Perceptions of Older Residents and Their Adult Children Regarding Continuing Care Retirement Community Staff

Abstract

This study examined the perspectives of continuing care retirement community (CCRC) residents and their adult children regarding services provided by staff in the CCRC. The study is based on semistructured qualitative interviews with 49 residents and their 34 adult children from 11 CCRCs. Transcripts were analyzed using qualitative content analysis. Three major themes emerged: (a) “Reliance on the CCRC staff,” (b) “Dissatisfaction with the CCRC staff,” and (c) “Disregard to the CCRC staff.” Findings suggest that staff should maintain constant contact with all residents, including those who are not satisfied with staff’s function and those who do not use staff services, to identify and respond to the residents’ changing needs. Attention should be paid in meeting residents’ physical needs prior to meeting their social and emotional needs, as these tend to be the most urgent.

Keywords

perceptions of care staffing community care

Introduction

Given the aging of the world population and the increase in life expectancy, an industry of alternative housing solutions started to flourish in early 2000 to address independent older adults’ changing needs (Oswald & Rowles, 2006). The continuing care retirement community (CCRC) is one of the alternative housing solutions, which allows older adults to “age in place.” The CCRC is defined as a residential community or life-care community that older adults move to for the remainder of their lives. This long-term care (LTC) setting is designed to foster residents’ independence by providing them with a variety of services and activities to meet their needs (Prawitz & Wozniak, 2005). CCRCs offer their residents 24-hr health care and security services, social and recreational activities, attractive dining options, housekeeping, and wellness and fitness programs (Zarem, 2010). Over the past decade, additional units that provide more intensive levels of care, such as assisted living or skilled nursing facility, were opened in the CCRCs in response to independent older adults’ changing needs (Shippee, 2012). As a result, the number of CCRCs has expanded (Mirovsky, 2007). In the United States, there are approximately 1,900 CCRCs, whereas a typical CCRC has fewer than 300 total units (Zarem, 2010).

The growth rate of older adults (65 years of age and above) in Israel is among the highest in the world, certainly when compared with the general population. From 1955 to 2010, the number of older adults has grown by 10.1% whereas the general population during that period has grown by 4.5% (Shnoor, 2011). Although most of the care provided to older Israelis is done at home by family members or home care workers, about 4% of older Israelis live in long-term institutions. Currently, in Israel, there are 184 CCRCs, which constitute of 31 units per 1,000 individuals above the age of 65, or 64 units per 1,000 individuals above the age of 75 (Brodesky, Shnoor, & Be’er, 2014).

The transition to a CCRC represents a turning point, given substantial changes involved in moving from one’s familiar home to a LTC framework. The adjustment to a CCRC requires psychological, familial, and social resources, which can be limited in the case of older adults (Burge & Street, 2010). Indeed, programs that support CCRC residents by reducing stress and enhancing psychological well-being (e.g., Mindfulness-Based Stress Reduction Program) have demonstrated effectiveness (Moss et al., 2015). Because of their constant presence and proximity, CCRC staff could potentially play a crucial role in fulfilling older adults’ changing needs during their “new lives” within the CCRC framework.

The Potentially Important Role of Staff in the Lives of CCRC Residents and Their Family Members

CCRCs employ staff that is in charge of delivering care and services to the residents. The staff includes health care professionals (e.g., physicians, nurses), social workers, social activity facilitators, maintenance staff, receptionists, security staff, management, and nursing staff (Tal-Sapiro, 2013; Zarem, 2010). The uniqueness of the CCRC lies in the freedom of the residents to decide whether and when to take advantage of the different services and activities offered to them (Brodesky, Shnoor, & Be’er, 2012).

Although a growing body of literature has suggested that the nature and quality of the relationships between staff and older residents are important determinants of the experiences and the satisfaction level among residents and their families in assisted living facilities (Bauer, Fetherstonhaugh, Tarzia, & Chenco, 2014; Biggs, Bernard, Kingston, & Nettleton, 2000; Kemp, Ball, Perkins, Hollingsworth, & Lepore, 2009; Wilson, Davies, & Nolan, 2009), relatively little is known about interpersonal relationships in alternative housing solutions such as CCRCs. Given the uniqueness of the CCRC setting as a place that meets the evolving needs of independent older adults and their family members (Ayalon, 2015), a further examination of staff–residents–family members’ relationships is highly needed.

According to the CCRC Service Quality Model (CCRC-SQM), favorable staff service quality perceptions lead to improved satisfaction reported by residents and families (Young & Brewer, 2002). Indeed, the lives of CCRC residents are bounded by their experiences within the CCRC setting and daily interactions with CCRC staff are central to residents’ quality of life (Burge & Street, 2010). For example, past research in assisted living facilities has shown that the more staff responds to residents’ evolving needs, the more residents are satisfied with the care and treatment they receive (Ball, Perkins, Hollingworth, & Kemp, 2010; Ball, Kemp, Hollingsworth, & Perkins, 2014). Another study demonstrated that residents are more satisfied with care when the staff enjoys their work environment and experiences job satisfaction and fulfillment. Hence, the lives of residents and staff are intertwined (Sikorska-Simmons, 2006). Indeed, lower staffing levels and higher staff turnover have a direct influence on residents’ quality of life (Burge & Street, 2010).

Because all CCRC residents live and operate in a single place that is separated from the general community, it has been argued that some features are shared by CCRCs and total institutions (Ayalon & Green, 2015). According to Goffman (1961) within the total institutions, there is a large social distance between staff and residents, which creates a feeling of inferiority and worthlessness among the residents. Yet, past research has concluded that the care home staff strives to maintain and support its residents’ autonomy and dignity (Hall, Dodd, & Higginson, 2014).

The transition to the CCRC does not abolish family involvement and care as past research has repeatedly demonstrated the active involvement of family members in the lives of CCRC residents (Bauer et al., 2014). Another study emphasized the linked lives of CCRC residents and their adult children (Ayalon, 2016). Consistently, the importance of fostering good relationships between family members and the residential aged care facility staff has been well established within the existing literature. Benefits were observed from the perspectives of residents (Wilson et al., 2009), family members (Bauer et al., 2014), and staff (Utley-Smith et al., 2009). Moreover, the implications of neglecting constructive staff–family relationships have shown to be significant (Bauer et al., 2014). For example, a study conducted in nursing homes found that when staff–family relationships lacked trust and communication, family caregivers felt that the staff was criticizing them directly (Majerovitz, Mollott, & Rudder, 2009). Another study conducted in a nursing facility argued that a perceived conflict between families and staff was directly correlated with the levels of caregivers’ stress and depression (C. Chen, Sabir, Zimmerman, Suitor, & Pillemer, 2007).

The Present Study

Given the increase in life span, the increasing number of CCRCs, and the potentially important role of CCRC staff in the lives of older adults and their family members, the objective of the present analysis was to examine Israeli CCRC residents and their adult children’s perspectives regarding the capacity of the services offered by CCRC staff to meet the residents’ needs and to explore CCRC residents’ and their adult children’s perceptions concerning different types of services (e.g., health services, maintenance, security staff, social workers, social activity facilitators, and management). Findings will provide valuable information about the perceived relationship between CCRC residents and their adult children and the CCRC staff.

Design and Method

Sample

The study used a purposive sample of “information rich” (Patton, 2002), meaning focusing on the selection of participants who best represent the population and best reveal the studied phenomenon (Mason, 1996). The sampling inclusion criteria were male or female independent older adults (65 years of age and over), living in the independent sections of the CCRC who are cognitively intact, as assessed by the CCRC staff. In most cases, older adults identified an adult child who would be available for an interview. In a few cases, we interviewed older adults who had no adult children available for an interview or had no children at all.

A total of 49 residents and 34 adult children were interviewed. Table 1 presents the demographic characteristics of the sample, and Table 2 presents the characteristics of the 11 CCRCs from which interviews were drawn.

Table 1.

Demographic Characteristics of the Sample.

	Older adults(n = 49)	Family members(n = 34)
Age	79.81 (4.37)	53.7 (8.0)
Women	88%	67.8%
Education (years)	12.02 (2.7)	14.9 (2.4)
Financial status (1= not good, 4= very good)	2.8 (0.5)	2.8 (0.5)
Married	34.8%	42.9%
Widowed	57.5%	0%
Subjective health (1 = poor, 5 = excellent)	2.9 (0.7)	4.2 (0.6)
Months in the CCRC	7.45 (2.54)	Not applicable

Note. Continuous variables are reported as means (standard deviations). Categorical variables are reported as percentage. CCRC = continuing care retirement community.

Table 2.

CCRCs’ Characteristics.

Name	No. of interviews with residents	No. of interviews with adult children	Year built	Year renovated	A pool	Nonemergency medical care	Nursing unit	No. of activities per month	District	Living arrangement	Rooms^a	Average age	Ownership	Type
GO	2	1	1988	2009	Yes	Weekdays	No	20	South	Town home	210	85	NPO	Nonchain
BY	1		1999	2006	No	Weekdays	Yes	40	South	Condo	160	82	NPO	Nonchain
NA	3	2	1962	2011	No	24/7	Yes	15	Center	Condo	140	87	Private NPO	Chain
TR	3	1	1997		No	Weekdays	Yes	10	Center	Condo	60	90	Private	Nonchain
GB	2	1	2001		Yes	6 days	Yes	20	Center	Condo	120	85	NPO	Nonchain
VS	2	2	1975	2009	No	None	Yes	10	Center	Condo	55	87	NPO	Chain
BJ	3	2	1979	1997	No	3 days per week	Yes	25	Center	Condo	120	87	NPO	Nonchain
BBJ	5	2	1989	2007	No	3 days	No	20	Center	Condo	90	80	NPO	Nonchain
BBR	2	1	1989	2007	No	24/7	Yes	20	Center	Condo	66	85	NPO	Chain
LG	2	2	1995	2005	No	4 days	Yes	20	North	Condo	80	82	Private	Nonchain
BBI	24	20		2010	Yes	24/7	Yes	40	North	Condo	300	84	NPO	Nonchain

Note. CCRC = continuing care retirement community; NPO = nonprofit organizations.

Not including nursing department rooms.

Procedure

Data collection

The present study is part of a larger qualitative study on CCRC residents and their adult children that included three waves of interviews. The current study was focused on data from the first wave of interviews with older adults and their adult children. Data were collected between 2010 and 2014. The study was funded by the Israel Science Foundation (ISF).

Older adults’ and adult children’s perceptions of services provided by staff were explored using in-depth, semistructured interviews. Interviews occurred within the first year of the older adult’s transition to a CCRC. We first conducted interviews with 32 older adults and 19 adult children from three different CCRCs under common ownership. A social worker employed by this chain explained the purpose of the study and offered the opportunity to participate. Interested residents and their adult children were referred to a graduate-level research assistant to schedule an interview. Following funding from ISF and to increase the variability of our sample, we approached eight additional CCRCs. This resulted in 11 CCRCs that were included in the current study.

Most interviews occurred in CCRCs. There was an explicit attempt to interview adult children separately from their older parents and vice versa. Interviews were conducted by five different interviewers with experience in qualitative interviews. All interviewers had prior training in qualitative interviewing including the conduct of mock interviews prior to the start of this study. Ongoing supervision and mentoring regarding interviewing style was provided by L.A., a psychologist with over 10 years of experience in qualitative research.

The interviewers promised anonymity and confidentiality and participation was voluntary. Participants were included in the study after signing a consent form. The study was approved by the Ethics Committee of the School of Social Work at Bar Ilan University and by the Helsinki committee of Maccabi Health Care Fund.

An interview guide was constructed including key questions to stimulate primary descriptions and concepts that participants might use to describe their reality regarding the phenomenon under study (Shkedi, 2003). The interview guide started from broad questions for both older adults and their adult children such as “Tell me your life story” and “Tell me about the decision to move to the CCRC,” followed by more detailed questions for clarification and emphasis such as “What are the advantages and disadvantages of this place compared with the community?” As the present study is based on secondary analysis that aims to examine a very specific aspect of the data (Heaton, 2008), only two questions, which specifically referred to the older adults’ and their adult children’s relationship with the staff, were used in the present study: “Tell me about the services you received from staff?” and “Are you in touch with the CCRC staff?” When needed, clarifying questions were used such as “Can you please elaborate your discussion regarding the CCRC’s staff?” and “Please tell me more about the CCRC’s staff.” Finally, selected demographic questions were included to better situate the respondents in a sociocultural context. Ten older adults and nine adult children who were not directly asked by the interviewer about the CCRC staff were excluded from further analysis. Interviews lasted between 1 and 1.5 hr; interviews were recorded and verbally transcribed.

Due to the rich data, the present study is devoted to analyzing interviews concerning CCRC residents’ and their adult children’s perspectives regarding the CCRC staff. Additional themes concerning other topics derived from the interviews are available elsewhere (Ayalon, 2014, 2015; Ayalon & Green, 2012, 2015).

Qualitative analysis

Content analysis of the issues raised by the participants was performed as follows:

Open coding: The researchers first independently read each interview transcript line by line, jotting down notes to capture and identify initial units of meaning (categories) emerging from the data (Strauss, 1987). Open-coding analysis was also conducted by a graduate student in social work. Differences between the coders were resolved through discussion until a final consensus was reached (e.g., whether quotations reflected the theme title and whether a particular theme was appropriate).

Axial coding: In a second reading of the transcripts, the researchers gradually detected associations between themes and subthemes related to context and content. They compared interviews to consolidate meaning to reach a theoretical construct (Strauss, 1987).

Integration: The core themes or main categories that emerged from the data were reordered conceptually and placed back into context, making it possible to analyze and integrate large amounts of data and to generate abstractions and interpretations (Shkedi, 2003). These themes included the abstraction and unification of the findings.

Trustworthiness

Trustworthiness was achieved in several ways. First, the interview material was transcribed verbatim, enabling the researchers to return to the original narrations. Second, both researchers performed the analysis separately. They compared the identified themes and attempted to negotiate disagreements regarding the main themes (Lincoln & Guba, 1985). Third, the researchers used credibility criteria that can be met if the data are presented as a thick, detailed description of multiple contextually based realities (Lincoln & Guba, 1985). To meet the credibility criterion, this study used in-depth interviews that allowed participants to freely and fully express perceptions concerning CCRC staff. The depth and breadth of the interviews enabled the researchers to claim that they obtained comprehensive and authentic understanding of the experiences and meanings of the respondents. Finally, to obtain a broader range of responses that are not directed by the unique characteristics of a single interviewer (Tietel, 2000), several interviewers conducted the interviews.

Results

Older adults and their adult children expressed a broad range of responses regarding the CCRC staff. Some respondents were highly satisfied with staff, some were highly dissatisfied with staff, and some expressed both satisfaction and dissatisfaction with staff. Finally, some residents disregard the CCRC staff altogether during the interviews.

These responses are demonstrated by three major thematic categories that emerged from the data. The first theme was identified as “Reliance on the CCRC staff.” This theme focused on older adults’ and their adult children’s reliance on the staff for fulfilling the older adults’ daily needs. This theme included the following domains: (a) satisfaction with health care providers, (b) satisfaction with maintenance staff, (c) satisfaction with receptionists and security staff, (d) satisfaction with social workers, (e) satisfaction with social activity facilitators, and (f) satisfaction with management. The second theme was identified as “Dissatisfaction with the CCRC staff.” This theme referred to respondents’ frustration and disappointment with the staff—mainly because the actual daily routine was perceived as not matching or not achieving the impressions created by the staff prior to, or soon after, moving into the CCRC. This theme included the following domains: (a) dissatisfaction with health care staff, (b) dissatisfaction with maintenance staff, and (c) dissatisfaction with the management. It should be noted that reliance on staff and dissatisfaction with staff were found in the same facility by different residents and adult children. In some cases, the same residents and adult children expressed satisfaction with some staff members but dissatisfaction with others. The third theme, “Disregard to the CCRC staff,” addressed older adults and their adult children’s failure to mention the CCRC staff during their interview. More often than not, staff was not voluntarily mentioned when respondents were questioned about their experiences in the CCRC. As a result, this theme is not very well elaborated. Below is a detailed account of the three themes supported by direct verbal illustrations from interviews with older adults and their adult children.

Reliance on the CCRC Staff

The majority of both older adults (n = 30) and their adult children (n = 19) reported satisfaction with and confidence in the CCRC staff. The main staff members that were identified during the interviews were health care providers, maintenance staff, receptionists, security guards, social workers, social activity facilitators, and management. It should be mentioned that although adult children trust the CCRC staff to fulfill their parents’ needs, adult children do not abandon their traditional caregiving roles and continued to visit their older parents and provide emotional care and support as one of the adult children explained:

I’m very satisfied with the services staff provides here. I trust them (staff members) . . . yet, I still continue to come and visit my mother twice a week, sit with her, talk with her, trying to find out if she needs something. (A 54-year-old married daughter)

Satisfaction with health care providers

This domain that is represented by physicians and nurses received the most attention. According to respondents, staying in the CCRC reduced concerns about the long waiting lists for health care services, traveling to receive care and managing bureaucracy. The CCRC health care services were compared with community dwelling where older adults struggled to receive health care services. Older adults and their adult children reported being less concerned about physical and functional decline, knowing that health care services are easily accessible in the CCRC. The following is a direct quote from an interview with an older adult:

I am relieved to know that there are health care providers here. No need to wait, no need to bother anyone When I think about the future I imagine that I will need more intense treatments of this kind . . . knowing that I have them [physicians and nurses] right here, makes me feel comfortable and protected. (An 82-year-old married man)

An adult child explained, “I am relieved that the time element does not play a role here (CCRC). If she [his mother] does not feel well, she immediately receives health care services” (A 54-year-old married son).

Satisfaction with the maintenance staff

Older adults stressed their increasing physical difficulties and their limited technical abilities to manage their home maintenance and repairs. In general, older adults preferred to turn to the CCRC staff rather than to their adult children for certain tasks because they did not want to bother their adult children. The availability of maintenance staff within the CCRC was described as making their lives much easier:

Before I moved to the CCRC, I used to call Uzi [pseudonym, her son] ‘Uzi come, I have no electricity . . . the water is leaking’ I often felt that I bother him. Here [in the CCRC] if something breaks down maintenance comes immediately. I don’t need to worry. I feel confident here. (An 84-year-old widowed woman)

This also had a direct impact on the lives of their adult children who were no longer held responsible for maintenance tasks.

Satisfaction with the reception and security staff

Both older adults and their adult children mentioned that every morning the receptionists called to check on the residents and to see how they were doing. This routine call was described by adult children as a huge source of relief: “I have confidence. Every morning they [CCRC receptionists] call her . . . good morning Judith, how are you? How are you feeling this morning?” (A 64-year-old married daughter). Older adults mentioned that the presence of receptionists and security staff allowed them to feel protected and substantially reduced their concerns about break-ins and burglaries: “It’s the feeling that I go to sleep at night and I don’t have to worry whether someone will break into my apartment. I know that the receptionist and security staff are there” (A 78-year-old widow).

Satisfaction with social workers

Social workers were perceived by older adults and their adult children as helping the residents to adjust to difficult life events such as coping with a dying spouse, as is illustrated in the present quote: “The social worker helps me. I asked her to help me when my husband passed away . . . she immediately agreed and she comes to see me every Thursday for one hour. We talk and she helps me to cope and to adjust to my life without him” (An 84-year-old widow).

Another example for the social workers’ unique involvement is reflected in the way the social workers helped residents to continue with their life and reconstruct their damaged self-esteem as illustrated by the following quotation:

I can tell that the social worker there [in the CCRC] is very concerned [about mother]. For instance, she comes at least once a week and sits with her [mother] . . . she [the social worker] asked her: “We have a new resident. Would you mind helping us to welcome her?” She helps her to continue with her life. (A 55-year-old married son)

Satisfaction with social activity facilitators

Older adults and their adult children were appreciative of the variety of lectures and classes they were offered. According to respondents, activity staff used these classes to empower residents as described in the following quote: “I draw and write songs . . . the social activity facilitators advertise them in the CCRC and it makes me feel important” (An 84-year-old widow).

Older adults were impressed by the tailored activities that suited the residents’ psychological and social patterns, as one resident clarified:

We requested a bible lesson as we used to have at home and they actually gave us one. I also gave many pictures of our country to a social activity facilitator and she included them in a poster she made. I was so excited and proud. (An 80-year-old married woman)

Satisfaction with management

Some older adults and their adult children noted that the management was involved in their daily lives in the CCRC and was open to criticism and new ideas to improve the CCRC:

I complained about something a month ago. The next day the manager took his team on a tour and wrote notes of the things that bothered us. They moved from one apartment to another and wrote all the things that bothered us.

Another adult child noted, “When they are in their office we are welcome to walk in and speak freely with them” (A 52-year-old married son).

Dissatisfaction With the CCRC Staff

This theme refers mainly to those older adults (n = 9) and their adult children (n = 5), who reported frustration and disappointment with the staff. Dissatisfaction was mainly due to participants’ perceptions that staff failed to meet their expectations by not providing an immediate response to their medical needs or by being unavailable. At times, actual daily routine was seen as not meeting the first impressions created by staff. Finally, older adults and their adult children highlighted the high costs of their stay in the CCRC and their expectations to receive an adequate compensation for the large amounts of money paid. Dissatisfaction with social workers, receptionists, and security and activity facilitators was not mentioned at all by either older adults or their adult children.

Dissatisfaction with health care staff

Respondents expressed deep dissatisfaction with the attitudes and responses of the health care staff. Respondents expected that the health care staff would be highly responsive to their physical complains and more involved and aware of their general medical condition: “When I suffered from pain, the physician just gave me a pill. I would have expected him to do a medical check-up. I am not protected here . . . no one here knows my true medical condition” (An 85-year-old widow).

According to respondents, before the older adults’ entrance into the CCRC, the staff introduced the older adults and their adult children to a range of available health care services. However, once the older adults settled in the CCRC, services have failed to meet expectations and were not as readily available:

Before she [mother] moved here [to the CCRC], we were told that there were physicians and nurses around the clock. When she was in need of a physician, they [the CCRC staff] told her that she should go to a family physician outside the CCRC. So what is this all about? Before she moved to the CCRC they [the staff] said one thing and now that she was here they said something else. (A 52-year-old divorced son)

Dissatisfaction with maintenance staff

Older adults felt disappointed with the performance of the maintenance staff in three main areas: (a) the long waiting period it took for maintenance staff to arrive from the minute the resident called for help, as one resident illustrated: “They [maintenance staff] promised to come and fix things in my apartment, however, I was already discouraged by the time they came. Sometimes it took about a month or two. I pay so much money to this place and it’s not worth the service they (staff) provide” (A 76 year-old divorced woman). (b) The low quality of the work was another source of grievances as the maintenance staff often did not fix the problem and the older adults had to cope with various problems in their apartment such as leaking water, a broken closet, and so on: “I constantly quarrel with them . . . for the last month a half, different staff members come and nothing is done” (An 80-year-old married man). Finally, (c) the limited presence and availability of maintenance staff was another source of dissatisfaction. At times of immediate need, there was no one in the facility to provide the required help and assistance. A lack of availability of staff often left the older adults and their adult children helpless: “I had requested urgent help when something exploded in my apartment . . . it was an explosion. I had no one to turn to (because they were unavailable)” (An 84-year-old widow).

Dissatisfaction with the management

Despite negative claims regarding staff performance (as outlined above), older adults and their adult children preferred not to turn to the management because they were concerned about the negative reactions, including anger, denial, or ignorance. Reportedly, complaints to the management did not receive any response. This is articulated in the following statement by an adult child:

I would not turn to them [management] because I do not want to cause harm to my mother . . . she lives there, not me. I tried to reach them by writing a note—no one called or questioned me, and I must admit that this did not come as a surprise to me. (A 52-year-old married daughter)

Another older adult clarified, “The manager here is nice, always smiles, talks nicely . . . however, he does not keep all of his promises” (An 80-year-old married woman).

Disregard to the CCRC Staff

This theme addressed older adults’ (n = 20) and their adult children’s (n = 19) disregard to the CCRC staff during interviews. Whereas some residents discussed the CCRC staff spontaneously, without being asked (older adults, n = 6; adult children, n = 7), others have made every attempt to ignore the staff in their discussion, even after they were explicitly asked about staff by the interviewer (older adults, n = 4; adult children, n = 3). As a result, this theme is not very well elaborated. Disregard to the CCRC staff could imply for some residents and their adult children that the older adults are, or wish to be seen as, independent people who do not need staff support. Indeed, older adults, who reported a lack of a regular interaction with staff also reported moderate subjective health. The limited attention given to staff and the limited contact with staff by these respondents are illustrated in the following interview with an older adult: “I have a great social life here, have met new friends . . . the facility is nice, like a 5 star hotel. I have whatever I need.” When asked about her experiences with the CCRC staff, she clarified,

I have no personal relationships with them [CCRC staff]. I used to know a girl from the management upon my arrival to the CCRC but now we are not in touch . . . whenever I see a staff member I just say “hello, how are you?” and that’s all. (A 78-year-old widow)

Older adults and their adult children noted that they do not have any personal relationships with the CCRC staff and therefore, the staff is perceived as fulfilling a professional role, rather than an emotional or a personal one: “The staff here [in the CCRC] is not personally involved in my mother’s life . . . they just do their job. I can’t say that I have any special relationship with them” (A 60-year-old married woman).

Discussion

In this study, we aimed to explore older adults’ and their adult children’s subjective perceptions of services provided by CCRC staff. Although a growing body of literature has suggested that the nature and quality of the relationships between staff and older residents are important determinants of the experiences and the satisfaction level among residents and their families (Bauer et al., 2014; Wilson et al., 2009), relatively little is known about interpersonal relationships in alternative housing solutions such as CCRCs. According to the present study, there was no consensus among older adults and their adult children regarding services provided by the CCRC staff. This was mainly reflected by the positive perceptions of the staff on one hand, and perceptions of the staff as nonfunctioning or noncrucial in their lives on the other hand.

We found that older adults and their adult children perceived the role of the CCRC staff as central and the majority reported high levels of satisfaction with the staff performance. Interviewees reported feelings of satisfaction and confidence with the presence of the CCRC staff. This demonstrates that the CCRC staff has an important role in residents’ lives by meeting their evolving needs and maintaining their activity engagement (Doron & Lightman, 2003; Oswald & Rowles, 2006). Furthermore, older adults and their adult children reported being less concerned about the physical and functional decline of the older adults, knowing that health care services are easily accessible in the CCRC. Indeed, individuals move to a CCRC in an attempt to continue with their daily life by improving their access to different services (Groger & Kinney, 2007). Access to a range of services allows a sense of confidence and well-being especially when functional capacity is deteriorated and there are mobility or mental challenges to consume services that are not readily accessible. Given the confidence and satisfaction levels reported about the CCRC staff, it appears that CCRCs fulfill their role and destiny as a protected framework that meets the changing physical needs of older adults (Doron & Lightman, 2003).

When participants described the different staff members involved in their lives, health services received the most attention. Consistent with Maslow’s (1943) hierarchy, basic concrete needs were perceived as being more crucial to participants compared with higher level, mental or social needs. This finding is in line with another study that has demonstrated that health status is the most frequently reported factor in the quality of life of older people (Y. Chen, Hicks, & While, 2013). Deteriorated physical health status has also been shown to be one of the main precipitators of a transition to a CCRC among older adults (Ayalon & Green, 2012). Hence, the present study reemphasizes the important role played by CCRCs in meeting older adults’ evolving health care needs.

Our findings indicate that many older adults preferred to turn to the CCRC staff rather than to bother their adult children for certain tasks, such as assistance with house repairs. This preference toward receiving formal assistance should be discussed by examining the place of the family in Israeli society. Israel is characterized by traditional norms of care for older family members (Lowenstein, Katz, & Daatland, 2005). Yet, in the past years, Israel, similar to other countries, has experienced a tension between formal (paid) and informal (family members) care, as a result of transitioning from traditional family-oriented values (Lowenstein et al., 2005) to more modern values. In the current study, similar to a past research (Bauer et al., 2014), even though adult children trust the CCRC staff to fulfill their parents’ needs, they do not abandon their traditional caregiving roles and continue to visit and be a part of their older parents’ life while providing them emotional care and support. The CCRC staff, on the contrary, is seen as providing concrete support and emotional care as needed.

The second theme concerned one’s despair and frustration with the CCRC staff, mainly because the staff was seen as being unresponsive to the residents’ evolving needs. Perceptions of the staff as nonfunctioning were evident not only among residents but also among adult children, hence contributing to the general sense of dissatisfaction. Feelings of insecurity and frustration were intensified when promises made prior to entering the CCRC were not fulfilled. Security and stability are important factors in older adults’ lives, because old age is interwoven with changes and loss (Kirkevold, Moyle, Wilkinson, Meyer, & Hauge, 2013). In the current study, dissatisfied residents were more likely to be in physical decline. Thus, the increasing dependency on staff members might create frustration and anger among older adults, especially because in their initial entry point to the CCRC, residents were portrayed as independent (Ayalon, 2014). It is possible that anger and frustration among older adults and their adult children with regard to staff members was fueled by their feelings of sorrow about various unspoken hidden losses in their lives, such as the transition to the CCRC and increased levels of independence (Ayalon & Green, 2012).

Dissatisfaction with the CCRC staff should be examined within the broader view of the nature of the CCRC. CCRCs are designed for older adults who are functionally independent (Sherwood, Ruchlin, Sherwood, & Morris, 1997). However, during periods of physical and/or mental decline there is an increased need to rely on staff in the performance of daily functions. At some point during their stay, a permanent decrease in physical and cognitive functioning and an increased need for formal services usually occur among CCRC residents. Yet, it is possible that CCRC staff is unaware of older adults’ changing needs and might not be able to respond to substantial levels of decline in this population, which at least on paper is expected to be independent. Older adults’ and adult children’s expectations of the staff in general and at times of physical and mental decline in particular, might be higher than what the CCRC staff can offer, given its original designation as an institutional setting for independent older adults (Doron & Lightman, 2003). It should also be noted that not all dissatisfied residents experienced a physical decline. Dissatisfaction with the CCRC staff was not always focused on health care needs, but rather encompassed an entire spectrum of services.

Another dimension, which might explain older adults’ and adult children’s high expectations of the CCRC staff, is related to the financial costs associated with the CCRC. Older adults and adult children stressed the high costs of the CCRC. Indeed, in CCRCs, a resident is required to pay a monthly fee, similar to a rental payment, which is based on the type of unit in which he or she lives. In addition, the resident pays an up-front fee, which is either structured as a deposit or as an entrance fee (Peterman & Sickelka, 2010). Given the high costs associated with CCRCs, older residents and their adult children, as consumers, expect the best value-for the “good money” they pay.

Whereas residents who were satisfied or dissatisfied with staff voluntarily mentioned the staff as an integral part of their lives in the CCRC, others have made every attempt to ignore the staff in their discussion, even if they were explicitly asked about staff. Ignoring the role of CCRC staff in the lives of CCRC residents could be an attempt to preserve a perception of “independence.” Indeed, past research has demonstrated that older adults and their adult children describe the CCRC as a place for potential growth on one hand and as the “last stop” on the other hand (Ayalon, 2014). Older adults rely on CCRC staff to receive help and support, and this might symbolize their heightened helplessness and need. Ignoring the CCRC staff might be a result of shame as it implies being in a position of need. In addition, fear and anxiety to demonstrate a lack of self-efficacy in an institutional framework that emphasizes independence can be expressed ignoring staff in their discussion, even after being explicitly asked about it.

Several potential shortcomings should be acknowledged. First, the qualitative and cross-sectional nature of the study does not allow for assumptions regarding cause and effect or about the representativeness of the findings. Second, differences in the staff composition across CCRCs and differential characteristics across the CCRC settings (e.g., “chain” and “nonchain” settings) might be a limitation, as differences in the reports of participants could potentially be due to the quality and availability of the CCRC staff in a particular setting. Nonetheless, this could also represent a strength as we were able to identify common themes beyond the diversity of the CCRC. Third, older adults and adult children, who were dissatisfied with the CCRC staff and as a result have left the CCRC, were not interviewed for this study. Finally, only two questions addressed the interaction with staff. Adding more questions would have given a wider picture of this understudied phenomenon.

Despite these limitations, the current study provides important insights about aging and institutional care among CCRC residents and their adult children. Given the increase of CCRCs as an LTC alternative (Mirovsky, 2007), the study expands the limited body of existing knowledge regarding experiences and feelings toward staff in the CCRC setting. In general, both older adults and their adult children shared similar views of institutional care. On one hand, they had positive perceptions of the staff. But, on the other hand, they perceived staff as being nonfunctioning or noncrucial in their lives. Overall, health services received the most attention from both older adults and their adult children. Thus, practically, the study reemphasizes the importance of meeting one’s basic needs prior to meeting social and emotional needs, even in the case of independent older adults. Although older adults who enter the CCRC are functionally independent, their physical health has an important place in their lives and CCRCs should cater not only to their mental and social needs as independent older adults but also to their evolving health care needs. It is important for CCRCs to maintain constant contact and communication with all residents including those who do not use staff services. At the same time, it is important to be sensitive toward residents who feel that accepting staff services is a sign of weakness and dependence. Occasional communication and interest in the residents’ daily functions might provide a professional response and maintain residents’ independence. Finally, because health services were seen as crucial, it is recommended to maintain and even enhance the accessibility and availability of these services.

The findings make a strong case for further research on the perceptions of CCRC residents and their adult children regarding services provided by staff in the CCRC. Future research should evaluate the longitudinal effects of respondents’ frustration and disappointment with staff and the consequences of a lack of a regular interaction with staff. Finally, the present findings can be used to develop more definitive role expectations for each category of staff members (e.g., health care providers, maintenance staff, receptionists, security guards, social workers, social activity facilitators, and management).

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was partially funded by the Israel Science Foundation.

Author Biographies

Shiri Shinan-Altman is a social worker and a researcher at School of Social Work, Bar Ilan University. Her research concerns illness representations, social work in health care settings, and formal and informal caregiving.

Liat Ayalon is a clinical psychologist and a researcher at School of Social Work, Bar Ilan University. Her research concerns the integration of mental health, age construction and deconstruction, and formal and informal caregiving.

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