Chestnut Lodge. At Holyoake, some family members felt that it was part of their role to make sure that care was being provided appropriately, not just to their relative but throughout the home. During the focus group with family members a participant said, ‘If I see something that's not right, I won't just walk past it. If you don't and you're not here, it might be happening to yours, it's not just for my husband, it's for everybody’. Family members who contributed in these ways usually described their relationships with staff in pragmatic terms. Some felt that making sure that their relative was receiving appropriate care was imperative and were unable to progress beyond pragmatic relationships with the staff. By contrast, the residents and family members who wished to develop personal relationships initiated social exchanges, which when returned by staff, tended to result in more personal and responsive relationships.
Personal and responsive relationships
The personal and responsive relationships developed by residents, family members and staff, and the sharing of personal information, were associated more often with small but important details in the care routines, which tended to result in more personalised care. Staff who worked in this way concentrated primarily on the person rather than the task on hand, and they sought significant details about a resident's preferences, such as what time they used to get up, the importance of having facial make-up, and details of how they liked to dress. Such information was used to influence care delivery, which was further personalised by the explicit involvement of the resident and their family members. For many staff, this involved spending time talking to residents during personal care routines, as about pictures in their rooms, or sharing personal information about themselves. They therefore used care delivery as an opportunity to get to know the resident, and to use such knowledge to shape the care provided to reflect personal preferences that enhanced a resident's sense of self. As a senior care worker at The Beeches said:
Well if I'm getting her up, I go in and always make sure she is presentable; with her earrings, her necklace, [be]cause she likes them doing, her watch, her glasses. She likes to talk about her sons, so I ask her how they're doing, talk about her family, because she very much likes to talk, so it's really a matter of listening.
This approach supported the development of personal and responsive relationships between residents and staff, which enabled the staff to appreciate what mattered in the residents' lives. The residents' contribution in developing relationships to a more personal level was most evident in their sharing personal information with staff. This often took the form of storytelling and promoted an opportunity for social exchange during the daily care routine. Residents who shared personal stories contributed to the store of personal knowledge held by care workers about them. As a resident at The Beeches said:
She [member of staff] is a country bumpkin like me, we can talk about going sticking and blackberrying; yes, she still goes blackberrying because she took me down the front, when it was the right time because there are some bushes in the front garden.
When residents were too frail to discuss their lives, family members often shared their life stories with the staff. At Chestnut Lodge, for example, family members and staff came in regular contact, which enabled them to share stories or anecdotes involving the resident. To facilitate this contact in other homes, some family members would visit the home when the staff were not busy. Residents and family members described how attention to small details, such as having matching clothing and jewellery, or wearing make-up, improved their experience. One resident at Chestnut Lodge often said that these details brightened her day. Some care workers also used personal information to create opportunities for residents to continue to enjoy activities that were significant for them, which reinforced their sense of self. As a care worker at The Beeches said:
I saw she subscribed to the RSPB and asked her about it.Footnote 3 She told me how she used to attract birds to her garden, so now I think to do something with her like with the nuts and the bird things. It's something to do that breaks the monotony up of that day and she enjoys doing it. She'll talk to me the next time she sees me [saying] that the birds haven't come yet, or I'll say to her, ‘I'm going to put another feeder up and I've done it’, and the next time she comes up to the room, she's looking for it. Then she'll talk to her son and daughter-in-law about when they come, and she tells them what we've been doing; and that opens it up for her, and it's letting them see that her time here isn't just about being cared for physically, and in a way you could almost say it was a spiritual kind of care really.
Recognising the significance of prior interests provided opportunities for social exchange across the three homes, which supported residents in making an active contribution towards the development of personal and responsive relationships with staff. This was particularly important for residents who had limited communication ability. A senior care worker at Holyoake said, ‘When I'm down in the dumps, even when I think I'm not showing it, he'll reach out his good hand and touch my hand or my knee as I walk past, to show me he understands’. This suggests that while residents actively made contributions, it was necessary for staff to provide opportunities for, and to acknowledge, such contributions if personal relationships were to develop. As personal and responsive relationships formed between staff, residents and family members, some residents and family members began to encourage more reciprocity in their exchanges.
Reciprocal relationships
Reciprocal relationships demonstrated a greater understanding of the communal nature of living in, working at and visiting care homes. The focus of such relationships moved beyond the resident to recognise the needs of family members and staff as individuals that could all make valued contributions. Recognising the needs of others in this way supported the development of shared understandings between the resident, the family and staff as they saw themselves and others as active in a wider community. Some residents deliberately contributed towards reciprocal relationships, which they felt supported the wellbeing of other residents and staff. At Chestnut Lodge, the residents would comfort each other or seek support from the staff on behalf of another resident. At The Beeches, one resident described the way in which she supported the staff in their work with other residents by waiting patiently while they completed a care task. As a resident at The Beeches said, ‘As long as you are reasonable in what you ask, you can't expect to ask and for them to do it straight away. I think that's a mistake – when Freda asks and expects it straight away’. This resident tempered her requests in recognition of the needs of others in the home, which fostered the development of reciprocal relationships that benefited everybody. She explained further:
I have always been interested in people, I still am. I try to do things to help when I can. I think it's nice to be popular and I'm vain enough to know I am popular with the staff. It makes you feel happy about it.
The staff who described reciprocal relationships were able to recognise when residents were making a contribution, which suggests that for reciprocal relationships to flourish, such contributions must be acknowledged. As a senior care worker at Holyoake said:
I mean it's like Taylor, he smokes like a trooper, he does, but he knows there are only designated smoking areas. Now he'll wait rather than lose his temper because he knows you're going back to him; and if you don't go back, you apologise and he accepts it; he sees you are busy. Yesterday, he said, ‘is it alright if I go for a cigarette, can I borrow your lighter?’ I said, ‘Okay, duckie, wait here, I'll be five minutes, I just have to sort these ladies out’; and I did literally forget but next time I saw him, I did apologise, and he said, ‘no, I saw that you were busy so it's alright, but can I go now?’
Some staff recognised that they were able to contribute to the care of residents in ways that were special to them, as captured by observations at Holyoake:
Johnny didn't like the hoist because he had a fear of heights from his prisoner-of-war days. When he went up in the hoist, he would cry out in fear, which distressed his family. Ruth knew that Johnny enjoyed singing Irish songs, so encouraged him to sing with her whenever he was going up in the hoist. Sian told me that Johnny used to play for the local football team and would ask him how many goals he scored and all about a local football hero he used to play with. She said that telling her this took his mind off the hoist.
Each of these care workers demonstrated an ability to understand what the experience must be like for the resident and their family, and used this understanding to provide more sensitive and appropriate care. They brought something of themselves to the relationship, which enabled them to work effectively with each other, the residents and their families. As noted earlier, the contribution family members made to the care of their relative, or to life within the home, also influenced how the relationships with staff evolved. Reciprocal relationships developed as staff became aware of the contribution family members made to the home's community. At The Beeches, a niece of a resident described how staff would always make sure she had a cup of coffee when she arrived. She also explained that could make a positive difference to life in the home by supporting both staff and residents:
There's never anyone to have conversations with them [the residents], the staff are all so busy. That's why I come at dinner-time because you get to know them; it's then they go into their rooms. I would never see Niall if I didn't come at tea time – a different face for conversation, isn't it? Well I say, ‘I'm doing this and I'm doing that’, and Freda will pick up on it. I talk about where I'm going and where I've been and then it gives them something to think about and the next time I come, they'll say, ‘Oh, did you so and so?’ They sort of remember, and that's nice.
While some family members only visited ‘their’ relative, there were others at Holyoake and Chestnut Lodge who recognised the communal aspect of the homes and contributed to the experience of all the residents. These family members valued the recognition that they received from other residents and the staff. In turn, the staff made clear that they valued their contributions to the home community, while family members in all three homes understood that the staff had to take into account the needs of all the residents. The son of a Holyoake resident encapsulated these ideas:
You know he's in good hands. If there's anything wrong, they'll tell us. We know he needs quite a bit of time, but we know he gets it, that they never walk past him … but not everyone's going to be the same all day every day, their needs change; like today we can see there's an issue with Ray [another resident].
The family members who recognised that the staff tried to meet the needs of all the residents also tended to trust the staff to make the right decisions for their relative. For example, at both Holyoake and Chestnut Lodge, some family members told us how they believed the staff recognised what it was like for them, and some staff described the complement, that residents and family members understood the pressures they faced. Such mutual understanding was also apparent between residents and staff at The Beeches, where several spoke about their relationship in terms of the care being provided and what each participant brought to the relationship. This suggests that over time a shared understanding of how care can best be delivered develops among residents, family members and staff, and that although this takes time, sensitivity and commitment, the result is the formation of reciprocal relationships.
Discussion
Limited previous studies of personal interactions in care homes and the findings of this study demonstrate that personal relationships are the key to residents, family members and staff having positive experiences of, and being able to make a valuable contribution to, life within a care home. Prior to this study, however, little was known about how relationships in care homes develop (Brown Wilson Reference Davies and Brown Wilson2007). The findings suggest that relationships initially flourish primarily during the delivery of direct care, which provides a legitimate focus for interaction. It has been shown that personal relationships in care homes influence residents' and family members' perception of the quality of care (Grau, Chandler and Saunders Reference Grau, Chandler and Saunders1995; Bowers, Fibich and Jacobson Reference Bowers, Fibich and Jacobson2001; Kellet Reference Kellett1998; Sandberg, Nolan and Lundh Reference Sandberg, Nolan and Lundh2002), and staff's feelings of job satisfaction (Moyle et al. Reference Moyle, Skinner, Rowe and Gork2003).
The presented findings indicate that staff members' approach to care delivery influences the types of relationships that develop, and that input from residents and family members is essential. When residents shared stories about important aspects of their lives with the staff, this helped the carers identify meaningful activities or to personalise care routines. Family members also contributed to relationships by timing their visits to ensure regular interactions with staff, which enabled stories and information about the resident to be shared. The way that the staff recognised and responded to relatives' efforts also influenced the relationships in the home. An important finding of this study, therefore, is that the ways in which residents, family members and staff interact in connection with care routines greatly influences inter-personal relationships in the home. This suggests that understanding and valuing everyday ‘routines’ is a useful starting point in supporting the development of positive relationships between residents, family members and staff.
‘Routine care’ frequently prompts pejorative reactions from researchers, who see much of it as impersonal and of poor quality. Pragmatic relationships that emphasise ‘getting the job done’ do appear on the surface to be similar to the ‘good geriatric care’ described by Reed and Bond (Reference Reed and Bond1991). Indeed, in many early studies of caring for older people (e.g. Evers Reference Evers1981; Wells Reference Wells1980), routines were described primarily as mechanisms for meeting the needs of the organisation, rather than providing opportunities for creating individualised care. Such notions are now being questioned, however, and routines are increasingly seen as necessary for everyday functioning and stability (Bouisson and Swendsen Reference Bouisson and Swendsen2003). Routines have been described as an effective means of coping by allowing the efficient allocation and conservation of care resources (both physical and mental) (Zisberg et al. Reference Zisberg, Young, Scepp and Zysberg2007). The present findings support the assertion that having a structure to the day enables staff to focus more on the individual needs of residents (Haggstrom et al. Reference Haggstrom, Skovdahl, Flackman, Kihlgren and Kihlgren2005). The care routines were described by many residents and their family members as providing markers in the residents' day that gave a sense of coherence to what was happening. There is some evidence that routines enhance rather than reduce an individual's sense of identity (Zisberg et al. Reference Zisberg, Young, Scepp and Zysberg2007). The issue therefore becomes not whether ‘routines’ are good or bad, but how they can be personalised and used to enhance relationships and the quality of care.
Bowers, Fibich, and Jacobson (Reference Bowers, Fibich and Jacobson2001) found that many residents valued the routine delivery of high quality care partly because this was what they expected. In the present study, some residents and family members who engaged in pragmatic relationships often made practical contributions to the care routines as a way of ‘keeping an eye’ on standards (Sandberg, Lundh, and Nolan Reference Nolan, Davies and Grant2001), thereby becoming ‘care watchers’ (Perkinson Reference Perkinson and Stafford2003). Whilst positive for some, this may also reflect family members' struggle to find a meaningful role in the care home, when otherwise they can be reduced to looking for inadequacies in the system and with the care that their relative receives (Perkinson Reference Perkinson and Stafford2003). Therefore, whilst important, when the staff focused exclusively on the practical support that residents or family members offered, and made little effort to engage with them on a personal level, this made it more difficult for family members and residents to engage in personal and responsive relationships.
The contribution of story-telling to developing relationships
Stories shared with staff by residents or family members made a major contribution to the development of personal and responsive relationships. For example, many of the staff described how such stories helped them better to know the person and understand their biography, which helped them create personalised care routines appropriate to each resident. Ronch (Reference Ronch2004) saw the telling of stories as a powerful tool for communicating shared values in a home, particularly when staff demonstrated their respect for the resident by listening to their stories and using these to improve the experience of the resident in ways that were meaningful to them. In the present study, storytelling supported the development of personal and responsive relationships, which enabled staff to see beyond the immediate physical needs of residents and to recognise their need for self-affirmation and a maintained identity. Encouraging residents to reminisce about their lives during personal care routines has been found to foster the contribution of residents (Thorman Hartig Reference Thorman Hartig1998), but unfortunately it seems that even when staff are aware of these opportunities, they do not always use them (Grasser Reference Grasser1996). The current study clearly suggests that staff need to value the contribution that residents and family members can make through their stories and to be active in using such insights to personalise their care and to support the development of personal and responsive relationships. Such ‘listening’ must be recognised as an important skill in a carer's repertoire, and accepted that its use on a regular basis requires ample time.
Creating opportunities for regular interaction
When residents and family members experienced personal and responsive relationships, they were more prepared to take a wider view, which could lead to reciprocal relationships. Reciprocal relationships developed when residents, staff and family members had a shared understanding of life within the home. In this study, shared understandings emerged primarily through a process of negotiation and compromise. Ronch (Reference Ronch2004) described this process as ‘improvisation’, which involves residents, staff and family members in creative problem solving. Staff who worked in this way described how they ‘weighed up’ the needs of each resident, the demands on staff and the needs of the family according to the situation, recognising the interdependence between resident, family members, staff and the wider community of the care home. This requires regular interaction and exchange among staff, residents and relatives. Davies (Reference Davies, Nolan, Lundh, Grant and Keady2003) found that residents choosing to stay in a central communal area facilitated interaction between residents, visitors and staff. In the present study homes, the use of a central communal area enabled staff, residents and family members to share personal anecdotes, which helped the staff see the resident as a person rather than a care recipient. Staff members also shared examples of everyday interactions with family members, demonstrating that they understood their changing needs and tried to reflect these in the care they provided.
Davies and Nolan (Reference Davies and Nolan2004) suggested that, as family members and staff interact more regularly, they come to respect and appreciate each other's contribution, which signals a move towards ‘working together’. The examples cited in this paper suggest that as family members develop a sense of security about their role in the home, they are more likely to appreciate how they may contribute to the wider community. As Seddon, Jones and Boyle (Reference Seddon, Jones and Boyle2002) noted, family members' roles in a nursing home are not static, and those who negotiate their roles are more likely to report positive relationships with staff. This suggests that the relationships which developed between a resident and the family member with the staff also provided family members with opportunities to support others in the home.
The importance of such relationships is increasingly recognised. For example, Help the Aged, the United Kingdom charity, recently launched the My Home Life initiative which seeks to improve the quality of life for those living, dying, visiting and working in care homes (see www.myhomelife.org.uk). Based on a major review of the international literature in the field, a team of over 60 academics worked with independent advisors and voluntary groups to identify key themes and issues. They explicitly promoted a relationship-centred approach both to creating community and developing a positive culture in care homes, as is detailed on the website. Whilst the study reported here was confined to England, the wider literature therefore attests to the value of its conclusions for an international community of interest.
Conclusions
This study is one of the few that has explicitly explored inter-personal relationships in care homes from the perspectives of all the key actors. As such it must be considered a starting point, for there were areas that we were unable to explore. For instance, we deliberately chose to focus on the development of positive relationships and can say little about the less positive outcomes that frequently occur. Inevitably, positive and negative interactions co-exist and how this tension is managed to promote the former requires further research. Furthermore, because time was limited we could not consider how relationships evolved over time; how, for example, they may develop from ‘personal and responsive’ to ‘reciprocal’ and what factors promote this. Moreover, as levels of cognitive frailty rise, there is a need to consider how individuals with limited personal-interaction abilities can contribute to the development of reciprocal relationships. Nevertheless, we believe that this paper has made an important contribution to the literature, particularly in recognising the role of routines and care delivery in the development of relationships in care homes.
The relationships observed in the three care homes were developed primarily through informal and frequent interactions between residents, family members and staff, often during care delivery, which enabled each other's contributions to be valued. The nature and content of these interactions varied, but a common factor was the level of personal information shared through the medium of stories. Story-telling has been described as a process through which people make sense of events that they experience, and is central to involving older people in decision making (Barnes Reference Barnes2005). In the studied care homes, sharing stories enabled staff to make decisions based on personal knowledge of the residents and family members and promoted flexible working. The stories were used primarily to personalise care routines for each resident. For example, photographs, personal belongings or stories shared by family members could be used by staff as conversation triggers during personal care. Family members were also involved in sharing stories with staff during their visits, and staff often reciprocated, indicating that they were interested in the life of the resident. This suggests the need for a re-evaluation of communication in care homes so that exchanging stories between residents, family members and staff is encouraged and valued.
Strategies to change practice are commonly based on (different) staff training but the majority of such initiatives in care homes rarely include the voices of older people or their family members (Meyer Reference Meyer2007). Ronch (Reference Ronch2004) argued that involving residents and their family members in identifying alternative ways of doing things brings in different perspectives, and that such involvement has the potential to create a more effective learning environment. For example, care workers tend to learn on the job from senior or experienced carers' demonstrations of what needs to be done. Residents and family members could be invited to share their stories with new members of staff as part of their induction to the job; it would be an innovative way of introducing a new carer to the residents' biographies. The presented findings suggest that involving staff, residents and family members in staff development might ensure that everyone has the opportunity to make a valued contribution. Furthermore, Gaugler (Reference Gaugler2005) argued that considering the dynamics between residents, family members, staff and the organisation could be key to improving outcomes in long-term care settings. While the outcomes of care remain of great relevance, many of the older people, family members and staff involved in this study described how the process of care influenced their daily experiences in care homes. Such processes need to be elaborated if a truly ‘enriched’ environment of care is to be created (Nolan et al. Reference Nolan, Brown, Davies, Nolan and Keady2006).
