Good care to older persons: Perceptions of managers, nurses, caregivers and older persons

Abstract

Background

Different studies have been conducted regarding the quality of care provided to older persons. However, at the onset of this study in South Africa, a developing country, it was not clear what the perceptions are of managers, nurses, caregivers, and older persons regarding good care to older persons. The following research question, indicating the need and unique contribution of this study, was formulated: What are the perceptions of managers, nurses, caregivers, and older persons, regarding good care to older persons in residential facilities in South Africa?

Methods

A qualitative descriptive design was followed. Demographic information was obtained from managers (n = 7), nurses and caregivers (n = 35), and older persons (n = 48) in residential facilities (n = 3) for older persons. They also wrote naive sketches by completing six open-ended sentences regarding good care to older persons. Data were collected from August 2021 until April 2022. The naive sketches were analysed using content analysis.

Findings

Perceptions of good care to older persons were categorised into the following themes: providing holistic care to older persons, recognising the individuality and autonomy of older persons, upholding values associated with good care to older persons, building good relationships with older persons, challenges that affect good care to older persons, and opportunities that will assist in providing good care to older persons.

Conclusions

The findings of our study provided a rich understanding of good care to older persons. Programmes to facilitate good care to older persons can be designed and developed for formal and/or in-service training using our findings. Practical guidelines and practices to promote good care to older persons need to be included in these programmes. When managers, nurses, and caregivers, follow these practical guidelines, and internalise these practices, it will empower them to provide good care to older persons.

Ethical approval

The North-West University Health Research Ethics Committee (NWU-HREC) approved this study on 30 September 2019 with ethics number: NWU-00034-19-A1. Written, informed consent was given by all participants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-025-06678-y.

Background

What is good care for older persons, according to the literature? The following section will be dedicated to exploring this question.

As people age, their need for care might increase. This usually happens when they cannot perform the basic activities of daily living, namely eating, bathing, dressing, getting in and out of bed, and toileting without assistance [1]. Older persons who experience a decline in their physical and/or mental health need to have access to quality long-term care [2]. Older persons may receive this care in their homes, in the community, or in residential facilities (RFs) that are also called assisted living facilities, nursing homes, old age homes, retirement villages, and so forth [1, 3, 4]. It is important to remember that these older persons form part of a family and a community [1] and that good care is embedded care; it adapts to the older persons, including the context, culture, and feelings of the older persons [5].

Different categories of nurses and caregivers with diverse training and experience provide care to older persons [1]. In South Africa, professional nurses – also called registered nurses (RNs), staff nurses, auxiliary nurses, and caregivers, provide care to older persons. Caregivers are employed widely in South Africa to care for older persons due to the shortage of registered nurses [6] and the fact that they can be paid less per hour than nurses. Good care to older persons includes receiving professional, reliable, and competent care by qualified nurses and caregivers [5].

Caring for older persons includes caring for their physical, psychological, and social needs, and providing material assistance as needed, with the purpose of promoting their quality of life and general well-being [3, 7]. The care provided to older persons needs to be focused on the needs and preferences of each individual older person who has their own unique experiences and needs [1]. Good care includes allowing older persons to share in decision-making regarding their care [1].

Nurses and caregivers in South Africa are encouraged to treat older persons with respect, dignity, consideration, politeness, empathy, and tolerance [8, 9]. They need to provide quality nursing and clinical care, practise ethically by always choosing the best options for the older persons, and reduce unintentional harm to them [9, 10]. They need to maintain and promote the status, well-being, safety, and rights of older persons and prevent the abuse of older persons [3].

Good care is embedded in a relationship and is care that the older person experiences as good care [11]. When nurses and caregivers provide good care to older persons by establishing a secure relationship with them, the older persons feel “seen”, recognised, and taken seriously, and they become “co-producers of good care” [5].

Studies regarding the quality of care provided to older persons include amongst others a study conducted with nursing assistants, enrolled nurses and registered nurses regarding perceptions of quality of care, working conditions, competence and personal health [12]. Another study explored the perceptions of quality of care for older people: associating factors, that also included these categories of nurses [13]. The perceptions of quality of older people care were explored in a study that included registered nurses, licensed practical nurses and nurses’ aides, and additionally older persons and their relatives [14].

Current literature provides a basic understanding of what good care to older persons entails [1, 3, 5, 7–11]. Different studies have been conducted regarding the quality of care provided to older persons that included different categories of nurses, caregivers, older persons and their families [12–14]. However, at the beginning of this study in South Africa, a developing country, it was not clear what the perceptions are of managers (general managers, nursing services managers, shift managers), nurses (registered nurses, staff nurses, auxiliary nurses), caregivers, and older persons, regarding good care to older persons. The following research question indicates the need and unique contribution of this study: What are the perceptions of managers, nurses, caregivers, and older persons, regarding good care to older persons in residential facilities in South Africa?

Methods

Objective

To explore and describe the perceptions of managers, nurses and caregivers, and older persons regarding good care to older persons in residential facilities in South Africa.

Study design

A qualitative descriptive design was followed.

Trial run

A trial run of the research was conducted at a RF in the JB Marks Local Municipality in the Dr Kenneth Kaunda District Municipality. All the participants provided written informed consent. The North-West University Health Research Ethics Committee (NWU-HREC) approved research proposal was followed, and the approved research documents were used. Feedback after the trial run recommended that some of the research documents need to be summarised. Additional explanations were also provided under the questions of the naïve sketches to make each question clearer. These minor language and technical changes were communicated to the NWU-HREC. The authors believed this data were too valuable not to use and submitted an amendment request to the NWU-HREC to request that the data generated in the trial run may be included in the main analysis of the study. NWU-HREC approval was granted. Reliability of the data were ensured by the first author that independently analysed the data obtained from the trial run together with the data collected for the main study, after all the data were collected, as one data set.

Setting of the study (Context)

The research was conducted in RFs for older persons in the Dr Kenneth Kaunda District Municipality in the North West Province (NWP) of South Africa. One RF was in the JB Marks Local Municipality, and two RFs were in the City of Matlosana. These three RFs provide accommodation and 24-hour services, including nursing care, meals, laundry, cleaning services, socialisation and so forth to older persons from different cultural and socio-economic backgrounds in urban and rural areas in the NWP. These older persons receive nursing care in their flats, apartments, rooms, or frail care units. All these RFs had managers, nurses, caregivers, and older persons with the necessary practical experience, knowledge, and skills to participate in the research.

Role-player engagement

Obtaining goodwill permission from management committees

The management committees or owners of the residential facilities that acted as gatekeepers into the RFs were invited to participate in the research. The first author phoned them, established a relationship with them, and then sent them the following three e-mails explaining the research, two weeks apart: e-mail one: invited the RF to participate in the research; e-mail two: requested goodwill permission and assistance to identify a mediator and an independent person; and e-mail three: summary pages of the tasks of all the role players.

The first author contacted the management committees often and made sure they had enough time to decide whether they wanted to participate or not. After the signed goodwill permission documents were returned to the first author, they were sent to the NWU-HREC together with the permission letters from the North West Department of Health Research Committee (NWDOHRC) and the North West Department of Social Development (NWDSD) for final ethical approval. After final ethical approval was obtained from the NWU-HREC, the management committees were informed that the research may proceed. They were also informed that Coronavirus disease 2019 (COVID-19) protocols would be followed throughout the study.

Mediators and independent persons

The researcher contacted all the mediators and independent persons after receiving their information from the goodwill permission documents. The mediators and independent persons were all employed full-time by the residential facilities. They were informed that boxes with files containing all the documents would be delivered to their residential facilities.

The mediators received a training file and a file with recruitment documents. The independent persons received a training file, a file with the informed consent documents, and a file with the data collection instruments. The first author arranged to send them a video of the PowerPoint presentation explaining the research and the PowerPoint presentation with internet links to COVID-19 information and videos via WhatsApp.

Training of mediators and independent persons

The training files for the mediators and independent persons were compiled to train them for their roles by guiding them to read through certain documents, complete and send back some documents, and watch some videos. The first author also trained them by using phone calls, training videos, photos explaining the completion of the documents, WhatsApp text messages, and WhatsApp voice messages. Their training included how to follow COVID-19 protocols throughout the study. They were invited to contact the first author if there were any uncertainties.

Tasks of mediators and independent persons

The mediators and independent persons received a summary page of their tasks. The mediators were responsible for the recruitment of the participants. They were also responsible to assist the independent persons during data collection. The independent persons were responsible to obtain informed consent. They were also responsible for data collection. All the documents were provided in Afrikaans and English. The mediators and independent persons received a stipend according to their Time spend on the research, the Inconvenience caused by the research, and the Expenses they incurred related to the research (TIE), and this was approved by the NWU-HREC.

Research method

Three residential facilities and three groups of participants participated in this study.

The three groups of participants included: Group 1: Managers; Group 2: Nurses and caregivers, and Group 3: Older persons.

Table 1 provides an outline of the sampling, population, sampling method, inclusion criteria, exclusion criteria, and sample size.

Table 1.

Sampling, population, sampling method, inclusion criteria, exclusion criteria, and sample size

	RESIDENTIAL FACILITIES	MANAGERS	NURSES AND CAREGIVERS	OLDER PERSONS
Population	N = 8.	N = 8	N = 68	N = 187
Sampling method	All-inclusive sample	All-inclusive sample	Purposive sample	Volunteer sample
Inclusion criteria	Not Applicable	Not Applicable	*Nurses (professional, staff, auxiliary). *Caregivers. *One year’s experience in caring for older persons. *Communicate/write: Afrikaans or English. *Complete demographic information and write naive sketches or ask someone else to write on their behalf.	*Receiving care from nurses and/or caregivers. *Resident in participating residential facility. *Orientated to person, time, and place. *Communicate/write: Afrikaans or English or make use of an interpreter. *Complete demographic information form and write naive sketches or ask someone else to write on their behalf.
Exclusion criteria	Not Applicable	Not Applicable	*Student nurses *Student caregivers *Moonlighting staff	*Older persons without the mental capacity to give consent to participate in the research.
Sample size	n = 3	n = 7	n = 35	n = 48

"Additional file 2" provides an outline of the target population and sample at each residential facility.

Recruitment of participants

The mediators were trained to recruit the managers, nurses and caregivers, and older persons. They asked assistance from the nursing services mangers to identify older persons that were orientated to person, time, and place. They recruited the participants verbally, handed out the printed recruitment documents, explained the recruitment documents, and showed them the PowerPoint presentation explaining the research on their cell phones. The mediators were available to answer any questions. The names of the participants that were willing to participate were given to the independent person to invite them.

Process of obtaining informed consent

The independent persons contacted the potential participants and provided them with the informed consent documents and explained it to them. They gave the potential participants 24 h to 7 days to decide if they wanted to participate in the research. After they had at least 24 h to decide, the independent persons contacted them and arranged for a suitable time and place to sign the informed consent documentation. All participants were informed that their participation was voluntary and that they could withdraw at any stage of the research without any penalty. The independent persons had to ensure the older persons were orientated to person, time, and place and had the mental capacity to participate in the research, using the protocols provided for this purpose. They also had to give each participant a copy of the informed consent documents to keep. The informed consent documents were stored in a locked cupboard until the first author arranged collection, together with all the other research documents, via courier services.

Data collection

The independent persons collected data from the managers, nurses and caregivers, and older persons, with the assistance of the mediators. Data were collected from August 2021 until April 2022.

Data collection tools

All the managers, nurses and caregivers, and older persons provided demographic information and wrote naive sketches.

Demographic information forms

To contextualise the findings and obtain a demographic picture of the managers, nurses and caregivers, and older persons, their demographic data were collected through a demographic information form for each group.

Templates: naive sketches

Each group was also invited to write naive sketches by completing six open-ended sentences specifically formulated for each group.

The templates to write the naïve sketches for each group with additional prompts are attached as.

“Additional file 3”, including:

• (3.1) Template for writing naïve sketches: Group 1: Managers;

• (3.2) Template for writing naïve sketches: Group 2: Nurses and Caregivers;

• (3.3) Template for writing naïve sketches: Group 3: Older Persons.

Hereby the open-ended sentences the older persons had to complete, as example:

1. When I think of good care to older persons, I think of the following. (Definition, description)

2. When I think of good care I have experienced from nurses and caregivers, I think of the following practical examples.

3. When I think of what made this good care for me, I think of the following things the nurses or caregivers did or said.

4. If I were the nurse or caregiver, I would do or say the following things in order for the older persons to experience the care as good care

5. In my experience of receiving care from nurses and caregivers, I think the following factors make it difficult for nurses and caregivers to provide good care to older persons.

6. In my experience of receiving care from nurses and caregivers, I think the following will help nurses and caregivers to provide good care to older persons.

Data collection process

The mediators communicated with the managers, nurses and caregivers, and older persons, and arranged venues for data collection while the independent persons were responsible for the administrative part of the data collection.

The mediators have arranged with management that the managers, nurses, and caregivers may complete their data collection instruments on duty or during their teatime or lunch time, and the older persons were allowed to take their data collection instruments to their apartments. The mediators arranged for private, comfortable venues with a table and chairs to allow the participants to complete their data collection instruments. Boardrooms or dining rooms with doors that could be closed were mostly used. The independent persons had to ensure the older persons were orientated to person, time, and place before they were allowed to participate.

The participants received an A4 zip-up plastic bag with all the data collection instruments. In the bag was a small white envelope containing a letter with a unique participant number and a request to the participants to provide their name and surname and, optionally, their cell phone number and network provider. The same number was used on their demographic information form and template for writing the naive sketches. The letter explained to them that this information was needed to check that they have provided informed consent, handed back all their data collection documents, to connect their data collection instruments to them, contact them if needed, and lastly, to send their token of appreciation to them. After completion of the information requested in the letter, they had to place it back in the small envelope and seal it with a sticker. These sealed envelopes were stored separately in a locked cupboard by the independent persons until the first author arranged for all the documents to be collected via courier services.

The rest of the data collection instruments were colour coded with a different colour for each residential facility. The allocated colour and the participant numbers were kept confidential by the first author. The mediators and independent persons explained the data collection instruments to the participants. Detailed instructions were provided on the data collection instruments to ensure the managers, nurses and caregivers, and older persons understood what was expected of them. The nurses, caregivers, and older persons were allowed to ask someone else to complete their data collection instruments on their behalf using their exact words. This person had to sign a declaration at the back of the demographic information form and at the back of the naive sketches and the nurse, caregiver, or older person had to co-sign, at the back of the data collection instruments. Although 60 min should have been enough to complete the demographic information forms and write the naive sketches, the participants were given seven days to complete them. The mediators and independent persons were also allowed to give them another seven days if they had not finished yet. After completion of the demographic information forms and naive sketches, the participants had to place them in the A4 zip-up plastic bags and give it to the independent person. The independent person locked all the data collection instruments in a cupboard until they were collected by courier services. The courier services delivered all the data collection instruments and other research documents to the first author who locked them in a cupboard for data analysis while still following the COVID-19 protocols.

Data analysis

Quantitative data analysis

The demographic information forms of the managers, nurses and caregivers, and older persons were analysed by a registered research psychologist using descriptive statistics. The demographic information of the managers, nurses and caregivers, and older persons were kept in mind when their naive sketches were interpreted.

Qualitative data analysis

The naive sketches written by the managers, nurses and caregivers, and older persons were analysed using content analysis. A protocol for qualitative content analysis was formulated, using the steps recommended by Erlingsson and Brysiewicz [15]. An independent, experienced co-coder analysed the data independently from the first author using the same protocol. There were only a few differences in the analyses by the first author and the co-coder, and these differences were resolved through discussions between them, keeping the research objective as an anchoring point to make decisions and come to consensus. The second author checked and approved the data analyses. All authors reached consensus regarding the final themes and sub-themes.

Reflexivity

The members of the research team have diverse backgrounds. The first author is a community health nurse specialising in geriatric nursing, the second author is a psychiatric nurse specialist, the third author is a research methodology specialist, and the co-coder is a research psychologist. It is possible that the first authors’ background in geriatric nursing could have influenced her interpretation of the data, hopefully for the best. However, since a research psychologist independently analysed the data, and a psychiatric nurse specialist, and research methodology specialist, agreed with the final themes and sub-themes, the truth value (credibility) of the data is ensured.

Findings

Demographic information

The following section depicts the demographic profile of the sample population, i.e., the managers, nurses and caregivers, and older persons.

Table 2 provides an outline of the combined demographic profile of the managers, nurses and caregivers.

Table 2.

Demographic profile of managers (n = 7), nurses and caregivers (n = 35)

	FREQUENCY	PER CENT
Job title
General Manager	2	4.8
Nurse Manager (Professional Nurse)	5	11.9
Professional Nurse (Registered Nurse)	2	4.8
Staff Nurse (Enrolled Nurse)	1	2.4
Auxiliary Nurse (Enrolled Nursing Auxiliary)	2	4.8
Caregiver	30	71.4
Time in position
< 6 months	0	0.0
6 months to < 1 year	1	2.4
1 year to < 5 years	13	31.0
5 years to < 10 years	8	19.0
10 years or more	20	47.6
Practical experience with older persons
1 year to < 5 years	7	16.7
5 years to < 10 years	10	23.8
10 years or more	25	59.5
Highest qualification
Caregiver Qualification	30	71.4
Auxiliary Nurse Qualification	2	4.8
Staff Nurse Qualification	1	2.4
Diploma	6	14.3
Bachelor’s Degree	2	4.8
Master’s Degree	0	0.0
Doctoral Degree	0	0.0
Other	1	2.4
Certificate	0	0.0
Age
< 18 years	0	0.0
18 years to 30 years	0	0.0
31 years to 40 years	15	35.7
41 years to 50 years	11	26.2
51 years to 60 years	9	21.4
61 years to 70 years	4	9.5
71 years to 80 years	3	7.1
81 years to 90 years	0	0.0
91 years +	0	0.0
Gender
Male	1	2.4
Female	41	97.6
Marital status
Single	17	40.5
Married	20	47.6
Divorced	3	7.1
Widow/widower	2	4.8
Home language
Afrikaans	9	21.4
English	5	11.9
Setswana	20	47.6
Other	8	19.0

Table 3 provides an outline of the demographic profile of the older persons.

Table 3.

Demographic profile of older persons (n = 48)

	FREQUENCY	PER CENT
Title
Mr	15	31.3
Mrs	24	50.0
Miss	9	18.8
Dr	0	0.0
Prof	0	0.0
Other	0	0.0
Time in residential facility
< 6 months	9	18.8
6 months to < 1 year	11	22.9
1 year to < 5 years	20	41.7
5 years to < 10 years	6	12.5
10 years or more	2	4.2
Highest qualification
Certificate	28	58.3
Diploma	8	16.7
Bachelor’s Degree	3	6.3
Master’s Degree	2	4.2
PhD	0	0.0
Other	7	14.5
Age
< 18 years	0	0.0
18 years to 30 years	0	0.0
31 years to 40 years	0	0.0
41 years to 50 years	0	0.0
51 years to 60 years	0	0.0
61 years to 70 years	9	18.8
71 years to 80 years	13	27.1
81 years to 90 years	22	45.8
91 years +	4	8.3
Gender
Male	15	31.2
Female	33	68.8
Marital status
Single	8	16.7
Married	7	14.6
Divorced	10	20.8
Widow/Widower	23	47.9
Home language
Afrikaans	40	83.3
English	3	6.3
Setswana	3	6.3
Other	2	4.2

Qualitative findings

The qualitative findings include the themes and sub-themes after analysing the naive sketches written by Group 1: Managers, Group 2: Nurses and caregivers, and Group 3: Older persons. Please see “Additional file 4” for the separate findings obtained for each group including:

• (4.1) Coding Summary: Group 1: Managers;

• (4.2) Table with quotes: Group 1: Managers;

• (4.3) Coding Summary: Group 2: Nurses and Caregivers;

• (4.4) Table with quotes: Group 2: Nurses and Caregivers;

• (4.5) Coding Summary: Group 3: Older Persons;

• (4.6) Table with quotes: Group 3: Older persons.

We synthesised the findings obtained from the three separate groups into a coding summary and a table with quotes. We will now present the combined findings from the managers, nurses and caregivers, and older persons.

Combined coding summary of managers, nurses and caregivers, and older persons

Table 4 provides a coding summary of the combined findings from the managers, nurses and caregivers, and older persons.

Table 4.

Coding summary: Managers, nurses and caregivers, and older persons combined

Theme 1: Providing holistic care to older persons.

1.1 Gentle physical care to older persons by providing in their daily needs.

1.2 Providing in the psychological, emotional, social and spiritual needs of older persons.

1.3 Having the ability to make older persons feel safe.

1.4 Acknowledging the importance of music.

Theme 2: Recognising the individuality and autonomy of older persons.

2.1 Being aware of the unique challenges and realities of older persons and following up on complaints.

Theme 3: Upholding values associated with good care to older persons.

3.1 Love is the most important value associated with good care to older persons.

3.2 Being compassionate towards older persons.

3.3 Having patience when caring for older persons.

3.4 Being friendly (kind) towards older persons.

3.5 Care that communicates empathy, sympathy, and understanding for older persons.

3.6 Care that upholds the values of respect and dignity for older persons.

3.7 Nurses and caregivers need to be passionate about caring for older persons.

Theme 4: Building good relationships with older persons.

4.1 Communicating with older persons in a manner that expresses care and understanding.

4.2 Listening to older persons.

4.3 Relieving the loneliness experienced by older persons.

4.4 Making the older persons feel at home.

Theme 5: Challenges that affect good care to older persons.

5.1 Interpersonal challenges experienced when caring for older persons, including older persons living with dementia.

5.2 Challenges related to the families of the older persons.

5.3 Lack of physical resources, shortage of staff, and low pay.

5.4 Training needs of nurses and caregivers.

5.5 Employee dynamics and relationships between managers, nurses, and caregivers.

Theme 6: Opportunities that will assist in providing good care to older persons.

6.1 Being role models on how to handle interpersonal challenges when caring for older persons, including older persons living with dementia.

6.2 Involving the families of older persons in their care.

6.3 Giving attention to the availability of resources.

6.4 Providing continuous training to nurses and caregivers.

6.5 Improving teamwork and relationships between managers, nurses, and caregivers.

Explanation of participant numbers/codes

The participant numbers/codes have been anonymised. The initial numbers started with the first letter of the name of the residential facility. We realised afterwards that the quotes could be identified as coming from a certain residential facility. We then decided to name the residential facilities number 1, number 2 and number 3 to protect the privacy and confidentiality of the participants. The original numbers are available on the data collection instruments for audit purposes. These documents are safely stored for five years.

Hereby an explanation of the participant numbers/codes:

• M = Manager; N/CG = Nurse/Caregiver; OP = Older Person.

• The first number 1, 2, or 3 is the number allocated to the Residential Facility, and the last number is the participant number at that residential facility.

For example:

• (M: 2:1) = Manager, working at residential facility number 2, with participant number 1.

• (N/CG: 1:8) = Nurse or Caregiver, working at residential facility number 1, with participant number 8.

• (OP: 3:48) = Older person, living in residential facility number 3, with participant number 48.

Combined qualitative findings of managers, nurses and caregivers, and older persons

Theme 1: Providing holistic care to older persons

Good care to older persons entails holistic care. In the context of this paper holistic care can be defined as caring for the body, mind, and soul of the older person. To provide holistic care, managers, nurses, and caregivers need to provide for the physical, psychological, emotional, social, spiritual, and safety needs of older persons while acknowledging the importance of music that the older persons enjoy. Holistic care thus focuses on the holistic needs of the older person.

“Holistic approach – mind, soul and body” (N/CG: 1:4).

“Physical, psychological, emotional, financial, spiritual care of an older person to improve the quality of their life” (M: 3:2).

Sub-theme 1.1: Gentle physical care to older persons by providing in their daily needs

Nurses and caregivers need to provide gentle physical care to older persons. Physical care includes their need for personal hygiene, nutrition, exercises, pressure care, and so forth.

“When holding him/her be gentle their skin is too soft you may end up breaking his/her skin” (N/CG: 2:21).

“Personal hygiene – give an older person a bed bath or shower every day, especially those who cannot take care of themselves” (N/CG: 1:21).

“Daily hygiene – Hair, nails, teeth” (M: 2:1).

“Dress comfortably and appropriately for the weather condition outside” (N/CG: 1:4).

“I will also make sure they have enough to eat and drink” (OP: 3:48).

“Exercise – passive + active” (M: 2:1).

“By doing pressure care you make an older person to feel better, and you avoid developing pressure sores” (N/CG: 3:29).

Sub-theme 1.2: Providing in the psychological, emotional, social, and spiritual needs of older persons

Nurses and caregivers need to provide in the psychological, emotional, social, and spiritual needs of older persons.

Their psychological needs can be met by always being there to assist them, by treating them with respect and dignity, and by never talking down to them.

“Psychological to always be there to assist and treat them with respect and dignity and never to undermine their thinking e.g. talk down to them. Treat them with love and care” (M: 2:3).

The emotional needs of older persons are just as important as their physical needs, and they may never be hurt emotionally.

“Physically everything can be done 100% but if that person is not looked after emotionally, the care will never be good enough” (M: 1:2).

“Work ‘gently’ with the older person. Not only physically not to hurt, but also not to hurt emotionally” (M: 1:2).

The social needs of the older persons need to be fulfilled by arranging social interaction, visitors, excursions, playing games, etc.

“Promote social interaction” (N/CG: 1:8).

“I will also play lots of games with them to keep their brains busy” (OP: 3:48).

“Visitors” (OP: 2:34).

The spiritual needs of older persons need to be respected by respecting their religion.

“If I were an older person, I would like the nurses and caregivers to respect my religion” (N/CG: 2:9).

Sub-theme 1.3: Having the ability to make older persons feel safe

The emotional and physical safety of the older persons is very important.

Older persons need to feel emotionally safe in the presence of nurses and caregivers. They must not be scared of them, but feel that they can tell them everything, almost as if they are family.

“They feel safe and comfortable around you, feel like they can tell you everything, feel like we are not judging them and feel like we are family” (N/CG: 2:16).

The physical safety of the older persons is equally important. Floors must not be slippery, there must be no obstacles on the floor that the older persons can fall over, and older persons must not fall off the bed.

“Always make sure that the patient is safe. Make sure there’s no obstacles that patient may fall and harm herself” (N/CG: 3:38).

“Be safe don’t let them fall off the bed” (OP: 2:35).

Sub-theme 1.4: Acknowledging the importance of music

Music can be used to provide good care to older persons. Play music the older persons enjoy and encourage them to sing during sing-along events.

"Music therapy – ask the family to bring a [memory] stick with Grandma’s music. It will calm them down and bring back certain memories and then you can talk about it". (M: 3:7).

“Play music and try to involve them in sing along events” (M: 2:5).

Theme 2: Recognising the individuality and autonomy of older persons

Older persons are individuals with their own unique personality, needs, and preferences, and they should be allowed to make their own decisions while they still can. The individuality and uniqueness of each older person need to be respected, and the older person should be accepted the way he or she is. It is important to remember that older persons have unique needs that are related to their age.

“They must be seen as individuals, each with their own unique personality, needs, and preferences” (M: 2:5).

“They should leave me to make my own decisions while I still can” (M: 3:7).

“Inform me and make decisions with me about my care and procedures” (N/CG: 1:4).

Sub-theme 2.1: Being aware of the unique challenges and realities of older persons and following up on complaints

Nurses and caregivers need to be well acquainted with the special needs of older persons due to the weakening of their physical and mental abilities, and they need to provide in those special needs. Each older person needs to have a unique, individual nursing care plan according to his or her needs to eliminate or prevent possible problems. It is also very important to follow up on information, complaints, and problems concerning the older persons for them to experience the care as good care.

“In other words, staff who are well acquainted with the special needs of aging people whose physical as well as mental ability are becoming weaker” (OP: 1:13).

“Draw up a nursing care plan for each individual older person according to their needs and to eliminate or prevent possible problems” (N/CG: 1:4).

“Follow-up on information, complaints and problems” (N/CG: 1:4).

“Attention is given to problems” (OP: 3:65).

Theme 3: Upholding values associated with good care to older persons

In the context of this paper values associated with good care can be defined as values that managers, nurses and caregivers have internalised and practice to provide good care to older persons. When managers, nurses and caregivers portray love towards the older persons; treat them with compassion, patience and friendliness; show empathy, sympathy, and understanding; treat them with respect and dignity; while being passionate to care for them, older persons experience the care as good care. The values associated with good care thus focus on values we want managers, nurses and caregivers to internalise and practice.

Sub-theme 3.1: Love is the most important value associated with good care to older persons

Nurses and caregivers need to provide tender, loving care to older persons and show them that they love them. They need to look after and care for them with compassion, love, and care. When older persons are loved, they feel protected.

“Tender Loving Care” (N/CG: 2:12).

“You must show them how much you love them” (N/CG: 2:11).

“Love made the older person feel protected” (M: 1:1).

Sub-theme 3.2: Being compassionate towards older persons

Nurses and caregivers need to look after older persons with compassion, love, care, empathy, respect, and patience.

“To look after and care for older persons with compassion, love and care” (M: 1:1).

“By always treating them with empathy and compassion” (OP: 1:16).

"Treat older person with compassion and respect. Be patient, have empathy" (N/CG: 1:4).

Sub-theme 3.3: Having patience when caring for older persons

It is very important that nurses and caregivers are patient while caring for older persons. They need to be patient, loving, friendly, tender, and never in a hurry while caring for older persons.

“Patience is probably one of the most important requirements for caring for older persons” (OP: 3:39).

“It you work with them be patient, they also need to be loved and always with good smile and tender every time” (N/CG: 2:13).

“They should never work in a hurry. I don’t want to feel in the way” (M: 3:7).

Sub-theme 3.4: Being friendly (kind) towards older persons

Nurses and caregivers always need to have a smile on their faces and be friendly and kind towards the older persons. They need to speak nicely to the older persons and treat them with respect and kindness while always being positive, considerate, and helpful.

“To greet friendly” (M: 1:1).

“I have to have a friendly face, speak with him/her nicely, have a smile for him/her so that he/she is relieved to talk to me” (N/CG: 2:21).

“Person providing care should be friendly with the older person” (OP: 1:10).

Sub-theme 3.5: Care that communicates empathy, sympathy, and understanding for older persons

Nurses and caregivers need to have empathy by putting themselves in the shoes of the older person. They need to treat older persons in the same way they would like to be treated when they are old. They need to be patient and have empathy with the older persons.

"Put yourself in their shoes: Do you think they enjoy being 100% dependent on you"? (M: 1:2).

“Treat the older person the way you would like to be treated” (OP: 1:10).

“Be patient, have empathy, try to imagine yourself in their situation” (OP: 1:25).

Sub-theme 3.6: Care that upholds the values of respect and dignity for older persons

Older persons experience care as good care when they are treated with respect, dignity, and care. Older persons need to be respected at all times irrespective of their age, race, or religion. To protect the dignity of the older persons, their privacy needs to be respected.

"If I was an older person, I would like to be treated with respect and dignity also with care". (N/CG: 3:29).

“Respect the older persons irrespective of age, colour or religion” (N/CG: 3:38).

“E.g. when the older person is washed, privacy is respected, curtains are drawn.

Anyone can’t just walk in. Only the area being washed is exposed” (M: 1:2).

Sub-theme 3.7: Nurses and caregivers need to be passionate about caring for older persons

Nurses and caregivers caring for older persons need to have a passion to care for older persons with respect, love, and compassion. They need to be dedicated to their work and care for older persons with all of their heart.

“Truly a difficult but honourable profession. You must have a passion for the older person and the sick so that you can and want to care for them with respect and love, with love in your heart, and compassion for your fellow man” (OP: 1:25).

"If you are a care worker you have to have that heart to work with older persons" (N/CG: 1:19).

“Get your mindset right and develop a passion for the older person” (M: 1:2).

Theme 4: Building good relationships with older persons

Managers, nurses, and caregivers can build good relationships with older persons by spending quality time with them. Older persons love to have company; someone to sit down with and who talks to them with respect and gentleness.

“Spend more time with the older persons” (N/CG: 1:6).

“Have some quality time with me” (N/CG: 1:21).

"To have company at times just to chat, somebody to just sit down and talk to me". (M: 2:3).

“Talk to the older person with respect and gentleness” (OP: 1:10).

Sub-theme 4.1: Communicating with older persons in a manner that expresses care and understanding

Nurses and caregivers need to talk nicely to older persons and be gentle, patient, and calm if the older person is anxious. They need to be patient and not in a hurry when communicating with older persons.

“Talking to them nicely makes them happy and free, all we have to do is to make sure they feel at home” (N/CG: 2:21).

“The caregiver’s gentle, patient, calm response calmed the agitated Alzheimer’s older person. She was quite satisfied with the situation and accepted” (M: 2:1).

“Don’t rush and leave them alone when they share something with you. They then feel secure and at ease” (M: 2:5).

Sub-theme 4.2: Listening to older persons

Nurses and caregivers need to listen carefully, by paying attention, to hear and understand when the older persons talk to them. They need to listen attentively, talk back, and be patient, not in a hurry.

“To be listened to and heard and understood” (M: 2:3).

“Listening carefully and paying attention to their needs” (N/CG: 3:32).

“Support their ‘brighter’ moments by listening attentively and engage in conversation. Don’t be in a hurry” (M: 2:5).

Sub-theme 4.3: Relieving the loneliness experienced by older persons

Nurses and caregivers need to remember that older persons also have social needs, and they often feel lonely because they might have lost a partner. By building a relationship with the older persons, they can alleviate their loneliness by smiling, giving love, and talking to them.

“Loneliness – in their mind they always feel lonely because sometimes their loss to partners” (N/CG: 2:18).

“Always give love and smile, talk to them so that they never feel lonely” (N/CG: 2:15).

“Those who can sit, we put them on the chair and just to sit with them and talk so that they can’t be lonely” (N/CG: 2:25).

Sub-theme 4.4: Making the older persons feel at home

Nurses and caregivers need to make older persons who recently moved into a residential facility and are feeling lost and scared, feel safe and at home because they often do not have a home or family anymore. The older persons need to be received with great kindness by friendly and helpful staff, and they need to feel as if they are in their own homes with their families.

"They must feel at home because the others do not have homes or children". (N/CG: 2:10).

“They feel as if they are at their homes with their families” (N/CG: 2:15).

“By being friendly and helpful, you immediately make us feel at home and also grateful that we are noticed” (OP: 3:75).

Theme 5: Challenges that affect good care to older persons

Managers, nurses and caregivers, and older persons agree that different challenges affect good care to older persons. Nurses and caregivers experience interpersonal challenges, for example, aggressive behaviour, when caring for older persons, including older persons living with dementia. Some of the families of the older persons also cause challenges by interfering with their care. Challenges are also experienced regarding a lack of physical resources, shortage of staff, and low pay. The training needs of the nurses and caregivers have also been identified as a challenge. The last challenge identified concerns employee dynamics and the relationships between the mangers, nurses, and caregivers.

Sub-theme 5.1: Interpersonal challenges experienced when caring for older persons, including older persons living with dementia

Some older persons are negative, complain a lot, and do not want to co-operate. Certain older persons do not respect the nurses and caregivers, do not appreciate what is being done for them, and even speak vulgar words. Another big obstacle is the language and culture differences between the older persons and the nurses and caregivers caring for them.

“Some older persons’ personality makes it difficult to work with them e.g., always negative, complains a lot, does not want to co-operate” (N/CG: 1:8).

“An older person with no respect, and older person that does not appreciate, that is speaking vulgar words” (N/CG: 1:21).

“The language/culture difference between older persons and caregivers can sometimes be a very big obstacle” (M: 1:2).

Nurses and caregivers agree that it is very difficult to care for older persons living with dementia because “they are in their own world”. These older persons often call the nurses and caregivers names, swear at them, fight them physically, and even hurt them. They may be angry, distressed, scared, have unrealistic experiences of treatment, or be especially demanding.

“Older persons with Alzheimer’s can be very difficult. They can call you names, they swear at you, they also can fight you physically, they can even hurt you” (N/CG: 2:15).

“…very hard to work with an older person who has Amnesia, Alzheimer’s. They are in their own world” (N/CG: 2:25).

“These older persons may be angry, distressed, scared, have unrealistic treatment experience or be particularly demanding” (N/CG: 2:19).

Sub-theme 5.2: Challenges related to the families of older persons

The families of older persons often interfere too much or too little in the care that is provided to the older persons. Some family members have too many expectations of the nurses and caregivers, and others are difficult when the older persons are sick or dying.

“The family that interferes too much and/or too little in the care” (M: 1:1).

“Older person feels loved in the friendly and safe environment, then children come and make rampage” (M: 2:5).

“Too many expectations from family members” (M: 2:1).

“Very sick and dying older persons’ families are sometimes difficult” (N/CG: 3:33).

Sub-theme 5.3: Lack of physical resources, shortage of staff, and low pay

The work environment affects good care to older persons when nurses and caregivers do not have enough information regarding the medical condition and background of the older persons they need to care for. The limited availability of services, including physiotherapy and leisure activities, is also a challenge.

“Not having necessary information about the older person’s condition e.g., medical or background (history)” (N/CG: 2:24).

“…limited availability of services (physio, leisure activities)” (N/CG: 1:4).

The lack of physical resources includes limited space in rooms and bathrooms and limited or broken equipment. Older persons recommend that each room needs to have its own bathroom and that the toilet seats need to be raised to assist older persons with knee and back problems.

“Limited space (bathrooms small, rooms small), limited equipment (e.g. hoist for heavy people), faulty, broken equipment (beds)” (N/CG: 1:4).

“Would have been easier if each room had its own bathroom” (OP: 2:31).

“I can only think of the fact that toilets should have raised (or higher) seats. Older persons struggle with knee problems and back problems” (OP: 2:31).

There are too many older persons for too few staff. More nurses and caregivers are needed, and they need assistance when caring for heavy older persons.

“Too many older persons for too few nursing staff” (OP: 3:63).

“More staff not 1–10 older persons or 1–15 older persons” (M: 3:7).

“Some older persons are heavy, and help is needed to work with them” (N/CG: 3:33).

Nurses and caregivers working at residential facilities often receive low pay due to a shortage of funds and no subsidy from the government. If possible, these nurses and caregivers need to receive better pay, appropriate to their qualifications and workload, then they will not need to do moonlighting (work at other facilities on their days or nights off duty).

“Little salary” (N/CG: 3:37).

“No subsidy from government” (N/CG: 3:37).

“If paid reasonable salaries, then no need to do moonlighting” (M: 2:3).

Sub-theme 5.4: Training needs of nurses and caregivers

Nurses and caregivers need more practice and more training. Their training should include how to care for frail older persons. They also need to learn how to have empathy with the older persons.

“More practice, training” (N/CG: 3:38).

“Their training should be geared towards frail older persons” (OP: 2:35).

“Don’t know how you teach people empathy – but it has to be learned” (M: 3:2).

Sub-theme 5.5: Employee dynamics and relationships between managers, nurses, and caregivers

Managers, nurses, and caregivers experience interpersonal friction in their relationships with one another. Junior staff feel disrespected by their seniors and are not happy with the way they are treated by the managers.

“Interpersonal friction, lack of interpersonal skills” (OP: 1:15).

“Disrespect by seniors” (M: 2:3).

“We as caregivers we are not happy concerning our management. We always say we are the ones who work with older persons in their room” (N/CG: 2:25).

Theme 6: Opportunities that will assist in providing good care to older persons

Fortunately, managers, nurses and caregivers, and older persons also identified opportunities that can be used to address the challenges. Managers, nurses, and caregivers, can be role models to one another and show each other how to handle the interpersonal challenges experienced when caring for older persons, including older persons living with dementia. The families of the older persons can be involved in their care. Management can give attention to the availability of resources. Continuous training can be provided to nurses and caregivers. Lastly, teamwork and the relationships between managers, nurses, and caregivers can be improved.

Sub-theme 6.1: Being role models on how to handle interpersonal challenges when caring for older persons, including older persons living with dementia

Nurses and caregivers can be role models to others on how to handle interpersonal challenges experienced when caring for older persons. They can also show others through their example how to treat older persons living with dementia by keeping them calm, treating them with respect and dignity, orientating them to person, time, and place, and making them feel comfortable and not scared.

“Many care worker learn from my experience. I’m proud of showing my student how to take care of the older persons” (N/CG: 1:17).

“I’ve experienced a lot about Alzheimer and dementia older persons, some of those older persons need a care plan of how to handle them because some are very aggressive. Some have fears so you must learn as a caregiver how to handle those kinds of older persons. Never be rude to such older persons, just make them calm. When they want to fight explain to them what you are going to do. Make them aware that you are not going to hurt them but give them care so that they can be sure about their surroundings” (N/CG: 2:23).

“…and learn to talk to those with Alzheimer’s, how to calm them” (N/CG: 2:23).

“Respect and talk to them with dignity. Make them to understand the things that they don’t understand. To tell them what’s todays date or day or month and years. To understand what they going to eat or drink. To wear the warm clothes or cool clothes. To tell them weather is rain or sunny. To make them feel comfortable not to feel scared” (N/CG: 3:34).

Sub-theme 6.2: Involving the families of older persons in their care

Obtain the trust, cooperation, and involvement of the family and make them feel part of the care. Appreciate their suggestions and help. Teach them how to handle their family members with dementia. Be thankful if family members show gratitude.

“Gain the trust and cooperation of family members” (M: 2:5).

“Involve family and make them feel part of the care. Welcome their suggestions and help” (N/CG: 1:4).

“Train the family members on how to behave with a dementia older person” (M: 3:7).

“Gratitude from family” (M: 1:1).

Sub-theme 6.3: Giving attention to the availability of resources

Managers can be encouraged to provide enough physical resources including all the necessary materials and equipment. They also need to be persuaded to employ enough nurses and caregivers for the number of older persons. They need to give attention to the pay of the nurses and caregivers to ensure it corresponds with their workload.

“All the necessary materials and apparatus must always be available” (M: 3:7).

“Staff must be enough” (N/CG: 3:29).

“Salary must be increased according to workload” (N/CG: 3:29).

Sub-theme 6.4: Providing continuous training to nurses and caregivers

Nurses and caregivers need occasional “short” refresher courses and as much in-service training as possible. It is also recommended that caregivers receive training regarding frail older persons, older person care in general, certain diseases, and a value system.

“It may help to give Nurses and Caregivers an occasional ‘short’ refresher training course” (OP: 1:13).

“A lot of in-service training as often as possible” (N/CG: 3:28).

“Training of caregivers can be improved to give them more information about older person care itself, certain disease states, value system” (M: 3:2).

Sub-theme 6.5: Improving teamwork and relationships between managers, nurses, and caregivers

Communication between the managers, nurses, and caregivers needs to improve. Good relationships are needed between managers, nurses, and caregivers. They need to show respect and understanding towards one another, accommodate each other, and be willing to learn. The care team, including the managers, nurses, and caregivers, always need to work together as a team.

“Better communication between caregivers and management” (N/CG: 3:29).

"Good relationships with fellow caregivers/nurses, with head nurse and employer. It includes respect and understanding, being accommodating and willingness to learn". (OP: 1:15).

“For that reason, it is so important that the care-team work as a team at all times. (An older person said on occasion that the care-team feels like their own family)”. (N/CG: 3:31).

Discussion

The findings of the study will now be embedded in literature. In Australia, the quality of aged care provided to older persons is measured using the “Quality of Care Experience (QCE) in aged care” that includes six aspects [16]. The findings of our study include all six these aspects, indicating the trustworthiness of our findings. Each aspect will be indicated in “italics”, followed by an explanation of how it is present in our study. “Respect & Dignity”: Good care upholds the values of respect and dignity for older persons. “Make Own Decisions”: The individuality and autonomy of older persons need to be recognised, and they should be allowed to make their own decisions while they still can. “Skills & Training (of staff)”: The training needs of nurses and caregivers caring for older persons were identified as a challenge and an opportunity to provide in. “Health & Well-being”: Holistic care (physical, psychological, emotional, social, spiritual, safety and music) to older persons. “Social Relationships”: Providing in the social needs of older persons (social interaction, visitors, playing games) and building good relationships with them. “Lodging Complaints”: Unique challenges and realities of older persons and following up on complaints.

Good care to older persons includes holistic care (physical, psychological, emotional, social, and spiritual), as supported by the literature [3, 7, 17, 18]. Physical care includes providing in the daily hygiene needs of older persons by washing them and socialising with them (social needs), while at the same time observing and assessing them [17]. When staff caring for older persons provided more assistance with meals (physical care) and made it a priority to fulfil their social needs by providing recreational activities to them at all times, the quality of care increased as well as the quality of life the older persons experienced; social care was therefore found to be equally important as good physical care [19]. The religious (spiritual needs) and cultural beliefs of older persons also need to be respected [20]. The fact that nurses and caregivers need to ensure the emotional and physical safety of older persons is confirmed in the literature [3]. The importance of music is confirmed by Lai et al. [21] who found that listening to music for 30 min per day improved the emotional and physical health of caregivers of cancer patients.

The individuality and autonomy of older persons are recognised when nurses treat older persons with respect, give them health education regarding their health condition, involve them in decisions regarding their care, and identify their preferences regarding their daily hygiene needs taking religious and cultural beliefs into account [20]. This is confirmed by the WHO [1] and Boye et al. [22] who add that the individual needs of older persons need to be met, and they need to be allowed to make their own decisions or be involved in these decisions, including decisions regarding their care, as long as they can. Care provided to older persons needs to be personalised by putting the older person first and treating them as an individual while being aware of and adapting to their needs while assisting them with eating and drinking, keeping them comfortable and happy while paying attention to detail [17]. Dignified care for older persons living with immobility in residential facilities includes person-centred, individually orientated nursing care [23].

Different authors agree on the importance of upholding the values associated with good care to older persons. Nurses and caregivers caring for older persons described loving older persons as a deep engagement with older persons and their families when providing end of life care [24]. This is confirmed by a study by Benadé et al. [25] where a nurse declared that she has tons of love for the older persons and that her love for them gives her the strength to care for them every day. Nurses and caregivers caring for older persons in residential facilities need to provide compassionate, person-centred care with kindness and empathy [23]. When nurses/caregivers have a mutual relationship with older persons, they share compassion [26]. Compassion in the relationship between the nurses/caregivers and older persons, as well as person-centred care, underpin the quality of care in residential facilities [26]. Nurses and caregivers caring for older persons need to have a lot of patience with older persons and they always need to be friendly because it makes the older persons feel peaceful and calm [25]. Nurses need to have empathy with older persons [8, 9]. They need to understand the needs and wants of older persons by being empathetic, listening, reassuring, and knowing the preferences of the older persons as well as their problems and moods [17]. Social and cultural factors also need to be considered [17]. Undergraduate nursing students were able to improve their empathy levels and positive attitude towards older persons to provide high-quality care to older persons by attending high-fidelity simulation-based training [27]. Simulation training needs to be included in the study plan for geriatric nursing to train nursing students how to care for older persons and prepare them for clinical practice [27]. When staff caring for older persons learned how to provide empathetic care for older persons, the quality of care and the quality of life of the older persons living with dementia improved [19]. While providing care to older persons, they need to be treated with respect and dignity [1, 8, 9, 17, 28]. The dignity and privacy of the older person need to be protected and maintained [17]. Older persons, family members, and nurses and caregivers all agree on the importance of dignity and respect, safety and security, and staffing and staff competence regarding the experience and well-being of older persons receiving long-term care [20]. Dignified care to older persons includes effective nurse-to-older-person communication, maintaining the privacy of the older person, providing respectful and compassionate care, as well as providing quality and safe care [29]. Nurses and caregivers who are passionate about caring for older persons by having positive attitudes towards them will improve the quality and efficiency of care and will have a positive effect on the caring behaviours [30].

The importance of building good relationships with older persons when providing good care is confirmed by research [5] which asserts that good care to older persons is rooted in a relationship with the older person. Nurses and caregivers working in residential facilities form bonds with the older persons, their families, as well as their team members [26]. The relationships that are formed with the older persons provide professional and personal growth [26]. The relational qualities of the interaction between nurses/caregivers and older persons in residential facilities should be essential and needs to be emphasised in clinical practice [31]. Research and education of nurses and caregivers should pay more attention to nurse/caregiver-to-older-person interaction as an important, fundamental part of the caring process that promotes “joy of life” and well-being [31]. The relational qualities of the nurse/caregiver-to-older-person interaction need to be an integral aspect of caring for older persons in residential facilities to develop a comprehensive practice-based view of good nursing care [31]. Insights into the potential for “joy of life”, activities that are meaningful, well-being, relief of symptoms, and health may inspire nurses and caregivers to perform their daily care practices in residential facilities [31]. When staff communicated with older persons living with dementia, the quality of care provided to them improved as well as their quality of life [19]. It is very important to communicate the diagnosis and care plan of the older person with them even if they have changing levels of mental alertness or experience hearing difficulties or visual problems [17]. Nurses and caregivers acknowledge the importance of “social chat”/“small talk” with older persons while care is provided; for example, when bathing an older person. By using every opportunity to get to know the older person better, nurses and caregivers can obtain all the information they need in 5 min, for example, and they will also get to know the older person better and find out how they are as well as their worries and concerns [17]. Volunteers can be used to provide social support to older persons to relieve their loneliness and improve their quality of life [32]. Older persons feel safe and validated when the nurses and caregivers caring for them treat them like relatives [17]; it makes them feel at home.

Challenges that affect good care to older persons. Interpersonal challenges include the fact that nurses and caregivers experience multiple challenges while caring for older persons because their needs are complex and they often suffer from several co-morbidities and sensory and cognitive deficits [17]. Challenges include problems with language, hearing, vision, mental alertness, inability to speak, and difficult personal characteristics; for example, being aggressive or demanding [17]. When older persons suffer from sensory deficits, the nurses and caregivers experience difficulty communicating with them because communication is often time-consuming and it is not always possible to determine the level of understanding the older persons have [17]. Some older persons are demanding, deliberately difficult, or may seek attention [17]. It is important that the nurses and caregivers do not have favourites [17].

Caring for older persons living with dementia is very difficult. When older persons suffer from mental confusion, the nurses and caregivers need to spend more time with them [17]. These older persons might refuse care; for example, mouth care, and then the family comes to visit, and they complain because mouth care was not provided [17]. It is difficult to care for older persons with dementia, but nurses and caregivers need to have patience with them and communicate verbally and non-verbally with them [17].

Our nurses and caregivers sometimes experienced challenges related to the family of the older persons. A study conducted with care providers of older persons living with dementia confirmed that they experienced a two-edged interaction with the relatives of the older persons [33]. Relatives often experience feelings of guilt, have unrealistic expectations of the care provided to the older persons, and do not always agree with what is the best for the older person [33]. Relatives are also of the opinion that they may come and go in the ward because they see it as the home of the older persons, whereas the care providers try to create a quiet and peaceful environment for the older persons, especially during mealtimes [33].

The challenges nurses and caregivers experience related to the work environment are confirmed in the literature. Nurses and caregivers caring for older persons often experience a lack of resources [34]. It may be unsafe for older persons when there is a lack of tools and equipment to care for them [17]. Studies confirm the challenges of shortage of staff [25, 34] as well as low pay [35].

Training needs of nurses and caregivers caring for older persons include that different categories of nurses and caregivers have different training needs [19]. Lower categories of nurses and caregivers need training in communication with older persons, while RNs need training to enhance their empathetic behaviour towards older persons [19]. All staff need to be attentive and concerned about older persons falling or experiencing pain and need to receive good education regarding the dangers of and alternatives to the use of restraints to help them to act in the best interests of the older persons [19].

The challenges related to the relationships between the managers, nurses, and caregivers are confirmed by care providers of older persons living with dementia who experience different feelings towards management and leadership [33]. Most care providers voiced that they lacked support from management even if they did their best to provide good care [33]. They received no stimulation and no appreciation from their managers [33]. There is often poor communication between nurses, and between nurses and caregivers [17]. Miscommunication and missed information are often a problem when one shift hands over to the next shift and this affects teamwork and patient care [17]. Nurses and caregivers often do not understand what is being communicated [17].

Literature confirms that opportunities do exist that can assist nurses and caregivers to provide good care to older persons. Being role models to others on how to handle interpersonal challenges and older persons living with dementia was identified as an opportunity that will assist nurses and caregivers to provide good care to older persons. This has been confirmed by a nurse who explains that when older persons experience difficulty to communicate, or are confused, you need to sit down with them and listen; you will get a lot out of them [17].

The importance of involving the families of the older person in their care is confirmed by research [17] which explains that it is very important to communicate the diagnosis and care plan of the older person with their families to obtain their co-operation. The dignity of older persons is maintained when they are treated with respect and compassion, receive privacy, and are allowed to have family members to assist with their physical care [29].

Giving attention to the availability of resources is another opportunity that can assist nurses and caregivers to provide good care to older persons. Managers of residential facilities have an important role in providing the technical and organisational resources and environments to ensure dignified nursing care of older persons restricted to bed [23]. Managers also need to ensure that nurses and caregivers who are enabled to provide person-centred care are employed [23].

When caring for older persons living with dementia, it is necessary to use a combination of permanent and alternating shifts to improve the quality of care provided to them and their quality of life [19]. Permanent shifts have the advantage that nurses and caregivers can build long-term relationships with older persons, whereas alternating shifts are more reviving for the staff [19]. It is also important to determine how and what staff are employed to do; for example, increasing the number of minutes a registered nurse spends with older persons with dementia might be the key to improving the care [19]. This is confirmed by a study [23] that found that it is also important that managers understand the importance of employing RNs in residential facilities caring for older persons to preserve the dignity of older persons and promote person-centred care. Nurses and caregivers caring for older persons are crucial instruments for improving the quality of life of older persons living with dementia through improved care [19]. They expect that there is normally a shortage of staff on their shifts; however, it is not only the number of staff but, notably, the expertise of the staff that is important when providing good care to older persons [17]. Managers need to understand the following three aspects regarding the relationship and quality: (1) quality is influenced by the behaviour of the staff; (2) behaviours are dependent on relationships cultivated by the environment and culture of the residential facility; and (3) managers have an important influence on how the resources of the organisation (enough staff utilised effectively, with the required knowledge, expertise, and skills to meet the needs of the older persons) are used to create and maintain quality-promoting relationships [36]. The best way to implement and support quality care in nursing homes is through the most valuable resource for any residential facility: its nurses and caregivers [36].

Providing continuous training to nurses and caregivers as an opportunity to provide good care to older persons is confirmed by research [19] which recommends that staff caring for older persons living with dementia need to be consulted regarding their training needs to assist them in their daily work. A more subtle approach is needed to address the staff and facility factors to improve the quality of care provided to older persons with dementia: it is necessary to look further than just to increase the number of nurses and caregivers or provide more training [19]. Nurses and caregivers caring for older persons need to receive opportunities for increased communication and interaction skills and competence [31]. The quality of care provided to and the quality of life experienced by older persons living with dementia can be improved when the training and qualifications of the staff are more relevant, applicable, and improved [19]. Training needs to be provided by someone who has clinical experience and involve practical placements and observation [19]. The training should be evaluated afterwards to determine whether it provided increased knowledge as well as more empathetic and compassionate care, which is crucial to achieve quality of life [19]. High-fidelity simulation-based training can be used successfully to improve the empathy levels and positive attitudes of undergraduate nursing students towards older persons [27]. The understanding of nurses and caregivers caring for older persons is very important to help older persons make sense of the changes they experience [37]. They need to attend regular training to assist the older persons to prepare for old age by understanding how to uphold mental integrity and searching for meaning in their lives [37]. They need to attend continuous training to promote professional development and encourage interdisciplinary teamwork [23]. Lastly, nurses and caregivers need to understand their value and importance in caring for older persons in residential facilities which might create feelings of worthiness, meaningfulness, as well as thriving in their daily work [31].

Improving teamwork and relationships between managers, nurses, and caregivers as an opportunity to provide good care includes that managers of residential facilities need to examine the working conditions of their nurses and caregivers carefully [38]. In particular, they need to try to understand the causes of the stress their nurses and caregivers experience while caring for older persons and work together to find ways to address the stressors [38]. Good communication is essential for all aspects of caring for older persons [17]. Leadership and the co-ordination of teams are often challenging for nursing teams and often result in role and task allocation misunderstandings and difficulty to reconfigure work goals when the priorities have changed [17]. Attempts to improve teamwork should focus on the development and support of the ability of nursing teams to adapt [17]. It is also necessary to address organisational factors that affect teamwork, including recognising the challenges involved when co-ordinating multiple teams and dealing with external agencies [17]. Teamwork between nurses and caregivers is a very important requirement for adapting to the pressures of providing high-quality care to older persons [17]. The perceptions of nurses regarding the quality of teamwork are positively related to their perceptions of the quality of care [17]. All levels of managers can be role models in using organisational resources to support and encourage relationships (at all levels) between managers, nurses, caregivers, older persons, and family members (relationship-centred care) that organise learning opportunities for nurses and caregivers, and encourage quality as experienced by older persons and their families [31].

Recommendations for clinical practice

• Managers, nurses, caregivers, and older persons identified several challenges that make it difficult to provide good care to older persons. Fortunately, they have also identified opportunities that will make it easier to provide good care to older persons. It is recommended that managers, nurses and caregivers use the opportunities identified in this research to address the challenges experienced while caring for older persons.

• The qualitative findings of this study can be used to design and develop programmes; in this case, a programme to facilitate good care to older persons that can be used as an in-service training programme followed on duty to promote good care to older persons. This programme can be implemented in residential facilities and can be updated yearly, using feedback and recommendations from the managers, nurses and caregivers that used the programme in practice.

Recommendations for education

• Management curriculums, undergraduate nursing curriculums, post graduate nursing curriculums and caregiver curriculums need to include theoretical and practical content regarding how to provide good care to older persons.

• In-service training programmes for managers, nurses, and caregivers, as explained earlier, can be designed, developed and evaluated to promote good care to older persons.

• The values associated with good care for example compassion and dignity can be integrated into training in the following ways:

  • Compassion and dignity can be taught during management, undergraduate, postgraduate and caregiver training as well as while on duty.
  • An in-service training programme attended by managers, nurses and caregivers can provide guidelines how to be compassionate towards older persons, the family members of the older persons, their colleagues and how to treat them all with dignity.

Compassion

• Practical procedures for example washing or feeding an older person can be demonstrated by showing compassion towards the older person.

• Compassion can also be role-modelled by managers, nurses and caregivers to students and new staff members.

Dignity

• Teach the managers, nurses and caregivers to maintain and promote the dignity of older persons.

• They need to treat older persons with dignity by speaking to them and by handling them with compassion.

Implications for policy

• The global ageing population confirms the importance of providing and promoting good care to older persons.

• Policy documents need to promote good care to older persons by including the importance of training for managers, nurses, and caregivers using in-service training and/or formal training programmes.

Recommendations for further research

• A programme for managers, nurses, and caregivers to facilitate good care to older persons can be pilot tested in residential facilities to determine if it will indeed promote good care to older persons.

• Further research can be conducted to explore the perceptions of managers, nurses, and caregivers caring for older persons regarding their needs for continuous training and development.

• Further research can be conducted regarding affordable online training courses that are available for managers, nurses, and caregivers caring for older persons.

Limitations

• Due to the COVID-19 pandemic in South Africa, the study took long to complete because the first author had to rewrite the research proposal several times to ensure data can be collected safely and to obtain ethical approval to conduct the study.

• Due the fact that the study was conducted during the last waves of the COVID-19 pandemic in South Africa, it was difficult to obtain goodwill permission from the management committees of the residential facilities because they were tired and experienced severe staff shortages.

• It was also a limitation that the first author was not allowed to be present to recruit the participants or during data collection due to the restrictions of COVID-19, she had to rely on her mediators and independent persons.

• The fact that someone else was allowed to write on behalf of the nurses, caregivers and older persons could be seen as a limitation because we had to rely on the honesty of the person writing, however, during the trial run one of the older persons thanked us for allowing someone else to write on her behalf.

• Because the study was only conducted in residential facilities in South Africa, it might have an influence on the generalisability of the research.

Strengths

• The strengths of this study include the fact that managers, nurses and caregivers, and older persons in residential facilities participated in the research.

• This made it possible to synthesise the findings of all three groups.

• These findings can now be used to design and develop programmes to teach managers, nurses, and caregivers how to provide good care to older persons.

Conclusions (and implications)

The perceptions of managers, nurses, caregivers, and older persons regarding good care to older persons provided a rich understanding of good care to older persons. The implications of the findings of this study are that it can be used to design and develop formal and/or in-service training programmes to facilitate good care to older persons. These programmes need to include practical guidelines and practices that were recommended by managers, nurses, caregivers and older persons to promote good care to older persons. If these practical guidelines are followed, and the practices are internalised, by managers, nurses, and caregivers attending these formal and/or in-service training programmes, it will empower them to provide good care to older persons.

Abbreviations

COVID-19

Coronavirus disease 2019

NRF

National Research Foundation

NuMIQ

Quality in Nursing and Midwifery

NWDOHRC

North West Department of Health Research Committee

NWDSD

North West Department of Social Development

NWP

North West Province

NWU-HREC

North-West University Health Research Ethics Committee

RF

Residential Facility

RN

Registered Nurse

SANC

South African Nursing Council

TIE

Time, Inconvenience, Expenses

Authors’ contributions

This research was conducted by the 1 st author PB in partial fulfilment of the degree Doctor of Philosophy in Health Sciences with Nursing Science at the North-West University in South Africa. The 2nd author EdP acted as the Promotor and the 3rd author SKC acted as Co-promotor. PB, EdP and SKC contributed to the design and development of the research. PB collected the data. PB and an experienced co-coder analysed the data independently. EdP checked and approved the data analyses. PB, EdP and SKC read and approved the final manuscript.

Funding

This research is based on work conducted with the support of the National Research Foundation (NRF) of South Africa (Grant Number: UID 123541). However, all opinions, findings, and conclusions are solely those of the author(s) and are not associated with the NRF in any way.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study has been approved by the NWU-HREC with ethics number: NWU-00034-19-A1 on 30 September 2019 . Please see Supplementary Information, "Additional file 1", Ethical approval NWU-HREC. Consent was given to conduct the study. Permission to conduct the research was also obtained from the NWDOHRC and the NWDSD. All the participants (managers, nurses, caregivers, and older persons) gave written, informed consent to participate in the research study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.