ORIGINAL ARTICLE

A qualitative study of the relationships between residents and nursing homes nurses Domingo Palacios-Ce~ na, Marta Elena Losa-Iglesias, Cristina G omez-Calero, Jose Miguel Cach onPerez, Miguel Brea-Rivero and Cesar Fern andez-de-las-Pe~ nas

Aims and objectives. To explore the relationships between residents and nurses in Spanish nursing homes. Background. The nurses are one of the elements conditioning the life of the nursing home resident, influencing sense of security and mediating the relationships among residents. Design. A qualitative phenomenological approach was applied. Methods. An initial purposeful sampling of Spanish residents from nursing homes in the southern area of Madrid was conducted. The study included nursing home residents, aged 60 and over, with no cognitive impairment and who were able to communicate verbally in Spanish. Data were collected using unstructured and semi-structured interviews, researcher field notes, and personal diaries and letters from the residents. Data collection was concluded once theoretical saturation was reached, and data were analysed using the Giorgi proposal. Results. Two main themes emerged: (1) ‘meeting the nursing home nurses,’ residents interact with nurses and establish relationships with them. The relationship is perceived as positive yet distant, and at times it is difficult to establish a closer relationship; and (2) ‘managing relationships with the nursing home nurses,’ residents learn to manage their relationships with the nurses, acquiring new behaviours to get closer to them, avoiding confrontations and helping each other. Conclusions. Residents manage their relationships with nurses using multiple behavioural strategies. They perceive these adjustments as necessary to facilitate daily life or avoid problems and/or confrontations. Deepening the relationships between residents and nurses could improve the management of nursing homes. Relevance to clinical practice. Dialogue and active listening with residents must be incorporated into the daily nursing care. It should be given the same attention to all residents, with special attention to residents with cognitive and functional difficulties. Key words: caregiver–patient relationships, nurses, nursing homes, phenomenology, qualitative research Accepted for publication: 6 November 2012

In Spain, nursing homes are an important resource for the welfare of older people (Casado-Marın 2006). Nursing homes provide care to older people who: (1) have disabili-

ties or chronic diseases; (2) are alone and without family; and (3) have no financial resources or a place to live (DıazMartın 2009). Trained teams of nurses, physicians, psychologists, occupational therapists, physiotherapists and others work in nursing homes (Casado-Marın 2006). The

Authors: Domingo Palacios-Ce~ na, PhD, RN, Professor, Department of Nursing, Universidad Rey Juan Carlos Alcorcon, Madrid; Marta Elena Losa-Iglesias, PhD, RN, Professor, Director, Department of Nursing, Universidad Rey Juan Carlos, Alcorcon, Madrid; Cristina G omez-Calero, OT, MSc, Professor, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcon, Madrid; Jose Miguel Cach on-Perez, MSc, RN, Professor, Madrid Health Services, Alcorcon, Madrid; Miguel Brea-Rivero, OT, MSc, Professor, Department of Physical Therapy, Occupational Therapy, Rehabilitation and

Physical Medicine, Universidad Rey Juan Carlos, Alcorcon, Madrid; Cesar Fern andez-de-las-Pe~ nas, PhD, Doctor, Director, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcon, Madrid, Spain Correspondence: Domingo Palacios Ce~ na, Professor, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n. 28922 Alcorc on, Madrid, Spain. Telephone: + 34 91 488 89 34 E-mail: [email protected]

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Introduction

Original article

objectives of nursing homes in Spain include providing a pleasant environment and a safe place to live, enhancing the capabilities of the resident, preventing disability and loneliness and promoting an environment where the resident is able to live a life with respect, dignity and autonomy (Pe~ nafiel-Olivar 2010). In Spain, nursing homes have standards for quality related to the assessment, care and monitoring of residents for health status and disease (Casado-Marın 2006, Pe~ nafiel-Olivar 2010). These standards are used to assess and monitor the adaptation of residents and the types of relationships established with the residential staff (Pe~ nafiel-Olivar 2010). Transitioning into a long-term care institution is one of the most difficult developmental challenges for older people (Stabell et al. 2004). Care in nursing homes has different components that strongly influence the quality of life for residents, including proficiency in caregiving practices, autonomy, individualised care, communication and relationships with caregivers and nurses (Cohen-Mansfield & Parpura-Gill 2008). Bergland and Kirkevold (2005) discussed how the relationship between caregivers and residents is asymmetric, with nurses and caregivers in a position of control over residents (Bergland & Kirkevold 2005, Cohen-Mansfield & Parpura-Gill 2008). But some studies have shown symmetric relationships between nurses and residents, where the two sides are mutually dependent (Westin & Danielson 2007). To date, several studies have shown that the personnel in the nursing home are one of the elements conditioning the life of the resident (Westin & Danielson 2007, Hauge & Kristin 2008), influencing social circle (Stabell et al. 2004, Westin & Danielson 2007), mental attitude, adaptability and sense of security (Bergland & Kirkevold 2006), which mediates the relationships among residents (Bergland & Kirkevold 2008) and improves their quality of life (Bergland & Kirkevold 2006). In general, encounters between residents and nurses can have either positive or negative effects (Westin & Danielson 2007). Studies from Finland and Sweden reported that, for the resident, life’s meaning is strongly influenced by interpersonal relationships (Takkinen & Ruoppila 2001, Westin & Danielson 2007). Previous studies also demonstrated that, for some residents, establishing a close relationship or friendship with the nurses is of great importance (Bergland & Kirkevold 2006, 2008). It is also necessary to note that residents are not monolithic in their approach to relationships with nurses or in their perceptions of care (Bergland & Kirkevold 2005, 2006, 2008). Residents generally perceive a close co-relation between the type and quality of care and the kind of interactions that they experience with nurses, but not every © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 550–559

Relationships: residents and nursing homes nurses

resident needs to establish close relationships with the nurses (Bergland & Kirkevold 2005). While some residents feel that close friendships with personnel are essential, others do not emphasise these relationships as much and view friendly interactions as sufficient. And there are other residents who do not consider these interactions important at all and maintain only distant relationships with the nurses (Bergland & Kirkevold 2008). Taken together, the available data highlight the importance of the relationships and encounters between caregivers and residents in how residents experience care in nursing homes (Sacco-Peterson & Borell 2004). In Spain, the EARCAS study (Aibar-Rem on 2011) reported that two of the factors associated with the presence of adverse effects in nursing homes were: (1) problems with communication; and (2) inappropriate relationships between residents and healthcare professionals. In Spain, no studies have looked deeper into the nature of interpersonal relationships involving residents and nurses in nursing homes. Such studies would provide useful information for improving care and perceived quality of life for residents (Westin & Danielson 2007, Cohen-Mansfield & Parpura-Gill 2008). The aim of the present study was to describe the relationships between residents and nurses in Spanish nursing homes.

Methods Design A qualitative phenomenological study to analyse the experience of nursing home residents, using a Giorgi proposal (Giorgi 1975), was conducted. Qualitative studies are typically used to achieve a deeper understanding of and find explanations for people’s behaviour under specific circumstances, such as disease or social exclusion (Kuper et al. 2008). The main characteristic of this method is that the researcher is intimately involved in data collection and analysis (Denzin & Lincoln 2005). Data collection requires the researcher to interact with the study participants and with their social context (Piot & Garnett 2009), which allows some degree of mutual influence. In the field of qualitative studies, phenomenology attempts to understand how individuals construct their world view; in other words, it looks through a window into other people’s experiences (Denzin & Lincoln 2005). The aim of phenomenology is to identify the essence of the experiences lived by participants (Giorgi 2005), which is the subjective reflection on human beings when taking part in events in a specific geographical, social and cultural environment (Reeves et al. 2008).

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This experience always has a meaning for the person who has lived it (Giorgi 1997), and thus, the qualitative phenomenological research method uses first-person narratives from the patients themselves as a data source (Denzin & Lincoln 2005). Phenomenology research uses the term ‘bracketing’ to indicate the need to ‘retain’ beliefs which, using the phenomenological reduction approach, would allow a critical examination of the phenomena without influence of the researcher’s own beliefs (Dowling 2007). Two bracketing conditions were therefore established in the current study on the basis of the recommendations: (1) performance of unstructured interviews; and (2) recording the positions taken by the researchers beforehand, describing previous theoretical framework, research question, chosen participants, beliefs regarding nursing homes and the residents, and professional experiences and motivations underlying the research (Gearing 2004). The researchers’ professional experiences and motivations are based on the following: (1) there is not an equal relationship between nurses and residents; (2) residents cannot always express or establish satisfactory relationships with nurses in nursing homes; and (3) one of the reasons for establishing relationships with residents is to find and collect information on their health status. Sampling strategies The first phase involved purposeful sampling to gather information from the residents themselves (Denzin & Lincoln 2005). The second phase involved theoretical or in-depth sampling of the remaining residents to gain a deeper understanding of certain issues and trends detected during the first phase (Kuper et al. 2008) (Table 1). Researchers made an initial contact with the residents through the Nurse Manager in each nursing home. Researchers explained to the residents, on a first face-toface contact, the purpose and design of the study. A twoweek period was then allowed for residents to decide whether they wished to participate. At the second face-toface contact, they were asked to give informed consent and

permission to tape the interviews if they wished to participate in the study. Following this, data were collected and the interview was completed. The point of theoretical saturation occurs when no new or relevant information emerges from the interviews (Kuper et al. 2008), and it is typically applied to qualitative studies. Nursing home residents from southern region of Madrid were surveyed for this study, and the following inclusion criteria were applied: age 60 or older, lack of cognitive impairments and ability to communicate verbally in Spanish or to communicate by other means. Residents were not excluded on the basis of their gender or the kind of services they were being provided at the nursing home (temporary or long term). The number of beds at each institution varied from 110– 200. Stay could be either on a permanent or temporary basis. A temporary stay would generally last for three months. Admissions were usually related to a need for long-term care, caregiver burnout and/or limitation or absence of financial resources.

Data collection Data collection methodology followed the sampling methods as outlined in Table 1. The first phase consisted of unstructured interviews (Murray et al. 2009), beginning with the following question: ‘What is your experience regarding the relationships between residents and nurses?’ The aim was to look for emerging themes and topics that could be further expanded on during the second phase of the study. The second phase consisted of semi-structured interviews based on a questions guide (Table 2) aimed at eliciting further information regarding specific themes and topics of interest that had emerged from the first round of interviews (Kendall et al. 2009). The question guide was developed after reviewing the residents’ accounts obtained during the purposeful sampling and following a literature review. It consisted of direct, yet

Table 1 Sampling strategies and data collection methods Data collection method

Phase

Sampling strategy

Participants

Type of interview

Documents

Number of interviews

Setting

1st

Purposeful

1–15

Unstructured

36 Researcher’s field notes + 2 Diary fragments + 7 personal letters

Four Nursing homes in the southern region of Madrid

2nd

Theoretical

16–26

Semi-structured + questions guide

10 residents were interviewed twice (face-to-face)Five residents were interviewed once (face-to-face) (n = 25) 1 interview each (n = 11)

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Table 2 Questions guide for the semi-structured interview Research topics

Questions asked

Relationships with the nurses

Is it important for you to maintain relationships with the nursing homes nurses? Is the nurses sensitive to your needs and likes? How do you feel about your overall experiences with the nursing staff of the nursing home? What significance do these experiences have for you? What would you emphasise about your relationships with nurses? Do you get emotionally close to your nurses and caregivers? Do you tell them about your personal life? How would you define your relationship with the nurses?Do you feel that you and the nursing staff are equals in the relationship? Have you had any confrontations with a member of the nursing staff? How did it happen? Do you have specific strategies or behaviours for interacting with the nurses? What kind? Why? Are you able to communicate your preferences and likes to the nurses? Do you feel listened to or understood? When do you feel that is appropriate to communicate your preferences and likes? What do you think about changes of nurses in the nursing home? Are you able to adapt to changes in nursing staff? How do you adapt when new personnel is incorporated into the nursing home? What do you think about the daily chores of the nurses? Do you feel that their chores can affect your relationship with nurses?

Characteristics of relationships with nurses

Communication

Turnaround and change in nursing staff

Relationship between the responsibilities of the nurses and the interactions between residents and nurses

open questions to allow residents to share their own experiences. The interviews were tape-recorded and transcribed verbatim. Personal documents provided by nursing home residents and researcher field notes were collected during both stages. Personal data collected from the residents are a rich source of information because they can describe personal experiences from the first-person perspective. All the residents included in the study were asked to voluntarily provide any personal documents, such as diaries or letters, where they describe and explain their experience at the nursing home organisation. Researchers collated these documents. During the interview, the researcher made notes including environment description, resident nonverbal responses to questions, the use of metaphors in their narratives and other relevant points raised by the interviewed resident. The authors followed recommendations for qualitative research interviews with institutionalised older people (Robinson 2000).

Data analysis Full literal transcription of each of the interviews, researcher field notes and resident’s documents were produced. Texts were collated to allow qualitative analysis to be performed (Giorgi 1997). The Giorgi method was used to implement qualitative analysis of data (Giorgi 1997), and it contains four essential steps (Giorgi 2000): ‘(1) one reads the entire description in order to get a general sense of the whole statement; (2) once the sense of the whole has been grasped, the © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 550–559

researcher goes back to the beginning and reads through the text once more with the specific aim of discriminating “meaning units” from within the perspective and with focus on the phenomenon being researched; (3) once “meaning units” have been delineated, the researcher then goes through all of the meaning units and express the insight contained in them more directly; and (4) finally, the researcher synthesises all of the transformed meaning units into a consistent statement regarding the subject’s experience.’

Quality considerations Guidelines for conducting qualitative studies established by the Consolidated Criteria for Reporting Qualitative research (Tong et al. 2007) were followed. The data reliability method consisted of: (1) cross-triangulation by the researcher, which included session planning where the cases analysed by each team member were presented to reach consensus; (2) auditing the material obtained from 10 randomly selected cases by an external researcher; and (3) resident verification (Cohen & Crabtree 2008). The resident’s verification was carried out in two steps: postinterview and postanalysis. To allow transferability, researchers provided sufficient detail on the context of the field work for a reader to be able to decide whether the prevailing environment is similar and whether the findings can be justifiably applied to the other setting (Shenton 2004). Details of the context are as follows: the number of participants involved in the field work; the data collection method employed; the number of data collection sessions; and the length of the study.

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Ethical approval The Clinical Research Ethics Committee at Universidad Rey Juan Carlos approved this study. Special attention was given to the ethical considerations related to data collection tools used (interviews, researcher field notes and resident’s personal letters) and to the treatment and management of personal data. Permission to record the interviews was always required prior. Informed consent was obtained before the interviews, and the participant was offered the possibility to suspend the interview or withdraw from the study. All personal data and information that might identify residents was redacted, and a numerical code was applied instead.

They are like residents. They spend more time here than in their own homes… (R10)

Residents are generally not unhappy about their relationships with nurses, and their opinions about personnel are positive and familiar: We have shared very intimate experiences. This brings you close together, so many tragedies and so many good times…and they are the ones standing next to you… (R27)

However, residents emphasise that their contacts with the nurses and their relationships within the nursing home must be based on sincere interactions: Their demeanor is sometimes distant, but they have always been there… (R7)

Results The study lasted one year, from February 2010–2011. It was implemented in four private nursing homes located in the South of Madrid (Spain). Twenty-six residents with a mean age of 83 were included. None of the residents withdrew from the study. Fourteen female residents were included. The mean time since nursing home admission was 32 months. Data saturation was attained with resident 22, after a total of 36 interviews were performed. The interviews produced 1882 minutes (31
4 hours) of recordings. Seven personal letters and two fragments from diaries were collected from the residents, together with the researcher field notes. All interviews were held at the nursing home in each resident’s bedroom. In presenting our findings, we follow each main idea with quotes obtained from residents during the interview process. From our analyses, two main themes representing resident perceptions about their interactions with the nurses at the nursing home emerged: (1) meeting the nursing home nurses; and (2) managing relationships with the nursing home nurses.

This is a time in my life when I want only sincere people around me. (I want) people that, when they talk, do so truly…to me…not to a resident…not to just a room number. I want them to be truly interested… (R11)

Residents perceive if the nurses initiate conversation at times of their own choosing and on topics that they are interested in. This is especially true if conversation revolves around care and chores, instead of around the experiences and memories of the residents. Residents need the nurses to appreciate their perspective and try to understand them: …they don’t usually talk to you, and if they do, it is to ask you about your illness, your medication… (R25) …I would like to tell them about the way I feel at night, but they are not interested. When I tell them something personal, they change the topic and ask me if I sleep well, if I eat… (R12)

Residents feel that nurses are required to perform a job, but that they are not the subject of this job: …I thought it was because they were always in a rush…always busy…the truth is that they do have a lot of work…I think they

Theme: meeting the nursing home nurses

don’t want to get close to us. (R22)

Living in the nursing home implies establishing relationships with other residents and with nurses. Relationships with nurses are important for residents because they depend on them for care:

They get paid to work and take care of us, but I guess they don’t

You have to get along…how couldn’t you…they are there in case something happens to you. (R29)

Residents think of nurses as close to them because of the long periods that they spend together. In particular, long shifts translate to long periods of contact and interactions:

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get paid to be talking to some old people… (R30)

Residents are aware of the large workload of the nursing personnel and that work conditions (low salaries, large workload, few opportunities for professional development) force nurses to leave the nursing home. Losing nurses with whom they have established close relationships makes them sad, and they avoid getting close to minimise suffering: © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 550–559

Original article There are times when they can’t be with us even if they are around because of the amount of work that they have…that is not their fault. There are too many of us. (R9) I have decided to try not to relate to them…one gets close and then they leave…This is a law of life. But I get sad… (R3)

Theme: managing relationships with the nursing home nurses The residents try to build and maintain their relationships with the nurses through different strategies. These include minimising confrontations to avoid being ‘labelled’ by the nurses. Residents who protest are perceived negatively by the nurses and get labelled as ‘problematic.’ Conciliatory behaviour, helpful to the nurses, puts residents in good standing, and they might, occasionally, receive special benefits in return, such as larger food portions, or priority in receiving morning calls for breakfast or in being assisted in their personal cleaning: … you need friends even in hell. That’s why I help them if I can. (R2) There are staff members with whom you should be interested in getting along, or at least avoid a bad relationship…at the end of the day the decision on whether to help you and take care of you (earlier or later) depends on them… (R15) ….because of the way I am, orderly and always willing to help everybody, they give me some privileges. They give me more food or allow me to be tardy… (R25)

From the perspective of the resident, behaviours that are viewed positively by the nurses include the following: good manners, being easy to take care of (clean their own room and themselves), being helpful to other residents (with walking or eating) and helpful to the nurses and willing to mediate in conflicts that may rise among residents. Other relationship management strategies may include the following: agreeing with the nurses, being quiet and avoiding talking about the performance of the personnel, who do not want to call attention to themselves: I prefer to shut up because being confrontational won’t help me. At the end of the day you have to live with them. (R1) One word wrongly spoken at the wrong time and they will hold a grudge on you. (R24) …you avoid asking them to take you to the restroom or to change you. With some of them, you have no idea how they will respond. (R26)

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Residents avoid talking about the performance of the nurses because of concerns that their comments might influence their relationships with nurses and affect the quality of their care. Many residents would clarify or carefully qualify their comments about nurses to minimise the severity of their complaints: The truth is that there are too few of them for so much work, but that doesn’t justify the things they sometimes say or do … (R5) I know it’s not their fault—that they are understaffed and underpaid—but sometimes they need to concentrate more… (R9)

Discussion Theme: meeting the nursing home nurses Our results show that, while nursing home residents perceive that they interact extensively with the nurses, this does not necessarily translate to more meaningful relationships. Nevertheless, residents have the need to share and to establish relationships with their care providers. These results are in agreement with previous studies (Bergland & Kirkevold 2005, Hauge & Kristin 2008). The main goal of seeking interactions with staff members is getting to know them better (Bergland & Kirkevold 2006). JonasSimpson et al. (2006) noted that nursing home residents build their lives collaboratively with their caregivers. Similarly, Westin and Danielson (2007) discussed the need of residents to belong to a place and to share this experience with others. Residents want to share their friendship and even fraternise with their caregivers (Westin & Danielson 2007). Residents emphasise that meaningful encounters are those based on authentic and sincere interactions, in which they are seen as unique individuals (Westin & Danielson 2007). But there is more than just one type of relationship between personnel and residents. Bergland and Kirkevold (2005) established three categories of relationship on the basis of the perception about the care that residents receive: (1) distant relationships where care is viewed as a service; (2) nonpersonal relationships where care is considered a source of comfort; and (3) personal relationships where it is considered a true relationship between two people. The type of relationship established in any given case depends to a great extent on the preferences of the resident. Another key element in the establishment of resident– nurses relationships is the extent to which the personnel are willing to get involved. Bergland and Kirkevold (2008) emphasised the role that caregivers can play in potentiating relationships with residents through conversation. On the

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contrary, other studies show that caregivers tend to focus on providing care from a technical perspective rather than investing time in socialising and promoting sincere interactions with residents (Stabell et al. 2004, Tuckett 2004, Westin & Danielson 2007). In our results, we observed that it is the nurses who initiate socialisation and define the nature of conversations. In this regard, our results coincide with those from previous studies (Bergland & Kirkevold 2005, Wadensten 2005). Importantly, the topics of conversation favoured by nurses are centred on issues of care and on the illnesses affecting the residents (Williams et al. 2005). Other studies have documented the fact that residents lack sufficient opportunities to tell caregivers about their experiences or to share their thoughts (Westin & Danielson 2007), and even when social contact does occur, it is often ignored (Stabell et al. 2004). The lack of interest among caregivers in initiating conversation could sometimes be related to the preconception that residents would rather be left alone and not be bothered (Stabell et al. 2004). Some of the participants in our study fit the profile reported by Heliker and Scholler-Jaquish (2006), who indicated that resident’s feel isolated when they are unable to communicate with their caregivers and express their needs. Westin and Danielson (2007) also described situations of isolation when residents perceive that they are not valued and in fact feel invisible to the personnel. In these cases, contacts between residents and nurses are only sporadic, and residents perceive that caregivers do not have the time to spend with them and are often in a rush (Westin & Danielson 2007). Residents perceive the lack of integration with their caregivers and often feel segregated from them (Agren-Bolmsj€ o et al. 2006, Heliker & Scholler-Jaquish 2006, Westin & Danielson 2007). There are instances when residents take these perceptions of segregation to the extreme and consider themselves undesirable or in some way ‘dirty or infected’ (Westin & Danielson 2007). In addition, a poor ability of caregivers to listen to residents is a significant obstacle in providing good quality care (Jonas-Simpson et al. 2006). Being heard is intimately linked to values, care, intimacy and relationships with others. Being heard makes relationships stronger, reinforces the concept of self and facilitates a positive outlook when facing problems (Jonas-Simpson 2003). The high turnover of personnel can also negatively influence the quality of life for residents (Scalzi et al. 2006) by precluding residents from building and strengthening their relationships with the nurses (Jacelon 1995, Scalzi et al. 2006).

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Theme: managing relationships with the nursing home nurses Residents develop strategies to justify or manage their relationships with nurses, attempting to influence the way personnel perceive them. Fiveash (1998) showed how residents adopt passive behaviours to avoid confrontations with their caregivers and keep cordial relationships. Residents are not interested in causing trouble and place the needs of others above theirs, even making up excuses for caregivers when they did not fulfil their obligations. Porter and Clinton (1992) described similar results, focusing on one of the strategies used by residents: keeping quiet and following instructions. Fiveash (1998) found that behaviours of a ‘good’ resident, as defined by the residents themselves, include the following: answering only when spoken to, having no special requests, always being cheerful, not ‘rocking the boat’, not causing trouble, being quiet, happy, friendly and noncomplaining, giving gifts to nurses and not ‘biting the hand that feeds you.’ One explanation for these perceptions of ‘good’ behaviour among residents is the idea of ‘reciprocity’ (Shield 1990), the mutual exchange between two individuals in a relationship. These exchanges occur routinely among residents themselves. Shield (1990) proposed that reciprocity between subjects in an institutional setting is essential in determining power, choice and control. Reciprocity, however, cannot exist when one individual in the relationship is always on the receiving end. The nursing home is a setting that can favour relationships that are unbalanced with respect to power, control and ability to choose (IngersollDayton & Talbott 1992). When relationships are not balanced, residents can adopt strategies aimed at levelling the playing field and create more reciprocity: some residents exaggerate their needs to get attention (Randers et al. 2002), others minimise their need for help (even when they are truly in need; IngersollDayton & Talbott 1992), while others create distance between themselves and the nurses or avoid criticising the nurses (Pearson et al. 1993). The authors believe that residents in their relationship with nurses seek mechanisms that allow them to feel secure and control their environment. In fact, previous studies (Bergland & Kirkevold 2005, 2006, 2008) showed how residents adopt strategies to facilitate their relations, such as changing behaviour, finding their own space in the nursing homes and choosing their own group of friends. In our study, no residents expressed a sense of fear in the relationship with the nurses, but some residents expressed © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 550–559

Original article

their unwillingness to specifically ‘speak negatively’ about nurses. Similar observations have been reported by Pearson et al. (1993), who showed that residents are apprehensive about criticising their caregivers and discussing negative aspects of the care that they receive (Koch 1994). In the Koch study (1994), a principal reason for this apprehension is their sense of vulnerability and fear of negatively affecting their relationship with nurses, including fear of vindictive behaviour towards them. This is especially true among residents that depend strongly on nurses for their normal daily activities. Based on our results, we believe that the responsibility for establishing a good relationship should be shared between nurses and residents. But the nurse has a greater responsibility because residents may have difficulty relating because of illness, disability or other reasons. In fact, in its Handbook about Criteria and Standards of Care in Nursing Homes (Pe~ nafiel-Olivar 2010), the Madrid Association of Gerontological Nursing states the following: (1) nurses must treat the residents with respect, accepting their beliefs, opinions and ideology; (2) residents should be able to make decisions about their life inside the residence, customise their room and have social relationships, as permitted by law; (3) health actions and activities cannot be limited by age, gender, ethnicity or social class; and (4) there should not be discrimination in the relationships with nurses, and access to services must be based on fairness and equality. In Spain, the main objective of the legal regulations is to protect the residents at nursing homes, maintaining their dignity, respect and autonomy, while establishing protective measures and control in situations of abuse (Government Official Bulletin 2001). The nursing home staff must report any kind of suspected situations of abuse. Also, the Spanish Society of Geriatrics and Gerontology Nursing specifies the level of competence of the nurses in nursing homes and the application of nursing care oriented to stimulating the autonomy and privacy of the residents (Spanish Society of Geriatrics & Gerontology Nursing 2002). A key consideration in understanding the forces that govern the relationships between residents and nurses is the need that residents have of creating a new home, and a new life, inside the nursing home. For residents, it is essential to generate new experiences and memories (Stabell et al. 2004), new stories to share with people around them and a whole new world that inevitably includes the nurses of the home (Heliker & Scholler-Jaquish 2006). It is necessary to discuss the limitations of the present study. First, it was only possible to survey four nursing homes for this study, and thus, the data gathered might © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 550–559

Relationships: residents and nursing homes nurses

represent a rather narrow sample of nursing home residents. Second, some residents expressed concerns about openly discussing their opinions because of the perception that their healthcare coverage or the services that they receive might be affected. To minimise this problem, participants were assured that all researchers were independent from the team that provides them with health care and services at the nursing home. Importantly, we caution against attempts to broadly generalise the findings presented here because our work constitutes a qualitative research study conducted in a very specific context.

Conclusions Residents have the need to build relationships with the nurses in the nursing home because caregivers are an intricate part of their new world. In fact, the high turnover rate of nurses is negatively perceived by residents. Residents manage their relationships with nurses by using multiple behavioural strategies. They perceive these adjustments as necessary to facilitate daily life, acquire privileges or avoid problems and/or confrontations. Reflecting about the relationships between residents and nurses in the nursing home has the potential to help caregivers understand the importance of fostering their relationships with residents, viewing them as equal and avoiding the establishment of unnecessary hierarchies. It can also help improve the overall management of nursing homes by placing due importance on the relationships between residents and nurses with the ultimate goal of enhancing the quality of life and the quality of perceived care of residents.

Relevance to clinical practice The nurses should schedule enough time to spend with residents. They should establish sincere relationships with residents, asking them about aspects of care, as well as their life, family, life story, tastes, etc. They should incorporate dialogue and listen to the residents daily. The dialogue and active listening with residents must be incorporated into the nursing care. It should be given the same attention for all residents, with special attention to residents with cognitive and functional difficulties.

Acknowledgements The authors would like to thank the Nursing and Physiotherapist School of San Juan de Dios and Universidad Pontificia de Comillas for funding this project following a

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peer-reviewed evaluation process. The authors would also like to thank all residents surveyed for this project and the managers of nursing homes involved.

Funding The authors received funding from the Nursing and Physiotherapist School of San Juan de Dios and Universidad Pontificia de Comillas.

Contributions Study design: DPC, MELI, CGC, CFP, MBR; data collection and analysis: DPC, JMCP, CGC, MBR and manuscript preparation: DPC, CFP, JMCP, MELI.

Conflict of interest The author(s) declare that they have no conflict of interests.

References Agren-Bolmsj€ o I, Sandman L & Andersson E (2006) Everyday ethics in the care of the elderly people. Nursing Ethics 13, 249–263. Aibar-Rem on C (2011) EARCAS Study: Adverse Events in Nursing Homes and Social Assistance Centres. Ministry of Health and Social Policy, Madrid. Available at: http://www.seguridaddel paciente.es/recursos/documentos/earcas. pdf (accessed 23 September 2012). Bergland A & Kirkevold M (2005) Resident-caregiver relationships and thriving among nursing home residents. Research in Nursing & Health 28, 365–375. Bergland A & Kirkevold M (2006) Thriving in nursing homes in Norway: contributing aspects described by residents. International Journal of Nursing Studies 43, 681–691. Bergland A & Kirkevold M (2008) The significance of peer relationships to thriving in nursing homes. Journal of Clinical Nursing 17, 1295–1302. Casado-Marın D (2006) Long-term care services in Spain: an overview. Gaceta Sanitaria 20(Suppl. 1), 135–142. Cohen DJ & Crabtree BF (2008) Evaluative criteria for qualitative research in health care: controversies and recommendations. Annals of Family Medicine 6, 331–339. Cohen-Mansfield J & Parpura-Gill A (2008) Practice style in the nursing home: dimensions for assessment and quality improvement. International Journal of Geriatric Psychiatry 23, 376–386. Denzin NK & Lincoln YS (2005) The Sage Handbook of Qualitative Research. Sage Publications, Thousand Oaks, CA. Dıaz-Martın R (2009) Older People in Spain. Statistical Data in the State and

558

Region: Report 2008/Volume I. Ministry of Health and Social Policy-Institute of Older People and Social Services, Madrid. Available at: http://www. imserso.es/InterPresent1/groups/imserso /documents/binario/infppmm2008.pdf (accessed 23 September 2012). Dowling M (2007) From Husserl to van Manen. A review of different phenomenological approaches. International Journal of Nursing Studies 44, 131–142. Fiveash B (1998) The experience of nursing home life. International Journal of Nursing Practice 4, 166–174. Gearing RE (2004) Bracketing in research: a typology. Qualitative Health Research 14, 1429–1452. Giorgi A (1975) Phenomenology and the foundation of psychology. Nebraska Symposium on Motivation 23, 281– 348. Giorgi A (1997) The theory, practice and evaluation of the phenomenological method as a qualitative research procedure. Journal of Phenomenological Psychology 28, 235–260. Giorgi AP (2000) Concerning the application of phenomenology to caring research. Scandinavian Journal of Caring Science 14, 11–15. Giorgi A (2005) The phenomenological movement and research in the human sciences. Nursing Science Quarterly 18, 75–82. Government Official Bulletin (2001) Decreto 72/2001 de 31 de mayo, Regimen Jurıdico B asico del Servicio P ublico de Atenci on a Personas Mayores en Residencias, Centros de Atenci on de Dıa y Pisos Tutelados [Legal Regulations of the Public Service Care for Nursing Homes, Day Care Centers and Supervised Apartments]. Justice Ministry,

Madrid. Available at: http://www. imsersomayores.csic.es/documentos/leg islacion/normas/doc-684.pdf (accessed 23 September 2012) [in Spanish]. Hauge S & Kristin H (2008) The nursing home as a home: a field study of residents’ daily life in the common living rooms. Journal of Clinical Nursing 17, 460–467. Heliker D & Scholler-Jaquish A (2006) Transition of new residents to longterm care: basing practice on residents’ perspective. Journal of Clinical Nursing 32, 34–42. Ingersoll-Dayton B & Talbott MM (1992) Assessments of social support exchanges cognitions of the old-old. International Journal of Aging & Human Development 35, 125–143. Jacelon CS (1995) The effect of living in a nursing home on socialization in elderly people. Journal of Advanced Nursing 22, 539–546. Jonas-Simpson C (2003) The experience of being listened to: a human becoming study with music. Nursing Science Quarterly 16, 232–238. Jonas-Simpson C, Mitchell GJ, Fisher A, Jones G & Linscott J (2006) The experience of being listened to: a qualitative study of older adults in long-term care settings. Journal of Gerontological Nursing 32, 46–53. Kendall M, Murray SA, Carduff E, Worth A, Harris F, Lloyd A, Cavers D, Grant L, Boyd K & Sheikh A (2009) Use of multiperspective qualitative interviews to understand patients’ and carers’ beliefs, experiences and needs. British Medical Journal 339, b4122. Koch T (1994) Establishing rigour in qualitative research the decision trail. Journal of Advanced Nursing 19, 976– 986.

© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 550–559

Original article Kuper A, Reeves S & Levinson W (2008) An introduction to reading and appraising qualitative research. British Medical Journal 337, 404–409. Murray SA, Kendall M, Carduff E, Worth A, Harris FM, Lloyd A, Cavers D, Grant L & Sheikh A (2009) Use of serial qualitative interviews to understand patients’ evolving experiences and needs. British Medical Journal 339, b3702. Pearson A, Hocking S, Mott S & Riggs A (1993) Quality of care in nursing homes from the resident′s perspective. Journal of Advanced Nursing 18, 18– 24. Pe~ nafiel-Olivar AE (2010) Standard of Care on Nursing Homes: Autonomy and Dignity in Old Age. Madrid Association of Gerontological Nursing, Madrid, pp. 57–60. Piot P & Garnett G (2009) Health is global. Lancet 374, 1122–1123. Porter EJ & Clinton JF (1992) Adjusting to the nursing home. Western Journal of Nursing Research 14, 464–481. Randers I, Olsson TH & Mattiasson AC (2002) Conforming older adults′ patients′ views of who they are and would like to be. Nursing Ethics 9, 416–431. Reeves S, Albert M, Kuper A & Hodges BD (2008) Why use theories in qualitative research? British Medical Journal 337, 631–634.

Relationships: residents and nursing homes nurses Robinson JP (2000) Phases of the qualitative research interview with institutionalized elderly individuals. Journal of Gerontological Nursing 26, 17–23. Sacco-Peterson M & Borell L (2004) Struggles for autonomy in self-care: the impact of the physical and sociocultural environment in a long-term care setting. Scandinavian Journal of Caring Sciences 18, 376–386. Scalzi CC, Evans LK, Barstow A & Hostvedt K (2006) Barriers and enablers to changing organizational culture in nursing homes. Nursing Administration Quarterly 30, 368–372. Shenton AK (2004) Strategies for ensuring trustworthiness in qualitative research projects. Education for Information 22, 63–75. Shield RR (1990). Liminality in an American nursing home: the endless transition. In The Cultural Context of Aging Worldwide Perspectives (Sokolovsky J ed.). Bergin & Garvey Publications, New York, NY, pp. 331–353. Spanish Society of Geriatrics and Gerontology Nursing (2002) Technical Document nº1/November/ 2002: Nurses′ Competencies in Nursing Homes. Spanish Society of Geriatrics and Gerontology Nursing, Spain. Available at: http://www.arrakis.es/~seegg/documentos/doc_tec/doc_tec_01.pdf (accessed 23 September 2012).

Stabell A, Eide H, Solheim GA, Solberg KN & Rustoen T (2004) Nursing home residents′ dependence and independence. Journal of Clinical Nursing 13, 677–686. Takkinen S & Ruoppila I (2001) Meaning in life in three samples of elderly persons with high cognitive functioning. International Journal of Aging & Human Development 53, 51–73. Tong A, Sainsbury P & Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32item checklist for interviews and focus groups. International Journal for Quality in Health Care 19, 349–357. Tuckett AG (2004) The care encounter: pondering caring, honest, communication and control. International Journal of Nursing Practice 11, 77–84. Wadensten B (2005) The content of morning time conversations between nursing home staff and residents. Journal of Clinical Nursing 14, 84–89. Westin L & Danielson E (2007) Encounters in Swedish nursing homes: a hermeneutic study of residents′ experiences. Journal of Advanced Nursing 60, 172–180. Williams KN, Ilten T & Coger BH (2005) Meeting communication needs topics of talk in the nursing home. Journal of Psychosocial Nursing and Mental Health Services 43, 38–48.

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