The provision of care to nursing home residents has, historically, been conceptualized as routine, repetitive work that is of low complexity and neither interactional nor dynamic (Rakovski & Price-Glynn, 2010). As a result, researchers have focused primarily on nursing home employees' workplace stressors, levels of job satisfaction, rates of turnover, and determinants of tenure (Lerner, Resnick, Galik, & Flynn, 2011; Thompson, Horne, & Huerta, 2011). In reality, the complexities of care and working environments are not well understood, and the knowledge, skills, and efforts of those who have chosen careers in residential care remain obscure and undervalued (Tolson et al., 2011). Few researchers have attempted to theoretically conceptualize the work of nursing home employees as caring, or empirically validate their compassionate efforts. In the current article, the authors (a) conceptualize care aide work as caring rather than caring activities, (b) explore relational care as a foundational and significant component of care aide work, (c) interpret care aides' relational care practices through the lens of Swanson's Middle Range Theory of Caring, and (d) describe how nursing home managers can empower care aides to do this work.
Care aides provide direct care and assist with residents' everyday personal needs. Although care aides always work under the direction of regulated professionals, they are the most central and accessible service providers. Interview data from 22 care aides were analyzed in a two-stage process, with emphasis on their perceptions and experiences of relational caregiving. Descriptive analysis was used to identify their perceptions and experiences and then the fit between their perceptions and experiences, context of care, and Swanson's Middle Range Theory of Caring was explored.
Swanson (1991) defined caring as “a nurturing way of relating to a valued other toward whom one has a personal sense of commitment and responsibility” (p. 162). Throughout the current study, data collection techniques were shaped according to this definition. After ethical approval was obtained from the appropriate academic agencies, convenience and purposive sampling (Strauss & Corbin, 1998) were used to recruit 20 female and two male care aides from one privately funded and four publicly funded nursing homes in a western Canadian province. Characteristics of participants are provided in the Table.
Characteristics of Participants (N = 22)
To ensure rapid establishment of close relationships with the care aides to encourage them to share their stories and contribute valid experiential knowledge, data were generated solely through individual or paired interviews, which occurred in neutral locations away from work-sites. The average length of an interview was 70 minutes. To maintain anonymity and confidentiality, each participant was assigned a pseudonym. Interviews were transcribed verbatim and qualitative software was used to manage the data. Participants were offered a $30 honorarium as acknowledgement for time and effort (Morse, 2005), equivalent to 1.5 hours of work. All participants worked full-time (two in the privately funded nursing home and 20 in the publicly funded nursing homes). The nursing homes ranged in size from 65 to 213 residents. The average assignment was 11 residents per care aide for a day shift. It is, therefore, within this cultural context that the results should be considered.
The current study is an inductive interpretive analysis (Thomas, 2006) based on the principles of constant comparison (Corbin & Strauss, 2008), following a coding process described by Charmaz (2006) and Boeije (2002) to identify categories, themes, and relationships. Verification strategies were used to incrementally monitor the concurrent data collection and analysis procedures, and identify and address threats to the validity of the study, thus ensuring rigor (Morse, Barrett, Mayan, Olson, & Spiers, 2002).
Swanson's Middle Range Theory of Caring
Swanson's Middle Range Theory of Caring is derived from three phenomenological studies: an investigation of women's experiences of care during pregnancy loss (Swanson-Kauffman, 1986), a study of care provision and care providers in a neonatal intensive care unit (Swanson, 1990), and a study of young mothers' perceptions of caring relationships in a mental health intervention group for high-risk mothers and newborns (Swanson-Kauffman, 1988). Five essential strategies that characterize caring were identified after the first study and were refined and validated in the two later studies. Ultimately, “an empirically derived definition of the concept of caring” was determined (Swanson, 1991, p. 163).
Although Swanson (1999) argues that caring strategies are central to nursing to enable patients to achieve well-being, she acknowledges that caring is not the sole domain of nursing. The theory has been applied to diverse clinical and social contexts, including family caregivers of individuals with AIDS (Powell-Cope, 1994), an anal dysplasia screening clinic (Ahern, Corless, Davis, & Kwong, 2011), critical care units (Hanson, 2004), and international adoptions (Murphy, 2009). In a seminal ethnography of care aides in nursing homes, Tellis-Nayak and Tellis-Nayak (1989) asked a crucial and troubling question: “How can residents be assured of caring and sympathetic concern from [care aides]?” (p. 307). When the theory is applied to an investigation of care aides' relational practices, it is proposed that care aides care about residents as much as they provide care to them via tasks, and that they will exhibit the capacity to enable nursing home residents and their families to experience enhanced well-being by:
Knowing residents and families (assessing all aspects of their experiences thoroughly, establishing partnerships with residents and families, and acknowledging that residents experience similar events differently).
Being with residents and families (listening carefully, sharing feelings, and conveying that what is happening to the residents matters very much to them).
Doing for residents and families (doing what they would do for themselves if it were possible; comforting, anticipating, and performing skillfully; protecting and preserving residents' dignity; and creating opportunities for the residents to perform well).
Enabling residents and families (informing residents and families about what is going on, coaching and validating their feelings, and giving feedback).
Maintaining belief in residents (holding residents in esteem, maintaining faith [a hope-filled attitude], and offering realistic optimism). (Swanson, 1991, p. 163)
Four themes were identified that contributed to an overall understanding of participants' caring practices and relationships with residents and families: (a) Desiring the Ideal Relationship, (b) Establishing Relationships With Residents and Their Families, (c) Maintaining Relationships With Residents and Their Families, and (d) the Reality of Care Aide Work.
Theme 1: Desiring the Ideal Relationship
Many care aides described an ideal relational state that included humanitarian and occupational ideals (e.g., altruism, compassion), values of inclusion, and explanations of why they chose the work or continued to stay in the role. Joanne (all care aides' names have been replaced with pseudonyms) said, “I just decided in my life that I want to look [after], care for [them].”
None of the care aides indicated they had any choice about residents who were assigned to them, so when they received a new assignment they hoped that their relationships with the new resident and his/her family would be agreeable, enjoyable, or pleasant for everyone.
Theme 2: Establishing Relationships With Residents and Their Families
A new resident generally meant that a previously established relationship had ended through death or transfer, so care aides must be able to accommodate their feelings of loss while simultaneously being open to a new resident and his/her family, as Linda explained:
You have a new resident coming in on the heels of somebody. And sometimes it is the very next day. And you are still trying to mourn the person that is gone and accept the new one that has taken their place.
Care aides described deliberate attempts to establish desired ideal relationships with new residents through investigational processes. They quietly gleaned extensive information as they created conditions that fit with residents' or families' attitudes and preferences. Rather than reading care plans, care aides indicated that their experiential knowledge was more useful, informative, or meaningful than any information in care plans, as Diane noted, “We don't even know what the care plan is. I haven't had time to read it. It is pages and pages and pages. I just do what I know what to do.”
Care aides observed new residents and their families to gain knowledge about their feelings, needs, and conditions. They also gathered details about residents' lives prior to institutionalization, such as what had previously mattered in residents' lives or what they may be thinking or worried about and interested in. Care aides and residents assessed one another and grew accustomed to each other's particular ways of doing things, as Kathy explained:
It takes some time to adjust to them, to get used to them, to get to know what their daily habits are and all that kind of stuff. So you are kind of having to go through the process of assessing this person…. So it is a learning curve.
Care aides were then able to draw on these details at strategic times when residents needed comforting.
A distinct period of passive and active negotiations or adjustments (to each other and the culture of care within the facility) by care aides, residents, and residents' families followed. Residents and families had their own preferences, habits, patterns, and ways of interacting and communicating their needs to the care aides, and the care aides had to work hard to find the time to talk to establish mutual expectations and norms. Although most new residents and families were able to convey their preferences, habits, and patterns adequately, their wishes and requirements still had to fit within the constraints of what the care aides and institutions were able to provide. Despite time constraints and heavy workloads, all participants placed a high value on conversations with residents and families, and many described spending a lot of time with families, enabling them by talking, describing care routines, and negotiating care. Susan described this process:
You spend a fair amount of time, which you really do not have but you make time…talking to them about different things regarding their family member. They are new to the facility and you try to make them a little more comfortable with the idea. It does take time and it is a pretty big assignment.
Theme 3: Maintaining Relationships With Residents and Their Families
Although negotiations with residents and their families did not always go smoothly, care aides tried to create opportunities for residents to perform well in ways that protected and preserved their dignity, as Jane explained:
I have one particular fellow. He is just brand new. I went into his room to call him for supper and he said, “Get out of here! I don't want to talk to you! If you don't get out I am calling the police!” And I went, “I came to ask you if you wanted to come for dinner. That was all.” [Later] I went back and I said to him, “Once you are in bed, I will bring you a couple of little sandwiches and some cheese.” And he said, “That would be good.” And so that is what diffused it all.
Some care aides described thinking almost constantly about the well-being of residents, especially if they had no close relatives, unresponsive relatives, or distant relatives (i.e., relatives living far away). When care aides were asked which residents they felt closest to, some reported that they felt close and dedicated to the most marginalized residents; they described doing things for residents that families would ordinarily do and many expanded their relational capacities by becoming alternative or surrogate family members. Jane mentioned:
I have a lady that has no one. Well, she does have family, but not in town. But I pick up shampoo and things like that. Little shopping things. Yeah, we do that. I never ask for permission. Little Christmas things. A blanket for one fellow who didn't have any family. Little things like that.
Other care aides provided friendly companionship to residents' spouses when those spouses needed someone to talk to, laugh with, rejoice with, or even eat with.
Experiential knowledge assured that care aides would not give up when work became difficult. Backing away was a dominant and dynamic strategy based on concern for the safety of the resident and a belief that eventually the resident would be calm enough to accept care. Waiting provided opportunities for residents to express negative feelings in a safe environment. Creating and following a routine designed to promote peace and tranquility enabled residents who were likely to lose composure to maintain some dignity, as Jane noted:
I used to go into one fellow who could be…very difficult. And I would always go in early and open the blinds so that the natural light would wake him rather than anything else. I made sure that I leaned over and—not close, just over so that he could see me. And, “How are you today? I have just come to help you get up.” I would say virtually the same thing every morning with very little variance in it…and start getting him dressed that way. And that would sort of give him a calming time.
Participants remarked, “I know what will work.” Therefore “doing” and “knowing” helped care aides maintain relationships with residents and families, and made these variables primary contributors to feelings of satisfaction at work. Many care aides were proud of their experiential knowledge, with Doris saying:
Certain family members, they will come to me before they go to the licensed practical nurse (LPN)…. And certain LPNs will ask, “Why are they asking you?” And I say, “Because I am the one. I know more about them than you.”
In the most challenging situations, most care aides continued to find ways to help residents who were angry and frustrated for varied reasons. These care aides were motivated by their beliefs in their ideal state and their abilities to develop good relationships, which energized them and provided them with feelings of occupational self-worth and contribution. Andy explained, “I think that we do make a big difference to them—their lives. You are their friend or confidant. You are there for them. I like it. I find it rewarding.”
Theme 4: The Reality of Care Aide Work
The essential caring strategy of “doing for” was most clearly demonstrated in participants' actions aimed at alleviating discomfort; it was distressing for care aides when they could not “do for” the residents by acting on information they had obtained. For example, Cheryl agonized over being unable to obtain analgesics for a resident because her assessment of the resident's condition was discounted by a regulated professional nurse:
I had this fellow who would bellow so loud that you could hear him at the desk. And they would do nothing to help with his pain. Three Tylenol®. That is all. And he died shortly after. That bellowing didn't come from nowhere. “Well, did you reposition him? Did you give him a drink?” Nobody wants to phone the doctor. Why would they not give something for pain? There has got to be something! You chase them and you chase them and you chase them. They don't want to do anything about it. And it is killing me. You are powerless.
Care aides also described discrepancies between their own expectations of “knowing” and those of the regulated professionals, and described a hierarchy of ability to obtain information. When one female care aide's resident was admitted to the hospital, it was distressing for her to be unable to obtain information during working hours. Linda explained:
Today I went into work and one of my girls (a resident) was in [the] hospital…. It is kind of a shock when you go in and the bed is empty. And no update on her! Did anybody phone? Well, nobody has phoned. So you don't know! I can ask the LPN or the nurse to do it. Which I did today, but they didn't have time…. I will make sure that it is an issue tomorrow. I have got to find out.
At other times, it was the organizational context that reduced care aides' influence and made them feel weak or ineffectual. For example, several care aides described trying to protect residents from organizational restraints imposed by cost-cutting strategies. Some resources needed by residents were kept locked away, suggesting that managers did not consider care aides to be legitimate sources of knowledge of residents' needs. Cheryl noted:
They are now counting pads. And pads are kept under lock and key…. Certain people are designated to count them out. They are locked in the med room…. I have to knock on the door and finally it will open and I say, “I need some daylites.” And [the nurse] doesn't want to give me them…. And I just keep breathing. Just keep breathing. That is all I can do.
Many care aides implied that their role was not only to provide care for dependent residents, but to “do for” regulated professionals by gathering and communicating important information to those who depended on them to provide it. In many ways, care aides felt responsible for the professionals in the same way they felt responsible for residents, as Jane described:
So it falls to you to make sure that they [regulated professionals] know what is going on…. That part too is demanding! Because you are trying to cover and help them…. It is up to me to report any skin breakdowns or wounds. Anything like that—their emotional well-being, as well as their general health. And for nine people, and sometimes 15, you know, that is a lot.
The combined processes of enabling regulated professionals (by completing and reporting resident assessments) and “doing for” residents left many care aides feeling overloaded with responsibilities. Some were perpetually torn between feelings of compassion for residents and resentment about the workload. Multiple assignments and tasks resulted in feelings of anxiety as well as mental and physical fatigue. When overloaded with responsibilities and work, care aides no longer had time for thought and reflection. Mary noted, “Physically you can't really last and mentally I don't know.”
The nature of the care aide role requires that they perform a great deal of physical work and when they help residents wash, dress, stand, and transfer, they should use transfer and lift techniques or machines designed to protect them from strain injuries and ensure safety and comfort for residents. Despite safety guidelines, some managers deviated from the usual practices for specific residents and mandated transfers that care aides believed were unsafe. Other participants described managers who required them to complete activities that left many feeling uncomfortable. Brenda described one uncomfortable event:
We had to put cotton batting in her [resident's] vagina. Every night! For what purpose? I still don't know to this day. But we had to put it in. They [management] finally did stop.... But you know how long we did that for? We were told this is what she wants. And we are to do it. Basically, we have to do anything. We have no recourse. We have no recourse....
Michelle added, “And God help you if you didn't do it.”
Some care aides described a state of constant uncertainty, continually reacting to stressful encounters with residents. Some residents were intoxicated by alcohol or marijuana, others made disparaging or insulting remarks, and some families complained. Diane explained:
You know what happened today? There was everything that was perfect. Everything the way they want it. The family, they came, and they couldn't find anything to complain about. Then they find that there is a plastic butterfly that was on the wall, and then on the counter. They came to me. They went to the LPN. They went to the RN. They went to everybody. “Why is the butterfly off the wall?” We finally found out that the housekeeper cleaned [it] and forgot to put it back…. It was like going on the whole day! With some families, you have a good relationship and they appreciate you and they do say thank you. But it is hard to feel good when they are always criticizing and they only see your mistakes. I think 50% of the stress is family.
In extreme cases, some care aides described feeling threatened by family members. When this occurred, they often coped by calling in to work to say they were sick when, in reality, they were not. They also noted that although they gave priority care to residents who had families who complained or made threats, they avoided spending any extra time with them.
Swanson's Middle Range Theory of Caring was validated explicitly in care aides' descriptions of their work and roles in nursing homes. These results support the generalizability of the theory beyond the perinatal contexts from which it was generated, and in caring contexts beyond acute care provided by regulated professionals. Some care aides' narratives could easily be applied to more than one caring strategy, demonstrating that the five caring strategies occur simultaneously in practice.
Consistent with Swanson's Middle Range Theory of Caring, all care aides should be capable of being in the ideal relational state if given the necessary resources. Swanson (1991) referred to this state as maintaining belief. However, some care aides felt powerless to fulfill their ideal state because they were unable to know (i.e., obtain information) or do (i.e., obtain adequate resources due to fiscal restraints). If care aides had adequate information, some were unable to act on it. Others were completely overwhelmed by the expanded workload, including the burden of completing resident assessments and reporting to professional nurses. Some care aides reported feeling uncomfortable in situations that were not alleviated by managerial remedial actions, as Michelle asked, “Why do I have to tolerate this abuse? 'Because [we] chose this profession,' they said.”
The resulting strains on interpersonal relationships caused some care aides to respond by ceasing to hold on to standards of the job. Although most participants indicated that they were drawn to the work because they “needed a job,” once they were in the job they held ideal values about what their roles could contribute to residents' and their families' lives. Based on Swanson's Middle Range Theory of Caring, managerial practices in nursing homes should be aimed at re-conceptualizing, validating, and recognizing the complex relational care that care aides provide by: (a) enabling them to “do for” residents by providing them with adequate resources, including supplies; (b) respecting their need “to know” by providing them with current and accurate information about assigned residents; (c) helping them feel strong and influential by considering their experiential sources of knowledge as legitimate sources of knowledge; (d) believing in them when they say they feel uncomfortable or unsafe; (e) reducing their increasing burden of expanding responsibilities that also include resident assessments; and (f) providing options/alternative workloads to those who are consistently assigned challenging residents, residents with complex issues, or residents with challenging families.
Swanson's Middle Range Theory of Caring encourages an individualistic approach to practice, and many care aides persevered because of their beliefs in the importance of their role and satisfaction derived when managers, residents, or family members acknowledged them and showed support or appreciation.
Care aides are a valuable human resource, so knowledge of their caring contributions as well as the conditions that strain their relational competencies is important. They do not simply complete tasks; their work occurs within a helping and caring framework (Carpenter & Thompson, 2008; Sikma, 2006). Incorporating caring theory within educational training standards for care aides would ensure that their preparation goes beyond training for “tasks” and empower them to more persuasively express their feelings and opinions about relational caregiving work. In addition, researchers, educators, stakeholders, and decision makers who are able to explain their efforts in a theoretical and logical way will not only support care aides, but also reinforce the meaning and value of their work to nursing home managers, legislators, and other health care professionals.