Nursing home residents’ perspectives on their social relationships

Abstract

Aims and objectives:

To explore nursing home residents’ perspectives on their relationships with other residents, family members and staff.

Background:

The cultivation of social relationships is central to promoting well-being in nursing homes, as these relationships allow residents, family members and staff to be valued as unique persons and empowered as partners in care. Few studies have examined how nursing home residents perceive the relationships in their social networks, both within and beyond the facility.

Design:

Qualitative secondary analysis.

Methods:

We analysed individual and group interviews obtained during “stakeholder engagement sessions” with cognitively intact residents (N = 11 sessions; N = 13 participants) from two nursing homes in North Carolina. The interviews were conducted as part of a larger study on person-directed care planning. We integrated thematic and narrative analytic approaches to guide the analysis of interview data, using a three-cycle coding approach. The COREQ checklist was followed.

Results:

Four broad themes emerged from this analysis: (a) peer relationships foster a sense of belonging, purpose, achievement and significance; (b) residents’ relationships with family members support a sense of belonging, continuity and significance; (c) mutual respect and reciprocity between residents and nursing home staff promote a sense of belonging and significance; and (d) organisational factors pose barriers to forging meaningful relationships. Each type of relationship—peer, family and staff—made distinctive contributions residents’ psychosocial well-being.

Conclusion:

Recognising the diverse roles of different actors from residents’ social networks raises questions for future research to optimise the distinctive contributions of network members that promote residents’ psychosocial well-being.

Relevance to clinical practice:

This study highlights the need for nursing home staff to understand how residents’ social relationships influence residents’ psychosocial outcomes. Staff training programmes are needed to support residents’ rights and to dispel inaccurate interpretations of regulations that threaten sustained meaningful relationships.

1 |. INTRODUCTION

Moving into a nursing home (NH) changes the structure and function of older adults’ social networks, introducing new challenges in maintaining relationships and new opportunities to develop new relationships (Antonucci, Fiori, Birditt, & Jackey, 2010). NHs provide personal care with 24-hr oversight and a social environment where residents can maintain existing relationships and develop new ones through formal and informal interactions (Roberts & Bowers, 2015). However, a higher proportion of NH residents experience social isolation compared to community-dwelling older adults (Abbott, Bettger, Hampton, & Kohler, 2015). Decreased frequency of family visits, lack of common interests with other residents and social activity programmes that are unmatched to residents’ previous lifestyle or current preferences have been identified as barriers to developing a sense of social engagement and connectedness among NH residents (Buckley & McCarthy, 2009). Negative relationships, such as resident-to-resident mistreatment, may increase the risk of functional decline, depression, anxiety and decreased quality of life for residents (Ellis et al., 2014; Ferrah et al., 2015). Despite the impact of social relationships on residents’ outcomes, little is known about how NH residents perceive the relationships in their social networks, both within and beyond the facility (Roberts, 2018; Roberts & Bowers, 2015). Exploring the residents’ perspectives on their relationships is essential to identifying opportunities to develop future interventions that promote positive relationships, which will ultimately enhance residents’ well-being.

2 |. BACKGROUND

Person-centred care, which recognises the importance of enhancing NH residents’ quality of life by promoting independence and self-determination, is an important principle in long-term care internationally and an essential part of the NH culture change movement in the United States (Koren, 2010). Kitwood, a leading proponent of person-centred care, maintained that a constant state of well-being can be achieved regardless of one’s functional status if one’s personhood is maintained through relationships (Kitwood & Bredin, 1992). Aligned with Kitwood’s perspective, supportive relationships among residents, family members and staff have been emphasised as essential to person-centred care (Koren, 2010).

The relationship-centred care framework promotes person-centred care by emphasising the relational aspect of personhood, which views human beings as belonging to a network of social relationships that shape individuals’ experiences (Nolan, Davies, Brown, Keady, & Nolan, 2004). While the relationship-centred care framework also views respecting personhood as essential to high-quality care and residents’ well-being, this framework emphasises the need to understand residents in the context of their relationships and to promote an inclusive environment that supports the quality of life of all the people involved in care (Nolan, Davies, Brown, Keady, & Nolan, 2004; Ryan, Nolan, Reid, & Enderby, 2008). Nolan et al. (2004) proposed the “Senses Framework” to delineate the dimensions of relationship-centred care, grounded in the premise that good care for older adults with dementia can be achieved only when all the people involved in care experience positive relationships that promote a sense of security, belonging, continuity, purpose, achievement and significance. The conceptual definitions of each sense are summarised in Table 1. The relationship-centred care framework also emphasises that person-centred care can only be actualised through broader support for two essential elements of a caring relationship: interdependency and reciprocity. Mutual appreciation of each others’ knowledge, perspectives and values supports residents, staff and family to work together to resolve challenges such as conflicts between medical priorities and a resident’s values and preferences (Nolan, Ryan, Enderby, & Reid, 2002). The similarities and differences between person-centred care and relationship-centred care are summarised in Table 2.

TABLE 1.

The six senses for older adults in the Senses Framework (Nolan, Davies, & Grant, 2001, p. 175; Nolan, Davies, Brown, Keady, & Nolan, 2004, p. 49)

A sense of	Conceptual definition
Security	To feel safe within relationships
Belonging	To feel “part” of things; to have opportunities to maintain and/or form meaningful and reciprocal relationships
Continuity	To experience links and consistency
Purpose	To have opportunities to engage in purposeful activity facilitating the constructive passage of time; to be able to identify and pursue goals and challenges; and to exercise discretionary choice
Achievement	To make progress towards a desired goal or goals; to feel satisfied with ones efforts; and to make a recognised and valued contribution
Significance	To feel recognised, respected and valued as a person of worth, that one’s actions and existence are of importance, that you matter

TABLE 2.

Differences and similarities between person-centred care and relationship-centred care (Kitwood, 1997; Koren, 2010; Morhardt & Spira, 2013; Nolan et al., 2002, 2004)

	Person-centred care	Relationship-centred care
Differences in focus	Focus on the resident rather than the medical diagnosis	Focus on the relationships among all individuals in a NH as a whole
	Focus on quality of life and well-being of residents	Focus on quality of life and well-being of all people involved in care and their positive caring experiences
	Support caring relationship between residents and caregivers	Support reciprocal relationship and interdependence among residents, family members, and staff
	Value each resident as a unique person	Value residents, family members and staff as unique persons and appreciate each others’ contribution
	Empower residents to make their own decisions on all resident-related activities based on their needs, preferences, values, and life histories	Promote an inclusive environment that respects the opinions and values of all the people involved in care
	Foster a homelike atmosphere to help residents feel a sense of home and belonging	Foster personally meaningful living and working environments for residents, family members, and staff
Similarities in focus	Recognising supportive relationship as central to supporting high-quality care and enhancing resident well-being.
	Treating residents as individuals with dignity and respect
	Emphasising strengths and capabilities rather than medical diagnoses, disability and deficits

A large body of evidence supports the impact of social relationships on outcomes such as life satisfaction, well-being and the capacity to thrive, in both the community and NHs (Carpenter, 2002; Ryan & Deci, 2000). Fessman and Lester (2000) noted that social relationships with fellow residents helped alleviate loneliness. Another study highlighted the role of seemingly insignificant social relationships, called weak ties, in filling the gaps between close relationships with people such as family and friends; these ties create diverse social networks resulting in better subjective well-being (Sandstrom & Dunn, 2014). Social relationships help older adults cope proactively with life’s daily physical and psychological challenges and with the stress of life transitions (Fiksenbaum, Greenglass, & Eaton, 2006; Ozbay et al., 2007). On the other hand, social relationships can be strained and conflicted, causing stress over the life course and consequently having a negative effect on health and well-being (Umberson & Montez, 2010). Both objective and subjective social isolation are public health concerns since they predict decreased well-being, functional decline and premature mortality among older adults (Holt-Lunstad, Smith, Baker, Harris, & Stephenson, 2015; Perissinotto, Stijacic Cenzer, & Covinsky, 2012).

A small number of ethnographic studies have explored residents’ perspectives on their daily life in NHs, highlighting the importance of social relationships in providing quality care and promoting psychosocial well-being. For example, in a comparative ethnography of NH care in the USA and Scotland, Kayser-Jones (1990) observed the staff in the US NH engaging in behaviours that were infantilising depersonalising and dehumanising, which created social distance between staff and residents, and damaged residents’ self-esteem, dignity and sense of self-worth, ultimately resulting in withdrawal and apathy. In contrast, she found that when staff and residents engaged in more balanced social relationships, such as when residents can give something to staff in exchange for their services, these relationships both contributed towards stronger social bonds between staff and residents and fostered residents’ sense of independence by preventing situations where staff unnecessarily exercised power over the residents. Gubrium (1975), as a participant-observer in a single NH, argued that there are distinct and separate worlds within the NH—the world of the administrative staff, the world of direct-care staff and the world of the resident themselves. For example, he noted that administrative staff lacked adequate information about residents’ ongoing complex social interactions and psychosocial needs due to limited close interpersonal interactions with residents. Such gaps between administrative staff, direct-care staff and residents resulted in discrepancies in goals of care. While administrative staff and direct-care staff focused on overall clinical care and personal care, respectively, residents cared about maintaining their outside ties to make their NH life similar to the outside world. Lack of understanding that the residents’ psychosocial needs and goals diverged from their clinical goals made it difficult for the staff to appreciate and meet residents’ psychosocial needs.

Despite these important insights from early studies of the social lives of NH residents and a growing body of literature highlighting the importance of person- and relationship-centred care, few studies examine relationships from the perspective of residents themselves. Recent empirical studies on social relationships in NHs have been conducted primarily using researcher- or staff-administered structured surveys or open-ended interviews that examined staff perspectives without including resident perspectives (Roberts, 2018; Roberts & Bowers, 2015). In addition, few studies have focused on the broader social network of residents beyond the caregiver and care recipient relationships. Without understanding residents’ experiences and perceptions in the context of contemporary NH care, we lack critical empirical knowledge needed to develop and operationalise the relationship component of person-centred care. The aim of this study was to address this gap in the literature by exploring residents’ perspectives on their relationships with other residents, family members and staff in NHs. The following questions were examined:

• How do residents experience their relationships with others in NHs?

• What do these relationships mean to residents?

• How do organisational factors influence these relationships?

3 |. METHODS

3.1 |. Data source, participants and settings

This paper analysed data obtained through stakeholder engagement sessions conducted as part of a larger participatory study on person-directed care planning in NHs. The term “stakeholder engagement sessions” was used to convey the intent of the larger study, which was to co-produce knowledge with stakeholders rather than just eliciting information from them. In practice, the stakeholder engagement sessions were similar to focus group interviews. The aim of the larger study was to develop a theoretical and operational framework for person-directed care planning in NHs (Lepore et al., 2018; Scales et al., 2019). The stakeholder engagement sessions were carried out in November 2015 and January 2016 at two NHs belonging to the same corporation, both located in suburban areas in North Carolina: one NH had about 90 beds and the other had just over 140 beds. Both were lower resource NHs with average or below-average performance on health inspections, staffing and quality measures; Nursing Home Compare quality ratings were two stars (Centers for Medicare and Medicated Services [CMS], n.d.). The choice of lower resource NHs was intended to enhance transferability of the study findings to NHs that serve a high proportion of low-income residents at risk for health disparities and to NHs that may be slower to adopt culture change. Residents who participated in the engagement sessions underwent screening to ensure they did not have cognitive disturbances that would interfere with their ability to participate using a simple cognitive test, consisting of four items including “what is your name?” “what date were you born?” “what year it is?” and “who is the current president?” (Porter et al., 2015). The data set of the parent study comprised transcripts from 24 stakeholder engagement sessions with 67 participants recruited by convenience sampling and included data from residents, families, nursing staff and managers/administrators.

Of the 24 stakeholder engagement sessions, 11 sessions involved residents. While the intent of the study was to convene separate sessions for each group of stakeholders (i.e. a session only for residents; family members; nursing staff; and administrators), two of the sessions with residents also included family members at the residents’ request, and six sessions were conducted with individual residents based on their preference or their inability to attend the scheduled group sessions. The remaining three sessions with residents included one to three residents each. The length of the sessions ranged from 18–102 min with an average of 42 min. The present study drew on the transcripts from all 11 stakeholder engagement sessions that involved 13 residents, since the study purpose was to examine the residents’ own perspectives. The average age of the resident participants was 71 years, and 80% were female. Table 3 provides resident demographics.

TABLE 3.

Residents’ demographic characteristics (n = 13)

	NH 1	NH 2	Total
N	5	8	13
Age—mean (range)	63.4 (53–87)	76 (55–92)	71.2 (53–92)
Years living in the facility—mean (range)	3.1 (1–4.9)	2.2 (0.1–10)	2.5 (0.1–10)
Gender—N (%)
Male	1 (20%)	1 (12.5%)	2 (15.4%)
Female	4 (80%)	7 (87.5%)	11 (84.6%)
Race—N (%)
White	2 (40%)	5 (62.5%)	7 (53/8%)
African-American	3 (60%)	3 (37.5%)	6 (46.2%)

A detailed description of the parent study is provided in a separate article (Scales et al., 2019). We followed the COREQ guidelines (Tong, Sainsbury, & Craig, 2007) to ensure rigour in our study (See Supplementary File S1).

3.2 |. Ethical considerations

The study was approved by the Institutional Review Board of the (Duke University Health System), endorsed by (RTI International) and conducted under a Federal Wide Assurance agreement covering both entities. Written informed consent was obtained from each participant. When the focus group recordings were transcribed, each speaker was assigned a code number to maintain anonymity. No names were transcribed. After transcription, the audio recordings were erased (McLafferty, 2004; White & Thomson, 1995).

3.3 |. Data analysis

To guide this secondary analysis of existing interview data, we integrated thematic and narrative analytic approaches which offered distinct, complementary advantages. While thematic analysis can identify patterns in a data set, such as commonalities and differences across cases (Braun & Clarke, 2006), narrative analysis highlights the particularity of each case by focusing on individuals’ stories (Clandinin & Connelly, 2000). Narrative inquiry seeks to understand how people make sense of their social world and perceive their relationships with others in social, cultural and institutional contexts (Clandinin, Cave, & Berendonk, 2017; Clandinin & Rosiek, 2007). Thus, a combination of the two methods was used to explore how residents perceive, talk about and make sense of their social relationships.

At least two members of the research team coded each transcript using a two-cycle coding approach for non-narrative data; a three-cycle coding approach was used for data that contained narratives (Saldaña, 2016). In the first cycle, we used the open code of “residents’ relationships” to identify all instances where residents implicitly or explicitly evaluated a social interaction, and we used data-driven codes related to the meaning of the relationships. During the coding process, we found that our data-driven codes for the meaning of the relationships were consistent with Nolan et al.’s (2004) Senses Framework. We therefore used the six senses from the framework (i.e. a sense of belonging, security, continuity, significance, purpose and achievement) as theory-driven codes during the second cycle coding to capture all instances where either residents experienced one or more of the six senses or where residents’ opportunities to experience the senses were challenged by their relationships. The use of theory-driven codes enabled us to be sensitised to the concepts and interpretations using an established person-centred care framework in a more systematic and consistent manner (Macfarlane & O’Reilly-de Brun, 2012). In the second cycle, we used focused coding to categorise the data and develop emerging themes (Saldaña, 2016). Codes that were used for the first and second cycle are listed in Table 4.

TABLE 4.

Codes from first and second cycle coding

Codes from first cycle coding	Category from second cycle coding
Relationship with other residents	Types of residents’ relationships
Relationship with direct-care staff
Relationship with family
Relationship with others
	Psychosocial outcomes:
Belonging; connection with others	– a sense of belonging
Connected to past life	– a sense of continuity
Respect; dignity; and valued as a person of worth	– a sense of significance
Independence; having choice; and engagement in purposeful activities	– a sense of purpose
Generativity/contribution to community	– a sense of achievement
Roles of residents	Diverse roles in supporting meaningful relationships
Roles of staff
Roles of family
Functional and cognitive impairment	Facilitators and barriers to forging meaningful relationships and psychosocial outcomes
Mutual respect
Reciprocity
Social activities
Communication
High turnover of residents
Prioritising clinical care/safety regulations over residents’ choice
Staffing shortage
Institutional and state rules and regulatory issues

In the third coding cycle, we used a structural analysis of narrative elements informed by Labov and Waletzky (1997, pp. 27–37) consisting of (a) “abstract” (a story summary), (b) “orientation” (information about the time, place, situation, and participants), (c) “complication” (what happened), (d) “evaluation” (the narrator’s appraisal of the story’s meaning), (e) “resolution” (how the story ended) and (f) “coda” (a signal that the story is over, when the narrator returns the perspective to the present) (Elliott, 2005). An example of structural coding is presented in Table 5. We applied structural coding only to data that were identified as residents’ narratives and plotted the six elements of the narratives’ structures on an Excel spreadsheet.

TABLE 5.

Example of structural coding

Element of structural coding	Data coded
Abstract	When somebody dies, or somebody gets sick, they don’t tell you. You know, they say it’s against state rules for them to tell you that a person has died
Orientation	When I first came in here, I was put in a room with a lady. And she died. And after she died they moved me to a private room to myself. But she was just as sweet as she could be. Just as sweet as pie. I hated when she died. Tore my heart all to pieces
Complicating action	You’ve been in here for four years with the same people and they’re not … you eat with them, you sleep with them, and then all of a sudden they die. Sometimes we just miss them and then when we keep on asking they say “Well, you know they gone on.” But you know what I’m saying. And then when they go to the hospital, you say “Well what happened to so-and-so?” “They say, “They in the hospital.” (You say) “Well what’s the matter with them?” (They say) “Can’t tell you that. It’s against state law for us to tell you that.” Come one
Evaluation	But she was just… that’s something else I don’t like out here. You miss them, you know something done happened to them. What kind of sense does that make? Why can’t they tell you that person has died?
Resolution	No relevant data
Coda	What are you going to do with a person that’s taken to the hospital? How can I hurt that person – they in the hospital. I need to know what’s wrong with them so I can see if I can help that person. These folks can’t tell you nothing. And I think that’s wrong

Digital transcripts were managed and analysed using NVivo 10 (QSR International Pty Ltd, 2012). To ensure the rigour of the analysis, coding team members (BK, KS, YS, and KC) conducted coding and engaged in peer debriefing on a weekly basis to discuss new codes identified from the individual coding process, refine the code book, review the coding until any discrepancies on applied codes between coders were reconciled, share preliminary data interpretations and collaboratively develop initial themes. After identifying the initial themes from the peer debriefing, the first author and co-authors in the interdisciplinary team, which included nursing scientists, sociologists and gerontologists who have clinical and research expertise in NHs, reconciled disagreements on the initial themes and finalised themes. The coding process continued until it was clear that no additional concepts or themes were emerging, which signified theoretical saturation (Ando, Cousins, & Young, 2014).

4 |. RESULTS

The residents described their social relationships with three categories of people: other residents, family members and NH staff. In residents’ descriptions of how these relationships were established and maintained, the meaning of their relationships was evident in how they served to support important psychosical outcomes, specifically residents’ sense of belonging, continuity, purpose and significance in the NH, consistent with the Senses Framework (Nolan et al., 2004). While residents described relationships in all three categories as supporting these outcomes, each type of relationship had both overlapping and distinctive contributions. Residents’ relationships with other residents fostered their sense of belonging, having a purpose and achievement, and being recognised as significant within the NH. Relationships with family members supported maintaining a sense of continuity with their prior lives, in addition to promoting a sense of belonging and significance. Mutual respect and reciprocity emerged as important elements that help to build meaningful relationships between residents and staff, which facilitated a sense of belonging and significance. Organisational factors that posed barriers to forging meaningful relationships and promoting residents psychosocial outcomes were also identified.

4.1 |. Peer relationships foster a sense of belonging, purpose, achievement and significance

Residents often commented that engagement in group activities helped them to build and maintain meaningful relationships with other residents, particularly relationships that helped them attain a sense of belonging and purpose. For example, one resident stated,

I like to do crafts. … And some of the ladies can’t use their hands so I make just about everybody’s out here. … And I run the store [in the NH]. It gives me something to do, and I meet the other residents, and get to talking and carrying on.

[Resident 030, NH 1]

Residents also described activities where they contributed to the community by helping other residents, from which they seemed to derive a sense of achievement and significance in the community. Although one resident with multiple sclerosis was unable to play bingo and do crafts such as making beads due to her physical limitations, she still found ways to contribute to these group activities:

Because I can’t use my hands to play bingo, [another resident] does my cards and … And when they call the number out, I start looking and I tell him her first card or her second card, you know. That way he doesn’t have to take time to look at every one of them, you know. I can tell him what to do, I just can’t do it.

[Resident 031, NH 1]

Residents were proactive in cultivating relationships with other residents to support their sense of belonging. Beyond engaging in structured activities, residents spoke about their efforts to connect spontaneously with others in day-to-day life in the NH. For example, one resident said,

I come up here every morning before I eat breakfast and I check on … everybody. … I go speak to [one resident]. And I talk to [another resident] across the hall … And I go outside with the ones that smoke, just to talk to them because I don’t smoke.

[Resident 118, NH 2]

Residents who participated in this study observed that some residents had fewer opportunities to socialise and connect with others due to more severe functional or cognitive impairment and greater dependency. For example, one resident described another resident with dementia who is more dependent on staff when connecting to others and participating in activities:

She just wants somebody to love her and nobody does.… She come in one day and … kissed [my husband] on the forehead and said ‘I love you.’ And that was so sweet, and I thought if somebody would just go up to her and do that, maybe she would feel a lot better.

[Resident 129, NH 1]

This excerpt indicates that NH residents with severe functional impairment may lack opportunities to maintain meaningful relationships that promote a sense of belonging.

Residents also described playing the role of advocate for other residents, particularly those with cognitive impairment. For example, one resident reported monitoring and raising concerns about the quality of care provided to her roommate and other residents:

When [my roommate] gets ready to go to bed at 4:30, … they put her diaper on then… She doesn’t get changed … till the next morning. I mean it’s just soaking wet.… I talked to somebody about it the other day and I think she got wrote up. She can’t say things for herself… I just hate to see these people in here being mistreated all the time. Some of these patients cannot defend themselves. And I try to watch as many as I can…

[Resident 118, NH 2]

This example demonstrates how peer relationships can serve to protect more vulnerable residents’ dignity and a sense of significance.

4.2 |. Residents’ relationships with family members support their sense of belonging, continuity and significance

Some residents mentioned that supportive relationships with family members and frequent family visits enabled them to remain connected to their past relationships and to visit familiar places, which could promote a sense of continuity. One resident stated,

The difference between me and most people in here, I got family that comes and sees me. … Thanksgiving. I went home for the day. Christmas I’ll go home for three days. … And once a month my wife comes and gets me and we’ll go out and eat… Tuesdays my parents and my wife come. Wednesdays my brothers come. Friday nights, my parents and my wife come…

[Resident 007, NH 1]

Residents also described family members as playing a vital role in supporting a sense of purpose and significance, specifically by fostering opportunities for residents to exercise choice and autonomy outside of their daily, structured activities. One resident attributed his satisfaction with and his sense of belonging to the NH to family support that enabled him to pursue interests outside the NH:

As a rule, I’m content here. I mean it’s my home now… I tell [my family members] to come get me and I’ll go out and eat with them. … And about every other Sunday, depending on my son’s schedule, he’ll come. If I need to get out of here and go do something, I can do it. Lot of folks around here can’t say that.

[Resident 007, NH 1]

Some residents reported that they sought support from family members when they felt that a lack of information or opportunities to engage in care planning and decision-making limited their opportunities to exercise autonomy, which threatened their sense of purpose and significance. Accordingly, family members mediated communication between residents and NH staff to resolve conflicts around clinical decisions and other aspects of daily care and activities. One resident provided the following narrative:

Now, here lately, I had a problem because in the morning for my breakfast they … cut out the sausage. So I was wondering what had happened… I told my son and my daughter… what was happening… And one lady told them that they was going to check with my dietician to find out what was really going on. And so she found out what was going on. … She said I was gaining too much weight. That’s why they cut the bacon and the sausage out. … So I’m satisfied now since I know [the reason].

[Resident 032, NH 1]

Another resident shared a narrative about her interactions with staff and with her sister regarding her ambulation. She recalled that staff did not engage her in the discussion about their decision that she would not be allowed to walk or use her electronic wheelchair as she wished. She believed that she was unable to walk because she had no chance to practice walking, and she complained about the situation to her sister. Given these particularly difficult interactions with the staff, she hoped that her family could intervene and support her autonomy and self-direction. However, after engagement in care planning, the sister explained to the resident that she was only eligible for 6 weeks of physical therapy, and if she could not walk after the 6 weeks, no additional physical therapy would be provided. Despite frequent family visits, the resident noted that their lack of experience of NH life limited the efforts of family members to fully support the resident’s autonomy and self-direction: “we talked everyday. But she… until you live here you don’t know what’s going on [Resident 031, NH 1].”

4.3 |. Mutual respect and reciprocity between residents and NH staff promote their sense of belonging and significance

Residents described their social relationships with NH staff as supporting their sense of significance, particularly when those relationships were characterised by mutual respect. One resident stated,”… we need to respect the ones that’s helping us, and they need to respect us [Resident 307, NH 2].” Another resident gave an example of how they perceived the importance of mutual respect; “My first shift I got a guy and a lady up there now. And they are just as nice as pie. … I treat them good and so they treat me good [Resident 030, NH 1].” This resident recalled that he advised other residents about the importance of mutual respect between NH staff and residents who wish to receive care that aligns with their preferences and wishes:

[W]e have a resident meeting every month. Sometimes they will be in there and they will be complaining about the CNA. I tell them… to quit. If you all treat those CNAs right, they will treat you all right… If you holler at them, naturally they’ll holler back at you.

Several residents also shared their concerns about staffing shortages and heavy workloads for direct-care staff and advocated for them to be respected and valued by the NH. One resident pointed out,

And [my CNA]’s been out of work because of her leg. And now… her knee was swelling. The doctor said you’re out of work because the swelling of your knee is not getting any better… Now she comes back to work yesterday and today and the rest of this week they’ll be splitting halls.… She loves what she does because if she didn’t … she would have been gone. I told her to quit because I care for her. And I see that they don’t care for her here.

[Resident 031, NH 1]

As in the example above, reciprocity was a notable feature of social relationships through which residents can derive a sense of belonging and being valued and recognised as a person of worth. A resident shared an example of a reciprocal relationship with a direct-care staff member:

I love people. I really do. Some of the girls come to me asking me about their problems. … It feels just like I’m their mama or something. And they treat me like that. Give me hugs all the time.

[Resident 127, NH 2]

4.4 |. Organisational factors pose barriers to forging meaningful relationships

Residents identified a number of instances where state regulations or institutional rules served as barriers to forging meaningful relationships with other residents and between residents and staff and to attaining a sense of belonging. For example, one stated that “When somebody dies, or somebody gets sick, they don’t tell you. You know, they say it’s against state rules for them to tell you that a person has died.” She went on to share the following narrative; “When I first came in here, I was put in a room with a lady. And she died… I hated when she died. Tore my heart all to pieces.” She described how staff typically responded when she asked for information about another resident: “‘Can’t tell you that. It’s against state law for us to tell you that.’ Come on.” She went on to reflect,

You’ve been in here for four years with the same people… you eat with them, you sleep with them, and then all of a sudden they die… You miss them, you know something done happened to them. What kind of sense does that make? Why can’t they tell you thhat person has died?

The resident closed the narrative with this coda—“I need to know what’s wrong with them so I can see if I can help that person. These folks can’t tell you nothing. And I think that’s wrong [Resident 030, NH 1].” This narrative shows that when residents successfully connected through personal relationships with other residents, they perceived rules and regulations governing the NH as actively blocking meaningful relationships.

The resident also noted that a regulation prohibiting residents from giving gifts to staff limited development of reciprocal relationships with direct-care staff stating “I love to give stuff at Christmas time. …my CNAs, I love them to death, but I am not allowed to give them anything.” She continued,

The first year I was here I bought little gifts for everybody. And I was passing them out…[administration]… told me I couldn’t do that.… because it was against state law for me to give them something. I said, where did these crazy folks come from? … If I give my CNA a gift, she would get fired if they caught her.

She went on to reflect, “That doesn’t make any sense. Christmas is Christmas. You get gifts. You give gifts [Resident 030, NH 1].” This narrative indicates how reciprocity, exemplified here by holiday gift-giving, is an important element of residents’ efforts to build relationships that foster a sense of connection and belonging, and how the prohibition of gift-giving limits the opportunity to engage in reciprocal relationships.

Frequent turnover among residents and staff shortages was also identified as barriers to developing or maintaining meaningful relationships. In particular, one facility’s increase in short-term rehabilitation residents was identified as a barrier to forming resident-to-resident relationships that fostered a sense of continuity and belonging. One resident stated, “[W]e’re not a nursing facility any more. We’re a rehab center. Let’s face it: people are in, people are out… A lot of turnover [Resident 122, NH 2].”

Residents also mentioned that staffing shortages encouraged task-oriented direct caregiving, which presented a barrier to building an emotional connection with direct-care staff:

So they’re overworking the CNAs to where they’re short-cutting … they just take their time and do what they’re supposed to do… because they have so many people. … [A CNA] walks from room to room with the same face, the same motions.

[Resident 031, NH 1]

An organisational culture of care that prioritised clinical concerns over residents’ preferences and wishes that manifested in residents’ interactions with staff appeared to threaten residents’ exercise of autonomy, self-direction and control over their daily activities, which could interfere with their maintaining a sense of significance and purpose in their lives. One resident stated,

They tell me… be careful, you got to look out for cars,’ I know that. I’m not stupid. I didn’t live to be 58 years old to be stupid. I’ve raised two children, so I know when the environment is safe or not. But don’t talk to me like I’m an invalid or a child who don’t have their right mind.

He went on to share the following story:

Like a couple weeks ago … last week when it was so warm I went outside with shorts and a T-shirt on. [Staff said]… this is pneumonia weather. What are you doing out here with shorts and T-shirt?’ I know it’s pneumonia season and flu season but that was my choice.” He closed the narrative with a coda, “Don’t try to correct me, especially if I’m old enough to be your daddy.

[Resident 007, NH 1]

5 |. DISCUSSION

Cultivating supportive social relationships is central to developing a culture of person-centred care in NHs; these relationships allow residents to express personhood and engage in mutually beneficial relationships, through which residents and others in the NH community achieve well-being. This study provides new insights into NH residents’ perspectives on the significance of social relationships by describing how relationships unfold, the meaning that residents ascribe to their relationships and how relationships support important psychosocial outcomes such as having a sense of belonging, continuity, purpose, achievement and significance. The study findings also support the vital roles of residents, family and staff in establishing a relationship-centred culture within NHs that promotes residents’ well-being, views all people involved in care with dignity and respect and values everyone’s positive contributions to the community. This study also suggests implications for future practice to help operationalise a person-centred care model into which mutual respect and reciprocity are integrated, with the ultimate goal of promoting residents’ well-being.

Resident’s social networks involved different types of relationships, including those with other residents, NH staff and family, and these different relationships supported different psychosocial outcomes. Residents expressed a sense of belonging to the NH community through descriptions of close connections with other residents and direct-care staff and a sense of achievement and significance through helping other residents during social activities or providing advice related to the staffs’ personal lives. NH staff helped residents preserve their dignity and identity by respecting and incorporating their preferences and personal values into day-to-day care, which promote a sense of significance.

Solid relationships with family members helped residents feel connected to the social world outside the NH, supporting a sense of continuity between the past and the present. Residents described family as a source of discretionary choice that supported their self-direction and a sense of purpose. Consistent with a previous study on the influence of perceived level of choice on residents’ perceived autonomy (Bangerter, Heid, Abbott, & Van Haitsma, 2017), residents felt control over their daily lives when they had expanded choices (e.g. meals or home visits) that were needed to exercise autonomy. Family members also served as mediators who facilitated communication between staff and residents and supported residents’ engagement in decision-making in their care plans when conflict over self-direction arose. The complementary roles of relationships with other residents and outside ties including family members are consistent with findings from Gubrium’s ethnographic studies. In his earlier study in a single U.S. NH (1975), he found residents encountered the experience of “breaking up a home” when they lost their ties with familiar people, objects and places (p.84). He also noted that residents maintained ties with the outside world through routine visitors who connected the residents to the familiar details of their past lives. In that study, routine visitors were valued since they not only influenced staff behaviours on behalf of the residents, but also helped residents to visit friends in their homes or go out to eat when they wanted. On the other hand, mutually supportive ties were formed within the NH among residents, who offered voluntary assistance as ears and eyes for each other. In a subsequent study in several NHs in one state in the United States, Gubrium (1993) noted how residents’ developing a sense of belonging to NH life, which he denoted as “making a new home,” was facilitated by residents having positive peer relationships with other residents, supplementing the support from family members who do not live in the facility and thereby may not be aware of residents’ psychosocial needs (p.37).

Recognising the importance of the diverse roles and functions within residents’ social networks and understanding who typically enacts a given role can inform future interventions to promote meaningful relationships that support positive psychosocial outcomes for NH residents. Future studies, for example, could focus on interventions that enhance the continuity of resident relationships with family members outside the NH through innovative options such as virtual social activities using a video call or social network service that would allow residents to maintain relationships with other residents discharged to home, as well as with friends and family members. Regarding the residents’ role as advocate for other residents with more severe disabilities, peer support groups are a potential intervention to foster residents’ sense of belonging, significance and generativity.

Mutual respect and reciprocity emerged as two important elements of residents’ relationships that promote well-being of older adults and the entire community, which is consistent with relation-ship-centred care framework (Nolan et al., 2002). The example of the institutional rule prohibiting giving Christmas gifts to direct-care staff shows how limiting reciprocal exchange of support caused residents to feel disconnected and threatened their sense of belonging. The meaning of the gift-giving practice was developed in Mauss (1925)’s classic anthropologic study carried out in Polynesia, Melanesia and the American Northwest. He noted that the early exchange system that built social ties and bonds in indigenous people centred on the obligation to give and receive presents through the reciprocal gift exchange. According to him, rejecting gifts that are supposed to be reciprocated signifies rejecting the bonds of alliance and commonality. Kayser-Jones (1984) applied social exchange theory to the positive aspects of reciprocal relationships between residents and staff. She noted that when residents had resources that they could exchange with staff, they were able to engage in more balanced relationships, which contributed to the development of social bonds and continued positive relationships. Given the loss of financial resources among many NH residents, especially those funded by Medicaid, and curtailed use of their skills due to their physical and cognitive impairment, it can be difficult for residents to maintain reciprocal relationships. Providing diverse opportunities to create “gifts” through recreational activities or occupational therapy will help them maintain reciprocity in their relationships with others and develop a sense of belonging and significance.

This study supports Kitwood’s assertion that social relationships are key to personhood and well-being by demonstrating how a network of relationships can help residents achieve important psychosocial outcomes (Kitwood & Bredin, 1992). The present study also extends Kitwood’s framework by showing how residents proactively promote positive relationships to fulfil psychosocial needs. Residents connected with others through routines where they checked in with other residents and fulfilled their need for dignity by communicating their preferences and values and receiving care based on that information. Residents also emphasised the importance of addressing their opinions to direct-care staff in a respectful way by honouring direct-care staff’s dignity, implying mutual respect and appreciation of each others’ equal worth (Nolan et al., 2002). Lastly, residents advocated for a sense of belonging and for the dignity and a sense of significance of residents with more severe functional impairment who were vulnerable to potential neglect by direct-care staff with heavy workloads. They also gained a sense of significance as contributing members of the community by supporting residents with greater difficulties and by providing advice related to the staffs’ personal lives, which in turn contributed to the well-being of the entire community.

Residents identified a variety of organisational-level barriers to the fulfilment of their psychosocial needs. A paternalistic approach to care planning posed an organisational barrier to fulfilment of residents’ needs for a sense of dignity and autonomy. For example, one-way communication from staff to residents and prioritising clinical care and safety regulations over residents’ choices contributed to residents’ perceptions of a loss of control over their own lives, undermining their sense of significance and purpose. Another example of barriers to meaningful relationships described by residents included the shift of services towards short-stay rehabilitation, leading to high turnover within the resident population, state regulations protecting residents’ privacy, high turnover of direct-care staff and staffing shortages.

The findings regarding organisational-level barriers to residents establishing or maintaining personal relationships suggest several opportunities to strengthen current organisational culture and practice. Some of these barriers—such as high turnover and staffing shortages—are long-standing and are widely recognised as negatively impacting NH quality and therefore demand profound national change in NH policy, financing, regulation, oversight and practice. However, other perceived barriers to meaningful relationships—such as state regulations protecting residents’ privacy—might respond to simpler interventions. For example, education and awareness campaigns for administrative and direct-care staff could prevent overly restrictive interpretations of federal and state regulations, clarify and support NH residents’ rights and dispel inaccurate interpretations of regulations that threaten resident relationships. To facilitate residents’ active engagement in their care planning to enhance their sense of significance and purpose, training programmes are needed for helping NH staff recognise the importance of bi-directional communication skills to promote development of meaningful relationships with residents, efficiently elicit residents’ preferences and incorporate them into care. Consistent assignment of direct-care staff to residents is another strategy to increase mutual familiarity, a sense of continuity and foster person-centred care (Koren, 2010). Lastly, understanding residents’ autonomy from a relational perspective can help address false assumptions about residents’ decision-making capacity. A fundamental step towards promoting residents’ sense of autonomy is to cultivate an organisational culture wherein NH staff understand that functional decline does not entail complete loss of decision-making ability, and supportive relationships can enable residents to fully exercise their autonomy (Sherwin & Winsby, 2011).

In addition, our participants perceived that more cognitively impaired residents had greater difficulty meeting their psychosocial needs through relationships. Future studies are needed to better understand the experiences of more cognitively impaired residents, since a majority of NH residents have some level of cognitive impairment.

5.1 |. Limitations

We analysed secondary data applicable to the present study’s research questions from interviews developed for a different purpose, and therefore, the data may not fully capture every participant’s perspective on their relationships. The majority of participants were relatively young, with an average age of 71.2 years; in contrast, during 2014, 52.6% of US NH residents were aged 85 and over (Harris-Kojetin et ah, 2016). While perspectives on social relationships may change with age or disability status, the parent study limited recruitment to cognitively intact residents. Further, the parent study was limited by the collection of data from only two NHs in one state. However, the focus on low-resource NHs helps strengthen the relevance of the findings for other NHs that may be struggling to implement culture change in spite of limited resources (Miller et al., 2013). Despite the small number of participants and secondary analysis method, two rounds of interview sessions generated rich, in-depth data that enabled both thematic and narrative analyses. Although the Senses Framework provided a rich lens through which to interpret the data on relationships, not all six senses were noted in resident’s descriptions of their relationships. Specifically, a sense of security and achievement from the Senses Framework was not as prominent in the analysis of this secondary data set, which does not mean that they are less important. Future research that will explore how the sense of security and achievement can be attained through residents’ relationships is also needed for more comprehensive interventions.

6 |. CONCLUSION

This study explored how NH residents experience their relationships with other individuals in NHs, as well as family members, and the meaning of these relationships. A relationship-centred culture that empowers everyone involved in NH life to promote reciprocal relationships can help to promote residents’ positive psychosocial outcomes such as a sense of belonging, continuity, purpose, achievement and significance, thus improving well-being throughout the NH community. Recognising the importance of the diverse roles and functions within residents’ social networks and understanding who typically serves in different roles informs future interventions that optimise their unique roles. Strategies that prevent overly restrictive interpretation of regulations and institutional rules and support residents’ rights and capacity to exercise their autonomy need to be developed to create psychosocial environments where residents form and maintain meaningful and reciprocal relationships.

7 |. RELEVANCE TO CLINICAL PRACTICE

Person-centred and relationship-centred care can only be fully operationalised when residents are able to form and maintain supportive and reciprocal relationships with other individuals within and outside the NH. This study highlights the need for NH staff, including administrative staff, nurses and direct-care staff, to understand how residents’ social relationships positively and negatively influence their psychosocial outcomes. Training and awareness campaigns are needed to strengthen staff’s capacity to support NH residents’ relationships and uphold their rights and to dispel inaccurate interpretations of regulations that threaten resident relationships.

What does this paper contribute to the wider global clinical community?

• This paper connects nursing home residents’ experiences of their social relationships to existing empirical literature on residents’ psychosocial needs and supports person-centred and relationship-centred approaches by adding empirical knowledge on the importance of mutual respect and reciprocity.

• This paper provides new insights on the diverse roles and functions carried out within nursing home residents’ social networks. Understanding who typically serves in different roles suggests future intervention opportunities to optimise the complementary roles of social network members, which will ultimately promote residents’ psychosocial well-being.

• This paper reveals barriers to forging meaningful and reciprocal relationships and suggests future interventions to facilitate positive psychosocial environments that will enhance residents’ psychosocial outcomes and well-being.