Abstract
Residents in nursing homes are old and frail and are dependent on constant care, medical, or otherwise, by trained professionals. But they are also social beings, secluded in an institutional setting which is both total and foreign. In this setting, most of the residents most of the time must relate to other residents: other residents are the nursing home residents’ peers, companions, and perhaps even significant others. In this article, we will discuss how resident communities in nursing homes are influenced by the approaches of nursing home staff. Two nursing homes have been included in this article—one from Canada and one from Norway. Participant observation was conducted at these two nursing homes, predominantly focusing on everyday-life activities. The cases from Norway and Canada are illustrative of two very different general approaches to residents: one collectivistic and one individualistic. These general approaches produce different contexts for the formation and content of resident communities, greatly affecting nursing home residents. The significance of these approaches to resident community is profound and also somewhat unanticipated; the approaches of staff provide residents with different opportunities and limitations and also yield unintended consequences for the social life of residents. The two different general approaches are, we suggest, “cultural expressions,” conditioned by more than official preferences and recommendations. The difference between the institutions is, in other words, anchored in ideas and ideologies that are not explicitly addressed.
Introduction
The nursing home (NH) is, and has been for several decades, a central institution in most Western countries: a significant segment of the population spends their last years at NHs, and few alternatives exist for many residents. While the number of elderly persons residing in NHs relative to total population varies between countries, as does the respective total, national expenditure on the NH sector (OECD, 2013), the NH as an institution has more similarities than differences across borders (Armstrong et al., 2009; Choinere et al., 2015). Often forgotten in popular and scientific accounts of the NH, addressing medical- and health related aspects, is the story of the NH as a communal setting. The NH can be seen as a prison, a boarding school, or a monastery, as a form of “total institution” (Goffman, 1961), wherein residents live together with few possibilities of “escape.” For the long-term resident of the NH, opportunities to leave the NH are few: some leave undesirably because of transfers to hospitals or emergency wards, while some, but far from all, NHs offer weekly “expeditions” (often for a minority of residents; Ågotnes, 2016). The social life for most NH residents is, in other words, limited to the physical and social boundaries of the NH. Because of these boundaries, and because visitors from “the outside world” can be few and far between (Ågotnes, 2016; Hauge 2004), we believe that the significant others for most NH residents are other NH residents. While communities of residents have been described to some extent (Bjelland, 1982; Gubrium, 1972, 1993; Kayser-Jones, 1981/1990), the way in which they are influenced by the NH institution appears to be a somewhat neglected area. How NHs’ staff promote and/or inhibit the social life of residents is often left out of the tales of the NH, in other words.
In this article, by drawing on ethnographic material from one NH in Canada and one in Norway, we will investigate how the social life of residents in different NHs can be facilitated. Through an empirical focus on mealtimes and activities, we will address how the approaches of NH staff can have different and often unintentional consequences for the social life of residents. We primarily aim at describing the differences observed between the two institutions—of putting to word an under-communicated and impalpable aspect of NH life; how the social life of residents is provided for by NH staff. Second, we will discuss whether the different approaches observed can be said to be connected to more than institutional differences; are the relatively homogeneous institutional approaches observed related to culturally conditioned ideologies of care?
Background
During the last decades, there has been an increase in emphasis by policy makers and health bureaucrats in the Western world on what can be described as a discourse of “person-centeredness” (Kitwood, 1997). It is argued that residents in NHs should live active lives based on their own needs and interests (Ervin and Koschel, 2012: Hellström et al., 2005). Residents of NHs should live active and meaningful lives based on personal preferences, even though they often suffer from cognitive impairment and experience a reduction in social interaction and social activities (Moyle et al., 2011). Care in NHs is supposed to be delivered in accordance with residents’ perspectives and person-centeredness (Dewing 2008; Ervin and Koschel, 2012). Such a focus on the individual and on personal preferences is anchored in an increased emphasis on “individualism” and “personhood” in health science literature in the last couple of decades (Dewing, 2008; Ellis and Astell, 2010; Kitwood, 1997; McCormack et al., 2011; Murray and Boyd, 2009; Smebye and Kirkevold, 2013; Stein-Parbury et al., 2012), also observable in official policies being from public entities or non-governmental organizations (NGOs; e.g. Alzheimer Society of Canada, 2011; https://helsedirektoratet.no/demens/personsentrert-omsorg-og-miljobehandling-ved-demens (retrieved 7 February 2017); Stortingsmelding nr. 35, 1994–1995). Accordingly, what can be described as an “individualistic turn” has taken place within policies and research relating to NH residents. While this “individualistic turn” has brought with it analyses of the relationship between staff and residents in residential care (e.g. Hellström et al., 2005; McGilton et al., 2012; Smebye and Kirkevold, 2013), such a relationship is primarily being treated as a dyadic one (Næss et al., 2016).
What can be described as an “individualistic turn” within research on NHs is also reflected in development of actual NH practices (McCormack et al., 2011; McCormack and McCance, 2017). NHs have been and are increasingly adopting to the principles of “person-centered care.” As we shall illustrate with specific examples, NHs do so differently and to varying degrees.
Method
This article is based on the multi-disciplinary and multi-national study “Re-Imagining Long-Term Residential Care: an International Study of Promising Practices” (http://reltc.apps01.yorku.ca/), comprising approximately 40 researchers from six Western countries investigating promising practices at NHs in Canada, the United States, the United Kingdom, Germany, Norway and Sweden. Rapid ethnography (Baines and Cunningham, 2011), wherein a relatively large group of researchers collaborate in a short and intense research visit, is the main source of data material within the project. The approach draws its primary strength from being a multi-site ethnographic study (Falzon, 2009), in which relatively rich data are gathered on several sites for comparative purposes.
Two NHs have been included in this article: one from Canada and one from Norway. While other NHs were included in the research project, the two NHs are included as they illustrate different institutional approaches to resident community. The two NHs were different than other NHs included, in the sense of having what appear to be consistent and homogeneous approaches to resident community, and different from each other in the form these approaches took. Both NHs are private, non-profit institutions. The Canadian NH, considered medium sized by local standards, is moderately smaller than the Norwegian NH.
The empirical material was collected in May 2014 in Norway and in May 2015 in Canada. For each NH, groups of 12–14 researchers conducted fieldwork for approximately 1 week, covering all shifts except night-shifts. The authors produced, relative to the short time-span, large amounts of data in the time period, primarily in the form of field-notes and transcribed interviews with NH administrators, staff, residents, and visitors/relatives, in addition to various forms of documentation regarding guidelines and regulations from the institutions and the administrative bodies they relate to. While the researchers within the project applied a broad approach to staff–staff, staff–resident, and resident–resident interaction as well as the contextual features of the respective institutions and their jurisdictions, we will in this article focus on interviews, conversations, and observations of and with residents. These often took the form of “walk & talk sessions” (Evans and Jones, 2011), wherein residents’ interaction with each other, with staff, and with the authors was observed, drafted, and transcribed.
Analysis
A comparative analytical multi-site fieldwork method was used (Falzon, 2009), based on coding of where, how, and what kind of resident community was organized. The empirical material, based on observations and conversations, was transcribed in situ, writing down what was heard or observed as faithfully as possible using standard spelling and punctuation (Silverman, 2005). The coding analysis procedure was conducted in two stages. The first stage was a thematic and comparative coding procedure (Falzon, 2009), where a thematic file was established based on a comparison of NH routines and resident activities in the two different NHs. The second stage was focused coding informed by the questions asked regarding resident community.
Resident communities at two NHs
In the presentation of the residents’ community at the two NHs, we will address three areas significant for social interaction: physical space and layout, mealtimes, and organized activities. These areas, although not exhaustively covering the subject, do cover the most important aspects and arenas of social interaction among residents at the NHs, and, we believe, at NHs in general.
Social interaction and space
The physical layout of NHs influences not only where residents interact but also how. More importantly for our benefit, the relative large variation in NHs’ architecture and use of space is accentuated by how interaction is facilitated by staff in the respective spaces of the NHs. This variation seems to be related to how residents move, meet, and interact socially.
The Canadian NH differs significantly from the Norwegian, in the sense of having far less physical barriers between wards, and between wards and living areas, allowing for easy access between private rooms and living rooms. In the Norwegian NH, conversely, residents and staff had to move through a relatively long corridor to get around, influencing not only the mobility of the residents but also interaction among them. Consequently, the physical space within the NHs served different purposes. At the Norwegian NH, residents seldom used the living room, with the exception of organized activities and watching TV in the evenings. A minority of residents used to sit in front of the TV at evening time, but the living room was otherwise not used routinely by residents, nor was it encouraged to be used by staff. Rather, residents would meet, mostly by accident, in transit between one place and the next, or simply by wandering around. Typically, they would meet in the hallway, more often than not before or after meals or organized activities. The hallway was the social center of the ward, used by residents going back and forth and intermingling with other residents or guests. It did not appear that NH staff intended this: the hallway had no furniture, except for a few chairs and an ergometer bike, nor was it particularly wide. Still, whenever a guest—whether researcher or visitor—and a resident started to interact in the hallway, another resident would usually appear, eager to be a part of the social life of the ward. Interestingly, residents at the Norwegian NH, although spending quite a lot of time in the public sphere of the NH, did not appear to enter the private rooms of one another; they did not “go visit.”
In the Canadian NH, most residents did spend quite a lot of time in the large living rooms. However, and as for the Norwegian NH, they did so whenever an activity or a meal was prearranged for them, rather than out of their own volition. As for the Norwegian NH, the living room was seldom used for recreational activities by and of the residents themselves, certainly not in groups. In contrast to the Norwegian NH, the largest living room at the Canadian NH served the function of being both living room and dining area. The room was rearranged between meals to be used for whatever purpose necessary at a given time. The room was larger than that of the Norwegian NH and had a more central placement, making it easy to access. Still, residents seldom gathered in the living room independently. The living room was used for three main purposes: mealtimes arranged by staff, activities arranged by staff or volunteers, and interaction with staff members. During mealtimes, residents would gather routinely, although, as we shall see, in a very different manner than that of the Norwegian NH. Residents would also meet during one of the many arranged activities at the NH, more often than not arranged by voluntary staff. In contrast to the Norwegian NH, the living room at the Canadian NH constituted the public sphere of resident interaction, even though residents rarely used it of their own volition. Rather, when seeking companions or interaction, residents would meet in their private rooms.
Social interaction and mealtimes
Mealtimes at the Norwegian NH served as the primary organizing principle of the day. At the Canadian NH, although important, mealtimes did not have such a function, nor did it have the same communal significance as at the Norwegian NH. At the Norwegian NH, mealtimes were in many ways the highlights of the day for the residents and constituted the basis of organization for the staff; other chores and happening were organized in accordance with the meals. Furthermore, mealtimes were, as in Norwegian culture in general, considered a communal activity; “one eats together.”
The outtake below illustrates the typical context of a meal at a Norwegian NH. Residents are brought into the dining area at a given time and seated at designated chairs, where they wait for other residents to attend and for the staff to serve them. Meanwhile, the residents who have been seated interact, not necessarily with companions of their own choosing. In essence, the context of the meal is provided for the residents, who have little influence. Still, they eat and interact together.
Mealtime (Norway)
Dinner was served in the kitchen, while the residents were placed on three different tables. The residents had allocated chairs with their respective names written on signs. The residents did not help out preparing the food, but some of them talked to each other while waiting for the food to be served. One of the patients said while waiting, “I have not been here before so I don’t what they usually serve here.” A co-resident replied, “Well, you were here yesterday, you sat exactly where you are sitting today, I saw that.” “No, I haven’t been at this exact place before.” “Well, you sat there”—she pointed at her chair. One of the residents who sat next to the table where the bread was prepared grabbed a piece of bread before it was served. A co-resident addressed her: “You should wait until they say that food is served.” The resident replied, “But I am so hungry.” “Yes, but you grab all the nice food, and it will be less food left for us.” Several of the co-residents laughed and gathered around the table apparently interested in the small quarrel. A staff member said, “Calm down, there is enough food for everyone.” After a while, still waiting for the food to be served, one of the residents started to talk about how she wished that they could sit closer together. That would be more fun she said; she was used to having more people to talk to while eating: “Not that I don’t like you (nodding to the three other co-residents at her table), but it would be more fun to be able to talk to more people sometimes.” A co-resident sitting next to her replied: “This is not a place to talk to others; this is a place to eat in order for staff to get it all done within ¾ of an hour.” He continued, while pointing at the staff: “You see how they work, they prepare the food, serve it—they want us to finish eating so that afterwards we can go to our room, so they can have some peace and quiet.” The others did not comment and he continued, “I don’t know what they are doing the rest of the evening, because then we have gone to our rooms, but this is the way it is supposed to be—they should work effectively, get the job done!”
Mealtime is, as presented, both communal and routinized at the Norwegian NH; the community is emphasized in the sense of an anonymized collective of residents. The meal proceeds in the same way, every day, regardless of who the participants are, in other words. At the Canadian NH, mealtimes took a different form. Mealtimes were far more disorganized and far less “efficient.” Residents would not necessarily gather in advance of being served, they would not necessarily eat at the same time, and they had more options of what to eat.
Mealtime (Canada)
Between 7.10 and 9.00 a.m.: at 7.10 only two residents had come out of their rooms to attend breakfast. Another male resident arrived 10 minutes later. These three male residents were the only residents attending breakfast for the subsequent hour and a half. The three, two seated when I arrived, one later, were seated at different tables, quite a distance from each other. The two first residents sat at their respective large tables with room for four people, while the last resident to arrive sat at a small table only for him. When he arrived, he barely acknowledged the presence of the others and quickly took his seat. For the following hour or so, the two first residents sat at their respective tables eating, not talking to each other for the entire time. The last resident, also not talking to the other residents, left about 15 minutes after arriving, of his own accord. While eating, he kept his head bent forward, looking down at the food at all times, not making contact with anyone. The caring staff seemed to “understand” him; they left him in peace, while talking to the other two residents, respectively, the entire time.
One of the residents was struggling with the ground plums he was served (presumable for digestive purposes): he tried, spoon in hand, to raise his hand to his mouth, but could not find the right angle. He sat like that, occasionally trying to raise his hand to his mouth, for about 10 minutes. He also had a bowl of cereal, but did not seem very interested. An assisting nurse—one of the three staff members present—went over to him and helped him with the plums. She made a joke about the food: “It’s not very good is it!” The resident took a while before answering: “No, it’s garbage!” They both laughed. Before leaving, an assisting nurse reminded the assistant: “Remember that [the resident] needs a little help.” The assistant went over to the resident and started helping him with the plums. After a couple of servings, he seemed satisfied and moved over to his cereal; 30 minutes later, only he remained. No other residents had joined him. The other original resident had left for an activity at another unit, of his own accord, without being reminded by staff. The residents who had not joined breakfast had still not left their rooms. They were either sleeping or were preoccupied in the rooms, without any staff members. The remaining resident, meanwhile, was still struggling with his food. The assistant, having finished her other chores and in the absence of other residents (and not going into the rooms of residents), was sitting beside him. She helped him with toast, while talking occasionally. He had finished his cereal, but had still not touched his plums.
In addition to a general approach accentuating resident independence and choice, the outtake also contains other, more implicit aspects connected to a focus on individual residents’ preferences and wishes. The staff members waited for the residents to get up from their beds or to come out to the living area before approaching them, instead of “gathering them,” as is typical in the Norwegian NH. When residents did not come out to the living room around the time of breakfast, staff would approach them in their rooms and ask whether they needed anything. Others would—based on previous experience—simply be left alone (in addition to those who were bedridden, who of course did not have a say in the matter, of which there were marginally more in Norway compared to Canada). For those who did attend breakfast in the living room, the staff left the preferences of food and beverages up to the residents as far as possible: toast was made especially for one of the residents, after being asked whether he would like a piece.
Organized activities
Organized activities (such as bingo, music activities, crosswords) were an important part of everyday life at both the Norwegian and the Canadian NHs. Activities provided an often much needed break from a mundane everyday life for many residents. As residents at any NH cannot be considered a homogeneous group, organizing an activity to suit the wishes and capabilities of all or even most can be difficult. Activities were organized into two vastly different ways at the NHs. At the Norwegian NH, staff provided a strictly organized activity containing a concrete scheme of what the residents were supposed to and expected to do. At the Canadian NH, the activities were more loosely organized, allowing for improvisation and variation. Residents at the Canadian NH were expected to play an active part in the flow of the activities, while residents at the Norwegian NH were expected to follow the provided plan.
Organized activity in Norway
Before dinner every Wednesday, music activities were arranged for the residents. The staff prepared for the activity by leading the residents into the living room, making sure they were ready when the leader of the activity entered. The leader took charge and started playing a variety of familiar local, Norwegian and American songs on his guitar. The residents seemed to enjoy the music; some danced and quite a few participated by singing or by humming along. Most of the staff also participated and tried to motivate the residents to take part in the dancing by asking them to dance. A majority of residents, however, only engaged in the dancing and singing when they recognized a song they liked, which was far from every song. Residents did not initiate the participation of themselves or others; they participated when told to do so.
After an hour, the activity ended abruptly. Most of the residents left the living room, except for four residents who stayed behind chatting with each other. One of the four spoke out loud: “The party has just started, and everyone leaves the party. What kind of party is this?” The other residents—the majority—drifted off into the hallway. Staff were preparing dinner at this time and were not to be seen. After a short while, several of the residents started walking up and down the hallway. One of the residents approached a researcher and asked whether she would like to be shown around. First, the resident showed the guest the outside area by pointing through the window and said that it was a shame that they were locked up in here, because there were so many nice places to go for a walk outside. Another resident approached and said that this was like being in a prison, and she asked a staff member who had appeared shortly before: “Why can’t we go out as we want to?” The staff member said a bit ashamed, “What if you get lost.” Then the resident answered, “But, see (she pointed out the window) where can we get lost, it’s just going around here.” The resident continued, “Well, even though we are a bit ‘nutty’ (pointing at her head).” “Yes, a bit ‘nutty’, I don’t know the word but …” The co-resident laughed and pointed at her head repeating the word “nutty.” Then she got serious again and said, “I really want to go outside for a walk, look at the nice weather, we are locked up here.” After a brief conversation about the outside area, the “tour” went on up the corridor. When approaching the ergometer bike, the resident climbed on the bike and started cycling. After a few minutes, five other residents came along mingling around the bike, and two male residents stood in a line waiting to get on the bike. When the first male resident in the line started to cycle, the other resident in the line took his walker and started to push it into the bike, and the resident who was trying to cycle told the man to stop because he was disturbing him: “I can’t cycle when you push that thing on my bike,” he said, pointing at the walker. The resident kept on pushing his walker until the other resident got off the bike. The other resident tried to get on the bike without success. He lost interest in the bike when the “tour guide” continued down the other corridor on her tour. The five residents followed her on the rest of the “guided tour” until it was over.
The organized activity took the form of a stringent and thoroughly planned activity, strictly limited to the 1 hour of time allotted to it. For the residents, it offered little in the way of variation, agency, and initiative, while also being predictable and familiar. This impression is clearly contrasted to the ebb and flow of movement and conversation at the hallway. The relatively hectic hallway gave the ward an impression of being lively—something was going on at all times—an impression that would not be given when visiting the living room or the kitchen.
Contrary to the music activity at the Norwegian NH, activities at the Canadian NH were far less strictly organized. During the activities, residents were provided options and variation. To a higher degree than for the Norwegian NH, residents who participated needed to be spontaneous or creative.
Organized activity in Canada
“Happy hour” is a weekly activity for the entire NH, placed at one of the wards. Untypically for NH activities, it did not have a specific time frame; it lasted until the residents had had enough. The residents sat at several different tables, five in total. Some of the tables seated few residents, 2 or 3, some, one in particular, seated many, up to 10 residents. There were different activities at each of the tables: a board game, two word puzzles and two card games. At some of the activities, participants drifted in and out, while the participants remained for the entire game at others. One of the word puzzles was the most popular activity; 8–10 female residents sat around a large table filling out a relatively complicated word puzzle, most of whom participated actively. At one of the card games, three to five female residents played cards with the help of a volunteer. At another table, two male residents sat on opposite sides of a small table with another card game in front of them. For approximately 40 minutes, neither of them played, perhaps waiting for assistance, or perhaps simply relaxing, enjoying their beers. An assisting nurse served food during the whole activity: potato chips and other snacks, soda, and beer (light beer, 0.5%). She had a “snack-trolley” which she walked around, serving everyone and refilling when needed. In addition, a volunteer walked around helping out residents with the different activities. Most of his time, however, was spent on the groups. Several of the female residents in this group had trouble holding the cards and needed continuous help playing. At times, residents would be assisted by the volunteer in starting or maintaining a conversation, but not frequently. At one of the groups, where the composition of residents was more varied than others, the two most physically fit players (one of whom left when receiving visitors) helped the others.
For the outsider, the activity appeared somewhat hectic and perhaps even chaotic: many residents were gathered at the same time, some residents drifted around, while constant talking and laughter could be heard during the entire activity. For the insider, meanwhile, the hectic and chaotic nature of events appeared to be a most welcoming one—perhaps as a much needed break from the mundane and predictable everyday life of the institution. Even though the activity can be seen as being relatively complex and demanding (especially compared to the relatively all-inclusive Norwegian activity), many residents, a majority, participated. This might be connected to higher, overall functional ability among residents at the Canadian NH compared to the Norwegian. As we understand the difference between the resident groups to be marginal (they are all long-term residents at NHs with severe cognitive and/or functional challenges), we believe that the difference between them does not fully explain differences in approaches from staff.
Discussion
The social life of residents
Within the Canadian NH, an individualistic approach toward residents was adopted, as evident in the (dis)organized activity. The included examples from the Norwegian NH, meanwhile, seem to undermine an emphasis on individual preferences. The significance of these approaches to resident community is profound and also somewhat unanticipated; the approaches of staff provide residents with different opportunities and limitations and also yield unintended (by staff) consequences for the social life of residents.
At the Norwegian NH, residents were brought together routinely, even though the gatherings can be described as staged and structured. While not meeting the social needs of all residents, NH staff provided an arena for resident interaction, which was only rarely visible at the Canadian NH. During mealtime at the Norwegian NH, residents talked, discussed, and quarreled, because a social arena allowing for such interaction was provided for them. Although not creating it on their own, nor influencing the context of the meal (such as time and seating arrangements), it created a social environment in which all residents played a part. The context provided residents with opportunities to meet the unforeseen; the content and meaning in the specific situation could only be created together with others. Mealtime at the Canadian NH, in contrast, did not promote interaction among residents at all, perhaps contributing to residents opting to stay in their rooms, or meet other residents privately rather than in the public sphere of the NH.
The organized activities, meanwhile, had an altogether different significance on the social life of residents when comparing the two institutions. At the activity in the Norwegian NH, resident interaction and fellowship was not stimulated. As a result, we believe, some of the residents did not participate; some showed little interest, while others were disappointed in the limited duration of the activity. When unsatisfied, residents at the Norwegian NH found an alternative in “wandering around,” actively seeking a lively surrounding. The hallway offered a social arena for the unexpected and unstructured, on the residents’ own premises, in contrast to the organized activity. Keeping in mind that residents of NHs often succumb to boredom, caused by the perpetual mundanity of everyday life (Diamond, 1992; Gubrium, 1993; Kayser-Jones, 1981/1990), creating a social arena of unpredictability, when all staff offer is predictability, might therefore be an adequate coping mechanisms for residents. This dynamic is similar to the underlife at the mental institution as described by Goffman (1961), particularly in the form of “secondary adjustments”—the adaptations of members of the institution connected to the inadequacies of what the organization is offering. Agents construct a more or less sovereign space, for play, negotiation, discussion, or even barter, to balance the level of control and supervision they are otherwise accustomed to. Similarly, resident community at the NH can be created without being intended to be so by NH staff, or even in contrast to the preferred approaches of staff.
At the Happy Hour in Canada, meanwhile, residents did not appear to have the same need to create a social underlife. They interacted spontaneously and actively with each other, in part, because they had to—there was no alternative than to depend on one another. They did not need NH staff as intermediaries, as is most often the case, but could control the situation collectively. In contrast to the activity at the Norwegian NH, residents seemed to not only find enjoyment at excitement in the activity but also a form of collective benefit. And this “collective benefit” was, as opposed to the Norwegian example, attainable through “the official life” rather than the underlife of the NH.
While the examples from the respective mealtimes illustrate how the social life of residents is directly influenced by the facilitation of NH staff, the examples from the respective activities signify unanticipated consequences for the social life of residents. At the Norwegian example, residents’ reception of the activity lead to a form of “resistance”; they were not satisfied, and created an underlife of their own, without the interference of staff. The Canadian example, meanwhile, illustrates another form of unintended consequence of the approaches of staff; through an individualistic approach toward activities, residents as a collective benefited.
Collectivism versus individualism
The differences observed between the two NHs can be synthesized, in our opinion, as an individualistic approach (Canada) and collectivistic approach (Norway). What are these relatively homogeneous approaches influenced by? Are they simply influenced by “local” preferences, from leadership, for instance, or by regulations and legislations from their respective jurisdictions? Or, are they somehow conditioned by socio-cultural expressions?
The respective institutions did not convey—officially (through websites or documents provided by the institutions) or unofficially (through interviews with various leaders and other NH staff)—a strategy or a method toward residents’ social needs explaining the relatively significant differences observed. While some staff members at the Canadian NH made anecdotal references pertaining to a preference of giving choice and opportunities to residents (“Having a variety (of food) is a big advantage. Some prefer bread and some prefer cereal, and sometimes it changes”—assisting nurse, Canadian NH speaking about breakfast), they did not convey an official, comprehensive, and commonly shared plan containing such ideas. At the Norwegian NH, neither leadership nor other staff made references to any form of a comprehensive, commonly shared institutional “plan.” Furthermore, the overall legislative and regulatory framework for the two jurisdictions did not seem to influence the respective approaches to resident community and interaction directly. While being different—NHs in Norway are subject to an overarching, national health legislation by being defined as medical facilities (Hauge, 2004), while Canadian facilities must be approved by territorial or provincial departments of social or health services (Harrington et al., 2012)—the overarching framework does not determine, nor does it directly influence, the local practice. National and/or regional guidelines and regulations do not specify, in short, how residents’ social (as opposed to medical) needs should be met.
Although we are wary in generalizing the representability of the labels “individualistic” and “collectivistic”—neither all Norwegian nor all Canadian NHs can be neatly categorized within them (nor are they, respectively, identical)—we still argue that the approaches exhibited by the two NHs can be viewed as cultural expressions (Prieur, 1993). The approaches can be seen, respectively, as cultural expressions alluding to different interpretations and emphases on collectivity and individuality.
Norwegian NHs have a general tendency to be oriented toward strict organizational formats: a proclivity toward organizing everyday life in accordance with the needs of the institution rather than the individual (Ågotnes, 2016), without having this as an official or explicit aim. The mealtime from the included NH is illustrative of such a general tendency. The ideal is to have as many residents as possible attending meals in the living rooms. Most residents attend mealtimes, together. In short, complying with the ideal of eating together is more heavily emphasized than the respective residents’ wishes, as an ideal. In contrast, the Canadian NH did not exhibit the same proclivity toward conformity to the abstract ideal of the NH as governed by patterns and demands of an organized bureaucracy serving the collective, during mealtimes and in general. The individual preferences of residents were given more emphasis, while adherence to the rhythm and structure of the institution was given less.
When seen in the context of the health sector in general, prevalent discourses on “personhood” and “person-centered care” seem to be substantial components of such cultural expressions. Perhaps prevalent discourses on “personhood” and “person-centered care” are prevalent to different degrees, resulting, ultimately, in different adaptations within the everyday life at the NHs? Within our material, mealtimes at the Canadian NH are the clearest example of such an influence, alluding perhaps to how ideas derived from “person-centered care” can become explicit. In this example, residents’ independence and individual adjustments are clearly valued, reflecting a more explicit transference of the neo-liberal governance principles representative for today’s health services in general (Glasdam et al., 2015) to the everyday life at the NH, compared to the Norwegian NH.
Conclusion
Two different general approaches toward residents’ social interaction, represented by the two included NHs, can be found and have profound effects on the social community for residents. The respective approaches, one that emphasizes the collective and the other that emphasizes individual preferences, seem to promote social interaction in different settings. A strict individualistic approach seems to inhibit social interaction among residents, while a collectivistic approach seems to promote it, creating also a space for interaction and community at the mundane institution. Still, the NH residents adapt and resist, creating an underlife of community, when not provided one, illustrating also the unanticipated consequences of the approaches of staff. As seen from the activity in Norway, facilitating for resident community can be a slippery slope: more is not necessarily better.
The two different general approaches observed and described in this article can perhaps be seen as “cultural expressions”; they are certainly conditioned by more than official preferences and recommendations. The difference between the institutions seems connected to how “person-centered care” is understood and consequently how the institutions adapt their practices accordingly. This understanding and adaptation is, however, not an explicit one: the respective NHs did not have an official approach toward “individualism” or “collectivism,” suggesting perhaps a fundamental difference in the overall approaches toward residents in Norwegian and Canadian NHs.
Footnotes
Acknowledgements
The authors would like to thank Penny Bayer for proofreading.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval
The project was granted ethical approval from York University, Ontario, Canada. Informed consent forms were collected before conducting interviews, and the institutions and its residents were anonymized.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article is a result of the authors’ participation in the international research project “Re-imagining Long-Term Residential Care: An International Study of Promising Practices” supported by the Social Sciences and Humanities Research Council of Canada.