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Resident-centred care and architecture of two different types of caring residences: a comparative study

Resident-centred care and architecture of two different types of caring residences: a comparative... INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 2018, VOL. 13, 1472499 https://doi.org/10.1080/17482631.2018.1472499 EMPIRICAL STUDIES Resident-centred care and architecture of two different types of caring residences: a comparative study Catharina Nord Department of Spatial Planning, Blekinge Institute of Technology, Karlskrona, Sweden ABSTRACT ARTICLE HISTORY Accepted 28 April 2018 The relationship between architectural space and resident-centred care is poorly understood, even though architectural space is indicated as an important factor in the quality of care. This KEYWORDS paper aims to address this gap in existing research by putting resident-centred care in the Patient-centred care; theoretical context of relationality and emergence in which space is a co-producing compo- architectural space; nent. This qualitative case study includes two housing alternatives, which are compared: one assemblage; assisted living; assisted living and one extra-care housing residence, which differ in their legal status and extra-care housing architecturally. Similar fieldwork was carried out in the two residences. Individual interviews with staff and residents, as well as observations—direct and shadowing—were the main data collection methods. The concept of assemblage was used for the analysis of how resident- centred care and architectural space co-evolved. The findings show that resident-centred care appears in similar but also diverse and sometimes contradictory ways in different spaces in the two housing alternatives, suggesting that resident-centred care is situated, volatile and emergent. Although architecture has strong agency, space and care need to be considered together—a caring architecture—in order to understand the nuances and rich conceptual palette of resident-centred care. care is not something that is, but rather something Introduction that becomes, dependent on circumstances and co- Resident-centred care is a hallmark of care practices constituting components. From this theoretical per- (Li & Porock, 2014; Yee, Capitman, Leutz, & Sceigaj, spective, it is expected that resident-centred care may 1999). There is no common definition of this care appear in various shapes and modes in different spa- ideology either in practice or theory (Li & Porock, tial circumstances. 2014), but certain shared elements can be identified. Although authors have highlighted the importance Resident-centred care is holistic and aims to satisfy of the physical environment for resident-centred care the older individual’s needs, wishes and choices, pro- (Li & Porock, 2014; McCormack & McCance, 2010), the vide individualized care, and strengthen his or her architectural environment is poorly understood in autonomy and self-determination (Brownie & relation to this type of care or its equivalents. Few Nancarrow, 2013; Li & Porock, 2014; McCormack studies have focused upon this topic, although one et al., 2010; Morgan & Yoder, 2012; Yee et al., 1999). paper focusing explicitly on the environment studies Resident-centred care concerns not just a relationship patient-centred care and hospital architecture between a nurse or caregiver and an older person, but (Bromley, 2012). Two studies on residences for the needs to be considered in a wider context of relations elderly have highlighted architectural qualities as fac- including, for instance, family, community, caring cul- tors that are expected to contribute to resident- ture and, of particular relevance to this paper, the centred care (Kane, Lum, Cutler, Degenholtz, & Yu, built or physical environment (McCormack & 2007; Molony, Evans, Sangchoon, Rabig, & Straka, McCance, 2006; Nolan, Davies, Brown, Keady, & 2011). However, the care model is not described in Nolan, 2004). This paper aims to contribute to the either study, even if it is referred to as resident- existing research by putting resident-centred care in centred care. The two studies examined residents’ a theoretical context of relationality and emergence performance and perception as well as outcomes of (DeLanda, 2016). A point of departure is that care is a care in small-house nursing homes compared to con- practice and an approach enmeshed in spatial, mate- ventional nursing homes. In both studies, residents rial and architectural circumstances (Foley, 2011; Mol, had moved from conventional nursing homes to Moser, & Pols, 2010; Nord & Högström, 2017). Thus, by small-house nursing homes. The architectural design adopting a theory of emergence, resident-centred is described in both studies: the small-house nursing CONTACT Catharina Nord [email protected] Department of Spatial Planning, Blekinge Institute of Technology, BTH – TIFP, Karlskrona 371 79, Sweden © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 C. NORD homes presented a small-scale environment, private Each elderly individual rents a bed-sitting room of flats with bathrooms, and facilities for the community about 30 m , including a bathroom, hallway and a of residents. The conventional nursing homes offered kitchenette. This design is a materialization of a col- double or triple resident rooms. Molony and collea- lective-care model where the residents are supposed gues (2011) examined at-homeness. The small-house to take part in common meals and activities (Nord, nursing homes came out in a better light in most 2017). The facilities are staffed around the clock. The aspects compared to the conventional nursing assisted living facility in this study is a reconstructed homes. The research revealed better performance in nursing home adapted to the building regulations, activities of daily living (ADLs) as well as improvement and, as such, a representative of this building type, in health. The resident preferences for the physical presenting a similar design (Figure 1). environment in the small-house nursing homes were The second case in this paper is an extra-care unanimously positive. In particular, the single rooms housing residence (Figure 1). It differs from the were highly appreciated compared to the shared assisted living facility in important respects, such as rooms in the conventional nursing homes. The higher architecturally, by offering full one-bedroom flats to degree of choice and the closer relationships with the the residents. Nor is it subject to the same legal staff in the small-house nursing homes were also restrictions of access as the assisted living facility. In appreciated. However, there were aspects which did other respects, it is similar: it has common rooms, a not differ in the compared facilities, such as the atten- dining facility and a living room. It is also a housing tiveness of staff, which was appreciated in both cate- alternative with permanent staff for people with gories of nursing home. Autonomy was strongly greater care needs, similar to those in the assisted linked to at-homeness in all facilities, although not living facility. These design differences are the point directly associated with residential satisfaction. Kane of departure for the analysis of resident-centred care, and colleagues (2007) measured aspects such as resi- which is expected to bring out nuances of this type of dents’ self-reported quality of life, their self-care abil- care. It is anticipated that it will give insight into the ities and functional performance, which in all ways architectural spaces give shape to resident- measurements were better than or the same as in centred care in two forms of housing which are two compared conventional nursing homes. Quality adapted to older peopleʼs needs. of life included aspects such as privacy, dignity, auton- omy and individuality, which are often associated Assemblage theory with resident-centred care. The study also found a higher level of quality of care. However, these were The main analytic question is how does resident- mostly assessed based on medical outcomes. The centred care emerge in architectural space in these small-house nursing homes were assessed as a better two different housing alternatives? The theoretical environment to live in than compared facilities, point of departure for this study is the concept of though to what extent this refers to the architectural assemblage, which refers to a constellation of hetero- environment is not entirely clear. geneous components that interact by forming asso- These studies take as an implicit point of departure ciations and relations (DeLanda, 2006, 2016; Deleuze the fact that architecture has an impact on resident- & Guattari, 2004). Components included are of differ- centred care. However, they do not explicitly discuss ent orders and types—human or non-human—struc- the architectural conditions or spatial impact, and this tured by self-organizing processes; a whole that has is the gap in existing research that this paper aims to emergent properties. Thus, an assemblage is con- address. stantly moving and changing. Emergence and becom- ing are two central concepts in this theory, indicating how different components are shaped in processes Assisted living and extra-care housing in Sweden of interaction (DeLanda, 2006, 2016). The concept of This study analyses resident-centred care in two dif- assemblage has been applied to architecture in the ferent architectural layouts of housing for elderly peo- sense that architecture is an assemblage formed by ple with caring needs in Sweden: assisted living and its included material, human and spatial components extra-care housing. Assisted living is a right-based (Dovey, 2013; Jacobs, 2006). Assemblage theory housing option for older people under the Social endows dead material with agency. Thus, the materi- Services Act, provided by the municipality in the ality of architectural space is an important agent in event that the person is assessed as needing 24- these assemblages (cf. DeLanda, 2016; Duff, 2014). hour care (SFS, 2001, p. 453). There are considerable Architecture does things to people (Gieryn, 2002). spatial similarities between all newly built assisted However, as Brott alerts us: “This does not mean living facilities. As a rule, they consist of a corridor that cities, buildings or interiors become persons, with small bed-sitting rooms and common spaces for but . . . [l]ived experience is altered as a result” dining and socializing (Nord, 2013; Regnier, 2002). (Brott, 2013, p. 3). When different architecture INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3 Figure 1. Plan of assisted living facility and extra-care housing (below). In comparable scales. impacts on other components such as residents and were the primary methods of data collection. They staff, it is expected that the lived experience of were adapted to assemblage theory by identifying resident-centred care will emerge in different shapes relations between care work and architectural space and modes. For instance, in this case, architectural using transcendental empiricism (Duff, 2014). This agency distributes staff and residents in different methodology aims to empirically ‘investigate a given spaces, which may affect their relations. These are assemblage to demonstrate how it is composed and processes that occur the other way around as well. the specific causal mechanisms by which social and/or Even though architectural space is often well defined structural processes enter into it’ (Duff, 2014, p. 55). by walls, ceilings and other building components, it Thus, by considering the two residences as assem- nevertheless gets its shape and meaning from its blages, it was possible to identify their various compo- interaction with people and non-human compo- nents, and associations between these components, as nents. A room is formed by the practices and habits well as processes going on in which resident-centred of the person who is living there. Thus, architectural care appeared. space does not provide a spatial container in which care practices are carried out, but becomes a caring architecture by co-producing quality, personal rela- Fieldwork organization tions and negotiations of routines in the practice of Similar fieldwork was carried out in the two different care situated in space (Nord & Högström, 2017). In housing alternatives, an assisted living residence this study, the differences and similarities between (18 months) and an extra-care housing residence the two residences compared are expected to form (10 months), in order to perform a comparison. The different assemblages in which resident-centred care first period of fieldwork, in the assisted living resi- will be enmeshed and moulded. dence, was more time-consuming, due to its more explorative nature, than the second, in the extra-care housing residence, where it was possible to focus The methodology of the study more intently on obtaining data. The field study This study is a case study that applies qualitative meth- started out in both residences with a period of obser- odologies to grasp the messiness and heterogeneity in vation of about one to one-and-a-half months. This data collection and analysis (Lather & St. Pierre, 2013; period was intended to provide an understanding of Law, 2004). Individual interviews and observations everyday life in the two residences and generate 4 C. NORD topics to be raised later in interviews. After interview- Furthermore, individual interviews were carried out ing started, observation continued, alternating with with the majority of the staff members; 15 in the the interviews. This way of organizing the fieldwork assisted living facility, and 16 in the extra-care hous- made it possible to compare and co-analyse data ing residence, including the unit managers. Eight resi- from the two methods throughout the work in order dents were interviewed in each residence. Both to develop new issues and to check whether people’s groups of interviewees participated voluntarily, on self-reporting of their activities was accurate. Space is condition that participation was anonymous. Only everywhere and is a self-evident framing to everyday residents with full cognitive capacity were asked to life, so it tends to go unnoticed. People may have participate, in order to ensure that they fully under- difficulties in reporting what they do in space because stood the implications of participation and the study they are enmeshed and embodied in spatially situated aims. People who were very fragile were also situations (O’Toole & Were, 2008). Fieldwork was excluded. The ambition was to include as many staff divided into sessions; that is, visits several times a as possible, so all staff members who wanted to be week when the fieldwork was most intense. Each interviewed were included. All agreed but two were fieldwork session lasted four to six hours during day- later excluded because of long-term sick-leaves. This time. In total, the fieldwork amounted to about gave naturally a mix of men or women staff members, 145 hours in the assisted living residence and 100 in although the latter was in the majority. Interviews the extra-care housing residence. The author partici- lasted around one hour for staff, and half an hour to pated to some degree in the care work, but only in one hour for residents. Staff interviews were carried tasks where there was no risk of affecting residents out in a staff room where no one else was present with any possible mistakes (Adler & Adler, 1994). apart from the interviewer and the interviewee, and the residents were interviewed in their flats. All inter- views were carried out in Swedish during the daytime, Data collection methods were recorded with the consent of the interviewee (no one declined) and then transcribed verbatim by a Observation occurred in two ways: as direct observa- professional transcriber. tion of everyday life in the residences (O’Toole & Were, 2008), and as shadowing (Czarniawska, 2007). The selection of resident participants for observations was discussed with the staff in order to exclude peo- Analysis ple who were, for example, too weak, or for other Using transcendental empiricism, data from the var- reasons. One person was recommended for exclusion ious methods were drawn together into wholes, form- because of his aggressive moods. (The person in ques- ing rich and multifaceted assemblages of situations in tion was later included in interviews because the space in which people and materialities were author connected well with him.) The ambition was immersed. By applying transcendental empiricism it to include as many residents as possible, men and is possible to investigate how concepts vary accord- women of different ages and with different condi- ing to the context in which they are articulated (Duff, tions, in order to cover as many types of caring situa- 2014). The analysis in this study builds on DeLanda’s tions as possible. The residents were approached by notion that relations of externality make it possible to the author in the company of a staff member and move the concept of resident-centred care from one asked in person whether they wanted to participate. assemblage to another (DeLanda, 2016) and, thus, to One declined and was thus not approached anymore. explore how it changes and varies. Deleuze & Guattari The direct observation comprised various situations. (1994, pp. 15–16) assert that The space where these situations took place and the people and things involved were observed and noted. [t]here is no simple concept. Every concept has its Shadowing also involved the recording of situations components and is defined by them. . .there is no in space but comprised the accompanying of care concept with only one component . . . Every concept has an irregular contour defined by the sum of its workers while they worked, observing the work that components, which is why, from Plato to Bergson, we they carried out and the different types of objects find the idea of the concept being a matter of articu- they used in different spaces. Thus, in the latter, the lation, of cutting and cross-cutting. focus was on work situations while the former could include any situation, such as interactions between These ontological assumptions were a guiding princi- residents. Both types of observations were documen- ple for the analysis. The two cases were analysed in two ted with detailed field notes, and the physical envir- steps. First, a separate analysis of the two housing onment was documented with photography and alternatives was completed that aimed at articulating drawings. I also interacted frequently with the staff co-constituting central concepts of resident-centred as well as the residents, both individually or in groups, care which were developed from the existing literature and had many informal conversations with them. presented above: (1) resident needs, wishes and INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5 choices, (2) individualized care, and (3) residents’ the whole unit, which was a restricted area on one floor autonomy. This analysis aimed to reveal the various with short distances between rooms and people, and assemblage components related to these concepts often open doors to the residents’ rooms. There were and their associations and relations, in order to give 13 residents, with no one below 80 years old. The oldest shape to the contours of the concept of resident- turned 98 during the study. The staff to resident ratio centred care in the two situations. In the second step, was 1:1, including the night staff, and about 3–6staff the results of the analysis of one of the two housing members worked during each shift. The fact that staff alternatives were compared, in which interlinks, simila- often worked in twos when assisting one resident rities and differences were defined by conceptual vari- added to the density. They planned their tasks together abilities with a special focus on architectural space. and did not follow any written caring protocol but provided the care they considered essential to satisfy the resident’s need. The resident bed-sitting rooms Ethical considerations were small, and there was a common room, furnished for dining and watching TV. This integration of spaces This study received ethical approval from the Ethical and people contributed to blurred borders between Board in Linköping, Sweden (no. 2015/335–31). An ethi- private and public areas. cal approval is, however, not sufficient; carrying out The extra-care housing residence was a three- research with weak older people demands an ethical storey building with long distances between the attitude throughout the study (Vetenskapsrådet, 2002). doors to the flats, which were closed as a rule. This Even though the participants had agreed initially to dissociation of spaces made it impossible to have a participate anonymously and voluntarily, according to view of the whole housing block at any point, and the established ethical procedures, I asked repeatedly at environment had clearer demarcations between pri- every visit to individual flats whether the resident vate and public areas. There were 24 residents, of approved of my presence (Loue, 2002). In particular, whom the youngest was 62 and the oldest 99. The the shadowing technique, in which the researcher may number of staff was similar to that of the assisted closely approach a resident’ssphere, demands repeated living residence. The staff to resident ratio was about consent (Czarniawska, 2007). Changes in the residents’ 1:2, including night staff. Every staff member received attitudes were also noted during shadowing; on one each day an individual list of tasks and scheduled occasion it was interrupted and the author left the flat visits to the residents, indicating the person visited, when the resident explicitly disapproved of her being the care task and the allocated minutes for this care there. work. Staff members often worked alone and could virtually “disappear”, distributed throughout the Results whole building. The following analysis aims to explore how resi- The two housing alternatives in the study can be dent-centred care appeared in these two distinctly understood as two architectural assemblages formed different assemblages by investigating the three by spatial and material components and their associa- aspects of resident-centred care adopted from the tions, giving rise to the emergence of distinctly differ- literature: (1) resident needs, wishes and choices, (2) ent environments. While the assisted living facility was individualized care, and (3) residents’ autonomy. a restricted, dense assemblage with weak or non- existent boundaries between private and public spaces, the extra-care housing residence was spread Residents’ needs, wishes and choices out, with strong demarcations between private and public space (Figure 2). The assemblages of the two housing alternatives had The high density of the assisted living residence was very different capacities to attract residents. produced by the fact that there was a view throughout Nevertheless, they had in common that 24-hour care Figure 2. Corridor in the extra-care housing and the assisted living facility (to the right). 6 C. NORD was available in both and that access to care was an element, with great attractive force contributing to important factor contributing to the attractiveness of facilitating the residents’ choices to come and live in both housing alternatives. Resident needs, wishes and the residence. A man answered the question why he choices with regard to access to care came about as had moved to the extra-care housing: “I wanted some effects of legal and architectural components in the help . . . but now I have it from the girls here.” A man respective housing assemblage. One self-evident who was part of a couple interviewed considered the aspect of the residents’ choice of housing was wish to access care to be an almost self-evident whether it was possible for the individual to decide aspect of the move: “Of course [access to care was a whether or not to move in. The extra-care housing reason]. Now [name of wife] gets help with showering was free to access based on the individual’s self- every week.” His wife added: “And cleaning every assessment of their need for care, whereas the Social other week.” Resident-centred care appeared to have Services Act associated with the assisted living made the double capacity of being an attractor of residents it accessible only if the individual was in need of 24- from the exterior while emerging according to resi- hour care, based on an assessment by a municipality dents’ needs in the interior of the assemblage. officer. This difference had a great impact on the clientele in the respective assemblage. Another differ- Assisted living ence was in the design of the architectural space. The heterogeneity was much less pronounced at the assisted living facility, due to the legal constraints, Extra-care housing which restricted its capacity to attract a variety of In addition to generally free access, a spatial analysis residents. Similar health status and care needs of and direct observation showed the architectural residents resulted in a more homogeneous assisted impact on the residents’ choices. The apartments in living assemblage than in the extra-care housing resi- the extra-care housing residence were flexible enough dence. Resident-centred care varied less, since all of to accommodate anyone who wished to stay there. In the residents were very old and fragile, and the great terms of architectural agency, it is possible to say that majority required support with most personal care, the space invited a multitude of residents by attract- such as hygiene, dressing, medication, mobility and ing residents with a great variety of needs to the sometimes eating. assemblage. Hence, the housing offered a high Resident choices were an ambiguous category degree of resident choice. Access to 24-hour care due to the legal embeddedness of this particular made it possible for those with very severe disabilities housing option and because of the residents’ health to choose this housing alternative, and residents with circumstances. Severe health conditions or frailty full bodily capacity were welcome as well. Residents had forced them to apply for residency, and, when in the extra-care housing residence in the study thus a sufficient level of need for care had been con- varied greatly in health status. One man had suffered firmed, they had been offered residency. The study a stroke that had left him completely dependent on results show that their capability to choose was assistance to perform daily tasks. In contrast, two severely circumscribed, and almost non-existent. women who lived in the residence needed very little One woman who stayed in a single room with her help but both had chosen to move in because they husband had vague ideas about why she had been felt isolated after the loss of their spouses. One of offered a place, possibly indicating that she was not them expressed her satisfaction with the residence involved in the decision to move: in the interview: “I actually don’t remember why I ended up coming here; I don’t know it and it just sort of happened that I Yes, they come and check up on me, and I am grate- was kind of placed here when I could not manage on ful for that, and then we sit down on the sofa and my own.” chat for a quarter of an hour or so. But they don’t It is important to point out that at the time of the need to help me with anything. I try to manage on my own. interview the woman had no diagnosis of cognitive decline, and she appeared self-contained and The individualized care needs of all of the residents answered the interview questions logically and were distributed between two poles: a substantial thoughtfully. It seemed that she had been under need for help and almost no need for help at all. The such stress during her move that she reacted with most common help the residents received was with confusion. Another woman remembered the process medication, meals, personal hygiene—in particular, of moving, but in the interview, she expressed that showers—cleaning and laundry services, supervisory she had not influenced the decision to move and that visits and accompanied walks outside to shops or she regretted the loss of her former flat. She said: elsewhere. Although the need for help varied among the resi- We had a good apartment. But then we could not live dents, the care offered was an important assemblage there any more . . . We, or I, simply wasn’t allowed to INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7 live there. It did not suit me. So we had to move out Extra-care housing of the apartment. But it worked out. It had to Negotiations of this kind were obvious also in the work out. extra-care housing residence but here the capacity to choose and barter was somewhat stronger than Comments of this type from the residents indicated in the assisted living facility. Similar to the results in more or less explicitly a lack of choice and involve- the assisted living facility, a flat that would not be ment in decision-making. accepted under circumstances where there were no The non-choice in assisted living also included care needs may become a valid alternative when care the acceptance of a low-quality flat, which sug- needs increase. However, the results indicate pro- gests a more or less coerced association to the cesses of changing relations between components, assemblage. Research has also shown that resi- such as the housing the residents had left, their dents tend to overrate the quality of the accom- increasingly recalcitrant bodies and new housing modation in order to justify their (non-)choice to alternatives. Most had moved because their former move to assisted living (Nord 2016). This was also homes had become a challenge in one way or the case in this study. Residents said that they another. A man talked about the hilly streets from were pleased with the bed-sitting room of about the town centre to his former home, which had 25 m they had been given, although the choice been increasingly difficult to manage until one day had explicitly been a non-choice. The wife from the when it was not possible any longer. In one case, a interview above continued: “But seeing as I didn’t woman had moved on the initiative of a municipality have a choice and I was forced to move, this is the officer as an alternative to home-care services. best imaginable.” The bed-sitting room she and The extra-care housing offered small but full flats her husband shared only had space for two beds with kitchens or kitchenettes. One could expect more and not very much more (Figure 3). She added: positive resident assessments of these than of the “This was the only room available. We had to accommodation in the assisted living facility, since take it, and we did so with light hearts, so that they were bigger and better equipped (Figure 3). we got somewhere to stay.” The final line of that However, this was not clearly the case. Most of the statement indicates the precarious situation in interviewees were somewhat reserved in their assess- which the couple found themselves when a move ments of their flats. They used words such as “OK”, to assisted living became urgent due to increased “decent”, “good enough”. “Well, in general there is care needs. They had to accept a very low standard nothing wrong with it [the flat]”, the man who was of living in order to have somewhere to reside part of the couple said. When asked his opinion about where they could access the care the woman the flat, another man emphasized his appreciation of needed. Nevertheless, the woman expressed satis- the services and the kind staff, rather than the quality faction for this in the quote. of the flat. His avoidance of answering this question The other woman interviewed also expressed satis- may demonstrate the link between acceptance of faction with her room, but the interview revealed lower housing quality and access to care. A woman several reservations. When I asked which one was described her flat thus: “It is peaceful and good her favourite room, she said: “This one”, referring to enough, I suppose.” Most of the residents interviewed her bed-sitting room. Later in the interview she ela- had faced the situation that only one flat was avail- borated further on that issue: “Of course, my bed-sitting room is not in the best condition, but I don’t let it bother me. You have to overlook some things, you cannot start demanding that they repair and renovate. So I’m happy.” Both of these women seemed to have accepted a low living standard in exchange for care, and they curbed their complaints by stressing how pleased they were with the situation over which they had little influence. Resident wishes and choices of housing were pushed into the background of their pressing need for care. This indicates that the move involves negotiation between the needs of disabled bodies, access to care and housing alternatives. In this case the women had chosen to associate them- selves with a small bed-sitting room but where Figure 3. Plan of flat in the extra-care housing and the bed- resident-centred care was available. sitting room in the assisted living (to the right). 8 C. NORD able. One male resident, who lived in one of the adaptations of routine tasks to individuals’ needs, smaller flats with a bedroom and a combined living interviews and observation revealed that much of room and kitchen, aired severe criticism of his flat. He the individualized care work took place at the same evaluated the components of his “flat” assemblage in time or in between the routine tasks. This care work is material and spatial terms when he said: “This is not a deeply embedded in the assemblage of human and flat. It would have been nice to have a kitchen. I don’t non-human components and emerges as much less know what to call this: two rooms and a stove or visible and more difficult to trace due to its vagueness something?” This man had been afflicted with a and heterogeneity. It appeared from the contingen- severely disabling condition before he turned 60, cies of the situation and fed on resources available in and thus found himself in a situation similar to the the assisted living assemblage, such as architectural people who had had to move to an assisted living space. The residentsʼ private flats or bed-sitting rooms facility. He expressed the incapacitating effect disabil- were important architectural agents contributing to ities have on the ability to choose and how confusing these processes in both housing alternatives. it is to cope with a situation of newly acquired Individualized care in the form of conversations disabilities: between the residents and the staff appeared as a significant part of care in these rooms, and offered Really, you don’t choose . . . It came up that “Now we an opportunity to build personal relations. One staff should have a care conference” and I didn’t know member in the extra-care housing facility stated in the what that meant . . . Perhaps I had mentioned that I interview: might want to stay in [name of present residence] because I knew that this [housing] was here . . . if the option came up I could take that. I have cleaned in John’s flat now, for half an hour or so. I think it is really nice and cosy to be able to talk to him and make some jokes. Yes, it is me and him, then The capability of the extra-care housing alternative to and there. accommodate a variety of care needs was an option Similarcommentscameupintheinterviews with staffin for this man, so he was not coerced into “choosing” the assisted living facility. Conversations seemed to grow the assisted living alternative at the age of 58. from the contingencies at the very moment in which they took place. They could be very mundane, and with or Emerging housing quality without any particular topic, such as in this description: These results suggest that perceptions of housing “Well, you chitchat a little bit and I get to know quality were emergent based on negotiations about his children and grandchildren when they between access to care and housing. The residents’ come . . . Then I also see to it that he can attend the chilly opinions about their comparatively spacious activities he likes.” flats in the extra-care housing residence possibly indi- It could also be an opportunity to comfort a dis- cate that the bed-sitting rooms offered in the assisted tressed resident: living facility would not have been an alternative for “You don’t know what to do when she gets her panic most of these residents at this point. The fact that attacks at night . . . Well, you can sit and talk for a while and many could have remained in their former homes pat her and so on.” with home-care services made them less prone to In the assisted living facility, it was once observed make big sacrifices regarding housing quality in through a chink in the door how a staff member order to access care. However, the relative importance was comforting a newly widowed woman in her of the components in the assemblage of housing and bed, hugging her and holding her hands. Situations resident-centred care changes with increasing care of this kind suggest the emergence of micro-assem- needs. At a later point, when access to care may be blages of care of limited endurance embedded in a question of life or death, an individual is prepared to greater assemblages of space and materiality; in this move to a substandard flat in order to access that case a bed, a staff member and a mourning widow in care. her private room. While get-togethers such as common meals did not generate much conversation between residents Individualized care in either of the two housing alternatives, it seemed as The staff interviews in the assisted living facility though the peacefulness of the private flat and a revealed a trajectory of routinized care over the meeting between only two people formed the small- course of a day in which staff made an effort to scale assemblage necessary for the emergence of the respond to each elderly individual’s wishes and residents’ ability to express themselves. When this needs. Routine care tasks in nursing homes are happened in a severely disabled resident with a mediated by personal and situational factors (Essén, speech impediment, it created joy and satisfaction in 2008). Not to underestimate the importance of these the staff member who experienced it: INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 9 “Sometimes in the afternoon when you enter his Residents’ autonomy room he is lying down, watching TV. Occasionally he Because architectural space in the two housing alter- has said that a programme was interesting and then natives contributed to two different communities in . . . you are almost taken by surprise; [laughter]; then it which encounters between residents and staff is fun.” emerged in distinctly different ways, they offered dif- The last comment, about being surprised, suggests ferent degrees of autonomy to the residents. In the that in between scheduled routines there is a flow extra-care housing residence, the residents were of emergent events that are volatile and perhaps easy expected to live independently with a higher degree to miss. Conversations were in a constant state of of autonomy, and this was encouraged by the clear becoming, depending on the staff’s abilities to seize boundaries between private and public spaces and the opportunity to enter into communication with the the care work organization, forming an assemblage resident. A difference between the extra-care housing where independence could grow. As was mentioned and the assisted living residences that shaped these above, there were few or no visits from the staff conversations was the easy access to the residents’ between the scheduled caring visits. Thus, the resi- rooms in the assisted living facility, in contrast with dents’ flats were assemblages in which solitude and the scheduled visits in the private flats in the extra- privacy were nurtured. Residents, even those with care housing residence. The dense architectural severe disabilities, retained responsibility for their assemblage with short distances and often open lives. The severely disabled man with the stroke was doors in the former offered emergent opportunities also expected to live independently. He was sup- for peeking in while doing something else. In an ported in this by his wife, who visited him regularly interview, one staff member commented on her occa- and cooked meals in his flat. sional interaction with one of the residents: In the assisted living facility, on the other hand, support from the staff was never far away, creating an Like for example Anna; she is so anxious in the eve- nings, so I tell her “I’ll come back to you before I go assemblage with emerging opportunities for meet- home. And I might not come inside but I’ll open the ings and assistance. One staff member commented door a little to see if you are asleep, then I’ll just leave, in the interview on the regular presence of staff in the and if you’re awake I’ll come in and say goodbye, public areas: because I’ll be on my way home.” “Yes, there are very often [staff] in the kitchen, actually. And we run and there are short distances, These examples above show that resident-centred care everything is close, so it is pretty certain that staff are may emerge as short-lived opportunities to grasp and here. Perhaps that makes residents feel safer.” cultivate as individualized care for a few moments. The One example was a woman suffering from dementia “messiness” of encounters between staff and residents who became very upset from time to time if she was nurtures individualized small-scale care which was of alone in her room, and expressed her distress very great importance in the assisted living facility. The fact loudly. When the staff took her out and she sat in her that the staff worked alone more in the extra-care wheelchair watching them work, according to obser- housing residence was also a component that offered vations she seemed to become less stressed and she scheduled and thus recurrent opportunities for private was able to settle down. It seemed important where encounters with residents. However, one staff member in the architectural assemblage she was situated and in the extra-care housing residence who also had with whom she could associate. experience working in assisted living thought that the The corridors in the two housing alternatives were frequent improvised encounters with residents in the architectural spaces which gave rise to different kinds assisted living encouraged a tighter relationship with of individualized care work and meetings between the residents than in the extra-care housing. Although residents and staff. In the extra-care housing residence, it may be a question of individual judgement in which observations revealed that the corridor was mostly type of residence the best relations develop, it is clear empty, with the exception of staff assisting residents that the different physical environments and the orga- to and from meals and activities, while in the assisted nization of care contributed to the emergence of dif- living facility, the doors to residents’ rooms were often ferent kinds of staff/resident relations. In the assisted open and a variety of care situations took place much living facility, encounters between caregivers and resi- more frequently there. Hence, the corridor had a more dents were more or less unanticipated happenstances pronounced capacity to link the individual bed-sitting interwoven in a flow of frequent care events situated in rooms to each other by the involvement of staff and many different spaces, while in the extra-care housing residents, and contributed in these situations to the residence they were clearly chiselled-out situations dense assisted living assemblage. Residents and staff more firmly emplaced in the residents’ flats, identified, often moved around in the corridor on a daily basis. appreciated and expected as such by the staff mem- One woman explicitly wanted to have a connection bers as well as the residents. 10 C. NORD with the corridor outside her bed-sitting room. She said in existing research, although without any particular that she wanted to have her door open “so that I can analysis or discussion (Kane et al., 2007; Molony et al., see the hustle and bustle outside”. She may have felt 2011). This study shows how architectural space con- more included and safe by having her door open, tributes to the emergence of resident-centred care, and being more tightly associated with the greater assem- the results show that it appears in different forms in blage of space, staff and other residents in the whole different architectural environments. Rather than facility. A more dramatic event took place when a ascribing stable and essential qualities to the environ- resident attempted suicide in the corridor and the ment, such as that this environment is good or that staff came rushing to his succour. It is highly likely environment is bad, the theoretical framework of that this man took advantage of the connecting capa- assemblage made it possible to discern care and city of the corridor and calculated that someone would space in becoming, and the outcome of relationships most probably see what he was doing. This would not with co-constituting heterogeneous components such necessarily have been a successful strategy in the as laws, bodies and artefacts—a caring architecture extra-care housing corridor, where people passed reg- (Nord & Högström, 2017). This resonates with theorists ularly but not very often, offering much fewer emer- who contend that resident-centred care is not com- ging associations due to less supervision. posed of relations between residents and staff alone, The architectural environment and the staff care but involves material factors such as space work thus formed a community with tight relations (McCormack & McCance, 2010). in the assisted living facility, in which the residents Architectural space appeared in this study as having could to some extent dispense with their autonomy various agentic capabilities, sometimes involving staff and leave their safety and choices in the hands of the or other components, sometimes with a strong agency staff. This was highly beneficial to people with almost of its own (cf. Brott, 2013). However, care was dementia, as was indicated in the situation with the always a co-constituting component. Sometimes the yelling woman described above, while the freedom residents’ perception of their need of resident-centred and responsibility demanded in the extra-care hous- care was a sufficient component. The latter indicates ing did not always work well with the needs of a that resident-centred care is immersed in relations that person with dementia. These problems manifested in do not necessarily involve staff at all. This was the case different ways when these individuals became when the residents faced a number of choices over increasingly dissociated from the assemblage due to which staff had little influence, such as the individual their progressing disease, which invariably redefined choice to move in, or the choice of a flat or a bed-sitting the components in the assemblage and gave them room in order to get access to care. These choices arose new emergent and sometimes terrifying meanings. as a significant aspect of resident-centred care, since One man had created a small micro-assemblage of they were an outcome of each individual’s negotia- himself, a bed and bedding behind a closed bedroom tions regarding his or her individual care needs. door in the extra-care housing residence. He seemed Choices grew out of circumstances. Thus, the relation- to be horrified by the “autonomy” he was supposed ships between perceived health, material, legal, discur- to assume, and lay in his bed waiting for the staff to sive and spatial components were more influential come. He whined from beneath his blanket: “I have than the staff. been waiting for you the whole day.” A woman The contrary appeared in situations in which staff experienced the extra-care housing quite differently were strong co-actors together with architectural because the assemblage of the housing could not space. The study results indicate that the staff were keep her contained, due to her disease. The architec- enmeshed in spatial and material circumstances, influ- ture was open, with weak or non-existent borders encing the quality and character of their provision of between buildings and the surroundings. She started resident-centred care. This appeared in a number of leaving the residence at night, since her perception of planned and unplanned care encounters with resi- day and night was in a process of deterioration and dents in which care could develop in unpredicted the supervision was not sufficient for her needs. One ways according to contingencies then and there. night, a stranger who had found her in town brought Different spaces had similar or different capacities in her back in his car. Obviously, her safety was endan- the two residences. The residents’ flats and bed-sitting gered. Both of the people afflicted with dementia rooms were on a par in many situations, both offering moved to assisted living during the fieldwork, having material and spatial circumstances for a rich palette of become completely dissociated from the assemblage. care encounters, perhaps because they minimized the number of actors, to the advantage in particular of frail residents. Very small-scale events emerged as Discussion individualized incidences of high-quality resident- centred care. At a larger scale, in which the corridor The importance of architectural space for the provision of the building was a major architectural agent, the of resident-centred care has been a point of departure INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 11 density of the assisted living proved to be more prone environment in the small-house nursing home. In parti- to connectivities and care events in becoming. In cular, the single rooms were highly appreciated com- these situations of openness, in which various trajec- pared with the shared rooms in the conventional tories of care were available, lay the possibility to nursing home. In the present study it seemed that the adapt the care to the individual’s needs, to offer residents had a tendency to overrate the quality of the individualized care (cf. Essén, 2008). In this study, accommodation because it gave them access to care autonomy appeared as a product of architectural (cf. Nord 2016). This has implications for the evaluation space and the organization of care, involving relations of services and care given to older people. How do we between both flats and corridors. Autonomy and priv- assess older peoples’ assessments of their housing qual- acy were strongly linked (separate flats) and involved ity? Canwebesure thatwe are measuring residential a lower degree of supervision in extra-care housing satisfaction if their assessment of the quality of their compared to the density of the assisted living, where accommodation is in fact an assessment of a caring residents could refrain completely from autonomy if architecture; that is, care and accommodation together? they preferred to. This is in line with Kane and collea- gues’ study (2007) in which autonomy and privacy Conclusions were aspects of quality of life which was found to be higher in the small-house nursing home with pri- This paper concludes that resident-centred care vate flats. This is a reasonably direct and discernible depends on the associations with components in the cause–effect mechanism. It is surprising, then, that the assemblage in which it is carried out. Architectural perceived autonomy the private flats offered to the space is a strong actor in these processes and negotia- residents did not appear as a factor influencing resi- tions. Architecture does things to people (Gieryn, dential satisfaction in the small-house nursing homes 2002), although not as a person acting, but in that in Molony and colleagues’ study (2011), although it lived experience is altered (Brott, 2013). This means affected at-homeness. The fact that perceived auton- that neither care nor architecture can be considered omy in conventional nursing homes in the same study alone. It is in their co-emergence as a caring architec- was not linked to residential satisfaction is less surpris- ture that roles of space and care are constituted and ing if the care needs of the residents are taken into sometimes visible. This is the major generalization that account. This study shows that the architectural it is possible to infer from this study; an analytic gen- impact on autonomy was much more indirect, intan- eralization from a multiple-case study, aimed at exam- gible and negotiated with care in assisted living. If ining variation or similarities (Polit & Beck, 2010). Thus, residents were happy about refraining from privacy on a theoretical level, the study suggests that the due to their care needs being satisfied by a higher different embedded concepts that were examined con- degree of supervision in a dense architectural envir- tribute to different contours of the concept resident- onment, and if they nevertheless perceived their centred care (Deleuze & Guattari, 1994). The limitation autonomy as sufficient, they would most probably of this generalization is that there are only two archi- not see this link between autonomy and architectural tectural settings in which resident-centred care was space and, thus, it would not influence their residen- examined in this study. In order to fully understand tial satisfaction. This shows the elusiveness of space as the impact of architectural space, it is necessary to taken for granted in everyday activities (O’Toole & scrutinize each concept—residents’ choice, individua- Were, 2008). The agency of architectural space can lized care and residents’ autonomy—in different con- be almost invisible. texts. The generalized results should be explored in The small-house nursing home in Kane and collea- other architectural conditions in order to expand and gues’ study (2007) was assessed as a better environ- deepen this theoretical contribution further (Morse, ment to live in than compared facilities. It is unclear to 1999). Moreover, only three aspects of resident-centred what extent resident-centred care contributed to this. care were in focus in this study. This multidimensional The results in this study show that the residents’ assess- and complex concept does have other features that ments of their flats were not necessarily congruent with can be subject to similar research. It is thus suggested, an objective assessment of their quality. The assisted in order to address the limitations of this study, that living home environment with smaller flats came out in other dimensions of resident-centred care also be a better light in the eyes of the residents than was the examined in relation to space. The study suggests case for the residents in the extra-care housing resi- that each individual concept gets its form and meaning dence, because it seemed to satisfy their pressing situated in relations in an assemblage of people, spaces needs for care. This somewhat surprising result, which and materiality in sometimes highly unstable and vola- contradicts the results of Kane and colleagues (2007), tile situations, processes of exchange, varying mutual- points to the importance of the co-constitution of care/ ity and associations, contributing to a flow of space. Molony and colleagues’ study (2011) also contingent circumstances in which resident-centred showed strong resident preferences for the physical care emerges. Resident-centred care is thus always on 12 C. NORD the move, unpredictable and ambiguous, situated in DeLanda, M. (2016). Assemblage theory. Edinburgh: Edingburgh University Press. architectural space. Deleuze, G., & Guattari, F. (1994). What is philosophy? New York: Colombia University Press. Deleuze, G., & Guattari, F. (2004). A thousand plateaus: Note Capitalism and schizophrenia. London: Continuum. 1. Care that is centred on the resident, patient or the Dovey, K. (2013). Assembling architecture. In H. Frichot & S. person is conceptualized differently by different authors Loo (Eds.), Deleuze and architecture. Edinburgh: and in different disciplines; however, they share similar Edinburgh University Press. traits and ideology. I have chosen the term ‘resident- Duff, C. (2014). Assemblages of health. Deleuze’s empiricism centredʼ for this article because the focus is on two and the ethology of life. Rotterdam: Springer. residences for older residents in need of care. Essén, A. (2008). Variability as a source of stability: Studying routines in the elderly home care setting. Human Relations, 61(11), 1617–1644. Foley, R. (2011). Performing health in place: The holy well as Acknowledgments a therapeutic assemblage. Health & Place, 17(2), 470–479. This work was supported by the Swedish Research Council Gieryn, T. F. (2002). What buildings do. Theory and Society, for Health, Working Life and Welfare, Forte; under Grant 31(1), 35–74. [number 2014-00427]; Kungsleden AB. Jacobs, J. M. (2006). A geography of big things. Cultural Geographies, 13(1), 1–27. Kane, R. A., Lum, T. Y., Cutler, L. J., Degenholtz, H. B., & Yu, T. C. (2007). Resident outcomes in small-house nursing Disclosure statement homes: A longitudinal evaluation of the initial green No potential conflict of interest was reported by the author. house program. Journal of the American Geriatrics Society, 55(6), 832–839. Lather, P., & St. Pierre, E. A. (2013). Post-qualitative research. Funding International Journal of Qualitative Studies in Education, 26 (6), 629–633. This work was supported by the Forskningsrådet om Hälsa, Law, J. (2004). After method: Mess in social science research. Arbetsliv och Välfärd (Swedish Research Council for Health, London: Routledge. Working Life and Welfare (Forte)) [2014-00427]; Kungsleden Li, J., & Porock, D. (2014). Resident outcomes of person- AB. centered care in long-term care: A narrative review of interventional research. International Journal of Nursing Studies, 51(10), 1395–1415. Notes on contributor Loue, S. (2002). Ethical issues in informed consent in the conduct of research with aging persons. In M. B. Kapp Catharina Nord is Professor in Spatial Planning and architect (Ed.), Issues in conducting research with and about older SAR/MSA. For a number of years she has carried out persons (pp. 3–17). New York: Springer Publishing research about ageing and architecture. She is currently Company. working on architectural space and care practice in assisted McCormack, B., Dewing, J., Breslin, L., Coyne-Nevin, A., living facilities. She explores these institutional buildings Kennedy, K., Manning, M., . . . Slater, P. (2010). mainly with the support of theories about relational space, Developing person-centred practice: Nursing outcomes assemblage theory and actor-network theory. arising from changes to the care environment in residen- tial settings for older people. International Journal of Older People Nursing, 5(2), 93–107. ORCID McCormack, B., & McCance, T. V. (2006). Development of a framework for person-centred nursing. Journal of Catharina Nord http://orcid.org/0000-0001-5295-2482 Advanced Nursing, 56(5), 472–479. McCormack, B., & McCance, T. V. (2010). Person-centred nur- sing. Theory and practice. Chichester, West Sussex: Wiley- References Blackwell. Mol, A., Moser, I., & Pols, J. (Eds.). (2010). Care in practice. On Adler, P. A., & Adler, P. 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R., Davies, S., Brown, J., Keady, J., & Nolan, J. tered care on residents and staff in aged-care facilities: A (2004). Beyond ‘person-centred’care: A new vision for systematic review. Clinical Interventions in Aging, 8,1–10. gerontological nursing. Journal of Clinical Nursing, 13(s1), Czarniawska, B. (2007). Shadowing and other techniques for 45–53. doing fieldwork in modern societies. Malmö: Liber. Nord,C.(2013). Design according to the law: Juridical DeLanda, M. (2006). A new philosophy of society. Assemblage dimensions of architecture for assisted living in theory and social complexity. London: Bloomsbury. INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 13 Sweden. Journal of Housing and the Built Environment, Polit, D. F., & Beck, C. T. (2010). Generalization in quantitative 28(1), 147–155. and qualitative research: Myths and strategies. International Nord,C.(2016). 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Observing places: Using space Yee, D. L., Capitman, J. A., Leutz, W. N., & Sceigaj, M. (1999). and material culture in qualitative research. Qualitative Resident-centered care in assisted living. Journal of Aging Research, 8(5), 616–634. & Social Policy, 10(3), 7–26. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Qualitative Studies on Health and Well-being Taylor & Francis

Resident-centred care and architecture of two different types of caring residences: a comparative study

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INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 2018, VOL. 13, 1472499 https://doi.org/10.1080/17482631.2018.1472499 EMPIRICAL STUDIES Resident-centred care and architecture of two different types of caring residences: a comparative study Catharina Nord Department of Spatial Planning, Blekinge Institute of Technology, Karlskrona, Sweden ABSTRACT ARTICLE HISTORY Accepted 28 April 2018 The relationship between architectural space and resident-centred care is poorly understood, even though architectural space is indicated as an important factor in the quality of care. This KEYWORDS paper aims to address this gap in existing research by putting resident-centred care in the Patient-centred care; theoretical context of relationality and emergence in which space is a co-producing compo- architectural space; nent. This qualitative case study includes two housing alternatives, which are compared: one assemblage; assisted living; assisted living and one extra-care housing residence, which differ in their legal status and extra-care housing architecturally. Similar fieldwork was carried out in the two residences. Individual interviews with staff and residents, as well as observations—direct and shadowing—were the main data collection methods. The concept of assemblage was used for the analysis of how resident- centred care and architectural space co-evolved. The findings show that resident-centred care appears in similar but also diverse and sometimes contradictory ways in different spaces in the two housing alternatives, suggesting that resident-centred care is situated, volatile and emergent. Although architecture has strong agency, space and care need to be considered together—a caring architecture—in order to understand the nuances and rich conceptual palette of resident-centred care. care is not something that is, but rather something Introduction that becomes, dependent on circumstances and co- Resident-centred care is a hallmark of care practices constituting components. From this theoretical per- (Li & Porock, 2014; Yee, Capitman, Leutz, & Sceigaj, spective, it is expected that resident-centred care may 1999). There is no common definition of this care appear in various shapes and modes in different spa- ideology either in practice or theory (Li & Porock, tial circumstances. 2014), but certain shared elements can be identified. Although authors have highlighted the importance Resident-centred care is holistic and aims to satisfy of the physical environment for resident-centred care the older individual’s needs, wishes and choices, pro- (Li & Porock, 2014; McCormack & McCance, 2010), the vide individualized care, and strengthen his or her architectural environment is poorly understood in autonomy and self-determination (Brownie & relation to this type of care or its equivalents. Few Nancarrow, 2013; Li & Porock, 2014; McCormack studies have focused upon this topic, although one et al., 2010; Morgan & Yoder, 2012; Yee et al., 1999). paper focusing explicitly on the environment studies Resident-centred care concerns not just a relationship patient-centred care and hospital architecture between a nurse or caregiver and an older person, but (Bromley, 2012). Two studies on residences for the needs to be considered in a wider context of relations elderly have highlighted architectural qualities as fac- including, for instance, family, community, caring cul- tors that are expected to contribute to resident- ture and, of particular relevance to this paper, the centred care (Kane, Lum, Cutler, Degenholtz, & Yu, built or physical environment (McCormack & 2007; Molony, Evans, Sangchoon, Rabig, & Straka, McCance, 2006; Nolan, Davies, Brown, Keady, & 2011). However, the care model is not described in Nolan, 2004). This paper aims to contribute to the either study, even if it is referred to as resident- existing research by putting resident-centred care in centred care. The two studies examined residents’ a theoretical context of relationality and emergence performance and perception as well as outcomes of (DeLanda, 2016). A point of departure is that care is a care in small-house nursing homes compared to con- practice and an approach enmeshed in spatial, mate- ventional nursing homes. In both studies, residents rial and architectural circumstances (Foley, 2011; Mol, had moved from conventional nursing homes to Moser, & Pols, 2010; Nord & Högström, 2017). Thus, by small-house nursing homes. The architectural design adopting a theory of emergence, resident-centred is described in both studies: the small-house nursing CONTACT Catharina Nord [email protected] Department of Spatial Planning, Blekinge Institute of Technology, BTH – TIFP, Karlskrona 371 79, Sweden © 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 C. NORD homes presented a small-scale environment, private Each elderly individual rents a bed-sitting room of flats with bathrooms, and facilities for the community about 30 m , including a bathroom, hallway and a of residents. The conventional nursing homes offered kitchenette. This design is a materialization of a col- double or triple resident rooms. Molony and collea- lective-care model where the residents are supposed gues (2011) examined at-homeness. The small-house to take part in common meals and activities (Nord, nursing homes came out in a better light in most 2017). The facilities are staffed around the clock. The aspects compared to the conventional nursing assisted living facility in this study is a reconstructed homes. The research revealed better performance in nursing home adapted to the building regulations, activities of daily living (ADLs) as well as improvement and, as such, a representative of this building type, in health. The resident preferences for the physical presenting a similar design (Figure 1). environment in the small-house nursing homes were The second case in this paper is an extra-care unanimously positive. In particular, the single rooms housing residence (Figure 1). It differs from the were highly appreciated compared to the shared assisted living facility in important respects, such as rooms in the conventional nursing homes. The higher architecturally, by offering full one-bedroom flats to degree of choice and the closer relationships with the the residents. Nor is it subject to the same legal staff in the small-house nursing homes were also restrictions of access as the assisted living facility. In appreciated. However, there were aspects which did other respects, it is similar: it has common rooms, a not differ in the compared facilities, such as the atten- dining facility and a living room. It is also a housing tiveness of staff, which was appreciated in both cate- alternative with permanent staff for people with gories of nursing home. Autonomy was strongly greater care needs, similar to those in the assisted linked to at-homeness in all facilities, although not living facility. These design differences are the point directly associated with residential satisfaction. Kane of departure for the analysis of resident-centred care, and colleagues (2007) measured aspects such as resi- which is expected to bring out nuances of this type of dents’ self-reported quality of life, their self-care abil- care. It is anticipated that it will give insight into the ities and functional performance, which in all ways architectural spaces give shape to resident- measurements were better than or the same as in centred care in two forms of housing which are two compared conventional nursing homes. Quality adapted to older peopleʼs needs. of life included aspects such as privacy, dignity, auton- omy and individuality, which are often associated Assemblage theory with resident-centred care. The study also found a higher level of quality of care. However, these were The main analytic question is how does resident- mostly assessed based on medical outcomes. The centred care emerge in architectural space in these small-house nursing homes were assessed as a better two different housing alternatives? The theoretical environment to live in than compared facilities, point of departure for this study is the concept of though to what extent this refers to the architectural assemblage, which refers to a constellation of hetero- environment is not entirely clear. geneous components that interact by forming asso- These studies take as an implicit point of departure ciations and relations (DeLanda, 2006, 2016; Deleuze the fact that architecture has an impact on resident- & Guattari, 2004). Components included are of differ- centred care. However, they do not explicitly discuss ent orders and types—human or non-human—struc- the architectural conditions or spatial impact, and this tured by self-organizing processes; a whole that has is the gap in existing research that this paper aims to emergent properties. Thus, an assemblage is con- address. stantly moving and changing. Emergence and becom- ing are two central concepts in this theory, indicating how different components are shaped in processes Assisted living and extra-care housing in Sweden of interaction (DeLanda, 2006, 2016). The concept of This study analyses resident-centred care in two dif- assemblage has been applied to architecture in the ferent architectural layouts of housing for elderly peo- sense that architecture is an assemblage formed by ple with caring needs in Sweden: assisted living and its included material, human and spatial components extra-care housing. Assisted living is a right-based (Dovey, 2013; Jacobs, 2006). Assemblage theory housing option for older people under the Social endows dead material with agency. Thus, the materi- Services Act, provided by the municipality in the ality of architectural space is an important agent in event that the person is assessed as needing 24- these assemblages (cf. DeLanda, 2016; Duff, 2014). hour care (SFS, 2001, p. 453). There are considerable Architecture does things to people (Gieryn, 2002). spatial similarities between all newly built assisted However, as Brott alerts us: “This does not mean living facilities. As a rule, they consist of a corridor that cities, buildings or interiors become persons, with small bed-sitting rooms and common spaces for but . . . [l]ived experience is altered as a result” dining and socializing (Nord, 2013; Regnier, 2002). (Brott, 2013, p. 3). When different architecture INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3 Figure 1. Plan of assisted living facility and extra-care housing (below). In comparable scales. impacts on other components such as residents and were the primary methods of data collection. They staff, it is expected that the lived experience of were adapted to assemblage theory by identifying resident-centred care will emerge in different shapes relations between care work and architectural space and modes. For instance, in this case, architectural using transcendental empiricism (Duff, 2014). This agency distributes staff and residents in different methodology aims to empirically ‘investigate a given spaces, which may affect their relations. These are assemblage to demonstrate how it is composed and processes that occur the other way around as well. the specific causal mechanisms by which social and/or Even though architectural space is often well defined structural processes enter into it’ (Duff, 2014, p. 55). by walls, ceilings and other building components, it Thus, by considering the two residences as assem- nevertheless gets its shape and meaning from its blages, it was possible to identify their various compo- interaction with people and non-human compo- nents, and associations between these components, as nents. A room is formed by the practices and habits well as processes going on in which resident-centred of the person who is living there. Thus, architectural care appeared. space does not provide a spatial container in which care practices are carried out, but becomes a caring architecture by co-producing quality, personal rela- Fieldwork organization tions and negotiations of routines in the practice of Similar fieldwork was carried out in the two different care situated in space (Nord & Högström, 2017). In housing alternatives, an assisted living residence this study, the differences and similarities between (18 months) and an extra-care housing residence the two residences compared are expected to form (10 months), in order to perform a comparison. The different assemblages in which resident-centred care first period of fieldwork, in the assisted living resi- will be enmeshed and moulded. dence, was more time-consuming, due to its more explorative nature, than the second, in the extra-care housing residence, where it was possible to focus The methodology of the study more intently on obtaining data. The field study This study is a case study that applies qualitative meth- started out in both residences with a period of obser- odologies to grasp the messiness and heterogeneity in vation of about one to one-and-a-half months. This data collection and analysis (Lather & St. Pierre, 2013; period was intended to provide an understanding of Law, 2004). Individual interviews and observations everyday life in the two residences and generate 4 C. NORD topics to be raised later in interviews. After interview- Furthermore, individual interviews were carried out ing started, observation continued, alternating with with the majority of the staff members; 15 in the the interviews. This way of organizing the fieldwork assisted living facility, and 16 in the extra-care hous- made it possible to compare and co-analyse data ing residence, including the unit managers. Eight resi- from the two methods throughout the work in order dents were interviewed in each residence. Both to develop new issues and to check whether people’s groups of interviewees participated voluntarily, on self-reporting of their activities was accurate. Space is condition that participation was anonymous. Only everywhere and is a self-evident framing to everyday residents with full cognitive capacity were asked to life, so it tends to go unnoticed. People may have participate, in order to ensure that they fully under- difficulties in reporting what they do in space because stood the implications of participation and the study they are enmeshed and embodied in spatially situated aims. People who were very fragile were also situations (O’Toole & Were, 2008). Fieldwork was excluded. The ambition was to include as many staff divided into sessions; that is, visits several times a as possible, so all staff members who wanted to be week when the fieldwork was most intense. Each interviewed were included. All agreed but two were fieldwork session lasted four to six hours during day- later excluded because of long-term sick-leaves. This time. In total, the fieldwork amounted to about gave naturally a mix of men or women staff members, 145 hours in the assisted living residence and 100 in although the latter was in the majority. Interviews the extra-care housing residence. The author partici- lasted around one hour for staff, and half an hour to pated to some degree in the care work, but only in one hour for residents. Staff interviews were carried tasks where there was no risk of affecting residents out in a staff room where no one else was present with any possible mistakes (Adler & Adler, 1994). apart from the interviewer and the interviewee, and the residents were interviewed in their flats. All inter- views were carried out in Swedish during the daytime, Data collection methods were recorded with the consent of the interviewee (no one declined) and then transcribed verbatim by a Observation occurred in two ways: as direct observa- professional transcriber. tion of everyday life in the residences (O’Toole & Were, 2008), and as shadowing (Czarniawska, 2007). The selection of resident participants for observations was discussed with the staff in order to exclude peo- Analysis ple who were, for example, too weak, or for other Using transcendental empiricism, data from the var- reasons. One person was recommended for exclusion ious methods were drawn together into wholes, form- because of his aggressive moods. (The person in ques- ing rich and multifaceted assemblages of situations in tion was later included in interviews because the space in which people and materialities were author connected well with him.) The ambition was immersed. By applying transcendental empiricism it to include as many residents as possible, men and is possible to investigate how concepts vary accord- women of different ages and with different condi- ing to the context in which they are articulated (Duff, tions, in order to cover as many types of caring situa- 2014). The analysis in this study builds on DeLanda’s tions as possible. The residents were approached by notion that relations of externality make it possible to the author in the company of a staff member and move the concept of resident-centred care from one asked in person whether they wanted to participate. assemblage to another (DeLanda, 2016) and, thus, to One declined and was thus not approached anymore. explore how it changes and varies. Deleuze & Guattari The direct observation comprised various situations. (1994, pp. 15–16) assert that The space where these situations took place and the people and things involved were observed and noted. [t]here is no simple concept. Every concept has its Shadowing also involved the recording of situations components and is defined by them. . .there is no in space but comprised the accompanying of care concept with only one component . . . Every concept has an irregular contour defined by the sum of its workers while they worked, observing the work that components, which is why, from Plato to Bergson, we they carried out and the different types of objects find the idea of the concept being a matter of articu- they used in different spaces. Thus, in the latter, the lation, of cutting and cross-cutting. focus was on work situations while the former could include any situation, such as interactions between These ontological assumptions were a guiding princi- residents. Both types of observations were documen- ple for the analysis. The two cases were analysed in two ted with detailed field notes, and the physical envir- steps. First, a separate analysis of the two housing onment was documented with photography and alternatives was completed that aimed at articulating drawings. I also interacted frequently with the staff co-constituting central concepts of resident-centred as well as the residents, both individually or in groups, care which were developed from the existing literature and had many informal conversations with them. presented above: (1) resident needs, wishes and INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5 choices, (2) individualized care, and (3) residents’ the whole unit, which was a restricted area on one floor autonomy. This analysis aimed to reveal the various with short distances between rooms and people, and assemblage components related to these concepts often open doors to the residents’ rooms. There were and their associations and relations, in order to give 13 residents, with no one below 80 years old. The oldest shape to the contours of the concept of resident- turned 98 during the study. The staff to resident ratio centred care in the two situations. In the second step, was 1:1, including the night staff, and about 3–6staff the results of the analysis of one of the two housing members worked during each shift. The fact that staff alternatives were compared, in which interlinks, simila- often worked in twos when assisting one resident rities and differences were defined by conceptual vari- added to the density. They planned their tasks together abilities with a special focus on architectural space. and did not follow any written caring protocol but provided the care they considered essential to satisfy the resident’s need. The resident bed-sitting rooms Ethical considerations were small, and there was a common room, furnished for dining and watching TV. This integration of spaces This study received ethical approval from the Ethical and people contributed to blurred borders between Board in Linköping, Sweden (no. 2015/335–31). An ethi- private and public areas. cal approval is, however, not sufficient; carrying out The extra-care housing residence was a three- research with weak older people demands an ethical storey building with long distances between the attitude throughout the study (Vetenskapsrådet, 2002). doors to the flats, which were closed as a rule. This Even though the participants had agreed initially to dissociation of spaces made it impossible to have a participate anonymously and voluntarily, according to view of the whole housing block at any point, and the established ethical procedures, I asked repeatedly at environment had clearer demarcations between pri- every visit to individual flats whether the resident vate and public areas. There were 24 residents, of approved of my presence (Loue, 2002). In particular, whom the youngest was 62 and the oldest 99. The the shadowing technique, in which the researcher may number of staff was similar to that of the assisted closely approach a resident’ssphere, demands repeated living residence. The staff to resident ratio was about consent (Czarniawska, 2007). Changes in the residents’ 1:2, including night staff. Every staff member received attitudes were also noted during shadowing; on one each day an individual list of tasks and scheduled occasion it was interrupted and the author left the flat visits to the residents, indicating the person visited, when the resident explicitly disapproved of her being the care task and the allocated minutes for this care there. work. Staff members often worked alone and could virtually “disappear”, distributed throughout the Results whole building. The following analysis aims to explore how resi- The two housing alternatives in the study can be dent-centred care appeared in these two distinctly understood as two architectural assemblages formed different assemblages by investigating the three by spatial and material components and their associa- aspects of resident-centred care adopted from the tions, giving rise to the emergence of distinctly differ- literature: (1) resident needs, wishes and choices, (2) ent environments. While the assisted living facility was individualized care, and (3) residents’ autonomy. a restricted, dense assemblage with weak or non- existent boundaries between private and public spaces, the extra-care housing residence was spread Residents’ needs, wishes and choices out, with strong demarcations between private and public space (Figure 2). The assemblages of the two housing alternatives had The high density of the assisted living residence was very different capacities to attract residents. produced by the fact that there was a view throughout Nevertheless, they had in common that 24-hour care Figure 2. Corridor in the extra-care housing and the assisted living facility (to the right). 6 C. NORD was available in both and that access to care was an element, with great attractive force contributing to important factor contributing to the attractiveness of facilitating the residents’ choices to come and live in both housing alternatives. Resident needs, wishes and the residence. A man answered the question why he choices with regard to access to care came about as had moved to the extra-care housing: “I wanted some effects of legal and architectural components in the help . . . but now I have it from the girls here.” A man respective housing assemblage. One self-evident who was part of a couple interviewed considered the aspect of the residents’ choice of housing was wish to access care to be an almost self-evident whether it was possible for the individual to decide aspect of the move: “Of course [access to care was a whether or not to move in. The extra-care housing reason]. Now [name of wife] gets help with showering was free to access based on the individual’s self- every week.” His wife added: “And cleaning every assessment of their need for care, whereas the Social other week.” Resident-centred care appeared to have Services Act associated with the assisted living made the double capacity of being an attractor of residents it accessible only if the individual was in need of 24- from the exterior while emerging according to resi- hour care, based on an assessment by a municipality dents’ needs in the interior of the assemblage. officer. This difference had a great impact on the clientele in the respective assemblage. Another differ- Assisted living ence was in the design of the architectural space. The heterogeneity was much less pronounced at the assisted living facility, due to the legal constraints, Extra-care housing which restricted its capacity to attract a variety of In addition to generally free access, a spatial analysis residents. Similar health status and care needs of and direct observation showed the architectural residents resulted in a more homogeneous assisted impact on the residents’ choices. The apartments in living assemblage than in the extra-care housing resi- the extra-care housing residence were flexible enough dence. Resident-centred care varied less, since all of to accommodate anyone who wished to stay there. In the residents were very old and fragile, and the great terms of architectural agency, it is possible to say that majority required support with most personal care, the space invited a multitude of residents by attract- such as hygiene, dressing, medication, mobility and ing residents with a great variety of needs to the sometimes eating. assemblage. Hence, the housing offered a high Resident choices were an ambiguous category degree of resident choice. Access to 24-hour care due to the legal embeddedness of this particular made it possible for those with very severe disabilities housing option and because of the residents’ health to choose this housing alternative, and residents with circumstances. Severe health conditions or frailty full bodily capacity were welcome as well. Residents had forced them to apply for residency, and, when in the extra-care housing residence in the study thus a sufficient level of need for care had been con- varied greatly in health status. One man had suffered firmed, they had been offered residency. The study a stroke that had left him completely dependent on results show that their capability to choose was assistance to perform daily tasks. In contrast, two severely circumscribed, and almost non-existent. women who lived in the residence needed very little One woman who stayed in a single room with her help but both had chosen to move in because they husband had vague ideas about why she had been felt isolated after the loss of their spouses. One of offered a place, possibly indicating that she was not them expressed her satisfaction with the residence involved in the decision to move: in the interview: “I actually don’t remember why I ended up coming here; I don’t know it and it just sort of happened that I Yes, they come and check up on me, and I am grate- was kind of placed here when I could not manage on ful for that, and then we sit down on the sofa and my own.” chat for a quarter of an hour or so. But they don’t It is important to point out that at the time of the need to help me with anything. I try to manage on my own. interview the woman had no diagnosis of cognitive decline, and she appeared self-contained and The individualized care needs of all of the residents answered the interview questions logically and were distributed between two poles: a substantial thoughtfully. It seemed that she had been under need for help and almost no need for help at all. The such stress during her move that she reacted with most common help the residents received was with confusion. Another woman remembered the process medication, meals, personal hygiene—in particular, of moving, but in the interview, she expressed that showers—cleaning and laundry services, supervisory she had not influenced the decision to move and that visits and accompanied walks outside to shops or she regretted the loss of her former flat. She said: elsewhere. Although the need for help varied among the resi- We had a good apartment. But then we could not live dents, the care offered was an important assemblage there any more . . . We, or I, simply wasn’t allowed to INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7 live there. It did not suit me. So we had to move out Extra-care housing of the apartment. But it worked out. It had to Negotiations of this kind were obvious also in the work out. extra-care housing residence but here the capacity to choose and barter was somewhat stronger than Comments of this type from the residents indicated in the assisted living facility. Similar to the results in more or less explicitly a lack of choice and involve- the assisted living facility, a flat that would not be ment in decision-making. accepted under circumstances where there were no The non-choice in assisted living also included care needs may become a valid alternative when care the acceptance of a low-quality flat, which sug- needs increase. However, the results indicate pro- gests a more or less coerced association to the cesses of changing relations between components, assemblage. Research has also shown that resi- such as the housing the residents had left, their dents tend to overrate the quality of the accom- increasingly recalcitrant bodies and new housing modation in order to justify their (non-)choice to alternatives. Most had moved because their former move to assisted living (Nord 2016). This was also homes had become a challenge in one way or the case in this study. Residents said that they another. A man talked about the hilly streets from were pleased with the bed-sitting room of about the town centre to his former home, which had 25 m they had been given, although the choice been increasingly difficult to manage until one day had explicitly been a non-choice. The wife from the when it was not possible any longer. In one case, a interview above continued: “But seeing as I didn’t woman had moved on the initiative of a municipality have a choice and I was forced to move, this is the officer as an alternative to home-care services. best imaginable.” The bed-sitting room she and The extra-care housing offered small but full flats her husband shared only had space for two beds with kitchens or kitchenettes. One could expect more and not very much more (Figure 3). She added: positive resident assessments of these than of the “This was the only room available. We had to accommodation in the assisted living facility, since take it, and we did so with light hearts, so that they were bigger and better equipped (Figure 3). we got somewhere to stay.” The final line of that However, this was not clearly the case. Most of the statement indicates the precarious situation in interviewees were somewhat reserved in their assess- which the couple found themselves when a move ments of their flats. They used words such as “OK”, to assisted living became urgent due to increased “decent”, “good enough”. “Well, in general there is care needs. They had to accept a very low standard nothing wrong with it [the flat]”, the man who was of living in order to have somewhere to reside part of the couple said. When asked his opinion about where they could access the care the woman the flat, another man emphasized his appreciation of needed. Nevertheless, the woman expressed satis- the services and the kind staff, rather than the quality faction for this in the quote. of the flat. His avoidance of answering this question The other woman interviewed also expressed satis- may demonstrate the link between acceptance of faction with her room, but the interview revealed lower housing quality and access to care. A woman several reservations. When I asked which one was described her flat thus: “It is peaceful and good her favourite room, she said: “This one”, referring to enough, I suppose.” Most of the residents interviewed her bed-sitting room. Later in the interview she ela- had faced the situation that only one flat was avail- borated further on that issue: “Of course, my bed-sitting room is not in the best condition, but I don’t let it bother me. You have to overlook some things, you cannot start demanding that they repair and renovate. So I’m happy.” Both of these women seemed to have accepted a low living standard in exchange for care, and they curbed their complaints by stressing how pleased they were with the situation over which they had little influence. Resident wishes and choices of housing were pushed into the background of their pressing need for care. This indicates that the move involves negotiation between the needs of disabled bodies, access to care and housing alternatives. In this case the women had chosen to associate them- selves with a small bed-sitting room but where Figure 3. Plan of flat in the extra-care housing and the bed- resident-centred care was available. sitting room in the assisted living (to the right). 8 C. NORD able. One male resident, who lived in one of the adaptations of routine tasks to individuals’ needs, smaller flats with a bedroom and a combined living interviews and observation revealed that much of room and kitchen, aired severe criticism of his flat. He the individualized care work took place at the same evaluated the components of his “flat” assemblage in time or in between the routine tasks. This care work is material and spatial terms when he said: “This is not a deeply embedded in the assemblage of human and flat. It would have been nice to have a kitchen. I don’t non-human components and emerges as much less know what to call this: two rooms and a stove or visible and more difficult to trace due to its vagueness something?” This man had been afflicted with a and heterogeneity. It appeared from the contingen- severely disabling condition before he turned 60, cies of the situation and fed on resources available in and thus found himself in a situation similar to the the assisted living assemblage, such as architectural people who had had to move to an assisted living space. The residentsʼ private flats or bed-sitting rooms facility. He expressed the incapacitating effect disabil- were important architectural agents contributing to ities have on the ability to choose and how confusing these processes in both housing alternatives. it is to cope with a situation of newly acquired Individualized care in the form of conversations disabilities: between the residents and the staff appeared as a significant part of care in these rooms, and offered Really, you don’t choose . . . It came up that “Now we an opportunity to build personal relations. One staff should have a care conference” and I didn’t know member in the extra-care housing facility stated in the what that meant . . . Perhaps I had mentioned that I interview: might want to stay in [name of present residence] because I knew that this [housing] was here . . . if the option came up I could take that. I have cleaned in John’s flat now, for half an hour or so. I think it is really nice and cosy to be able to talk to him and make some jokes. Yes, it is me and him, then The capability of the extra-care housing alternative to and there. accommodate a variety of care needs was an option Similarcommentscameupintheinterviews with staffin for this man, so he was not coerced into “choosing” the assisted living facility. Conversations seemed to grow the assisted living alternative at the age of 58. from the contingencies at the very moment in which they took place. They could be very mundane, and with or Emerging housing quality without any particular topic, such as in this description: These results suggest that perceptions of housing “Well, you chitchat a little bit and I get to know quality were emergent based on negotiations about his children and grandchildren when they between access to care and housing. The residents’ come . . . Then I also see to it that he can attend the chilly opinions about their comparatively spacious activities he likes.” flats in the extra-care housing residence possibly indi- It could also be an opportunity to comfort a dis- cate that the bed-sitting rooms offered in the assisted tressed resident: living facility would not have been an alternative for “You don’t know what to do when she gets her panic most of these residents at this point. The fact that attacks at night . . . Well, you can sit and talk for a while and many could have remained in their former homes pat her and so on.” with home-care services made them less prone to In the assisted living facility, it was once observed make big sacrifices regarding housing quality in through a chink in the door how a staff member order to access care. However, the relative importance was comforting a newly widowed woman in her of the components in the assemblage of housing and bed, hugging her and holding her hands. Situations resident-centred care changes with increasing care of this kind suggest the emergence of micro-assem- needs. At a later point, when access to care may be blages of care of limited endurance embedded in a question of life or death, an individual is prepared to greater assemblages of space and materiality; in this move to a substandard flat in order to access that case a bed, a staff member and a mourning widow in care. her private room. While get-togethers such as common meals did not generate much conversation between residents Individualized care in either of the two housing alternatives, it seemed as The staff interviews in the assisted living facility though the peacefulness of the private flat and a revealed a trajectory of routinized care over the meeting between only two people formed the small- course of a day in which staff made an effort to scale assemblage necessary for the emergence of the respond to each elderly individual’s wishes and residents’ ability to express themselves. When this needs. Routine care tasks in nursing homes are happened in a severely disabled resident with a mediated by personal and situational factors (Essén, speech impediment, it created joy and satisfaction in 2008). Not to underestimate the importance of these the staff member who experienced it: INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 9 “Sometimes in the afternoon when you enter his Residents’ autonomy room he is lying down, watching TV. Occasionally he Because architectural space in the two housing alter- has said that a programme was interesting and then natives contributed to two different communities in . . . you are almost taken by surprise; [laughter]; then it which encounters between residents and staff is fun.” emerged in distinctly different ways, they offered dif- The last comment, about being surprised, suggests ferent degrees of autonomy to the residents. In the that in between scheduled routines there is a flow extra-care housing residence, the residents were of emergent events that are volatile and perhaps easy expected to live independently with a higher degree to miss. Conversations were in a constant state of of autonomy, and this was encouraged by the clear becoming, depending on the staff’s abilities to seize boundaries between private and public spaces and the opportunity to enter into communication with the the care work organization, forming an assemblage resident. A difference between the extra-care housing where independence could grow. As was mentioned and the assisted living residences that shaped these above, there were few or no visits from the staff conversations was the easy access to the residents’ between the scheduled caring visits. Thus, the resi- rooms in the assisted living facility, in contrast with dents’ flats were assemblages in which solitude and the scheduled visits in the private flats in the extra- privacy were nurtured. Residents, even those with care housing residence. The dense architectural severe disabilities, retained responsibility for their assemblage with short distances and often open lives. The severely disabled man with the stroke was doors in the former offered emergent opportunities also expected to live independently. He was sup- for peeking in while doing something else. In an ported in this by his wife, who visited him regularly interview, one staff member commented on her occa- and cooked meals in his flat. sional interaction with one of the residents: In the assisted living facility, on the other hand, support from the staff was never far away, creating an Like for example Anna; she is so anxious in the eve- nings, so I tell her “I’ll come back to you before I go assemblage with emerging opportunities for meet- home. And I might not come inside but I’ll open the ings and assistance. One staff member commented door a little to see if you are asleep, then I’ll just leave, in the interview on the regular presence of staff in the and if you’re awake I’ll come in and say goodbye, public areas: because I’ll be on my way home.” “Yes, there are very often [staff] in the kitchen, actually. And we run and there are short distances, These examples above show that resident-centred care everything is close, so it is pretty certain that staff are may emerge as short-lived opportunities to grasp and here. Perhaps that makes residents feel safer.” cultivate as individualized care for a few moments. The One example was a woman suffering from dementia “messiness” of encounters between staff and residents who became very upset from time to time if she was nurtures individualized small-scale care which was of alone in her room, and expressed her distress very great importance in the assisted living facility. The fact loudly. When the staff took her out and she sat in her that the staff worked alone more in the extra-care wheelchair watching them work, according to obser- housing residence was also a component that offered vations she seemed to become less stressed and she scheduled and thus recurrent opportunities for private was able to settle down. It seemed important where encounters with residents. However, one staff member in the architectural assemblage she was situated and in the extra-care housing residence who also had with whom she could associate. experience working in assisted living thought that the The corridors in the two housing alternatives were frequent improvised encounters with residents in the architectural spaces which gave rise to different kinds assisted living encouraged a tighter relationship with of individualized care work and meetings between the residents than in the extra-care housing. Although residents and staff. In the extra-care housing residence, it may be a question of individual judgement in which observations revealed that the corridor was mostly type of residence the best relations develop, it is clear empty, with the exception of staff assisting residents that the different physical environments and the orga- to and from meals and activities, while in the assisted nization of care contributed to the emergence of dif- living facility, the doors to residents’ rooms were often ferent kinds of staff/resident relations. In the assisted open and a variety of care situations took place much living facility, encounters between caregivers and resi- more frequently there. Hence, the corridor had a more dents were more or less unanticipated happenstances pronounced capacity to link the individual bed-sitting interwoven in a flow of frequent care events situated in rooms to each other by the involvement of staff and many different spaces, while in the extra-care housing residents, and contributed in these situations to the residence they were clearly chiselled-out situations dense assisted living assemblage. Residents and staff more firmly emplaced in the residents’ flats, identified, often moved around in the corridor on a daily basis. appreciated and expected as such by the staff mem- One woman explicitly wanted to have a connection bers as well as the residents. 10 C. NORD with the corridor outside her bed-sitting room. She said in existing research, although without any particular that she wanted to have her door open “so that I can analysis or discussion (Kane et al., 2007; Molony et al., see the hustle and bustle outside”. She may have felt 2011). This study shows how architectural space con- more included and safe by having her door open, tributes to the emergence of resident-centred care, and being more tightly associated with the greater assem- the results show that it appears in different forms in blage of space, staff and other residents in the whole different architectural environments. Rather than facility. A more dramatic event took place when a ascribing stable and essential qualities to the environ- resident attempted suicide in the corridor and the ment, such as that this environment is good or that staff came rushing to his succour. It is highly likely environment is bad, the theoretical framework of that this man took advantage of the connecting capa- assemblage made it possible to discern care and city of the corridor and calculated that someone would space in becoming, and the outcome of relationships most probably see what he was doing. This would not with co-constituting heterogeneous components such necessarily have been a successful strategy in the as laws, bodies and artefacts—a caring architecture extra-care housing corridor, where people passed reg- (Nord & Högström, 2017). This resonates with theorists ularly but not very often, offering much fewer emer- who contend that resident-centred care is not com- ging associations due to less supervision. posed of relations between residents and staff alone, The architectural environment and the staff care but involves material factors such as space work thus formed a community with tight relations (McCormack & McCance, 2010). in the assisted living facility, in which the residents Architectural space appeared in this study as having could to some extent dispense with their autonomy various agentic capabilities, sometimes involving staff and leave their safety and choices in the hands of the or other components, sometimes with a strong agency staff. This was highly beneficial to people with almost of its own (cf. Brott, 2013). However, care was dementia, as was indicated in the situation with the always a co-constituting component. Sometimes the yelling woman described above, while the freedom residents’ perception of their need of resident-centred and responsibility demanded in the extra-care hous- care was a sufficient component. The latter indicates ing did not always work well with the needs of a that resident-centred care is immersed in relations that person with dementia. These problems manifested in do not necessarily involve staff at all. This was the case different ways when these individuals became when the residents faced a number of choices over increasingly dissociated from the assemblage due to which staff had little influence, such as the individual their progressing disease, which invariably redefined choice to move in, or the choice of a flat or a bed-sitting the components in the assemblage and gave them room in order to get access to care. These choices arose new emergent and sometimes terrifying meanings. as a significant aspect of resident-centred care, since One man had created a small micro-assemblage of they were an outcome of each individual’s negotia- himself, a bed and bedding behind a closed bedroom tions regarding his or her individual care needs. door in the extra-care housing residence. He seemed Choices grew out of circumstances. Thus, the relation- to be horrified by the “autonomy” he was supposed ships between perceived health, material, legal, discur- to assume, and lay in his bed waiting for the staff to sive and spatial components were more influential come. He whined from beneath his blanket: “I have than the staff. been waiting for you the whole day.” A woman The contrary appeared in situations in which staff experienced the extra-care housing quite differently were strong co-actors together with architectural because the assemblage of the housing could not space. The study results indicate that the staff were keep her contained, due to her disease. The architec- enmeshed in spatial and material circumstances, influ- ture was open, with weak or non-existent borders encing the quality and character of their provision of between buildings and the surroundings. She started resident-centred care. This appeared in a number of leaving the residence at night, since her perception of planned and unplanned care encounters with resi- day and night was in a process of deterioration and dents in which care could develop in unpredicted the supervision was not sufficient for her needs. One ways according to contingencies then and there. night, a stranger who had found her in town brought Different spaces had similar or different capacities in her back in his car. Obviously, her safety was endan- the two residences. The residents’ flats and bed-sitting gered. Both of the people afflicted with dementia rooms were on a par in many situations, both offering moved to assisted living during the fieldwork, having material and spatial circumstances for a rich palette of become completely dissociated from the assemblage. care encounters, perhaps because they minimized the number of actors, to the advantage in particular of frail residents. Very small-scale events emerged as Discussion individualized incidences of high-quality resident- centred care. At a larger scale, in which the corridor The importance of architectural space for the provision of the building was a major architectural agent, the of resident-centred care has been a point of departure INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 11 density of the assisted living proved to be more prone environment in the small-house nursing home. In parti- to connectivities and care events in becoming. In cular, the single rooms were highly appreciated com- these situations of openness, in which various trajec- pared with the shared rooms in the conventional tories of care were available, lay the possibility to nursing home. In the present study it seemed that the adapt the care to the individual’s needs, to offer residents had a tendency to overrate the quality of the individualized care (cf. Essén, 2008). In this study, accommodation because it gave them access to care autonomy appeared as a product of architectural (cf. Nord 2016). This has implications for the evaluation space and the organization of care, involving relations of services and care given to older people. How do we between both flats and corridors. Autonomy and priv- assess older peoples’ assessments of their housing qual- acy were strongly linked (separate flats) and involved ity? Canwebesure thatwe are measuring residential a lower degree of supervision in extra-care housing satisfaction if their assessment of the quality of their compared to the density of the assisted living, where accommodation is in fact an assessment of a caring residents could refrain completely from autonomy if architecture; that is, care and accommodation together? they preferred to. This is in line with Kane and collea- gues’ study (2007) in which autonomy and privacy Conclusions were aspects of quality of life which was found to be higher in the small-house nursing home with pri- This paper concludes that resident-centred care vate flats. This is a reasonably direct and discernible depends on the associations with components in the cause–effect mechanism. It is surprising, then, that the assemblage in which it is carried out. Architectural perceived autonomy the private flats offered to the space is a strong actor in these processes and negotia- residents did not appear as a factor influencing resi- tions. Architecture does things to people (Gieryn, dential satisfaction in the small-house nursing homes 2002), although not as a person acting, but in that in Molony and colleagues’ study (2011), although it lived experience is altered (Brott, 2013). This means affected at-homeness. The fact that perceived auton- that neither care nor architecture can be considered omy in conventional nursing homes in the same study alone. It is in their co-emergence as a caring architec- was not linked to residential satisfaction is less surpris- ture that roles of space and care are constituted and ing if the care needs of the residents are taken into sometimes visible. This is the major generalization that account. This study shows that the architectural it is possible to infer from this study; an analytic gen- impact on autonomy was much more indirect, intan- eralization from a multiple-case study, aimed at exam- gible and negotiated with care in assisted living. If ining variation or similarities (Polit & Beck, 2010). Thus, residents were happy about refraining from privacy on a theoretical level, the study suggests that the due to their care needs being satisfied by a higher different embedded concepts that were examined con- degree of supervision in a dense architectural envir- tribute to different contours of the concept resident- onment, and if they nevertheless perceived their centred care (Deleuze & Guattari, 1994). The limitation autonomy as sufficient, they would most probably of this generalization is that there are only two archi- not see this link between autonomy and architectural tectural settings in which resident-centred care was space and, thus, it would not influence their residen- examined in this study. In order to fully understand tial satisfaction. This shows the elusiveness of space as the impact of architectural space, it is necessary to taken for granted in everyday activities (O’Toole & scrutinize each concept—residents’ choice, individua- Were, 2008). The agency of architectural space can lized care and residents’ autonomy—in different con- be almost invisible. texts. The generalized results should be explored in The small-house nursing home in Kane and collea- other architectural conditions in order to expand and gues’ study (2007) was assessed as a better environ- deepen this theoretical contribution further (Morse, ment to live in than compared facilities. It is unclear to 1999). Moreover, only three aspects of resident-centred what extent resident-centred care contributed to this. care were in focus in this study. This multidimensional The results in this study show that the residents’ assess- and complex concept does have other features that ments of their flats were not necessarily congruent with can be subject to similar research. It is thus suggested, an objective assessment of their quality. The assisted in order to address the limitations of this study, that living home environment with smaller flats came out in other dimensions of resident-centred care also be a better light in the eyes of the residents than was the examined in relation to space. The study suggests case for the residents in the extra-care housing resi- that each individual concept gets its form and meaning dence, because it seemed to satisfy their pressing situated in relations in an assemblage of people, spaces needs for care. This somewhat surprising result, which and materiality in sometimes highly unstable and vola- contradicts the results of Kane and colleagues (2007), tile situations, processes of exchange, varying mutual- points to the importance of the co-constitution of care/ ity and associations, contributing to a flow of space. Molony and colleagues’ study (2011) also contingent circumstances in which resident-centred showed strong resident preferences for the physical care emerges. 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Journal

International Journal of Qualitative Studies on Health and Well-being – Taylor & Francis

Published: Jan 1, 2018

Keywords: Patient-centred care; architectural space; assemblage; assisted living; extra-care housing

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