Staff-resident interaction in the nursing home: An ethnographic study of socio-economic disparities and community contexts

In recent years, nursing home (NH) researchers have paid increasing attention to socio-economic and racial/ethnic disparities in quality of care. Although there is growing evidence of disparities in resident health outcomes, less is known about the ways in which these differences manifest in care processes from a qualitative perspective. This paper addresses this gap by comparing staff-resident interactions in two urban, non-profit NHs, including roughly 50 staff participants in each facility. The researcher conducted ethnographic observation in one facility serving a white, middle class community and another serving low-income Black and Hispanic clients from an underserved neighborhood. Grounded theory methods generated three categories of interaction—activating, relating, and attending—which were performed differently in the two NHs. In the more affluent facility, staff interacted with residents in a dynamic fashion, adapting to residents’ responses, and they were relatively well equipped with resident-specific information when responding to individual concerns. In the safety-net facility, staff interacted with residents in a one-directional, “didactic” fashion, providing instruction without a mechanism for adapting to residents’ responses, and they were not as well equipped with resident-specific information. These differences reflected disparities between the two facilities in staff communication skills, underscoring the importance of workforce development to enhance the quality of staff-resident interaction and promote resident-centered care. This study raises further questions about the role of neighborhood contexts in shaping organizational processes that influence quality of life for NH residents. Moreover, the study offers a unique contribution to the NH literature by generating a typology of styles of interaction that can be used to develop a conceptual framework for understanding staff-resident interaction in the nursing home. Such a framework can inform efforts to improve residents’ quality of life.     

Staff perceptions of staff-family interactions in nursing homes

Each year thousands of older adults are admitted to nursing homes. Following admission, nursing home staff and family members must interact and communicate with each other. This study examined relationship and communication patterns between nursing home staff members and family members of nursing home residents, as part of a larger multi-method comparative case study. Here, we report on 6-month case studies of two nursing homes where in-depth interviews, shadowing experiences, and direct observations were completed. Staff members from both nursing homes described staff–family interactions as difficult, problematic and time consuming, yet identified strategies that when implemented consistently, influenced the staff–family interaction positively. Findings suggest explanatory processes in staff–family interactions, while pointing toward promising interventions.     

The missing family: Staff perspectives on and responses to familial noninvolvement in two diverse nursing homes

Although the continuum of familial involvement with nursing home residents includes those who are deeply engaged and those who are totally absent, little is known about how staff perceive and react to family noninvolvement. This article explores staff perspectives on and responses to family absence. Semistructured interviews were conducted with 52 employees and 18 residents from two NHs, one an urban facility with a largely chronic mentally ill population and the other a rural, tribally owned facility with a predominately cognitively impaired American Indian clientele. Medical record reviews were also conducted. Staff theories of family absence were informed primarily by dominant American and American Indian cultural values regarding kinship, psychiatric disorders, and institutionalization. In each facility, metaphoric kinship relationships between staff and residents compensated somewhat, but not entirely, for perceived family noninvolvement. This research highlights the cultural variability of staff perspectives on family absence but also points to similar strategies for coping with it.     

Communication in assisted living

This study of communication in an Assisted Living Facility (ALF) focuses on staff's interpretive frameworks and situational tactics for managing elderly residents. It is based on interviews with staff and residents in an ALF together with ethnographic fieldwork. As in other quasi-total institutions, staff members engage in control as well as care, monitoring residents for compliance with rules and directives. Residents, aware of the threat of being moved to a nursing home, also monitor their own behavior and cognition in comparison to other residents. Other communication issues include the infantilization of the elderly by staff, and the race, class, and ethnic prejudices of residents.     

Using group process to educate staff and manage aggressive behavior of nursing home residents

1. Group process can be an effective tool to cope with aggressive behaviors of nursing home residents. 2. Staff education in and commitment to group process are essential. 3. Peer pressure, therapeutic confrontation, and a supportive environment empower residents and staff to cope constructively with negative behaviors.     

The ties that bind? Social networks of nursing staff and staff's behaviour towards residents with dementia

This study investigated social networks of nursing staff and staff's behaviour towards residents with dementia. We focused on two types of networks: communication networks among staff, and networks between nursing staff and relatives/acquaintances of residents. Data was collected in 37 long-term care units in nursing- and residential homes in the Netherlands.     

Staff responses to age‐related health changes in people with an intellectual disability in group homes

The purpose of this study was to explore how supervisors in group homes caring for people with intellectual disability responded to the development of age‐related health changes in their residents. Ten group home supervisors working in the disability sector were interviewed once. Data were analysed using Dimensional Analysis. The study identified several factors related to whether a resident could stay ‘at home’ or would need to be moved to residential aged care (nursing home) including: nature and extent of group home resources, group home staff comfort with residents’ health changes, staff skill at navigating the intersection between the disability and ageing sectors, and the supervisor’s philosophy of care. The ability of older people with an intellectual disability to ‘age in place’ is affected by staff knowledge about and comfort with age‐related illnesses, staff skills at navigating formal services, staffing flexibility, and the philosophy of group home supervisors. Despite the growing international concern for the rights of people with disability, particularly in relation to decision making, questions about the older person’s choice of residence and participation in decision making about what was best for them, were almost nonexistent. Rather, decisions were made based on what was considered to be in ‘the best interest’.     

Physical abuse of older adults in nursing homes: a random sample survey of adults with an elderly family member in a nursing home

Few empirical studies have focused on elder abuse in nursing home settings. The present study investigated the prevalence and risk factors of staff physical abuse among elderly individuals receiving nursing home care in Michigan. A random sample of 452 adults with elderly relatives, older than 65 years, and in nursing home care completed a telephone survey regarding elder abuse and neglect experienced by this elder family member in the care setting. Some 24.3% of respondents reported at least one incident of physical abuse by nursing home staff. A logistic regression model was used to estimate the importance of various risk factors in nursing home abuse. Limitations in activities of daily living (ADLs), older adult behavioral difficulties, and previous victimization by nonstaff perpetrators were associated with a greater likelihood of physical abuse. Interventions that address these risk factors may be effective in reducing older adult physical abuse in nursing homes. Attention to the contextual or ecological character of nursing home abuse is essential, particularly in light of the findings of this study.     

Physical Abuse of Older Adults in Nursing Homes: A Random Sample Survey of Adults With an Elderly Family Member in a Nursing Home

Few empirical studies have focused on elder abuse in nursing home settings. The present study investigated the prevalence and risk factors of staff physical abuse among elderly individuals receiving nursing home care in Michigan. A random sample of 452 adults with elderly relatives, older than 65 years, and in nursing home care completed a telephone survey regarding elder abuse and neglect experienced by this elder family member in the care setting. Some 24.3% of respondents reported at least one incident of physical abuse by nursing home staff. A logistic regression model was used to estimate the importance of various risk factors in nursing home abuse. Limitations in activities of daily living (ADLs), older adult behavioral difficulties, and previous victimization by nonstaff perpetrators were associated with a greater likelihood of physical abuse. Interventions that address these risk factors may be effective in reducing older adult physical abuse in nursing homes. Attention to the contextual or ecological character of nursing home abuse is essential, particularly in light of the findings of this study.     

Sibling Roles in the Lives of Older Group Home Residents with Intellectual Disability: Working with Staff to Safeguard Wellbeing

Abstract

When parents die, siblings of older people with intellectual disability are likely to take responsibility for oversight of their wellbeing and negotiation with formal support services. This study explored the roles siblings played in the lives of older people with intellectual disability who live in group homes, and the relationships between residents’ siblings and group home staff. The siblings of 13 group home residents and the 17 supervisory staff associated with these services were interviewed, initially face-to-face and then intermittently by phone over a period of three years. Data were analysed using an inductive analytical approach. Siblings valued the relationship with their brother or sister with intellectual disability and played a significant role in safeguarding their wellbeing. Sibling–staff relationships fluctuated over time, sometimes becoming tense and difficult. Few protocols guided these relationships. A principle-based framework could facilitate negotiation between staff and siblings about expectations of communication and decision making.     

Surprise in Social Work Education

Training is commonly seen as the most viable way of ensuring good quality care in residential homes for elderly people. The literature on training has focused on a shift in emphasis from traditional 'professional' social work training for staff at a senior level to training which is to be provided for junior level staff. To this end, Scottish/National Vocational Qualifications have been introduced which, through workplace assessment of competence, have been proclaimed to be the means by which to raise the status and career prospects of a social care workforce. This article argues that task-based competence is increasingly being seen as relevant for a 'para-professional' social care workforce such as that found in the residential care sector. In the light of this, research was undertaken to establish whether residents preferred 'trained' staff, holding formal qualifications and/or NVQs, to 'untrained' staff with no recognised qualifications. The research concluded that residents want kind, understanding and experienced staff, and when length of time in post was taken into account, the effect of training was negligible. The study concluded that homes need to select staff for their good personal qualities and encourage them to stay. Staff need training that integrates skill with understanding and above all, assessment should reflect this perspective. Moreover, residents need to be involved in the assessment process.     

Preservation of self in the nursing home: Contradictory practices within two models of care

Researchers have identified several aspects of nursing home care that interfere with residents' preservation of self. This paper examines how different models of care shape residents' opportunities for preserving a sense of self, adult identity, and agency. Using ethnographic data, I analyze staff practices in two facilities that reflect the contrast between the home and hospital models of long-term care. Previous research on long-term care suggests that an informal, “home-like” approach to care creates more opportunities for residents to preserve a sense of self-identity, whereas a formal, “institutional” approach fosters depersonalizing practices that interfere with residents' psychosocial well-being. My research suggests, however, that both approaches can have contradictory effects on residents' preservation of self. I analyzed patterns of objectification and infantilization that emerged in the social interactions between residents and staff members, as well as practices that mitigated these patterns. This study highlights how a larger culture of ageism and stigma surrounding dependency can become embedded in micro-level practices and underscores the challenges of defining and implementing “good” care.     

Social work in the development of institutional care for older people in Slovenia

Social work in homes for older people in Slovenia has a special role since we have extremely institutionally-oriented care for older people. Characteristic of the development of Slovenian homes for older people is a shift in the dynamics of the orientation of the homes from a medical to a social one. Different factors influenced the shift towards a social orientation, i.e. the policy of establishing homes, the influence of sociogerontological principles, the development of social work and, recently, by their engagement with residents with dementia. In socially-oriented homes a different model of social work is used than in medically-oriented ones. The difference lies in social work methods as well as in the roles of the social worker in different areas of work with the residents, relatives and staff. By defining a model of social work in a socially-oriented home, a special field of social work with older people in the field of institutional care in Slovenia has been developed.     

Living in a Retirement Village: Choice,Contracts, and Constraints

Retirement village living is a growing housing option for older people. Research to date has focused primarily on the social milieu of the village with limited attention to the legal and financial obligations associated with this form of specialized seniors' housing. Using data from a survey of 312 Australian residents, this article suggests while residents place financial and legal obligations at the forefront when considering relocation and during residency, there is variability in professional advice and constraints on choices when needs and capacities change. The distinctive obligations associated with retirement village living require greater attention to ensure an informed lifestyle decision.     

“It’s a Dignity Thing”: Nursing Home Care Workers’ Use of Emotions1

This article examines how nursing home care workers use emotions to construct dignity at work. Previous scholarship has shown how the financial and organizational characteristics of nursing homes shape and constrain emotion work among staff. Using evidence gathered during 18 months of participant observation in two nursing homes and 65 interviews with staff, this article analyzes how, despite obstacles, nursing home care workers generated authentic emotional attachments to residents. Surprisingly, some staff members said they particularly appreciated working with residents difficult to control. They felt accomplished when such residents successfully transitioned from life at home to life in institutional care. Emotions created dignity for staff and induced compliance among residents. Emotions are not only generated by organizations and imposed on workers; staff themselves produced emotions—sometimes in ways consistent with organizational demands, and sometimes not—and they consistently found in their emotions a resource to manage the strains of their work lives.     

Ensuring an Abuse-Free Environment:

Abuse and neglect of nursing home residents are recognized as a major concern in the United States. The small amount of research conducted to date concerning the extent and correlates of the problem of abuse highlights the need for specialized staff training in abuse prevention. The residents' right to be free from abuse demands that facility staff be equipped with an awareness of the types of abuse, how to recognize the potentially abusive situations, and how to appropriately defuse conflict. This paper describes the development and test implementation of an eight module abuse prevention curriculum designed specifically for nurse aides in long term care facilities.     

Experiences of a Mass Interinstitutional Relocation for Long-Term Care Staff

This research explored long-term care (LTC) staff perceptions and experiences of working in LTC and providing care to residents following a mass interinstitutional relocation. In-depth, semistructured interviews were conducted with 63 LTC workers. Thematic analyses revealed three overarching themes related to how staff members perceived their relationships with other staff members following relocation. The first theme, post-relocation relationships between staff members, included the subthemes “Staff are segregated from each other” (physical distance) and “We were a family” to “barely say hi” (psychological distance). The second theme, post-relocation stress, has two subthemes: “Staffing is our big issue” and consequences of stress: absenteeism and leave. The third theme is recommendations for improving and managing staff relationships post-relocation. Relationships among staff members are integral to working in LTC and providing care to residents following a mass interinstitutional relocation. Recommendations for improving staff relationships and morale are suggested.     

‘IT'S TIME IT ENDED AND YET I HESITATE,I HESITATE TO END IT’: THE EMOTIONAL WORLD OF AN OLD PEOPLE'S HOME

Institutionalized responses to human care have been prone to developing unhelpful practices. Inquiries into malpractice often generate recommendations focusing on improving protocols or procedures, while neglecting the emotional experiences of both clients and staff. In this study, we aimed to address why and how complex and challenging emotions enter into care work. We explored the emotional world of a residential home for older people, using a psychosocial observational approach based on the Tavistock method. We have presented four themes: attacking–defending, living–dying, paralysis–movement and emptiness–fullness, which illustrate the complex existential challenges faced both by residents and staff in such a context. Our observations revealed how a range of defensive processes operated to protect the observer from experiencing painful feelings and emotions. Throughout the observation period an increasingly complex understanding developed of the emotional life of the home. This process was made possible by reflective supervision sessions. Our findings generate implications for the type of support that may be needed by care staff in such environments.     

Unpacking barriers to quality care for Deaf people in residential aged care facilities

Residential aged care providers often face difficulties in meeting the needs of residents with a lifelong disability. In this article, I explore these issues from the perspective of signing Deaf residents. While previous studies have documented a number of issues around staff training and communication for Deaf residents, there remains a dearth of literature considering the root causes of these problems. Drawing on interviews with a variety of service providers, this article suggests a number of ways current practices might be improved as well as discussing funding changes required to ensure Australian Deaf residents do not fall through the cracks.