Introduction
The nursing home as a place to live and receive care has been under examination for many years. Nursing homes have been criticised for reducing the care of older people to mere physical necessities, making hardly any allowance for the social or cultural needs of the residents. Despite repeated attempts to modernise and improve care, life in nursing homes has never corresponded with society's vision of a ‘good life’ and modern living standards. Consequently, most older people would rather remain living in their own homes as long as possible, even when they are in need of care. As in many welfare states, a key objective of German care policy has been to allow older people to receive care in their own homes. In 1995–96, Germany introduced a universal long-term care insurance (LTCI) scheme, and with it, nationwide access to professional home care services and support for family care-givers. Moreover, in an effort to share responsibility and create ‘a new culture of helping and humane care’ (Social Code Book XI, §8), many initiatives now encourage the involvement of the broader society in the care of older people and promote the social inclusion of older people with disabilities (Klie and Ross Reference Klie and Ross2005).
Nevertheless, even though entering a nursing home is perceived as loss of quality of life and there are increasing demands to abolish them (Dörner Reference Dörner2012), many Germans can expect to spend part of their lives in one. While nearly 70 per cent of the 2.34 million Germans in need of long-term care live at home, the number of older people living permanently in nursing homes is rising steadily; in 2009, it was 26.2 per cent (Federal Statistical Office 2011: 16). Given the rapid ageing of the German society, further growth of the nursing home sector is expected. Considering that surveys only provide snapshots of a given situation, the true significance of nursing home care remains masked: most older people remain in their homes as long as possible with the help of relatives and care services, some try to extend the period of their autonomy by moving into a residence with assisted-living arrangements. It is only when these arrangements can no longer cover the care needs of individuals – usually in the late phase of a chronic illness, often after an acute hospital stay – that they enter a nursing home (Luppa et al. Reference Luppa, Luck, Weyerer, König, Brähler and Riedel-Heller2010; Schmidt and Schneekloth Reference Schmidt and Schneekloth2011; Wingenfeld Reference Wingenfeld, Kuhlmey and Schaeffer2008). This has important ramifications for nursing home care: the average age of residents is presently 82 years; 23 per cent of residents are 90 years old or more (Schmidt and Schneekloth Reference Schmidt and Schneekloth2011: 121–4). The health status of residents is characterised by (mostly multiple) chronic conditions and varying, often cognitive functional impairments (dementia) (Kleina et al. Reference Kleina, Brause, Horn, Wingenfeld and Schaeffer2012; Wingenfeld Reference Wingenfeld, Kuhlmey and Schaeffer2008). In other words, an increasing number of care home residents require not only intensive nursing care, but also assistance with everyday activities and companionship; these, however, are areas of care that traditionally have been neglected in German nursing homes (Hämel Reference Hämel2012). Moreover, those professional care services refunded within the LTCI scheme focus mainly on somatic needs of older people. At the same time, practices of person- and relationship-centred care (cf. Edvardsson, Varrailhon and Edvardsson Reference Edvardsson, Varrailhon and Edvardsson2014; Nolan et al. Reference Nolan, Davies, Brown, Keady and Nolan2004), such as support in managing daily life with cognitive impairments, fostering social contacts and activities outside the house, as well as dealing with cultural aspects of death and dying, are still marginalised (Büscher, Wingenfeld and Schaeffer Reference Büscher, Wingenfeld and Schaeffer2011; Strohbuecker et al. Reference Strohbuecker, Eisenmann, Galushko, Montag and Voltz2011).
Several studies have confirmed that, in the past, German nursing homes rarely prioritised residents' needs, operating instead according to professional resources and routines (Amrhein Reference Amrhein, Schroeter and Rosenthal2005; Koch-Straube Reference Koch-Straube1997). This failure to place residents' needs first underlined the impression of a ‘total institution’ (Goffman Reference Goffman1961) characterised by limited social interaction of the nursing home residents with the outside world. Such institutions have a strong hierarchical structure and the administration's primary goal is the smooth running of the organisation. In the 1980s, a new and increasingly vocal interest group surfaced, questioning professionalisation as the sole path to good care. Critics of the existing elder-care system pointed out that higher standards of care have not prevented nursing homes from becoming ‘fortresses’ in the community, neglecting residents' quality of life (Hummel and Steiner-Hummel Reference Hummel and Steiner-Hummel1986).
Much has changed in the last decades. For one, public funding and professional standards of care have improved significantly. Generally, residents are no longer seen as ‘patients’ totally dependent on the nursing home staff; of late, they are regarded as citizens with the right to appropriate care, and as consumers who can choose between services. In addition, although German nursing homes today can still be regarded as closed operations, they no longer can be considered closed-off worlds. In conjunction with a de-institutionalisation movement in Germany, there have also been attempts to redesign the nursing homes themselves. The growing demands for a change in nursing home social environment and a greater involvement of civil societyFootnote 1 have resulted in the development of varied types of community involvement in nursing homes: today nursing homes can be found in which relatives and volunteers take an active role in the welfare of nursing home residents. Some work with hospice associations that organise end-of-life care, others with support associations which secure additional funding for care institutions. Some nursing homes have partnerships with local clubs or other institutions such as schools and kindergartens, which organise social and cultural events for the residents (Hämel Reference Hämel2012).
Organisational hybridism as an attribute of German nursing homes
If this manner of ‘opening up’ of nursing homes to the principles of civil society is to become a permanent feature of elder care in Germany, the active mobilisation of interested families and community partners as well as the on-going maintenance of their participation is necessary. These tasks must also become an integral part of administrative routine: they require an understanding of the differing mechanisms of the state, the market and the community, for they consequently begin to operate in a mixed economy of welfare. The fusion of different spheres of welfare services has been termed the ‘hybridisation’ of welfare organisations (Evers Reference Evers2005). Evers sees this capacity to shape hybrid structures as an opportunity and advantage for care institutions: hybrid organisations can tap into resources in different areas of welfare services and thus expand their scope of action (similar: Brandsen, van de Donk and Putters Reference Brandsen, van de Donk and Putters2005). Due to the limited coverage of LTCI, the combining of public and privately funded services has become a necessity for all nursing homes. This − politically intended − trend to mix is now to be broadened and enhanced by mobilising the commitment of community partners and further developing social capital.
The question is, how are nursing homes dealing with the resulting conditions of hybridity? In addition to meeting state regulations and running a business in the nursing care sector, care institutions must now also win over the solidarity of community organisations and co-ordinate voluntary support (Evers, Rauch and Stitz Reference Evers, Rauch and Stitz2002: 30f). Utilising and combining different resources also means care institutions are continually confronted with a diversity of organisational objectives and demands. To fulfil diverse expectations, the nursing homes need to understand how the control mechanisms of the state, the market and civil society relate to one another, and, where needed, offset possible breaches and/or conflicts.
Taking a closer look at the debate surrounding the development of hybrid governance structures in the field of health and social care services, there are few issues that have been discussed so intensively in Germany as the introduction of the principles of free market and competition into the context of long-term care (Strünck Reference Strünck2000). The government expected long-term care services to be boosted by entrepreneurship and innovative strategies as well as benefits in competition for customers (Deutscher Bundestag 1993: 136). Equally, through state control of the health service standards they expected to be able to safeguard against excessive profit orientation and the dominance of market interests. Accordingly, with the opening up of long-term care services to the free market, the government broadened state regulations of quality control, the definition of services as well as the possibility of co-determination of price structure. Whether the ‘quasi-market’ of welfare care services in Germany can be considered a success has yet to be conclusively assessed. However, it is already clear that the combination of consumer freedom and civil rights has attributed little towards improvements for those in need of long-term care; more often, restrictive government spending is accompanied by a limited range of services. Instead of the hoped for competition for quality, a price competition has taken hold of the nursing home sector (Gerlinger and Röber 2011).
This indicates that hybrid structures are complex and may function differently than originally intended. However, little research has been done on the dynamics that come into play when community involvement is added to the mix. The hope is that nursing facilities will become more open to the specific needs of their local and social environment. Furthermore, they are expected to contribute to the social integration and cohesion of society (Evers and Olk Reference Evers, Olk, Evers and Olk1996: 25) − in this case, through the commitment to the concept of a dignified life for older people and for those needing long-term care and assistance. Still, the dynamics that develop in a nursing home when family and community support are added as a partner have rarely been looked at closely. We need to ask whether the hybridisation truly promotes a ‘humanisation of nursing homes’ and a ‘new culture of compassion and affection’, or have perhaps unexpected or even unwanted effects evolved in hybrid organisational structures?
Past research has shown that when taking a closer look at the functionality of hybrid organisations the functionality cannot be defined simply as the sum of the various contributions. Rather it is the combination of diverging institutional principles which appears as something ‘new,’ ‘different’, which produce organisations with a ‘new identity’ (Brandsen Reference Brandsen2004: 14; Evers Reference Evers2005: 742). However, some researchers argue that instead of the intended trend towards the innovative development and balancing of the diverse needs and interests within hybrid arrangements, the dissimilar resources and steering mechanisms of state, market and community remain disconnected, which could, at times, lead to conflicts (Bode Reference Bode2006; Enjolras Reference Enjolras, Brandsen, Dekker and Evers2010), for example, between commercial and community interests. One must ask, given that trust and solidarity function as the ‘currency’ of civil society, how can solicitousness and supportiveness develop in the nursing homes, be preserved and shaped, when simultaneously the pressure to economise and the constant monitoring of performance continue to define their everyday life?
The aim of this study was thus to explore the current opportunities and obstacles of applied change in the German nursing home sector triggered by an opening up of long-term care facilities for communal assistance and support, more specifically here, relatives and community partners. The key research question was, to what extent have synergies occurred, or rather tension and even conflicts arisen due to family and community involvement owing to the necessity of aligning the service structure of these nursing homes with state regulations and market demands.
Methods
In this study, 12 nursing homes were examined. The data collection entailed semi-structured qualitative research interviews with nursing home directors. As directors, they were most likely able to provide a comprehensive overview into the concept, objectives, responsibilities and operations of the long-term care facilities, and were responsible for the opening up of the nursing home to civil society principles. The directors were encouraged to invite further individuals, who made a major contribution to opening up the facilities to the community, to participate in the interview; three respondents did this.Footnote 2 Furthermore, local documentation and materials such as programmes of events, mission statements, quality reports and nursing home newsletters were analysed in depth. The data collection and content analysis were implemented according to the basic principles of qualitative research and the step-by-step procedure of qualitative content analysis (cf. Flick, von Kardorff, and Steinke Reference Flick, von Kardorff and Steinke1995; Gläser and Laudel Reference Gläser and Laudel2004; Glaser and Strauss Reference Glaser and Strauss1998).
Due to extensive state regulations on quality guidelines, staffing, staff qualification requirements, pricing, etc., general conditions and requirements in the nursing home sector are quite similar nationwide. In order to gain insights into viable concepts of opening up to the community and their practical implementation, it was necessary to look into nursing homes that have placed a clear emphasis on outside involvement. The sample included only public and non-profit nursing homes run by various welfare associations, since these are the care institutions that traditionally have developed structures of community involvement in Germany and have better access to certain resources, e.g. donations and volunteer work. In 2011, 54 per cent of nursing homes in Germany were private non-profit, 5 per cent were public and a further 40 per cent were run by for-profit organisations (Federal Statistical Office 2013: 16). To allow for varying degrees of access to community social capital, nursing homes from different regions of Germany as well as both in rural and urban settings were included in the sample, as were nursing homes in neighbourhoods of differing socio-economic status (see Table 1).
Table 1. Basic characteristics of case examples
Notes: 1. BY: Bavaria, BB: Brandenburg, HH: Hamburg, HE: Hesse, NI: Lower Saxony, NW: North Rhine-Westphalia, SN: Saxony, ST: Saxony-Anhalt. 2. According to categorisation of the German Federal Institute for Research on Building, Urban Affairs and Spatial Development (2013). 3. According to interviewees’ estimations. 4. Case number 11 includes two nursing homes of the same provider, based on the same ‘opening concept’.
In accordance with the principle of purposive sampling, the factors discussed above served as a preliminary structure for searching out possible cases. In selecting case examples, care was taken to include nursing homes with varying levels of openness to the community. Criteria used to pre-assess levels of ‘openness’ included the use of volunteers, the existence of booster clubs, special support provided for relatives, co-operation with other community organisations, etc. These data were determined through expert recommendations, publications, information on model programmes and internet research. The development of these services was also pre-assessed. Nursing homes likely to fit the study criteria were then chosen and their management contacted to sound out mutual interest.
The interviews began with questions dealing with the care facilities' partners involved in services offered and their forms of participation; the interviewees were asked how their involvement had been initiated and how it has been co-ordinated with other areas of service since then as well as general questions about the administrative and care tasks of the nursing home. The respondents were also questioned on subsequent changes that have taken place and development prospects (e.g. practice change). To ensure the freest possible narrative flow, the interviewees were encouraged to review the history of the nursing home. However, questions concerning potential difficulties or conflicts were introduced in order to increase the interlocutor awareness of this area of interest and break through socially desirable response behaviour. The nursing home directors were then asked for a general assessment of the benefits and problems they would associate with the inclusion of community partners in care services, as well as the reactions of their residents and staff. Factors which promote or inhibit the participation of the community were also of importance. However, in order to assure that their answers remained unaffected by preliminary conceptual considerations, the interviewees were never explicitly asked to describe synergies, tensions or conflicts induced by state guidelines and a competitive environment. Lastly, the interview partners were asked to describe the role their nursing home currently plays in the community with the intention of establishing whether the opening up of the care facility to the community has been linked to a particular sense of identity. Upon conclusion, each interview was subsequently assessed; then, based on the data collected, further nursing homes were chosen. Initially, 17 interviews were carried out. All interviews were conducted in 2006; each interview lasted one and a half to two hours.
Using a typological framework which compared and contrasted the cases, 12 case examples were then selected for closer study. As Table 1 shows, the sample included nursing homes based in eight out of the 16 German states of varying sizes. On average, the nursing home assessed offered 87 residents permanent care, and most had 100 per cent capacity utilisation. All of the nursing homes surveyed in this study also provided various services for seniors in the community (e.g. day care, seniors' lunch, assisted living, café, etc.), which is even today exceptionally high (Schmidt and Schneekloth Reference Schmidt and Schneekloth2011: 116).
The 12 interviews were transcribed and a preliminary analysis carried out using the MaxQDA software program: the text was inductively categorised and an initial interpretation was undertaken in order to identify repetitive structures and identify case-specific attributes in the form of initial hypotheses. Endeavours to involve family and community were noted on a case-by-case basis along a uniform description framework in order to identify the ‘opening up’ concept of each nursing home and enable discussion of its potential and limitations. Based on the initial hypothesis, the structured evaluation and discussion of the various case examples and general modes of involving community partners were identified and analysed.
Results
Social and economic opening up by nursing homes
Taken as a whole, the case studies indicated that nursing homes are capable of activating a large number of partners and resources in their local communities. In most cases, co-operation with volunteers and family, along with the founding and maintaining of support groups (associations, advisory boards) in the community remains the core of the ‘opening’ approach. Additionally, some nursing homes had local businesses as donors and patrons, and partnerships with other community institutions (e.g. visiting programme with kindergartens, co-operation with schools). A few were sponsored by public programmes, which led to the development of volunteer projects. Finally, in some cases, the nursing homes had partnerships with local authorities, which supported them in organising events or, for example, incorporating a senior citizens' centre into the nursing home building. In other words, these nursing homes demonstrated that partners and resources from all facets of welfare production have been activated and co-ordinated with the aim of opening up the nursing home to the community. In brief, civil society is not adequately conceptualised as a distinct set of actors and a special sector, but more a principle to act with partners of different spheres of welfare production.
Obviously, there were large differences between the nursing homes assessed – the sample included institutions which limited their partnerships to a few, usually value-based community relations (e.g. one Caritas nursing home co-operated primarily with Catholic parish groups); as well as nursing homes which had built up manifold support structures. The resources of various partners had been integrated into their own structures in order to provide new services. For example, local businesses donated to one nursing home support association, which instigated intergenerational exchange projects at the nursing home, and reimbursed volunteers' out-of-pocket expenses incurred while running a cafeteria in the nursing home. Considering their physical environment, most of the nursing homes surveyed may enjoy a higher quality of facilities than the national average (i.e. place for cafeteria, rooms for group meetings). However, there are no data available for a comparison.
The involvement of community partners is intended to counteract constraints resulting from growing financial and administrative pressure caused by state regulation and the need for cost-effectiveness in the nursing home, as this typical statement illustrates:
It used to be that we had a lot more personnel. The attitudes of the staff were just different from now. Now you keep an eye on the cost-effectiveness, now timing analyses are conducted. They watch to see that the things listed in the duty roster are really done … There is less time for the personal [individual] care, significantly less. That means we are also dependent on outside help – volunteers. (Interview 10_Z.843–856)
Regardless of the extent of a nursing home's outside involvement, most institutions surveyed adjusted their programmes to the quality guidelines of community care. The interview partners cited aims of their community partner programmes, such as promoting ‘normalisation’ (i.e. to live as normally as possible with disabilities), the ‘everyday orientation’ of life in the nursing home, ‘greater wellbeing for the residents’ and ‘the opening of the institution to the community’. The idea was for residents to acquire support needed as well as the acknowledgement that they were people with strong family and community ties, and, finally, to provide them with access to social and cultural life.
In some cases, an integral part of the ‘opening up’ concept of the nursing homes was the promotion of services in community care, for instance, introducing home care services, providing assisted-living apartments in co-operation with local building co-operatives or providing seniors’ lunch at the nursing home, etc. ‘Opening up’ here has taken on an entrepreneurial quality. Entrepreneurial and social interests were not regarded as contradictions; rather, they have been synergistically entwined.
What is normal? Involvement as a transporter of nursing home concepts
The opening of nursing homes to the community can be promoted in the context of different concepts. The case examples were dominated by action plans which sought to break down barriers between the worlds ‘inside’ and ‘outside’. In the course of shifting towards home and community care (in principle as well as in practice), these nursing homes have developed options other than their all-round, institutional care. In nursing homes, the goal has basically been to revitalise residents’ everyday life with leisure activities and culture. These aims are similar to services offered by seniors’ programmes; however, community programmes for seniors are not directed exclusively towards nursing home residents. Closely related to this is the endeavour to bring a variety of people from the community into the nursing home – members of community clubs, special-interest groups, seniors living nearby, new clients, potential volunteers, school students, kindergarten children, etc. The integration of these assorted partners – who figuratively represent ‘normal life’ – is intended to help vanquish the impression of a ‘closed’, ‘long-term care institution’. The nursing home is to be seen as the focus of manifold social possibilities, converted into a place shared by the community at large.
There was also a second approach to ‘opening up’ to be found among the surveyed nursing homes: these endeavoured to open up the nursing home in order to develop it as a protected space for the residents. Institutions in which this approach was most apparent concentrated their efforts on their ‘core’ services – institutional care. New options or services were not usually directed at seniors in the community as well; they were primarily made available to the residents. Here a new development in German institutionalised care can be perceived: traditional support groups such as short-term volunteers have been given further training to be able to take on a more professional companionship role; new support groups specialising in dementia or end-of-life care were promoted and trained. In these cases, involvement has not been focused on bringing ‘normal life’ as defined by the outside world into the nursing home; rather, it attempts to ensure a different kind of normality – one which acknowledges and respects age, illness and death, by accentuating that more special contributions are required. With this approach, once again, a large number of different partners could be involved. Such nursing homes were also just as dependent on a broad public interest and willingness to help as those seeking to integrate the community into the nursing homes. However, here, in the direct encounters between the wider community and nursing home residents, it was always stressed that the continuing relations were to take place ‘in sheltered zones’. Co-operation with families and volunteers as personal carers for the residents were core elements of this ‘opening up’ concept.
Different forms of involvement
The case studies made it possible to identify three different types of collaboration with community partners that underline the opportunities and difficulties of hybrid arrangements in nursing homes.
Structural separation
The first model could be labelled ‘structural separation’. In this model, nursing homes focus on offering professional services, while community partners advance additional services. The two spheres of action do not deal with one another for the most part; there is no or little interaction between the two. For instance, nursing home staff may be informed of the activities and events organised by volunteer groups, however, they will not be involved in organising them. Only minimal co-operation is expected: operational schedules must be organised so that the residents may take part in the ‘other’ activities. Beyond that, the role of community involvement in the institution is governed by the principle: ‘work schedules are never changed’. In this way, the ‘core services’ provided by the staff remain separate from the ‘extra options’ offered by community involvement. They exist parallel to, but independent of one another, unless the need for some small form of integration arises; for example, when volunteers are called in as a stop-gap to aid the staff in caring for the residents during a crisis or a transition (i.e. renovation of the building). This kind of structural division between hybrid organisation's spheres of activity demonstrates the split between ‘professional’ services – which run according to clear-cut institutional standards, economic viability, time management, etc. – and ‘social life’ in the nursing home, which is reserved for community partners to manage. Moreover, typically the assessed nursing homes that deal with the hybrid organisation in this way consider the contributions from the community as subordinate to meeting the more important demands of their core services:
And as a rule, I must first ensure that the [home] here operates, runs seamlessly, can subsist, run reliably … If the business goes bad due to economic reasons and then it no longer exists, then the other things [opening for contributions from the community] are of no use. (Interview 06_Z.500–507)
Instead of grasping the opportunities that community resources could offer for improving cost-effectiveness and the success of the enterprise – as intended in the hybridity concept – these directors emphasised the extent to which the expenditure of time necessary for attracting and maintaining partnerships and contributions deflect from the task of operating the nursing home. In other words, they do not discern the opening up to partners in the community as a core objective; thus, such activities must take the backseat to operative tasks. Another interviewee voices a similar attitude:
So I tried that [acquiring volunteers] two years ago among the Catholic congregation. And then I gave up very quickly because I realised … just how much I would have to invest. I can‘t invest that, I have other tasks. (Interview 09_Z._826–830)
In this context, ‘self-propelling’ community participation is sought, in which no additional effort has to be invested. Even when the contributions of community partners can constitute important support for a care facility, it must be noted that there are few opportunities for nursing homes to strike out on new paths.
Organisation with a focus on classical care services
What are classic structures, the classical means of increasing the staff, which can be instigated in an institution? On the one hand, there are the interns … The other is the key issue of voluntary work. (Interview 01_Z.128–133)
While in the first model discussed above, the two spheres of action – professional and community – are clearly separated, in the second model, the two spheres have merged. Nevertheless, contributions from community partners are primarily organised according to the rules and needs of the care services, and their options for participation are determined largely by the professionals working for the nursing home. The care professionals retain the right to define what is considered appropriate community input, for example, by predetermining a precisely defined concept of volunteer work and then seeking out suitable community participants to fulfil the role (at the same time, possibly leaving them blind to further potential in the community). Volunteers are given closely structured tasks to minimise potential disruption of the daily care routine, while ‘getting the most’ out of their support. Support associations tend to be only involved in fund-raising activities, while the nursing home administration largely maintains control over the utilisation of those funds. The institutions concentrate on doing what they do best, i.e. organising the community contributions according to the rules of the nursing home business.
Assuming that an assistant job [nursing assistants] generates 38,000 Euros in personnel costs … Recalculated in the sums paid back then that was about 60,000 German Marks that we had to take out of the till. But that covered about 1,300 hours of work. We said, ‘We're not going to do that’. We primarily use volunteers at 15 Marks, for 4,000 hours. So we have a surplus of 2,700 hours in the [care] facility. In the implementation, that's almost two established positions. (Interview 01_Z.185–192)
In this particular case, the economical perspective of communal assistance was taken to even further extremes, by integrating volunteers into standard care services. Their names could be found on the work rosters and it was possible that they would be advised of ‘grounds for dismissal’. The director of the nursing home constituted the making use of community resources as a type of ‘risk management’.
The opening of the care facility to communal involvement is indeed regarded in such cases as a way of humanising the nursing home life; however, other aspects nuance this perspective: voluntary work is taken up not only to ‘humanise care’, but also, in a sense, to ‘humanise costs’. The integration of resources from civil society is described using the language of economics and evaluated under the business aspects – and for this reason regulated in standard ways. The difference between the status of staff and volunteers becomes blurred, because the latter have long since been dealt with as ‘human resources’.
Repositioning within co-operative structures
The last model discerned can be considered as the one coming closest to the ideal of hybridisation. Community involvement is highly visible, because it is framed by an overall repositioning of the organisation within co-operative structures. The involvement of family and community partners is deemed to be an ‘autonomous’ contribution, which is considered essential to the development of the organisation. This autonomy – as well as the direct responsibility of the partner – can be identified in the make-up of certain organisational and representative structures in the nursing homes:
I began very quickly [to develop] the different areas that then increased in number − we had a visiting service that we used to call ‘Fun and Games’; today, it is called the ‘Active and Creative Seniors Accompaniment’. [Another group is] End-of-Life Care. We then introduced a working group DCM [Dementia Care Mapping], which also has volunteers in it. And I said, in every area everyone must work responsibly. Therefore, we founded a Board [of Volunteers], so that every area of voluntary work was represented on the board. And they then take over part of my workload. And those [are] who I then work with. (Interview 12_Z.317–329)
These care facilities have recognised that ‘the community’ cannot be seen as a homogeneous group, but rather is made up of actors with a wide variety of interests. This is acknowledged and emphasised, for example, by setting up representatives of the various interest groups within the nursing home − and providing professional support for them. The following quote is an example of the differentiated perception of residents’ and families’ different interests:
Because their interests are not congruent, they may even be very different. So the women on the Nursing Home Advisory Board [representing residents] deal with the everyday problems: Have the sunshades in the garden been stored properly or have the benches placed correctly? Problems with the laundry and such stuff, that's what they deal with. Whereas the Family Members Advisory Board … looks more right and left, seeks political influence, and also deals with all the issues from a different perspective. In this respect, they have little in common. (Interview 05_Z.613–621)
Well aware of the different points of view, these different perspectives are pursued for the further development of the nursing home. The administration also accepts that they cannot always be in control of every situation, so that community partners are allowed into the core of the organisation ‘nursing home’ and are given a say in decisions. Moreover, in such cases, participation is not just an option for volunteers, relatives, local clubs, etc. The desire to attract community partners may become the catalyst for a participation-oriented evolution of the entire organisation.
Comprehensive forms of exchange and co-operation were developed in two of the 12 case studies. More than 100 volunteers were active in each institution. In both care facilities, the directors introduced community involvement as a key strategy to sustain and augment the nursing home. Moreover, both care institutions have developed similar processes: the institution's basic principles were discussed in mixed groups of volunteers and staff members: these included the mission statement, care concept, concept for volunteer work and organisation of co-operation with the community.
And before, Caritas dealt with the woman's support association (Frauenhilfe), this Christian group. Once a year, they came [to an official meeting with the staff of the home], and there was a list of grievances – with a list of everything that had gone wrong. And the [employees] trembled in the nursing home weeks beforehand. And I just changed that a bit – let them organise small working groups, collect questions and requests, and also asked about the good things and amplified the development processes, pointed out possibilities. Included them a bit more. I then quickly realised that there was little conceptual work being done here in the [nursing] home … And then I took the classical path – value consensus, an employee survey, we then developed a value consensus. Then, based on this value consensus with the help of a business consultancy … developed with various workshops a concept in which we have also involved nursing home residents, family members, volunteers, support representative, full-time employees. It was a real community process from the outset, so to speak. (Interview 12_Z.117–133)
Similar participatory approaches to planning and development were found in certain areas of other nursing homes as well. These focused primarily on dementia care and hospice work, i.e. areas that had been newly introduced into their professional concept. In all these cases, the options available via community involvement meant having to work closely together and developing new methods and tasks for volunteers and staff alike, which more often than not led to interpersonal conflicts and strenuous developmental processes to resolve them. Conflicts are also prominent here. However, they are not ignored or suppressed, but rather accepted as a consequence of the opening for contributions from the community. Even so, civil society has been allowed into the core of the organisation: not just new partners have been let in; increasingly, civil society negotiation processes are also being introduced into the organisations. Despite a functional differentiation of the organisation ‘nursing home’, the various actors are attempting to find a common understanding of how the care facility should be modelled, which is then to be the basis for a shared approach and shared responsibility. In this case, a new jointly sponsored corporate identity has been cultivated within hybrid organisational structures which encompasses both a common guiding approach to care, as well as, in part, a democratisation of care organisation.
Discussion
The aim of the study was to explore the opportunities and obstacles that arise by opening up nursing homes to the wider community. It was based on the premise that the involvement of families and other community partners can facilitate a new quality of care in nursing homes. Not only can they provide new resources, they also present an opportunity to deal with dimensions of care that have often been neglected in long-term care institutions, such as and in particular, continuity of care, fostering social and cultural relations with the community, but also providing residents with a sense of ‘normality’ in their everyday life in the nursing home. More concisely, as advocates point out, nursing homes have the opportunity to rid themselves of their institutional, ‘closed’ character and advance to a community-oriented dwelling in which older people can live and be cared for.
Regarding the governance of such nursing homes, this entails that they act under conditions of hybridism: care facilities have to learn to deal with diverse attitudes and objectives set down by state regulations, the market and economic competition, and civil society. In this context, opportunities that could temper or even resolve shortcomings of the quasi-market governance in long-term care organisations arise. Despite existing research concerning other sectors of health and social service production, there has been little research on the extent of tensions and conflicts emerging within such three-sided hybridism formed between the state, market and civil society governance. This study focused on the concept of organisational hybridism while taking an in-depth look at the operational capabilities and practice change that emerge when family members and community partners are invited to participate in German nursing homes actively.
The cases discussed indicate that the varying objectives behind moves to open up and differing ways of dealing with community involvement ultimately determine the extent of reforms. Those nursing homes surveyed stressed that in opening their institutions to the community they were guided by a desire to create a greater sense of normality in the institutional setting. However, this aim conceals highly differing basic perceptions of how ‘normality’ should be defined. One approach focused on integration of the world outside and the world inside. Another approach focused on encouraging more comprehensive forms of care within a protected nursing home community. Both approaches to improve social interaction of the nursing home residents with the outside world represent a move towards shared responsibilities in nursing home care. Nevertheless, this raises the question as to whether older disabled residents possibly have a different definition of normality than healthy, active members of the wider community, and how important this is for quality care. This is a question which requires further discussion.
The study also revealed differences in the way the nursing homes deal with community partners and their contributions. The general tendency is either to limit the potential of community involvement by strictly controlling it and allow only a small niche for co-operation, or to neglect it so that the options offered give rise to little enthusiasm among professionals, and thus remain largely undeveloped. Instead of seizing the opportunity to gain a new, more creative outlook from the outside world, nursing homes may ultimately stick with their own inflexible institutional viewpoint. Staff members tend to take care that community involvement does not disrupt their operations and schedules. Although management may well desire to open up the institution, it is often not prepared to invest the necessary time to deal with the conflicts incurred. Thus, they tend to embrace only small, easily controlled opportunities for those seeking involvement in the nursing home. Here, the development of mutual trust and a culture of involvement remain limited.
It is also apparent that the participation of family and community partners has been deliberately sought in some nursing homes in order to gain new perspectives; and with the help of these insights, an attempt has been made to enhance their care services further as a whole. The central factor of a comprehensive concept of care as a common basis for action is practice change and with it an initial change in the ‘corporate identity’ of nursing homes. Concepts such as ‘community-oriented nursing home’ are not courses of action that can be achieved ‘automatically’, simply through the integration of a particular service sector. More accurately, they encompass actions that must be endorsed and supported by all the actors involved, particularly by professionals; in other words, the new concept must be an integral part of the professional self-conception of good care in order to be effective.
These findings illustrate once more that emphasising responsibility for elder care of the wider society does not inevitably mean the ‘withdrawal’ of professional responsibilities; rather, it requires professionals to redefine themselves and their role in a relationship-centred approach to care. However, in this case, professionalism would also mean a retreat from professional dominance, and the inclusion of other points of view (Dörner Reference Dörner2012; Nolan et al. Reference Nolan, Davies, Brown, Keady and Nolan2004).
In order to progress in Germany, we urgently need reform in long-term care as well as a change in nursing practice. This is because in German social security legislation, long-term care has been restricted to somatic impairments and body-related care, and thus, the chances of a new nursing practice are quite limited. After years of intensive debate regarding a new definition of long-term care, it is now intended to be implemented systematically (Deutscher Bundestag 2014). In future, those dimensions of care which have hitherto been marginalised are to be incorporated; in particular, the promotion of social inclusion and support for cognitively impaired people. This is an important step, allowing professionals and citizens to act on a common basis and share responsibility, instead of − as was evident in the assessed nursing homes − family members and concerned citizens bestowed with the task of providing humanity and quality of life in compensation for deficiencies in the professional care system.
In addition, this study demonstrates that successful opening up depends on a process of organisational development. To foster such organisational growth, awareness must be raised as to how to connect and collaborate with community partners. Supportive structures need to be built up at the community level; at the same time, nursing homes need to be regarded in society as an integral part of the community care movement and not as a hindrance to it. Since the implementation of the study, community-based care has attracted further political attention; comprehensive, locally organised and integrated care approaches are in increasing demand and new approaches are being tested. Nursing homes can make an important contribution if they succeed in becoming places that allow older people and those needing constant care to remain in their accustomed social and cultural environment.
This exploratory study gives just a small insight into the complex world of nursing homes in Germany from the viewpoint of nursing home directors. Further research is much needed in this area, in particular regarding other key actors – the nursing home residents, volunteers, relatives, various professionals in the home and wider community members. In addition and building upon data collected, the further development of theoretical frameworks relating to community-oriented nursing homes could follow.
