“They are the reason I come to work”: The meaning of resident–staff relationships in assisted living

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Abstract

This article aims to provide understanding of how direct care workers (DCWs) in assisted living facilities (ALFs) interpret their relationships with residents and to identify factors that influence the development, maintenance, quality, and meaning of these relationships. Qualitative methods were used to study two ALFs (35 and 75 beds) sequentially over seven months. Researchers conducted in-depth interviews with 5 administrative staff and 38 DCWs and conducted 243 h of participant observation during a total of 99 visits. Data were analyzed using a grounded theory approach. Results showed that the emotional aspect of caregiving provides meaning to DCWs through both the satisfaction inherent in relationships and through the effect of relationships on care outcomes. Within the context of the wider community and society, multiple individual- and facility-level factors influence DCW strategies to create and manage relationships and carry out care tasks and ultimately find meaning in their work. These meanings affect their job satisfaction and retention.

Section snippets

Assisted living facilities

Although ALFs vary from state to state in what they are called and how they are regulated and defined, for the most part they are non-medical, community-based settings that provide shelter, meals, and 24-hour protective oversight and personal care services to residents (Ball et al., 2000, Hawes et al., 1999). In 2004, ALFs numbered 36,451 with 937,601 units or beds (Mollica & Lamarche-Johnson, 2005). When defined broadly, ALFs encompass a wide range in size and type of facility and include

Worker–client relationships in long-term care

Long-term care research addressing social bonds between DCWs and the elders they care for indicates that these ties have importance for both caregiver and care recipient. In their ethnographic study of homebound elders, Ball and Whittington (1995) found that an elder's relationship with a home care worker could fill in for missing family ties and influence perceptions of care quality. Other home care studies (Eustis and Fischer, 1991, Piercy, 2000), as well as research in AL (Ball et al., 2000,

Methods

This paper is based on a study of the role of workplace relationships in job satisfaction and retention of DCWs in ALFs. Although the study examined the range of DCWs' relationships in AL, including those with residents' family members, other DCWs, and administrators, this paper focuses on DCW–resident relationships. The goal of the study and this paper is to understand personal and cultural meaning, as well as significant processes operating in the setting, and we, thus, used a grounded theory

Data collection

We collected data using participant observation and in-depth and informal interviewing for a period of three months in Blue Castle and four in Forest Manor, with a one-month interval for data management and analysis. Our strategy of sequential study permitted all researchers to study both homes, adding to data credibility.

We conducted participant observation at both sites during visits on all days of the week during day and evening hours to observe a range of DCW experiences, for a total of

Data analysis

We used a three-level grounded theory coding process (Strauss & Corbin, 1998) to analyze data pertaining to staff-resident relationships. In the first stage, known as open coding, we examined all data line-by-line for emergent categories based on our research questions and issues raised by the participants. Examples of initial codes included: work strategies, resident encounters, trust, job frustrations, and care roles. We then developed codes in terms of their properties (e.g., type,

DCW and resident factors

The principal factors pertaining to DCWs included personal characteristics and values, family and employment histories, and work-related training. Most DCWs in these two homes accounted for positive relationships with residents in terms of their own special traits and values. Myra at Forest Manor was typical: “I am a nice person. I get along with elderly people more than I get along with people in general. I can understand where they are coming from and where they are going and the kind of care

Workplace factors

A variety of workplace factors influenced DCW strategies, relationships, and care outcomes. The physical environment was one. Because Blue Castle was smaller and situated on one floor, DCWs were in regular contact with all residents. Interaction was further promoted by the location of a DCW work station in the home's main common area, where residents routinely gathered. The DCU at Forest Manor, which occupied the third-floor, was similarly conducive. Joanne explained: “It is more intimate. You

Relationship type

The type of relationship that developed between DCWs and residents was influenced by the multiple factors discussed above, as well as by worker strategies and care outcomes. Specific relationships ran the gamut from loving to downright hostile, but almost all DCWs had close emotional bonds with at least one resident, typically more. Some considered such bonding inevitable. One long-term worker said, “I know you say we don't need to get attached to people, but trust me, you do get attached.”

Worker strategies

In essence, DCWs employed two types of strategies in their jobs — those to develop and manage relationships and those to provide care. Because DCWs believed their work involved both physical and emotional care, typically relationship and care strategies complemented one another or were one in the same. Strategy choice was influenced by DCW, resident, and workplace factors, the type and length of the relationship, and the unique care situation. The following excerpt from field notes again shows

Care outcomes

Care outcomes in our conceptual model refer to whether or not a worker is able to carry out an assigned task, as well as her perception of the impact of the care process on the resident. Care outcomes are influenced by, and in turn influence, relationships and strategies. Outcomes also are influenced directly and indirectly by DCW, resident, and workplace factors. The following passage from field notes describes Elaine's attempt to give a bath to Carole, the difficult Blue Castle resident

Creating meaning

In our conceptual model, creation of meaning is a process that unfolds over time. As shown in Fig. 1, the meaning that relationships with residents holds for DCWs involves multiple components, which relate to affirmation of lifelong values, nature of affective ties and interactions with residents, continuity of caregiver identity, perception of the care provided and job status. Components have variable properties and dimensions. For example, affirmation of values varies from weak to strong and

Discussion

This research sheds light on relationships between direct care workers in AL and the residents they care for and the effect of these relationships on their job satisfaction and retention. We found that a variety of macro-level factors provided the context for the process of creating meaning through relationships. Multiple DCW and resident factors influenced: the type of DCW-resident relationships; the strategies DCWs used to manage relationships and provide care; care outcomes; and the ultimate

Acknowledgements

This research was supported by a grant from the National Institute on Aging (R03AG022611-01) “Relationships of Care Staff in Assisted Living,” Mary M. Ball, Principal Investigator. We also would like to thank Dr. Frank J. Whittington and Dr. Candace Kemp for reading multiple manuscript drafts and providing valuable feedback.

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