Introduction
As long-term care (LTC) homes have been shifting their focus of care from institutional to home-like environments, growing attention has been paid to the exploration of meanings of home in these settings (Hauge and Kristin, Reference Hauge and Kristin2008; Cooney, Reference Cooney2012; Verbeek et al., Reference Verbeek, Zwakhalen, van Rossum, Kempen and Hamers2012). Living in small, home-like settings is regarded as positively impacting social engagement and the behaviour of older adults (Verbeek et al., Reference Verbeek, Zwakhalen, van Rossum, Ambergen, Kempen and Hamers2014; Lee et al., Reference Lee, Chaudhury and Hung2016). Although a number of studies have investigated what home means to older adults, little is known about how perceptions of home are affected by moving from institutional LTC settings to a purpose-built LTC home. This paper explores how residents, family members and staff perceived home during a two-year institutional relocation process.
An extensive body of literature explores meanings of home for older adults in various living contexts, such as a family home (Molony et al., Reference Molony, Evans, Jeon, Rabig and Straka2011), in assisted living (Marsden, Reference Marsden1999, Reference Marsden2001; Cutler, Reference Cutler2007; Lewinson et al., Reference Lewinson, Robinson-Dooley and Grant2012) or in LTC homes (Verbeek et al., Reference Verbeek, van Rossum, Zwakhalen, Kempen and Hamers2009; Molony, Reference Molony2010; Molony et al., Reference Molony, Evans, Jeon, Rabig and Straka2011; Johnson and Bibbo, Reference Johnson and Bibbo2014; Rijnaard et al., Reference Rijnaard, van Hoof, Janssen, Verbeek, Pocornie, Eijkelenboom, Beerens, Molony and Wouters2016; Eijkelenboom et al., Reference Eijkelenboom, Verbeek, Felix and van Hoof2017). These studies have consistently identified physical (e.g. building structure and design, interior design) and social (e.g. relationships with staff and family, friendships) features as important factors in helping create a home-like environment regardless of the setting. According to Kaufman (Reference Kaufman1981), one creates meaning based on interpretations of one's social and cultural world, and so meanings essentially define and reflect older adults’ relationships to their environment. Thus, older adults’ perceptions of home – what ‘home’ means to them – are dictated by and reflect their sense of identity according to how they interpret their physical environment and social engagement. In synthesising previous studies on meanings of home, Oswald and Wahl (Reference Oswald, Wahl, Rowles and Chaudhury2005) identified five domains in the meaning of home: physical, social, behavioural, cognitive and emotional features, the last three of which are nested together as personal features. These are presented below.
Physical aspects of home
Physical features of built environments, including spatiality and size, physical structure, private and public space, internal design, architectural design, location, views and technology, are critical to a sense of home (Sixsmith, Reference Sixsmith1986; McCracken, Reference McCracken and Hirscheman1989; van Hoof et al., Reference van Hoof, Verhagen, Wouters, Marston, Rijnaard and Janssen2015; Rijnaard et al., Reference Rijnaard, van Hoof, Janssen, Verbeek, Pocornie, Eijkelenboom, Beerens, Molony and Wouters2016; Eijkelenboom et al., Reference Eijkelenboom, Verbeek, Felix and van Hoof2017). Building material (e.g. wood, brick), human-scale entryways commonly found in single-family houses (e.g. porches, small portico entries), decorative elements (e.g. window trims) and landscaping (e.g. flowers and trees) are all perceived as influencing how home-like a setting feels (Marsden, Reference Marsden1999), as does general cleanliness and seasonal, colourful decorations that remind residents of time with their families (Martin, Reference Martin2002; Lewinson et al., Reference Lewinson, Robinson-Dooley and Grant2012). The height of a building is another salient aspect of the sense of home: the lower a building is, the more home-like it feels for older adults (Marsden, Reference Marsden1999).
Small-scale LTC settings, which offer care to 5–15 residents, are often described as home-like, home-style physical settings (Verbeek et al., Reference Verbeek, van Rossum, Zwakhalen, Kempen and Hamers2009), or, more generally, the ‘housing model’ and identified as a trend (Marshall and Archibald, Reference Marshall and Archibald1998: 336). Designs of private and public space in LTC homes impact residents’ sense of home by meeting their needs primarily of privacy and social interaction, respectively (Rijnaard et al., Reference Rijnaard, van Hoof, Janssen, Verbeek, Pocornie, Eijkelenboom, Beerens, Molony and Wouters2016). The size of a LTC home is considered particularly influential in creating a sense of home (Marshall and Archibald, Reference Marshall and Archibald1998; Verbeek et al., Reference Verbeek, Zwakhalen, van Rossum, Kempen and Hamers2012). For instance, the size of a LTC home has been shown to affect how older adults care for each other, how friendly they are and how much they collaborate (Cloutier-Fisher and Harvey, Reference Cloutier-Fisher and Harvey2009). Lighting, colour of the walls and floors, and temperature also influence whether or not residents experience LTC as home-like (Cooney, Reference Cooney2012). Elements such as visible nurses’ station, however, are likely to cause residents to have a sense of being in a medically oriented rather than a home-like setting (Dobbs, Reference Dobbs2003). For residents with dementia, important design features of LTC homes include clear signage and instructions posted on the wall (Marshall, Reference Marshall1999), though these features are associated with institutional settings (Kane and Cutler, Reference Kane and Cutler2009).
A sense of ownership over one's physical environment, often manifested by residents’ personalisation of their living areas with their belongings, contributes to older adults’ sense of home (McCracken, Reference McCracken and Hirscheman1989; Marsden, Reference Marsden2001; Johnson and Bibbo, Reference Johnson and Bibbo2014; van Hoof et al., Reference van Hoof, Janssen, Heesakkers, van Kersbergen, Severijns, Willems, Marston, Janssen and Nieboer2016). Chuck et al. (Reference Chuck, Milke and Beck2005) found that in a home-like LTC setting, residents decorated their bedrooms with significantly more items of their choice, such as pictures, ornaments and greeting cards, than did residents in an institutional LTC setting. Such personal touches that recall nostalgic memories can help create a home-like environment for residents and reduce the sense of being in an institutional setting (Cooney, Reference Cooney2012; Marquardt et al., Reference Marquardt, Bueter and Motzek2014; van Hoof et al., Reference van Hoof, Janssen, Heesakkers, van Kersbergen, Severijns, Willems, Marston, Janssen and Nieboer2016).
Building size, structure, internal design and various other physical features have all been consistently identified as – and are accepted to be – important factors in creating a sense of home in LTC settings in the previous studies. However, much of the existing research that has focused on these physical features has been cross-sectional, which has limited our understanding of how the physical features of LTC settings can influence residents’ sense of home when older adults are relocated from one care setting to another.
Personal aspects of home: cognitive, behavioural and emotional aspects
Oswald and Wahl (Reference Oswald, Wahl, Rowles and Chaudhury2005) identified three personal domains that influence meanings of home: cognitive, behavioural and emotional. Cognitive aspects of home represent a statement of bonding to home, such as the experience of familiarity, identity and autonomy (Oswald and Wahl, Reference Oswald, Wahl, Rowles and Chaudhury2005). The familiarity of and attachment to the physical environment because of past experiences are important factors that contribute to a sense of home (Cloutier-Fisher and Harvey, Reference Cloutier-Fisher and Harvey2009). Research suggests that one's feeling of familiarity and predictability derives from knowledge of and comfort with their environment, including continuity in their daily routine and the layout and organisation of the built environment, which is important for their sense of home (Molony, Reference Molony2010; Cooney, Reference Cooney2012). Autonomy (e.g. control over daily schedules), choice (e.g. of activities and meals) and control over the physical environment (e.g. personalising bedrooms) have been found to be contributing factors to older adults’ sense of home (Dobbs, Reference Dobbs2003; Cloutier-Fisher and Harvey, Reference Cloutier-Fisher and Harvey2009; Molony, Reference Molony2010; Lewinson et al., Reference Lewinson, Robinson-Dooley and Grant2012; Falk et al., Reference Falk, Wijk, Persson and Falk2013; Bigonnesse et al., Reference Bigonnesse, Beaulieu and Garon2014; Johnson and Bibbo, Reference Johnson and Bibbo2014; van Hoof et al., Reference van Hoof, Verhagen, Wouters, Marston, Rijnaard and Janssen2015, Reference van Hoof, Janssen, Heesakkers, van Kersbergen, Severijns, Willems, Marston, Janssen and Nieboer2016; Rijnaard et al., Reference Rijnaard, van Hoof, Janssen, Verbeek, Pocornie, Eijkelenboom, Beerens, Molony and Wouters2016). Furthermore, residents who have chosen to move to a LTC home are more likely to experience a sense of home than residents who were not given a choice in relocation (Leith, Reference Leith2006; Cooney, Reference Cooney2012). Giving older adults who are living in LTC settings opportunities to make choices empowers them (Kane and Cutler, Reference Kane and Cutler2009; Molony, Reference Molony2010).
Behavioural aspects of home correspond to older adults’ everyday behaviours and proactive arrangement of their home environment (Oswald and Wahl, Reference Oswald, Wahl, Rowles and Chaudhury2005). Previous research suggests that older adults’ capacity to manage their daily activities and the accessibility of amenities, resources and opportunities that enable them to do so are important contributors to meanings of home (Marshall and Archibald, Reference Marshall and Archibald1998; Bigonnesse et al., Reference Bigonnesse, Beaulieu and Garon2014; van Hoof et al., Reference van Hoof, Verhagen, Wouters, Marston, Rijnaard and Janssen2015). Behaviours that indicate and sustain older adults’ independence may be particularly associated with a sense of home because independence, including physical independence and self-determination, is associated with non-institutional living environments (Sixsmith, Reference Sixsmith, Bytheway and Johnson1990; Kontos, Reference Kontos1998; Oswald et al., Reference Oswald, Schilling, Wahl, Fänge, Sixsmith and Iwarsson2006). In a care setting, when residents share some responsibility for housekeeping tasks, e.g. with staff, they are more likely to develop a sense of home (Verbeek et al., Reference Verbeek, van Rossum, Zwakhalen, Kempen and Hamers2009). Oswald et al. (Reference Oswald, Schilling, Wahl, Fänge, Sixsmith and Iwarsson2006) suggest that such behaviours are linked to the cognitive and emotional bonding that helps to create a sense of home and that organising and having control over everyday tasks creates and nurtures feelings of familiarity and safety in a living environment, both of which contribute to a sense of home.
Emotional aspects related to meaning of home include feeling a sense of privacy, safety and pleasure (Oswald and Wahl, Reference Oswald, Wahl, Rowles and Chaudhury2005). In LTC settings, privacy is a critical characteristic for creating a sense of home (Kane and Cutler, Reference Kane and Cutler2009; Molony et al., Reference Molony, Evans, Jeon, Rabig and Straka2011; Eijkelenboom et al., Reference Eijkelenboom, Verbeek, Felix and van Hoof2017). In community settings, privacy has been found to be related to social domains of home, such as having control over the timing and degree of interaction with others (Bigonnesse et al., Reference Bigonnesse, Beaulieu and Garon2014). Safety, another crucial component of home, has been associated with bodily integrity and physical security in the home and neighbourhood (Bigonnesse et al., Reference Bigonnesse, Beaulieu and Garon2014; Johnson and Bibbo, Reference Johnson and Bibbo2014), and, thus, suggests a relationship between feeling safe and physical aspects of home (e.g. door lock). Similarly, McCracken (Reference McCracken and Hirscheman1989) indicated that feeling protected is symbolised through physical enclosure and familiarity, suggesting a link between physical, cognitive and emotional aspects of home.
Social aspects of home
Interpersonal connections have been identified as critical to a sense of home (Dobbs, Reference Dobbs2003; van Hoof et al., Reference van Hoof, Verhagen, Wouters, Marston, Rijnaard and Janssen2015; Canham et al., Reference Canham, Battersby, Fang, Sixsmith, Woolrych and Sixsmith2017). For example, older adults and stakeholders who work in LTC settings perceive home as a place that provides individuals with activities and opportunities to gather and connect, and to develop and nurture a sense of belonging and community (Cloutier-Fisher and Harvey, Reference Cloutier-Fisher and Harvey2009; Lewinson et al., Reference Lewinson, Robinson-Dooley and Grant2012; Bigonnesse et al., Reference Bigonnesse, Beaulieu and Garon2014; van Hoof et al., Reference van Hoof, Verhagen, Wouters, Marston, Rijnaard and Janssen2015). Findings from research on social domains of home, defined as interrelationships with neighbours, staff and visitors (e.g. family and friends) (Oswald and Wahl, Reference Oswald, Wahl, Rowles and Chaudhury2005), suggest that an environment that allows older adults to continue to adhere to their perceived socio-cultural rules helps create a sense of home (Rubinstein, Reference Rubinstein1989).
Previous studies suggest that features of the physical environment influence the development and nurturing of interpersonal connections (Rijnaard et al., Reference Rijnaard, van Hoof, Janssen, Verbeek, Pocornie, Eijkelenboom, Beerens, Molony and Wouters2016). For example, when front doors and walkways in retirement communities are close to each other, it is more likely that residents will talk to their neighbours when they are walking their dogs or unloading groceries from a car. Such interactions can contribute to a sense of community and connection (Cloutier-Fisher and Harvey, Reference Cloutier-Fisher and Harvey2009). In LTC settings, creating opportunities for residents to interact with their families in daily-life situations, as opposed to formal, scheduled visiting periods, facilitates the development of a home-like environment (Lewinson et al., Reference Lewinson, Robinson-Dooley and Grant2012). However, this can be challenging for staff, as the environment is their workplace, whereas for residents it is their living space. Nevertheless, relationships between residents and staff in LTC settings are important for creating and nurturing a sense of home (Molony et al., Reference Molony, Evans, Jeon, Rabig and Straka2011; Lewinson et al., Reference Lewinson, Robinson-Dooley and Grant2012; Falk et al., Reference Falk, Wijk, Persson and Falk2013).
Philosophy of care
In addition to the physical, personal and social aspects of home, previous research has identified that the philosophy of care is an important factor in the development of a home-like atmosphere in LTC settings. The person-centred care philosophy, based on compassion, sensitivity, acceptance, caring and active listening, with particular emphasis on promoting residents’ human growth, subjective wellbeing and quality of life, aligns with and is reflected in the physical, personal and social aspects that create a meaning of home (Crandall et al., Reference Crandall, White, Schuldheis and Talerico2007). Person-centred care interventions for LTC settings include enhancing the physical environment (e.g. bringing in houseplants), creating interactive opportunities for social stimulation (e.g. increasing interaction opportunities with other residents and staff) and individualising care (e.g. recognising and responding to residents’ individual needs) (Brownie and Nancarrow, Reference Brownie and Nancarrow2013). Notably, however, it may not be possible to incorporate all aspects of home into LTC settings because they may conflict with each other. For example, for the sake of safety, older adults with cognitive and physical frailties may not have complete autonomy to participate in certain activities. Yet, finding a balance between older adults’ autonomy and physical and emotional safety leads to better wellbeing (van Steenwinke et al., Reference van Steenwinke, Baumers and Heylighen2012).
While an extensive body of research has explored what home means to older adults in various LTC settings, little research has examined how home is perceived and how a sense of home is affected by the move from one LTC setting to another. Exploring how older adults’ perceptions of home change following an institutional relocation is warranted, as the disruption to a sense of home, or lack thereof, may reveal factors that affect it and could contribute to a more comprehensive understanding of a conceptual structure of home. To address the existing knowledge gap, this paper explored how home was perceived by residents, family members and staff over two years before and after a relocation from two institutional LTC settings to a purpose-built LTC home in Western Canada.
Methods
In this qualitative study, 210 semi-structured interviews were conducted with 139 participants at five time-points over a two-year period to understand how residents, family members and staff perceived home in LTC settings and how perceptions of home were affected by the relocation to a new LTC home. To this end, this research was designed as a case study conducted during the relocation of residents and staff from two traditional institutional LTC homes (referred to hereafter as Holly Oak and Juniper Fields) to a single purpose-built LTC home (referred to hereafter as Jasper Grove) in Western Canada.
Research context
Jasper Grove, a seven-storey, 260-bed LTC home, was built in a suburban residential area to replace two LTC homes, Holly Oak and Juniper Fields, both of which were located in the downtown core of a small city (population of approximately 80,000) that were deemed by their non-profit operator to be no longer fit-for-purpose to support residents’ complex care needs. Holly Oak, built in 1906 and redeveloped in the 1970s to function as a LTC home, accommodated approximately 80 beds; Juniper Fields, built in the 1970s, had 147 beds. Both homes had long hallways, small single-occupancy bedrooms, one communal bathroom on each floor and centrally located nursing stations. In comparison, Jasper Grove is organised into 13 communities, made up of 20 resident rooms and a central living area, which serves as the heart of the house. Resident rooms are private with a full en-suite bathroom.
Purposefully designed with the aim of providing home-like care, Jasper Grove adopted a wellness model that aims to involve residents and family members in the care planning process to make every day as pleasant and fulfilling as possible for residents. Jasper Grove integrated innovative design features to create a home-like environment with the aim of (a) improving residents’ mobility in and around the home, promoting social interaction, and ensuring the safety and security of residents; (b) enhancing the quality of care by offering care in an environment that is conducive to a person-centred approach; and (c) supporting family visitation and providing a welcoming, open space to the surrounding neighbourhood community for socialising.
In 2014, the non-profit operator that developed Jasper Grove commissioned our research team to evaluate the relocation process and how the move to a purpose-built home-like care environment affected the perceptions of home of residents, family members and staff. This took place over a two-year period, beginning before the move in June 2014 and concluding 18 months after the November 2014 move date.
Recruitment
Using purposeful sampling, we recruited LTC residents, family members and staff. Residents’ family members were included in the study because, often, family members in their role as primary care-givers can provide useful insight into what home means to their loved ones based on their shared experience of personal home environments. Staff were included because through providing day-to-day care for the residents, staff frequently foster personal connections with them and thus develop better understandings of residents’ perceptions of home. The perspectives of the three groups contributes to a holistic understanding of residents’ views of home and helps to triangulate the data. All family member participants had to be 19 years old or over and able to communicate in English. To be eligible to participate, staff had to be working at Holly Oak or Juniper Fields before the move, for the pre-move data collection. For the post-move data collection, staff participants had to have worked at Holly Oak or Juniper Fields and be working at Jasper Grove. Due to high staff turnover after the move, however, staff who had not worked in Holly Oak or Juniper Fields before working at Jasper Grove became eligible to participate. Resident participants had to reside in Holly Oak or Juniper Fields for the pre-move data collection. For the post-move data collection, as the pool of resident participants was affected by deaths and cognitive decline, the inclusion criteria included anyone who resided in Jasper Grove, who was able to respond to questions, understood the purpose of the research and consented to their involvement.
Participants were recruited through information sessions held with residents, family members and staff at Holly Oak, Juniper Fields and Jasper Grove; emails circulated via employee and family email lists; and word of mouth. In the information session, the purpose of the study, research methods, potential risks and benefits, and confidentiality were explained. All participants provided informed consent and agreed to be audio-recorded. Ethics approval was obtained from Simon Fraser University Institutional Review Board.
Data collection
Semi-structured interviews were conducted with residents, family members and staff at five time-points over two years (from June 2014 to May 2016): four to five months prior to the move, and then three, six, 12 and 18 months after the move. A semi-structured interview was effective for exploring perceptions of home because open-ended questions allowed participants to respond freely and more broadly, and allowed researchers to ask probing questions to facilitate in-depth discussions of participants’ experiences, meanings and perspectives (Charmaz, Reference Charmaz2014).
Interviews with residents, family members and staff explored perspectives on (a) how Holly Oak, Juniper Fields and Jasper Grove were perceived in the context of ‘home’; and (b) how the move affected a sense of home in these LTC settings, with a particular focus on identifying features of Jasper Grove that contributed to or detracted from creating a home-like setting. Interviews with residents were conducted in their bedrooms or in quiet spaces at Holly Oak, Juniper Fields or Jasper Grove; family interviews were conducted in person at the LTC homes or by phone; and interviews with staff took place in private meeting rooms at the LTC homes.
Data analyses
The interviews were audio-recorded, transcribed verbatim, de-identified to ensure anonymity and analysed using Braun and Clarke's (Reference Braun and Clarke2006) thematic analysis approach. Trained qualitative researchers first became familiar with the data by reading and re-reading transcripts to gain an overall understanding. Using the qualitative data analysis software NVivo, the data were organised and managed; we inductively generated initial codes from the data by using words and phrases used by participants. We then collated all the codes into categories that described an essential feature of home. Following team discussion to assess whether the interpretation of data was culturally and semantically reasonable and whether the categorisation was internally coherent, the categories were clustered to generate overarching themes. Ongoing team discussions were used as a reference point as categories and themes were modified and refined until we reached consensus that each theme was internally and thematically consistent and mutually exclusive. We then defined and named the themes to capture the essence of each one.
Findings
Table 1 shows the number of residents, family members and staff who participated in the pre- and post-move interviews. In total, 35 residents, 23 family members and 81 staff participated in 210 interviews over the two-year study period. The number of interviews in which residents, family members and staff participated is presented in Table 2. Eleven residents (31%), 19 family members (83%) and 22 staff (27%) were interviewed more than once. Of 81 staff, 88 per cent were female; care aides comprised the majority (63%), followed by administrators or managers (12%).
Number of participants who participated in semi-structured interviews
Number of interviews in which residents, family members and staff participated
Thematic analysis generated four superordinate themes that contributed to creating and enhancing a sense of home: (a) physical environment features; (b) privacy and personalisation; (c) autonomy, choice and flexibility; and (d) connectedness and togetherness. Following participant quotes, the LTC home is indicated by ‘JF’ for Juniper Fields, ‘HO’ for Holly Oak and ‘JG’ for Jasper Grove. We also indicate participant group, identification numbers and data collection point (e.g. ‘Staff 22-JF&HO, 6-month post-move’ means staff participant number 22 having worked in both Juniper Fields and Holly Oak before the move interviewed at the six-month post-move data collection point).
Physical environment features
Pre-move findings
Physical features of Juniper Fields and Holly Oak that were identified as contributing to these settings feeling institutional included the size, layout, smell, light levels and furniture. For example, one family member commented that Juniper Fields ‘[is] very, very institutional; it's dark … there's no real lounge area on the floors for people to sit so they're all kind of lined up where they eat’ (Family 9-JF, pre-move). Excited about moving to Jasper Grove, one resident commented, ‘It is going to be more spacious, places to walk, which I am really looking forward to. That is about it. It is still another institution’ (Resident 8-JF&HO, pre-move). Juniper Fields’ environment was described by family members and staff as a ‘dark’, ‘old’ space with common areas that were ‘crowded’ and ‘not inviting’ and ‘long, wide hallway(s)’. Similarly, staff in Holly Oak indicated that it would have been more home-like had it been ‘cleaner’, ‘newer’ and ‘fresher’, and had a living room and kitchen. In addition, both staff in Holly Oak and family members in Juniper Fields identified ‘dirty carts’ (i.e. medication and linen carts) left sitting in hallways as a factor that makes LTC settings feel more like ‘a hospital’ or ‘nursing home’. In contrast, some staff suggested that the small size of the LTC homes contributes to a home-like environment: ‘The smaller the place, the more of a homey feeling’ (Staff 12-JF, pre-move).
Post-move findings
Many participants, particularly family members and staff, identified aspects of Jasper Grove's physical environment that influenced residents’ sense of home, namely the size, layout and furniture. While some participants commented that the spaciousness of Jasper Grove made it feel institutional, others identified the spaciousness as a primary contributor to Jasper Grove feeling like a home-like environment, as exemplified by the following statement: ‘The whole place is just bigger. Everything is bigger … I feel much more at home here [because of] the size of the building’ (Resident 16-HO, 6-month post-move). Residents and family members reported that Jasper Grove was more home-like because the bedrooms were bigger than in Holly Oak or Juniper Fields. Because the internal structure and layout of Jasper Grove did not feel excessively large, it did not feel institutional: ‘From the outside, the building looks huge and it really is for residential care, it's a big box. But once inside, it still feels manageable, it doesn't feel overly large once inside’ (Staff 47-JF&HO, 6-month post-move). In contrast, some participants felt that regardless of size, because there were 20 residents living in each community Jasper Grove is institutional. One staff participant explained: ‘The physical space … is an institution … because you're living also with…19 other people inside that community … it is just unrealistic that it is going to be like a home environment’ (Staff 62-JG, 12-month post-move).
For other participants, Jasper Grove felt more like a ‘hotel’ than a home because of the ‘fancier’ design of the public entrance space. One staff participant recounted some residents’ reactions when they first saw Jasper Grove: ‘High-end, definitely, some residents were upset at first, they said, “Oh, I can't afford to stay in this expensive hotel”’ (Staff 20-JF&HO, 6-month post-move). One family member agreed:
It feels a bit like a hotel to me … You go in, there's the little bistro there, there's kind of the check-in desk, there's the fish tank and the fireplace, which you see in the lobbies of a lot of hotels. And then you go up and there are these rooms with private bathrooms, just like a hotel. (Family 17-JF, 6-month post-move)
In addition, the spacious layout of the building resulted in staff and residents being spread out, which led some residents and family members to feeling isolated, uncomfortable and hotel-like. One family member summed up the difficulty in finding staff in the hallways and lounges:
[L]ots of times … I didn't see any staff at all … It was so big, and so spread out. I mean, it does look very spacious, but I think as a home, it was more like a hotel with everybody in their individual little rooms. Whereas Juniper Fields, there was always somebody there if something happened. (Family 6-JF, 6-month post-move)
Other physical features of the 20-resident communities in Jasper Grove that were identified as contributing to a sense of home included the television (TV) lounges, fireplaces, kitchens, and patios and balconies, all of which are features typically found in homes. One staff participant said:
From the residents’ point of view, I would definitely say that this is more home-like. We have so many different features that we didn't have in the old place; we have spacious hallways; we have a really nice living room with a TV; we have the overhead music; we have the fireplace; all luxuries … it's designed pretty good. (Staff 40-JF, 12-month post-move)
In this participant's opinion, a home-like care environment distinguished Jasper Grove from the previous LTC homes because Jasper Grove offers residents ‘luxuries’ that LTC homes do not traditionally have.
The big windows and patio that brought natural light into the communities and allowed residents to have access to protected outdoor areas were other physical features that contributed to a home-like environment, as summarised by one family member:
The way they've done all the large windows in the rooms and the common area on each floor, there where you can actually go outside and sit in the enclosed deck, it's so bright in there. It makes it brighter and more like being at home. (Family 12-HO, 6-month post-move)
While some participants reported ‘nice’ and ‘comfy’ chairs and sofas in Jasper Grove to be critical for a home-like atmosphere, other participants reported that some of the chairs and sofas were not suitable for residents:
Some of the chairs are hard for the residents to get off. They're … too deep … I don't find them very comfortable … they could have been, in my estimation, a little bit nicer, bigger … that would have made it look more home-like. (Staff 60-JG, 12-month post-move)
Finally, artificial plants in Jasper Grove were viewed as detracting from a home-like environment. Several staff participants expressed a desire for more ‘real’ plants, artwork and pictures to make Jasper Grove more home-like, suggesting that home is associated with comfort and personal belongings, as well as physical features that residents are interested in and have attachment to.
Care-related physical features of Jasper Grove that were perceived as compromising a sense of home included medical equipment, overhead lifts in bedrooms, medication carts left in sight of residents and staff scrubs. These items have come to symbolise institutional settings and thus medicalise these environments. One staff participant noted how the issue of carts is being dealt with: ‘I think that's the big thing that we have to remember. You don't want carts, and they've always implied that with us. Like when you've done your morning care, just put it in the closet’ (Staff 53-JG, post-move 12-month). Another staff participant explained how residents feel when staff wear scrubs:
I'm wearing the name tag, I'm wearing the scrubs. I'm staff. Even with the dementia, you see it. That they still associate you as staff, not family …They notice if the staff wear personal clothing, it is more family-like because they don't see you as somebody that's going to get them to do everything … Actually, a lot of them think it's pill time … So that tells me they associate me as staff. (Staff 43-HO, 18-month post-move)
While scrubs give staff more freedom of movement, they also symbolise institutional settings, which in turn is associated with ill-health and power relations between residents and staff. Creating a home-like environment in a LTC setting is challenging amongst equipment, devices and technologies that are frequently required to provide care but not typically seen in a home.
Privacy and personalisation
Pre-move findings
Before the move, participants from both Juniper Fields and Holly Oak noted that allowing residents to decorate their bedrooms with personal items, such as pictures, facilitates a sense of home. For example, one staff participant from Juniper Field commented that ‘the décor [would make the home] not look so clinical’ (Staff 27-JF, pre-move). Related, family and staff participants critiqued the limited space in bedrooms that made it difficult to bring in residents’ personal furniture and belongings. One staff participant from Juniper Field commented: ‘So many of the residents will say to me, “This isn't my home”, because none of the furniture is theirs because they can't bring any of their furniture with them’ (Staff 16-JF, pre-move). A sense of familiarity with a place is critical to creating a home-like environment, and a lack of personalised items in a bedroom might undermine this.
Family members and staff in both pre-move homes also noted that the lack of privacy resulting from there being no shower or bath in residents’ bedrooms compromised the sense of home for residents. One family member said that ‘definitely not having the shower in [father's] bathroom’ (Family 11-HO, pre-move) influenced the perception of Holly Oak as not being home-like. In these settings, residents had to be escorted down public hallways to a shared bathroom to be bathed.
Post-move findings
Private bedrooms were reported to be crucial to helping residents feel a sense of home. One staff participant commented: ‘I do think it is a far better home for our residents, having the larger private rooms, the bathroom with a shower, everything accessible’ (Staff 47-JF&HO, 6-month post-move). However, privacy was somewhat compromised from some residents’ perspectives because they could not lock their bedroom door for safety reasons, which negatively affected their sense of being in a home-like environment. One resident said, ‘The fact that people are always coming into the room. They knock, but then they just come in so I feel like I don't have privacy … It's just, it's just not home’ (Resident 11-JF, 6-month post-move).
Being able to personalise their own space was another essential element for residents to develop a sense of home at Jasper Grove. One resident noted, ‘In my room I feel comfortable … I've got all my stuff in here’ (Resident 8-JF&HO, 12-month post-move). Acknowledging that bigger bedrooms can be more easily personalised, participants identified numerous items and objects that they used to do this. For example, one resident commented on having furniture:
There is still some furniture from my house that needs to come here like my computer desk and I have a reclining chair that is electric that I'm going to really love when it gets here … then I'll feel a little bit more at home. (Resident 11-JF, 6-month post-move)
Similarly, family members indicated that having furniture that residents like and feel comfortable with would create a sense of home.
Decorating their bedrooms with personal furniture, artwork and pictures was identified as not only creating a space that gives residents a sense of comfort and familiarity, but also generating a sense of ownership. One staff participant said, ‘Even though it's not their room, they have personal stuff that they [use to] make [the bedroom] theirs’ (Staff 62-JG, 12-month post-move). Thus, while a resident does not own their bedroom, they can personalise it to maintain their identity, autonomy and sense of home.
The importance of decorating spaces with personal items in order to create a home-like environment was emphasised beyond residents’ bedrooms. For example, a staff participant in one community expressed the benefits of displaying residents’ arts and crafts in common areas:
About two months ago we were told we weren't allowed to hang up any of the residents’ artwork … That's been hard, because the residents really like it … they were quite proud of their artwork hanging up, and showing their families, and the other residents enjoyed it, but we had to take it all down … That's not making something home-like, right? (Staff 65-JG, 12-month post-move)
Decorating common spaces with residents’ artwork showed residents that they were recognised for their work and place in their community, and had the freedom to display their skills and interests. Participants thought that displaying residents’ artwork or other framed pictures in common areas should be encouraged.
Autonomy, choice and flexibility
Pre-move findings
Participants frequently identified autonomy as an important factor in the creation of a home-like environment, both before and after the move. For residents, having the freedom to take a bath whenever they wanted and having choices about their food were critical to nurturing a sense of home. While some resident participants in Juniper Fields and Holly Oak noted their satisfaction with the food served, others were more negative. One of the residents who was not entirely happy with the food options in Holly Oak identified having ‘choice’ as a key characteristic that differentiates a home from an institution:
When you make dinner, it's a real home … it certainly doesn't happen here. When you're at your home, you buy the vegetables and you cook them the way you want them and there can be a tremendous difference between vegetables at home and vegetables here … And the quality, it's up to you; you don't have any say about that in an institution. (Resident 20-HO, pre-move)
Having control over and choices about the quality and variety of food and the way it is prepared were identified as critical for residents to feel at home in LTC. Family members commented on the lack of choice regarding special diet meals (e.g. vegetarian, non-chewable), meal times and the serving process, which contributed to an institutional rather than home-like feeling:
The meal process is more institutional than home-like. They cart the food up on the elevators and the people have to gather outside the lunchroom, wait out there until they open the lunchroom for them to go into, and then the meals are put out. It seems to be fairly regimented in that respect. (Family 13-JF, pre-move)
For staff, giving residents flexibility around when they could wake up, have meals and bathe was critical to creating a sense of home. One Holly Oak staff participant said, ‘You got certain times for their meals here … I don't think this particular place is [home-like]’ (Staff 9-HO, pre-move).
Post-move findings
After the move, freedom to access amenities and to participate in activities was mentioned as contributing to a sense of home. Having ‘freedom to walk’, choose which dining table to sit at, when to come to the dining room and have drinks whenever desired were common examples of autonomy and choice. One staff participant expressed gratitude for the organisational change that resulted in flexibility around the time residents are woken up and given breakfast:
Before [the move], all the residents were up and had breakfast at a certain time. Now we can take our time if they're sleeping … before I had ten [residents] so it was go, go, go … get ’em there by 8:30 am to 10 am. It was an hour and a half; it was go, go, go. Now it's slowed down … I like it. (Staff 38-JF, 6-month post-move)
Having to rush residents through their daily routines prior to the move made staff feel like they were working in an institutional setting rather than a home-like environment. Another staff participant expressed that the openness of the dining rooms at Jasper Grove enabled residents to access and create social spaces, and in turn provided them with more autonomy than they had before the move:
This dining room [at Jasper Grove] is much better because it is in the middle between two living areas … the one in Juniper Fields was closeted off and locked. So this is much better … they can sit propped up at the table with their coffee and people go back and forth … it is open, more homey somewhat. (Staff 45-JF, 6-month post-move)
Nevertheless, it was reported that there remained some challenges in giving residents full autonomy and choice. For instance, one resident commented that a lack of being able to access independently space outside their community diminished their sense of home:
Not really [home-like]. The thing that bothers me is the limited access … I can't go down to the main floor unless I have somebody go with [me], and I think that there should be a time when I'm recognised as being intelligent and reliable and not going to steal the silverware or run away. (Resident 26-JG, 18-month post-move)
Moreover, though person-centred care was reported to contribute to a sense of home, licensing requirements and low staffing levels challenged the delivery of person-centred care, as explained by one staff participant:
Because of licensing there's a lot of hiccups … letting residents sleep as long as they want, that can't just happen because they have to have something to eat or drink by a certain time. And you try to make it resident-centred care as much as you can, but at the end of the day we don't have enough staff to be able to have it fully resident-centred. (Staff 49-HO, 6-month post-move)
Low staffing levels were suggested to result in increased rigidity around routines, which is a feature of institutional settings and prevented staff from fully providing person-centred care. One staff participant noted: ‘Now it is like a factory feeling, getting them up and ready and on to the next one’ (Staff 43-HO, 6-month post-move).
Connectedness and togetherness
Pre-move findings
Before the move, only family members and staff identified connectedness and interaction as factors they felt contributed to residents’ sense of home. A wide range of social interaction opportunities were described as contributing to a home-like environment: from one-on-one attention from staff in daily care routines to conversations during recreational programmes. One family member commented on the opportunities for interaction in Juniper Field:
Just because you're in the throes of dementia, doesn't mean your essential personhood disappears … if you're an extrovert, I think people need places where … you can have a conversation with one other person, to sit quietly and have tea. And then more social places too where you can play cards or have puzzles out and available. (Family 15-JF, pre-move)
For LTC settings to have a home-like feel, participants suggested that residents should feel cared for and be given sufficient opportunity to converse and interact with others. Staff participants in Holly Oak mentioned relationship building between residents and staff as essential for residents to develop a sense of home in LTC.
Post-move findings
Following the move, participants again identified social interaction as an important feature that made Jasper Grove feel like home for residents. Having common areas in Jasper Grove that allow residents, family members and staff to gather in small groups was perceived as particularly important for helping residents feel socially connected: ‘There is always good in having shared [common] rooms … if people … are just alone or by themselves in their room, it felt more lonely or sad’ (Staff 69-JG, 12-month post-move). Several participants, however, expressed a desire for a larger lounge space, big enough to allow larger groups of people to gather in one place, instead of the multiple smaller lounges that accommodated smaller groups. It was suggested that the smaller lounges resulted in residents being spread out and the community looking empty: ‘I think our lounges could have been a little bit bigger, because if you get a couple of wheelchairs in there, it sort of takes over the room’ (Staff 60-JG, 12-month post-move).
In addition, participants identified a lack of social opportunities at Jasper Grove to facilitate resident interaction. One resident recounted:
I liked Juniper Fields better … you can watch people, but here … you don't see a single person walk down the street … So, I more or less watch TV in my room … I haven't got a good thing to say about it other than it's new, it's shiny, it's polished. It's institutional in other words. (Resident 5-JF, 3-month post-move)
Similarly, one staff member explained how few activities were available to residents in Jasper Grove in comparison to activities offered in Juniper Fields:
You do have that one TV area, but you have the other side that has nothing … there is nothing to do over there. So, social space is a big one, or social activities … At Juniper Fields, they had everybody sitting in a circle, and … they read to them, or they played ball with them … Seeing what kind of abilities they still had. But I don't see any of that here. (Staff 58-JF, 12-month post-move)
Finally, because of the additional demands staff had been assigned at Jasper Grove, as well as low staffing levels, staff reported having limited time to spend with residents. One staff participant explained:
We just don't have time for [residents]. We don't have as much time as we used to have. Doing extra things for them, doing their nails, soaking their hands if their nails are really dirty. There's just no time for that now because we're busy doing dishes. (Staff 67-JG, 12-month post-move)
The limited time and opportunity to connect and build rapport with residents was implicated in hindering the creation of a home-like environment in Jasper Grove.
Summary of pre- and post-move perceptions by participant group
Table 3 summarises the pre- and post-move perceptions of each participant group.
Pre- and post-move perceptions of home of the residents, family members and staff
Notes: J: Juniper Fields. H: Holly Oak. (+): positive contribution to a sense of home. (−): negative contribution to a sense of home. (±): both positive and negative contributions to a sense of home.
Residents
Juniper Fields and Holly Oak residents’ perspectives of home before the move were primarily related to personalisation (e.g. decorating their bedrooms with pictures), privacy (which was compromised by having to share a communal bathroom) and freedom of choice (related to choosing their bath times); social connection and physical environment features were not identified as primary factors. After the move, residents perceived personalisation (e.g. having personal belongings in their living areas), privacy and choice about their food as critical factors that contributed to a sense of home, just as they did before the move. The freedom to go outside and access to social interactions and connection also appeared as important to residents after the move.
Family members
Before the move, family members, particularly in Juniper Fields, identified physical features (e.g. small size, smell, linen carts left in hallways), a lack of personalised items (e.g. furniture) in bedrooms and insufficient choice about food as contributing to an institutional environment. Families in both Juniper Fields and Holly Oak emphasised that the lack of privacy resulting from having to share a communal bathroom compromised residents’ sense of home, whereas recreational activities and companionship contributed to it. After the move, family members’ perceptions remained focused on these factors. Overall, many physical features in Jasper Grove (e.g. spaciousness, layout, light levels) were perceived as contributing to a home-like environment, although the spaciousness was viewed less positively, as it made it difficult to keep other residents and staff within a reachable distance. Two factors that also contributed to nurturing a sense of home at Jasper Grove were the ability for residents to have personal furniture in their bedrooms and more opportunities for them to spend time with family members in Jasper Grove.
Staff
Staff participants, particularly in Holly Oak, identified physical features – such as size, layout and the presence of linen carts in hallways – as factors that influenced a sense of home before the move. Staff also noted that the residents’ inability to personalise their bedrooms with furniture, the lack of privacy resulting from there being no en-suite baths/showers and the lack of flexibility in daily schedules were all factors that negatively affected a sense of home for residents of Juniper Fields and Holly Oak. After the move, the key features that staff participants identified as influencing a sense of home were physical features (e.g. size, layout, light levels, furniture and medication carts left in hallways); the option to personalise bedrooms with photographs, furniture and artwork; flexibility regarding wake-up and meal times for residents; and relationships between residents and staff.
Discussion
This paper explored how home was perceived by residents, family members and staff over two years, prior to and following a relocation from two institutional LTC settings to a purpose-built LTC home in Western Canada. The four features identified as contributing to a sense of home in LTC reflect the findings from previous research: physical environment characteristics; privacy and personalisation; autonomy, choice and flexibility; and connectedness and togetherness.
Findings reveal that the physical environment is a crucial factor in contributing to a sense of home. Physical structures and design characteristics reported to influence a sense of home in this study are consistent with findings from previous research: lighting (Cooney, Reference Cooney2012), cleanliness (Lewinson et al., Reference Lewinson, Robinson-Dooley and Grant2012), small-scale community (e.g. Verbeek et al., Reference Verbeek, van Rossum, Zwakhalen, Kempen and Hamers2009), welcoming communal spaces (Falk et al., Reference Falk, Wijk, Persson and Falk2013) and furniture typically seen at home (e.g. Lewinson et al., Reference Lewinson, Robinson-Dooley and Grant2012; Verbeek et al., Reference Verbeek, Zwakhalen, van Rossum, Kempen and Hamers2012). In addition, our participants revealed that fancy, luxury features that are often associated with hotels rather than home settings may make it difficult to develop a sense of place attachment, given that hotels are, by their very nature, associated with temporary stays rather than permanent homes (Falk et al., Reference Falk, Wijk, Persson and Falk2013).
One of the prominent findings of this study was that physical environment features are foundational to nurturing the emotional, cognitive, social and behavioural aspects that contribute to a sense of home. For example, for LTC settings to feel like home, bedrooms need to be spacious enough for residents to decorate them with their own pictures and artwork, and with larger personal belongings and furniture that are important to them. This enables personalisation, ownership and familiarisation with place (cognitive aspect) (e.g. Falk et al., Reference Falk, Wijk, Persson and Falk2013; Johnson and Bibbo, Reference Johnson and Bibbo2014; Marquardt et al., Reference Marquardt, Bueter and Motzek2014; van Hoof et al., Reference van Hoof, Janssen, Heesakkers, van Kersbergen, Severijns, Willems, Marston, Janssen and Nieboer2016). Privacy (emotional aspect) and freedom to bathe whenever residents want (cognitive aspect) were also affected by the physical environment – that is, the lack of en-suite bathrooms before the move negatively affected residents’ sense of home. Previous research has found that having to share a bathroom with others may compromise residents’ sense of control and privacy (Eijkelenboom et al., Reference Eijkelenboom, Verbeek, Felix and van Hoof2017), indicating the influence that physical design has on cognitive and emotional aspects of home. Further, in the present study, smaller common areas were viewed as limiting the capacity for large group gatherings and engagement in activities (behavioural), which limits connectedness and togetherness (social), as also suggested by Rijnaard et al. (Reference Rijnaard, van Hoof, Janssen, Verbeek, Pocornie, Eijkelenboom, Beerens, Molony and Wouters2016).
Our findings illustrating how perceptions of home changed after the move reveal that home is a multifaceted, dynamic construct. Before the move, a limited sense of home was directly attributed to physical features or indirectly associated with them through other aspects such as lack of privacy and ability to personalise bedrooms. After the relocation, many of the physical features that contributed to generating an institutional feeling or prevented the nurturing of a sense of home were changed, and the associated issues of privacy, autonomy and personalisation, therefore, appeared to have been addressed. However, a sense of home after the move appeared to be derived mainly from the operationalisation of care at Jasper Grove. For example, residents were offered a limited number of activities, which restricted their connectedness and sense of community. This, combined with the infrequency of residents seeing or interacting with staff, was a primary reason why participants in all three groups noted that residents did not experience a sense of home. Although each community at Jasper Grove had fewer residents than the communities in Holly Oak or Juniper Field, the areas that staff had to cover in order to care for their assigned residents increased as bedrooms and hallways were made bigger while the staffing level remained unchanged. The staff's heightened workload reduced the time they were able to spend connecting with residents, which, in turn, diminished residents’ sense of home. Theoretically, small-scale LTC homes should foster staff's attentiveness to, knowledge of and engagement with residents; however, previous research has also identified that low staffing levels are an issue in small-scale LTC homes, as staff work alone and residents do not receive adequate attention (Verbeek et al., Reference Verbeek, Zwakhalen, van Rossum, Kempen and Hamers2012). Consequently, behavioural (e.g. shared activities) and social (e.g. connectedness) aspects that contribute to a sense of home are compromised, which resonates with the notion that the physical environment alone is insufficient in creating a sense of home (Verbeek et al., Reference Verbeek, Zwakhalen, van Rossum, Kempen and Hamers2012).
The fact that the three participant groups commonly identified certain factors as contributing to or detracting from a sense of home before and after the move suggests that a successful person–environment integration in terms of experiencing a sense of home requires these factors to be in place or circumvented. The process of institutional relocation demands new person–environment integration, and familiarity and continuity of space, self and activities are key to reconstructing, restoring and sustaining a sense of home after a move (Sixsmith and Sixsmith, Reference Sixsmith, Sixsmith, Newton and Putnam1990; Molony, Reference Molony2010; Cooney, Reference Cooney2012; Wiersma, Reference Wiersma2008). To this end, personalising spaces by decorating their bedrooms with pictures and comfortable furniture helped residents not only to recreate a space that expressed and reinforced their identity, but also to regain a sense of control over their living environment (Power, Reference Power2017). In contrast, day-to-day social interactions and activities with familiar staff and residents were disrupted by the institutional relocation, which diminished residents’ emotional attachment and sense of belonging, and impeded their sense of control over their daily lives, both of which are critical to a sense of at-homeness (Power, Reference Power2017).
The findings from this study reveal the tension that exists between intentions to create home-like LTC environments and the Province of British Columbia's requirement that LTC homes provide 24-hour professional care, including clinical supervision and support (British Columbia, nd). This provincial requirement limits the capacity of LTC providers to create a home-like environment as medical equipment and devices (e.g. built-in ceiling lifts in bedrooms, the visible presence of medicine carts), as well as structured daily schedules, are inevitable features of the provision of daily medicalised care. The dual-purposes of LTC homes – care and home – create the complexity of developing a setting. Receiving necessary care and having a sense of home both contribute to wellbeing and are not mutually exclusive in late life. In general terms, however, home is defined symbolically as personal and social life, whereas care is symbolised through medical care, services and work. Therefore, in terms of operationalisation, combining the requirements of both care and home in a single physical space creates tension and requires unique negotiations between residents and staff (Davis et al., Reference Davis, Byers, Nay and Koch2009; Milligan, Reference Milligan2009). As such, more innovative research that advances technologies (e.g. ambient assisted living; Fang et al., Reference Fang, Coatta, Badger, Wu, Easton, Nygård, Astell and Sixsmith2017) within the context of LTC may address this tension.
This study has both strengths and limitations. The fact that very few participants were involved in multiple data collection points limited our capacity to examine how an individual's sense of home developed throughout the institutional relocation. However, because participants had moved from one LTC home to another, they could compare their perceptions of two LTC homes, which enabled deeper insight into what influenced a sense of home in LTC. Additionally, due to the cognitive decline of some resident participants, these accounts were not as in-depth and reflective as they could have been, which limited an understanding of their experiences and perspectives. However, to augment our understandings of sense of home in LTC, we were able to draw on reports from family members and staff. Future research should include data collection methods that enable residents with cognitive decline to describe their perspectives more effectively (e.g. photovoice). Further, due to a significant difference in the number of participants we were able to recruit in each group, comparisons among the findings of these three groups were not feasible. Nevertheless, we were able to conduct multiple semi-structured interviews over a two-year period with three different participant groups, which gave us access to a wide array of perspectives on the sense of home in LTC and allowed us to compare these perspectives before and after the move. Finally, because this study was conducted at three LTC homes (two traditionally institutional ones and one purpose-built one) in Western Canada, the transferability of the findings may be limited.
Conclusions
This is one of a limited number of studies that have explored how home is perceived by LTC residents, family members and staff who have experienced an institutional relocation. Further research is required to investigate how different aspects (e.g. physical environment features, autonomy) influence the creation of a sense of home when relocating from one LTC home to another. In addition, it is critical to investigate how physical and organisational features that are essential for the provision of medical care can be incorporated into LTC settings without compromising residents’ sense of home.
Acknowledgements
We thank the participants for their interest and participation in this project.
Author contributions
All authors for this paper have contributed to designing and conceptualisation of the described study; analysing and interpreting data; drafting, critically revising and editing the manuscript; and approving the version submitted for publication.
Financial support
This work was supported by Baptist Housing.
Ethical standards
Ethical approval was obtained from Simon Fraser University.
