The following section presents the results from the analysis focusing on which practices provided quality of care, meaningful activities, and social life for the residents in the shared living spaces of the nursing home. Three interlinked themes emerged from the data: working within the given frames, forming practices, and organising activities.
Working within the given frames
We identified three different kinds of frames forming the practices in the shared living space of nursing homes: environmental frames, mealtimes, and residents' health situations and individual needs. Overall, there were substantial similarities in how daily life in the shared living spaces was carried out across the six units, and we did not observe any major differences in practices that could be related to the nursing homes’ size, organisation, business model or location in the city.
Environmental frames that form practices
The physical frames of the shared living areas, such as the architecture, furnishing and decorations, represented opportunities and limitations in providing quality care for the residents.
For example, the care workers spent a large amount of time in the kitchen, and they could observe and communicate with the residents while preparing the meals. In this way, the care workers were available and present for the residents while doing other tasks. This was important, as the care workers had busy days and were constantly working and moving around. In all nursing home units, the residents paid much attention to the care workers' activities in the kitchen. In one of the units, the architectural layout even situated the kitchen as something of a theatre scene, where the residents could sit like an audience paying attention to the care workers “acting” out the kitchen work.
Aesthetics were highly valued by the care workers as important for the residents' well-being, and they took pride in keeping the living rooms tidy and nicely decorated with tablecloths, flowers, and décor, as well as setting the table nicely for meals by using napkins and candles. The quotation of a care worker below provides a typical example.
At the weekends and birthdays, we lay the table with nice clothes and napkins. We have a patient here that attended fine restaurants. She seldom wants to join the others at the table, but when it is nicely done, she sits by the table and enjoys the meal. It makes a difference you know, having nice surroundings. But look at the flower over there (points at a rather sad potted plant). It is dreadful, it should have been thrown away. However, a resident owns it, and she loves it.
The quotation also illustrates one of many examples of how care workers were attentive to the residents' wishes even when they conflicted with other values, such as aesthetics. The care work included a constant negotiation between different values, such as keeping the interior nice and tidy and meeting the personal wishes of the residents.
Meals as frames for work
Mealtimes structured the day in the nursing homes, starting with breakfast (typically 9 am), followed by lunch (approximately 1 pm), dinner (approximately 4 pm) and an evening meal (approximately 7 pm). In addition, coffee with snacks or fruit was served in between. Normally, the residents had all their meals in the social eating area, and a large part of life in the common areas circled the meals. At first glance, it seemed that the time-consuming work related to preparing and serving meals was taking time away from other forms of care. However, throughout the observations, it appeared that the care workers used the mealtimes for several purposes in addition to fulfilling the residents’ nutritional needs, such as making conversation, making jokes, and performing observations.
The care workers acknowledged that they spent a large amount of time preparing and serving meals and that this could be stressful. At the same time, several care workers argued that work related to food and drink was an essential part of care work and a gateway to observing the residents’ condition and needs and looking for symptoms of deterioration or different problems that the care workers needed to act on.
We would like to have more time to do the care work, however, working with the meals is important too. Then we can observe the patients. Then we can see how they eat. We are planning and documenting the care, and it is easier when we have observed how and what they eat and drink.
A high level of service was provided with meals. The residents were served at a table almost like in a restaurant. During our observations, the residents were never involved in setting the table, and only once was a resident observed helping to clean up after a meal.
The dinner menu was fixed, but the residents were asked how much food they wanted, what they wanted to drink, etc. The residents often praised the food and ate with a good appetite. A few times, the food was not quite to their taste, but then a typical comment would be “I have always eaten what I have been served”. If the care workers noticed that a resident was eating less than normal or if the residents signalled that they would prefer something else, they were offered alternatives. Such individual adjustments sometimes made a substantial difference for the residents:
Don’t you want soup? – the care worker asks. The resident shakes her head. She mimes that she eats something. Do you want a sandwich? - the care worker asks. The resident nods. With cheese, the care worker asks. Again, the resident nods. Always with cheese, the care worker says. I will find you a variety of sandwiches to choose from. She goes to the refrigeration and fetches a platter that she shows the resident. She asks the resident kindly what she wants. The resident points to some sandwiches and the care workers serve them to her.
Occasionally, the care workers sat by the table during the meal, especially when some of the residents needed assistance with eating. They usually sat down facing the person they were helping. Assisting someone in eating a meal could take as much as an hour. This time was spent talking to the resident whom they were helping as well as to the others around the table while observing, offering, and serving drinks in between, etc.
The care worker is sitting beside one resident and helps her to eat. Another resident starts coughing. The care worker stands up and goes over to him immediately. She strokes his forehead and says, “Are you okay? You must eat carefully so you don’t have to cough.” Then, she sits down and continues helping the other resident again. She says, “So you like fish – that is good! Here comes another piece.” Then, the care worker raises her glass and proposes a toast to everyone around the table.
This quotation illustrates how the care workers typically combined tasks, e.g., caring for one person while carrying out a social conversation with the group and additionally motivating them to drink by toasting to them all. There was generally a lot of toasting, often in a humorous way.
Talking about food was an important area of conversation, both among the residents and between the residents and the care workers. What to eat and drink and when to do so were probably the most common topics of conversation.
Residents’ health situations
Another important determinant of social life in the nursing home units was residents' health and functional level. Most residents were frail and suffered from multimorbidity.
The residents always had a personal choice of where to spend their time; however, the care workers often encouraged them to spend time in the common areas, in part to increase the residents’ social lives and in part for organisational reasons, as it was easier to take care of all the residents when they were in the same room. In the living room, the residents often switched between paying attention to the television or the kitchen and nodding off in their chairs.
Many of the residents were fragile, and saving energy for the most important activities was crucial. The care workers took this into account when organising the day. There were always opportunities for resting before and after planned activities, and the activities usually lasted no longer than 1 hour. The care workers focused on finding a balance between activities and rest as illustrated in the quote below:
Some of the residents are so frail that morning care is a huge strain. They get so exhausted that they don`t have the energy to eat breakfast and just fall asleep. afterwards. Food is most important, so then we serve breakfast in bed before the morning routine.
Forming practices
There was a major focus on the basic physical needs of the residents, and the care workers spent most of their time meeting the residents' physical needs, such as providing the appropriate nutrition and helping the residents move around and go to the toilet. This left rather little time for other individual social activities with each resident. Much of the social interaction between the care workers and residents occurred during or in between this practical work.
Being alert
The care workers rarely sat down for more than a couple of minutes to talk with residents, as they were always on the go to complete new tasks. Many of the care workers managed to be calm and create an impression of not being busy, showing attentiveness when sitting with the residents. However, they were constantly watching out, observing the rest of the room to ensure that everybody was alright, putting the roller to the side so that nobody fell, adjusting the position of a resident slipping down in his chair, finding a jumper for a resident who felt cold, etc.; they were always alert. They reacted quickly but calmly to prevent agitation and turbulence between residents when there was a sign of any escalating behaviour, as illustrated below.
The care worker helps a resident into an armchair while communicating calmly. Afterwards, she makes sure that the wheelchair is placed safely and not in the way of someone. While doing this she observes that another resident looks cold, and offers her a scarf. She also puts a pillow behind her back to comfort her seating. Then she leans over to another resident and asks if she wants to watch the TV. Suddenly a resident shouts out angrily. The care worker gently takes his hand and calms him down. She sits next to him and talks calmly while also smiling at the other residents.
Utilising personal resources
There were opportunities for the care workers to use their personal skills and interests at work. For example, one care worker who enjoyed singing often sang old songs with the residents when she had time. Another care worker who enjoyed physical activities played with a ball and went for walks with some of the residents. Another care worker often baked a cake for the residents when at work. The work culture in all units seemed to encourage individual initiative from the care workers to utilise their resources.
All units were staffed with both registered nurses and other care workers with different competencies, ages, and cultural backgrounds. In total, in the six units, only two residents were from another country. They both suffered from dementia and no longer spoke or understood Norwegian. Care personnel who spoke their language knew them and could reach out to them, which became important.
In one unit, a nurse was speaking one of the resident’s languages. She used to go over to him and talk to him in his native language. His face lit up in a smile. Often, he walked around mumbling words to himself with his eyes closed, looking stressed. The nurse took her mobile phone, uploaded old folk songs from his country and slipped the mobile phone into his pocket while gently talking to him and telling him about it. When the music started, he stopped mumbling. He started to hum and clap, tears came into his eyes, and he was smiling. He seemed calmer in his body, and his hands carefully moved along with the beat of the music.
Engaging in relational work
It was observable that the personal knowledge the care workers had of each resident to a large extent guided their care, even when they were addressing a resident as part of a group. One example is how the residents were seated during the meals. The care workers described how the seating plan was carefully designed to create a nice atmosphere. Residents who enjoyed each other’s company were placed close to each other, and residents who were jumpy were placed away from those who needed peace.
Most of the social interaction observed in the common areas was initiated by the care workers. Small talk and conversations in the living/dining rooms were almost always initiated by the care workers. They often enforced their words by physically touching the residents to capture their attention while talking.
The care worker always has her face at the eye level of the resident. She often puts her hand gently on their shoulder before she talks. This gives the residents time to be aware of her and seems to improve the communication between them
If a nurse initiated a conversation and the residents joined in, the conversations seemed to dwindle if the care worker left the conversation. There were many examples of how the care workers adjusted communication and care to the resident’s individuality and related differently to individual residents depending on their personalities and backgrounds to initiate conversations. Some of the care workers also shared aspects of their personal lives with the residents by telling them news about their children or their pets. These personal small conversations often generated engagement from the residents and formed a basis for talking about memories from their own lives, creating an atmosphere of awareness, happiness, and laughter.
Organising activities
Due to cognitive or physical impairment, most residents had limited possibilities to initiate and perform activities by themselves. The number of practical tasks to solve during the day, related to meals and physical care of the residents, left the limited number of staff with few opportunities for initiating individual activities with the residents. Consequently, group activities had a prominent place.
Likewise, there were several situations in which the residents’ physical and cognitive functional levels guided which activities the care workers chose to do. The residents decided for themselves which activities to attend. However, care workers often actively motivated or nudged residents to attend a concert or other activities based on their knowledge of all the resident’s preferences.
Planned activities
All the units had a weekly activity plan describing the activities offered in the nursing home each week. There were both institutional and unit activities presented. Examples of group activities included visits from kindergarten children, a singsong and group training with the physiotherapist. Some activities took place in the common areas and were open to all residents in the nursing home, not only those in the unit. Examples of these activities were church services, bowling, concerts, etc, as illustrated in the fictive weekly plan presented in Table 3.
Table 3
| | Monday | Tuesday | Wednesday | Thursday | Friday |
| Morning | Exercise with a physiotherapist | Breakfast gathering on the third floor | | Breakfast gathering on the fourth floor | |
| Noon | Vocal lesson singalong | Baking Christmas cookies | Visit from children from the kindergarten | Church service arrangement | Balloon activities with an occupational therapist |
| Afternoon | | Therapy dog from The Red Cross | Singalong in the living room | | Reading aloud in the living room |
| Evening | Bowling in the cafe | Concert with the boys’ chorus | Walking Group | Bingo in the cafe | The movie “Mary Poppins” in the cafe |
Table 3. Weekly plan for activities
The goal of the activity plan was to have something for everybody’s taste. Many of the activities were very popular, and most of the residents participated. One example was visiting from the voice teacher.
Observations: The voice teacher sings old familiar songs. Some songs make the residents applaud and make approval comments. Some residents sing along to some of the songs. The voice teacher has a beautiful voice, and one lady sits with her eyes closed during the singing. She opens them when the song is finished. Another resident sits up straight in her wheelchair and mimes the lyrics while looking at the singer.
While singing, one of the residents rolls her wheelchair out of the room. While passing me, the resident says, I can’t take this anymore. I think this is dreadful.
This provides an example of how not all group activities had the same appeal to all the residents, which made it possible for them to withdraw from activities.
Some of the activities had a considerable impact. Visits from kindergarten children and therapy dogs especially created lively engagement among the residents.
One resident had been sitting without talking or moving the whole day. When the therapy dog came into the room, she smiled and reached for the dog. The dog owner placed the dog close to her chair and the care worker helped the resident so that she could pet the dog. A smile animated her face.
The care workers extended the value of the activities by talking about them before and after they took place. This created room for discussion and reflection and gave the residents joy in remembering their experiences.
Spontaneous activities
There were some examples of individual activities, such as a resident going for a walk with a student and a resident having her nails polished when a nurse assistant had a spare moment. However, it was striking during the observation how few individual activities took place. It also seemed that individual activities were more often spontaneous, meaning that they were not planned but took place if by chance there was time for it. The main exception to this was when relatives or visitors involved individual residents in activities.
In addition to the regular care workers, the nursing home often had students present. Several of the care workers mentioned the students as a resource contributing to social activities that they had problems finding time for. The students generally spent more time socialising with the residents than the care workers, which was important in initiating spontaneous activities for individual residents.