The Challenges of Moving from Regular Nursing Homes toward Innovative Long-Term Care Settings: An Interpretative Description Study of Staff Experiences

Abstract

This study examined how staff experiences a relocation from a regular to an innovative living arrangement and what procedures are followed. Semi-structured interviews and observations were conducted. Staff (N = 41) were included if they worked at the selected locations (N = 3). Staff reported feeling lost physically and emotionally. They stressed the importance of constructive communication and collaboration and having a say in the physical environment. Staff acknowledged the opportunities of the new environment, but also experienced several challenges when relocating and working in an innovative environment. This study showed that relocating is a stressful undertaking for staff. The help they needed in adjusting to a new environment, and to a new way of working, was underestimated.

Keywords:

• Innovative housing with care
• nursing
• relocations
• older adults
• care environment

Background

Within long-term care, a culture change has been taking place for many years that involves a shift in both philosophical and practical viewpoints (White-Chu et al., 2009). This change in viewpoints has led to a more psychosocial approach with a primary focus on quality of life (Hill et al., 2011; Roberts & Pulay, 2018). As a result, innovative living arrangements are being developed to accommodate this culture change, which are purpose-built to meet the needs of residents. These innovative living arrangements are aimed at not only changing the physical environment, but also the social and/or organizational aspects. When a relocation in long-term care is taking place, not only residents but also staff are relocating to this new location, a so-called “mass interinstitutional relocation” (Canham et al., 2018; Castle, 2001).

Relocating in general within long-term care is an extensive and intensive undertaking, and is stressful for residents and staff (Canham et al., 2018; Falk et al., 2011). On the other hand, one study showed that relocating to an innovative living arrangement might lead to a reduction in anxiety (Kok et al., 2018). Research concerning this topic is, however, scarce. Besides having to physically move residents, staff, and equipment, care has to be continued as well. Furthermore, the relocation is an ongoing process, from the preparation phase to the actual relocation process and ending with the post-relocation phase lasting for months after the actual move (Kearney et al., 2015). Research shows that a relocation can be very stressful for staff. A relocation can have an impact on the social relationships among staff and may lead to an increased sense of isolation and uncertainty (Bellagamba et al., 2016). Furthermore, the experienced stress can in turn lead to more absenteeism (Canham et al., 2018), which can be detrimental for care organizations in the face of existing staff shortages.

The focus of innovative living arrangements is not only on altering the physical environment but also on implementing changes in the social and organizational environment, a so-called culture change. Regarding culture change, the aim is to transition nursing homes from institutions to homes for residents, to improve quality of care and quality of life (Chisholm et al., 2018), and to achieve a better person-environment fit (de Boer et al., 2021). A good person-environment fit occurs when the person’s needs and abilities match with the resources of the environment (Jao et al., 2021). This can be achieved for example by training staff to consider the location as the house of the resident, respecting privacy and mutual consent, or by creating shared values that are facilitated by the managers (de Boer et al., 2021). Within the social environment, staff are key in helping residents to remain as independent as possible through social support, such as by getting to know the residents and empowering them (Fazio et al., 2018). Within the organizational environment, culture is important in obtaining a higher quality of care. When staff are empowered and involved in the work culture, this may lead to a higher quality of care (André et al., 2014). Implementing this culture change, however, is hard and only a small percentage of nursing homes actually succeed in implementing a new work culture (Koren, 2010).

Studies have focused on the experiences of staff when relocating within long-term care. However, as there is a trend within long-term care where innovative living arrangements are developed, this inevitably increases the amount of relocations from a regular to an innovative living arrangement. The combination of relocating and concurrently achieving a successful culture change may be a daunting task for staff. It is yet unknown how staff experience relocating from a regular nursing home to an innovative living arrangement. Hence, the research question of this study is: “How do staff experience a relocation from a regular to an innovative living arrangement?” To answer this question, two subquestions are posed: (1) what procedures were followed throughout the relocation process? and (2) How did staff experience the relocation process?

Methods

Study design

A qualitative study using semi-structured interviews and observations was conducted based on an interpretative description approach (Thorne, 2016). This approach was chosen, as interpretative description captures the subjective experience of individuals and leads to extended practical knowledge of relocating (Thompson Burdine et al., 2021). To ensure transparency and rigor, the COREQ checklist was used for reporting (Tong et al., 2007) (see additional file 1 in Supplementary Material). This study has been preregistered at “onderzoekmetmensen.nl.”

Setting and participants

Nursing homes that have experienced a relocation to an innovative living arrangement were selected. A location was regarded as an innovative living arrangement when it aimed to substantially change the physical, social, and/or organizational environment and presented itself as an alternative to regular nursing home care. Furthermore, the location had to offer 24-h care to older people above the age of 60 with psychogeriatric and/or somatic symptoms. In total, three Dutch locations were selected (for a description of the locations, see Table 1).

Table 1. Description of all relocation locations.

Location	Description old location	Description new location
Location A (N = 3)	A large building where residents live on the second floor. The environment has one large hallway where all rooms are adjacent. The residents live together in smaller groups. One small group (about ten residents) was followed.	Aims to create an environment that focuses on dementia-friendly living, with the motto of adding life to days instead of days to life. The relocation has led to an increase in staff members that were recruited while emphasizing the importance of the new vision. It is a larger building within the village with a vibrant “living kitchen,” centered at the front of the building. No formal courses were provided.
Location B (N = 15)	A large nursing home with wards. It has a large staff member pool and about 30 residents.	Small houses for seven residents in a park-like environment with an aim of creating more freedom of movement for residents and more person-centered care. The houses aim to resemble an archetypal house, with a combined living room and kitchen, a hallway with seven bedrooms and shared toilets and showers. Domotics, such as sensors and GPS, are implemented with the aim to increase the amount of freedom for residents. Staff members were prepared for the new location by visiting other locations with a similar vision and discussing the vision within work groups.
Location C (N = 21)	A building resembling an apartment building, consisting of five floors with one kitchen/living room and about seven residents on each floor.	A care environment with elements of green care farms in the countryside, including outside walking routes and animals. They focus on the strength and independence of residents and doing everything together with them. The new building is large, with multiple hallways where bedrooms are located. There are three combined living rooms and kitchens. All staff members followed several courses, both practical courses in using technology and cooking, as well as courses in vision implementation. These courses started just before the relocation and continued after.

Staff of identified locations were included if they: (1) worked at the included locations or (2) were involved either internally (e.g. care staff, management, or policy officers) or externally (e.g. architect, or project leader of the relocation process) in designing/developing the innovative living arrangement.

In this study, maximum variation sampling was used, meaning we aimed for a group of participants with a variety of demographic characteristics representing the target group per location regarding gender, age, educational level, work function, and amount of years staff worked at the location (Moser & Korstjens, 2018). The sample size depended on data saturation, meaning that no new themes were observed within the data (Guest et al., 2006). It became evident that a larger group of participants was necessary to understand the lived experience of the entire relocation process. This because some stakeholders were more involved in the preparatory phase, while other were more involved in the weeks after relocating. Furthermore, every included relocation case was unique in its own, and we wanted to include the voices of staff members of all locations. The Medical Ethics Committee of Zuyderland approved this study (registration number: METCZ20210065).

Data collection

Semi-structured interviews and observations were conducted between June 2021 and May 2022. Interviews took place two weeks after the relocation. The topic list (see additional file 2 in Supplementary Material) was based on the relocation phases (Davies, 2005; Groenvynck et al., 2021): (1) weeks before the relocation (e.g. how did staff experience the weeks before the relocation?), (2) the relocation day (e.g. how did staff experience the relocation day?), (3) weeks after the relocation (e.g. how did staff experience the first weeks after relocating to the innovative living arrangement?), and (4) the new location (e.g. how to staff experience the new location and new way of working?). When care organizations agreed to participate, staff members received information concerning the study and were asked to participate. All approached staff members agreed to participate. Interviews took place at the included locations during working hours, or right after their shift. The interviews were recorded and a summary was sent afterwards for a member check. Furthermore, demographic data were collected: age, gender, educational level, years of employment within the location, current work position, and number of working hours per week.

To gain a deeper understanding of the entire relocation process, method triangulation was used, by additionally performing observations (Polit & Beck, 2008). The researcher (MB) attended preparatory meetings about the relocation, such as project meetings, discussions concerning the vision, family gatherings, and other related meetings. The researcher also observed the weeks before the relocation, the relocation day itself and the weeks after the relocation, taking field notes.

Data analysis

The demographic variables were analyzed using descriptive statistics. The interviews were transcribed verbatim and then analyzed using a thematic analysis (Braun & Clarke, 2012). An inductive coding method was used, with the research question in mind (de Casterlé et al., 2012; Dierckx de Casterlé et al., 2021). First, all interviews were read thoroughly to become familiar with the data. Second, all interviews were summarized to capture the essence of the interview. These summaries were shared with interviewees for a member check. Third, a list of statements was developed, with each one being assigned a “code” (e.g. the relocation process was exhausting/tense for staff). All statements were associated with or related to the research question and the codes were intended to remain as close to the statements as possible. Qualitative data analysis software MAXQDA was used (VERBI Software, 2021). The codes were then clustered into several themes. Throughout the entire process, the interviews were compared, the codes were improved, and new emerging themes were checked with the already-coded interviews. MB coded all the interviews. To ensure the quality of the analysis, a second researcher independently analyzed 10% of the data as well, and the findings were discussed with the research team. Field notes were analyzed, using a narrative approach. The first author (MB) reviewed the field notes multiple times to look for a generic narrative. Themes, characters, and events were identified and compared with the interview data.

Results

Sample characteristics

A total of 39 interviews with 41 participants were conducted, each lasting an average of 48 min (range 16–85 min). Two interviews were conducted with two staff simultaneously. See Table 2 for participant characteristics.

Table 2. Participant characteristics.

Demographic variables (mean, SD, number, percentage)
Age, mean (SD, range)	45.7 (10.9, 24–60)
Gender, number (%)
Male	9 (22.0%)
Female	32 (78.0%)
Work position, number (%)
Manager	3 (7.3%)
Baccalaureate-educated registered nurse	4 (9.8%)
Vocationally trained registered nurse	5 (12.2%)
Certified nurse assistant	6 (14.6%)
Nurse aid	6 (14.6%)
Client attendant	3 (7.3%)
Activities supervisor	3 (7.3%)
Social worker	2 (4.9%)
Occupational therapist	1 (2.4%)
Psychologist	1 (2.4%)
Architect	1 (2.4%)
External advisor	2 (4.9%)
Policy officer (focusing on relocation)	2 (4.9%)
Project manager (focusing on relocation)	2 (4.9%)
Educational level, number (%)
Preparatory secondary vocational education school	4 (9.8%)
Senior secondary vocational education and training	19 (46.3%)
Senior general secondary education and university preparatory education	13 (31.7%)
Bachelor or Master level	5 (12.2%)
Years of employment, mean (SD, range)	10.8 (11.2, 0.4 − 41.0)
Number of working hours, mean (SD, range)	30.3 (5.1, 20–36)

Relocation procedures

All locations established project and/or working groups that were responsible for either the entire relocation process or a part of it. These groups consisted of managers, nursing staff, and client council members. All groups started preparations more than a year before the actual relocation.

Weeks before relocation

In the weeks before the relocation, the process of providing information concerning the relocation was considered very important. Care organizations mostly informed either staff or family by organizing informational meetings, letting them visit the location pre-relocation, and either informing them through a face-to-face meeting or a mail, folder, or letter. For residents, staff emphasized that they tailored their way of informing based on how the resident would respond and what their needs were. This meant that a large number of residents was informed in a very informal way (e.g. mentioning it during care moments) or were not informed at all. In the weeks before the relocation, the procedure differed among locations. Furthermore, a project manager, architect, and other external parties were actively involved in the preparation phase, creating the physical environment, the vision, and also the procedures of the relocation. Workgroup members created a script for the relocation day with clear information on what the relocation day would look like and what everyone’s task was.

Nursing staff not directly involved in project or work groups criticized the information process. They felt that they were not involved properly in the preparation phase of the relocation, either due to not receiving important information, receiving information too late, or not being involved in the decision-making process. The field notes showed that most preparatory workgroups mainly consisted of policy officers, management, and a few staff members. So even though some staff were involved in the preparatory phase, the transfer of information to the rest of that care team was experienced as unsatisfactory and the need for clear communication and involvement in the relocation process was mentioned in several interviews.

(Nurse, 32, interview p02_03) [I have to say that there was some commotion the last weeks before the relocation, because the communication had not gone well. You could tell that the “top layers” were properly informed and were in possession of a script, but the care staff was not yet informed and you could hear the commotion (…) Staff wanted to be involved, they really could have been and should have been involved better.]

The relocation day

The relocations differed in how the relocation day was organized. Some staff emphasized the importance of a short and stimulus-free relocation, while others emphasized the importance of celebrating and creating a festive environment. Three aspects were the same throughout all relocations: first, most relocations arranged for a place (e.g. hall or restaurant) where the residents could gather, so they would not experience the actual relocation of boxes with belongings; second, all relocation days were focused around eating moments, for example by having an elaborate breakfast or lunch and ending the day with a nice dinner; lastly, family were invited to enter the new location together with the residents.

Most staff were very satisfied with the relocation day. They felt that the relocation was organized properly (e.g. no unexpected setbacks, clear planning). Furthermore, the relocation day was experienced as a very festive day as there were decorations, a red carpet, and champagne.

Weeks after relocation

The emphasis during the weeks after the relocation was mainly orientation to the new location. Staff focused on routines to help residents with wayfinding and getting used to the new environment. Furthermore, every location or team arranged diverse activities and procedures to help residents get used to their new surroundings, ranging from arranging numerous recreational activities, to distracting the residents, to sticking to routines that the residents were familiar with. However, staff felt that they did not have enough time to help the residents get used to the new environment. They experienced the weeks after the relocation as a stressful and chaotic period. A lack of time and practical issues with the new location (e.g. missing equipment or having problems with the available facilities) were mentioned the most. The members of the project team (e.g. project manager, architect, manager) were not that actively involved in the weeks after the relocation and thus struggled with commenting on how these weeks were experienced. However, they did emphasize that the environment was still under development and that it was not operational as intended.

(Certified nurse assistant, 43, interview p06_03) [I have to say, this is important to mention, that they painted a beautiful picture how the location would look like, and the building itself is beautiful, but the loose elements have to “make” the location. So, for example, the animals, and that is not up and running yet.]

Experiences of staff

Overall, staff experienced the relocation from a regular nursing home to an innovative living arrangement as an impactful event. Four main themes emerged from the data: (1) feeling lost both physically and emotionally, (2) the importance of having a say in the physical environment, (3) the opportunities and challenges of a new way of working, and (4) the importance of constructive communication and collaboration. These themes are described subsequently in more detail.

Feeling lost both physically and emotionally

The emotions that nursing staff experienced were largely negative, with an emphasis on the stress they experienced throughout the relocation process. They described the process as a “hectic,” “intense,” and “busy” undertaking, often emphasizing that they felt lost, both in a literal sense (e.g. not knowing where to find materials, and not knowing the direction) and in an emotional sense (e.g. not knowing what to expect and how to respond/act). Another evident emotion was frustration. This frustration originated from the new way of working and the barriers staff experienced when trying to implement this new working culture.

(Nurse aid, 41, interview p01_04) [For us it is new as well, a new way of working, where can we find everything, where do we place everything? (…) All we are doing is searching, searching, searching. How are we going to do this? How are we going to do that? How can we solve this? All small things that reveal themselves in the weeks after the relocation and that we have to get used to.]

On the other hand, nursing staff also described the new way of working as exciting, as they felt that it had a positive impact on the residents and that it offered more possibilities. Other positive emotions were related to being excited about going to the new location and being satisfied with the relocation day and how this was organized. Staff responsible for the relocation process (e.g. architect, project manager) were mostly positive, stating that they had the feeling nursing staff were excited to move to the new location.

Staff also reflected on the emotions of residents. For staff, it was very important to organize the relocation process in a way that would minimize the stress for residents. Despite their efforts, staff felt that residents did experience stress. Most staff described the residents as looking lost and being restless. Some staff even mentioned that they believed that the relocation, sometimes indirectly, led to the decline of cognitive or physical functioning or even the passing of vulnerable residents. Multiple staff members were sometimes surprised about which residents remained calm and which became agitated. Their expectations did not always match the residents’ actual behavior. Furthermore, staff acknowledged that their own emotions had an impact on the emotions of the residents. When the staff felt tense and stressed, this reflected on residents, leading them to become agitated as well. They described this as an “interplay” between the residents and staff.

(Psychologist, 30, interview p03_02) [The ward was dripping with tension (…) So staff were already working on everything they needed to arrange. This made residents tense and staff did not react to this tension, because they were too busy. This meant that residents continued to be tense and would build up more tension, leading to a situation where staff were confronted with very agitated residents.]

Importance of having a say in the physical environment

Staff mostly emphasized that the location was beautiful, with nice facilities and delightful surroundings. The old location was often outdated, while the new building was very modern and unique. Furthermore, staff had the feeling that the new location offered more possibilities in terms of facilities and space, creating a calm environment and outside surroundings.

Staff were also critical of the new environment. Three aspects were mentioned most: first, the location was furnished in a modern and minimalistic manner (e.g. furniture followed latest trends, walls were white), making it less recognizable for residents; second, staff sometimes struggled with the size or layout of the building (e.g. too little showers and toilets, the building as a whole was too large, or the living room too small); and third, they felt that some facilities were not thought through properly, despite the effort that all locations displayed concerning the design of the building. An architect, project manager, and multiple workgroups discussed the design together extensively. Although this group was also largely positive concerning the physical environment, they did acknowledge that rebuilding an already existing building poses challenges and limits the possibilities. Furthermore, they felt that some social elements were still missing, such as optimal usage of the available spaces. Staff not included in these workgroups mentioned feeling like they did not really have a say in how the environment would look and what it currently looked like. They were not involved in the process of developing ideas for the new location, or were bound to strict regulations when wanting to decorate the new building.

(Certified nurse assistant, 26, interview p03_04) [The walls are all white, the door is white, the lights are too bright. It needs to be more homelike. Hanging something nice on the wall, stuff like that. You are actually not allowed to just do that, especially in the hallway. You are definitely not allowed to drill a hole, you have to be careful with everything, you know.]

The opportunities and challenges of a new way of working

Most staff were enthusiastic about the cultural change focusing on person-centered care and the self-reliance (i.e. being able to rely on own powers and resources) of residents. They felt like the new way of working would be advantageous for the residents in terms of personal attention and flexibility. Nursing staff were largely positive about the new vision and its possibilities. They experienced more freedom to work at their own pace and that of the residents, which led to more flexibility in care and eating moments and more opportunities to follow the preferences of the residents themselves. As a result, staff were better able to deliver person-centered care and felt there was more opportunity to focus on the well-being of residents. However, nursing staff often stated that the way of working was different from what they expected, or that the care organization did not think through the way of working, which led to discrepancies between the plans and the actual execution.

When wanting to implement a new way of working, nursing staff experienced several barriers. First, staff experienced a tension between the residents’ freedom and safety. Most locations aimed to create an open living arrangement, meaning that residents could walk outside freely. In all locations, this was not yet functioning, as they felt that it was not yet responsible and safe enough. This and other situations led to the question as to whether freedom or safety should be the top priority.

(Project manager, 38, interview p19_03) [More freedom also means more risk and less freedom means less risk (…) One family said: well, even if our family member “escapes” and however it may end, we hope he can keep a certain amount of freedom. Because if we “lock him up” he will pass away as well. (…) But not every family member feels this way, so that makes the situation very complex (…) because staff wants to guarantee the safety of the residents, so where is the balance? How can you act properly, knowing that you can never please everyone?]

Second, the mindset of the staff did not yet match the new way of working. Staff often still focused on nursing home routines and determining the daily routines of the residents, meaning that, for example, they felt residents had to get up at a certain time and be washed and ready. This led to a decline in person-centered care and self-reliance in residents.

Third, staff were searching for new ways of working correctly and lacked the practical tools and guidelines that would help them.

(Nurse aid, 52, interview p09_02) [The organization should have been more active, you know, to communicate what the possibilities are, how to involve residents during daily activities in between the meals. And you can tell we are trying to implement this, but I think it would have been nicer if we could have been coached, or someone could have joined us for a few days to give pointers on how to approach the residents.]

Fourth, the new environment was still under development, especially when looking at domotics. Most new locations make use of domotics, often new and advanced, and this might not function optimally yet. Furthermore, staff had to get used to these new information- and communication-technology systems and domotics, which takes time.

The importance of constructive communication and collaboration

The interviews showed that relocating was a massive undertaking, especially when moving to an innovative living arrangement with a change of culture. Most staff acknowledged that the team climate (i.e. the ambiance and circumstances in which staff work) was very important throughout this relocation and implementation process. Collaboration and clear communication were key for success. Some initiatives were set up to stimulate this collaboration and communication, for example by planning meetings, such as “vision-meetings,” or “catch-up meetings” to discuss how staff are feeling and what issues they encounter during their shift. The nature and number of meetings differed not only among the locations, but also even among teams. Some teams planned regular meetings to catch up, while others did not plan such meetings regularly.

Staff were critical about the collaboration and communication and acknowledged that this was not always a smooth process. This was especially clear in one location. They stressed the importance of having a good relationship with your colleagues to be able to communicate and collaborate in a constructive way. They felt that the communication could be better, as staff sometimes acted without discussing. Furthermore, other points for improvement were mentioned, ranging from needing more meetings and wanting a culture that involves less gossiping, to needing a clear point of contact.

(Social worker, 29, p12_03) [What you often see is, with good intentions of course, that the manager is very involved and wants to help the people and colleagues, but as a result functions on a micro-level, which leads to overlap with tasks and responsibilities that we have. And that in turn leads to confusion for colleagues. For example, the manager says A and we say B and then the colleagues get confused and do not know what to do next.]

In other locations, however, they felt that the new location had led to more opportunities to collaborate in a constructive manner.

Relocating often leads to some of your old colleagues leaving, and having new colleagues on the work floor, which is very challenging. All locations had to recruit new colleagues, as some were not interested in relocating or implementing a new way of working. Furthermore, two locations switched to a new manager and unit manager just before or just after the relocation day. As these new employees did not go through the same preparation stage as their already employed colleagues, this led to discrepancies between the expectations and values of the “old” colleagues and the “new” ones. New colleagues were not yet familiar with their role and the new way of working and they did not know the residents, their family, and their fellow colleagues yet. This could lead to confusion and even some hostility, as they had to settle in and get familiar with the way of working and existing norms and values.

Discussion

This study showed that relocating from a regular nursing home to an innovative living arrangement had a large impact on the involved staff. They experienced feelings of being lost, both physically and emotionally. Although the new location was often seen as beautiful, staff mentioned the importance of involving them in the development of the new location, as in their opinion the physical environment was not always optimally designed for the residents. Staff noticed a lot of potential in the new way of working that they wanted to implement in the new locations. However, they did experience barriers related to finding balance between freedom and safety of residents, the unmatched mindset of colleagues with the new way of working, and the lack of practical guidelines as the new way of working was still developing. This is in line with previous research, showing that implementing a new way of working is challenging (Koren, 2010).

Our study shows that shared decision-making is important throughout the relocation process. Staff emphasized that it was not only important for them to be informed properly and in a timely manner, but also to be able to contribute to decision-making in the relocation process. Staff experienced stress and uncertainty when not informed properly, which could be associated with greater emotional exhaustion (Rai, 2010). When staff, on the other hand, felt they had autonomy, self-determination and were actively involved in the relocation process, this may increase job satisfaction (Aloisio et al., 2021). Furthermore, being included by the entire team (e.g. supervisors, coworkers, clinicians) led to an increase in staff empowerment (Barry & Longacre, 2018). When staff felt stressed and emotionally exhausted, this affected the residents as well. The participants described this as an “interplay” between residents and staff. So when staff experienced stress and felt unsure, this reflected on the residents as well, and their stress levels and agitation increased as well. This is supported by research, showing that the way staff interact with residents is associated with the residents’ mood (Anderson et al., 2016).

Relocating to an innovative living arrangement is more than just moving belongings from A to B. Innovative living arrangements attempt to alter the physical, social and organizational environment. This study shows that staff experience additional insecurities when relocating to an innovative living arrangement, compared to relocating to a regular nursing home. There is quite some literature available concerning the role of the environment in long-term care. For example adding homelike features (e.g. furnishings, wall coverings and pictures, house-like layout) might lead to an increase in overall well-being of residents (Chaudhury et al., 2018). Furthermore, the way a nursing home’s environment is designed is associated with a sense of home and belonging (Johansson et al., 2022). Staff plays an important role in using the environment creating a sense of purpose and belonging in residents (Fleming et al., 2017). Nevertheless, for staff, it is complicated to adequately use these new environments. They miss practical guidelines and feel lost, which leads to a relapse into old and familiar behaviors that do not match the intended new way of working, hindering culture change. It is not easy to implement a new way of working, as previous research has also shown (Koren, 2010; Miller et al., 2010). Research concerning innovative living arrangements show different results, ranging from a positive effect on residents (e.g. more social engagement, more physical activity) to no effect (Ausserhofer et al., 2016; de Boer, Hamers, Zwakhalen, Tan, Beerens, et al., 2017; de Boer, Hamers, Zwakhalen, Tan, & Verbeek, 2017; de Rooij et al., 2012; Verbeek et al., 2014).

A recent scoping review showed that in the literature, most relocation support initiatives (i.e. that aimed to optimize the relocation process) focused on residents (Broekharst et al., 2022). Only two initiatives also focused on staff with staff preparation as a key aspect. Our results show that working at a new location causes stress and problems for staff, which highlights the need for staff support programs. One example is the tension between freedom and safety. The new locations often aimed to increase the amount of freedom of residents. However, staff struggled with finding the right balance between providing freedom and maintaining safety, and previous studies show that safety is often chosen over freedom (Portegijs et al., 2022). Furthermore, research shows that relocating hinders the ability to maintain the ideals of person-centered care, such as resident choice, rights, and autonomy (Weaver et al., 2021). Research has already shown that job resources, such as developing coping skills and self-efficacy (Abdollahi et al., 2014; Guo et al., 2017), and having social support (Schierberl Scherr et al., 2021; Wang et al., 2018) could help with fostering resilience in nursing staff. Institutional strategies could help nurses to become and remain more resilient within their health-care environment, helping them to endure stressful events, such as a relocation (Yu et al., 2019).

Implications for research and practice

Future research should focus on gaining more insight into how to optimize the process of relocating to an innovative living arrangement, with a specific focus on adjusting to the new way of working. Based on the current study it is evident that care organizations need to increase their focus on the social and organizational changes with which staff have to deal after a relocation, instead of mainly focusing on the changes in the physical environment. Relocating is an event that requires certain skills and competencies of both staff and management. Future research and practice should focus on how to develop the skills and competencies among staff to successfully relocate and implement and adapt to a culture change.

Methodological considerations

By approaching both care staff as organizational staff, we were able to capture a diverse group of staff members, leading to insight in all perspectives and a broadened understanding of overarching themes that are of importance. However, the interviews took place shortly after the relocation. We did not perform a second interview after the entire relocation period. It is possible that staff reflects differently on the experienced relocation afterwards. Performing interviews later in time might have led to additional insights.

Furthermore, the study sample consisted of several organizations relocating to an innovative living arrangement. Although a diverse selection of innovative living arrangements was approached in this study, the findings might not be generalizable to all settings. As innovative living arrangements are diverse, for future research it is important to gain more insight into the setting and context of these arrangements and how they interrelate.

During the relocating period and when we were conducting interviews, we were dealing with the consequences of COVID in the form of not being able to meet in person and lockdowns. Consequently, not all preparations could proceed as planned, such as visiting the new location pre-move, or meeting in person with the entire team to discuss the relocation. This might have affected staff experiences, as highlighted in previous research (Nestor et al., 2021; Siddiqui et al., 2021).

Conclusion

This study shows that, rather than the primary emphasis on physical environment changes, there is a need to place more emphasis on the emotions of staff during the relocation to a new environment. The help they need in adjusting to a new environment, as well as a new way of working, was underestimated.

Acknowledgments

The RELOCARE consortium consists of

• The Living Lab in Aging and Long-Term Care/Maastricht University: Prof. Dr., Hilde

  Verbeek, Prof. Dr. Jan P.H. Hamers, Prof. Dr. Jos M.G.A. Schols, Dr. Bram de Boer, Dr. Judith H.J. Urlings, Mara Brouwers (MSc)

• The University Network for the Care Sector Zuid-Holland/Leiden University Medical Center: Prof. Dr. Wilco P. Achterberg, Dr. Monique A.A. Caljouw, Damien S.E. Broekharst (MSc)

• The University Network of Elderly Care e UMCG/University of Groningen: Dr. Elleke G.M. Landeweer, Dr. Dika H.J. Luijendijk, Miranda C. Schreuder (MSc), Prof. dr. Sytse U. Zuidema

• The University Knowledge Network for Older People Nijmegen/Radboud University Medical Center, Nijmegen: Dr. Marieke Perry, Prof. dr. Raymond T.C.M. Koopmans

• The Academic Collaborative Centre Older Adults e Tranzo/Tilburg University: Prof. dr. Katrien G. Luijkx, Dr. Annerieke Stoop

• University Network of Organizations of Care for older adults of Amsterdam UMC (UNO Amsterdam). Amsterdam UMC, location VUmc. Dr. Wim G. Groen.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author.

Additional information

Funding

This work was supported by the RELOCARE consortium, which has received a grant from the Dutch Ministry of Health, Welfare, and Sport [grant number 330436].