Nursing home residents tell their story: researchers find themes emerging from a resident survey--and they offer actions for administration to take.

In your nursing home, what makes residents happy or unhappy? What are their special wishes? We posed those questions to 245 residents at 10 nursing homes located in two Midwestern states. Approximately three-fourths of the residents we interviewed reported positive feelings about being in their present nursing home, and 43% told us that that nothing makes them unhappy there. Four themes emerged from resident responses: community, care, supportive relationships, and loss and grief. In this article, we share our findings with nursing home administrators and staff. Some of this may confirm what you already know and the actions you should be taking. We offer our own recommendations and suggestions to address these themes.

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Community

As in any community, nursing home residents focus on their living space, neighbors, and what is happening. For some residents, having others around affords conversation and companionship, especially when their roommate is or becomes a friend. The nursing home provides a sense of "fellowship, friendship, and care." In contrast, other residents may be uncomfortable with the number of people and the amount of activity level within the environment. These residents are unhappy because they "always have someone around," and wish for "a private room" or "a lot of space like I had at home."

Residents enjoy going to the dining room and visiting with their tablemates. They are happy when the food is good, there are snacks at night, and they celebrate birthdays together. They are unhappy when the coffee is not freshly brewed, the same foods are served too often, or the food is not cooked to their personal taste. Residents' special wishes include "to have food and meat like I had on the farm," "for someone to bring food from outside for my birthday," and "to have a martini once in a while."

The planned activities provided by nursing homes are an important part of the community. Residents like to be busy and enjoy "the chance to play bingo and laugh." Some are happy because church services are offered in their home. Many residents want to get into town and see new sights. One resident's special wish is to "get a group together and get away from here," whereas another simply would like to "get out more and see flowers and trees." Others want to go shopping or go out to lunch.

Most residents are elders, and the nursing home community may be less satisfying for younger residents. A younger resident says, "There's a bunch of old people here instead of people my own age." Another tells us, "It's such a sad place, so many old people."

Actions. Fulfilling residents' special wishes could increase their sense of community. One approach would be for the care planning coordinator or social worker to ask residents about special wishes when completing the quarterly or annual MDS assessment. Many of the wishes are easy to grant through staff or family members, and that special treat could be added to the respective resident's care plan as a onetime event. Using the MDS assessment process ensures that residents with limiting physical or mental impairments would be included.

Other actions to increase residents' sense of community might include providing quiet places where they can go to be alone or arranging activities targeted for younger residents that offer interactions with age-mates. Access to the Internet, with assistance in learning to use that technology, could facilitate participation in chat rooms and, perhaps, cyber friendships with peers in other facilities.

Care

Residents come to nursing homes because they need help with basic activities of daily life. Many residents are happy because someone else does the housework, prepares the meals, washes the dishes, and does the laundry. They like having someone who pays attention to them and helps them meet their needs.

Having things go the resident's way is important. Residents appreciate special attention to unique interests or needs, such as having staff communicate with sign language, being able to listen to music of their choice, and having coffee with the chaplain. They need flexibility; for instance, too many baths make one resident unhappy, whereas another's special wish is to have more baths.

Residents are happy when they are satisfied with staff and believe they receive good care. They describe good care as having staff listen to what they say, having someone respond quickly to the call light, being handled gently by staff during care, receiving proper medications and treatments, and having the doctor visit. Personal cleanliness is valued--being kept clean, having clean clothes, and having clean teeth.

Good care depends on the facility having enough qualified staff to meet resident needs. Long waits--for meals to be served, for help to the bathroom, or for the nurse--make residents unhappy. Sometimes busy staff save time by doing things residents could do for themselves. It may be faster to change a resident's briefs than to take him to the bathroom, or to push a resident's wheelchair to the dining room rather than letting her use a walker. High staff turnover also creates problems. One resident says, "The people who help me change all the time; they don't know what they're supposed to do."

Some residents are more vulnerable than others because of cognitive impairment, hearing or vision loss, or limited mobility. A touching special wish is that everybody be treated the same. A resident observes, "Some people who don't know where they are get left behind on answering call lights."

Actions. It is important that staff seek input from residents and family members about care. Feedback about how their concerns are addressed reinforces a need for their participation.

Although maintaining independence is desirable, a resident's ability to do a task warrants careful evaluation. For example, vision and fine motor skills must be considered in deciding how a resident participates in an insulin injection.

Employee recognition programs should emphasize specific staff behaviors that make a difference for residents. One simple approach we have seen is an "Atta Girl/Boy" program. Staff members recognize one another for exceptional resident assistance by offering a written acknowledgement to a nurse manager for the helping colleague to receive a can of soda. We also saw a program in another facility where residents and family members nominate staff for a "STAR" award based on outstanding performance, and a star is attached to the employee's name tag.

Supportive Relationships

Establishingnew relationships with staff and other residents is part of settling into a nursing home community. Support from family, friends, and staff is critical to new residents' successful transition and adaptation.

Family and friends. "Being with those you love" makes residents happy. They enjoy face-to-face contact with their spouse, children, siblings, in-laws, other family members, friends, and pets. The telephone or e-mail facilitates contact for relatives and friends between visits. Talking with a sister in another state every day by telephone maintains a vital link. A husband bringing the dog to visit is wonderful! Residents' hearts are warmed by small gifts and services from family and friends, such as a cassette player from a nephew, a fish fillet from a friend, and dresses laundered with a daughter's special touch.

A resident who goes to a family event or to a friend's house is affirmed as a continuing member of social groups that are part of his or her identity, and the change breaks the day-by-day sameness of the nursing home environment. Having relatives or friends in the same facility is a major happiness factor. Visiting, meals, and other activities shared with people who have been part of residents' lives enhance their sense of belonging and community.

Residents who are unhappy about relationships with family most often feel greater separation because of distance or a perceived lack of concern. Residents may resent the person(s) whom they view as responsible for placing them in a nursing home. Telling comments include "I took care of everybody, but nobody comes to see me," and "My sister put me here; she comes twice a week, but doesn't talk much." Residents miss friends, and the desire for visits with them becomes poignant as disability and death diminish that opportunity.

Special wishes regarding family and friends usually relate to having more contact. However, one man feels there is too much pressure on his wife and wishes for someone to help her take care of him. Another man wishes that staff would watch his wife, a resident in the same facility, more closely.

Staff. Staff members make residents happy through interactions based on respect, kindness, and concern, and by taking time to help, listen, and share their lives. Residents are happy when staff are attentive, but without fuss; when they invite them to events, but also allow them to be alone; and, in general, when they try to make things better for them. Residents appreciate a pat on the shoulder and staff coming to tell them good-bye. It is important for them to have something in common with staff; for example, boosting the same sports team. Shared laughter is a crucial happiness factor. For some residents, teasing staff and being teased, kidding, telling jokes, playing tricks on each other, and "picking on" staff add spice to the day.

Residents are unhappy with disrespectful staff behaviors toward their personal belongings, such as leaving a dresser drawer in disarray or using a resident's perfume. They are unhappy when staff are mean, will not tell their names, or will not talk with them.

Actions. In addition to the resident council, residents need an opportunity to voice concerns privately to someone who can do something about them. Residents may feel powerless or threatened by abandonment in conflicts with staff, and may need support from a family member or friend in voicing their concerns.

Family members and friends who do support residents and add quality to their daily lives deserve recognition. Examples of uncomplicated acknowledgments include feedback from staff about how much a resident enjoyed a special outing or a snapshot of a resident wearing a new sweater sent by a brother in another town.

Relatives living in the same facility--spouses, siblings, cousins, or friends--may not see each other every day. Establishing a communication mechanism to share updates about loved ones would relieve their anxiety about each other's well-being.

Loss and grief

Loss and grief are common reactions of a new resident's transition to a nursing home. Long-term admission usually is precipitated by a loss of ability to care for oneself, so the new resident loses independence as well as his or her former lifestyle. "I had to give up my home" is a common lament. One resident's special wish is to "go home and manage my own house and fix my own breakfast." Simple, everyday tasks give one meaning and purpose in life, and the loss of one's health and productivity causes grief, frustration, and embarrassment for the frail older adult. Residents wish "for my health back," that "I didn't have to ask for help," or that "I could walk."

For many, declining health has made living at home or with family an unsafe situation. Others have no available family or friends. Residents mentioned prior deaths of a spouse, children, and friends when talking with us, and they lose other family members and friends as time goes by. Residents describe the loss of loved ones as a source of great sorrow and loneliness, and wish for those people to return to their lives. The passing of other residents is a very real part of living in a nursing home. They wish for them to "come back because they made it more interesting here."

A number of residents appear to be predisposed to make the best of things. Such individuals take on new roles within the facility that carry a sense of worth and purpose; for example, by helping in a coffee or ice cream shop, serving as a resident council member, or staying busy helping other residents. A few residents view living in the nursing home as maintaining their independence; they do not want to live with their family and are happy to have an acceptable alternative.

Approximately 10% of the residents we interviewed may be "stuck" in tangible and unresolved feelings of loss and grief for their homes. Nothing in the nursing home makes these residents happy, and they seem sad, lonely, and sometimes clinically depressed. Not only are residents with unresolved grief likely to withdraw from activities that might facilitate their integration into the nursing home community, other residents also may avoid them because they only talk about sad things and wanting to go home.

Actions. Residents who seem "stuck" in unresolved loss need professional counseling. Although antidepressants may be useful, they are no substitute for a therapeutic grief process. Residents also need support in coping with the losses that are part of their daily lives. Providing an opportunity for individuals to reminisce and share photos or stories helps validate their feelings. Rituals that acknowledge resident deaths facilitate grief and closure for both the remaining residents and staff.

In sum, these residents' insights offer a glimpse into life in a nursing home. The survey showed that residents generally have a positive outlook--approximately three-fourths of residents reported positive feelings about being in their present nursing home, and 43% said that nothing makes them unhappy there. However, residents also offered a number of concerns, which our suggestions address. And, finally, this study documents a basic truth: If administrators and staff listen to their residents, they'll find out what residents want--and what they don't--and what it will take to gain improved resident satisfaction.

This study is part of a larger project, Care Planning Integrity & Nursing Home Resident Outcomes, Grant # R01 NR008028-03, funded by the National Institute of Nursing Research to the University of Kansas Medical Center, School of Nursing, Roma Lee Taunton, Principal Investigator.

Roma Lee Taunton, PhD, RN, FAAN, is Senior Scientist; Valorie Coffland, MA, is Project Manager; Ubolrat Piamjariyakul, PhD, RN, is Research Assistant Professor; and Marjorie J. Bott, PhD, RN, is Associate Dean for Research at the School of Nursing, University of Kansas Medical Center, Kansas City, Kansas. Sara Pedram, BS, is Administrator, Pastoral Care & Counseling, Village Presbyterian Church, Prairie Village, Kansas. For more information, phone Dr. Taunton at [phone]. To send your comments to the authors and editors, e-mail [e-mail].

BY ROMA LEE TAUNTON, PHD, RN, FAAN; VALORIE COFFLAND, MA; SARA PEDRAM, BS; UBOLRAT PIAMJARIYAKUL, PHD, RN; AND MARJORIE, J. BOTT, PHD, RN