A sense of home in residential care

Development of the Music Therapy in Transition to Long-Term Care Model

Transition to long-term care can be a challenging period for older adults, with high risk for negative outcomes, including depression, anxiety, and fear. However, music therapy has the potential to enhance related protective factors because it emphasizes individual strengths by leveraging culture-specific resources, facilitates relationships and a sense of belonging through joint music-making, and provides opportunities to process and make sense of one's experiences in the "new normal" through sharing of music-related emotions. The purpose of this study was to explore the perspectives of older adult long-term care residents, their care team staff, and their music therapists to develop a conceptual framework for the role of music therapy in older adults' transition and adjustment to long-term care. A grounded theory approach was used to conceptualize this process. Interviews with 17 participants were transcribed and analyzed using open, axial, and selective coding. The resulting theoretical model describes a progression of qualities and benefits of music therapy that leads to residents "feeling their best self." Related categories include: Music therapy is accessible and engaging; Music therapy is personal and meaningful; Music therapy acts as a bridge to other resources; Music therapy facilitates transformation; and Music therapy facilitates community integration. This initial theoretical model provides a foundation for clinical assessment and interventions. Future research is needed for continued testing and refining this theory.

The perspectives of older people living with dementia regarding a possible move to a nursing home

BACKGROUND/OBJECTIVES

Moving into a nursing home is often an unavoidable life event for older people living with dementia. It is associated with negative emotions and outcomes. Research capturing their perspectives is scarce. This study aims to identify how older people living with dementia perceive a potential life in a nursing home and to understand their (future) care wishes.

MATERIALS AND METHODS

This study is part of the European TRANS-SENIOR research network. The study followed a qualitative phenomenological methodology. Semi-structured interviews with 18 community-dwelling older people living with dementia were conducted between August 2018 and October 2019 (METCZ20180085). A stepwise interpretive phenomenological analysis was performed.

RESULTS

The majority of community-dwelling older people feared the idea of potentially moving to a nursing home. The participants associated a possible move with negative perceptions and emotions. Additionally, this study emphasized the importance of knowledge of current and past experiences with care when identifying the participant's wishes. They wanted to remain (a) individuals, who are (b) autonomous and have (c) social contacts if they would move to a nursing home.

DISCUSSION/IMPLICATIONS

This study showed how past and current care experiences can educate/inform healthcare professionals on the future care wishes of older people living with dementia. The results indicated that listening to the wishes, and life stories of people living with dementia could be a way of identifying 'a suitable time' to suggest a move to a nursing home. This could improve the transitional care process and adjustment to living in a nursing home.

Cumulative Disempowerment: How Families Experience Older Adults' Transitions into Long-Term Residential Care

Although emerging research links family experiences with long-term residential care (LTRC) transitions to structural features of health care systems, existing scholarship inadvertently tends to represent the transition as an individual problem to which families need to adjust. This secondary qualitative analysis of 55 interviews with 22 family members caring for an older adult engages a critical gerontological lens. A concept of cumulative, structural empowerment informs this analysis of families' experiences across a broad continuum of older adults' moves into LTRC. Leading up to transitions, families have little power over home care services, and family members have little control over their involvement in care provision. Some families respond by making choices to refuse publicly provided service options, therein both resisting and reinforcing broader relations of power. Expectations for family involvement in LTRC placement decisions were incongruent with some families' experiences, reinforcing a sense of powerlessness compounded by the speed with which these decisions needed to be made. A broad temporal analysis of transitions highlights LTRC transitions as a process of cumulative family disempowerment connected to broader formal care structures alongside emphases on aging in place and familialism that characterize LTRC as the option of last resort.

Family members' reasoning in relation to pleasant environments in nursing homes

The physical environment plays an important role in how everyday life is shaped and experienced for persons living in nursing homes as well as for the residents' family and friends. Still, there is a scarcity of research exploring the perspectives of family members of residents regarding everyday life in common areas in nursing homes. In this study, we chose the term, 'a pleasant place', with the ambition of remaining open to various ideas and aspects that family members perceive as relevant when reasoning about the nursing home environment. The study aimed to explore how family members of nursing home residents reason in relation to pleasant places in nursing homes. Four focus group sessions were conducted with a total of 14 family members. Data were analysed using qualitative content analysis. The analysis resulted in four themes. 'A door ajar', highlighted the importance of a nursing home environment that provides potential opportunities for pleasurable everyday moments. 'Why does it have to be so ugly?', revealed how family members perceived institutional logics as guiding the design of the nursing homes, which were misaligned with the logics of a pleasant place. 'A place to care for?', emphasised the physical environment as an integrated aspect of care, in terms of being carefully arranged and used with sensitivity. Finally, 'allegiance to the place' showed that despite the family members' recognitions of shortcomings in the nursing home physical environments, their allegiance to the place provided a sense of the nursing home as a pleasant place. The study contributes knowledge regarding the perceived value of the design of the physical environment in nursing homes, particularly in common areas, as an integral aspect of care, and moves beyond the ideas of homelike and non-institutional nursing home environments.

A sense of home for people with dementia in a long-term care facility: A design perspective

The study aims to provide new insights into the approach to the spatial design of homelike dementia care facilities. This paper builds on Molony's (2010) findings that home meaning in care facilities is a process of people-place integration, and then proposes that people living with dementia can accomplish this process through their bodily habit. This research adopted an ethnographic case study approach. Three cases from a long-term care facility were studied by using semi-structured interviews and observations. According to the findings, having a sense of home for people living with dementia can be understood as a process of re-establishing people-place integration through their bodily habits in a long-term care facility. As a result, designers can consider which design features can assist people living with dementia in re-establishing this integration through bodily habit to create home feelings in a dementia care facility.

Experiences of health care personnel with promoting a sense of home for older adults living in residential care facilities: a qualitative systematic review

OBJECTIVE

The objective of this review was to evaluate the experiences of health care personnel with promoting a sense of home for older adults living in residential care facilities.

INTRODUCTION

Moving to a residential care facility represents a critical moment for older adults. It disrupts the continuity of their lives and distances them from significant people and objects. Health care personnel working in residential care facilities can help create a sense of home for residents. There is a lack of qualitative reviews reporting health care personnel's experiences with promoting a sense of home for older adults living in residential care settings.

INCLUSION CRITERIA

Qualitative studies exploring the experiences of health care personnel with promoting a sense of home for people aged 65 and older living in residential care facilities, including, but not limited to, nursing homes, residential care homes, retirement homes, assisted-living facilities, and skilled nursing facilities were included in the review.

METHODS

This review followed a meta-aggregation approach according to JBI methodology for systematic reviews of qualitative evidence. PubMed, CINAHL, Embase, PsycINFO, Scopus, Web of Science, and ILISI databases were searched, as well as Google Scholar, OpenGrey, and ProQuest Dissertations and Theses Global. Studies published in English, Italian, French, Portuguese, or Spanish were considered for inclusion. Study selection, critical appraisal, data extraction, and data synthesis were conducted by 2 independent reviewers using the JBI approach and JBI standardized tools. Finally, the ConQual approach was used to assess the confidence level in the study findings.

RESULTS

Seven studies conducted in Canada, the United States, the United Kingdom, Sweden, and the Netherlands between 2014 and 2020 were included. The studies reported the experiences of nurses, nurse aides, and directors of facilities. From the aggregation of 69 findings, 14 categories were generated that were then grouped into 3 synthesized findings describing the experiences of health care personnel as follows: the promotion of residents' sense of home in residential care facilities is influenced by i) the built environment, including private, single rooms with bathrooms, homelike-domestic spaces, personalization of residents' rooms, homelike interior and exterior design, and non-hospital-like environment; ii) the national and local policy and regulations, and work organization, as well as leadership of managers and directors; and iii) the facilities' care culture, including philosophy of care, maintaining autonomy of residents and ties with the community, participation in domestic and recreational activities, and family relationships. Based on the ConQual scores, the confidence level in the synthesized findings was graded as low.

CONCLUSIONS

According to health care personnel, the physical environment, interpersonal and social aspects, regulations, work organization, and the facilities' care culture can contribute to creating a sense of home for older adults in residential care facilities. The evidence derived from this review can help health care personnel, facility directors, and policy-makers identify the changes that should be implemented to promote a sense of home in older adults residing in care facilities.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020214383.

Factors associated with perceptions of dignity and well-being among older people living in residential care facilities in Sweden. A national cross-sectional study

The care of older people living in residential care facilities (RCFs) should promote dignity and well-being, but research shows that these aspects are lacking in such facilities. To promote dignity and well-being, it is important to understand which associated factors to target. The aim of this study was to examine the associations between perceived dignity and well-being and factors related to the attitudes of staff, the care environment and individual issues among older people living in RCFs. A national retrospective cross-sectional study was conducted in all RCFs for older people within 290 municipalities in Sweden. All older people 65 years and older (n = 71,696) living in RCFs in 2018 were invited to respond to the survey. The response rate was 49%. The survey included the following areas: self-rated health, indoor-outdoor-mealtime environment, performance of care, attitudes of staff, safety, social activities, availability of staff and care in its entirety. Data were supplemented with additional data from two national databases regarding age, sex and diagnosed dementia. Descriptive statistics and ordinal logistic regression models were used to analyse the data. Respondents who had experienced disrespectful treatment, those who did not thrive in the indoor-outdoor-mealtime environment, those who rated their health as poor and those with dementia had higher odds of being dissatisfied with dignity and well-being. To promote dignity and well-being, there is a need to improve the prerequisites of staff regarding respectful attitudes and to improve the care environment. The person-centred practice framework can be used as a theoretical framework for improvements, as it targets the prerequisites of staff and the care environment. As dignity and well-being are central values in the care of older people worldwide, the results of this study can be generalised to other care settings for older people in countries outside of Sweden.

Implementation of a Sense of Home in High-Density Multicultural Singapore Nursing Homes: Challenges and Opportunities

Many studies have introduced principles for creating a sense of home in nursing homes, yet they mostly feature cases from low-density developments in Western countries. This raises a question about how those principles are interpreted and implemented in other cultural contexts, especially in high-density, multicultural environments such as Singapore. This paper examines how a sense of home is implemented in Singapore nursing homes, with a specific focus on the role of the built environment. Participant observations were conducted in five nursing homes in Singapore comprising various architectural design typologies, with the focus on the residents’ everyday interactions with their built environment. The study identified the extent of the presence of a sense of home in Singapore’s nursing homes and the prevalence of an institutional care model. More specifically, the study explicates Singapore nursing home residents’ management of privacy and personalization in shared spaces, illuminates the need for holistic implementation of homelike environments integrated with building designs and care programs and reiterates the pivotal role of social relationships in fostering a sense of home for the residents in the nursing homes.

'The Primacy of 'Home': An exploration of how older adults' transition to life in a care home towards the end of the first year

This grounded theory study sought to explore how older adults' experience the transition from living at home to a care home with a specific focus on the latter part of the first year of the move. The study was carried out within a large Health Trust in the UK between August 2017 and May 2019. Purposive sampling was used in the initial stages of data collection. Thereafter and consistent with grounded theory methodology, theoretical sampling was employed to undertake semi-structured interviews with 17 individuals from eight care homes between 5 and 12 months after the move. This paper reports five key categories which were: (a) The lasting effect of first Impressions 'They helped me make my mind up' (b) On a Journey 'I just take it one day at a time', (c) Staying connected and feeling 'at home' 'You get something good out of it you know…you get hope'. (d) Managing loss and grief 'It was important for me to say cheerio to the house' and (e) Caring relationships 'I didn't realise that I was lonely until I had company'. Together these five categories formed the basis of the core category 'The Primacy of 'Home' which participants identified as a place they would like to feel valued, nurtured and have a sense of belonging. This study identifies that it is important for individual preferences and expectations to be managed from the outset of the move. Individuals and families need to be supported to have honest and caring conversations to promote acceptance and adaptation to living in a care home while continuing to embrace the heart of 'home'. Key recommendations from this study include the need to raise awareness of the significance of the ongoing psychological and emotional well-being needs of older people which should be considered in policy directives and clinical practice.

‘Knowing me, knowing you’: an exploration of the views and experiences of nursing home residents and staff on their nursing home as ‘home’

The overall aim of this grounded theory study was to explore the context of a nursing home as ‘home’ from the perspective of residents and staff. Sixteen focus group interviews were used to collect qualitative data from nursing home residents (N = 48) and staff (N = 44). Five distinct categories captured the views and experiences of participating residents and staff. These were: (a) Starting off on the right foot, ‘First impressions can be the lasting ones; (b) Making new and maintaining existing connections, ‘There is great unity between staff and residents’; (c) The nursing home as home, ‘It's a bit like home from home for me’; (d) Intuitive knowing, ‘I don't even have to speak, she just knows’; and (e) Feeling at home in a regulated environment, ‘It takes the home away from nursing home’. Together these five categories formed the basis of the core category ‘Knowing me, knowing you’, which captures the experiences of participants who repeatedly highlighted the importance of relationships and feelings of mutuality and respect between and among staff and residents as central to feeling at home in a nursing home. The reciprocity and mutuality associated with the core category, ‘Knowing me, knowing you’, was at times challenged by staff shortages, time constraints, and conflicting priorities associated with the co-existence of a regulated and homely environment.

Structure and agency attributes of residents' use of dining space during mealtimes in care homes for older people

Research stresses that mealtimes in care homes for older people are vital social events in residents' lives. Mealtimes have great importance for residents as they provide a sense of normality, reinforce individuals' identities and orientate their routines. This ethnographic study aimed to understand residents' use of dining spaces during mealtimes, specifically examining residents' table assignment processes. Data were collected in summer 2015 in three care homes located in England. The research settings looked after residents aged 65+, each having a distinct profile: a nursing home, a residential home for older people and a residential home for those with advanced dementia. Analyses revealed a two-stage table assignment process: 1. Allocation - where staff exert control by determining residents' seating. Allocation is inherently part of the care provided by the homes and reflects the structural element of living in an institution. This study identified three strategies for allocation adopted by the staff: (a) personal compatibilities; (b) according to gender and (c) 'continual allocation'. 2. Appropriation - it consists of residents routinely and willingly occupying the same space in the dining room. Appropriation helps residents to create and maintain their daily routines and it is an expression of their agency. The findings demonstrate the mechanisms of residents' table assignment and its importance for their routines, contributing towards a potentially more self-fulfilling life. These findings have implications for policy and care practices in residential and nursing homes.

What kind of home is your care home? A typology of personalised care provided in residential and nursing homes

This paper examines how care home managers in England conceptualised the approach to delivering personalised care in the homes they managed. We conducted interviews with care home managers and mapped the approaches they described on two distinct characterisations of personalised care prominent in the research and practitioner literature: the importance of close care relationships and the degree of resident choice and decision-making promoted by the care home. We derived three ‘types’ of personalised care in care homes. These conceptualise the care home as an ‘institution’, a ‘family’ and a ‘hotel’. We have added a fourth type, the ‘co-operative’, to propose a type that merges proximate care relationships with an emphasis on resident choice and decision-making. We conclude that each approach involves trade-offs and that the ‘family’ model may be more suitable for people with advanced dementia, given its emphasis on relationships. While the presence of a range of diverse approaches to personalising care in a care home market may be desirable as a matter of choice, access to care homes in England is likely to be constrained by availability and cost.

Between Social Inclusion and Exclusion: Integration of Daycare Guests in the Nursing Home Setting

Background and Objectives

In integrated daycare, community-dwelling older people in need of care join existing groups in residential care facilities during the day. This study focuses on how nursing home residents experience the integrative care approach, exploring opportunities for social inclusion and mechanisms of exclusion.

Research Design and Methods

A purposive sample of residents differing in cognitive capacity and level of (non)conflictual interaction with daycare guests was selected. Episodic interviews with residents (N = 10) and close relatives (N = 2) were conducted in 3 pilot facilities in Germany and analyzed using thematic coding.

Results

The analysis revealed different orientation patterns towards the presence of daycare guests: respondents (a) demonstrated indifference to the daycare guests, (b) saw bonding with guests as a means to connect to the outside world, and (c) perceived incompatibility between in-group and out-group. Criticisms included disruption of daily routines and loss of privacy. Most interviewees came to terms with the care situation using rational and moral arguments.

Discussion and Implications

The study reveals the importance of residents’ participation when integrating daycare guests. Institutional procedures are required to prevent exclusion of daycare guests and avoid overtaxing residents.

The experiences of the process of planning, starting and organizing a culturally specific nursing home for Finnish-speaking older persons: a qualitative study

BACKGROUND

Globally there are growing multicultural and multilingual societies. As a result of extensive international migration, the number of elderly migrants has increased and will further increase in the future. This makes it necessary for elderly healthcare services to meet elderly migrants' healthcare needs concerning language and cultural barriers. To our knowledge, previous research in the area of culturally specific nursing homes for migrant seniors is still limited. Thus, the study aimed to investigate the experiences of planning, starting and organizing a culturally specific nursing home for Finnish-speaking older persons.

METHODS

An explorative qualitative study using both semi-structured individual interviews and focus group interviews as data collection. Thirteen informants were purposively recruited, two from Finnish-speaking association, seven healthcare professionals and two family members. Data were analysed by qualitative content analysis.

RESULTS

Three categories, each with sub-categories, emerged from the data: 1) Motivation to develop this particular culture-specific nursing home; 2) Organizational issues and 3) Aspirations for the future. The study found that information from policy makers, the localization and activities of the nursing home, having healthcare staff who speak the minority language, organizing the nursing home as a mixture of older members of both the majority and the minority communities, all affected the planning, starting and organization of a culturally specific nursing home.

CONCLUSION

This study found that information, localization, activities and language adapted to elderly migrants affected the planning, starting and organization of a culturally specific nursing home for Finnish-speaking older persons. These findings should support the healthcare organization in planning, managing and organizing sustainable nursing home care for older people belonging to a minority in order to attain the aim of person-centered and equal healthcare.

Relocation experiences of the elderly to a long-term care facility in Taiwan: a qualitative study

BACKGROUND

Relocation to a long-term care (LTC) facility is a major life change for most elderly people. Following relocation, many elderly experience difficulties in adapting to changes in the living environment. Taiwan is increasingly becoming an "aging society" and the numbers of those who relocate from family residences to long-term residential care facilities have increased over years. However, in-depth evidence on the experiences of the elderly of their stay in LTC facilities in Taiwan is relatively sparse. This study aimed to explore the relocation experiences of the elderly to a LTC facility to inform policy and practice to address their needs effectively.

METHODS

A qualitative study, using semi-structured in-depth interviews, was conducted to explore the experiences of 16 elderly people who have relocated to and lived in a LTC facility in Taiwan for up to a period of 12 months. All interviews were recorded, transcribed, and analyzed using grounded theory approach.

RESULTS

Participants' accounts reflected four interrelated key themes: wish to minimize the burden, but stay connected with the family; perceived barriers to adaptation; valuing tailored care; and acceptance and engagement. Each theme included interrelated subthemes that influenced one another and represented the different stages in the relocation journey. Most participants viewed relocation as a way of minimizing the burden of their care from family members, but desired to keep a close connection with family and friends. Participants recounted experiences of psychological resistance while making the decision to relocate. Fear of losing autonomy and the ability to perform self-care was a major reason for resistance to adapt. Provision of tailored care was accorded much value by the participants. The decision to accept the relocation and to adapt themselves to the new environment due to their needs for constant care was explicit in some accounts.

CONCLUSIONS

Relocation to LTC facility is a dynamic process in the first year of moving into the facility, and involves a range of emotions, feelings and experiences. Adaptation of the elderly into the LTC facility can be maximized if the relocation is well planned with provisions for individually tailored care and family involvement.

Qualities of the environment that support a sense of home and belonging in nursing homes for older people

The aim of this study was to contribute with knowledge about how a sense of home and belonging is enacted and can be supported in everyday life, with a particular focus on the relationships that connect everyday life and the environment in nursing home contexts. The concepts ‘a sense of home’ and ‘belonging’ were chosen with the ambition to grasp values grounded in experiences and everyday practices, with an openness for various aspects that can support an enjoyable life and comfort for nursing home residents. The study focused on communal areas, e.g. dining room, kitchen, corridors and gardens, that serve as arenas where nursing home residents’ everyday lives expand beyond the private room. Ethnographic methods were applied to identify and explore situations where a sense of home and belonging were enacted in nursing homes that had been acknowledged as good examples of nursing home environments. Through the analytic process, four qualities were identified: (a) a cornerstone for stability and everydayness, (b) the beating heart, (c) spatial dynamics, and (d) magnetic places. Following from the chosen methodology, the findings provide a situated understanding of how communal areas in nursing homes can invite a sense of home and belonging for the residents.

‘Waiting and Wanting’: older peoples’ initial experiences of adapting to life in a care home: a grounded theory study

A grounded theory approach, consistent with the work of Strauss and Corbin, was used to undertake semi-structured interviews with 17 older people, to explore their experiences of living in a care home, during the four- to six-week period following the move. Purposive sampling was initially adopted, thereafter, theoretical sampling was employed to recruit individuals identified by care managers within older peoples’ community teams and care home managers within a large Health and Social Care Trust in the United Kingdom. Consistent with grounded theory methodology, data collection and analysis occurred simultaneously. Constant comparative analysis underpinned data analysis and data management techniques. Data analysis revealed five distinct categories that captured these experiences. These were: (a) wanting to connect – ‘I am so lost here’, (b) wanting to adapt – ‘Well mentally you have to make the best of it’, (c) waiting for assistance – ‘it's a frustration for me’, (d) ‘waiting on the end’ – I am making no plans’ and (e) wanting to re-establish links with family and home – ‘I love getting home and I like getting out to the town’. Together these five categories formed the basis of the core category, ‘Waiting and Wanting’, which encapsulates the initial adaptation experiences of the men and women in the study. Findings indicate that individuals were dependent on others to create a sense of belonging, independence and wellbeing. Moreover, risk aversive practices were perceived as a threat to individuals’ independence and autonomy. Recommendations include the need to amend policy and practice for the development of a bespoke induction programme for each resident facilitated by a senior member of the care home staff working in partnership with individuals and families, in addition to the health and social care team, to support a more positive transition for new residents, relatives and care home staff.

What matters to you when the nursing is your home: a qualitative study on the views of residents with dementia living in nursing homes

BACKGROUND

Dementia is recognised as one of the greatest global public health challenges. A central tenet of national health and social care policy is to ensure that services support people in achieving their personal well-being and outcomes, defined as the things important to people in their lives, also people with dementia. The aim of this study is to explore what matters to nursing home residents with dementia based on their perceptions of nursing homes as home.

METHODS

There were conducted 35 interviews with people with dementia in nursing homes. We conducted the in-depth unstructured qualitative interviews. Thematic analysis was applied to analyse the data.

RESULTS

The analysis resulted in one over-arching theme "tension between the experiences of a nursing home being a home and an institution" and five themes; "myself and my relationships with fellow residents", "creation of individualised living spaces", "single rooms with personal decor that enhances a sense of connectedness", "transition between the old home and the new home" and "significant activities providing meaning". The participants stated that the transition to the supported, structured living environment in nursing homes to be a clear need based on immediate, serious safety concerns. They went from being masters of their own lives to adhering to nursing home routines. Fellow residents could be both resources and burdens, creating feelings of security and insecurity. A home-like environment was created by allowing the participants to bring their important personal belongings into private spaces. The participants said they needed to be able to decorate their rooms to their own specifications. They wanted involvement in meaningful activities.

CONCLUSIONS

The findings showed that 'home' was an emotive word that awakened many associations. The participants reported mixed feelings and stated that they could thrive even if they missed their old homes. What mattered was that the participants felt safe, had single rooms where they could retire from the community, their own belongings and did activities. The participants wanted greater possibilities for meaningful relations. They appreciate that nursing home were similar to their previous homes. They desired opportunities to continue some activities they did in their former home.

Conceptualising trust in aged care

This article calls for a sociological understanding of the importance of trust to aged care. It connects existing theories of trust to empirical evidence from gerontology and nursing research. Trust is defined as a response to and management of social vulnerability. It is argued this makes trust a fundamental concept for understanding human service and social care institutions, including aged care. In light of Australia's Royal Commission into Aged Care Quality and Safety, as well as generational shifts in consumer expectations and care ethics, the article highlights four distinct yet interrelated forms of trust: interpersonal, institutional, organisational and public trust. All of these forms are shown to be critical in conceptualising and evaluating the perceived trust deficit facing contemporary aged-care systems, and existing evidence shows how these forms of trust can reinforce, conflict and misalign with each other. Efforts to rebuild trust in aged care at an organisational and institutional level should ensure mechanisms facilitate rather than hinder the formation of interpersonal trust relations between individual service users, their families and aged care staff. Broader social policy reforms must also consider and address the way cultural understandings of ageing, and media representations of aged care, have diminished the public's trust in the sector, and how the cycle of scandals, reviews and piecemeal reforms contributes to this.

‘It gives you more to life, it's something new every day’: an Interpretative Phenomenological Analysis of wellbeing in older care home residents who keep a personal pet

There is a substantial amount of literature that suggests that animals, and specifically animals kept as pets, can have a positive effect on wellbeing. Research exploring the impact of animals on wellbeing in care homes mainly concerns visiting animals as well as shared communal pets. In light of the lack of research regarding personal pets in care homes, the aim of this study was to explore what the experience of keeping a personal pet in a care home means for residents’ sense of wellbeing. Semi-structured interviews were conducted with seven care home residents who were currently living with their pet in a care home. Interviews were analysed using Interpretative Phenomenological Analysis (IPA). Analysis revealed four master themes deemed to be relevant to participants’ wellbeing. these were: ‘sense of self and identity’, ‘responsibility and ownership’, ‘motivation and desire to live’ and ‘feeling content in the care home’. The analysis indicated that living with a personal pet in a care home has the potential to enhance residents’ wellbeing. At the same time, it also found that the benefits of keeping a personal pet may be dependent on specific circumstances, such as the attitudes of staff and fellow residents at the care home. This study indicates that it may be advisable for more care homes to accept personal pets.

Care Home Life and Identity: A Qualitative Case Study

Background and Objectives

The transition to a care home can involve multiple changes and losses that can affect an older person’s well-being and identity. It is not clear how older people perceive and manage their identity within a care home over time. This study explores how living in a care home affects the identities of residents and how they address this in their daily lives.

Research Design and Methods

A multiple qualitative case study approach incorporated interview and observational data. Eighteen semistructured interviews and 260 hr of observations were conducted over 1 year with care home residents, relatives, and staff across three care homes within Greater Manchester, UK. Data were analyzed using framework analysis, drawing on the social identity perspective as an interpretive lens.

Results

Four themes were identified: (a) changing with age, (b) independence and autonomy, (c) bounded identity, and (d) social comparison. The impact of aging that initially altered residents’ identities was exacerbated by the care home environment. Institutional restrictions jeopardized independence and autonomy, provoking residents to redefine this within the allowances of the care home. Strict routines and resource constraints of well-meaning staff resulted in the bounded expression of personalities. Consequently, to forge a positive identity, residents without dementia engaged in social comparison with residents with dementia, emphasizing their superior cognitive and physical abilities.

Discussion and Implications

Social comparison as an adaptive strategy has previously been unidentified in care home literature. Residents need more support to express their identities, which may reduce the necessity of social comparison, and improve interrelationships and well-being.

"You're at their mercy": Older peoples' experiences of moving from home to a care home: A grounded theory study

BACKGROUND

Internationally, it is recognised that the transition to a care home environment can be an emotional and stressful occasion for older people and their families. There is a paucity of research that takes into consideration the initial phase of the relocation process, incorporating individuals' experiences of the move.

AIM

To explore individuals' experiences of moving into a care home. This paper has a specific focus on the preplacement (7 days) and immediate postplacement (within 3 days) period of the move to the care home.

DESIGN

A grounded theory method was used to conduct semi-structured interviews with 23 participants.

RESULTS

Data analysis revealed five distinct categories that captured the experience of the preplacement and immediate postplacement period. These were as follows: (a) inevitability of the move: "I had to come here," (b) making the move: "Abrupt Departures," (c) decision-making and exercising choice: "What can I do, I have no choice," (d) maintaining identity: "Holding on to self" and (e) maintaining connections: "I like my family to be near." Together, these five categories formed the basis of the concept "You're at their Mercy" which encapsulates the perceived transition experience of the older people within the study. Participants felt that the move was out of their control and that they were "at the mercy" of others who made decisions about their long-term care.

CONCLUSIONS

Moving to a care home represents a uniquely significant relocation experience for the individual. Key factors influencing the move were the individuals' perceived lack of autonomy in the pre- and postrelocating period of moving to a care home. Nurses have a key role to play in working with older people to influence policy and practice around decision-making, planning and moving to a care home with greater emphasis on autonomy and choice so that older people do not feel "at the mercy" of others as they navigate such a major transition.

IMPLICATIONS FOR PRACTICE

There is a need to standardise approaches and develop person-centred interventions to support older people considering relocation to a care home and nurses have a key role to play in making this happen.

Resident and staff perspectives of person-centered climate in nursing homes: a cross-sectional study

BACKGROUND

Person-centered care is widely recognized as a gold standard and is based on a supportive psychosocial climate for both residents and staff in nursing homes. Residents and staff may have different perspectives as to whether the climate in which they interact is person-centered, perhaps due to their different expectations of the nursing home environment and the provision of care services. The aim of this study was to explore and compare resident and staff perspectives of person-centered climate in aged care nursing homes.

METHODS

This is a descriptive cross-sectional study using a cluster random sampling method. The study collected data in 2016 from residents (n = 251) and nursing staff (n = 249) in 23 nursing homes using a Person-centered Climate Questionnaire-Patient version and Person-centered Climate-Staff version. T-tests for independent-samples were used to compare scores ranked by nursing staff and residents.

RESULTS

The mean scores of 'A climate of safety' subscale and 'A climate of everydayness' subscale rated by residents were significantly lower than those rated by nursing staff. The mean scores of 'A climate of hospitality' rated by residents were very low among the three subscales, an indicator of the need to improve a more home-like environment for residents. Residents in larger size nursing homes showed a higher score of person-centered climate compared with their counterparts in small size nursing homes.

CONCLUSIONS

This study reveals that the perspectives and perceptions of person-centered climate differ between residents and nursing staff. Therefore, both resident and staff perspectives should be taken into account in attempting to improve person-centered climate for better care outcomes.

Facilitators and inhibitors of transition for older people who have relocated to a long-term care facility: A systematic review

Moving into a long-term care facility to live permanently is a significant life event for older people. Care facilities need to support older people to make a healthy transition following relocation. To help achieve this, we need to understand what facilitates and inhibits the transition process from the perspective of older people, their families, and care facility staff. Our review generated new knowledge to inform this understanding. We addressed the question: what factors facilitate and inhibit transition for older people who have relocated to a long-term care facility? Five electronic databases, PsychINFO, British Nursing Index, CINAHL, MEDLINE and Web of Science were searched for the period January 1990 to October 2017. Grey literature searches were conducted using Google Scholar, and Social Science Research Network. Data were extracted for individual studies and a narrative synthesis was conducted informed by Meleis's Theory of Transition. Thirty-four studies (25 qualitative, 7 quantitative and 2 mixed methods) met the inclusion criteria. Data synthesis identified that transition following relocation was examined using a variety of terms, timelines and study designs. Potential personal and community focused facilitators and inhibitors mapped to four themes: resilience of the older person, interpersonal connections and relationships, this is my new home, and the care facility as an organisation. These findings can inform the development of interventions for these target areas. They highlight also that further research is warranted to understand the organisational culture of long-term care facilities, how this influences transition, and how it might be shaped to create and sustain a caring culture for older people.

Porcelain for All - a nursing home study

PURPOSE

The Porcelain for All project was an initiative by Figgjo AS, a porcelain factory in Norway, which needed more research on different coloured porcelains. The paper aims to discuss this issue.

DESIGN/METHODOLOGY/APPROACH

The study aimed to gain new knowledge about how different décor and dinner plate colours can positively influence dementia sufferer food intake and appetite. The intervention period lasted three weeks. Four days were randomly picked during that period. Each plate was photographed before and after the resident had eaten, researchers conducted observations during mealtimes. Two CurroCus® group interviews were used to collect additional empirical data. In total, 12 dementia sufferers (five females) between 65 and 85 years were observed during dinnertime.

FINDINGS

Plates with a white well, yellow lip and red rim seemed to be preferred regarding food intake. Three main categories were noted from the observations and group interviews: mealtime dignity, porcelain design and appetite.

RESEARCH LIMITATIONS/IMPLICATIONS

Future research could incorporate well-being in people with dementia regarding food weight, testing different meal room environments, user involvement, food presentation and should include more nursing homes and residents.

PRACTICAL IMPLICATIONS

This study only encompasses a small sample (12 residents), all diagnosed with dementia.

SOCIAL IMPLICATIONS

Outcomes may help to prevent undernutrition among elderly people.

ORIGINALITY/VALUE

Combined coloured porcelain, food intake and residents with dementia is scarcely investigated.

Perceptions of home in long-term care settings: before and after institutional relocation

Although moving from institutional to home-like long-term care (LTC) settings can promote and sustain the health and wellbeing of older adults, there has been little research examining how home is perceived by older adults when moving between care settings. A qualitative study was conducted over a two-year period during the relocation of residents and staff from an institutional LTC home to a purpose-built LTC home in Western Canada. The study explored perceptions of home amongst residents, family members and staff. Accordingly, 210 semi-structured interviews were conducted at five time-points with 35 residents, 23 family members and 81 staff. Thematic analyses generated four superordinate themes that are suggestive of how to create and enhance a sense of home in LTC settings: (a) physical environment features; (b) privacy and personalisation; (c) autonomy, choice and flexibility; and (d) connectedness and togetherness. The findings reveal that the physical environment features are foundational for the emergence of social and personal meanings associated with a sense of home, and highlight the impact of care practices on the sense of home when the workplace becomes a home. In addition, tension that arises between providing care and creating a home-like environment in LTC settings is discussed.

Ideas of home in palliative care research: A concept analysis

AIM

To explore the concept of home and its' expressed spatialities in current palliative care research.

BACKGROUND

Home is a central environment for living, caring, and dying. However, pure investigations of the sets of ideas linked to the concept seemed missing. Although identified as an important location, spatial perspectives expressed through the concept of home appeared unexplored.

DESIGN

Rodgers' evolutionary concept analysis.

DATA SOURCES

Scientific articles published between January 2009 and September 2015.

REVIEW METHODS

Rodgers' evolutionary concept analysis. Resulting attributes were explored from two geographically informed spatial perspectives.

RESULTS

As main results, six attributes were identified and explored: Home as actor-capable of acting; emotional environment-something people have feelings for; place-a part of personal identity and a location; space-complex and relational spatial connections and a site for care; setting-passive background and absolute space; becoming-a fluid spatiality constantly folded. Examples of attributes and suggestions for further concept development were identified.

CONCLUSIONS

The concept reflects various sets of ideas as well as expressing both relational and absolute perspectives of space. The most challenging for nursing research and practice seems to be investigation, operationalization, and testing the implementation of sets of ideas reflecting a relational thinking of space.

Quality of experience during horticultural activities: an experience sampling pilot study among older adults living in a nursing home

Horticulture was shown to represent a well-being source for older adults, encompassing the physical, mental and social domains. Aim of this pilot study was to contribute to extant literature through the investigation of the quality of experience associated with horticultural versus occupational activities. A group of 11 older residents of a nursing home were involved in a crossover study with a baseline measure. Participants attended weekly horticultural and occupational sessions for two six-week cycles. Experience Sampling Method was administered before the program and after each session, to assess participants' levels of happiness, concentration, sociability, involvement, challenges and stakes, and self-satisfaction. Altogether, 332 self-report questionnaires were collected. Findings showed that participants' levels of the cognitive and motivational variables increased during both activities, but horticulture was also perceived as providing higher challenges and stakes, and improving self-satisfaction. Results can have practical implications for well-being promotion among older adults through meaningful activity engagement.

The experience of lived space in persons with dementia: a systematic meta-synthesis

BACKGROUND

Identifying how persons with dementia experience lived space is important for enabling supportive living environments and creating communities that compensate for the fading capabilities of these persons. Several single studies have explored this topic; however, few studies have attempted to explicitly review and synthesize this research literature. The aim of this systematic meta-synthesis was therefore to interpret and synthesize knowledge regarding persons with dementia's experience of space.

METHODS

A systematic, computerized search of AgeLine, CINAHL Complete, Embase, Medline and PsycINFO was conducted using a search strategy that combined MeSH terms and text words for different types of dementia with different descriptions of experience. Studies with 1) a sample of persons with dementia, 2) qualitative interviews as a research method and 3) a description of experiences of lived space were included. The search resulted in 1386 articles, of which 136 were identified as eligible and were read and assessed using the CASP criteria. The analysis was inspired by qualitative content analyses.

RESULTS

This interpretative qualitative meta-synthesis included 45 articles encompassing interviews with 672 persons with dementia. The analysis showed that living in one's own home and living in long-term care established different settings and posed diverse challenges for the experience of lived space in persons with dementia. The material revealed four main categories that described the experience of lived space: (1) belonging; (2) meaningfulness; (3) safety and security; and (4) autonomy. It showed how persons with dementia experienced a reduction in their lived space due to the progression of dementia. A comprehensive understanding of the categories led to the latent theme: "Living with dementia is like living in a space where the walls keep closing in".

CONCLUSION

This meta-synthesis reveals a process whereby lived space gradually becomes smaller for persons with dementia. This underscores the importance of being aware of the experiences of persons with dementia and the spatial dimensions of their life-world. To sustain person-centred care and support the preservation of continuity and identity, one must acknowledge not only the physical and social environment but also space as an existential experience for persons with dementia.

Improving socially constructed cross-cultural communication in aged care homes: A critical perspective

Cultural diversity between residents and staff is significant in aged care homes in many developed nations in the context of international migration. This diversity can be a challenge to achieving effective cross-cultural communication. The aim of this study was to critically examine how staff and residents initiated effective cross-cultural communication and social cohesion that enabled positive changes to occur. A critical hermeneutic analysis underpinned by Giddens' Structuration Theory was applied to the study. Data were collected by interviews with residents or their family and by focus groups with staff in four aged care homes in Australia. Findings reveal that residents and staff are capable of restructuring communication via a partnership approach. They can also work in collaboration to develop communication resources. When staff demonstrate cultural humility, they empower residents from culturally and linguistically diverse backgrounds to engage in effective communication. Findings also suggest that workforce interventions are required to improve residents' experiences in cross-cultural care. This study challenges aged care homes to establish policies, criteria and procedures in cross-cultural communication. There is also the challenge to provide ongoing education and training for staff to improve their cross-cultural communication capabilities.

Relocation experiences with unplanned admission to a nursing home: a qualitative study

BACKGROUND

In many countries, people over 85 years of age are relocated involuntarily or unplanned to a nursing home. In Switzerland, 43% of elderly over 85 years are admitted to nursing homes after hospital discharge. This percentage is higher than in the USA with 32.5% or in Germany with only 19%. Despite those more frequent Swiss admissions, no research has been conducted exploring how unplanned admissions to nursing homes affect the adaptation. Therefore, the aim of this study was to gain an in-depth understanding into unplanned admissions to nursing homes and to explore its impact on adaptation.

METHODS

The study used a qualitative interview design based on Meleis' transition model. Secondary data analysis was guided by Mayring's qualitative content analysis. Face-to-face interviews with elderly over 77 years (n = 31) were conducted from a convenience sample in Switzerland between January and March 2013.

RESULTS

The following four patterns of adaptation emerged from the analysis: "being cut-off," "being restricted," "being cared for," and "moving on." The patterns evaluate the relocation into nursing homes and provide an opportunity to appraise the stages of adaption.

CONCLUSIONS

This study presents a model of analysis to evaluate patterns of adaptation following an unplanned admission to a nursing home after hospital discharge.

'We see it as being heterosexualised, being put into a care home': gender, sexuality and housing/care preferences among older LGB individuals in the UK

This paper considers the lack of choice in sheltered housing and residential/nursing care provision for older lesbian, gay and bisexual (LGB) individuals in the UK. While there is a growing body of knowledge about their concerns about current options, the precise kinds of alternative provision which older LGB individuals would prefer are not yet well understood. This article reports on a qualitative study conducted in 2012 which aimed to explore ageing, gender and sexuality from an equalities perspective. The study deployed semi-structured interviews with 60 older LGB individuals living in the UK, and used a thematic analysis approach to the data. This paper describes one aspect of the data, relating to participants' concerns about health and social care provision. The analysis identified several key themes underpinning older LGB individuals' concerns about mainstream sheltered accommodation and residential care, namely: lack of visibility, risky visibility, unequal openness and compulsory co-occupation of care spaces. It highlights the significance of gender for housing/care preferences, with a greater proportion of older LGB women wanting gender- and/or sexuality-specific provision compared with men. The social policy, equality and human rights implications of these findings are considered.

A three perspective study of the sense of home of nursing home residents: the views of residents, care professionals and relatives

Background

The sense of home of nursing home residents is a multifactorial phenomenon which is important for the quality of living. This purpose of this study is to investigate the factors influencing the sense of home of older adults residing in the nursing home from the perspective of residents, relatives and care professionals.

Methods

A total of 78 participants (n = 24 residents, n = 18 relatives and n = 26 care professionals) from 4 nursing homes in the Netherlands engaged in a qualitative study, in which photography was as a supportive tool for subsequent interviews and focus groups. The data were analyzed based on open ended coding, axial coding and selective coding.

Results

The sense of home of nursing home residents is influenced by a number of jointly identified factors, including the building and interior design; eating and drinking; autonomy and control; involvement of relatives; engagement with others and activities; quality of care are shared themes. Residents and relatives stressed the importance of having a connection with nature and the outdoors, as well as coping strategies. Relatives and care professionals emphasized the role the organization of facilitation of care played, as well as making residents feel like they still matter.

Conclusions

The sense of home of nursing home residents is influenced by a multitude of factors related to the psychology of the residents, and the social and built environmental contexts. A holistic understanding of which factors influence the sense of home of residents can lead to strategies to optimize this sense of home. This study also indicated that the nursing home has a dual nature as a place of residence and a place where people are supported through numerous care strategies.

Resident and family member perceptions of cultural diversity in aged care homes

Similar to many developed nations, older people living in residential aged care homes in Australia and the staff who care for them have become increasingly multicultural. This cultural diversity adds challenges for residents in adapting to the care home. This study explores: (i) residents' and family members' perceptions about staff and cultural diversity, and (ii) culturally and linguistically diverse residents' and family members' experiences. An interpretive study design employing a thematic analysis was applied. Twenty-three residents and seven family members participated in interviews. Four themes were identified from interpreting residents and family members' perceptions of the impact of cultural diversity on their adaptation to aged care homes: (i) perceiving diversity as an attraction; (ii) adapting to cross-cultural communication; (iii) adjusting to diet in the residential care home; and (iv) anticipating individualized psychosocial interactions. The findings have implications for identifying strategies to support staff from all cultural backgrounds in order to create a caring environment that facilitates positive relationships with residents and supports residents to adjust to the care home.

The Factors Influencing the Sense of Home in Nursing Homes: A Systematic Review from the Perspective of Residents

Purpose. To provide an overview of factors influencing the sense of home of older adults residing in the nursing home. Methods. A systematic review was conducted. Inclusion criteria were (1) original and peer-reviewed research, (2) qualitative, quantitative, or mixed methods research, (3) research about nursing home residents (or similar type of housing), and (4) research on the sense of home, meaning of home, at-homeness, or homelikeness. Results. Seventeen mainly qualitative articles were included. The sense of home of nursing home residents is influenced by 15 factors, divided into three themes: (1) psychological factors (sense of acknowledgement, preservation of one's habits and values, autonomy and control, and coping); (2) social factors (interaction and relationship with staff, residents, family and friends, and pets) and activities; and (3) the built environment (private space and (quasi-)public space, personal belongings, technology, look and feel, and the outdoors and location). Conclusions. The sense of home is influenced by numerous factors related to the psychology of the residents and the social and built environmental contexts. Further research is needed to determine if and how the identified factors are interrelated, if perspectives of various stakeholders involved differ, and how the factors can be improved in practice.

Normalizing suffering: A meta-synthesis of experiences of and perspectives on pain and pain management in nursing homes

Older people who live in nursing homes commonly suffer from pain. Therefore, relieving suffering among older people that stems from pain demands knowledge improvement through an integration of international knowledge. This study aimed to integrate current international findings and strengthen the understanding of older people's experiences of and perspectives on pain and pain management in nursing homes. A meta-synthesis study using Noblit and Hare's interpretative meta-ethnography approach was conducted. Empirical research papers from journals were collected from various databases. The search process and appraisal determined six articles for inclusion. Two studies were conducted in the US and one each in Iceland, Norway, the UK, and Australia. The older people's experiences of pain as well as perspectives on pain management from all involved (older people, their family members, and healthcare staff) were integrated into a theoretical model using three themes of "identity of pain," "recognition of pain," and "response to pain." The metaphor of "normalizing suffering" was devised to illustrate the meaning of pain experiences and pain management in nursing homes. Society's common attitude that pain is unavoidable and therefore acceptable in old age in society-among older people themselves as well as those who are responsible for reporting, acknowledging, and relieving pain-must change. The article emphasizes that pain as a primary source of suffering can be relieved, provided that older people are encouraged to report their pain. In addition, healthcare staff require sufficient training to take a person-centered approach towards assessment and management of pain that considers all elements of pain.

From Familiar Faces to Family: Staff and Resident Relationships in Long-Term Care

Objective: Long-term care (LTC) facilities are increasingly intent on creating a “homelike” atmosphere for residents. Although residential staff are integral to the construction of a home within LTC settings, their perceptions have been relatively absent from the literature. Method: Thirty-two LTC staff participants were interviewed about their experiences and perceptions of the physical environment and conceptualizations of home, and thematic analyses were conducted. Results: An overarching category—interpersonal relationships—emerged from our analyses emphasizing the importance of relationships in creating a homelike environment within institutional settings. Sub-themes that inform our understanding include the following: (a) Staff members’ perceptions of home; (b) “Their second home”: Adjustment to and familiarity in LTC; and (c) “We become family”: Relationality makes a home. Discussion: The study provides evidence to inform current policies and practices in LTC. Specifically, enough time and space should be given to residents and staff to create and maintain personal relationships to make residential care homelike.

Advancing the Big Five of user-oriented care and accounting for its variations

Purpose

– Care process quality (i.e. how care is enacted by a care worker toward a client at the interpersonal level) is a strong predictor of satisfaction in a wide range of health care services. The purpose of this paper is to describe the basic elements of care process quality as user-oriented care. Specifically, the questions of how and why quality in user-oriented care varies were investigated in the context of elderly care.

Design/methodology/approach

– Two municipalities were selected for in-depth field studies. First, in each municipality, the authors interviewed and observed care workers’ interactions with the older persons in both home care and nursing homes during two weeks (Study 1). Second, in an attempt to gain a deeper understanding of why process quality in terms of user-oriented care varies, the authors conducted interviews with care workers and care unit managers (Study 2).

Findings

– A new taxonomy for categorizing process quality variation, the Big Five of user-oriented care (task-focus, person-focus, affect, cooperation, and time-use), is proposed. In addition, the perceived reasons for process quality variation are reported in our own developed Quality Agents Model, suggesting that variations in care process evaluations may be explained from different perspectives at multiple levels (i.e., older person, care worker-, unit-, department-, and municipality level).

Originality/value

– The proposed taxonomy and model are useful for describing user-oriented care quality and the reasons for its variations. These findings are of relevance for future quality developments of elderly care services, but also may be adapted to applications in any other enterprise employing a user-oriented approach.

A shared respite--The meaning of place for family well-being in families living with chronic illness

Living with chronic illness is a family affair that involves ongoing changes and challenges in everyday life. When life changes, the environment is important for family health and well-being. The relation between a place and a family is rarely described, and therefore the aim of this study was to explore the meaning of place for family well-being in families living with chronic illness. A qualitative design was chosen. Data were collected by photovoice combined with narrative family research interviews with 10 families living with chronic illness. A phenomenological hermeneutic analysis was used to interpret the data. The results showed that the meaning of place for family well-being in families living with chronic illness can be described as "a shared respite." This main theme included three subthemes: "a place for relief," "a place for reflection," and "a place for re-creation." These results were further understood by means of the concept place security. Feeling well means having place security in these families. Through knowledge about the meaning of place for family well-being, health care personnel can stimulate families living with chronic illness to find respite in places that contribute to well-being, both in familiar and new places.

Organizing principles and management climate in high-performing municipal elderly care

Purpose

– Previous research has shown that user-oriented care predicts older persons’ satisfaction with care. What is yet to be researched is how senior management facilitates the implementation of user-oriented care. The purpose of this study is to investigate the organizing principles and management climate characterizing successful elderly care.

Design/methodology/approach

– The department in one highly ranked municipality was selected and compared with a more average municipality. On-site in-depth semi-structured interviews with department managers and participatory observations at managers’ meetings were conducted in both municipalities.

Findings

– Results revealed three key principles for successful elderly care: organizing care from the viewpoint of the older person; recruiting and training competent and autonomous employees; instilling a vision for the mission that guides operations at all levels in the organization. Furthermore, using climate theory to interpret the empirical material, in the highly successful municipality the management climate was characterized by affective support and cognitive autonomy, in contrast to a more instrumental work climate primarily focusing on organizational structure and doing the right things characterizing the more average municipality.

Originality/value

– The authors suggest that guiding organizing principles are intertwined with management climate and that there are multiple perspectives that must be considered by the management, that is, the views of the older persons, the co-workers and the mission. These results can guide future care quality developments, and increase the understanding of the importance of organizational climate at the senior management level.