The experience of entering residential aged care: The views of residents, family members and staff—an Appreciative Inquiry

To understand resident, family and staff perspectives of older people's transition to residential aged care and initiatives that support this transition.


| INTRODUCTION
][6] Risk factors for admission include increased frailty, decreased mobility, recurrent falls, compromised nutrition and poor medication compliance, resulting in complex care needs. 6,7In Australia, entry to residential aged care requires a comprehensive assessment by a federally funded Aged Care Assessment Team, most commonly triggered as a result of recurrent presentation to a health-care service as the level of frailty increases. 7,8nce the decision is made to seek residential care, there is a need to locate a suitable placement.This sets the individual and/or their carer on a path to find such a placement during a period of crisis and duress. 4,6There is considerable variation in the availability of residential aged care places across metropolitan, regional, rural and remote areas. 2 Carers speak of their frustration with the aged care entry portal, MyAgedCare, a concern also raised at the Royal Commission into Aged Care Quality and Safety. 1 Critical life events allow little time for residents and carers to prepare for this significant change. 4This experience is referred to as relocation stress, 5 often resulting in feelings of relentless grief and loss. 9,10egative experiences of residential aged care by a family member or friend can contribute to increased unease or fear of admission to residential care.These concerns are reinforced by negative stereotypes and adverse media attention. 11Older adults who experience anxiety about transitioning to residential aged care fear losing control over the decision-making process, potentially further impacting their declining health. 12A review of carers' experiences of a relative transitioning to residential aged care reported that they felt under duress to make a decision that may not have aligned with their personal preferences or cultural values, and they felt the need to defend their decision as their own health was impacted.In addition, the findings show that entry to residential care directly from an acute setting, particularly after a crisis event, is problematic. 13arers can flounder after their relative is admitted to residential care.They may struggle with this change in their role, having to relinquish their relative to people they do not know nor yet trust to provide the care they know is needed. 14Family members see themselves as an advocate for the resident 15 and feel the need to demonstrate this commitment by monitoring the quality of care provided. 16,17There can be a lack of recognition from staff of the ongoing importance of family carers, and their need for support both before and after entry to aged care. 6,13,17hile in some countries, such as the United States, gerontological social workers assist to address these complex issues, comparatively few social workers are employed in residential aged care in Australia to provide this support. 18,19 lack of communication between families and staff can be a source of conflict. 20Studies in North America have shown that when communication between staff and carers is prioritised, there are improved quality of life outcomes for residents. 21A literature review of culture change models in the United States, the UK, Canada and Australia demonstrated that collaborative relationships between residents, staff and family members are indicators of a successful aged care culture. 22Involvement of family in the coordination of resident care was found to have positive benefits for both the resident and family dynamics and the relationship with staff and the service. 16,23Overall, prioritising staff-family relationships has been found to reduce negative outcomes and to have a beneficial effect on not only the care environment, but also the workforce's perceptions of family caregivers, resulting in improved relationships and reduced complaints. 9espite what is known of the challenges experienced by carers and older people as they enter residential care, more insight is needed into any positive experiences and what was helpful in supporting the resident, family carers and staff to adapt to this change.This paper addresses the following research questions: 1. What is the experience of transitioning to residential aged care for residents, family members and staff? 2. What initiatives can support residents, family members and staff through this process?

| METHODS
This paper draws on the perspectives of aged care residents, family members and staff.The research was part

Practice Impact
Transition to residential aged care can be supported by an orientation program for residents and their family members and prioritising communication processes that meet the needs of the individual.A consistent approach to staffing allocations can increase trust and provide confidence that residents needs will be met.
of a larger study on the introduction of an organisational culture focused on relationship-centred care and the well-being of aged care residents.The project adopted a qualitative design and was guided by Cooperrider's social constructionist Appreciative Inquiry (AI) approach. 24 The study was conducted in a residential aged care organisation which operates multiple residential facilities across Brisbane.Stages 1 and 2 were carried out in a new aged care facility, while Stage 3 was implemented across the whole organisation.The study site for Stages 1 and 2 was opened 1 year prior to the commencement of this study and is home to 144 residents over two levels with accessible gardens and interior green spaces, with multiple dining and lounge areas and entertainment amenities.The study was approved by the Southern Cross University Human Research Ethics Committee (ECN-17-076).All participants volunteered to be involved in the study, were provided with an information sheet, advised of the purpose of the project and gave informed consent.

| Participants
Participants in Stages 1 and 2 were residents, family members and staff who met the inclusion criteria and were recruited to the study through internal advertising.Eligibility criteria for residents included no or mild cognitive impairment.Family members were eligible if their relative was not a participant in the study.This was to ensure a broad range of family experiences including that of caring for a relative with cognitive impairment.Family participants were not selected to act as proxies for their relatives.Staff were purposively sampled to seek as wide a representation of staff roles as possible.Sampling for Stage 3 was also purposive and involved board members, corporate managers, clinicians, residential aged care managers, frontline care staff, relatives and an invited resident panel with lived experience of residential aged care.

| Procedure
Stage 1 of the AI involved semistructured interviews with residents, family members and staff at the new residential care facility.Undertaking the research at a greenfield site assisted understanding implementation of a new culture of relationship-centred care.The topics explored during the interview stage included residents' perceptions of wellbeing, experience transitioning into residential care and the relationships they valued and how these developed.This was followed by three focus groups (Stage 2): one each with residents, family members and staff who participated in the earlier interviews, acknowledging that each cohort may benefit from being able share their views more freely among their peers.The focus groups explored further the themes emerging from the earlier interview stage and sought to identify points of consensus.
The AI approach afforded the opportunity to explore examples of initiatives that had made a positive difference to the participants and the culture of the home.An organisational summit (Stage 3) was held to share findings from the interviews and focus groups and consider how they could inform wider organisational change.Workshop attendees participated in activities that acknowledged the constraints on innovation in aged care and focused on the organisation's strengths and willingness to challenge conventional practice.Further activities asked participants to develop initiatives that empowered residents in everyday decision-making.All data collected in Stages 1 and 2 were audiorecorded, uploaded to NVivo12 and independently transcribed.Stage 3 data were collected through workshop activities; all materials generated through the interactive collaborations were collated and sorted using the same approach as the earlier stages.The data generated at each stage informed the next phase and provided the opportunity to expand on previous findings.
All data were analysed thematically using Ritchie and Spencer's framework analysis, 25 based on the approach by Ritchie, Lewis, McNaughton Nicholls and Ormston. 26his involved Author A (FL) familiarising themselves with the recorded and written data, field notes and reflections.These data were entered into NVivo12 and, in collaboration with Authors B and C (MH, SN), repeated indexing and sorting was undertaken to identify agreed primary and secondary themes.Author A returned to the data extracts for direct quotes supporting the main themes and provided visual data displays to demonstrate the iterative process of data analysis.
The potential for researcher bias was addressed through Lincoln and Guba's 27 construct for trustworthiness utilising credibility, transferability, dependability and confirmability.To address any potential predetermined views or influence in the work, the first author kept contemporaneous field notes and a reflective journal throughout the study, along with frequent debriefing with the second and third authors.

| Stage 1: Appreciating-Adapting, guilt, grief and trust
The interviews were conducted with 40 participants, comprising residents (n = 13), family members (n = 10) and staff (n = 17) (Table 2).A series of themes emerged from this first stage.Residents stressed the importance of adapting to the situation, while family members and staff acknowledged the guilt and grief that can arise from a decision to admit a relative to residential aged care.The importance of trust was raised in this first stage and continued to be raised throughout the remaining stages of the study.

| Adapting
Residents emphasised the important role their family members played in assisting them to adjust to their new environment.They spoke of the need to accept the decision, despite preferring to remain in their own home, and that they did not wish to be a burden to their family.One resident explained, 'you know… we just have to accept that this is our last address and just be happy about that' (Evie), while others expressed positive appreciation and acknowledged the importance of family: 'I'm incredibly fortunate in [having] my grandchildren and my daughtersin-law' (Kora).

| Feelings of guilt
Deciding to admit a relative to residential care weighed heavily on family members.All spoke of feeling overwhelming guilt, even when they knew the decision was necessary for their relative's well-being.Family participants described how the complexity of the aged care system contributed to their anxiety about the decisions they made: 'I think it's just the whole aged care funding thing… Oh, my God.The whole thing could've been a lot smoother had that been more explained or simply made sense' (Iris).

| Grief response
Many of the family participants expressed their experience in terms of a grief response, as the health decline of a parent coincided with a period of denial and the relative's wish to remain in their own home.However, this was less evident among resident participants who, once the decision was made, became more accepting of their circumstances: 'It's a very hard thing to accept, in the beginning.Difficult to accept.I think about it a lot because when you first get sick you think you're going home … then the realisation comes that it's not going to happen.… It takes a while to digest that and, having done that, you just move forward' (Julia).

| Need for trust
Family members struggled with trusting others to provide the care their relative needed.Their concern was that staff would overlook the care needs of their family member.This manifested as hypervigilance of staff practices and the need for frequent clarification and proactive relationship building by the service.Over time, trust was formed, and relatives were able to step back from their carer role: 'You want to be a daughter again and not a carer' (Abbie).

| Stage 2: Envisioning-Relationships, identity, communication and trust
Three focus groups were conducted with residents living at the site (n = 6), family members (n = 5) and staff (n = 7) (Table 2).The benefit of focus groups in AI was evident when residents and family members were able to collectively share how they had overcome their earlier reactions to entering the residential care system.).Family members valued their role as an advocate for the resident, while at the same time attempted to relinquish their formal carer role.

| Communication
Communication processes proved problematic for members of the family focus group, particularly regarding staff changes and the impact on residents: 'I think she loves having the same people all the time.When they go through a change … she doesn't like it much because she's got to know her people and they know her' (Evie).In the staff focus group, participants were aware of the strain felt by relatives and the complexity of resident needs.This led to awareness of the need to support family members through improved communication: 'At the end of the day they [families] become your family as well … you are there to support their family… it's definitely an extremely customer-focused position' (Isabel).

| Developing trust
In each of the focus groups, the importance of developing trusting relationships was a recurring theme.Family focus group members valued the friendships they made with other relatives during the days following admission.Staff focus group participants emphasised getting to know residents and their families to reassure and support them through the early stages and beyond.Members of both the resident and family groups spoke of the importance of building positive relationships with staff they knew and felt they could trust to anticipate and provide for the residents' needs.The organisational summit participants (n = 72) represented a wide a range of roles across the provider's services including senior leadership, frontline workers and those with lived experience.They included executive and senior management (n = 17), registered nurses (n = 16), care workers (n = 19), allied health staff (n = 4), leisure and lifestyle staff (n = 8), grounds and maintenance workers (n = 2) and administration officers (n = 2).There were also three residents and one family member who participated.During the summit, earlier themes were explored collaboratively through workshop activities.The focus was outcomes that met the wellbeing needs of residents.Participants stressed the need for the organisation's culture and reputation to be considered trustworthy by the community and clients they serve.They acknowledged that a leadership model that created high trust through clear and consistent communication was the next step in sustained culture change.This would assist transition to residential aged care for residents, family members and staff.Summit participants focused on solution-based outcomes to the themes identified in the study.To achieve these outcomes, they proposed the following initiatives: • Supporting the organisation's senior leaders to advocate for an improved pathway to residential aged care services and the role social workers can play in assisting transition to residential care.• Piloting a service navigator role to orientate residents and families to the new environment.• Developing resources that support orientation to the services, co-designed with residents and family members.
• The finance team co-designing with residents an improved system that streamlined the process and made the statement costs easier to understand.• Improving the organisation's handbook to better meet the needs of multilingual consumers and those with diverse needs.• Committing to the organisation's recently introduced application platform that provides regular daily updates of life in the home with photographs and short posts from residents and staff.• Improving the staffing model to ensure more consistently assigned staff, aiding communication and developing trust between participant groups.• Given the cultural backgrounds of the staff working in the organisation, developing sensitive education on cultural and linguistic diversity in consultation with residents and family members.

| DISCUSSION
This paper examined two key questions: What is the experience of transitioning to residential aged care and what initiatives can support residents, family members and staff through this process?In terms of experiences, while the AI approach focused on positives, it was clear that admission to residential aged care was a challenging time for residents and family members and it is worth noting that more than 50% of the resident participants had resided at the site for less than 9 months.People expressed concerns about their adjustment to this life change, the conflicting emotions of grief and guilt and a recognition the decision was inevitable.This underlines the ongoing challenges residents and family members face when entering residential aged care and the tangible and intangible losses that accompany the move. 6onetheless, there were also positive experiences reported, including recognition of the importance of family members in the lives of the residents and their role as advocates, the willingness of most residents to accept and adapt to the new phase in their life and the positive relationships built between residents, staff and families.Participants valued the physical environment at the site such as the café, gardens and private dining room, which created a sense of community.There were several initiatives that supported the culture of the site.Staff were consistently allocated to the same residents, which enhanced staff knowledge of individual residents' needs.
Trust was a key theme that emerged through each of the stages of this study and was central to the success of initiatives to support admission to residential care.In the earlier stages, the residents spoke of the challenge in getting to know staff and having faith in them to provide their care.This was supported by family participants who felt that once staff learned about their relative, demonstrated their knowledge and engaged with the family, a relationship of trust evolved.The theme of trust was picked up again in the organisational summit and informed the proposed initiatives, such as advocating for improved pathways to service navigation and the consistent staffing model.In this way, the findings of this study led to recommendations for streamlining entry to aged care in the organisation, focussing on the experience of residents and family members.
Several of the findings support Australian and international literature, including the need to address the complexity of the admission process to reduce consumer stress and the ongoing emotional support required for both residents and family members. 6,13,18,19Introducing a formal orientation for family members could improve communication and create positive first impressions. 15,28Developing a consistently assigned staffing model can contribute to mutually trusting relationships between staff and family and increase confidence in the care provided. 20,29Creating constructive relationships between family members and staff has been associated with improved communication, knowledge of residents 18 and their individuality, 16 and reducing the potential for conflict or hypervigilance. 15,20here were some limitations to this study.Stages 1 and 2 were undertaken at a new residential aged care facility.Many residents had only been living at the site for less than a year and their views may have been different to those living in a more established site.The cohort at this site were relatively homogenous, coming from a similar cultural background.The experiences entering a similar residential aged care facility for people from culturally diverse backgrounds may be different, as might the experience of being admitted to a service targeting a particular cultural group.

| CONCLUSIONS
This paper reported findings on the residential care transition experience and practical initiatives to support residents, family and staff.Transition to residential care is a complex and difficult time for both residents and family members.Building positive relationships between residents, family members and staff relies on consistent and clear communication to create a culture of trust.Having staff who are well known to the resident and family members helps reduce anxiety and addresses misunderstandings before they develop into a complaint.Proactively developing collaborative relationships with family members that values their role in the life of the resident not only promotes resident wellbeing, but also increases trust in the organisation to the mutual benefit of all groups.
T A B L E 1 Stage 2: Envisioning Three focus group interviews with residents (n = 6), family members (n = 5) and staff (n = 7) Residents, family members and staff were asked 'what could be'.What would you like to see change to support the best possible experience of aged care?Stage 3: Constructing Organisational summit involving (n = 72) participants An organisational summit was held to explore potential organisational changes and methods of adapting to meet the needs expressed by the study participants.
Demographics of Stage 1 and Stage 2 participants.
T A B L E 2Family members saw themselves as the 'keeper of the resident's identity'.As one daughter stated, 'I think it's really important for staff to know about where you've come from, who you were, what you were like in the recent years before you've actually become a resident because everybody's so individual here' (Dana