Research in Gerontological Nursing

Original Research: Mixed Methods 

Story Sharing: Enhancing Nurse Aide-Resident Relationships in Long-Term Care

Diane Heliker, PhD, RN; Hoang Thanh Nguyen, PhD

Abstract

National surveys often report nursing home deficiencies related to the preservation of residents’ dignity and respectful care. Many nurse aides (NAs), who provide the majority of personal care, are unprepared to engage in empathic and meaningful relationships with residents. This article reports the findings of a pilot mixed method study comparing two interventions, Story Sharing (StS) and Communication Skills, on NA levels of mutuality, empathy, job attitude, and self-efficacy and resident levels of empathy and perceived caring behaviors. A quasi-experimental/interpretive phenomenological design was used. Total Mutuality and subscale (Shared Values, Affective Closeness, Shared Pleasurable Activities, Reciprocity) scores were significantly higher in the StS NA groups only, as were postintervention Empathy scores. Other trends are reported as well. StS is one approach toward helping NH staff and residents understand, respect, and connect with one another.

Abstract

National surveys often report nursing home deficiencies related to the preservation of residents’ dignity and respectful care. Many nurse aides (NAs), who provide the majority of personal care, are unprepared to engage in empathic and meaningful relationships with residents. This article reports the findings of a pilot mixed method study comparing two interventions, Story Sharing (StS) and Communication Skills, on NA levels of mutuality, empathy, job attitude, and self-efficacy and resident levels of empathy and perceived caring behaviors. A quasi-experimental/interpretive phenomenological design was used. Total Mutuality and subscale (Shared Values, Affective Closeness, Shared Pleasurable Activities, Reciprocity) scores were significantly higher in the StS NA groups only, as were postintervention Empathy scores. Other trends are reported as well. StS is one approach toward helping NH staff and residents understand, respect, and connect with one another.

Care in nursing homes (NHs) has been described as dominated by routines and tasks that frequently take precedence over the needs of individual residents (Gubrium, 1975, 1993; Kane, 1995–1996). Care that lacks awareness of and sensitivity to the recipient’s background, life history, and significant life events often depersonalizes the giver and receiver and precludes development of meaningful, caring relationships among staff and residents (Williams, 1994).

National surveys report that more than 1 in 10 NHs have deficiencies related to preserving residents’ dignity and providing respectful care (Harrington, Carrillo, Thollaug, & Summers, 1999; Vohra, Brazil, Hanna, Abelson, 2004). Nurse aides (NAs), who provide more than 80% of personal care, are taught few of these skills and thus may be unprepared to offer care that fosters personally meaningful and respectful relationships (Pennington, Scott, & Magilvy, 2003). Clearly, NHs need a caring system that perceives the human face behind descriptive labels such as confused, incontinent, and frail, or worse, simply a room number. A social and hospitable environment, as represented by caring and meaningful relationships among NH staff and residents, is essential for residents to maintain a sense of personal identity and meaningful quality of living (Heliker, 2007). As the foundation of shared, reciprocal, and compassionate individualized care, meaningful relationships enhance residents’ quality of life (Bowers, Esmond, & Jacobson, 2000) and can alleviate the boredom, isolation, and loneliness often experienced by NH residents (Fagan, 2003; Thomas, 1996). Organizations such as the Pioneer Network (Fagan, 2003) are increasing awareness of the importance of a long-term care (LTC) model that emphasizes relationships and friendships among staff and residents.

Literature Review

The literature reveals an appreciation for the significance of the relationship between caregiver and care recipient. Nurse-patient relationship studies have explored relational capacity as a foundation for nursing practice (Hartrick, 1997), intersubjective relational understanding and mutuality, the intersubjective sharing of feelings and beliefs in a respectful way (Vatne & Hoem, 2008), and mutuality and connectedness that can empower both nurse and patient (Jerzak, 2001).

Little is known about the dynamics of the relationships between NAs and residents in LTC, and few studies have examined how these relationships might be enhanced to achieve individualized care (McGilton et al., 2003). This article reports the findings of a pilot mixed method longitudinal study that sought to explore how NAs and residents come to know and connect with one another and how these relationships might be enhanced through a Story Sharing (StS) intervention.

Studies suggest that the exchange of stories and experiences can increase understanding among diverse cultures and age cohorts (Eddins & Riley-Eddins, 1997) and fosters mutual relationships (Banaszak-Holl & Hines, 1996). Studies also show that NAs who come to know a resident and contribute to the translation of this knowledge into the plan of daily activities are most satisfied with the job and remain stable employees (Banaszak-Holl & Hines, 1996; Mercer, Heacock, & Beck, 1994). The StS process can create a social context in the LTC facility and provide an opportunity for mutual interaction between NAs and residents. This exchange process extends the focus of humane care, providing an empathic give and take between caregiver and resident. StS encompasses moments from day-to-day experiences and meaningful life events. The encounters begin a transformation in relationships between NAs and residents (Heliker, 1997, 2007).

Theoretical Framework

StS is based on the findings of previous studies (Heliker, 1995, 1999, 2007) and on Watson’s (1988, 1999) Theory of Transpersonal Caring. Watson’s theory, based on Husserlian phenomenology and the meaning of everyday experiences, describes a humane approach to care that is attentive to what matters to an individual, and starts with respectful listening and bearing witness to each other’s stories. Watson described the caring encounter as one in which two individuals enter the experiences (i.e., stories) of each other.

Watson (1988, 1999) emphasized interpretation and an understanding of human concerns and practices as situated within an environment characterized not only by sharing these practices, but also by rituals, language, history, and culture. According to Benner (1994), this approach considers human lives as “situated within meaningful activities, relationships, commitments, and involvements that set up both possibilities and constraints for living” (p. 352). NAs are situated in their practice; their interpretation and understanding of that practice are informed by their own values and experiences, the values and cultural beliefs of residents for whom they care, and the values of the local setting. Taking into account this context and the inherent situation of meaning, the basic tenets of Watson’s (1988) 10 carative factors comprise a comprehensive conceptual framework for the StS intervention (Table 1).

Watson’s Carative Factors

Table 1: Watson’s Carative Factors

StS is an interactive process that promotes recognition of commonalities and differences and provides a context for developing friendships and empathy. Reciprocity that involves a receptive listener and speaker characterizes StS (Kivnick, 1996). Inherent in the stories is a mutual sharing of values, beliefs, and cultural traditions. StS creates a space in which Watson’s (1988) carative factors come alive and become visible. For example, by sharing one’s story, one explicates the phenomenal field or personal frame of reference (i.e., Watson’s Carative Factor 10. This sharing includes cultural beliefs, values, and attitudes [Carative Factors 1, 3, and 8].). In sharing, NA and resident become sensitized to and accepting of each other’s worlds, giving voice to what is meaningful to each and forming a relationship with promise for respectful, transpersonal care (Carative Factors 2 and 4).

Method

Research Design

A mixed method (Tashakkori & Teddlie, 1998, 2003), repeated measures, and hermeneutic phenomenological design was used in this pilot study to determine whether an StS intervention enriched relationships between NAs and residents more than a comparison intervention, Communication Skills (CS) training. It was hypothesized that (a) NAs in the StS group would demonstrate significantly higher levels of empathy, mutuality, StS self-efficacy, and positive job attitude immediately and 3 and 6 months postintervention compared with the CS group, and (b) residents cared for by NAs in the StS group would report significantly higher levels of mutuality and perceived caring behaviors immediately and 3 and 6 months postintervention than residents cared for by NAs in the CS group. The CS comparison condition allowed for a possible Hawthorne effect from introducing specific structured attention to NAs in the NH environment. This intervention was not expected to have the same immediate or enduring positive effects as the StS intervention.

The phenomenological interviews following the intervention addressed two research questions:

  • How do NAs and residents come to know and connect with one another?
  • How does StS (or CS) affect the NA-resident relationship?

Setting and Sample

Six NHs owned by three different corporations were invited to participate. Each corporation provided two facilities that were matched on size, funding sources, location, hiring practices, values, mission statements, inservice opportunities, job descriptions, NA-resident ratios, and pay scale. The first NH from each corporation was randomly assigned to either the StS group or the CS group by way of a coin toss. The matching NH received the other intervention.

Institutional Review Board approval was obtained from the university, as were corporate, owner, and administrator approval from each participating NH. The study was conducted from March 2003 through November 2006. NAs were recruited during monthly inservices and represented all shifts. The only inclusion criterion for NAs was the ability to speak, read, and understand English so they could complete the questionnaires and participate in monthly follow-up small group forums. Interested NAs signed informed consents, of which they were given a copy. To defray costs of child care and gas, NAs received $20 every time they completed the questionnaires. A $50 raffle was held at each support forum to encourage attendance.

NAs who participated in the study chose five residents with whom they shared stories or with whom they felt they had connected. The researcher (D.H.) then chose one of the five residents at random and invited him or her to participate in the study, provided he or she met the inclusion criteria: older than 60, ability to speak and understand English, and a Mini-Mental State Examination (MMSE) score greater than 24, indicating cognition is intact (Folstein, Folstein, & McHugh, 1975). A research associate explained the study to residents, answered any questions they had about the study, and obtained signed informed consent forms. Residents also received copies of their signed forms. If a resident preferred not to participate or did not meet the inclusion criteria, another name from the NA’s chosen residents was picked at random. All residents who were invited agreed to participate.

Eighty-four NAs (n = 43, StS group; n = 41, CS group) and 54 residents (n = 26, StS homes; n = 28, CS homes) were recruited. However, the attrition rate in both groups approached 50% by 6 months postintervention. All but one of the NAs who dropped out of the study did so because they left the facility due to personal problems, pregnancy, higher pay somewhere else, or frustration with witnessing poor care, among other reasons. Resident attrition occurred as a result of cognitive impairment, death, hospitalization, and discharge to home. Reasons for attrition were similar in both StS and CS groups.

Intervention Protocol

StS Intervention. The StS intervention, detailed elsewhere (Heliker, 2007), involved three 1-hour interactive sessions; each was offered every other week during the overlapping hour between shifts, and make-up sessions were held in between. The first session began with a discussion about maintaining confidentiality, and all participants agreed to respect the privacy of session conversations. This session focused on how everyone shares stories with one another every day. Topics included attentive listening, significance of stories, and ways in which our stories identify who we are. Each NA received a notebook/sketchbook, colored pencils, and a pen to draw and journal private thoughts and experiences, which would become a basis for some of the small-group discussions later. At the end of the hour, all NAs were asked to bring a significant personal object to the next session. To encourage an environment of mutuality and improve rapport, the researcher and research associate participated fully in all activities.

During Session Two, participants and researchers shared stories about their objects and discussed the importance of meaningful possessions, the tools of self-expression and self-identity (Csikszentmihalyi & Rochberg-Halton, 1992). Participants were then led on an imaginary journey 50 years in the future, as they found themselves increasingly frail, occasionally falling, taking multiple medications, and becoming forgetful. They imagined being admitted to the NH in which they now work and were invited to bring their treasured belongings, including the day’s special object. After being asked, “How would you like the NA, who is helping you get settled, to handle this special object?”, the significance of residents’ belongings immediately became evident. NAs were encouraged to share stories with residents during the following week.

During the last session, NAs were invited to share stories about residents they had come to know and with whom they had connected. In this session they came to realize how they “read” or interpreted their residents’ likes, dislikes, cultural beliefs, and values through stories shared and personal belongings. NAs came to understand the value of sharing stories, forming friendships with one another and with residents, and the ways stories are “conveyors of meaning” (Banks-Wallace, 1999). As a practice, StS is encouraged throughout the day, during tasks, meals, and even NA breaks. StS becomes a way of being with one another and being with a resident. How often NAs attentively listen to residents or share stories with residents is at the discretion of the NA, who learns to “read” the individual resident’s unique needs and concerns.

CS Comparison Condition. The CS intervention consisted of three 1-hour sessions every other week, along with make-up sessions, following the format of traditional didactic inservices. Topics included communication strategies when speaking with residents who had experienced a stroke or had hearing, visual, or cognitive impairments. Examples of verbal and nonverbal communication, such as use of touch and eye contact, were discussed, and case studies exemplifying resident communication deficits were presented. The only relational element involved was the NA’s ability to understand a resident’s physical needs, such as the need to use the bathroom, and to communicate to a resident that it was time for a shower. The CS behaviors were to be used in all resident contacts.

Data Collection

NAs completed measurements before and immediately, 3, and 6 months postintervention (Table 2). Both groups of participating NAs (n = 84) were invited to meet in small gatherings (n = 45) once per month for 6 months following the interventions. These forums were held to ascertain fidelity to the practice of StS or use of CS and included open-ended questions and prompts such as “How has StS (or CS) affected your relationship with residents?” and “Tell me about how you connect and come to know your residents.” All NAs brought their journals to the sessions.

Measurement of Variables

Table 2: Measurement of Variables

Fifty-four residents were interviewed, 21 of whom were interviewed twice for clarification and validation of thematic findings. The researcher and two associate researchers, trained in hermeneutic interviewing technique, interviewed residents (Benner, Tanner, & Chesla, 1996; Weber, 1986). Residents cared for by NAs participating in both groups were presented the same unstructured prompt: “Tell me about your favorite NA. Tell me a story about how you came to know him or her.” This prompt initiated a conversation between resident and interviewer that would offer a new take or complement the findings that address whether StS enhances relationships more so or differently than CS.

Instruments

Levels of empathy, mutuality, job attitude, and StS self-efficacy were measured in two groups of NAs in 6 NHs who participated either in a StS intervention or in a CS intervention. Following the interventions, small group interviews were conducted with all participants over a period of 6 months to ascertain if there was fidelity to the intervention. Residents cared for by the NAs were also interviewed.

As shown in Table 2, demographic information was collected for all NAs and residents. Each NA completed pre- and postintervention questionnaires selected through review of the literature and piloted among LTC NAs (Heliker & Brooke, 1998) for readability, comprehension, and appropriateness for NAs. The questionnaires measured characteristics of caring relationships following Watson’s (1988) carative factors: Mutuality, Empathy, StS Self-Efficacy, and Job Attitude. Residents were asked to complete two instruments measuring perceived caring behaviors and mutuality (Table 2). These two instruments were not pretested in LTC residents prior to use in this pilot study. This proved to be a limitation of this study, as 15 of the participating 54 residents were unable to complete the questionnaires or decide on any one response option.

The Mutuality Scale (Archbold, Stewart, Greenlick, & Harvath, 1990, 1992) was chosen for the family-like relationships observed between NAs and residents for whom they care every day over time (Heliker, 1999). The defining attributes of mutuality include a feeling of connecting with and understanding each other and an exchange between individuals related to a shared or common goal. Mutuality is present when the conversational language used reflects the give and take of shared understanding, exchange of ideas, respect for all possibilities, comfort, humor, and humanness (Henson, 1997). The four subscales in this instrument are Shared Values, Affective Closeness, Shared Pleasurable Activities, and Reciprocity. This scale has not been used with LTC staff or residents.

Using the Emotional Empathy Tendency Scale (EETS) (Mehrabian & Epstein, 1972), empathy measured a person’s ability to replicate another’s feelings without egocentrism or reference to the cognitive nature of the response (Brems, 1989). The researcher-developed StS Self-Efficacy scale, based on Bandura’s (1997) theoretical assumptions, addressed StS among NAs (6 items), and confidence in sharing stories with residents (11 items). Job Attitude measured pay, benefits, and job status (which were not expected to change or be influenced by StS), as well as interpersonal relationships, job tasks, and autonomy (which might be affected) (Helmer, Olson, & Heim, 1993; Robinson, 1994). Caring Behaviors are reflected in what a NA says or does that residents perceive as caring, and were measured using the Caring Behaviors Assessment (CBA) questionnaire (Cronin & Harrison, 1988). Higher scores indicate higher perceived levels of caring.

Data Management and Statistical Analysis

Data were checked for accuracy and completeness, and responses were analyzed using SPSS version 14. If the number of items missing on a particular instrument was less than or equal to 10% for an individual participant, the item with missing values was replaced with the group mean for that item. After this substitution for missing items, the instruments and their subscales were scored. If any questionnaire had more than 10% missing items, the instrument was excluded in the data analysis for that participant.

To evaluate the effectiveness of the intervention, a series of analyses of covariance (ANCOVA) were conducted to examine group differences at each assessment point, after adjusting for baseline scores. In addition, changes over time (pre- and posttest) were examined using a series of paired t tests. For each group, the t test compared baseline scores with subsequent scores at 1 month, 3 months, and 6 months postintervention. This approach, rather than using repeated measures analysis of variance (ANOVA), was taken because of the straightforwardness of the interpretation of results. However, as a check, we also conducted repeated measures ANOVA and mixed model regression analyses, and the results were comparable to those with the simpler statistical approach.

NA small-group gatherings and resident interviews were audio recorded, transcribed verbatim, and interpreted by the researcher, two master’s-prepared students familiar with hermeneutic phenomenology, and an expert consultant (Diekelmann & Ironside, 2003). This seven-stage analytic iterative process, based on Heideggerian hermeneutic phenomenology, was developed by Diekelmann, Allen, and Tanner (1989). The research team read each narrative multiple times, summarized sections, identified themes, and interpreted emerging patterns across texts. A more descriptive report of the hermeneutic phenomenological methodology of this study has been published elsewhere (Heliker, 2009).

Results

Demographic Characteristics of NAs and NH Residents

NAs in both groups were very similar. The sample of NAs was also similar to those employed in LTC settings nationally, in that they were certified and primarily women (StS, 88.6% [39/44]; CS, 95% [38/40]; Z = 0.66, p = 0.51) (Centers for Disease Control and Prevention, 2010). Their mean age was 33 (age range = 18 to 64; StS mean age = 33.4, SD = 11.6 years; CS mean age = 36.5, SD = 11.2 years; t = −1.22, df = 78, p = 0.23). The average number of years of formal education was 14 (range = 7 to 16 years; StS mean = 13.0, SD = 2.81; CS mean = 12.4 years, SD = 1.69, df = 78, t = 1.20, p = 0.23). All had a minimum of a high school diploma or equivalent. More than half of all the NAs in the sample identified themselves as African American (StS, 54.5% [24/44]; CS, 50% [20/40]; Z = 0.198, p = 0.84), with the remaining identifying themselves as Caucasian (StS, 20.5% [9/44]; CS, 17.5% [7/40]; Z = 0.066; p = 0.95), Hispanic (StS, 18.2% [8/44]; CS, 27.5% [11/40]; Z = 0.759; p = 0.45), or Other (StS, 6.8% [3/44], CS, 5.0% [2/40]; Z = −0.11; p = 0.91). Participating NAs had worked in LTC settings for an average of 8 years (range = 8 months to 28 years).

The average age of the residents was 74 (age range = 65 to 104). Thirty-six were women, 39 were Caucasian, 8 were African American, and 7 were Hispanic. Of the original participating 54 residents, only 39 completed all of the study questionnaires.

Nurse Aides

Mutuality. Table 3 presents the scores on the total Mutuality scale and the individual subscales (Shared Values, Affective Closeness, Shared Pleasurable Activities, and Reciprocity) for each assessment period by study group. The differences between groups at each assessment are tested after adjusting for preintervention scores using ANCOVA. At baseline, no statistically significant differences existed between the StS group and the CS group on the Mutuality total score or any of the subscales. Immediately postintervention, the StS group had a significantly higher total Mutuality scale score than the CS group (t = 3.55, df = 1, p = 0.0008), indicating that the intervention had a positive impact on increasing mutuality. Positive outcomes were also found for the Shared Values subscale (t = 2.28, df = 1, p = 0.03), Affective Closeness subscale (t = 2.20, df = 1, p = 0.03), the Shared Pleasurable Activities subscale (t = 3.48, df = 1, p = 0.0009), and the Reciprocity subscale (t = 2.76, df = 1, p = 0.008) at 1 month postintervention, after controlling for baseline scores. At 6 months postintervention, the StS group had significantly higher total Mutuality scores (t = 3.50, df = 1, p = 0.001), Shared Pleasurable Activities subscale scores (t = 3.10, df = 1, p = 0.004), and Reciprocity subscale scores (t = 3.41, df = 1, p = 0.002) than the CS group, after adjusting for baseline differences.

Mean Differences in Mutuality Total and Subscale Scores Between Story Sharing and Communication Skills Groups

Table 3: Mean Differences in Mutuality Total and Subscale Scores Between Story Sharing and Communication Skills Groups

Cronbach’s alpha coefficients for the total scale and each of the subscales observed in this sample were as follows: Total Mutuality (0.91), Shared Values (0.56), Affective Closeness (0.66), Shared Pleasurable Activities (0.80), and Reciprocity (0.84). Changes across time were assessed with a series of pre and post t tests within a study group. The Figure depicts the results for the Mutuality total scores. The significant differences in mutuality between the two groups can be attributed to the improvement in Mutuality scores over time by the StS group, rather than a change by the CS group, since those scores showed little change in Mutuality over time.

Change in Mutuality Scale Total Scores.Note. NS = not Significant.* Statistical Significance; Actual p Values.

Figure. Change in Mutuality Scale Total Scores.Note. NS = not Significant.* Statistical Significance; Actual p Values.

Empathy. At baseline, the EETS scores of both groups were similar. At immediate postintervention, the StS group had significantly higher positive empathy scores (t = 2.46, p = 0.02) and significantly lower negative empathy scores (t = −2.31, p = 0.03) than the CS group. This trend continued at 3 and 6 months postintervention. The Cronbach’s alpha coefficient for the EETS in this study was 0.75.

StS Self-Efficacy and Job Attitude. StS Self-Efficacy and Job Attitude scores remained stable in both groups throughout the study. No significant differences between groups or over time were observed. This was expected, as several items on the Job Attitude Scale (JAS) referred to satisfaction with pay, benefits, and tasks. The Cronbach’s alpha coefficient for the JAS in this study was 0.80; for the five items in the Attitudinal Survey of Nursing Home Aides scale (Robinson, 1994), it was 0.70.

The StS Self-Efficacy Scale may not have demonstrated a difference between groups if the NAs believed they already had good relations with each other and with residents. The Cronbach’s alpha coefficient for the StS Self-Efficacy scale in this study was 0.88.

NH Residents

Caring Behaviors Assessment. Thirty-nine residents completed this scale in this study (n = 26, StS group; n = 13, CS group). Except for the Teaching/Learning subscale, no significant differences in mean scores were observed between the group cared for by StS NAs and those by the CS NAs. Residents in the StS group scored significantly higher on the Teaching/Learning subscale after the intervention (p = 0.05), and results were similar at follow-up assessments. Interestingly, this subscale captures an interpersonal element, a reciprocal caring for and being cared for, rather than confidence in technical proficiency. The Cronbach’s alpha coefficient for the total scale in this study was 0.94.

Several older adults found it difficult to respond to 62 questions, each with five response options. Even sectioned to be administered over several visits, the NH residents preferred to tell stories about their caregivers. As a result, use of this questionnaire was discontinued, and all residents were interviewed and asked to talk about their favorite NA. These audio recorded and transcribed conversations were phenomenologically interpreted and elicited quality of relationships and how the resident and NA came to know and care for one another.

Mutuality. The same number of residents completed this scale (n = 39), and no significant differences in total or Mutuality subscale mean scores were found between residents cared for by the StS NAs and those by the CS NAs.

Hence, the first hypothesis comparing StS NAs with CS NAs was only partially supported with significant differences on levels of mutuality and empathy. The second hypothesis that compared residents cared for by the NAs on perceived caring behaviors and mutuality was not supported, most likely due, in part, to the limitations inherent in the instrumentation used (discussed below under Limitations).

Narratives and Interviews. Small group narrative (n = 45) and individual resident interview (n = 75) data together revealed nine major patterns and 25 subthemes (Table 4). Each small group was attended by 6 to 15 NAs. To prevent bias, the researcher did not review quantitative results of the study until all narratives had been interpreted. This rigorous approach and the emergent patterns will be explicated in a separate manuscript. However, the findings of the interpretive phenomenological phase do complement and extend the quantitative results related to mutuality and empathy. Many StS participants in particular would often refer to each other and certain residents as family and the facility as a “second home.” NAs spoke of visiting residents on their days off and “slipping into” a resident’s room on breaks to have a conversation. Residents spoke of favorite NAs who “checked on” them and understood what mattered to them. Residents and NAs spoke of a reciprocal give-and-take relationship, of quality of lives enriched not because tasks were completed efficiently but because of being cared for and cared about. NAs who became “known” to their residents felt more valued as they entered into a more respectful collaborative relationship. Each small group session was filled with stories shared among NAs and residents. Thematic findings from resident interviews overlapped with those of NAs. NAs in the CS groups spoke primarily of behaviors that addressed resident deficits (e.g., hearing loss).

Constitutive Patterns and Supporting Themes Revealed Through Narratives and Interviews

Table 4: Constitutive Patterns and Supporting Themes Revealed Through Narratives and Interviews

Limitations and Recommendations

Given the population selected for study, attrition was expected (Feng, Silverstein, Giarrusso, McArdle, & Bengston, 2006). Annual turnover rates for NAs working in NHs in the United States have been reported to be as high as 60% to 200% (Ryden & Krichbaum, 1996). As much as 50% of NA attrition similarly reflected the average NA turnover experienced by the participating NHs. Only one NA who left the study remained at the NH. Resident attrition was a limitation as well. Because participating NH residents were chosen because they were receiving care from participating NAs, 50% of resident attrition was due to NAs leaving the NH. Further, the size of the two groups of residents was significantly unequal and was a limitation in the final statistical analysis.

Due to the limitations surrounding the use of lengthy questionnaires, completing the instruments was a significant challenge for residents. Questionnaires were read to most residents, and research associates split data collection meetings to allow for participant fatigue. Even so, the CBA, in particular, was too long and had too many response choices for this group of older adults, something that may have been discovered had the instrument been pretested. The researcher also tried to use the instruments as an interview guide; this approach was also challenging. Residents preferred to tell stories about their NAs in their own way; hence, the hermeneutic interview approach that allows older adults to use their own voice was most effective. Due to the increasing numbers of residents with cognitive impairment, future studies should include those with varying levels of such impairment. These older adults also have perceptions of their caregivers that should be heard and addressed. Using a cut-off MMSE score as an inclusion criterion excludes and depersonalizes the most vulnerable older adults. An added limitation related to the resident sample population is the proportion of White non-Hispanic residents. Sample characteristics were dependent on the choices of the participating NAs.

Regarding the lack of significance on JAS, items on the JAS relating to satisfaction with pay and benefits showed no significant difference because the interventions did not affect these factors. Regarding the lack of significance on the NA-to-NA relations section of the StS Self-Efficacy scale, NAs may feel they already have good relationships with each other, so no change was observed.

The empirical findings of this pilot study are limited and cannot be generalized to other facilities or populations. A further limitation is related to the self-selection of the volunteer NAs. These individuals might be viewed as more committed in their relationships with residents. To improve sample size, the researcher repeated the interventions in four of the facilities. The StS groups maintained higher levels of Mutuality than the CS groups. As more NAs from different shifts participated and came to know one another, camaraderie increased. NAs covered the floor for one another to allow others to attend. NAs began to create “little change of shift reports” among themselves, relating the needs and concerns of their residents. NAs spoke of coming to know and connect with residents in ways that made everyday tasks more enjoyable and comfortable for residents. The StS NAs spoke of learning how their own values and assumptions inform their practices.

Although the relationships among NAs and residents appeared to be enhanced, a major limitation of this study was the absence of outcome measurements that would explicate how certain aspects of care delivery were or were not improved at the same time. Examples of such measurement for future studies might include NA absences, response to call bells, frequency of toileting, weight loss, family satisfaction, turnover, and inclusion of NAs in care planning. In the participating NHs in this study, NAs were rarely invited to any formal or informal care plan meeting or shift report.

Implications for Future Research, Education, and Practice

To effectively address ongoing LTC quality of life issues, the culture of not only the staff and residents but also the organization must be understood (Muñoz, 2007). Mixed methodology using more than one paradigmatic approach is vital to addressing the complexity of the lives of the most vulnerable older adults, their families, and their caregivers. Programs and interventions should include all direct care providers and innovative educational strategies (Diekelmann & Ironside, 2003). The Omnibus Budget Reconciliation Act of 1987 mandates a minimum of 75 hours of education for NA certification, but the 21 performance skills evaluated for competency include primarily physical tasks. This performance-based pedagogy leaves too little time to emphasize the significant value and uniqueness of NAs who bring a world of experience to the caregiving situation. Interpersonal skills such as self-reflection, attentive listening, and “reading” residents to understand what matters to them seldom receive emphasis during certification, orientation, or inservice programs.

Empathic relationship skills are not considered essential for certification, yet this study points toward the need for an increased focus on the significance of relationships between all caregivers and recipients of that care. According to Duffy (2006), “The Institute of Medicine’s first simple rule for quality health care is a long-term healing relationship” (p. S45). Suchman (2006) challenged the assertion that medical encounters should be intentional or that all communication be a transfer of information. Relationship-based care is highly valued in nursing as well (Koloroutis, 2004). In the unique environment of LTC, where residents spend an average of 870 days (National Center for Health Statistics, 2000) and NAs provide 80% of the care, new possibilities for mutual and empathic relating must be examined.

StS provides a framework for relating and begins to explore how all caregivers might become reflective practitioners who understand how one’s own values and experiences inform one’s everyday practices, whether that practice is giving a bath, dressing an ulcer, or assessing pain. In LTC, mutual and empathic relating through StS can restore the humanity and dignity not only of the older adult but the NA as well (Heliker, 1997, 1999). More and more, story-centered approaches are being used in a variety of health care venues such as policy (Newman, 2003), public health (Steiner, 2005), medicine (Charon, 2004; Greenhalgh, 1999), education (Davidhizar & Lonser, 2003; Diekelmann & Ironside, 2003), nursing (Ironside, 2003; Liehr et al., 2006), and organizational leadership (Denning, 2004).

In this study, NAs shared their own stories and began to understand how their lived experiences informed their delivery of care and their relationships with NH residents. The stories and the myths one lives inform practice in the workplace (McAdams, 1993). A personal myth is our lived story patterned by the “integration of our remembered past, perceived present, and anticipated future” (McAdams, 1993, p. 12). Vittoria (1999) noted that direct care workers perceive residents through a personal, rather than a medical, lens. As individuals relate to one another, their approaches are both guided and limited by their personal stories, including cultural beliefs, values, experiences, and biases. The power differential that often occurs between care providers and receivers in the NH may eventually be overcome as connections are developed through the sharing of stories, common language, and meanings (Henson, 1997).

The findings of this study introduce the caring possibilities inherent in an StS intervention. An expanded version of the Story Sharing Workbook based on the findings and stories of this study is being piloted by 100 LTC staff (nurses, aides, social workers, educators) in Texas and Illinois. Moving toward a relational model of care, the workbook incorporates practices of self-reflection, awareness of one’s own values and beliefs, and sensitivity to the uniqueness of each person. An interdisciplinary trainer’s guide that will accompany the workbook is being developed and will include learning/teaching strategies, evidence-based practices, and options for customizing StS to meet individual and facility needs.

Conclusion

Due to the use of a lengthy instrument with residents, small samples, and large attrition rates affecting measurements, this project must be viewed as a pilot study but one that reveals lessons to be learned on the basis of the limitations noted above and identifies directions for further study in the area of enhancing relationships in NHs. Of the human relational dimensions measured in this study, levels of empathy (immediately postintervention) and mutuality, including subscales of Shared Values, Affective Closeness, Shared Pleasurable Activities, and Reciprocity, were significantly higher among the StS group than the CS group. Mutuality is the sharing of values and beliefs in a relationship that is based on trust and respect and is revealed in the “in-between” of human relationships (Archbold et al., 1990, 1992). It is a way of relating that may precede care and is satisfactory to both giver and receiver. The significant quantitative and emergent qualitative findings in this study point toward new possibilities for future research and practices in LTC.

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Watson’s Carative Factors

Formation of humanistic-altruistic system of values.

Nurturing of faith and hope.

Cultivation of sensitivity to oneself and others.

Development of a helping and trusting human care relationship.

Promotion and acceptance of the expression of positive and negative feelings.

Use of creative problem-solving processes.

Promotion of transpersonal teaching and learning.

Provision for a supportive physical, sociocultural, and spiritual environment.

Assistance with gratification of human needs.

Allowance for existential, phenomenological, and spiritual forces.

Measurement of Variables

Variable Instrument Sample Frequency
Demographic data Questionnaire: Age, gender, ethnicity, years of education, total years working in a NH Interview and questionnaire: Age, ethnicity, gender NAs Residents Pre-intervention Pre-intervention
Mutuality Mutuality Scale (Archbold, Stewart, Greenlick, & Harvath, 1990, 1992): 15 items; Cronbach’s alpha coefficient = 0.91; 4-point Likert format; four subscales (Shared Values, Affective Closeness, Shared Pleasurable Activities, Reciprocity). FKGLS: 2.3. Measures the relationship between caregiver and care receiver; Mutuality is the sharing of values and beliefs within a relationship based on trust and respect. NAs Residents Preintervention; immediately, 3, and 6 months postintervention Immediately, 3, and 6 months postintervention
Empathy Emotional Empathy Tendency Scale (Mehrabian, 1996; Mehrabian & Epstein, 1972): 30 items; Cronbach’s alpha coefficient = 0.84 (Mehrabian & Epstein, 1972); Likert format; validity evidence correlates with heart rate to emotional stimuli, aggression, helping behaviors. FKGLS: 6.7. NAs Preintervention; immediately, 3, and 6 months postintervention
Self-efficacy Story Sharing Self-Efficacy tool (researcher developed)—17 items; 5-point Likert format; evaluation by a panel of expert judges showed content validity index scores above 0.90 for all items (Polit & Beck, 2006). FKGLS: 6.8. Researcher-developed tool to assess the confidence of NAs in cultivating relationships with residents and other NAs. Generated through use of task analysis and a test grid (Gable & Wolfe, 1993; Owen, Froman, & Moscow, 1981). Items were partially based on the responses of NAs in a pilot study (Heliker & Brooke, 1998). Asks the question “How confident are you that you can do the following?” with responses on a scale of 1 (very little) to 5 (quite a lot). NAs Preintervention; immediately, 3, and 6 months postintervention
Job attitude Job Attitude Scale (Helmer, Olson, & Heim, 1993): 17 items; 3-point Likert format. FKGLS: 7.2. Measures five components of job attitude: pay and benefits, informal interpersonal relationships, task requirements, job status, and autonomy, as well as perceived treatment during interpersonal relationships. Items include “How do the older residents treat you?”, “How do you enjoy talking with elderly residents?”, and “How satisfied are you with your work?” Higher scores signify more positive job attitudes. Attitudinal Survey of Nursing Home Aides scale (Robinson, 1994): 5 selected items. FKGLS: 6. Psychometric data unavailable. NAs Preintervention; immediately, 3, and 6 months postintervention
Caring behaviors Caring Behaviors Assessment (Cronin & Harrison, (988): 62 items; 7 subscales; 5-point Likert format; r = 0.66 to 0.090; content validity. FKGLS: 6. Based on Watson’s (1988) theory and carative factors, the Caring Behaviors Assessment has seven subscales; Cronbach’s alpha coefficients for the subscales in this study were: Humanism/Faith-Hope/Sensitivity (0.80), Helping/Trust (0.88), Expression of Positive/Negative Feelings (0.69), Teaching/Learning (0.86), Supportive/Protective/Corrective Environment (0.74), Human Needs Assistance (0.69), and Existential/Phenomenological/Spiritual Forces (0.57). This has been used in printed form with older adults in long-term care and assisted living facilities (Marini, 1999). Residents Immediately, 3, and 6 months postintervention

Mean Differences in Mutuality Total and Subscale Scores Between Story Sharing and Communication Skills Groups

Pre-Intervention 1 Month Postintervention 3 Months Postintervention 6 Months Postintervention

Scale/Subscale n Mean (SD) n Mean (SD) n Mean (SD) n Mean (SD)
Mutuality Total
  Story Sharing group 44 3.18 (0.57) 31 3.39 (0.48) 24 3.27 (0.56) 17 3.44 (0.45)
  Communication Skills group 40 3.13 (0.42) 32 3.06 (0.52) 27 3.23 (0.51) 23 3.15 (0.56)
t = 0.44 p = 0.66 t = 3.55 p = 0.0008 t = 1.55 p = 0.13 t = 3.50 p = 0.001
Shared Values
  Story Sharing group 44 2.98 (0.71) 31 3.24 (0.56) 24 3.23 (0.68) 17 3.21 (0.75)
  Communication Skills group 40 3.01 (0.58) 32 2.97 (0.54) 27 3.00 (0.54) 23 3.00 (0.62)
t = −0.23 p = 0.82 t = 2.28 p = 0.03 t = 1.97 p = 0.054 t = 1.38 p = 0.18
Affective Closeness
  Story Sharing group 44 3.22 (0.65) 31 3.51 (0.57) 24 3.29 (0.61) 17 3.45 (0.55)
  Communication Skills group 40 3.23 (0.53) 32 3.22 (0.62) 27 3.33 (0.55) 23 3.32 (0.60)
t = −0.08 p = 0.93 t = 2.20 p = 0.03 t = 0.10 p = 0.92 t = 1.13 p = 0.26
Shared Pleasurable Activities
  Story Sharing group 44 3.48 (0.59) 31 3.65 (0.46) 24 3.50 (0.52) 17 3.70 (0.37)
  Communication Skills group 40 3.44 (0.43) 32 3.40 (0.42) 27 3.56 (0.39) 23 3.45 (0.45)
t = 0.35 p = 0.72 t = 3.48 p = 0.0009 t = 0.47 p = 0.64 t = 3.10 p = 0.004
Reciprocity
  Story Sharing group 44 3.01 (0.66) 31 3.20 (0.58) 24 3.11 (0.63) 17 3.34 (0.47)
  Communication Skills group 40 2.90 (0.59) 32 2.79 (0.69) 27 3.03 (0.73) 23 2.92 (0.77)
t = 0.82 p = 0.42 t = 2.76 p = 0.008 t = 1.54 p = 0.13 t = 3.41 p = 0.002

Constitutive Patterns and Supporting Themes Revealed Through Narratives and Interviews

Gathering Calling forth stories Welcoming and inviting the new resident
Creating Places Keeping open to a future of possibilities Letting be
Staying: Knowing and Connecting Recreating home and family Visiting as friends Coming to know Becoming known Disconnecting
Caring: Engendering Community Befriending Restoring the reciprocity of caring
Preserving Story Sharing stories Sharing family Being witness to legacy Remembering
Presencing Attending Being with Being open Checking on
Making Meaning Visible Sharing meaning
Interpreting: Self, Other, and the In-Between Knowing what matters Reading the resident Knowing when and how to care
Cultivating Nourishing friendships Becoming neighbors
Authors

Dr. Heliker is Professor and Edgar and Grace Gnitzinger Endowed Chair in Geriatric Nursing, University of Texas Medical Branch, Galveston, School of Nursing, Galveston, and Dr. Nguyen is Statistician, LifeStat LLC, Kemah, Texas.

The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Address correspondence to Diane Heliker, PhD, RN, Edgar and Grace Gnitzinger Endowed Chair in Geriatric Nursing, University of Texas Medical Branch, Galveston, School of Nursing, 301 University Boulevard, Galveston, TX 77555-1029; e-mail: dheliker@utmb.edu.

Received: June 18, 2008
Accepted: September 08, 2009
Posted Online: March 31, 2010

10.3928/19404921-20100303-01

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