Original Article

Care Process in Iranian Nursing Homes: A Grounded Theory Study

Introduction

With the beginning of the 21^th century, aging of population has manifested as an important phenomenon. ¹ High prevalence of chronic diseases among the older people is the main cause for the demand of overall health care. ² Care of older people is a major concern to all of us. When a good care is not available, the results are suffering in older people, stress and worry for families, and often ineffective efforts to find an alternative one without support. ³ Support for older people who lose independence through disability, illness, and age-related frailty or poverty takes many forms ranging from family-based community models to long-term care within institutions such as hospitals and nursing homes. ⁴ The nursing home is defined as a center for providing long- term health services for the older people with chronic illness and disability, especially the older people who need help with their activities of daily livings (ADLs), but there is a vast concern about the quality of care in nursing homes which are related their problems including dignity, abuse, nutrition and medical care. ^5,6

Despite improvement in older people care, there are some challenges in long term care, because the nursing homes are inappropriate and inadequate to meet the needs of older people. ⁷ There are some reasons such as absence of a clear expectation from healthcare professionals to do to provide optimal care, focus of care only on the physical aspects, without considering the psychosocial ones, prevention of health problems and safety of the older people and high level needs of older people for care. ^6,8,9 Based on an Iranian research, caring for patients’ with Alzheimer’s disease consists of physical routines without professional attention to other aspects of care, based on personal experience. ¹⁰ If we consider the care as a mutual phenomenon between care recipients and caregivers, there is limited knowledge about consensus between them for care delivering. ¹¹ Another important reason is lack of agreement about care concept. ¹² However, doctors are one of the main components of providing services to the older people, but there is little research on medical care in nursing homes. ¹³

As a care provider to provide holistic care, we need to know how care is delivered in nursing homes, but in Iran, we know nothing about it and there is any study on it. So, this study was performed using grounded theory method to discover the care process in Iranian nursing homes until care gaps to be discovered to deliver holistic care as much as possible and improve the quality of care.

Materials and Methods

Data were collected using unstructured interviews and analyzed based on a grounded theory approach as described by Strauss and Corbin 1998. ¹⁴ The participants in this study were the older people (OP) residing and their caregivers (CG) and managers (Mg) in three nursing homes in Isfahan, Iran.

Sampling was purposive with maximum variation. ² The study participants consisted of 14 older people, as the main participants, (5 males and 9 females), and 14 caregivers (4 nursing aids, 3 nurses, 3 managers, 2 physicians and 2 family caregivers) (Table 1 and Table 2).

The inclusion criteria were the age more than 60 years and absence of cognitive diseases to remember their everyday life experiences for the older people and minimum 1 year work experience in nursing home for the caregivers and willingness to partici­pate in the study for both groups. Their consent was obtained and the interviews were individu­ally conducted in Persian. Twenty-eight 20–60 minutes interviews were conducted and continued until data saturation (when there were no new themes).

The interviews were conducted in nursing homes in a quiet environment at the time and place desired by the older people. Most of them were done in morning and after breakfast in their rooms. Interviews were conducted for caregivers at the nursing station or their office.

The data were collected via unstructured interviews. The interviews with the participants began with general questions based on research question. We asked from the older people about “daily life experiences”, and from caregivers about “daily care experiences for the older people in the nursing homes”. So, we obtained the participants’ experiences concerning the given care in nursing homes. We also used probing questions to clarify the information and to gain additional data.

Researchers also used memo writing about the interviews and compared extracted findings with the resulted concepts. We also used theoretical sampling where there were gaps in analysis. Researchers presented and interviewed with participants in all shifts to achieve participants’ experiences. The in­terviews were digitally recorded and transcribed verba­tim word for word, and analyzed, based on a grounded theory approach. Data collection and data analysis took place simultaneously. Researchers used the paradigm model for analyzing the data. This model has some basic components include: causal conditions, contextual conditions, actions and interactions or strategies taken in response to the phenomena and intervening conditions that help or hinder interactions and the consequences of the actions. We analyzed each interview before the next interview and if some important issues emerged, these were then brought up in the next interview. ¹⁴

Open, axial and selective coding was applied to analyze the data. ¹⁴ Before starting the data analysis the researcher intended not to put his previous ideas on analysis process (Bracketing). In open coding we used a line by line analysis, labeling and grouping of the data into themes and sub-themes. In this stage we found 543 substantive codes and 11 themes. In axial coding stage the themes resulted in open coding conceptualized by specifying the relationships among them and integrating them into a new form. Eventually the number of themes was reduced and 5 major new themes were emerged as axial codes (experience based caring”, “inappropriate structure for care”, keeping instead of caring”, “dismal life” and “up and down of the path”). At the selective coding process the core theme which related to all other themes was recognized. ¹⁴ All the analyses were done by the first author in collaboration with the research team.

In this study trustworthiness of data include credibility, transformability, dependability and conformability were considered. ¹⁵ To increase reliability, the first research­er directly communicated with participants in all work shifts to collect data. We, also, used member check and peer check. We record precisely all stages and processes of the study and reports. ¹⁶

Ethical consider­ations were considered in this study, which include attaining informed consents, explana­tion about secrecy and anonymity of the interviews and participants’ right to withdraw from the interview and research at any time, based on general ethical guideline for human researches by the ministry of health of Islamic Republic of Iran. The ethical approval of the research was taken from ethics committee in University of Social Welfare and Rehabilitation Sciences (92/801/A/2/6861). Thesis registration number is 950-148. This study conducted from June 2013 till September 2015.

Collection and analysis of data was carried out simultaneously. After recording the interviews, the data transcribed verbatim and analyzed using constant comparative method.

Each interview analysis was made before the next interview and important issues that emerged from one interview, brought up in the next interview. ¹⁴ We used field notes during the observations and memos in the analysis process. The research lasted 26 months.

Results

In this study “fragmented care” was identified as core category. This concept reflects the viewpoints of participants about care process in nursing homes.

illustrates how the core category is related to the 5 categories identified in the study. Some them3es are completed via theoretical sampling such as adjustment with conditions and peaceful coexistence.

Close

Figure 1. Organization of data (concepts and categories), using the paradigm model and core category of care process in Iranian nursing homes

Causal conditions

There are conditions that lead to deliver care as a nonprofessional task. Some of these conditions are related to caregivers and some to administrators (untrained caregivers and market administration). Caregivers are without professional training and work by their experiences. One of them said “I am illiterate but by experience I do their works. For example I bath them (older people) better than other”. (CG1)

This cause to everyone concludes a personal result about care. A nurse aid about the meaning of care said “care means that I give them water when they are thirsty or exchange their napkins”. (CG3)

An older people said “when nurse aids say: my dear, to me I become glad and is sufficient for me”. (OP5)

Although, an administrator said “we take care of their spiritual needs and organize religious trips for them”. (Mg2)

Market administration causes that the care organization become nonscientific and based on decreasing costs. For example in care planning there are some failures. An older people in response to answer about his caregiver said “I don’t know him. My urinal catheter must be changed but I don’t know when and by whom?”. (OP2)

Also this type of administration leads to nonprofessional caregiver’s recruitment. An older people said “the recruitment system must be changed. We need the professional caregivers. The care system must be changed, too”. (OP 14)

Contextual conditions

There are the specific sets of patterns of conditions that interfere with care in nursing homes and cause the set of circumstances or problems to which caregivers respond through actions/interactions. ¹⁴ The participants described the contextual factors which affected care delivery in nursing home. These conditions caused inappropriate structure for care. There were two themes: first, insufficient resources for care with two aspects including: experienced and skilled caregivers and the necessary equipment for care. In this regard, there were several problems, which leaded to dissatisfaction of the caregivers and care recipients about the given care.

Ignoring rehabilitation experts and lack of specialized nurses in the older people care is one of the issues. In this regard an older person said, “There is a deficiency in personnel, especially male ones. So they can’t give good care to us. Also there are many older people in each ward.” (OPs 1 and 4)

One of the nurse aides said: “We are very busy. Sometimes we ignore minor cases. One of the reasons is shortage of personnel. In a ward with about 100 older people, two personnel are very low.” (CG4).

Another factor which influences the care in nursing homes is shortage of equipment for care. A nurse complains that: “Unfortunately, we did not have a blood glucose meter in the ward. Mr.… says anytime you need it, come and get it from me. It is a big problem.” (CG 3) or an older people said: “There aren’t enough clothes and medicines in our access. The caregivers are strict. I must request several times for clean clothes. ” (OP2)

The second theme was conflicted environment, which reflected general schema of the nursing home. Here, we discuss about culture, attitudes and rules.

The culture of nursing home formed based on mutual relationships. So there were mutual benefits. An independent older people said: “I help them (caregivers) and they do my works or give me flowers or pickle.”(OP4)

Another older people which were dependent had opposite idea: “we can’t help them or give them anything. They know this matter. Why they expect us?” (OP8)

Attitudes were results of culture. An older people believed that: “Here, life has three parts: Breakfast, lunch and dinner, only eating. Life is barren, for all of us. The caregivers don’t notice us if we become dependent.” (OP14)

The rules were organizational rules. A nurse discussed: “We have morning report. The older people say us about their problems and then we do according to our duties. ” (CG7). A manager about administrative hierarchy said: “If there is a problem, the head nurses must report. We have highlighted duties for every person and they must do them. If our caregivers have any negligence, we questioning them and if they repeat, they will be punished. ” (Mg 2)

Intervening conditions

The intervening conditions are the broad factors which affect the caregiving process and facilitate or constrain it in this context. Two themes extracted: control on conditions and no control on conditions.

When there is control on conditions, the care process is facilitated. Some factors from participants mentioned.

Organizational constructs are an important factor. A caregiver said: “According to my duties I check them room by room. Sometimes we must help together. I must supervise the nurse aids.” (CG2)

A manager discussed that: “We must supervise the caregiver’s actions. We codified their duties. They must notice on the health, nutritional, mobility and mental affairs of older people. Our supervision leads to better caring.” (Mg1)

Spiritual beliefs are another facilitator. A caregiver believed that: “I like here. If I couldn’t go here I would be homesick. Our duties are very hard and we earn very low, but it is sufficient forme. My work satisfies me.” (CG3)

A manager said: “All of us work here with good intent. Money is the next matter. We serve for poor people. We love our tasks.” (Mg 2)

Obstacles of care process are diverse and are from family and older people. Vulnerability is an important component. One of physicians mentioned that: “The older people are frail in physical and mental aspects. They suffer of many problems such as depression, loneliness and incontinence. So we must meet their needs properly.” (CG8)

From family aspect, also there are some problems. Often, their family are careless and the older people have the excommunicated sense. An older people expressed that: “I have two daughters. I am not satisfied of them. I worked hard for them, but they don’t care of me. The strangers are better than them.” (OP8)

A caregiver had an experience: “We had an older people which cried very much. When I requested why do you cry? He answered me: my son don’t visit me for many time.” (CG5)

Action/ Interaction strategies

There are purposeful or deliberate actions, which are taken by individuals or groups in response to events, problems or issues which occur under certain conditions. ¹⁴ Participants described that different persons act and react with present conditions, for care delivery in nursing home.

When we notice to relationships in nursing home, we understand that they selected a peaceful coexistence. It is useful in some condition. An independent older people described this situation: “I help nursing aids. I like to help. I wash dishes, change the clothes, sort beds and every other work.” (OP4)

A nurse said: “They help us. It is useful for them because they would be active. It isn’t mandatory and is their option. Every work which they can, they do. Washing dishes and clothes, help to dependent ones, sweepingthe floor.” (CG2)

But there are some conditions in which the caregivers care, as an unpleasant task and resulted to indifference to older people problems. The most prevalent reasons for this issue were a shortage in caregivers, their low sal­ary and lack of caregivers’ education. In this regard an older people said: “I said to Mr. … to exchange my urinary catheter, yesterday. He exchanged it about two months ago.” (OP1). Another of them said: “When I request them (caregivers) to check my blood glucose, they don’t answer. They check it every two or three weeks.” (OP11)

As the same way, caregivers had some viewpoints. A nurse believed that: “We accept to work here. It is true that our salary is very low, but we are committed to do our duties.” (CG2). The other nurse said: “We care for older people and we must know about their physical and psychological needs, so we must have necessary education about treating their needs.” (CG7)

Consequences

The action/interaction strategies chosen by the participants leads to consequences. ¹⁴ As the older people transition to nursing home, often is mandatory, so they try to adapt themselves and satisfy from conditions. They reduce their dependency to others and feel better and have the sense of normal life.

An older people said: “If they permit, I take a shower by myself. I want to live like my home. I wash my clothes by hand. I don’t like to be dependent.” (OP14)

In some cases, the older people tried to diversify in their life. They used of free time and had some engagements. An older person said: “I pray in my free time. I have a hand held radio which listen to it.” (OP2) or “I occupy myself, for example I weave jackets or read book and newspaper.” (OP5)

For other older people which were dependent, they had harder conditions. They suffered more and in some cases the result was disappointment. “I am sad. I don’t have comfort. I must bear and can’t do anything.” (OPs7 and 8) or “Are we happy? Do you know when? When we die and buried.” (OP2)

A manager believed that they are like prisoners: “Unfortunately, we are witness that they are await for their families, like prisoners, but prisoners will be released.” (Mg2)

Residents of the nursing home have been relocated for various reasons, such as poverty and loneliness. They suffer from many diseases and need comprehensive care in physical, psychosocial and spiritual aspects. The participants’ experiences showed that they are not provided with holistic care. Therefore, the care is performed incompletely and without considering the different dimensions of older people needs. Fragmented care was therefore considered as the core variable.

“I have to call several times for them (caregivers) to come. When I have a request, they no longer ask if we have another job or not. They do not pay much attention to all our needs.” (OP8)

Discussion

The aim of this study was to investigate the care process in nursing homes. This grounded theory study was con­ducted to discover participants’ experience. We selected the nursing homes with different managerial methods (through charity and private sectors) and tried to have the highest variety in collection of data.

Based on participants’ experiences, fragmented care is the core category of care process in nursing home. Inappropriate structure for care and experience based care were defined the main factors which contributing with fragmented care in nursing homes. Also, some barriers such as funds, job conflicts and time limitation prevent a suitable care and they cause fragmented care. ¹⁷

This concept was chosen against integrated care. Care is integrated when it benefits the individual and fits the situation of the healthcare setting, and include all physical, psychological and social aspects of care. ¹⁸

Some influential factors were related to the context of the nursing homes such as complicated environment of nursing homes and the extent of control on conditions.

Various strategies used in order to deal with the conditions resulted in fragmented care, and between them the peaceful coexistence could promote the conditions.

Contextual conditions

Untrained caregivers

Observations in nursing home demonstrated that caregivers are without training related to care of older people. Unauthorized people working in nursing homes (i.e., care aides or personal support workers) provide up to 80% of general personal care. ¹⁹ The most prevalent reason for defective care in nursing home, is a shortage in caregivers, their low sal­ary and lack of caregivers’ education. ² Staff with different levels of education are necessary for better caregiving, for example baccalaureate nurses and nursing aids. ²⁰ The use of untrained caregivers in nursing homes causes to reduce in the quality of care for older people. ²¹

Market administration

In charity and private sectors, there are nonscientific and nonprofessional administration which lead to disorganized care program. There are many problems such as ineffective leadership, poor communication between nursing home managers, and lack of staff support which have led to a large turnover of personnel and their withdrawal from the care system. ²²

The education level of administrators and all five quality indicators include physical restraint use, pain management, urinary catheter use, and pressure sores are positive associations. Likewise, there are positive significant associations between state educational requirements and state training requirements and the five quality indicators. ²³ Implementation of guidelines were perceived by staff as beneficial for both staff and the residents which developed by professional administrators. ²⁴

Causal conditions

Insufficient resources for care

Insufficient resources in nursing homes often means insufficient types of staffing and the inability to make a multidisciplinary team to decide and carry out suitable care plans. ²⁵

Adequate personnel can guaranty highly caregiving from qualitative and quantitative aspects. Two major problems of workforce are shortage and high rotation of caregivers in nursing homes which have resulted in weak administra­tion of care for those who really need it.

A further three problems related to personnel in Netherland nursing homes, including personnel shortage, negligence, and lack of knowledge. ²⁶ Adequacy of caregivers and being skilled in older people long-term care, is among the factors leading to high quality of care.

High staff turnover rates are associated with poor quality of care. Turnover rates for licensed nursing staff in LTC homes is a widespread problem influencing care quality which leads to attrition among direct care workers (i.e., nurse aides). ²⁷ The ability to use care equipment is something that needs to be improved, the rehabilitation system and its necessities, and telecare, are causes for insufficient care for older people in nursing homes. ^28,29

Conflicted environment

The nursing home atmosphere has a great effect on care delivery. For example abusive or neglecting behaviors in care are reasons for ignoring the dignity of the older people. Such neglect could reflect a culture of common values that unconsciously ignores or abuses the dignity of patients, in this case, older patients in a nursing home. ³⁰

Neglect of the elderly is a forgotten issue in nursing homes. Care manager’s lack of knowledge to identify and managing of this phenomenon is an important reason. ³¹

Nurses are reluctant to work in nursing homes, one of the reasons is poor working conditions due to unorganized roles and tasks in nursing homes. ³² Also, negative relationships caused by inadequate trust among older people and caregivers. ³³ Social relationships in nursing homes are essential for resident’s quality of life, life meaning and satisfaction, and psychological well-being. ³⁴

The most limitation was our acceptance by managers of nursing homes. The second one was problems during interview with older people.

Action/ Interaction strategies

Task elimination in care

In the process of caring for the older people, there were cases of negligent services during care. The older people complained that the services were provided carelessly and not as they should be. The older people sometimes feel that caregivers are uncomfortable with meeting their needs, especially when eating or taking care of personal hygiene, and as a result they turn away from asking staff for help. ³⁵ The focus of care is on performing activities of daily living, and attention is paid less to the complaints of the older people about their health conditions. ¹¹

Modesty of older people

Looking at the conditions and context in the nursing homes, the condition of the older people is such that they feel satisfied and happy with the least attention from caregivers. Resident satisfaction with care in a nursing home is related to experiences such as their close connection with caregivers or the existence of daily comforts in their lives in addition to routine medical care. ³⁶

Peaceful coexistence

Peaceful coexistence between the residents and caregivers, as well as the older people, was remarkable. Older people tend to establish friendly relations with other residents who are in the same social, financial and educational class. ³⁷ It is vital for the older people to have the right communication to create a sense of satisfaction, independence and well-being in general. ¹²

Intervening conditions

Lack of control over the situation is a common phenomenon due to the high risk of vulnerability in the nursing homes residents. Transfer of an older people to nursing home causes physical and mental vulnerability and loss of hope, ³⁸ and reduces performance. ³⁹ They used different methods to control the condition such as asking for a respectful relationship from caregivers, ¹² and creating a spiritual connection between the older people and caregivers. ⁴⁰

Consequences

Living in a nursing home can have two consequences; Dissatisfaction with life or adaptation to circumstances.

Dissatisfaction of life:

Transfer to a nursing home, lack of family support, chronic illness and poor living conditions cause dissatisfaction with life. The daily life of the older people is interpreted as a life without a future, the possibility of moving towards a worse situation, increasing dependence and getting closer to death. So, frustration and depression are more common. ⁴¹

Adjustment with conditions

Over time, and given the possibility of not leaving the nursing home, the residents come to the conclusion that they should accept the nursing home as a permanent place to live and try to adapt to it. As a result, they try to keep themselves happy, ⁴² to diversify their life, ⁴³ and reduce their dependence on caregivers. ⁴⁴

Conclusion

The findings in the current study can hopefully contribute to a better understanding of factors influencing the care process in nursing homes and also provide useful information for policy making and development of the nursing home management. The results can also generate new hypotheses within this research area. Using the core variable of this study can help policymakers, managers and caregivers for better caring of older people in line to reach to holistic care.

Acknowledgments

We appreciate contributions and financial support from the Department of Gerontology, University of Social Welfare and Rehabilitation Sciences and all older people and caregivers and managers for their helps and supports.

Ethical Issues

The current study is a part of Ph.D thesis approved by the ethics committee of the University of Social Welfare and Rehabilitation Sciences, Iran. The objectives of research explained for participants and they signed informed consent forms. The participants participated in the study voluntarily and they could leave the research anytime. They were also assured about secrecy of their information and knowing the results of the study.

Conflict of Interest

The authors declare no conflict of interest in this study.

Authors’ Contributions

RF, HA: Conception and design, analysis and interpretation of data, review of article and find approval; MR: Conception and design, acquisition of data, analysis and interpretation of data, drafting the article, review of article and find approval.

Research Highlights

References

1. Goharinezhad S, Maleki M, Baradaran HR, Ravaghi H. A qualitative study of the current situation of elderly care in Iran: what can we do for the future?. Glob Health Action 2016; 9. doi: 10.3402/gha.v9.32156 [Crossref]
2. Rahimi M, Fadayevatan R, Abedi HA. Care Instability in nursing homes: a qualitative study. Iran Red Crescent Med J 2016; 18(2):e21515. doi: 10.5812/ircmj.21515 [Crossref]
3. Cameron G. Older people’s care survey. England: family and Childcare Trust; 2016.
4. Tolson D, Rolland Y, Andrieu S, Aquino J, Beard J, Benetos A. International association of gerontology and geriatrics: a global agenda for clinical research and quality of care in nursing homes. J Am Med Dir Assoc 2011; 12(3):184-9. doi: 10.1016/j.jamda.2010.12.013 [Crossref]
5. Adel Bergland A, Kirkevold M. Thriving in nursing homes in Norway: contributing aspects described by residents. Int J Nurs Stud 2006; 43(6):681-91. doi: 10.1016/j.ijnurstu.2005.09.006 [Crossref]
6. Shah S, Carey I, Harris T, Dewilde S, Hubbard R, Lewis S. Identifying the clinical characteristics of older people living in care homes using a novel approach in a primary care database. Age and Ageing 2010; 39(5):617-23. doi: 10.1093/ageing/afq086 [Crossref]
7. Batista MF, Meneses K, Pumpeo M, Silva RS, De Sousa C, Lago EC. Elders´ perception of their lives in long-term care facilities. Journal of Nursing UFPE on Line 2014; 8(7):1988-96. doi: 10.5205/reuol.5963-51246-1-RV.0807201421 [Crossref]
8. Kitson A, Marshall A, Bassett K, Zeitz K. What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing. J Adv Nurs 2012; 69(1):4-15. doi: 10.1111/j.1365-2648.2012.06064.x [Crossref]
9. Zimmerman S, Williams C, Reed P, Boustani M, Preisser J, Heck E. Attitudes, stress, and satisfaction of staff who care for residents with dementia. Gerontologist 2005; 45(1):96-105. doi: 10.1093/geront/45.suppl_1.96 [Crossref]
10. Yektatalab S, Kaveh MH, Sharif F, Fallahi Khoshknab M, Petramfar P. Caring for patients with alzheimer’s disease in nursing homes: a qualitative content analysis. Journal of Qualitative Research in Health Sciences 2012; 1(3):240-53.
11. Karlson S, Edberg A, Hallberg I. Professional’s and older persons assessment of functional ability, health complaints and rcieved care and service: a descriptive study. Int J Nurs Stud 2010; 47:1217-27. doi: 10.1016/j.ijnurstu.2010.03.003 [Crossref]
12. Hwang HL, Hsieh PF, Wang H. Taiwanece long- term care facility residents’ experiences of caring: a qualitative study. Scand J Caring Sci 2012; 27(3):695-703. doi: 10.1111/j.1471-6712.2012.01082.x [Crossref]
13. Fahey T, Montgomery A, Barnes J. Quality of care for elderly residents in nursing homes and elderly people living at home: controlled observational study. BMJ 2003; 326(7389):580. doi: 10.1136/bmj.326.7389.580 [Crossref]
14. Strauss A, Corbin J. Basics of qualitative research: Techniques and procedures for developing grounded theory. 2^nd ed. London: Sage Publications; 1998.
15. Holloway I, Wheeler S. Qualitative research in nursing. 3^rded. America: Wiley-Blackwell; 2013.
16. Polit D, Beck C. Essentials of nursing research : Appraising evidence for nursing practice.9^th ed; Philadelphia: Lippincott Williams & Wilkins; 2010.
17. Robertshaw D, Cross A. Roles and responsibilities in integrated care for dementia. Journal of Integrated Care 2019; 27(2). doi: 10.1108/JICA-05-2018-0037 [Crossref]
18. Moore KJ, Candy B, Davis S, Gola A, Harrington J, Kupeli N. Implementing the compassion intervention, a model for integrated care for people with advanced dementia towards the end of life in nursing homes: a naturalistic feasibility study. BMJ Open 2017; 7(6):e015515. doi: 10.1136/bmjopen-2016-015515 [Crossref]
19. Arnetz JE, Hasson H. Evaluation of an educational “toolbox” for improving nursing staff competence and psychosocial work environment in elderly care: results of a prospective, non-randomized controlled intervention. Int J Nurs Stud 2007; 44(5):723-35. doi: 10.1016/j.ijnurstu.2006.01.012 [Crossref]
20. Shin J. Relationship between nursing staffing and quality of life in nursing homes. Contemp Nurse 2013; 44(2):133-43. doi: 10.5172/conu.2013.44.2.133 [Crossref]
21. Morowatisharifabad MA, Bahram AH, Bidaki R, Namayandeh SM. Comparison of knowledge and attitude of health care providers towards aging phenomenon in Yazd and Hamadan, Iran. Elderly Health Journal 2019; 5(2). doi: 10.18502/ehj.v5i2.2151 [Crossref]
22. Mueller C. A framework for nurse staffing in long-term care facilities. Geriatr Nurs 2000; 21(5):262-7. doi: 10.1067/mgn.2000.110834 [Crossref]
23. Chu LW, Chi I. Nursing homes in china. J Am Med Dir Assoc 2008; 9(4):237-43. doi: 10.1016/j.jamda.2008.01.008 [Crossref]
24. Castle NG, Furnier J, Ferguson Rome JC, Olson D, Johs-Artisensi J. Quality of care and long-term care administrators’ education: does it make a difference?. Health Care Manage Rev 2015; 40(1):35-45. doi: 10.1097/HMR.0000000000000007 [Crossref]
25. Ballesteros-Pomar MD, Cherubini A, Keller H, Lam P, Rolland Y, Simmons SF. Texture-modified diet for improving the management of oropharyngeal dysphagia in nursing home residents: an expert review. J Nutr Health Aging 2020; 24(6):576-81. doi: 10.1007/s12603-020-1377-5 [Crossref]
26. Vikström S, Sandman PO, Stenwall E, Boström AM, Saarnio L, Kindblom K. A model for implementing guidelines for person-centered carein a nursing home setting. Int Psychogeriatr 2014; 27(1):49-59. doi: 10.1017/S1041610214001598 [Crossref]
27. Kunst A, Britstra R. Implementation evaluation of the dutch national heat plan among long-term care institutions in Amsterdam: a cross-sectional study. BMC Health Serv Res 2013; 13(135).
28. McGilton K, Boscart V, Brown M, Bowers B. Making tradeoffs between the reasons to leave and reasons to stay employed in long-term care homes: perspectives of licensed nursing staff. Int J Nurs Stud 2014; 51(6):917-26. doi: 10.1016/j.ijnurstu.2013.10.015 [Crossref]
29. Whittaker E, George Kernohan W, Hasson F, Howard V, McLaughlin D. The palliative care education needs of nursing home staff. Nurse Educ Today 2006; 26(6):501-10. doi: 10.1016/j.nedt.2006.01.004 [Crossref]
30. Patterson L. Making our health and care systems fit for an ageing population: david oliver, catherine foot, richard humphries King’s Fund March 2014. Age and Ageing 2014; 43(5):731. doi: 10.1093/ageing/afu105 [Crossref]
31. Myhre J, Saga S, Malmedal W, Ostaszkiewicz J, Nakrem S. Elder abuse and neglect: An overlooked patient safety issue A focus group study of nursing home leaders’ perceptions of elder abuse and neglect. BMC Health Serv Res 2020; 20(1):199. doi: 10.1186/s12913-020-5047-4 [Crossref]
32. Rehnsfeldt A, Lindwall L, Lohne V, Lillestø B, Slettebø A, Aasgaard T. The meaning of dignity in nursing home care as seen by relatives. Nursing Ethics 2014; 21(5):507-17. doi: 10.1177/0969733013511358 [Crossref]
33. Ebai D. Supporting professional caregivers working in nursing home: a literature review. PhD Dissertation: University of Helsinky; 2013.
34. Roberts T, Bowers B. How nursing home residents develop relationships with peers & staff: a grounded theory study. Int J Nurs Stud 2015; 52(1):56-67. doi: 10.1016/j.ijnurstu.2014.07.008 [Crossref]
35. Martinsson H, Edberg AK, Janlöv AC. Growing old in a foreign context – older immigrants’ experience of everyday life in residential care facilities. Nord J Nurs Res 2013; 33(3):34-8. doi: 10.1177/010740831303300308 [Crossref]
36. Plaku-Alakbarova B, Punnett L, Gore RJ. Nursing home employee and resident satisfaction and resident care outcomes. Saf Health Work 2018; 9(4):408-15. doi: 10.1016/j.shaw.2017.12.002 [Crossref]
37. Blanca Gutiérrez J, Linares Abad M, Grande Gascón M, Aranda Marín D. The personal relationships that are established by residents of a nursing home. Enfermeria Global 2012:13-22.
38. Moore SHL, Hall SE, Jackson J. Exploring the experience of nursing home residents participation in a hope-focused group. Journal of Nursing Research and Practice 2014; 9. doi: 10.1155/2014/623082 [Crossref]
39. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci 2004; 59(3):255-63. doi: 10.1093/gerona/59.3.m255 [Crossref]
40. Haugan G. Nurse-patient interaction is a resource for hope, meaning in life and self-transcendence in nursing home patients. Scand J Caring Sci 2014; 28(1):74-88. doi: 10.1111/scs.12028 [Crossref]
41. James I, Blomberg K, Kihlgren A. A meaningful daily life in nursing homes - a place of shelter and a space of freedom: A participatory appreciative action reflection study. BMC Nurs 2014; 13:19. doi: 10.1186/1472-6955-13-19 [Crossref]
42. Cooney A. Finding home: a grounded theory on how older people find home’ in long-term care settings. Int J Older People Nurs 2011; 7:188-99. doi: 10.1111/j.1748-3743.2011.00278.x [Crossref]
43. Brandburg GL, Symes L, Mastel-Smith B, Hersch G, Walsh T. Resident strategies for making a life in a nursing home: a qualitative study. Journal of Advanced Nursing 2012; 69(4):862-74. doi: 10.1111/j.1365-2648.2012.06075.x [Crossref]
44. Hillcoat-Nallétamby S. The meaning of “independence” for older people in different residential settings. J Gerontol B Psychol Sci Soc Sci 2014; 69(3):419-30. doi: 10.1093/geronb/gbu008 [Crossref]