Living life in residential aged care: a process of continuous adjustment
Aim The aim of this study was to examine whether, and how, residents living in residential aged care homes (RACH)1 become involved in their care, and what areas of their care and life they work to influence or negotiate.
Scope This grounded theory study, conducted in two Australian RACHs, comprised 24 days of participant observation and interviews with 22 residents and 19 staff members. Data collection and analysis were concurrent, with theoretical sampling guiding the ongoing data collection. The findings revealed a complex set of perspectives, interactions and processes which explain how residents work to live their life in residential aged care (RAC).
Findings Findings reveal three dimensions of living in RAC: presenting an acceptable self, living a communal life and preserving the self. Three salient conditions can influence these dimensions of living in RAC. These conditions have been named situational change, shaping expectations and environmental shaping. Presenting an acceptable self involves activities conceptualised as getting to know, building an information framework and deciding how to be. In these ways, residents learn what is or is not acceptable and to whom. The second dimension of living in RAC, living a communal life, includes residents’ efforts to become known by establishing an identity and connecting and contributing to the community. In this dimension, residents both confer and gain reputations. Preserving the self includes maintaining a private self, managing their own health, accepting help and maintaining independence while at the same time maintaining a private self. Depending on the resident‘s situation (situational change),at a particular time, one or more of these dimensions may be backgrounder or fore grounded. Loss of family or friends, changes in health conditions or a perception that their values are threatened may lead the resident to focus their efforts on preserving the self (foregrounding) while presenting an acceptable self and living a communal life are of less importance and are back grounded. When a resident is foregrounding living a communal life, they may background preserving the self and make every effort to be present at community activities. At these times residents may ―act as if‖; they will present as though they are well when they are not.
Additionally, residents‘lives can be shaped through interaction with staff. Shaping expectations can influence residents‘efforts to have their expectations met. Residents use a range of strategies to have an expectation or need met. These strategies include becoming someone problematic when the staff and residents‘ perception of the need are mismatched; bypassing staff in favour of approaching a staff member who is perceived to be more amenable to the resident‘s request, and calling in a proxy to act on residents‘ behalf.
Staffs also employ a range of strategies which influence residents‘expectations. These strategies have been conceptualised as gap filling where the resident has expressed an aspect of their life as missing; boundary setting when the staff perceive residents are presenting an unacceptable self and boundary breaking and collusion when a staff member perceives an unjust boundary. Additionally, when residents are experiencing distress, staff may work to assist the resident to work through their distress. This aspect of staff work has been conceptualised as working with tunnel experiences.
Environmental shaping (physical and structural) provides a third condition which influences how residents live their lives. The influence of the facilities physical layout has been conceptualised as connecting in congregate places. Additionally, while the residents may or may not be aware of some dimensions of the structural influences on their life, the facility culture, government legislation and staffing levels and funding have an impact on how the residents live their lives. As physical and structural environments are relatively inflexible, this aspect of residential living is xigenerally less responsive to residents‘efforts, requiring a high level of flexibility from residents.
The three processes, presenting an acceptable self, living a communal life and preserving the self, together with the conditions which shape them, (situational change, shaping expectations and environmental shaping), demonstrate that residents are in a process of continuous adjustment. This study adds to the body of knowledge in that it explains the effort that residents put into living in RAC and could serve to assist staff, management and policy makers to examine the ways in which residents are supported to live their lives as effectively as possible.