From Person-Centered to Relational Care: Expanding the Focus in Residential Care Facilities

Long-term residential care facilities for older adults currently espouse a philosophy of person-centered care (PCC). However, these facilities operate according to a medical model with highly structured administration and regulation. As a result, there is tension between the priorities of the resident and the organization. A qualitative study conducted with 4 social workers and 1 physician employed in residential care facilities demonstrates not only the structural barriers to PCC, but also the importance of meaningful relationships to residents' socio-emotional well-being. The final section explores how organizational barriers might be mitigated through the complementary use of relational care.     

Residential care: an effective response to out‐of‐home children and young people?

The ever‐growing number of out‐of‐home children in Italy over the last decade has urged an assessment of the available care services. Although foster care is spreading rapidly, many young people are still housed in residential facilities. Reflection on residential care quality has intensified at both a national and an international level. This paper presents the results of a study on residential care facilities for children and young people in the region of Northern Italy (Lombardy). Four dimensions of ‘quality’ are considered: efficiency, effectiveness, participation in planning and intervention, and empowerment of children and their family relationships. The combined effects of these dimensions are defined as ‘relational quality’. The results show that residential care facilities are generally good, while Social Services resources often appear inadequate for interventions aimed at birth families (efficiency). The well‐being of children in residential care facilities is high, even if they tend to move from one facility to another, rarely returning to their birth family (effectiveness). The involvement of children and their families at different stages of the care path is limited (participative approach). Finally, the most critical element is the failure to properly involve birth families (empowerment).     

Therapeutic residential care in Spain. Population treated and therapeutic coverage

Therapeutic residential care (TRC) is the name given to specialized children's homes for treating cases with severe emotional and behavioural problems that have been placed in residential care. A recent international review has revealed great diversity in the referral criteria of cases and in the models of intervention carried out. The goal of this study is to describe the population treated in these types of facilities in Spain and the therapeutic coverage given. The sample is made up of 215 young people in children's homes, of whom 93 are in TRC. The cases referred to TRC have been in residential care for less time but have gone through a greater number of placements. These young people also exhibit more problems of drug use, and there is a larger percentage of clinical‐range cases in the Child Behaviour Checklist scales of attention problems and aggressive behaviour. Nevertheless, the results of logistic regression indicate that the only variables that significantly increase the probability of being referred to TRC are drug use and changes of care placements. With regard to therapeutic care, there is a higher percentage in the TRC group receiving psychiatric care, and the sessions are also more frequent.     

Multilevel factors related to psychosocial care outcomes in Washington State skilled nursing facilities

As the primary providers of psychosocial services in skilled nursing facilities, social services professionals report barriers interfering with their ability to meet residents' needs. This study utilizes a 3-category quality assessment framework and a cross-sectional survey design to assess factors impacting the provision of effective psychosocial services in Washington State facilities. Hierarchical linear regression results indicate that the 3-factor model explains 26.4% of the variance in psychosocial outcomes; 4 variables exert the most influence: ownership turnover, practitioner experience, practitioner role identity, and the importance of individualizing care. Findings have implications for developing necessary supports for quality psychosocial care delivery.     

Screening for Geriatric Depression in Residential Care Facilities: A Systematic Narrative Review

Studies in residential care facilities suggest that routine screening can assist in the early detection of geriatric depression. However, the effectiveness of screening instruments in residential care in the US and Canada has not been adequately evaluated. We conducted a systematic narrative review of the English-language literature published between 2000 and 2010 on screening instruments used for depression detection in older adults living in residential care facilities. The review yielded nine scales and their modifications tested in residential care, which we evaluated. We provide specific recommendations for the use of effective scales and discuss implications for practice, policy and research.     

Commercial,non‐profit and governmental residential elderly care in Flanders: Differences in client selection and efficiency?

Verschuere B, Moray N, Decramer A. Commercial, non‐profit and governmental residential elderly care in Flanders: differences in client selection and efficiency? Inspired by New Public Management, governments have stimulated competition, outsourcing and privatisation in the public sector. Also, in care of the elderly, there has been a substantial increase in commercial provision. The present study explored the presumed differences in the performance of public (governmental), private non‐profit and private commercial elderly care organisations. We used quantitative indicators on the population of residential elderly care organisations in Flanders (Belgium). Although we found that commercial elderly care facilities tended to be more input‐efficient while non‐profit and public elderly care facilities tended to be more attentive to recruiting and housing residents with high care needs, these results need to be interpreted in light of the regulatory framework in which the different types of elderly care facilities operate.     

Treatment progress of foster care adolescents with severe behavioural problems: Factors conditioning their performance in the residential treatment centres

Behavioural problems are a recurring issue in the child welfare system population. Normative residential centres do not have the characteristics to address the specific needs of these adolescents, so they are usually treated at therapeutic residential centres. In Catalonia (Spain), these cases are treated in intensive educational residential centres (CREIs), a variant of therapeutic residential care (TRC) facilities. This exploratory study seeks to understand the treatment progress of adolescents with severe behavioural problems who were placed in the CREIs, a variant of TRC facilities. Data from 206 cases, the totality of population under treatment in the CREIs, were collected using a questionnaire administered to the treating team. A cross‐sectional design was used, applying quantitative methods to analyse the incidence and interrelation of a series of variables related to the progress of adolescents in the CREIs. Significant differences among profiles by sex, place of origin, criminal offences, substance abuse and mental health disorders were found. Furthermore, adolescents who performed a positive treatment progress according to the professional staff arrived at the CREI at an earlier age and had longer stays than the group with an unremarkable progress. Logistic regression indicated that duration of stay in the centre and runaways predict the adolescents' treatment progress. This treatment is working well with the milder cases; however, it does not tend to be successful for adolescents with greater difficulties. It is recommended that interventions focus on factors that engage the adolescents in their own rehabilitation process, include substance abuse programmes and consider the gender perspective.     

Unheard voices,unmapped terrain: Care work in long‐term residential care for older people in Canada and Sweden

Daly T, Szebehely M. Unheard voices, unmapped terrain: care work in long‐term residential care for older people in Canada and Sweden This article aims to contribute to comparative welfare state research by analysing the everyday work life of long‐term care facility workers in Canada and Sweden. The study's empirical base was a survey of fixed and open‐ended questions. The article presents results from a subset of respondents (care aides and assistant nurses) working in facilities in three Canadian provinces (n= 557) and across Sweden (n= 292). The workers' experiences were linked to the broader economic and organisational contexts of residential care in the two jurisdictions. We found a high degree of country‐specific differentiation of work organisation: Canada follows a model of highly differentiated task‐oriented work, whereas Sweden represents an integrated relational care work model. Reflecting differences in the vertical division of labour, the Canadian care aides had more demanding working conditions than their Swedish colleagues. The consequences of these models for care workers, for older people and for their families are discussed.     

Is home care a realistic alternative to residential care among institutionalized elderly people in Finland?

The high rate of institutionalization among elderly people in Finland is widely discussed among policy-makers. We studied how realistic the wishes for deinstitutionalization are among the least sick elderly people in residential care, and what patient characteristics predict whether residential care is appropriate. This issue was assessed by the residential home personnel. Personnel assessment of institutional care as appropriate was mainly explained by patients' needing help with medication, limitations in activities of daily living, absence of own home to return to, no living children, incontinence, and poor vision. Discharging elderly people from long-term residential care back to society is limited by factors such as inadequate housing and shortage of domiciliary and rehabilitative services, as well as by attitudes among the institutionalized elderly people themselves. It seems more realistic to prevent the inappropriate institutionalization of elderly people than to discharge the small numbers of fairly independent individuals already in residential homes.     

A good death for residents of long-term care: family members speak

Little research has been done on the topic of end-of-life care in long-term care settings to identify important themes regarding end-of-life care structures, processes, and outcomes. This study utilized data gathered in a stratified, random sample of 437 family members of residents who died in 31 nursing homes (NHs) and 199 residential care/ assisted living facilities. Structural components of care including staffing adequacy, training, and consistency as well as facility environment and size were important factors for family members interviewed. "Being there" and manner of care delivery (e.g., staff attitudes/empathy) were major elements in the process of care. These factors were mentioned more than direct care, Hospice, or resident preferences. Family members identified themes of [dying at] home and being comfortable and clean as important outcomes of care. These identified structural components, processes, and outcomes have implications for the role of social workers in these settings despite that social work support is notably absent in these findings.     

Interpretative phenomenological analysis of young people's lived experiences of therapeutic residential care

Concerns of maltreatment and poor outcomes persist in residential care despite numerous government inquiries and recommendations. Young people in residential care continue to be the most vulnerable and marginalized group in the out‐of‐home care population. Young people's voices are also underrepresented in research. Existing studies predominantly focus on service evaluations in which individual voices of young people are overshadowed by adults' perspectives. Other studies examine the perspectives of young people in out‐of‐home care as a homogenous population, limiting understandings of the subjective experiences of young people in residential care. This study focused exclusively on young people's lived experiences in Australian therapeutic residential care, utilizing interpretative phenomenological analysis. The young people in this study revealed experiences of peer victimization, ambiguous loss and uncertainty during transitions. These findings suggest that more work is required in order to provide safe and healing environments and experiences for young people in therapeutic residential care. Each individual voice captured in this study offers valuable insights into how residential care practitioners can strengthen practice to enhance protection, engagement, connection with families and leaving care support.     

Multi-system factors impacting youth justice involvement of children in residential out-of-home care

Children placed in residential care are significantly over-represented in youth justice systems. Drawing on interviews and focus groups with service providers, this exploratory study examines practice factors that impact on the criminalization of this group of children across multiple services and systems, including in the residential care environment, police, lawyers, courts and youth justice systems, as well as multi-systems practice with this group in one Australian state. Positive outcomes were observed for children in residential care where well-functioning care teams existed, as well as for children in therapeutic residential care settings. However, clear limitations were identified across all phases of children's youth justice system involvement, including placement with offending peers, the criminalization of behaviours of concern, greater use of remand and detention, limited support to navigate legal and youth justice processes, challenges to service collaboration, and limited applicability of sentencing considerations. The findings indicate a pervasive level of systemic disadvantage for this group of children, and imply that a holistic strategy underpinned by affirmative action across several systems will be necessary to address the ongoing criminalization of children in residential care.     

Policy transfer,social pedagogy and children's residential care in England

Much concern has been expressed about the quality of care and poor outcomes for looked‐after children (‘children in care’) in England, especially regarding residential homes. This paper builds on a recent evaluation of the piloting of the continental European model of social pedagogy (SP) in English residential care. It does three things: it considers the theoretical social policy literature on policy transfer and its implications; discusses European residential care for children and the discipline of SP; and reflects on these debates and the situation of children's residential care in England. The paper concludes that there are some major hurdles to a widespread implementation of SP in England. This particularly concerns the differing social, professional and political context of children's residential services across neighbouring countries.     

Risk,resilience and identity construction in the life narratives of young people leaving residential care

The role of residential care for children has developed very differently internationally, but in all cultural contexts, there are questions about the extent to which it can help young people recover from high risk backgrounds. In the UK, residential care has come to be seen as the placement of last resort, yet new government guidance on permanence has suggested that residential care can provide security and a sense of belonging. Narrative analysis of interviews with 20 care leavers identified their different pathways from birth families through residential care to early adulthood. Some experienced a transformation from a negative sense of self as victims or ‘bad children’ to survivors, while others continued to struggle. Key to successful turning points were four interacting factors, all associated with resilience; connection, agency, activity and coherence. These narratives revealed the importance of nurturing relationships and a sense of ‘family’, and also the role of support after leaving residential care, when transitions workers helped them to move on but stay connected. The study highlighted how residential care leavers from adverse backgrounds attribute very different meanings to their experiences, which affects identity construction, resilience and the need for support.     

Resilience of Young People in Residential Care

Children and young people in residential care may have experienced or may experience various difficult, life-threatening events, such as neglect, abuse, or violence and maltreatment known as adversities. Despite this, some of them are able to function and even prosper and this has been attributed to the development of resilience. In this qualitative empirical study, we focus on the under-researched area of how young people in care reflect on and cope with such adversities. The exploratory research comprised of semi-structured interviews with young people in two different care settings – re-education centres and children’s homes. The results showed that the sample of 34 young people had experienced 73 adversities prior to leaving residential care and that half of them were not able to resolve some of these adversities. It was found that methods for dealing with adversity change during time spent in care and that a combination of various individual strategies, adaptation and accepting support are effective. The findings also indicate that the development of resilience may vary according to type of residential care setting specifically, whether these facilities allow the development of multiple individual strategies for dealing with adversities, or whether they provide social support. The article discusses implications for future research and practice in residential care.     

Research review: Aging out of residential care in South Africa

Approximately 21,000 children were accommodated in residential care in South Africa in 2011/2012. Despite this large number, and the state's substantial financial investment in residential care, there has, until recently, been little research on care‐leaving: the transition out of care due to reaching adulthood. Furthermore, much of the research available has not been published in international journals. This article reports on a systematic review of research on residential care‐leaving in South Africa, from 2003 to 2016. A thematic analysis of the resulting 40 research outputs maps the scope of findings from South African research, in relation to theory of leaving care, measurement tools developed, young people's experiences of leaving care, transitional outcomes, processes of leaving care, facilitators of improved outcomes, care‐leaving services, and policy on leaving care. Critical gaps in the current research opus are identified, with a view to refining future research on young people aging out of care in South Africa.     

Managing behaviour in child residential group care: unique tensions

Residential group care workers are frequently required to support children with extremely challenging and aggressive behaviour. Our knowledge about the tensions that may exist for workers that manage difficult behaviour is theoretically and empirically underdeveloped. The aim of this exploratory study was to contribute to our understanding of the dynamics of behaviour management in the residential environment by identifying the worker‐reported tensions involved in the management of challenging and disruptive behaviour. Seventeen South Australian residential group care workers participated in semi‐structured interviews in which they were asked to describe their management of behaviour. These interviews were subjected to thematic analysis. The analysis revealed several dynamics that influence workers' management of challenging behaviour: the sense of parenting at a distance, the pressure for consistency, the desire for balance between control and connection, the desire for normality and the inconsistent nature of relationships. These findings contribute to our knowledge about the interpersonal context in which behaviour is addressed in the residential group home and enhance our understanding of the unique tensions that workers' experience in managing behaviour in the residential environment. The findings have implications for the development of staff training and the support of residential care workers managing challenging behaviour.     

Consumer direction in long-term care policy: overcoming barriers to promoting older adults' opportunity for self-direction

There has been a growing trend in long-term care policy to offer individuals with disabilities the option of consumer direction (CD), where responsibility of managing care and support services is transferred from agencies to care recipients, thus supporting clients' self-determination. Although CD has been accepted as an option for non-elderly individuals with disabilities, barriers persist to promoting older adults' autonomy through CD. This article reviews the incorporation of CD in long-term care policy, addresses the current barriers to providing older adults the right to self-direct, and makes recommendations for overcoming these barriers through social work practice, policy, and research.     

Multilevel Factors Related to Psychosocial Care Outcomes in Washington State Skilled Nursing Facilities

As the primary providers of psychosocial services in skilled nursing facilities, social services professionals report barriers interfering with their ability to meet residents' needs. This study utilizes a 3-category quality assessment framework and a cross-sectional survey design to assess factors impacting the provision of effective psychosocial services in Washington State facilities. Hierarchical linear regression results indicate that the 3-factor model explains 26.4% of the variance in psychosocial outcomes; 4 variables exert the most influence: ownership turnover, practitioner experience, practitioner role identity, and the importance of individualizing care. Findings have implications for developing necessary supports for quality psychosocial care delivery.     

Culture change in long-term care: educating the next generation

Long-term care facilities for frail elders are usually based upon the medical model, which is focused primarily on the biological functioning of these elders. The medical model allows for little choice on the part of the residents of these facilities. By way of contrast, culture change is a new approach to long-term care. This model of care seeks to meet a wide variety of needs for the elders and aims to expand their choices. This article presents the observations of college students responding to interactions with frail elders and looks at the implications of culture change for young adult college students.