How Stories Can Contribute Toward Quality Improvement in Long-Term Care

Abstract

It is important to evaluate how residents, their significant others, and professional caregivers experience life in a nursing home to improve quality of care based on their needs and wishes. Narratives are a promising method to assess this experienced quality of care as they enable a rich understanding, reflection, and learning. In the Netherlands, narratives are becoming a more substantial element within the quality improvement cycle of nursing homes. The added value of using narrative methods is that they provide space to share experiences, identify dilemmas in care provision, and provide rich information for quality improvements. The use of narratives in practice, however, can also be challenging as this requires effective guidance on how to learn from this data, incorporation of the narrative method in the organizational structure, and national recognition that narrative data can also be used for accountability. In this article, 5 Dutch research institutes reflect on the importance, value, and challenges of using narratives in nursing homes.

Nursing homes provide 24-hr care for the most vulnerable people in our society who have demanding health needs (Sanford et al., 2015). Moving to a nursing home is an impactful life event (Sun et al., 2021). Henceforth, after having moved to a nursing home, it is important that residents’ preferences and needs are heard in order for them to be able to continue living their life (Nakrem et al., 2013). In most Western countries, however, nursing home care is often very medically oriented and institutionalized, which is also reflected in standardized quality evaluations (Castle & Ferguson, 2010). Residents are required to adjust to the culture of the nursing homes, whereas nursing homes should provide tailored care to each individual resident. One may argue that providing tailored care is unrealistic due to lack of time and resources, yet often small adjustments can have a large impact on how residents experience living in a nursing home (Nakrem et al., 2013; Sun et al., 2021). To improve quality of care, it is important to discover what residents truly value. Thus, the resident’s voice needs to be heard during quality evaluations.

In this article, five Dutch research institutions share their collaborative vision of the added value of narrative methods for quality evaluations in nursing homes. First, the concept of quality of care and how this can be assessed will be elaborated on. This will be followed by a description of narrative inquiry, its added value, and examples of narrative approaches for quality evaluations in nursing homes. Hereafter, practical and theoretical implications will be discussed.

Evaluating Quality of Care and Person-Centered Care in Nursing Homes

In general, quality of care is often defined as safe, effective, person-centered, timely, efficient, equitable, accessible, and affordable (Institute of Medicine Committee on Quality of Health Care in America, 2001). In nursing homes, whereas all these concepts are important and monitored, there has been a shift from more medical-oriented care toward person-centered care, which is often considered the gold standard for high-quality care. Over the past decades, many definitions of person-centered care have emerged due to its idiosyncratic nature (Edvardsson & Innes, 2010). What these definitions have in common is that it is essential to (a) understand care users on a personal level, (b) engage them in decision-making, and (c) acknowledge their care relationships (Wilberforce et al., 2017). In addition, the healthy aging policy framework of the World Health Organization stresses that care receivers should maintain a level of functional ability consistent with their basic rights, fundamental freedoms, and human dignity (World Health Organization, 2015). Person-centered care is more closely related to concepts such as experienced quality of care, in which quality of care is conceptualized as a process consisting of each individual’s expectations and needs, their interactions during care experiences, and each individual’s assessment after care delivery (Sion et al., 2019). It is personal and subjective, and shaped by the social and physical environment, including relational, political, and organizational aspects (Goffin & Mitchell, 2016; Kremer & Koksma, 2017). Thus, person-centered care and quality of care can only be shaped in the relationship between residents, their significant others, and professional caregivers, and the experiences of all these stakeholders should be considered (Pew-Fetzer Task Force & Tresolini, 1994; Tronto, 2016). Our narrative approaches take these different perspectives into account.

Quality of care can be improved by focusing on personal experiences. This is in line with the shift from static external control toward more active learning and reflection in the care organization (Reinders & Nazarowa, 2020). Such a process actively engages stakeholders to improve the quality of care and integrates this process into care provision, which can potentially result in more tangible outcomes (Raad Volksgezondheid en Samenleving, 2019). Learning from experiences requires professional caregivers (i.e., care aids and nurses) to reflect on the norms underlying their actions and how to handle tensions between these norms (triple-loop learning). This critical reflection is essential because quality of care is a multifaceted concept and practice has shown tensions between different aspects of quality often occur. Merely learning if standards and procedures are followed the right way (single-loop learning) or if the right procedures are followed (double-loop learning) does not suffice (Tosey et al., 2012). Triple-loop learning is fostered by qualitative data such as residents’ narratives, because these provide detailed information and case descriptions from the resident’s perspective.

Narratives provide rich information that is complementary to the more frequently used quantified assessments of person-centered care such as patient-reported outcome measures, patient-reported experiences measures, and satisfaction assessments (Weldring & Smith, 2013). Whereas these measures support the inclusion of person-centered care in quality assessments, there are some limitations. For instance, they are unable to fully capture the experienced quality of care in its context, as they are mostly closed-ended, theme-based surveys, limiting space for elaboration, and depth on what truly matters to residents. In addition, findings are often anonymized and aggregated, limiting their usability to improve quality on an individual level in nursing homes. Therefore, narratives can be considered a complementary data source for quality improvements in nursing homes.

Narrative Methods to Evaluate Quality of Care in Nursing Homes

Narratives have several qualities that enable understanding, reflection, and learning: they provide time to share stories about care experiences, space to identify dilemmas in providing quality care, and rich data to learn from. Scholars have advocated for a narrative approach in gerontology to better understand the perspective of aging people themselves and as a way to organize care in such a way that it supports older people in maintaining their personhood (Kenyon et al., 2010; Villar & Serrat, 2017). The use of narratives in quality improvement is grounded in the field of narrative inquiry. Narrative inquiry is aimed at facilitating respondents to tell their own stories, and interpret and prioritize their own experiences (Thomas et al., 2009). The approach is not limited to interviewing, as narratives can be shared in small real-life interactions in fragmented ways through for example participant observation or participant documentation as well (Bamberg & Georgakopoulou, 2008). In the nursing home context, this could be the observation of residents’ behavior by professional caregivers or the documentation of experiences with the care process by significant others when people with advanced dementia are not able to express themselves verbally anymore.

There are many different ways to use narratives in nursing homes depending on the aim of the evaluation, the participants, and the needs and culture of the nursing home. In the Netherlands, multiple evidence-based narrative methods for quality evaluations in nursing homes are used, each providing unique possibilities depending on organizational contexts and populations. A selection is presented in Table 1 and the references provided for each narrative method provide further details and examples. It is very valuable to have different options for these quality evaluations as each has different strengths and possibilities for different organizational contexts and populations. This allows for choice and a better fit within the vision, culture, and needs of a care organization. Each narrative method has its own aim, participants, and unique features. Connecting Conversations aims to evaluate experienced quality of care by having separate appreciative conversations with a resident, a significant other of that resident, and a professional caregiver, and connecting these three perspectives (Sion et al., 2020). The story as a quality instrument enables stakeholders to improve care by reflecting together on rich narrative portraits of residents’ experiences (Scheffelaar et al., 2021). Experiences Central enables the evaluation of care based on experiences by structurally collecting micro-narratives from residents, significant others, and professional caregivers on their experiences, and aggregating these data for learning purposes on a micro, meso, and macro level (Eijnde et al., 2022). Ask Us! aims to reflect on experiences in several group conversations with residents (advocates), significant others, and professionals resulting in the development of common goals for improvement initiatives and co-designing these improvements together (Heerings et al., 2022a). What do you need? is a method that combines narrative interviews with residents, significant others, and professionals about three basic psychological needs that are often challenged in nursing homes: autonomy, competence, and relatedness (Custers et al., 2013; Kloos et al., 2020).

Table 1.

Narrative Quality Evaluations

Method	Aim	Brief description	Underlying theories
Connecting Conversations (Sion et al., 2020)	To evaluate and improve experienced quality of care in nursing homes from the resident’s perspective	Separate appreciative conversations with a resident, significant other, and professional caregiver of that resident. -Independent interviewer receives training -Appreciative inquiry (focus on what is going well) -Conversations +/− 20 min -Six questions to support the conversation -Interactive reflection sessions	Narrative inquiry, Relationship-centered care, INDEXQUALa (Sion et al., 2019)
The story as a quality instrument (Scheffelaar et al., 2021)	To improve care with stakeholders involved by reflecting on rich narrative portraits of resident’s experiences	-Caregivers interview older adults openly -The professional caregiver summarizes the main themes in a holistic narrative portrait -In a quality meeting stakeholders reflect on the portraits and create an action plan -After 6–12 weeks a follow-up meeting takes place to evaluate the progress	Narrative inquiry, Biographical narrative interviewing method
Experiences Central (Eijnde et al., 2022)	To enable co-creation and evaluation of care based on the experiences of staff, residents, and significant others	Staff, residents, and significant others share their experiences (micro-narratives in text and/or image). With the care and support in an app. By adding metadata to their experiences, the micro-narratives can be used for learning and development on the micro, meso, and macro level.	Complexity theory, Relationship-centered care, Democratic care
Ask Us! (Heerings et al., 2022a)	To foster reflection, deliberation, and codesign between resident (advocates), significant others, and professionals	A process of different group conversations in which resident (advocates), significant others, and professionals share experiences and reflect on tensions between quality aspects and the differences and similarities between their perspectives; develop common goals for improvement and codesign these improvements together.	Small story approach, Counter-narratives
What do you need? (Custers et al., 2013; Kloos et al., 2020)	To explore similarities and differences in perspectives on need fulfillment	Interviews are being held with triads of residents, significant others, and professionals about the fulfillment of the needs of autonomy, competence, and relatedness.	Small stories approach, Self-determination theory

^aINDEXQUAL = individually experienced the quality of long-term care.

Potential quality improvement resulting from the application of these methods include empowerment of residents, as they are enabled to share their experiences with care; improved relationships as professionals, residents, and significant others develop a better understanding of each other’s perspectives; learning by professionals as they practice with skills such as listening to residents’ stories, reflection on value tensions and conflicting perspectives and learn about residents needs and experiences with care; and, specific improvements as changes in care processes are made based on residents’ stories.

The Added Value of Using Narrative Methods in Nursing Homes

Narrative methods allow more space for respondents to voice what they find important regarding the quality of care. They have a much more open structure as opposed to quantitative surveys, allowing respondents to shape their own stories. The advantage of this approach is that it provides respondents the opportunity to share their stories and emotions and elaborate on points for improvement that they deem important (Clandinin & Connelly, 2000). Research has shown that participants appreciate the time that is taken for these conversations (Sion et al., 2020; van Delft et al., 2023).

Narrative methods are equipped to cover the complexity and multifaceted nature of quality. They reveal the complex reality of care, as they consist of care experiences, context, and interpretation from different points of view (Hsu & McCormack, 2012). These qualitative descriptions provide insight into the contextualized needs, preferences, and dynamic relationships of residents, their significant others, and professional caregivers, and convey more nuance, detail, and emotional content (Grob et al., 2019). Narratives are more prone to show the tensions that may arise between different quality aspects in practice, as opposed to normative outcomes from surveys. For instance, the preferences of residents may not always be in line with predetermined indicators such as health and safety, which poses dilemmas to professionals when providing person-centered care (Miller & Barrie, 2022). An example of such a dilemma could be that residents prefer a nonpureed diet, although professionals fear a choking incident. Another example could be tension between a professional’s aim to prevent functional decline and a resident’s preference to be left at peace and watch television (Laffon de Mazières et al., 2017). Moreover, residents, significant others, and professionals may prioritize these quality aspects differently (Miller et al., 2018). Narratives can serve as a starting point to discuss each stakeholder’s norms and values, make dilemmas explicit, and create a shared vision of the considerations that should be taken into account during care provision. By including a diverse group of stakeholders in quality improvement processes, tensions between these perspectives can be made visible (Sion, et al., 2019). Reflection and deliberation on these differences may lead to quality improvement initiatives that are more broadly supported (Heerings et al., 2022b).

Narrative methods foster learning and inspiration to engage in quality improvement efforts. Research has shown that professional caregivers can use narratives to evaluate, learn from, and improve care services based on care recipients’ stories (Hsu & McCormack, 2012). Narratives about care experiences contain rich insights into the experienced quality of care, which help to explore the meanings from the respondent’s point of view. These rich stories can help professional caregivers to understand an individual’s expectations, needs, and wishes within their specific contexts. They can provide care organizations with insight into what is meaningful to residents, and help to improve tailored quality of care (Heliker, 1997). In general, professional caregivers are eager to use narrative information as it is more closely related to the lived experiences of residents, their significant others, and themselves in everyday practice (Ubels, 2015). When professionals reflect on stories together this has additional benefits for learning, as they can share their detailed views on events, better understand each other, and give each other advice (Bartel & Garud, 2009). Facilitating collaboration between people with different knowledge, positions, and interests, enables them to get new ideas and insights that enable them to reflect in practice (Nonaka & von Krogh, 2009; Robert et al., 2015). It is also expected that the involvement of a variety of stakeholders will create more support for quality improvement initiatives, which is essential to achieve goals (Heerings et al., 2022a; Leviton & Melichar, 2016).

Implications for Practice

Our research so far has focused on developing evidence-based, reliable, and valid narrative evaluation methods, distinguishing them from standard day-to-day conversations. For these narrative methods to reach their full potential in quality improvement, our current research is focused on implementation and usability of these narrative methods in practice.

Close collaboration with all involved stakeholders is indispensable for the successful implementation of narrative methods, which requires time and flexibility. As time is already scarce in most nursing homes, further insight is needed into the existing processes and reporting tools in nursing homes to better incorporate these methods into existing structures and processes. Communicating and listening are fundamental competencies of caregivers and henceforth there should be time for this in daily practice. Furthermore, evaluation could establish whether the outcome of a narrative method also saves time, as narratives discover what care should focus on (van de Bovenkamp et al., 2020). Moreover, to create a better balance between time investment and outcome, more insight is needed into the impact of participating in narrative methods. For residents, participation may foster empowerment. For professionals, it may foster empowerment as well, and reflexivity. Lastly, residents, significant others, and professionals may develop a better understanding of each other’s needs and perspectives on good care and develop common goals which further strengthens their relationships (Palmer et al., 2019). Hence, the process itself contributes to quality improvement and thus, becomes time well spent. These ideals, however, need to be further investigated, as, for example, successful implementation and use of narratives also require a clear vision, managerial support, and specific competencies from staff (Murray et al., 2010; van Delft et al., 2023).

Crucial for the valuable use of the narratives is that the information is used by care organizations to learn from. This is challenging due to the amount of data, as well as the potential differences in preferences and experiences among residents, significant others, and professionals. Previous research has shown that a structured approach to translating narratives into quality improvement initiatives is indispensable. Without such an approach, people legitimize their own stories and interests instead of letting themselves genuinely be guided by the narratives (Fancott, 2016; Fear, 2014). Examples of approaches could be a process of deliberation and co-design, yet this should be tested in the nursing home setting (Bate & Robert, 2006; Heerings et al., 2022a).

Organizational learning from narrative methods can also be fostered by aligning accountability structures, such as monitoring and auditing procedures dictated by funders, inspectorates, or inscribed in national policies. An accountability paradigm that fosters the use of narrative methods is narrative accountability (Reinders & Nazarowa, 2020; Ubels, 2015). Narrative accountability celebrates narrative information as part of the accountability process. The complexity of daily practice is better reflected in this data and aspects that are valuable for good care are made visible, which would not be possible if this data were quantified (Vriens et al., 2018). Narrative accountability emphasizes the relational aspect of accountability, for instance by allowing regulators and care organizations to be in dialogue about good care and how this can be further improved (Wiig et al., 2021). The regulator’s role can also entail ensuring care organizations have systems in place that foster organizational learning from qualitative and quantitative quality information (Pot, 2022). Narrative methods could be an important part of shaping such a system. Although aspects of narrative accountability are experimented with in practice, it requires further development to become a completely developed accountability paradigm.

The narrative methods described in this paper have primarily been developed for older adults, significant others, and professionals who are able to talk about their own experiences. In long-term care, residents’ capabilities are diverse, and not all older adults are able to express themselves, such as those suffering from advanced dementia. For people with advanced dementia, significant others and care professionals can share their experiences in words, but additional sources such as observation or creative, and non-verbal methods can also be useful to incorporate the viewpoint of the people with dementia themselves as well. Future research is needed to further study and develop additional tools to collect narrative data in a suitable way for people with dementia. Furthermore, the narrative methods described in this paper are currently mainly used within the context of funded research projects in the Netherlands and have not often been structurally adopted by care organizations. Further research is necessary to investigate the facilitators and barriers for organizations to implement such narrative methods.

Conceptual and Theoretical Implications for Quality of Care

The use of narratives for quality evaluations also has conceptual and theoretical implications for how person-centered care and quality of care are defined and assessed. Traditionally, quality of care is objectively measured with structure, process, and outcome indicators (Castle & Ferguson, 2010). Yet, this distinction is deemed insufficient when subjective narratives are added to the equation. Narratives provide a different data source for evaluating and improving quality, in which quality of care is perceived as a process that is highly influenced by expectations, relationships, and the context (Sion et al., 2019). These developments are in line with the ethical care principles, stating that care is individual, relational, and contextual, and care delivery needs to be aligned among these aspects (Tronto, 2010). Henceforth, the use of narratives is essential for high-quality care. Narrative data are rich, descriptive, and subjective. Residents, significant others, and care professionals themselves decide what is considered high-quality care and conflicting norms and values can be revealed (Kremer & Koksma, 2017). This implies that the quality of care is a much more individualized concept that cannot be captured in standardized themes that are the same for everyone; it is dynamic and versatile for each individual.

This new view on the quality of care requires a different approach toward quality assessments. Care organizations need to reflect on why they want to assess quality of care as it should not be about the assessment itself, but the purposes for which the data are used. Narrative information can be used as a starting point for quality improvement in a participatory and co-creative process with a variety of stakeholders to generate new understandings together. To successfully achieve this, a culture change in care organizations is required which is focused less on checklists and more on reflecting and learning.

In conclusion, the use of narratives is deemed very valuable for quality evaluations and improvements in long-term care. Further research should focus on how these methods can be successfully implemented and used within the full quality cycle to fully reach their potential in practice.

Funding

None.

Conflict of Interest

We deem it relevant to mention all authors have been involved in research regarding the development of narrative methods for long-term care.

Data Availability

The authors do not report data and therefore the pre-registration and data availability requirements are not applicable.