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Chapter 2: Literature Review
care for older people. Using a qualitative case study design this study was conducted
across two American residential units (NH1=125-bed unit and NH2=120-bed unit). It
used multiple data collection methods including formal and informal interviews,
participant observation and document review. The aim of the research was to explore
in depth the experience of dying in two nursing homes from the perspectives of
residents, staff and family members. Observations were recorded in multiple
locations around the residential unit and formal interviews were semi-structured.
Observations were carried out by three graduate students who spent a total of 40
hours each week, including different shifts and days of the week, for nine months in
NH1 and for eight months in NH2. The participant observations included
observations of care processes and everyday life in the homes. Interviews, both
formal and informal, were conducted with residents, staff and family members. The
resident sample included those with cognitive impairment (total sample n=56).
Thirty-one residents participated in NH1 while 25 participated in NH2. Qualitative
content analysis was used to code and categorise the textual information. Each
residential unit was described in its appearance and atmosphere.
The researchers found that NH1 and NH2 adopted different approaches to care. NH1
operated on a philosophy of only providing physical care and paying higher wages to
a core group of staff rather than lower wages and employing more staff, whilst NH2
operated on a philosophy of providing the best possible nursing home services to
residents who had limited assets. Resident admissions to NH2 were in line with
staffing levels and were reduced during times of staff shortages. NH1 was described
as noisy, lacking privacy and with unpleasant odours while NH2 was described as
bright with a home-like feeling, pets and gardens adding to the initial impression.
NH1 focused on task orientation while NH2 facilitated residents’ requests to stay in
bed and eat outside meal times, and demonstrated affectionate relationships with the
residents. The researchers discussed the powerful connections between structure,
process and outcomes in an organisation’s approach to care. At the structural level
the two homes had contrasting institutional philosophies, which were reflected in
staffing and the environment. The two homes contrasted in their processes of care by
having different patterns of planning, communicating and making decisions. Thus
the outcomes were substantively different and the relationship between the
organisation’s approach to care and positive resident outcomes, particularly in