Sustaining the Long-Term Care Workforce: An Appreciative Inquiry into the Relational and Generative Factors Driving Staff Retention

Methodology

Appreciative inquiry was selected as the methodological approach for this study. Rooted in action research and organizational development, this approach emphasizes collaborative dialogue and the co-construction of meaning (Bushe, 1995; Cooperrider et al., 1987). Rather than beginning from a deficit orientation, appreciative inquiry invites participants to identify strengths, envision possibilities, and collaboratively develop strategies for improvement within healthcare settings (Hung et al., 2018). This approach aligns with a relational and constructivist ontology, where reality is understood as socially produced through interactions among individuals within specific contexts (Lee, 2012). Knowledge is therefore not a fixed truth, but is continuously shaped through relationships and shared experiences.

This methodological approach was particularly important given that research on workforce retention in LTC homes often focuses on staff burnout. Instead of asking only why workers experience dissatisfaction, appreciative inquiry prompts inquiry into when and why workers feel most motivated and fulfilled at work. This approach helps uncover positive experiences, values, and practices that can inform workplace policies (Havens et al., 2006; Stulz et al., 2021; Trajkovski et al., 2013; Watkins et al., 2016). Our study examines the positive factors that influence the decisions of staff to remain in LTC. Consistent with this stance, the study is guided by a constructivist epistemology, which views knowledge as co-created between researchers and participants (Lee, 2012). Through dialogue, reflection, and storytelling, participants and researchers work together to generate insights about workplace experiences. This perspective is reflected in our use of generative questions and emphasis on collaborative meaning-making throughout the research process. Using appreciative inquiry, we fostered a collaborative and supportive environment that encouraged the co-creation of practices to strengthen staff retention. Generative questions are central to appreciative inquiry because they engage people in creative problem solving and challenge the status quo (Hung et al., 2018). Guided by these principles, we designed interview questions (e.g., “What makes you stay and continue working at [care home’s name]?”) that invited staff to share what supports their decision to stay and to propose new ideas to sustain the LTC workforce. Participation promoted autonomy and empowerment, thereby increasing awareness of alternative approaches and opening opportunities for experiential learning (Hung et al., 2018). Rather than criticism for perceived shortcomings, the process supported critical reflection and change in clinical practice (Hung et al., 2018). This approach aligns with our aim to understand the positive drivers of staff retention in LTC settings.

In addition, we recognize the importance of researcher positionality in shaping the research process. The author team includes individuals with backgrounds in nursing, social work, medicine, health policy and leadership, and clinical practice in LTC and acute care settings. Several team members have direct experience working with older adults and diverse staff in LTC environments, which informed our interest in workforce sustainability. These experiences shaped our sensitivity to team dynamics, workplace culture, and the everyday realities of care work. At the same time, we remained attentive to how our roles and assumptions could influence data interpretation. Consistent with appreciative inquiry, we approached the research process as a collaborative space, where meaning was co-constructed with participants rather than imposed by researchers.

Setting and Participants

The study was conducted in a large, urban LTC home in Vancouver, British Columbia, Canada, purposively selected for its relevance to the research focus. Preliminary consultations with regional clinical partners indicate that the site has a highly stable interdisciplinary team. Notably, several key interdisciplinary staff members have served there for over a decade. This established stability provides an opportunity to explore the drivers of long-term staff retention. The LTC home is not-for-profit with 156 single-occupancy rooms. Convenience sampling was used for recruitment. Local staff leaders sent group emails to invite participants. Inclusion criteria were (1) currently hired in the care home, either full-time, part-time or casual, (2) provided direct care to residents or contributed to the LTC work environment. There were no exclusion criteria. Participants were invited to attend a group or an individual interview at times that accommodated their schedules.

Data Collection

Data were collected by JW and YZ through seven group interviews and one individual interview in May 2025, each lasting 20 to 45 minutes depending on staff availability. Group sizes varied. Interviews were conducted in private meeting rooms within the LTC home. To reduce disruption and facilitate engagement, managers supported staff participation during their scheduled work time, often aligning with break periods. Interview questions were guided by appreciative inquiry principles and designed to illustrate staff reflections on retention. All sessions were audio-recorded and transcribed verbatim. Core questions included:

Data Analysis

We conducted reflexive thematic analysis (Braun & Clarke, 2022) because it aligns with our study aim of understanding how staff make sense of their experiences working in a long‑term care setting and the positive elements that support their retention. Reflexive thematic analysis views experiences and meanings as contextual, relational, and situated, and understands interpretation as a co‑constructed process between researchers and participants. These assumptions align well with our research aim and our team’s beliefs.

Regarding the process, JW and YZ familiarized themselves with the dataset by repeatedly reading the transcripts. Informed by appreciative inquiry, they attended to its principles as they independently generated initial codes. Guided by the principles of reflexive thematic analysis, they engaged in ongoing reflexivity by meeting regularly to discuss their interpretations, ask questions of one another, and challenge each other’s assumptions. Through this iterative process, they refined their preliminary codes and identified patterns across the dataset. These patterns were grouped into categories and developed into initial themes.

JW and YZ presented the preliminary themes to the wider research team, who provided conceptual and contextual feedback according to their lived experience and expertise. Through further discussion, questioning, and reflexive engagement, the themes were refined to enhance coherence and analytic depth.

Study Rigour

An audit trail of analytic decisions, meeting notes and reflexive memos was maintained throughout the study (Onwuegbuzie & Leech, 2007). Credibility was reinforced through collaborative and reflective discussions on coding. Triangulation of perspectives among team members enhanced the robustness of the findings. Team members engaged in reflexive conversations about their positionalities, which might shape their interpretation of the data and dialogues with participants. These reflexive practices enhanced analytic rigour and transparency.

Ethics Approval

The study was approved by the Research Ethics Board at the University of British Columbia. All participants provided written informed consent before participation.

Being Valued as a Whole Person Rather Than Solely as a Worker

Feeling treated as a “person” rather than a worker is a common theme in what works in retaining staff in this care home. Staff felt enjoyment and fulfillment in their work, and that the work’s value aligned with their philosophy of care. Many expressed their love for working with older adults and enhancing their quality of life. A recreation staff said, “What motivates me is wanting the people [older adults] to have the best quality of life. . . I know I did the best I could, and made a difference in somebody’s life.” Many staff also felt fulfilled when their work was meaningful and made a positive impact on residents. A nurse shared, “When your residents have dementia and tend to know your name. . .you get the response that you don’t expect. It’s really fulfilling.” Another recreation staff mentioned, “Helping them. . .turn that kind of pain into something calmer and more peaceful. That means something to me.” One dietary aide further shared how her passion for cooking aligned with her work, “I’ve been here almost 20 years. I enjoy cooking.”

Besides, many participants continued to work in the care home because they felt valued and seen as individuals with intersecting identities, not merely as workers. Some participants mentioned that the staff members at the care home were multicultural and the importance of respect among them. A dietary aide noted, “It’s just like because they’re Filipino, Chinese is all mixed here. We don’t criticize people.” Another nurse echoed, “We respect each other. We have staff from different countries, different cultures.” Staff also recognized and supported the needs of casual staff who worked occasionally but not regularly in the care home. The recreation manager explained,

Sometimes it’s very different for casuals because you’re just coming in and working with residents you haven’t worked with for a couple of weeks. So I think the experience can be quite different for casuals. . . making sure they know what they’re doing, have the information they need, and we, as co-workers, are supportive.

Staff felt heard by the leadership team and could contribute to improvements. One care aide expressed, “We have a suggestion box for our[staff] ideas.” Another care aide shared: “You can go directly to the office and tell them about your problem. You can speak directly to the manager. . .” Similarly, the leadership team emphasized how a non-hierarchical style could support teamwork and value staff input. The dietary manager stated, “Listen to your staff. Don’t be a manager. Be part of the team.”

Furthermore, staff felt appreciated, from receiving ‘thank you’ from the residents, small tokens from family members, to recognition from the community. A care aide shared an example with a family member, “. . . this one family member. . . they treat the whole staff with bubble tea or pizza. Just that small token of appreciation is very appreciated. . . It’s the thought that counts.” Another care aide proudly shared how their work is being recognized in the area, “We are always number one here [in the area]. . . it was in the news. We are very confident to say that!” A recreation staff also commented, “I think we’re doing a good job. [The care home’s name] has a good reputation.”

Collectively, these narratives suggest that identity affirmation operates as a retention mechanism. When staff experience recognition of their cultural backgrounds, personal aspirations, and caregiving values, work becomes integrated with self-concept rather than experienced as transactional labour. In a predominantly female and culturally diverse workforce, such identity-affirming environments may counteract broader structural marginalization of care work. Being treated as a whole person appears to strengthen both emotional commitment and organizational attachment.

Experiencing Relational Belonging Through Team Cohesion and Family-Like Connections With Residents and Colleagues

Staff from various disciplines shared how much they valued teamwork and highlighted the benefits of fostering a strong bond within the care home, among workers, family members and residents. A care staff mentioned how teamwork lightened their workload and encouraged them to continue working there: “Sometimes it can be stressful, but when your coworker is there, it brightens up.” Another care aide elaborated on how they supported each other:

We [Staff] are united here. We look after each other. . . If somebody needs help, we assist. We don’t say, ‘Oh, this is my job. That’s yours.’” Another dietary aide reflected on teamwork during an emergency involving flooding and a power outage: “We called everybody for help. If there is a flood, everybody has to move and clean the mess. We are one team.”

Beyond a well-functioning team, staff mentioned the family-like feeling and joy from these connections as reasons they stayed. One nurse said, “I’m an LPN working in a special care unit for 12 to 13 years. It seems like it’s family. We are working together.” A care aide expressed how she was attached to other colleagues as family members, “I found the sisters here because I’m the only daughter in the family. I have so many sisters here. . . it’s fun working.” Many staff experienced joy with colleagues. A casual dietary aide stated, “Sometimes we are spreading the joy. When I come into [the care home], my colleagues smile and say, ‘Hi’. I’m a casual [worker], I’m so enjoying.” The relationships were also strengthened through social events initiated by staff and leadership teams, as well as through food and small talk during breaks. Another care aide emphasized, “Best moment when I go on my break, and I talk to the ladies and talk about travel.”

Staff also valued the intergenerational relationships with residents, in which their care went beyond the “staff and clients” relationship. A care aide shared that the emotional attachment she had with residents:

Residents, I love them. Especially during pandemic time, you get attached to them. . . I remember when I had a resident who died, but I cried so much. [Residents are] Just like our own [family members]. I think everyone [every staff], we give all our best [to care for them].

Another care aide saw the residents as her mother and grandmother. She said, “I took care of my mom and my grandmother before, so it feels like I’m taking care of my family too.”

The recurring metaphor of “family” illustrates how relational continuity functions as emotional infrastructure within LTC. These bonds foster belonging and mutual accountability, buffering stress during crises. However, such closeness also suggests the emotional intensity of long-term caregiving, particularly in contexts of resident decline and death. The family-like culture thus operates simultaneously as a source of resilience and emotional vulnerability, underscoring the need for institutional bereavement supports.

Working Within a Supportive Organizational Environment That Fosters Flexibility, Autonomy, and Career Development

This theme encompasses a supportive physical and organizational environment and career development. Some staff highlighted the importance of a comfortable working environment. A care aide compared this care home with another one: “It’s very clean because I work somewhere else too. This place is clean, maintenance is good too.” The convenience provided by the LTC home, including its location and flexible working schedules, was also valued by staff, supporting family responsibilities and childcare. One care aide said, “This place is close to home.” Another care aide expressed, “The work schedule matches my kids’ schedule.” One recreation staff resonated, “I had a family and that kind of thing. So I like the balance that here provides me.” Financial security was another factor influencing staff decisions to stay at the LTC home. One care aide said, “Because it’s [my role’s] unionized, there’s one rate. In private [homes], it’s a lower rate.” The director of care expressed, “I’m a mom, so I have to look for something that provides good benefits, right?”

Some care staff mentioned challenges with workload and the fast-paced workflow. A staff shared her enjoyment in this environment: “I like working in a fast-paced environment. I like to keep myself busy. I think the time goes by really fast if it’s like busy.” The recreation manager noted that having control over their work and the ability to make decisions contributed to their job satisfaction: “What keeps me here. . .I have control over my work. I have the ability to try and incorporate new things.” At the same time, both care and allied health staff expressed a preference for additional staffing support for the current workload. The dietitian shared the perspective of a few allied health staff in the care home: “Being the only dietitian. . .It would be nice if there were two of us here regularly. . .It’s one person to deal with the whole 150 residents.”

The inspiration and support for career growth also retain staff in the care home. A former dietary aide shared her career journey to becoming a care aide: “I was a dietary care aide before. Seeing how the other staff worked here, I decided to study to be a care aide. And I applied back here. . . I am a living proof [of career development].” Staff also mentioned how the management team supported educational leaves and encouraged care aides to pursue nursing. Furthermore, staff appreciated the regular education sessions on the latest protocols, which increased their confidence in the care they provided. One care aide shared, “They sometimes give us educational services, so you’re more knowledgeable in the work that you’re doing.” However, the dietitian recognized the opportunities for extra training and support for allied health training:

I feel like nursing and the care aides are the ones that get the in-service because they are the majority. . . But I [as a dietitian] don’t really get any extra training being here, like I’m kind of expected to bring my own training. . . If there were additional opportunities to further develop my skills, that would be great.

These findings indicate that structural supports, such as unionized wages, flexible scheduling, autonomy, and internal career mobility, interact with relational culture to sustain retention. While meaning and belonging are central, they are reinforced by tangible organizational conditions. Workforce sustainability, therefore, emerges not from culture alone, but from the alignment of relational, material, and professional development structures.

Implications

To help clinical, policy, and research partners and advocates co-construct and strengthen staff retention and foster sustainable and generative work environments in LTC, we have summarized our learnings from diverse staff into the C.A.R.E. model: C ultivate, A mplify, ensure R esources, and E mpower the LTC workforce. To achieve C — C ultivate community, leadership teams and staff can value colleagues and staff as unique individuals rather than only “workers,” and recognize the often-overlooked relational pieces that hold these diverse individuals together. LTC workplace can encourage practices and opportunities, such as peer support and social events, to help affirm staff’s individual and shared identities and passions. To A — A mplify the positive core of LTC homes, clinical teams and researchers can consider regularly examining positive practices and moving beyond just addressing deficits in the workforce. By engaging with diverse staff, whether frontline or administrative staff, leadership teams, researchers and policymakers can understand what good practices can be leveraged and amplified. Our research uses appreciative inquiry as one of the explorative approaches, and we hope our study and interview questions can serve as an example to guide or inspire others seeking to surface more positive aspects of their LTC workforce. For example, the questions can be further expanded to other relevant studies or even integrated into regular evaluation events within LTC. To increase R — R esources for growth and inclusivity, a safe, comfortable working environment that offers a stable income for staff is a necessity. Equally important is creating an environment that supports staff in exercising professional autonomy in their roles, encourages educational opportunities, and fosters internal career mobility. Lastly, it is essential to E — E mpower through equity and diverse voices, and continue to offer opportunities for diverse staff, not just specific roles and individuals, to share their opinions and fairly address or showcase them in research and practice.

Strengths and Limitations

A key strength is the use of appreciative inquiry, which focuses on the positive, sustaining aspects of the workplace that are often overlooked. The diverse, interdisciplinary sample from a high retention site strengthens the credibility of the findings. However, the study was conducted in a single high-performing urban LTC home in Vancouver, which may limit transferability to other settings. In addition, the purposive convenience sample may have introduced self-selection bias, and the cross-sectional design captures views at a single point in time. Therefore, the focus on positive experiences may mean that ongoing systemic challenges might not be fully examined in this paper.