Relationships in Care Homes

Can they really make a difference to quality of care?

W

e often hear the importance of independence when providing care and support or frail older people. Within the literature the voices of older people are suggesting the importance of reciprocity and mutual exchange in social relationships. The research I have undertaken within care homes certainly suggests that care and support occurs within the context of a relationship, which is very important to older people, their families and staff (Brown Wilson et al, 2009). Indeed, relationships are integral to living, visiting and working within a care home. The aim of this presentation is to discuss how relationships are influenced by the approach to care that staff adopt (Brown Wilson and Davies, 2009). This was qualitative research undertaken across there care homes in one geographical location in England. The research involved the perspective of older people who lived in care homes, their families and direct care staff. Three approaches to care were observed and described by all participants across the three homes. A representation of each of these approaches is provided in the accompanying powerpoint presentation.

Individualised task centred

This approach focused on the task of care and tended to develop more pragmatic relationships. This approach was observed with new members of staff, when residents were newly admitted to the care home, or if they were short staffed. Some members of staff felt this was the most effective way to give the best care. Efforts were made to understand individual needs but the focus remained on getting the job done favouring the staff experience. Residents and families understood this focus but also described situations where they had to wait in discomfort until staff had time to attend to their needs. This suggested that while an individualised task centred approach provided a good level of care, it also provided the least positive experience for residents and their families.

Person centred

This approach focused on who the resident was and the life they had lived developing personal and responsive relationships between residents and staff. Residents and their families often shared stories about their lives, communicating what was important to them. Staff who adopted a person centred approach, recognised how they might transfer significant details about a person’s life into their care routines. This might include important attention to details when supporting someone to wash and dress, such as making sure a woman who believed she lived in a flat had her makeup on before she came out into the communal area, or supporting someone else to choose jewellery to wear. For residents who might not be able to communicate verbally knowing how that person approached their life enabled staff to interpret behaviour in a different way. Both residents and families described positive experiences when staff adopted this approach. However, it was also evident that it was not always possible in a communal environment to provide a person centred approach to everyone in the community simultaneously due to the changing context of care.

Relationship centred:

Adopting a relationship centred approach considered the needs of residents, families and staff in the context of each other as part of the wider community of the home. This approach enabled reciprocal relationships to develop that took into account the needs of everyone involved in the relationship. Recognising the needs of others in this way, often supported the development of shared understandings between the resident, the family or staff as they saw themselves and others as part of a community. This approach was evident in the organisation of care that anticipated the needs of residents ensuring their significant details were taken into account. Flexibility was also important to enable staff to negotiate changes to the care routines when things might not go according to plan. Negotiation between staff, residents and families developed shared understandings of each other’s positions supporting a sense that they all had a place within the wider community. To achieve this approach, the contribution that residents and families made to the community needed to be recognised and valued by staff. In addition, a number of factors needed to be in place (Brown Wilson, 2009):

• Leading by example from the manager as well as direct care staff was essential to communicate a culture where the contribution of everyone involved in the relationship was valued
• A critical mass of staff who believed this was the right way to provide good care and who could work well together
• Continuity of staff enabling positive relationships to develop between staff, residents and families Residents and families who experienced a relationship centred approach to care described very positive experiences within the home.

These approaches to care provide staff in care homes with a way of thinking about how they might approach their care moving beyond a focus on the task. Within the literature, older people and direct care staff strongly identify their relationships with the quality of care they receive and give. Therefore, I have undertaken a secondary analysis of the data within my research to identify how quality criteria might be developed from these approaches to care that reflect the priorities of older people, families and staff in care homes. My preliminary findings suggest a hierarchy of quality, which starts with the individualised task centred approach as the minimum standard, moving towards person centred care with relationship centred care being the highest level of quality. A representation of this hierarchy is in the accompanying powerpoint presentation. It is at this point, I would like to invite your comments ...

references

• Brown Wilson, C (2009) Developing community in care homes through a relationship-centred approach, Health and Social Care in the Community. 17(2), 177–186
• Brown Wilson, C. and Davies, S.(2009) Using relationships in care homes to develop relationship centred care - the contribution of staff. Journal of Clinical Nursing 18, 1746–1755
• Brown-Wilson, C., Davies, S. and Nolan, M. R. (2009), Developing relationships in care homes - the contribution of staff, residents and families. Ageing and Society 29, 1041–1063.

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1. How might the three approaches to care from this presentation support staff in considering different ways of providing care and support to older people, including those experiencing dementia
2. How might the associated hierarchy of quality support staff in assessing the quality of the care they are providing based on these three approaches? - Dr. C. Brown Wilson