Abstract
The aim of this study was to describe from a staff perspective what promotes a positive atmosphere in a nursing home for people with dementia. A nursing home renowned for its positive atmosphere and quality of care was chosen for our research. The study has a qualitative descriptive design using a modified grounded theory. Eight members of staff were interviewed. The analysis consisted of open, axial and selective coding and constant comparison between each narrative. The core category was ‘A safe haven for everyone’, with three categories; ‘Relating to people with dementia’, ‘Relating to work’ and ‘Relating to each other’. A shared set of values embraced by all staff was the foundation in the nursing home and supported the atmosphere and quality of care. The positive atmosphere had been founded on mutual trust between manager and staff, lending staff the freedom to be creative in their work, and ensuring that the residents with dementia were cared for in the best possible way.
Introduction
Caring for people with dementia has been a subject of great interest to the research community, and in both scientific literature and the daily newspapers there are reports of adverse care, violation of nursing home (NH) residents by staff and difficulties recruiting and retaining staff. Yet in some NHs there exists an atmosphere of calm, where the residents, their significant others as well as the staff all thrive. This motivated the authors to study what characterized such a NH, and we therefore conducted the present study in a NH in Sweden, renowned for its positive NH atmosphere and quality of care.
Background
People with dementia living in NHs have complex care needs and can have difficulties describing how they experience their surroundings due to communication problems. Therefore, a crucial aspect of care is how staff approach and relate to the residents and their families as well as to each other. 1 According to Edvardsson 2 the atmosphere in a NH ward is made up of the physical environment and people’s behavior, and is founded on the organization’s philosophy of care which directs the clinical practice. These dimensions are interwoven, interact and can affect the well-being of everyone. An atmosphere that characterizes the daily life in a NH where people are acknowledged, are a part of relationships and interactions, feel secure and where staff show a willingness to help, can be perceived as positive. 3
In this project, the concept ‘atmosphere’ is used as an understanding of what characterizes the daily life in a NH for residents with dementia. This has been studied from different angles, such as the organizational culture, or the work environment. 4 Organizational culture can be described as values and norms within a working group that affect attitudes and behavior. 5 In a review of NH organizational culture, the importance of a safe and caring culture to ensure the dignity and the well-being of both residents and staff was reported. 1 The study suggests that there exists an established foundation of values and ethical guidelines, support for discussions about values and difficult ethical situations and room for development of knowledge. It also necessitates an inner commitment to care involving presence and caring encounters as well as leadership with a clear vision and strategies. Studies of daily life in a NH for residents with dementia have also focused on staff experiences of the work environment and its effect on the quality of care. Backhaus et al. 6 found that a good team climate was important for the quality of care in NHs, which was also reported by Schwendimann et al. 7 Backhaus et al. 6 also reported significant association between the quality of care and both communication/coordination and multidisciplinary collaboration. Van Beek and Gerritsen 8 found that a NH culture that is denoted by shared goals, values and good cohesion and a feeling of fellowship provided better quality of care.
High quality care of people with dementia has become synonymous with person-centered care, which has become a guiding principle for dementia care internationally, including in Sweden. 9 McCormack et al. 10 reported that the practice of person-centered care requires the attributes of a practitioner that include, amongst other qualities, interpersonal skills, and clearly expressed beliefs and values. In addition, the setting in which the care is practiced needs to be supportive. Therefore, a crucial aspect is how staff relate to the residents and their families as well as to each other. However, there are many studies that report the difficulties and strains for staff working in NHs.11,12 While it is rare that positive aspects of working in NHs are highlighted, Choi et al. 13 reported a significantly higher level of job satisfaction among staff who work in NHs with a supportive work environment. Eldh et al. 14 reported that a caring relationship with residents fostered personal and professional growth and suggested that person-centered care could contribute to job satisfaction.
Backman et al. 15 found in a cross-sectional study that middle managers have an important role in supporting and developing the practice of person-centered care. The study focused on the association between the leadership behavior of managers in NH care, person-centered care and the psychosocial climate in the care facilities. In doing so, managers create both a positive climate and high-quality care.
In this project, we wanted to study what characterizes daily life in a dementia NH. Although atmosphere may be an implicit part of the organizational culture and work environment in NHs, the concept of atmosphere was used since it encompasses what we wanted to study, the subtler signs of how people acknowledge, respect and treat each other. 3 Also, we wanted to study what characterizes the daily life in a dementia NH that is renowned for its positive atmosphere and quality of care. To the best of our knowledge in the field of dementia care there is a lack of studies exploring a positive atmosphere in NHs caring for residents with dementia, and what is perceived to promote it. The aim of the study therefore was to describe what promotes a positive atmosphere in a NH for residents with dementia from the staff perspective.
Methodology
Design
A qualitative descriptive design with a modified grounded theory approach was chosen for this study. 16 Grounded theory is based on symbolic interactionism and involves the belief that meaning is constructed and can change within the interaction between people. 17 We explored the facilitators for a positive atmosphere in one NH for residents with dementia, where such an atmosphere existed. Modified grounded theory was chosen due to the lack of studies exploring the social processes and interactions between persons that resulted in a positive atmosphere for all parties in a NH. The constant, comparative method of modified grounded theory is deemed particularly appropriate for studying social processes for the collection and analyses of data.
Participants and setting
Prior to the study, an information meeting was held for staff members working at the NH. They were then able to volunteer to participate in the study by contacting the first author (MS). Eight of the eligible 11 staff participated in the study: one social worker (the manager), two enrolled nurses, and five nurse aids. Three staff were unable to participate due to long-term sick leave. The median age of participants was 50 years (range 28–66 years) and they had a median of 16 years (range 0.5–24.0 years) of care experience. Five of the eight participants had been trained in dementia care on different short courses. No Registered Nurses or Physicians were employed at the NH but were on call and could be contacted should the staff need their help. Daytime shifts were covered by one or two members of staff and one staff member worked alone at night.
The NH is located in a residential neighborhood in a small town in a metropolitan area and is situated on the ground floor of a larger building with a total of eight single rooms with private bathrooms and kitchenette. The NH has common areas for dining and socializing and a private garden, which the residents, their significant others and staff can enjoy during the summer months. All eight residents had severe dementia. The NH had been successful in yearly quality index surveys and also received a prize as the best NH of the year in the municipality, and the manager had received the manager of the year prize. There is a waiting list of staff interested in working at the NH as well as a waiting list of people with dementia wanting to move in and live there.
Data collection
The eight participants were individually interviewed by the first author. All interviews were recorded in an undisturbed, quiet room at the NH. The participants were asked to narrate experiences of their work and to give examples of both positive and negative situations (example question: ‘Please can you tell me about a positive/negative event that you experienced in your work here?’). Follow-up questions were asked based on participants’ responses in order to learn more about their experiences. Each interview was listened to in its entirety before the next one was conducted. With the previous interview/s in mind, new and critical questions were raised in the subsequent interview. The interviews lasted between 44 and 74 minutes (M = 54 min).
Data analysis
Overview: Core category, categories and subcategories.
Ethical considerations
For this present study an advisory statement was obtained from the ethical committee (2014/1657-31/5) since the study did not need ethical permission according to the Swedish Act on Ethical Review of Research Involving Humans (2003:460). Participants were informed both verbally and in writing about the study, that they could withdraw from the study without giving any reason and were guaranteed confidentiality. Before signing a written consent to participate they were given the opportunity to ask questions. Neither of the authors were working or had worked at or been associated with the facility.
Results
The results will be presented with the core category first, followed by the three supporting categories.
Core category ‘A safe haven for everyone’
The three categories; ‘Relating to people with dementia’, ’Relating to work’ and ‘Relating to each other’ together form the core category ‘A safe haven for everyone’. In the participants’ descriptions, the principle had been embedded that the residents, their significant others and co-workers were seen as valuable human beings where everyone was treated with the same level of respect and dignity. Interpersonal relationships were the foundation for the care and safety of both residents and staff, and the atmosphere was a product of this. Participants described their work as complex, difficult and challenging but not as a negative experience.
‘Relating to people with dementia’
The subcategories ‘A common ground for caring’ and ‘A feeling of trust for a person’ form the category ‘Relating to people with dementia’.
‘A common ground for caring’
The residents were described as valuable individuals contributing to the social life of the NH, all with their different backgrounds, acting and reacting differently based on how their disease affected them. The participants described that it was important to give the residents time to adapt to their new surroundings when they moved in, and for staff to get to know them.
The NH was home for the residents and the participants said that they were there for them, which was also clearly expressed by the manager who said that the resident’s routines should govern, and not the NH work schedule. Thus, staffing would be based on a person’s needs and capacity. The starting point for activities was the individual’s condition and ability, which were assessed on a daily basis, as these would change from day to day. Participants saw themselves as an extended arm, a supplement to the abilities that a person had lost. It was important for the individual’s dignity to be allowed to continue with things they still could manage and not have these taken away from them. On the other hand, it was also important that the activity was something they could cope with and was not offensive. This entailed participants needing to find alternative ways to provide care, acting as a ’jack of all trades’.
It was not only in relation to every single resident that the participants described they needed to adapt, but also in relation to the residents as a group. When a person’s demeanor was different from day to day the whole group was affected, and it was more important for those with dementia to feel an affinity to the situation rather than to participate in different activities. There were therefore no scheduled group activities at the NH. Instead participants described how they spent time with a single resident every week doing something that he or she liked.
‘A feeling of trust for a person’
The participants described how they worked towards creating a feeling of coming home to a place where the resident felt safe, a place where they could just be and had trust in the staff. They worked to break up dreariness and to create a trust in the staff for the residents, which they believed to be more important than the actual surroundings. The participants were aware that the way they themselves behaved and reacted during the day was reflected in the residents’ demeanors. They found it important that the surroundings for the residents were peaceful and quiet, unnecessary talking or sounds being avoided. They decided that to create a peaceful atmosphere at mealtimes it was important that the clatter of china and the noise of the dishwasher should be avoided. Residents were seated individually, or two or three together with a nurse sitting with them and another nurse serving. Participants stated explicitly that to create peaceful surroundings it was important that only the staff needed should be present and that they should talk in calm voices and not rush around. However, when complex care situations did occur that affected the peaceful atmosphere, staff tried to keep stimuli for the residents to a minimum. In difficult situations, they described how they balanced between being as close as the upset resident could accept without disturbing them. They avoided direct eye contact and just observed any signs that the resident might accept help. Even if the situation was difficult to handle they found it important to be sensitive and respectful to what the resident was trying to communicate. And I saw in his eyes that it was not the time for me to speak as he was very angry with those of us who were working there. So I let him just be on his own, carrying out his own business. Then he stood by the sink and I asked him gently ‘Do you want me to help you with the zipper?’ ‘Um … yes’ he said. (Participant 4)
‘Relating to work’
The subcategories ‘Taking responsibility’, ‘Being flexible’ and ‘A leadership providing mutual trust’ form the category ‘Relating to work’.
‘Taking responsibility’
Taking responsibility for their work was described by participants as important, giving them the satisfaction of experiencing a safe work situation. They described a willingness to come to work before their scheduled time to start in order to be prepared for their shift and to meet the residents and to get a sense of the atmosphere at the NH. When working alone on the night shift one participant explained that the first thing to do was to ensure that the fire equipment was in good working order, implying a focus on safety for both staff and residents. When caring for residents it was important to find alternatives to medication in difficult situations where sedation was not considered a good option. A lady who was resident here had her birthday in the summer when there is a Blues festival here in town and at night the music echoes. And when it was quiet here we heard the music and she just did not want to go to sleep. So, I thought, we have the garden furniture out there so I arranged for candlelight and coffee and then I called the home care night patrol and asked them: ‘Are you busy?’ ‘No,’ they replied ‘it is quite calm right now’. ‘Would you like a cup of coffee?’ I asked, ‘Go by the petrol station and bring some ice cream with you and come up and join us. We have a lady who has her birthday’. And they came along and brought ice cream and we had our coffee out in the garden, listened to the Blues festival together with the lady and she had her little party out there at midnight. Then she went to bed and slept very well! (Participant 7)
‘Being flexible’
Being flexible described how the participants behaved towards others on the staff, the residents and their significant others. They said that flexibility in their work was important both towards the residents when tasks had to be carried out. This was to alleviate difficult situations where a resident might be upset and could not calm down, or when the work situation required other measures to be taken. It was challenging to find alternative ways to work with residents to ensure they were comfortable and content. Within the NH they were flexible with staffing issues. If someone was ill they found solutions within the staff group to find a replacement. This was because the participants considered it not to be beneficial for residents if someone unknown to them came as a replacement.
The participants said that they were asked by their manager to also work in other NHs within their area of responsibility when the situation elsewhere was difficult and they were expected to serve as role models and challenge the existing way of working. They were happy to accept and found it interesting to try to change ways of working at these other places, and they had good support from their own work group. Likewise, some of the participants conducted sessions of reflection with staff in other NHs, and found it rewarding when staff came to realize that they needed to change their ways of working or to think again about their work routines. This also gave them a good knowledge of how other NHs in the municipality worked and the problems they had to deal with there.
‘A leadership providing mutual trust’
The participants described leadership as important for them as they trusted their manager and were in turn trusted by her. They were a closely knit group and could cope with different situations including accepting extra support when needed, for instance when a resident was approaching death. Within fiscal limits the participants discussed with their manager what was expected of them and they rose to the challenge.
The participants stated that their work group functioned well, that they had fun together and that anything reasonable would be considered. The rate of sick leave had been reduced and the manager was proud of a work group that functioned well.
‘Relating to each other’
The category ‘Relating to each other’ applied to both the residents and their significant others and colleagues, and was formed of the subcategories ‘Showing respect’ and ‘Using each other’s strengths’
‘Showing respect’
To show respect for each other was described as a ‘golden rule’ by which everyone lived and included everyone at the NH. The atmosphere at the NH was important and the significant others of the residents could come and go as they pleased and participate in activities at their discretion. Likewise, the participants showed respect for their co-workers by asking them how things were, because they quickly noticed if something bothered a colleague. The motto of the NH was to take care of each other to be able to care for others. Above all trust was important for the residents, their significant others and the co-workers at the NH. A safe working situation is everything. If we cannot cope with each other then we will not be able to cope with the residents and they are important to us. They are not just here in order for us to have a job. They are a large part of everything and I find that important. We are here for them and they must have trust in that. (Participant 2)
‘Using each other’s strengths’
Using each other’s strengths was important when participants recognized that they were all good at different things, and that they all had their bad days and would need support. All knew each other well and a golden rule was to talk with each other instead of talking about each other. Everyone could provide support and advice if someone found it difficult working with a resident, and if the co-worker had a ‘bad day’ they could withdraw and focus on other things that needed to be done. The participants described that everyone is involved, which creates unity within the group, but that they work independently yet solve problems together. When problematic situations occurred with a resident they helped each other to resolve the situation. We talk a lot to each other. We take a moment and just sit down and talk through a problem. I think that’s good, because it gives you the energy to go on. … Maybe advise each other on how to deal with different situations. (Participant 1)
Discussion
The core category ‘A safe haven for everyone’ points towards a shared set of values for everyone involved in the NH. This shared set of values is the foundation for how the staff regard everyone they meet and work with, irrespective of whether it is a colleague, a resident or a significant other.1,8 Everyone is worthy of respect and this shared set of values is supported by their manager, which is important and has been highlighted by Sjögren et al. 18
Wilson 19 found that a personal philosophy among staff was an important aspect of how the staff approached and treated residents in three NHs. When the staff worked as a team it was understood that they all shared similar personal philosophies and valued their relationships with the residents. This is similar to our results yet different. In the NH, we found a shared set of values had evolved for all staff, and was not dependent on personal philosophies, but rather was formed because people on the staff had worked together for a long time. The shared set of values was strongly supported by their manager and leadership was important for the atmosphere and quality of care. This was also found by André et al. 20 and Sjögren et al. 18
In this present study, the participants stressed that how they behaved towards their fellow human beings had nothing to do with why they were in the NH, be they staff, residents with dementia or their significant others, they were all equal. Prahl et al. 21 studied the certification of an educational model in one NH for people with dementia that involved all staff that worked there and not just staff caring for the residents. The results showed that staff appreciated that they had increased their knowledge of dementia and of how to care for those suffering from the disease. They had also developed a shared set of values to underpin how they worked together with each other and those in their care. It therefore seems reasonable to believe that a shared set of values that considers the intrinsic worth of every human being, irrespective of who they are, is important for creating a pleasant atmosphere for everyone in a NH. Barnes and Brannelly 22 discuss the core principles of an ethic of care: attentiveness, competence, responsibility, responsiveness and finally trust, and most importantly that these qualities are shared amongst those who care for people with dementia. This seemed to be the case in this study, and possibly these were the core elements that created the atmosphere in the NH, involving also the significant others when they came to visit. Öhlander 23 describes the impact of preserving the dignity of people with dementia who share their lives with others in a NH. From the results in this present study it can be argued that not only the dignity of the residents was preserved but the dignity of their significant others and staff as well. The shared set of values amongst the staff was characterized by the importance of dignity, a nurtured care and one’s attitude towards one’s fellow human beings. 1 Thus, the staff concentrated on person-centered care, assessing the condition of each resident on a daily basis in order to be able to tune in with them.10,24,15 This happened even though person-centered care per se had not been implemented at the NH.
A shared set of values requires staff to have time for interaction with each other, and to discuss how to deal with the difficult situations that may occur in daily work, as described by the participants in our study. Communication and interaction among staff will also have an impact on the quality of care according to Anderson et al. 26 and Backhaus et al. 6 This is also related to leadership. As Anderson et al. 26 stated, the quality of care depends on how the manager relates to the staff, which in turn affects how staff relate to each other and how they create caring relationships with the residents. 1 To achieve good qualitative interaction requires leadership that provides opportunities for staff to make things as good as possible for those in care. A common traditional top-down leadership model could negatively influence this process. 26 In this present study there was a consistency between how staff and the manager expressed how the care of residents would be performed, demonstrating a shared vision of that care. The manager had confidence that staff would make life as pleasant as possible for the residents and they in turn had confidence in the manager.
Willemse et al. 27 suggested that training and trying to engender an attitude of person-centered care could lead to a stronger and more confident team. However, to avoid staff becoming emotionally exhausted, a balance between engagement with those they cared for and maintaining a professional distance was suggested. Focusing on creating a positive work environment could improve job satisfaction among NH staff. This included a balanced workload, delegated authority and social support. Support from the manager was considered particularly important. 15 In our study, it appeared that in their everyday work staff experienced that there was a workload balance, as special issue of this was not made in the interviews. This only came to the fore in particularly demanding situations, when they said that they had the support of their manager. In everyday care, it was up to them to find the best solutions for situations that occurred, both with regard to residents and in staff related issues, which equated to having delegated authority to do what feels right and appropriate.
Methodological considerations
Some critical questions need to be addressed. This study was carried out in one NH for people with dementia renowned for its positive atmosphere and quality of care. It was a purposive sampling since we wanted to explore facilitators for a positive atmosphere in this specific NH. It could be questioned whether it was a good idea to explore such a positive example when the clear majority of facilities face great problems in their care of people with dementia. Nevertheless, we deemed it important to try to find out what characterized a NH where both staff and the residents living there seem to thrive, and, if possible, to use the findings to encourage intervention in other NHs where the atmosphere was less positive. The fact that the study accessed only a small sample and looked at just one NH needs to be taken into account when transferring the results to other contexts and settings. The interviews with the eight participants can be questioned but the last interview did not provide any new information that had not been presented in the previous interviews. We do not know whether the three members of staff who were on sick leave could have added something new to what had already emerged. So full data saturation might not have been reached.
To ensure trustworthiness both authors worked independently on the analysis and the result was critically discussed with colleagues at research seminars. These seminars helped us to keep a critical perspective and diminished the risk of giving an idealized picture of the NH. The authors’ preunderstanding was that it was a well-functioning NH and we did not want our preunderstanding to block our views in the interviews and data.
Application
In this study, a shared value implemented and shared with all staff was the foundation in the NH and supported the atmosphere and quality of care. The atmosphere was built on mutual trust between manager and staff which allowed staff the freedom to be creative in their work, ensuring that those with dementia would be cared for in the best possible way. The results can be a starting point for further studies of the importance of the atmosphere in NHs. Knowledge of the importance of various aspects of the atmosphere created can guide interventions in NHs wishing to change a less satisfactory situation.
Footnotes
Acknowledgements
The authors wish to thank the participants for their time and contribution to this study, which made this research possible.
Funding
This work was supported by Stiftelsen Ragnhild och Einar Lundströms minne [Diarie Nr: LA2014-0166], and Ersta Sköndal Bräcke University College, Stockholm, Sweden.
Conflict of interest
The authors declare that there is no conflict of interest.