Negotiated risk and resident autonomy: Frontline care staff perspectives on culture change in long term care in Nova Scotia,Canada

Abstract

BACKGROUND: Regulating risk, freedom of action, and autonomy in decision making are problems shared by both caregivers and residents in long term care settings, and may become the subject of tension and constant negotiation.

OBJECTIVE: This study focuses on long term care staff and management perceptions of day to day life in a care community which has gone through a culture change transition, where small residentially scaled households replace large instutional models of care. In each household, the setting is considered to be home for the 8–12 residents, creating a major shift of roles for the caregivers; they are, in essence, coming into a home rather than institutional environment as a place of work. This potentially changes the dynamics of both patterns of work for caregivers and patterns of daily living for residents.

METHODS: Participant observations and care staff interviews.

RESULTS: Several key themes emrged which include: teamwork; the culture of care; regulating risk; the physical environment and care staff empowerment.

CONCLUSIONS: An unexpected outcome was the consensus among care staff that it is they who feel at home while working in the care households, leading to empowerment in their work roles and a deeper understanding of the importance of their role in the lives of the residents.

Keywords

Person-centered care small house model skilled nursing facility

1 Background

The design of the physical environment in long term care (LTC) facilities has been shown to have substantial effects on resident patterns of social behavior, and it is widely recognized that social and physical environments can profoundly influence quality of life of older adults [1 –3]. Past research has sought to understand the core needs of individuals in continuing care settings and investigated how aspects of the physical and social environments can best meet those needs [4, 5]. Mirowsky [6] writes that residents in care facilities who feel their environment is responsive to their efforts, choices, and actions tend to enjoy better health than older adults who believe their lives are shaped by forces outside their influence.

There is little argument that long term care organizations are facing a range of daunting environmental changes and challenges [7], and internationally there is a long history of efforts to improve quality of care and life in nursing homes [8]. One challenge in these communities is to provide residents appropriate settings for social interaction in order to buffer against social isolation, as well as an environment which encourages autonomy and proactive responses to changes in competencies [9]. Autonomy can be a problem not only because institutions limit the freedom of frail elders, but because the existential conditions that create the need for LTC rail against the autonomy of independent self-sufficiency [10]. While individuals who seek LTC share three distinct needs; housing, assistance with activities of daily living (ADLs) and chronic disease management [11], institutional settings of the past have been characterized by social distance between residents and staff, with the requirements of organization routines trumping personal preference and choice issues [12].

Internationally, LTC organizations are adopting a new paradigm for care, which is part of a culture change that accepts person-centered care as the guiding or defining standard of practice. Typically, this culture change movement is descriptive of multifactorial interventions comprised of elements of significant environmental enhancement through residentially scaled settings; leadership and management changes; and staffing models focused on staff empowerment [13]. The culture change movement advocates for a less hierarchical structure, encouraging residents and frontline staff to be more involved in the decisions that affect them [14].

Various health authorities across the United States and Canada are embracing these concepts and are attempting to implement changes in care facilities which are being built or adapted, based on what is variously called a “cottage,” “household”, or “small house” model, where no more than 10–14 residents live in one residentially scaled dwelling unit. A key feature to this approach is the encouragement of relationship building between and among residents, families and staff. The more familiar staff are with residents, the better they can understand the person and their individual unique needs [15]. These households may be stand-alone structures similar to a single family residence, or more typically, several of these units are attached to a central administrative core in a large building.

Another key component in culture change is the decentralized care staff which are empowered to better meet the needs of residents in the households [16]. This approach to the provision of care has moved from a highly scheduled approach, to a flexible, resident-centered approach based on the activities of daily living. Staffing patterns have changed from task-specific, with considerable rotation, to multi-skilled, with deliberate continuity of universal staff which carry out cooking, cleaning, and resident care within the small resident households. A general staffing goal within the culture change model is to have staff teams always work with the same group of residents [17], creating strong reciprocal relationships between themselves and the residents [18].

Resident-centered care has been embraced by practitioners across the United States and Canada, and yet challenges remain to its implementation in the front lines. Because care recipients and care providers are locally situated at the intersection of domestic and healthcare worlds in these settings, they may participate in confused relations of social and occupational emplacement [19]. With expanded autonomy and choices for the residents, some care staff also see expanded risk of illness or injury. Regulating risk, freedom of action, and autonomy in decision making become problems shared by both caregivers and residents, therefore becoming the subject of tensions and constant negotiation.

The Province of Nova Scotia, Canada has built 11 new LTC facilities to support the vision of “living well in a place you can call home” [15]. A key feature within the guidelines is that the new facilities have been built in the model of small households, in a building conjoined by offices and community spaces. Within these facilities, 4 households each have a living room, dining room, residentially scaled kitchen, and private resident bedrooms. In addition, implementation of culture change and person-centered care in which residents are given choices in the daily activities are operational requirements. Through site observations and care staff and management interviews, this study focuses on the working relationships and care staff perceptions of their role in the regulation of resident risk and autonomy in one of the new Canadian care settings adopting the culture change model.

2 Daily routines in the physical environment

When moved into LTC, a frail elder becomes dependent to others in a way that is atypical for most normal adults. These clinical needs can lead to experiences of loss of hope and mistrust, while accommodating the incapacity and the dependence on caregivers [20]. Multiple studies [21 –23] have focused on the history of this institutional culture of nursing homes. In these studies, it is evident that the physical environment and daily routines in a traditional nursing home are designed to serve the needs of the staff and the fiscal “bottom line”. Large dining rooms in traditional settings make it easier for staff to serve meals to all residents at regimented times; wheeling the medication cart to the dining room three times a day is perceived to be less labor intensive than walking to each resident’s room to administer medications; offering only one meal choice without regard for personal preferences; and so forth [24].

The objective of the reorganization of the LTC systems in culture change is to break down both the physical and social environments into units where residents may achieve a greater degree of autonomy and control over their day [25]. The model creates a new set of distinctions between care staff public workspace and resident private domains and the transitions and divisions between these domains [26]. For a caregiver in the traditional medical model of care, while the private or semiprivate resident bedroom or apartment was considered the residents’ private domain, the rest of the facility including the corridors, dining areas, and nurses’ station were considered a part of the caregivers work environment. In a SH setting, each cottage is considered home for the residents, creating a major shift of roles for the caregivers. They are, in essence, coming into a private domain, rather than an institution, as a place of work, therefore altering the dynamics of both patterns of work for caregivers and patterns of living for residents [16].

3 Choice, risk and autonomy

While caring is an activity fraught with conflicts and ambiguities [27], for a caregiver, resident habits and routine movements are managed on the basis of ensuring their safety and protection. In LTC, residents are at home, and staff are at work, inherently implying differing participant goals. Each world provides its participants with a way of looking at and understanding daily life. The resident may have the perspective that ‘this is my home, I may do as I please’ and the caregivers may have the perspective that ‘this is where I work, you are my responsibility’. Therefore, within the culture change model, the logic of home, its social relations and structures continue to be linked with relations of power, inclusion, and exclusion in the organizational aspects of caregiving and resident autonomy [16].

Ideally, an opportunity for choice that enhances autonomy is a choice that is meaningful for individuals and allows them to express and develop their own individuality. This suggests that caregivers and managers must be attuned more thoroughly to the question of the meaningfulness of choices actually afforded residents under their care [10]. In LTC, some resident actions and choices reflect habit, therefore the picture of actual autonomy is more like a complex collage than a schematic or line drawing. It is a picture rich with detail that is experientially established and grounded because choice is always contextual, and for each individual, there are consequences associated with any choice [10].

4 Research needs

Currently there is a fair amount of literature on the scale, layout, and configuration of communities which have gone through culture change [2 , 28], though Calkins [29] writes that there is still much that is not known about the model of care. What is often missing is an evaluation of how well the organizational structure of person-centered care in the setting actually achieves the hypotheses of the model. Designers and providers often believe that configuring the environmental features in a certain way will lead to a certain set of outcomes for residents, yet less is known about the outcomes for the caregivers who work there. In particular, little is known if there are differences the person-centered care perspectives among the formal caregiver groups (i.e. RNs, CNAs).

In 2008, Rahman & Schnelle [17] took a retrospective approach to the critique of the research base underlying the nursing home culture change movement. The context was to propose research agendas aimed at strengthening the movement’s empirical base, thereby facilitating culture-change interventions, as well as helping the movement navigate the next steps in its evolution. Casper, O’Rourke and Gutman [30] studied the statistical significance of the impact of structural empowerment in allowing for provision of individualized care for LTC residents. Sharkey,Hudak, Horn, James & Howes [31] have studied the differences in overall staffing hours per resident day in culture change homes and traditional skilled nursing care, determining that staffing efficiencies could be achieved in the small house model.

Other studies which have been conducted in nursing facilities which have gone through culture change have addressed the complex relationships which have emerged between resident perceived self-care ability and functional performance. Molony, Miller, Jung, Stern, Clark & Mor [32] addressed a meta-synthesis of the meaning of home and write that the SH setting is both a place-based experience and a process of person-environment integration. Achieving this meaningful experience of choice, mastery, refuge, relationship, and self-reconciliation involves a relationship with dynamic interaction within and between the intrapersonal, interpersonal, physical, and transpersonal environment for staff and residents. In their 2011 study of LTC residents who moved to a household model, the environment was described by the residents as “normal”, “more relaxed”, and “more private” [32].

Despite this past research, there is still little known about the effects of small-scale and homelike environments on residents, family, and caregivers [33], with little written about the relationships between care staff and resident shared perceptions of risk and autonomy in these settings. Therefore the research questions related to this study include:

. How do the changes in the configuration and the organizational structure of the household setting impact the care staff’s ability to allow residents choice and autonomy in their daily activities? Is there a consensus amongst care staff around the functional performance of new philosophy of care?

. In what ways are care staff adjusting their work schedule and patterns to accommodate resident autonomy in the households?

. What are the resident outcomes in the physical environment in the small house model? Have resident social patterns been altered by the changes in the social and physical model of care, changing care staff responsibilities?

5 Research design and methods

5.1 The study site

The study site for this research was located outside of Halifax, the capitol of Nova Scotia, Canada. The study site, Stonebridge Continuing Care Center (a pseudonym, as are all names of study participants), was built for 50 residents and opened in 2009 as one of the first of 11 new communities built by the province in the culture change model. Within the two-story building, there are four self-contained cottages, each for 12 residents. The cottages are named for better recognition by staff and residents as Birch, Cypress, Willow and Alderwood. Every cottage has a living room, dining room, and residentially scaled open kitchen, and all resident rooms are private. There is central lobby with amenities like a community center, offices and storage (see Figs. 1–6).

5.2 The case study

This research was conducted as a qualitative case study, using multiple sources in data collection to provide an in-depth picture of the daily life and social patterns at Stonebridge. The case study is an opportunity to understand how the people being studied see things and it evolves in time, often as string of concrete and interrelated events that occur at such a time, in such a place [34]. This study was conducted for approximately eight weeks and the outcomes of provincial guidelines for the culture change model applied at Stonebridge were addressed, exposing the multiple themes behind creating system-wide change in a culture of care in the province of Nova Scotia.

5.3 Data collection

In many qualitative studies, inquirers collect multiple forms of data and spend a considerable amount of time in the natural setting [35]. In this study, the principle methods of data collection were participant observation, pre-arranged staff interviews, as well as interviews with the facility administrators. There was also a gathering of information from the legislative documents of the 2006 CCS and the provider archives.

5.3.1 Interviews

Twelve Stonebridge staff members were interviewed to gain their perspective into negotiated risk and resident autonomy. These staff members included the Director of Care, the Activity Director, and eight frontline Continuing Care Assistants (CCAs) from the four households, and two community Registered Nurses (RNs). All interviews were pre-arranged and prior to commencing the interviews, participants received an information sheet and consent form. Interviews were audio-taped and lasted approximately 30–45 minutes. An interview protocol was used, beginning with general questions and followed by subsequent probing questions that asked individuals to explain their ideas in more detail. The interviews were then transcribed at a later date.

5.3.2 Observations

Qualitative observations are those in which the researcher takes field notes on the behavior and activities of individuals at a particular research site in an unstructured or semi-structured way [35]. The observations in this study were focused primarily on resident and care daily, using an observation protocol which included sections for descriptions of the physical setting, accounts of a particular event or activity, description of the physical settings and reconstruction of dialogue [35].

5.4 Data analysis

After the initial interviews were transcribed, they were assessed along with the observational field notes leading to a fracturing or rearranging of the data into categories which aided in the development of theoretical concepts [36]. Thematic analysis can be conducted using deductive or inductive focus on theme development [37]. For this study, an inductive process of building broad study themes for the data was used, which allowed the opportunity to look for broad patterns to create themes or categories [36]. Achieving intimate familiarity with the studied phenomenon is a prerequisite to this type of analysis, and such familiarity not only includes an in-depth knowledge of the people connected with the phenomenon, but also a level of understanding that pierces their experience [38]. In this study, a detailed analysis of themes was developed in order to assign meaning to the data compiled, with reoccurring themes inductively interconnected to describe the social and physical environment at Stonebridge.

6 Study findings

The thematic analysis of staff interviews and participant obersevations revelaed how both the physical layout of Stonbirdge, as well as the organizational culture of care impacted the care staff relationships with the residents, particularly with respect of negotiatied risk and residents autonomy (see Table 1). The five themes which emerged became: (1) teamwork (2) the culture of care (3) regulating risk (4) the physical environment and (5) staff empowerment.

7 Teamwork

Stonebridge opened in July of 2009, fully staffed. The four cottages are divided with two on the main level and two on the upper level. Willow, the Alzheimer’s cottage, and Cypress are on the lower level; and Alderwood and Birch are on the upper level. The caregiving goal in the model is for the resident needs to be the central focus, and hands-on care providers are trained and given responsibility for the multiple roles in the daily care of both the physical and emotional needs of the residents. This may be accomplished with the reduction of middle management in the existing staff hierarchy empowering CCAs with a new set of responsibilities which can run antithetical to the prevailing organizational culture [26]. Each cottage has had to formulate bonds of trust between the CCAs, and with those bonds, come a sense of ownership of the team and the work setting. A Willow CCA sees the power of care staff teamwork in the community:

We have a good team here, not just to say that. This cottage is the best for helping each other; management will tell you that, it’s true. More people will come in and help each other out than any of the other cottages. We know what the other’s strengths and weaknesses are. We know, say if I’m not so good at doing that, then someone else will come in and do it and I’ll go do something else.

Her co-worker agrees, but points out the all members of the team need to be on the same page. “I just think we’ve got a good bunch of workers here, that’s what makes it the best, that’s my opinion. You can have as much flexibility as you need, but if people aren’t willing to switch and people aren’t willing to help be a team, it doesn’t work.” A Birch CCA compares the cottage to the home care she had done in the past:

I like this better than home care, I like being in the same spot every day. I like routine. Being here, being in the same cottage and knowing the residents as well as I do and my co-workers as well as I do, and having the consistency. I like being able to count on someone else at any time.

Caregivers trade off on meal preparation duties, and scheduling is customized to the resident and staff needs in each cottage. The goal of this organizational model is to create an environment similar to a residence, where all staff and residents are well acquainted with each other.

8 The culture of care

Multiple studies have focused on the institutional culture of nursing homes [10 , 39] and how the daily routines in the traditional institutional nursing homes are designed to serve the needs of the staff rather than those of the residents. Many of the Stonebridge CCAs interviewed for this study had stories about their previous work routines in institutional settings and a Birch CCA describes her routine when she worked at another traditional nursing home:

At the other place I worked, it was one of the hardest things that I’ve done. It was the people, the amount of work, it was a lot. They have that set amount eight or nine people and I had to get them up. It was just go, go, go. You didn’t get to spend any time with the residents at all, you hardly know them. We called them by their room number, not even their names, because you had this eight people today, but then the next day you had eight other people, you never got to know anyone.

One of the most difficult things for the CCAs in their previous work settings was caring for residents in a way that they knew in their heart was ethically wrong. A Willow CCA describes how the culture of care in her previous education and work environments ran antithetical to her desire to be a caregiver:

Here, you get so close with the residents, you can’t help it, here we’ve learned that it’s OK to get close to them. What we were taught in school is “No, no, no, don’t be like that.” In school, it’s was like, “Do your work and go home” kind of thing, that’s what I was taught, that I wasn’t allowed to care.” If you care, then you care too much,” that’s what I was told. I was like “Then why am I a CCA then? Because I care!”

8.1 Resident choice

For the Stonebridge CCAs, allowing residents a choice in their day to day activities is a primary benefit to culture of care, and many saw the restrictiveness in the policies in previous care locations (see Table 2). The more control residents have over the timing of going to bed, getting up in the morning, the nature of meals and the way they spend their time may define the individual’s level of autonomy or choice in the environment [40]. Not only is tolerance of diversity of choice and taste a prerequisite for respecting liberty, but so is acknowledging the irreducible individuality of concrete expressions of autonomy in individuals [10]. A Cypress CCA describes how difficult it was for her in her in past nursing setting when she had to get residents up early in the morning:

I just couldn’t do it, there were some residents, if they didn’t want to get up, I didn’t have the heart to make them. I figured, they worked their whole life, this is for them, what’s the rush? If they want to sleep in, let them sleep in. When you take something as minor as that, when you take that choice away from them, whatever time they want to wake up, it makes a big difference to them.

Another Cypress CCA explains the importance of choice for residents at Stonebridge, “They have choice, they have their autonomy, it’s very open. There are rules and guidelines in place, but still at the end of the day, it’s their choice. They are still an individual, they don’t lose that.” She goes on to describe why letting each resident be who they are is so important at Stonebridge, “This is their home, just because they are 89 years old doesn’t mean they don’t know that they want anymore. They are more of a person than I am; they have so much more experience. They are entitled to do whatever they want.”

The Director of Care at Stonebridge agrees. Her experiences working for many years in traditional nursing facilities has led her to the conclusion that residents should be allowed these small choices in their day, “It’s OK if somebody doesn’t want to have breakfast and they skip a meal, it’s OK if they don’t want to get out of bed, and they say, ‘I’m staying in my pajamas all day.’ It’s just fine that we don’t have to go pick out the blue outfit for them today.” While there is consensus amongst the management and CCAs about the importance of choice for residents, the RNs at Ridgemont have a much more conflicted perception of their caregiving roles.

9 Regulating risk

In any LTC setting, regulating risk, freedom of action, and autonomy in decision making is sometimes the subject of tensions and constant negotiation [41]. Parker, Barnes, Mckee, Morgan, Torrington & Tregenza [42] write that caregiving and control practices are connected in such a way that it is difficult to extricate one from the other. The regulation of boundaries is two-fold: the resident is intent on retaining control and in order for that to happen, there is an important point where the caregiver needs to step back from the role of deploying discipline over the resident and their body [42].

Risk is related to concepts of danger, yet simultaneously related to the opportunity to gain benefits precisely in those situations in which harm is also possible [43]. The central problem regarding resident choice and autonomy, as described by Radar [44] states that behavior and lifestyle choices may have been contributed to the need for this level of care. A RN at Stonebridge explains this distinction:

It’s the whole thing about looking at it from the nursing perspective. It’s one thing to look at the individual; this is their home, this is what they want to do. But when I look at it from a nursing perspective, what the people are doing is not necessarily best for their health. To sleep in till 1 in the afternoon or skip meals when you are a diabetic, if you look at it from the nursing perspective, it’s not the best thing to do. But then you have to look at this care philosophy, if that’s what they want to do, that’s what they want to do.

Another RN did her clinical internship at a hospital within a strictly regimented model of care and has strong feelings about the push and pull between the caregiver goals and the resident goals at Stonebridge:

We’re here to give out pills and assess things and we’re supposed to go on how the resident wants it. Whereas in the hospital, we know at this time, this is what’s happening. That’s the biggest thing that I had to get used to in this job, it’s flexible here in that way. It’s just very different from how I’ve been trained for the last four years where we had specific times to get things done.

She goes on to point out that there is a fine line between telling someone what they have to do versus suggesting what might be best for their overall health. The conflict between resident/caregiver roles becomes very apparent when an individual vocalizes their desire for autonomy in a situation. The RN describes tension when residents at Stonebridge overtly override her suggestions in order to express their desire to live by their personal preferences, rather than what is best for their health, “We even have some residents who we’ll give them suggestions, right? And they’ll look at us straight in the face and say, “I’m not going to do that, if I were at home I wouldn’t do that”. So, it kind of makes nursing, where we are trying to look out for their health, a little difficult.” She goes on to ask the central question around the culture of care in the SH model, “How are you supposed to deal with that, still go by the person-centered philosophy, and at the same time have your nursing coincide? Their (resident) choices might have been part of their health issues, which might be why they are here to begin with.”

The Activity Director agrees that there is a fine line between telling someone what they have to do, versus suggesting what might be best for their overall health. She invites residents to many of her scheduled activities and describes a recent incident at Stonebridge when a resident had almost died as a result of eating a special dinner with his wife:

George has been in the hospital, he has severe pooling in his lungs, and he’s been on a feeding tube for years. His only goal in life is to eat, so we’ve had care conferences with his family and made these decisions. He would have a snack twice a day that was the consistency of pudding and then he would eat once a month with us at supper club. The whole thing with aspiration and pneumonia comes into play, that’s what happened just a couple months ago, he ate Christmas dinner with his wife for the first time in three years, that was so exciting because she loves him so much, but he almost died in the days following. The things that he wants to do are contributing to his illness. That’s the thing here, we can’t tell you what to do, but we can help you with your decisions.

10 The physical environment

In any setting, the physical environment is meaningful because, within it, we directly experience environmental connections, meaningful events, meaningful places, and social actions [45]. In the case of the LTC environment, the setting becomes home and community, and the relationships and social interactions which take place on a daily basis are critical to individual coping capabilities [46].

10.1 Staff and management communication

Due to the household layout of the Stonebridge community, there is no central nurses’ station, which often leads to a breakdown in communication between the RNs, CCAs, and the management. Care staff have small nurse’s charting areas integrated into the household kitchens. The Activity Director, Noreen, describes the conflict around staff communication in the new model:

The relaxed environment is both the best and the worst thing here. The management doesn’t micro manage you, nobody is breathing down your neck, that’s great. But that also is the worst thing about it, because communication is sometimes an issue. Staff sometimes feels like the management don’t care because they’re never here, and sometimes it feels like they don’t know what’s going on.

A CCA from Alderwood has a similar perspective about the communication issues between staff and management, and shares the fact that communication is probably the number one problem in her job at Stonebridge:

The worst thing about this (job) from my own experience would probably be communication, but I don’t know. The management is not here all of the time and they do travel from place to place. It’s hard to get answers sometimes.

10.1.1 Night-time staff shortages

There are other factors relating to the physical environment at Stonebridge which impact staffing needs, particularly in the evening. The staffing ratios for all of the new LTC communities are set by the province, and in the evenings there is one RN and one Licensed Practitional Nurse (LPN) on duty for the entire community, and one CCA in each household. Many of the CCAs agree that there are staff shortages at night, particularly if there is an emergency like a resident falls or passes away. Even on a normal night, the demands of looking after that many residents can be too much for one person. A CNA working in the Birch household describes the problem as she sees it:

There’s only one RN at night time, one person on this cottage, one person on the other three. It’s difficult when something happens, like when a resident has passed at night. So if the RN is now occupied with that resident, the other three cottages don’t have a nurse. If there’s a fall, which I’ve had on mine, a resident fell and broke her hip; they had to call the paramedics to come take her. And some nights, like my last night shift, at 1 o’ clock in the morning, I had six residents wide awake wandering around. You need help. So that’s the one major thing I would say, we need an extra RN here at nights. Basically what happens is if we are short, the CCA will sit in the middle by the elevator so they can watch both cottages. Yeah, it can be quite hectic.

11 Staff empowerment

While the care staff have clear voices about the benefits and drawbacks of the new care model at Stonebridge, they feel that residents are not particularly aware of the changes in the way care is given in the new setting. While residents may not have a specific understanding of the philosophy behind the model of care, the care staff do feel that the residents have a connection to the staff and to other residents living in the households due to both the organization and physical environment. They see that residents have concern for each other and a Cypress CCA discusses the comfort level of the residents in her cottage:

This is very much like a home for them, not like the other ones like Oakdale and Ridgemont, where it’s more hospital style. Where here, it’s like a home, they have their dining room, kitchen, the living room. They have their personal bedrooms that they don’t have to share with anyone else; they have their bathrooms they don’t have to share with anyone else. So, this is what I think a nursing home should be like.

More broadly, there is a general consensus amongst the CCAs that it is they, the care staff, who truly feel at home when they walk through the door of their cottage to come to work. They spend so much time in the cottages, taking ownership and responsibility for all aspects of the physical and organizational environment, that often they feel they are coming into their own home to work. A Birch household CCA expresses her sentiment about her work setting:

Actually, I feel like I’m coming into my home. Like when I worked at that other new facility, I just didn’t feel like home there. Here, I feel like I’m home. I honestly feel that I could live here at any time.

Another CCA agrees, “It feels like home, definitely. Yeah, in the morning, when somebody’s frying bacon and doing scrambled eggs, it’s just like at home.”

At Stonebridge, the intersection of domestic and caregiving worlds have led to mixed outcomes for care staff in their new role as universal workers. Yet despite some care staff perceptions of conflict, communication and ambiguity in the regulation of risk for residents, the culture of care in the new settings allow care staff empowerment in the work environment. With a strong philosophy and residentially scaled environment, care staff now have the opportunity to develop a focused understanding of the positive outcomes of their daily work.

12 Discussion

The successes and failures in any LTC setting are the result of the relationships created within that setting or the value within the walls. Through the three research questions, the findings of this study have revealed that the physical, as well as organizational environment at Stonebridge has impacted staff relationships with residents in multiple ways. The first research questions asked how the culture change model has impacted care staff’s ability to allow residents choice and autonomy in their daily activities. Is there consensus amongst care staff around the functional performance of this philosophy of care? For the care staff at Stonebridge, gone are the conflicted days when staff called the residents by their room number, or wheeled them into a large dining room at 8 am. The philosophy of care, as well as the physical environment has allowed the staff to relate to the residents in a way that in their heart they know is ethically correct. There are highly motivated teams working in each of the cottages, with shared goals of consistency and a person-centered approach to the care that they give. Tensions do exist relating to the delicate balance of risk and autonomy at the intersection of domestic and healthcare worlds. In particular, while the RN understands the philosophy of choice in person centered care, due to her medical training, she is also acutely aware of the risk in allowing a resident to do as they please with respect to health and medication issues. This philosophical debate between allowing residents autonomy and choice in their daily lives, and the resulting health implications, reflects back to the entanglement of the logics of space introduced in the opening paragraphs of this paper.

The second research question asked for the ways in which care staff are accommodating resident autonomy in the household settings. The findings reveal that care staff are determined to follow the principles of the philosophy of care, letting residents make choices about when and what to eat, when to get up, and when to take showers. These resident choices do make an impact of the care staff workloads, and in some cases, cause nursing shortages, though the care staff compensate the best that they can through team work and sharing of responsibilities.

Finally, question three asked what the resident outcomes are in the culture change model and if their social patterns been altered by changes in the social and physical model of care. Care staff report that residents, while unable to fully comprehend the philosophical changes behind model, are benefiting from the model due to their private bedrooms, strong relationships between staff and other residents and the opportunity to follow their individual daily patterns creating a sense of normalcy in the residentialsetting.

13 Conclusion

Through care staff perspectives and participant observations, the goal of this research has been to provide insight in the research questions, as well as provide new areas for future study in the development of culture change models Because of the self-selection bias and retrospective nature of this research, however, the findings are not generalizable to the wider population.

As the design of culture change models become more commonplace, some important questions remain regarding strategies for improvement of the model. Though there continue to be breakdowns in staff communication and confused semantics about resident choice, risk and autonomy, these issues will be worked as the culture change model grows from evidence-based practices, rather than debated in the black hole of conjecture and unknowns. This strengthens the argument to continue to study this model of care, so that future models may better address the distinctions between negotiated risk and a model of care which puts the resident’s need for autonomy first.

Finally, as future LTC planners and designers strive to promote functional autonomy and freedom of action in the lives of LTC residents, sickness will continue to place limits on the scope of meaningful action [10]. Despite the higher levels of choice and autonomy for residents at Stonebridge, there are no silver bullets; the truth of the matter is that life will never be as it used to be for these individuals. Yet it is a mistake to think that caring for older adults can involve only saving or preserving some remnant trace of past self [10]. For the individual resident, there is necessity to redefine their personal identity, allowing their former selves to change as their bodies and life situations have [47]. Expectations for resident outcomes in the culture change model can then be aligned with a new bar of success, reflective of the seamlessness of each resident’s integration into their new setting. This does not mean physically doing all of the things that they used to do, it means living in a setting where there is freedom to be the person who did those things, an individual with individual abilities, needs and preferences. The care staff at Stonebridge are moving toward an understanding of this dynamic complexity, as their work role evolves into a new empowered status in the lives of theresidents.

Conflict of interest

The author has no conflict of interest to report.

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