In search for the “humane”: staffs’ perspectives on everyday activities in a nursing home

Abstract

Objectives: To better understand how a dialogue about the influence of nursing home residents on their everyday activities evolve among diverse practitioners and to identify the consequences of such an understanding in practice.

Methods: Inspired by a collaborative approach, five workshops, one focus group and follow up interviews were conducted. The participants were 19 diverse practitioners. Analysis followed a dialogical approach.

Findings: Tensions, opportunities and challenges were articulated and discussed during the workshops and are developed in: a) Bypassing the “humane”? The dilemma between using shields preventing engagement or acting in a clandestine manner b)“What is our stance?” Seeking common ground on which to stand regarding everyday activities and c) Recognising expertise and seeking connections.

Discussion: For the staff, acting in a clandestine manner seems to create ways of enabling “humane” practices towards nursing home residents. The “clandestine manners” seem to be grounded in an effort on the part of the staff to make sense of the everyday activities for the nursing home residents. These “clandestine manners” could be seen as responses to institutional routines and a lack of common ground on the understanding of everyday activities in the context of nursing homes.

Keywords:

• Occupation
• well-being
• identity
• participatory
• long-term care

Introduction

Nursing homes (NH) residents depend on nursing home staff to engage in everyday activities. Dependence has mostly been discussed as a negative aspect of growing older instead of as a key condition of humankind (Kristensson Uggla, 2014; van der Meide, Olthuis, & Leget, 2015). However, there is an emerging and growing critique towards the emphasis on individual autonomy and independence within person-centred care research in the field of eldercare (Breheny & Stephens, 2012; Nolan, Davies, Brown, Keady, & Nolan, 2004). Our research proposes to acknowledge the concept of interdependence (Perkins, Ball, Whittington, & Hollingsworth, 2012) that captures more accurately the necessary conditions for collaborative practices with NH residents (Abbott, Fisk, & Forward, 2000; Backhouse et al., 2016; Hydén 2011, 2014; Katz, Conant, Inui, Baron, & Bor, 2000). Engagement in everyday activities serves as a clear example of interdependence and has been identified as playing a pivotal role in upholding quality of life (Björk et al., 2017; Edvardsson, Fetherstonhaugh, & Nay, 2010; Edvardsson, Petersson, Sjögren, Lindkvist, & Sandman, 2014; Green & Acheson Cooper, 2000; Harmer & Orrell, 2008; Popham & Orrell, 2012; Smit, de Lange, Willemse, Twisk, & Pot, 2016), well-being (Bergland & Kirkevold, 2006; Chung, 2004; Hasselkus & Murray, 2007; O'Sullivan, 2011) and identity preservation (Beard & Fox, 2008; Cohen-Mansfield, Parpura-Gill, & Golander, 2006; Moyle et al., 2011; Phinney, Chaudhury, & O’Connor, 2007) among NHs residents. For NH residents, engaging in everyday activities increasingly requires cooperation with others in order to take place (Baur & Abma, 2012; Baur, Abma, Boelsma, & Woelders, 2013; Mondaca, Josephsson, Borell, Katz, & Rosenberg, 2018). Based on such reasoning, it is important to highlight the role of nursing home staff regarding their awareness and readiness to engage in emergent everyday activities (Fjaer & Vabø, 2013) that can enable cooperation in addressing the capabilities NH residents and foster experiences of well-being (Mondaca, Josephsson, Borell, Katz, & Rosenberg, 2018; Mondaca, Josephsson, Katz, & Rosenberg, 2018).

For NH residents, the care they receive and everyday activities they engage in become merged, blurred and exist side by side (Harnett, 2010). At a NH, what was previously considered familiar, predictable and unremarkable is left behind and residents are expected to navigate through a less familiar set of social life patterns. This unfamiliarity can create frictions, dilemmas and tensions that emerge in everyday practices (Grenier, 2006; Harnett, 2010, 2014). One of these tensions is that the care culture can have a strong institutional focus (Diamond, 2006; McCormack, 2003) and it can consequently be a challenge for NH residents to engage in everyday activities that correspond to their own values and preferences (Persson & Wästerfors, 2009; Sacco-Peterson & Borell, 2004). Institutional routines can easily disregard everyday emergent choices such as type of clothing, food or activities, thus reducing the possibility of NH residents to influence such matters (Gilleard & Higgs, 2010; Lohne et al., 2017; Sletteb⊘ et al., 2016).

There are different kinds of understanding about everyday activities in a NH, with different origins. These can be expressed in everyday practices as being contradictory, compatible or reinforcing each other. One understanding of everyday activities is derived from the paradigm of “active aging” (Clemson & Laver, 2014; Gilleard & Higgs, 2010; Gilleard & Higgs, 2011; Higgs & Gilleard, 2014; Katz, 2000), suggesting that being active and maintaining an active life style, through engaging in activities, contributes to better health. In the context of NHs, this translates as structured activities being an essential part of everyday life for the residents of the NH and the enablement of activities is considered part of the quality standard of the NH (Sjögren, Lindkvist, Sandman, Zingmark, & Edvardsson, 2013). A second understanding of activities is grounded in the medical tradition in which everyday activities are a marginal aspect of care provision that mainly serve to restore discrete functions. The character of the activities within this understanding is supportive, sometimes even redolent of a therapeutic nature, e.g. trivia, physical exercise with balls, bingo, etc. Research shows that what happens at an NH is often decided according to institutional needs and not necessarily according to the residents’ preferences and capabilities (Fjaer & Vabø, 2013; Grenier, 2006; Harnett, 2010; Mondaca, Josephsson, Borell, Katz, & Rosenberg, 2018). In this understanding, running the NH is characterised by structured procedures of care that fulfil specific care tasks, such as taking a shower, getting dressed or being fed. A third understanding of everyday activities is related with the ideal of framing the institution as a “home” (Cutchin, Owen, & Chang, 2003; Hauge & Heggen, 2006), in which NH residents can continue living a meaningful life and continue doing what matters to them. This is rooted in policy frameworks of participation, empowerment and influence in everyday matters (National Board of Health & Welfare, 2008, 2012, 2016). This ambition is often reduced in practice to including NH residents in household activities such as watering plants, folding laundry or peeling potatoes (National Board of Health & Welfare 2016; Edvardsson, Winblad, & Sandman, 2008; National Board of Health & Welfare, 2008, 2012). What is common to such understandings of everyday activities is that NH residents are mainly considered to be passive care recipients.

We argue that everyday activities can play a role in creating and sustaining a sense of stability and predictability and also because the day-to-day activities of people carry meaning, are complex and constantly evolving (Bruner, 1990; Fjaer & Vabø, 2013; Perkins et al., 2012; Scott, 2009). Everyday activities have been a core focus within NH research (Björk et al., 2017; Clemson & Laver, 2014; Edvardsson et al., 2014) and research suggests that activities can serve well-being (Hasselkus, 2011; Wilcock, 2006, 2007) and the creation and maintenance of meaning (Hasselkus, 2011; Hasselkus & Murray, 2007). However, little is known about the processes of engagement in everyday activities when living in an NH setting (Tollén, Fredriksson, & Kamwendo, 2007, Tollén, Fredriksson, & Kamwendo, 2008). In this study, everyday activities are understood to comprise small events and situations that emerge in everyday practices, normally taken for granted or labelled as mundane and menial (Hasselkus, 2011) such as cooking, going for a walk, getting dressed, meeting friends or mealtime situations.

Staff at an NH play a key role in maintaining the social life (Cahill & Diaz-Ponce, 2011) and dealing with all these understandings and mandates (Petriwskyj, Gibson, & Webby, 2015) about everyday activities in everyday practices. However, a knowledge gap exists regarding how staff negotiate and act upon everyday activities in diverse situations (Baur et al., 2013; Boelsma, Baur, Woelders, & Abma, 2014). Knowledge about this reasoning is key to creating supportive strategies that will help enable opportunities for engagement in activities with NH residents (Petriwskyj et al., 2015). It seems to be important from an ethical perspective to gain insights into strategies that eliminate structural barriers that stifle everyday practices and highlight the ethical aspects at stake for NH residents in everyday activities (Baker et al., 2013; Gilleard & Higgs, 2010). In order to create a culture change in care in such settings, researchers have increasingly focused their efforts on characteristics that are more amenable to change, such as staffing practices (Rahman, Applebaum, Schnelle, & Simmons, 2012). We argue that a dialogical understanding (Tsoukas, 2009) of everyday activities could act as a path of transformation for everyday practices in an NH (Chulach & Gagnon, 2016; Frank, 2005). Dialogue involves the possibility of mutual influence and the development of new insights and reflexivity, thus having the potential to expand the understanding about everyday activities with NH residents (Tsoukas, 2009). Dialogue is based on the premise of relational engagement. This means jointly acknowledging responsibility for improving a collaborative action (Tsoukas, 2009). As described above, everyday activities can easily adopt a standard, “definitive” or finalising character (Frank, 2005) and not create space for emerging meanings. A “definitive” understanding of activities, as standardised and “professionalised”, rests on the assumption that identities are fixed and final (Bruner, 1990; Frank, 2005) which, translated into practice, could be detrimental to the well-being of NH residents. It this sense, it is important to further explore the conditions necessary to uphold the communicative and meaning-bearing dimension of everyday activities (Hasselkus, 2011; Hasselkus & Murray, 2007; Mattingly & Fleming, 1994) in the context of the NH. Engaging staff members of an NH in a dialogue about everyday activities could help to engender transformative practices and redefine professional identities (Chulach & Gagnon, 2016).

The aim of this study is to better understand how a dialogue about the influence of nursing home residents on their everyday activities evolve among diverse practitioners and to identify the consequences of such an understanding in practice.

Methodology

Setting

The NH is located in an urban area of Stockholm and has a capacity of approximately 200 residents. The healthcare staff comprise a total of 207 nursing assistants, 5 occupational therapists, 10 nurses, 3 physiotherapists and two caretakers. Time to attend the workshops and focus group was granted by the NH management. The residents’ age ranged between 74 and 90 years and their length of stay at the NH ranged from two weeks to five years. The majority of the residents lived with multiple chronic conditions and diverse degrees of cognitive impairment, including being diagnosed with a dementia disease. The decision to live at the NH was granted by a municipal care manager once it had been determined that the older adult was not capable of safely managing everyday activities on their own, and that the social services couldn’t cover all their needs at home. NH residents (or their legal representative) had signed a contract that included rental of the apartment, care and meals at the NH.

Procedures and data gathering

Inspired by a dialogical approach (Baxter, 2011; Tsoukas, 2009), a set of five experience-based workshops (Freire, 1994; Tsoukas, 2009) were conducted once a week at the NH. Each workshop lasted two hours and was conducted in a spacious group location in the main building of the NH. A total of 19 participants agreed to take part in the study and expressed an interest in the topic of “a meaningful everyday life for NH residents”. The group included 16 nursing assistants, one occupational therapist, one nurse and one caretaker. The participants had diverse roles regarding the NH residents’ everyday activities which positioned them as key actor for possible collaborative practices. The participants work experience in the context of the specific NH varied from 1 year to 20 years. Nursing assistants were more closely in contact with everyday care needs and everyday life of the residents. The nurse had a comprehensive responsibility of the residents’ health status. The occupational therapist’s role was to coordinate the activity program to the whole NH. The caretaker role was of building’s maintenance, which granted him access to the private and shared spaces of the NH residents, and their everyday practices. The invitation for the workshops was open and the inclusion criteria were to be interested in the topic of activities with NH residents and to be employed at the NH. More detailed information of the participants in Table 1 (see Table 1). In addition to the workshops, one focus group focusing on everyday activities (Krueger & Casey, 2000) was conducted two weeks after the workshops were finalised. Twelve participants (of the total of nineteen) attended the focus group session that had a focus on activities and the everyday life of the NH residents. The focus group were moderated by one of the authors (SJ) that had not been involved in the previous workshops session and the first author that had a facilitator role. The session took 2 hours and was scheduled accordingly to the participant’s available time. Five individual follow-up interviews were conducted three months after the workshops. The character of the workshops was experiential and focused on the participants’ expertise and day-to-day challenges concerning their everyday activities with residents. The workshops were facilitated by the first and last authors. The first workshop introduced a pedagogical approach that would characterise the sessions, combining dialogue, experience and group work (Freire, 1994; Reason & Bradbury, 2008). A key element in this planning was to place residents’ experiences at the centre of the discussions. This was initially articulated by giving each participant the task of exploring the everyday activities of residents living at the NH. This exploration took place by asking one older adult about what they like doing, what they were interested in, dreamed or longed to do. Maintaining a non-judgmental position and not dismissing the remarks of the NH residents living at the NH when they might sound “unrealistic or impossible” was emphasised in order to create a potential for dialogue (Tsoukas, 2009). The facilitators also encouraged the participants to ask questions to further understand the meaning of the residents’ outspoken desires. This approach to communicating with residents living at an NH had been practiced in previous studies (Mondaca, Josephsson, Borell, Katz, & Rosenberg, 2018; Mondaca, Josephsson, Katz, & Rosenberg, 2018) as a key beneficial approach to gaining new insights into what matters to the residents. At the second workshop, the participants jointly reflected over the answers they received from the residents and the way they approached the task of posing questions. The participants started their work by exploring the interests of the residents they worked with in their own settings. The group discussed alternative strategies regarding how they collected this information from the residents. This triggered a reflexive dialogue about the ways of approaching this matter with the residents living at the NH and the type of activities available for residents at the NH. In the third workshop the participants started working together on innovative ideas that could resonate with the desired everyday activities they uncovered regarding the residents they had previously approached. With the residents’ interests, needs and desires at the centre of the workshops, the group progressively started to envision, create and scrutinise everyday activity projects together that might work in their particular settings. The fourth workshop focused on critically reviewing and reframing the ideas into feasible activity projects to be applied at the participants’ respective workplaces. All workshops built on each other and were planned according to the group evolvement. The staff progressively advanced in reflecting and jointly creating alternatives with regard to the existing everyday activities at the NH. The fifth and final workshop focused on each participant presenting a novel, small project about everyday activities with the residents living at the NH, created in cooperation with their peers in the workshops. The group members were constantly encouraged to act both as agents of potential innovation and as “critics” of the other staff members’ ideas. Two weeks after the workshops were completed, a focus group lasting two hours was conducted by the first and third author. The focus group focused on the participants’ experiences during the workshops and on what the participants had done in their workplaces. Three months after the workshops, one individual follow-up interview was conducted with five of the participants in their respective workplaces to explore how the activity projects had developed. The criteria for follow up was to have diversity in the kind of activities the participants wanted to try out in their practices (different focus and level of complexity).

Table 1. Information of the participants.

Profession	Number of participants	Formal education	Sex
Nurse assistants	16	1–2 years at high school	12 females and 4 males
Nurse	1	3 years at university	female
Occupational therapist	1	3 years at university	female
Caretaker	1	1 year at high school	male

Data analysis: All workshops sessions were video and tape recorded. A reflective analytical dialogue between the facilitator researchers (MM and LR) followed each session and additional field notes were taken by the first author (MM). The focus group session and the follow-up interviews were audiotaped. The role of the researchers throughout the process was to facilitate the discussions and to build a progression within the workshops based on the reflections that emerged. Each session was discussed between the workshop’s facilitators (MM and LR) in order to identify the most revealing aspects and present them as a summary in the next workshop. Video and audio tapes were watched/listened to multiple times and analytical notes were taken. Inspired by a dialogical approach (Tsoukas, 2009), the analysis focused on the collaborative group process while the participants were unfolding and creating a new understanding of everyday activities together. As suggested by the dialogical approach, special attention was given to the manifestation of the conceptual development (Tsoukas, 2009), in this case about everyday activities. Specifically, the focus of analysis of the group sessions, focus groups and individual interviews was the detection of “conceptual expansion” and “conceptual reframing” about the potential meanings and consequences of the everyday activities of residents living at the NH. In this study, “conceptual expansion” refers to the development of the understanding and use of the term “everyday activities” beyond its traditional and dominant use at the NH. “Conceptual reframing” refers to reclassification or shifting from one perspective to another, resulting in a new form of understanding or practicing everyday activities in this setting (Tsoukas, 2009). One example of conceptual expansion was the participants’ use of the expression Putting on the shields, in order to reflect on their patterns of work with residents in everyday activities without really engaging in the emerging situations. This concept was discussed and identified as being crucial in the analysis and was finally framed as “shields” preventing engagement. An example of conceptual reframing was the incorporation of the notion of “the humane” as a core quality pursued through everyday activities. The emerging analysis of these workshop sessions was discussed with the participants to ensure a proper understanding of the emergent knowledge about everyday activities. Additionally, analytical sessions with the co-authors were regularly conducted to enhance the trustworthiness of the findings.

Findings

The findings are presented as the tensions, opportunities and challenges articulated and discussed during the dialogue sessions, with special focus on conceptual expansion and reframing of everyday activities.

1. Bypassing the “humane”? The dilemma between using “shields” preventing engagement or acting in a “clandestine manner”

This finding became the most relevant and striking aspect discussed among the staff. The staff increasingly started talking about the various tasks within their role that prevented them from being in close contact and engaging with the residents in their everyday activities. They talked in particular about administrative tasks such as detailed documentation about their care measures, ordering supplies and cleaning. The group also considered how activities with the residents would usually take shape of structured and in groups. This form was described as sometimes preventing staff from creating a sense of connectedness in everyday life with the residents. The group discussed these activities as impeding engagement with the residents in emergent everyday life situations. Furthermore, the group concluded that these activities even served to create shields preventing engagement or as obstacles that would obstruct or disrupt any engagement. They stated that their duties and the way activities are conducted at the NH fail to capture what it is important to engage in with the residents. Thus, the subtle “humane” aspects of the everyday life of the residents are being excluded.

“I have to ask and document if the residents would like to participate in a group activity, I even have to document if they refuse to participate in a group activity. All that time lost on documentation is ridiculous! But only then when I had finished documenting, was there evidence that I asked, not otherwise. It’s the same when we give someone a shower. “Shower” is documented but nothing about what happened at the time, the conversations we had, the resident’s hesitation, what we said to calm them down and how this finally happened. And we do all this, anyway. It’s as if the current system is forcing us to bypass what is humane”.

(Participant #3, workshop #2)

In this dialogue, the staff are highlighting the struggle with activities that paradoxically form part of everyday life but become “bureaucratised” by institutional practices, such as documenting a resident’s non-participation. This could be partially understood by the institutional routines and the focus on efficiency and control, privileged by the New Public Management of welfare care (Dahl & Rasmussen, 2012). Within this understanding, qualities such as realness, ordinariness and the mundane tend to be less prioritised, making them less present at the forefront of everyday practices. The staff must focus on delivering care services, giving less space to the ordinary and mundane lives of the residents. The group reflectively discussed their experiences of how this risked bypassing the “humane” part of their work.

“We have a list of all the care activities and other tasks we must perform in our shift. The end of the list includes activities with the residents, if we have any time left. It’s as if we are expected to care more about their bodies than their souls”.

(Participant #18, workshop #1)

Within this understanding of everyday activities, it could be suggested that the staff are forced to adopt a reductionist view on everyday activities of the residents, limited to what forms part of their professional role and duties. As a response to the lack of common ground on how to act regarding activities for the residents, the understanding of shields preventing engagement emerged, as exemplified by the following statement:

“Talking about activities is somehow taboo. We all know that we like working with activities, but it’s not something we talk about. We just do these things, regardless of whether or not we have time for them. Other colleagues desist from doing so, they put on their shields, and this is also ok”.

(Participant #7, follow up interview)

This view of everyday activities could be understood as a “professionalisation” of human contact. The metaphor of “shield” here is understood as the staff to acquiring a professional shield, a shield preventing engagement with the residents in “humane” ways. These professional shields could be seen as inhibiting natural encounters between people. The tendency of understanding everyday life fragmentarily could ultimately cause a de-humanising understanding of the everyday life of the residents.

“You don’t realise that what we are talking about here [everyday activities] is essential, the same as being fed. It’s life we are talking about here. The life of these people [the residents]”

(Participant #6, focus group)

As a response to the threat of not realising the value of everyday activities for the residents living at the NH, the staff challenged each other, on both an individual and a collective level, to take action. One of the options the staff considered was: “follow the matrix”. This meant doing what they were expected to do, as regulated by the NH; two group activities each day if time permits or, alternatively, doing “what is right”, what the staff were able to address as the important preferences and desires of the residents in a kind of “clandestine manner”. This “clandestine manner” was described as stepping outside or “working around” the regulations and their prescribed professional role and tasks, seeking to do good, with personal commitment and without the recognition of the institution. The “clandestine manner” was exemplified by one of the participants as follows:

“I was in the dining area doing Lucy’s hair, removing her curlers, fixing her hair and chatting with her. She was expecting her daughter to visit later. When I finished her hair, her friend Kicky, who was sitting with us all the time, also wanted to have her hair fixed with curlers. I didn’t really have time to do this for any of these ladies before lunch, but I did it, anyway. What else could I have done?”

(Participant #2, workshop #3)

This was described as a “clandestine manner” of doing things in the sense that fixing the residents’ hair (representing an otherwise mundane issue) is not prioritised as a care activity. Performing activities as and when they emerge according to the residents’ pace and desires is a norm-deviating response of the staff. According to the staff, many of them resolve the dilemmas that emerge on a daily basis by acting in a “clandestine manner”. For example, they buy coloured napkins or newspapers with their own money or use their free time to fulfil the resident’s wishes, if there was no time to do so during their regular working hours. Allowing the minor wishes of the residents to go unnoticed or unmet causes stress and what the staff refer to as “impoverishment” at the NH, and the atmosphere at the NH is something they feel responsible for. Another direct consequence of choosing to respond to or disregard the residents’ desires on a daily basis is the creation of small inequalities within the NH community. This is because each staff member will be individually challenged to make these decisions on a daily basis.

2. “What is our stance?” seeking common ground on which to stand regarding everyday activities

The process of the workshops served to uncover the diversity of understanding about the value of everyday activities for the residents. Furthermore, the group discovered how assumptions about the potential meaning of everyday activities had concrete consequences in everyday practices and in how the residents are approached, encountered and addressed in the realm of everyday life in an NH. The discussion about the various types of everyday activities and the staffs’ role in them showed that there was no common ground they could relate to, apart from the institutional regulations. It also became clear that the staff had no formal forum where they could reflect about everyday activities, and that these concerns constituted either an individual concern or an informal discussion with a peer.

“We don’t talk about activities in our unit. You need to ponder every activity, limitations, time, closeness to their [residents living at the NH] interests. It's more complex than you think, there is a lot to consider. It’s also very difficult to leave the residents you are sitting with and continue with what you should be doing. I wonder, how are we going to think about activities? What do we stand for?”

(Participant #5, focus group)

During the workshops the staff began to realise that they assumed different things when talking about everyday activities, suggesting a lack of common ground. For some of the staff, everyday activities meant actions that bring to actuality some essential qualities of everyday life: meaning and joy as exemplified in the following dialogue:

“We went to buy some provisions with two residents who are more able to take part in outdoors activities. We took the train, just a few stations away. Just taking a train ride is a whole experience for the residents. There is so much to see! When we had almost finished shopping, I asked Hans [one of the residents] if he might like to eat dinner “out” instead of at the NH. He wanted to do this. Then I asked him where he wanted to eat and he looked around and chose McDonald’s. He wanted to eat a Hamburger with fries. We had such a good time. It felt just like something I would do with my own family, you know”.

(Participant #4, workshop #4)

This is an example of how the staff accommodate the emerging desires of the residents, taking a stance where qualities such as spontaneity and the possibility to influence are important on a daily basis for the residents. In contrast, for other members of staff, working with emergent everyday activities could mean something else. It would mean following the institutional routines with preconceived ideas of what could be important or valued by the residents, as illustrated by the following example:

“I don’t need to ask the residents what they want, I know what they want. They like to do handicrafts, listen to music or listen to someone reading a newspaper aloud”

(Participant #11, workshop #1)

This certainty of “knowing” even without asking, expressed by one participant, was contested by other participants. The group dialogue engaged in critically questioning whether knowing the residents might create “fixed” assumptions of what the residents like and prefer. The dialogue continued with reflections on how this kind of culture could risk reducing the opportunities for the residents to influence their everyday activities on a daily basis.

The discussions revealed that the staff had a diversity (palette) of assumptions about the meaning, form and their role regarding the everyday activities of the residents of the NH. Instead of a shared understanding, they had been superficially operating in agreement, relying on a “presumed” shared/tacit understanding, i.e. believing they had a shared unspoken knowledge and understanding of activities and everyday life in such an institution. When discussing these assumptions, it became clear that a common ground was missing, as well as a forum to reflect on the understanding of everyday activities. “What is our stance?” became a key question for the group participants. It is important to state that this question was posted to the entire group, making evident the need for reflection. Discussions continued to advance into what the staff assumed as being the “right thing to do” about everyday activities of the residents.

3. Recognising expertise and seeking connections

As it became clear that the everyday practices of the staff took place according to both the regulations and the false assumptions of having a tacit agreement on the meaning of everyday activities, the need to further explore each other’s expertise in capturing and enabling the residents’ desires and preferences became a key discussion.

“Last week when I asked Catty (one of the residents) what she wanted to do, she answered: New York. I kept trying to find out what it was about New York that was so special to her and asked her: “Do you want to visit New York? I think you’ve already been there once. Shall we look at some of your photo albums together?” And so, we did. We discovered that she had actually visited New York a couple of times. We riffled through the pages looking at many pictures; we took our time. At the end, she told me: “Now I feel I’ve travelled to New York again!” The nursing assistant concluded his story saying: “I felt really good at the end to have taken the time with her”.

(Participant #9, workshop #5)

This example presented by this participant resulted in great admiration among the other participants, not just because of the positive reaction of the resident but because of the participant’s knowledge of the resident and the way he posed questions in order to further involve her. This dialogue allowed further discussion on the possibilities of using this approach to engage in an evolving story. This aspect of the process could be theoretically linked to the notion of suspension (Tsoukas, 2009), an attitude of being open to uncertainty, but also other possibilities as if the story would be favourably resolved.

Another important aspect that was discussed and shared was the expertise in mastering various approaches to harnessing potential resources among the residents. This expertise was highlighted as a tool that could enrich the everyday life of the residents by positioning them as protagonists or partners in some emergent activities. This is exemplified by the following extract from the dialogue

“I know she [one of the residents] likes and can still read out loud and I also know she likes receiving attention so I decided to ask her if she could read the newspaper to two other residents sitting with her in the dining area. I stayed there until she started, and when I saw everything was going well I left for a moment. When I came back from the storage room after a couple of minutes, the three of them were still sitting together talking and having a good time”.

(Participant #15, workshop #3)

Another way of recognising mutual expertise was revealed when recalling how the residents responded to the question of what they were interested in doing, longed to do or would like to do (the starting point of the dialogue with the staff in the first workshop session). The various ways the staff used to identify the residents’ interests was acknowledged as an important, yet tacit, kind of expertise. When discussing the issue of basing the activities on the residents’ interests, the staff recognised a sort of apprehension and presumption about the potential answers or wishes the residents might have. A kind of demystification of this uncertainty occurred after engaging in dialogue with each respective resident and subsequently reflecting about it with the entire group of workshop participants. The original presumption that the residents will “respond irrationally or ask for unattainable things” was replaced by an understanding of the residents ultimately being “just normal, regular people”, longing to do “just regular things”. However, the staff recognised that there was a hidden complexity in bringing the “trivial” the “normal” and the “mundane” naturally into the institution.

In an effort to get closer to the “mundane” and “normal” qualities of everyday life, in the context of this study, the staff designed activity projects based on the residents’ interests and preferences. This resulted in activity projects in which the emphasis was placed on seeing the residents as fellow humans rather than care recipients. One of the common characteristics of these projects was the ambition to connect with others and to have activities that could blur the hierarchies and fixed roles at the NH. The staff envisioned being part of the wider community in an “uncomplicated and natural manner” as they stated. Examples of these projects were: “Own time”, which focused on ensuring a space during the week to plan activities that were individual and of importance to the resident, such as buying flowers, posting a letter, buying some hygiene products. Another example was the project “Walking and having a good talk”, which focused on both the frequently expressed desire of taking outdoor walks and giving space to more existential conversations if it was important to the resident and developed naturally.

Another common aspect of the activity projects was the ambition to open up the NH to influences that could make the institution and everyday life more dynamic and alive. Examples of this ambition were articulated through multiple ideas about engaging in external activities that involve other players, day-care centres, family members, community facilities, restaurants and natural surroundings. In the discussions, the staff highlighted the challenges that these kinds of activities might entail, for example, that residents with dementia might quickly change their minds despite previous preparations, or anxiety surrounding the trips or activities involving others.

“Sometimes we have prepared everything, explained everything and finally everything is settled. But when the residents reach the lift, some of them change their minds and want to return. It’s really frustrating, but what can we do? They just want to go back to their room”.

(Participant #13, follow up interview)

Nevertheless, the staff seemed positive about giving these projects a try, or at least believed the projects were possible. Regarding connections inside the NH, two aspects were central and common to the projects. One was the idea of better matching residents with common interests so that they could enjoy each other’s company. Another idea was the reorganisation of staff-resident constellations in such a way that could facilitate the flow of everyday life. By engaging in the latter, the group recognised the diversity among the staff regarding the various interests and skills as a resource to enable a meaningful everyday life among the residents. The second common aspect was the need to slow down the pace or the scale of activities with the residents in order to bring quality to their everyday lives. Follow-up interviews with five of the participants showed that even if the activity projects were designed and scrutinised as something that could be tried out, the general experience of the participants was that they were “waiting for the right time” to set them in motion. They had started but not persisted. Three projects proved to be the exception and were launched successfully by the participants. The common denominator of these three projects was that they were small scale, set in motion in collaboration with someone else and simple to introduce to the current practices.

Discussion

As identified in this study, there was a clear perception among the participants that their patterns of working with everyday activities were not fully under their own control but shaped by the NH as an organisation. The staff had institutional care tasks to be fulfilled and they did not have any guidance related to the way of enabling more collaborative practices with the residents if they wanted to change their way of working. The dialogical approach opened up a forum for staff members that permitted them to reflect upon their work and share insights into the challenges they faced regarding understanding everyday activities (Ward, Vass, Aggarwal, Garfield, & Cybyk, 2008). This dialogue also served to ground ideas and potential alternative practices based on the residents’ preferences and values. A reflective and non-normative dialogue with residents was key to these discussions. In this sense, the development of new insights and exchange of views among the staff about everyday activities included the view of some of the NH residents. They were “voices” within the staffs’ voices, a novel experience for the participants in this context. This strategy is in line with previous research that aimed to create reflective practices within health care (Frank, 2005), and particularly with older adults (Katz et al., 2000; Katz & Mishler, 2003). We suggest that an additional contribution in this regard is the possibility of trying out new forms of engagement in practice, contributing to trigger new ways of practicing. This dialogue forum served to articulate more than just the official understanding and practices of everyday activities, or at least to explore new shared sensibilities (Tsoukas, 2009) about everyday activities. In dialogue, the participants negotiated their understanding and tried to influence each other. Such dialogue and performance in practice may, as demonstrated by these findings, help other peers understand their role and the value of everyday activities (Diamond, 2006). However, given that just a small part of the NH community showed interest in working and reflecting on everyday activities, there is no guarantee of significant changes being made in practices. Moreover, the participants explicitly expressed an interest in doing with the residents and discuss about activities before started the study, which is reflected in the findings. The dialogue might have been different if the participants were less motivated in the topic of activities and everyday life of the NH residents. Regardless of the extent to which this change in sensibilities about the key value of everyday activities for NH residents might evolve, the disruption in normative practices that emerged in this reflective forum has the potential to leave its mark on everyday practices (Chulach & Gagnon, 2016; Katz & Alegria, 2009).

The finding Bypassing the “humane”? The dilemma between using shields preventing engagement or acting in a clandestine manner captures the challenges that staff encounter when facing different demands and perspectives surrounding the understanding and practice of everyday activities. As developed in the findings, an understanding of everyday activities that lack the potential of meaning-making seems to be a common practice at the NH, creating practices that are dissonant with the “humane”, according to the study participants. Acting in a clandestine manner, as an alternative to using shields that prevent engagement in everyday practices, seems to create ways of enabling “humane” practices for the staff. The “clandestine” actions seem to be grounded in an effort on the part of the staff to make sense of the everyday activities for the NH residents. This could be seen as staff being sensitive to aspects of the context and activities for the maintenance of identities (Beard, 2004) at the NH, and even an acknowledgment of small events as being pivotal social interactions that will help to maintain identity. However, even if these clandestine measures are taken for “the greater good”, the staff are challenged by being aware that they are overstepping the regulations and by also being aware that these are individual measures, meaning that only some residents will benefit from these types of measures, thus creating inequalities. Giving extra time or prioritising relevant activities for the residents instead of favouring institutional tasks is then transformed into the “humane” thing to do when everyday activities are “institutionalised”. The clandestine manner of acting performed by the staff can then be seen firstly as problematic, but also as generating alternative practices (Scales, Bailey, Middleton, & Schneider, 2017; National Board of Health & Welfare, 2008), addressing the “humane” aspects of social relationships.

Recognising expertise and seeking connections could be seen as a promising step towards a more critical stance regarding the strive for independence and autonomy in this setting with residents (Nolan et al., 2004; Perkins et al., 2012) and a step forward in the recognition of collaboration and interdependence as guiding values in everyday practices. Both potential practices and rewarding practices recounted by the participants included interdependence and community engagement as guiding values. These results also shed light on the complexity of everyday life in this setting, which is highly regulated by institutional routines. These regulations are ingrained and enacted in everyday practices, which makes it difficult to recreate the “mundane” for residents.

One of the challenges of this study was the low level of interest from the NH community in general to participate in this study, considering that time was granted by the management group of the NH. This posed the question of how everyday life in NH contexts could gain a higher status for critical reflection, for greater involvement of the NH community in this development. A methodological limitation is that within the dialogical approach some participants spontaneously occupied more time in the discussions, making it necessary for the facilitating researchers to actively try to incorporate more marginal voices within the group. This required a careful assessment and applied reflexivity towards the group dynamics while conducting these workshops. Further, the study design could have been improved by creating more workshop sessions that followed up the testing of the various projects, as it became evident that projects were difficult to set in motion without the collective support of the group. Observations and discussions in practice about new approaches regarding everyday activities would have been ideal for gaining a deeper understanding of the new insights when confronted by real practices and challenges.

Conclusion

This study has focused on everyday activities with residents living in an NH by initiating a dialogue with various practitioners in order to reflect upon the relevance of everyday activities in their current practices at the NH. This dialogue strived to explore alternatives to the value of independence in an NH setting. The results highlight the need to create reflection forums as a strategy to critically reflect on current and potential strategies that affect everyday activities and the experience of the well-being of residents living at NHs. The findings of this study also suggest that NH staff possess valuable expertise on how to enable the capabilities of NH residents and how to use each other and themselves as resources. However, this approach is not always recognised as being important, facilitated or encouraged by the institutional culture, which places staff in difficult and ethically-demanding positions.

Disclosure statement

No potential conflict of interest was reported by the authors.