Although it has been a long time coming, quality of life for residents living in longterm care (LTC) facilities has become an important objective. Evidence suggests the most important element of quality of life for older adults is having meaningful and genuine relationships with their care providers, who, in LTC, are mainly health care aides and licensed practical nurses (Aller & Van Ess Coeling, 1995; Ford, 1995; Grau, Chandler, & Saunders, 1995; Kayser-Jones, 1989). People are social beings, and interacting with others provides support, comfort, love, and affection, which are universal needs.
If older adults become institutionalized as they age, social contact with friends and relatives may diminish, and many may experience intense needs for attachment, nurturance, and support (Barnard, 1988). Therefore, relationships with care providers are required. From the family's perspective, this relationship is paramount, because families believe caring for their family member is not just a set of tasks that can be assigned to particular roles, but an ongoing process that must occur within meaningful relationships (Duncan & Morgan, 1994). Care providers also have experienced the necessity of being involved in relationships with residents. They have indicated interpersonal relationships with residents in nursing homes are what makes them stay at their jobs (Robertson, Herth, & Cummings, 1994), is the best aspect of their jobs (Monahan & McCarthy, 1992), and enriches their days at work (Rundqvist & Severinsson, 1999).
Care provider-resident relationships represent a largely untapped resource for improving quality of life, although researchers tend to ignore them. Despite mounting evidence of the need for meaningful relationships between care providers and residents, no models of care were found that specifically explain the development of these relationships as well as measure their contribution to secondary resident and care provider outcomes.
The main purpose of this article is to propose a model for establishing relationships with residents based on Kayser-Jones's (1991) theory of the environment and on a relationship theory by Winnicott (I960). Additional aims are to critically review the theoretical and empirical evidence that support the elements of the model. This new model of care is proposed as one way to enhance the quality of life of elderly individuals living in institutions.
THEORETICAL UNDERPINNINGS FOR THE MODEL OF CARE
Kayser-Jones's (1991) theory of the LTC environment and Winnicott's (1960) theory of the holding relationship provided the foundation for the development of the model of care. These theories were chosen because they acknowledged the important role of the environment in caregiving. Furthermore, these theories purported that for a relationship between the care provider and resident to be created and sustained, care providers needed support from their supervisors.
Kayser-Jones's Theory of the Environment
Kayser-Jones (1989) proposed the LTC environment in which elderly individuals live may impact on resident outcomes such as stability, morale, health, and well-being. She described three major contextual aspects of the environment: physical characteristics, social climate, and psychological milieu. For the model of care described in this article, the psychological milieu of Kayser-Jones's framework was primarily emphasized.
Psychological milieu refers to the existing norms, values, activities, and philosophy of the administration, the attitudes and beliefs of the care providers, and the personal interactions of all who are part of the institution. Kayser-Jones (1989) contended while the physical and organizational environments have been shown to be important, the human relationships and social contact with others are far more crucial in determining quality of life than the color of the room or the absence of irritating noises. Specific elements of Kayser-Jones's (1991) theory adapted for this newly created model included:
* The importance of the relationship between the care provider and the resident.
* The effect of this relationship on outcomes.
* The supervisors' philosophy related to their support of the development of these relationships.
Winnicott's Relationship Theory
Winnicott's (1960) theory of the parent-infant relationship provided theoretical direction for understanding and enhancing the health care provider-client relationship. The parent-infant relationship theory describes the essential capacities of the mother and the relationship she develops with the child that meets the specific and developing needs of the infant (Winnicott, 1960). This relationship, which Winnicott referred to as the holding relationship, is constituted by reliability, empathy, and consistency in the mother's approach. Winnicott also emphasized to provide this holding relationship, mothers could be enabled to do better by being cared for themselves by family members and by the community.
In his later work, Winnicott (1970) proposed some phenomena he observed in the parent-infant relationship were analogous to those in the health care provider-client relationship. In both situations, it was important for the care providers themselves to be in the relationship. Also analogous to the mother-infant relationship, the elderly resident and care provider come to the relationship differently, one in dependence and the other in responsibility.
Both mothers and care providers required the capacities of reliability, empathy, and consistency in their approach, and it was recognized by Winnicott (1960; 1970) that both, too, needed to be cared for so they could be enabled to do better. Differences between the two relationships included the mothers' level of investment and commitment, and the expectation of an eventually reciprocal relationship between the mother and child, which may not occur between the care provider and resident.
Although adapted from the parent-infant relationship theory, the new model of care should not be misconstrued as leading to infantalization of older adults. Because of the dependency and vulnerability of the institutionalized elderly individual, there is a concern that care providers may more easily exercise their authority over residents. Yet, infantalization is not what Winnicott (1970) espoused in his theory. He argued there is no room for power relations and hierarchies in his proposed holding relationship. Instead, his theory can be used to uncover the essential capacities care providers need to build holding relationships with their residents, namely reliability, empathy, and consistency in approach. Additionally, care providers must be able to work in a supportive environment to facilitate the building of these relationships.
Reliability. Winnicott (1970) argued that elderly individuals live with an increased risk of dependency and vulnerability and what is required in these situations is dependability, or reliability, from the care providers. Residents may become anxious because they have to depend on strangers and need to ask for and accept help (Winnicott, 1970). Care providers caring for dependent older adults are called on to build reliability into their overall approach.
Figure. Conceptual framework for the study.
Winnicott stated reliability in care is not merely mechanically based in a good technique delivered in the same way to every resident. Instead, reliable care should express the uniqueness of each care provider and arise from the individual needs and style of each resident. Care providers need to be themselves when caregiving and be responsive to their residents' needs in their own ways. Moreover, this care should also protect the resident from impingements that might cause deep distress and anxiety. Care providers protect residents from impingements (i.e., events that threaten the residents' adaptation to their environment) by buffering them from loud music, very hot foods, cold drafts, bright lights, hunger, pain, or unanticipated changes in their days.
According to Winnicott (1970), being reliable also involves acceptance of the residents' feelings of love and hate. It is possible, at times, care providers will dislike the residents they care for because, for example, the resident tries to hit the care provider during care or the resident is ungrateful. Even so, the care provider has to be able to tolerate these feelings and not retaliate.
Empathy. Empathy, which is also a central capacity required of care providers, involves sensitivity to the residents' responses. Instead of care providers' imposing their routine on the resident, they need to respond and adapt to the resident's rhythm. This empathy necessitates a recognition of the resident's physical and psychological needs. Without empathy, caregiving may be reduced to only a technical function. Consequently, understanding one's own motives and feelings is central to the empathie approach.
Without an understanding of where one has come from and how one's values may impede the empathie process, one cannot get beyond the technical approach to care (Winnicott, 1970). Care providers must be sensitive to the particularities of the resident through awareness of the person's expressions and recognition of the person's individuality. The elderly individual living in the facility has a history and life experience that may be crucial to assist with this recognition.
Consistency in approach. Care can be delivered in a more consistent manner with continuity of care provider. Care providers, thereby, may be better able to interpret the residents' responses, learn about how to minimize the residents' reactions to impingements, understand what the residents' particularities are, and learn how to meet their needs. When care is provided by only a few permanendy assigned care providers for each resident, the residents will eventually understand the unique and particular ways care providers deliver care to them. This may minimize the unpredictability in their days.
Supportive environment. Winnicott proposed that for a care provider to be involved in a holding relationship with a resident, the provider must, in turn, experience a supportive environment. Such an environment includes not only a unit manager, but also RNs because they are the charge nurses in LTC environments who have the most contact with nonprofessional staff. Therefore, professional staff in supervisory positions are called on to be empathie and reliable with the care providers on the units and, thus, to create holding relationships for care providers. The supervisors' empathy was conceptualized to refer to an ability to:
* Recognize the care providers' standards of care.
* Recognize and accommodate the care providers' expressed needs, such as providing for shift changes.
* Understand the care providers' points of view when they come forward with concerns.
Reliability was conceptualized as the ability of the supervisor to:
* Be available for care providers if things are not going well with residents or families.
* Protect the care providers from the unpredictable by keeping them informed of changes in the work environment.
* Tolerate care providers' feelings of frustration in the workplace.
THE MODEL OF CARE
The Figure shows the newly developed model of care (McGilton, 2001). The model proposes if a care provider is reliable, empathie, and consistent when interacting with a resident, and if a supportive environment is available, (i.e., a holding relationship is established for the care provider), the care provider would be able to establish a holding relationship for the resident. Supervisors support care providers in their efforts to be more empathie, reliable, and consistent in practice by modeling these capacities with their staff. After holding relationships are developed for residents, continued support from the supervisors is required to assist with maintaining the milieu that supports these relationships. Based on empirical evidence, presented below, and from KayserJones' (1991) theory the model further proposes the development of this holding relationship will lead to positive secondary outcomes for the residents and care providers.
EMPIRICAL SUPPORT FOR THE MODEL
The model of care, while primarily conceptualized using Winnicott's theory of relationships, received preliminary support from the following review of the literature. This model focused on combining and extending three different strategies to enhance relationships between residents and care providers that had previously been tested individually and for which some evidence of effectiveness existed. The three strategies are:
* Continuity of care provider.
* The acquisition of the skills and knowledge (i.e., reliability and empathy skills) required by the care providers to enhance interpersonal relationships.
* Support to care providers from nursing supervisors to assist in maintaining effective care provider-resident relationships.
Continuity of Care Provider
In the reviewed literature, continuity of care provider assignments were implemented to improve the general quality of care to elderly individuals, but they also have demonstrated benefits for the care provider-resident relationship. Within nursing, continuity of provider is emphasized in the primary nursing literature. Although primary care models with all licensed staff do exist in some long-term environments (Goldman, 1998), in the majority of facilities, certified nursing assistants or health care aides comprise the largest portion of nursing staff (McAiney, 1998). As a consequence, primary nursing continuity of care assignments are not appropriate in LTC settings without modifications.
In a setting with a broad skill mix, the professional nursing staff retain the primary accountability for client care. Health care aides or nursing aides, who provide direct care, are consistently assigned to the same resident and report to the registered staff. It is also important to note continuity of care provider is challenging at times for care providers, as some residents are difficult to be with every day. For these care providers, the need to have a break from challenging residents is vital for the continuing success of a continuity of care provider assignment over time.
The continuity of care provider research reviewed suffers from various methodological shortcomings that limit the generalizability of the findings. The main limitations include inadequacy of instruments (Anderson & Hughes, 1995; Campbell, 1985), lack of control groups (Campbell, 1985; Patchner, 1987), and small care provider samples (Cox, Kaeser, Montgomery, & Marion, 1991; Wilson & Dawson, 1989). Despite the methodological shortcomings, the research in this area has consistently indicated continuity of care provider models can lead to positive outcomes for residents and care providers. Residents showed:
* Fewer incidences of agitation (Patchner, 1987; Teresi et al., 1993b).
* An improved affect (Teresi et al., 1993b).
* An improved physical integrity (Campbell, 1985).
* A general increase in well-being (Cox et al., 1991).
Care providers showed:
* A better attitude toward elderly individuals (Cox et al., 1991).
* Less turnover (Campbell, 1985).
* Decreased levels of job-related stress and improved perceptions of the work environment (McAiney, 1998).
* More certainty about interpreting residents' behaviors (Athlin & Norberg, 1987).
* Closer relationships with residents (Teresi et al., 1993a).
Four of these studies, however, provided evidence that more than just a continuity of care provider model was required. Cox et al. (1991) tested a Quality of Life Nursing Care Model that, instead of being focused exclusively on the physical care of the resident, encouraged the staff to expand their focus to include important quality of life considerations such as residents' needs for choice and control.
Teresi et al. (1993b) evaluated a primary care model implemented in a LTC unit. The added intervention included the development of a team approach and an enhanced communication component. McAiney (1998) evaluated a permanent assignment model of care focused on empowerment, organization, education, and teamwork for the health care aides. In a study by Patchner (1987), the other intervention allowed the nursing aides to choose their permanent assignment based on the residents they enjoyed caring for.
The additional interventions are warranted because clients who have task-focused and controlling care providers may suffer under a continuous assignment system of delivery (Mitchell Òcjonasy 1995). As such, the need to maintain continuity of the care provider was only one element of the new model of care.
Skills and Knowledge Required by Care Providers
A consensus has emerged from investigators that positive care provider interactions with residents can have a critical impact on the development of the relationship between nursing home residents and their care providers (Caris-Verhallen, Kerkstra, & Bensing, 1999). Yet, a literature review demonstrated only a few researchers have attempted intervention studies to enhance these care provider-resident interactions.
Research studies were reviewed that focused on attaining care provider capacities similar to reliability and empathy. One series of studies was designed to enhance interactions with residents (Allen & Turner, 1991; Caris-Verhallen, Kerkstra, Bensing, & Grypdonck, 2000; Kihlgren et al., 1993; Loveridge & Heineken, 1988; McCallion, Toseland, Lacey & Banks, 1999; Williams & Tappen, 1999), whereas another series of studies focused on learning about the individuality of the person (Best, 1998; Coker et al., 1998; Heliker, 1999; Pietrukowicz & Johnson, 1991).
The first group of interactional studies focused on increasing the reliability of the nursing staff to the residents' needs. Allen and Turner (1991) provided an intervention to nursing staff, which consisted of developing the staff's awareness of the wide spectrum of people's psychological and physical needs, in the hope of increasing the staff's interactional behaviors with residents.
Loveridge and Heineken (1988) developed an in-service program to introduce nursing staff in a LTC institution to an intervention that consisted of confirming interactions. Nursing staff on all shifts received the program and then were observed in practice for evidence of these confirming behaviors. These investigators did not find significant changes in care providers' confirming behaviors or the level of interactional behaviors.
Kihlgren et al. (1993) provided integrity promoting care education that consisted of 20 hours of lectures and 18 hours of group discussion, in which the following three messages were given:
* Care should be delivered in a reliable way so a patient's experience of integrity is promoted.
* A model of interaction should be taught.
* Care providers should be taught how to make the environment calmer for their residents.
Findings indicated care providers on the treatment ward had increased verbal contact with residents.
Caris-Verhallen et al. (2000) evaluated the effectiveness of a communication skills training program for nurses working in a home for older adults. The Video Interaction Analysis training consisted of individual and group sessions. Trainees were asked to pay more attention to both the physical and social needs of patients, to be more supportive, to be less dominant, to disagree less, and to show empathy. Post-intervention, the treatment group was rated as more involved and less patronizing, and the group demonstrated a warmer attitude when interacting with their residents. Concerns related to contamination between the groups make the results tentative. As such, replication of the study is required.
The most convincing results were found in two recent studies. McCallion et al. (1999) developed and evaluated a nursing assistant communications skills program (NACSP). The program was designed to teach nursing assistants to interact more effectively with individuals with moderate or severe dementia.
Following the intervention, the residents' aggression and depression significandy decreased. Williams and Tappen (1999) trained advanced practice nurses (APNs) to communicate with individuals with dementia, and these APNs met with the same residents three times a week for 16 weeks. The researchers found residents with dementia displayed evidence of being involved in a therapeutic relationship with their APNs following the communication intervention. For this study to be more applicable to LTC environments where there are few APNs, it should be replicated with RNs, LPNs, and health care aides as the participants for the intervention.
Empathy is considered one of the primary avenues to a positive connection with residents (Olsen, 1995). Several nurse researchers posited that becoming familiar with the individual may enhance the care provider's empathy (Happ, Williams, Strumpf, & Burger, 1996). Knowing a person should alter nurses' practice by enabling them to encourage individuals to use identified abilities, strengths, potential, and attributes as long as possible. Evidence is accumulating that there is a link between knowing the person and positive nursing staff and resident outcomes.
Positive nursing staff outcomes were anecdotally found in Coker et al.'s (1998) descriptive study. These investigators worked with a group of 10 nursing staff members to develop the life stories of residents who lived on a LTC unit. Following the completion of a life story with a resident, care providers suggested the knowledge they had gained about the individual would change the way care was delivered because they would no longer impose their own values on their patients.
In the quasi-intervention study by Pietrukowicz and Johnson (1991), the nurse aides rated nursing home residents on a semantic differential scale. Aides received one of two versions of an anonymous resident's medical chart, identical except for the inclusion of a one-page history. Nursing staff who received the chart with a life history rated the resident as more adaptable, autonomous, personable, and as having more interactional skills than did aides in a control group.
In two case studies, Best (1998) and Heliker (1999) described a biographical approach to understanding the residents in LTC. Best (1998) developed life histories for her residents and found benefits for the residents because the nursing staff had a better understanding of them. Heliker (1999) used an innovative narrative approach in the format of storytelling to learn about the life story of the resident. With permission, the resident's life story was then shared at a patient care conference. Best (1998) and Heliker (1999) concluded, with limited evidence, learning about the life histories of residents and sharing them in clinical practice could lead only to enhancing the relationship between practitioner and client.
Because so few controlled studies of interactions have been conducted, it is not possible to draw any conclusions about their overall impact or about the specific way to improve care providers' interactions. Results are mixed regarding the effect of interactional training on changing care providers' practice. The work of Allen and Turner (1991) and Loveridge and Heineken (1988) challenges using only education or training as the way to enhance interactions and change care providers' practice. These investigators did not find significant changes in outcomes, which may be related to the threats to the internal validity of their studies.
The studies by Caris- Verhallen et al. (2000), Kihlgren et al. (1993), McCallion et al. (1999), and Williams and Tappen (1999) also used interactional skills, but the emphasis was placed not on saying the right thing, but on listening to the person and responding to what was said. These investigators found positive outcomes, enough to warrant a continuing search for ways to improve interactions. Evidence is also emerging that suggests knowing the individual's history or personhood may lead to better care and enhanced interactions (Best, 1998; Coker et al., 1998; Heliker, 1999; Pietrukowicz & Johnson, 1991).
Supportive Environment for Care Providers
Administrators and supervisors are central to the residents' experience because they determine the ambience of the facility and the way nursing staff feel about their work (Glass, 1992) and quite possibly how they perform their work. Four studies were found that hinted at this relationship in LTC environments. An underlying assumption of these studies is when attempts are made to care for the care providers (i.e., establish a holding relationship for them), a commitment from them to deliver high quality care may occur, which may facilitate the care provider-resident relationship.
Both Hallberg and Norberg (1993) and Montegar, Reid, Madsen, and Ewell (1977) investigated the impact of a clinically supervised environment for nurses on outcomes. Hallberg and Norberg provided an intervention for nursing staff caring for residents with dementia. Systematic clinical supervision for 6 months, combined with individualized care, was implemented. For 1 hour each week, a particular resident was selected, and the group shared personal opinions related to caring for residents.
In the reviewed studies, the researchers found evidence that clinical support reduced burden for the nursing staff because they saw the residents as significandy more responsive and less stubborn (Hallberg & Norberg, 1993). The effects of supervisor approval on staff-resident interactions were investigated in a state center for multi-handicapped elderly individuals (Montegar et al., 1977). Following baseline testing, an in-service training program designed to teach staff members appropriate methods of interacting with and stimulating residents was instituted along with contingent supervisor approval. The supervisors were shown effective ways to reward staff for attempting to interact appropriately with residents. Results showed when the supervisor commented and attended to staff members for interacting with residents, staff-resident interaction increased 25% to 50% above baseline rates (Montegar et al., 1977).
Investigators Kihlgren et al. (1992) and Kovach and Krejci (1998) found anecdotal evidence for the link between supportive management practices and quality care. Kihlgren et al. (1992) found staff who work with residents with dementia need supervision and support aimed at giving them a deeper experience and meaning in their work. The analysis of their data suggested if staff concerns were not addressed, poor job satisfaction may develop, which in turn could have an impact on the quality of care. Kovach and Krejci (1998) surveyed 181 LTC employees and found management personnel may need to be more visible, open, and validating of staff's contribution to dementia care outcomes. Employees also identified that a better relationship with administrative staff, which included support, would facilitate improvement in dementia care.
A review of the research on supportive work environments in LTC shows the following:
* There is a paucity of research conducted in this area.
* Confounding factors may affect this supportive environment, for example, the supervisors' visibility in the environment (Kovach & Krejci, 1998).
* Non-probability convenience samples characterize this area of research (Kihlgren et al., 1992; Kovach & Krejci, 1998; Montegar et al., 1977).
Based on these concerns, only a few tentative conclusions can be drawn. Hallberg and Norberg (1993) provide preliminary evidence that clinical supervision may affect nurses' perceptions of their residents. Montegar et al. (1977) suggest supervisor's approval may increase staff-resident interactions and philosophies of care focused on care providers' needs may lead to an improvement in care and to the development of supportive relationships with administrative staff (Kovach & Krejci, 1998).
The reviewed empirical evidence and Kayser-Jones's (1991) theory suggest if residents perceive their care providers to have effective interactional skills, provide continuity in care, and are supported in their workplace (i.e., a holding relationship is established for them), positive resident and care provider outcomes would ensue. These outcomes were found to be related to the three strategies reviewed in the literature.
The proposed secondary resident outcomes included the residents feeling less agitated (Patchner, 1987; Teresi et al, 1993b), improved affect (McCallion et al., 1999; Teresi et al., 1993b), and physical integrity remaining intact (Campbell, 1985). A potential positive care provider outcome included care providers establishing closer connections with their residents (Coker et al., 1998; Patchner, 1987; Teresi et al., 1993a) and communicating with more empathy (CarisVerhallen et al., 2000). Further, Kovach and Krejci's (1998) evidence suggested if the unit manager and charge nurse were supportive, care providers would have better relationships with their supervisors.
Research in three different areas was examined and several conclusions can be drawn. Continuity of care provider is critical to understanding the resident and to developing relationships with the resident over time (Patchner, 1987; Teresi et al., 1993a). The teaching of interactional skills is not enough; the care provider must be engaged in some way, such as learning about the person through life stories (Best, 1998; Caris-Verhallen et al., 2000; Coker et al., 1998; Heliker, 1999; McCallion et al.,1999; Pietrukowicz & Johnson, 1991; Williams & Tappen, 1999). If care providers are called to enhance relationships with residents, they too must be supported in their work environments (Hallberg & Norberg, 1993; Montegar et al., 1977; Kovach & Krejci, 1998). Finally, research confirmed positive secondary resident and care provider outcomes can be achieved following the development of holding relationships.
Overall, preliminary empirical support for the capacities of the care provider - reliability, empathy, continuity - and for the requirement for support were established from a review of the literature. However, no intervention studies were found that incorporated the complete set of theoretical variables. Testing the combined influence of these variables, as conceptualized by Winnicott's (1970) theory of relationships, and the manner in which they affect the holding relationship for residents, and subsequently secondary care provider and resident outcomes, is essential to assess the usefulness of this theory to relationship building in LTC.
Caregiving relationships involve all kinds of social interaction during the course of which the patient's sense of self -worth can either be enhanced or thwarted (Agich, 1990). Therefore, a milieu should be developed to accentuate care provider-resident relationships and lead to a systematic and encompassing framework of positive expectations on the part of all nursing personnel involved. A model of care focusing on relationships may be one means to this end.
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