‘Good Treatment’ in Residential Care Settings in Quebec: Meanings,Practices and Conditions

Abstract

The concept of ‘bientraitance’(good treatment) of older adults was introduced in Quebec policy a few years prior to the pandemic, and its significance from the perspectives of those directly involved in care remains underexplored. Centring these perspectives, this article presents findings from a study of the meanings, practices and conditions of good treatment. Data was collected at three different residential care settings through world cafés with residents, staff, management, volunteers and family members (n = 61) and through interviews with care aides (n = 13). The study results indicate that those directly involved in care identify good treatment as fundamentally oriented towards developing and maintaining good relationships with residents; as contingent upon interpersonal, material, and organizational factors; and as requiring (more) time. Given the need for radical reform within Quebec’s residential care settings revealed by the pandemic, it is imperative that these perspectives inform the changes introduced.

What This Paper Adds:

• explores the concept of ‘bientraitance’ (good treatment) within residential care settings

• demonstrates its meanings from the perspectives of those involved in care

Applications of Study Findings:

• suggest the need for policy change regarding support for good treatment within residential care settings

• demonstrate the importance of centring the perspectives of those involved in care in residential care settings in order to improve care in these contexts

Introduction: The Emergence of the Promotion of Good Treatment in Quebec

For the past several decades, research and policy developments in Quebec have largely focused on addressing mistreatment of older adults. As several researchers note (Beaulieu, 2012; Beaulieu & Crevier, 2010; Pomar-Chiquette & Beaulieu, 2019), the explicit promotion of ‘bientraitance’ of older adults (translated hereafter as ‘good treatment’) did not occur during this period, though provincial policies that promoted quality of life and supported the dignity of older persons had been put in place (e.g. Ministère de la Santé et des Services sociaux [MSSS], 2003a; 2003b, 2005). Recently, policymakers have shifted towards directly promoting good treatment. Quebec’s Action Plan to Counter the Mistreatment of Older Adults, 2017–2022 (Ministère de la Famille et Secrétariat aux aînés [MFSA], 2017) was the first of these initiatives. In addition to including this broader orientation in the Action Plan, a specific measure was introduced to support research on good treatment of older adults.

The project presented in this article, An Approach to Enhancing ‘Ordinary’ Practices of Good Treatment in Residential Settings in Quebec: Mobilizing All of the Actors Concerned,¹ was funded in relation to this measure in the Action Plan. Indeed, the Action Plan identifies the residential care sector as one of the sites where good treatment of older adults should be promoted. Like many other OECD countries and provinces across Canada, Quebec’s residential care sector has long been criticized with regards to the quality of care provided to residents (Quebec Ombudsman, 2016; 2018; 2020).² Promoting good treatment within that sector, therefore, was identified as a component of a broader project promoting good treatment of older adults across Quebec society.

What Is Good Treatment?

The concept of good treatment did not originate in Quebec. It was first developed in France in the early 2000’s, and has been the source of debate and critical reflection ever since (e.g. Duportet, 2010; Lambert Barraquier, 2016; Moulias et al., 2010; Pomar-Chiquette, 2019; Svandra, 2010). The research literature indicates that several meanings have been attributed to good treatment, including a culture, a movement, an approach, a position, and an attitude (Casagrande, 2016; Éthier et al., 2021b; Pomar-Chiquette & Beaulieu, 2019). The literature also demonstrates that these definitions of good treatment generally align with other well-established concepts in health and social services, particularly the concept of person-centred care (Pain, 2010; Pellissier, 2010).

To date, the meanings of good treatment advanced in Quebec policy reflect several of these observations about the research literature. Regarding alignment with the concept of person-centred care, for example, the Action Plan defines good treatment as involving the ‘promotion of well-being, respect for dignity, fulfillment, self-esteem, inclusion and security of person’ (MFSA, 2017, p. 38, authors’ translation). It also states that good treatment is ‘expressed through attentiveness, attitudes, actions and practices that are respectful of the values, culture, beliefs, life course, uniqueness and the rights and freedoms of older adults’ (MFSA, 2017, p. 38, authors’ translation). Quebec’s new residential long-term care policy reiterates those definitions of good treatment, while also describing it as ‘a concrete approach that responds to the rights of residents, [thereby] respecting their choices and their autonomy’ (MSSS, 2021, p. 20, authors’ translation). This latter policy also reflects the multiple ways good treatment is identified in the research literature, describing it as ‘values, a position and know how³ that is never finally achieved’, and referring to it as both an ‘approach’ and a ‘culture’ (MSSS, 2021, p. 20, authors’ translation).

In light of its recent introduction in Quebec and the fact that it was introduced by policymakers, an exploration of how good treatment is understood and practiced by those directly involved in giving and receiving care is necessary. Good treatment inevitably takes place ‘on the ground’, yet research on these perspectives has not been conducted in Quebec. Attending to these meanings and practices is particularly imperative given both the long-standing critiques of Quebec’s residential care sector and the more recent, pandemic-related devastation experienced in these residences (Cabinet de la ministre responsable des Aînés et des Proches aidants, 2020; Gagnon, 2020; Quebec Ombudsman, 2021). The promotion of good treatment within these settings should build upon the insights of those with the lived experience of giving and receiving care.

Project Objectives and Research Questions

The project presented in this article begins to fill this gap in knowledge about ‘on the ground’ understandings and practices of good treatment. One key project objective was to identify ‘ordinary’ good treatment practices within the different types of residential care settings in Quebec: long-term care facilities (CHSLD), intermediate resources (RI), and private seniors’ residences (RPA).⁴ Building on the work of Anchisi et al. (2017), Aubry (2017), Aubry and Couturier (2017), and Gagnon (2017; 2021), we recognized these ‘ordinary’ practices as everyday attitudes and actions that remain under-recognized and poorly documented, but which are essential to the provision of good care. At the same time, we also recognized that these ‘ordinary’ practices are constrained, but not entirely precluded,⁵ by the conditions shaping residential care settings. The project, therefore, also sought to identify both that which supports and hinders these practices. Finally, the research team sought to explore the meanings of good treatment and the relevance of this term for those living and working in residential care settings. In line with these key objectives, two research questions were posed in this study: According to those who live and work in residential care settings:

(1) What is good treatment in these settings, including ‘ordinary’ good treatment practices?

(2) What supports, and what hinders or prevents, good treatment practices in these settings?

Research Methods

Following project approval by two Research Ethics Boards (CIUSSS-CN, Approval No. MP-13-2019-1779 and CIUSSS-CODIM, Approval No. MEO-13-2020-1969), the research questions were explored in three⁶ residential care settings. These settings included: a long-term care residence (CHLSD); a mixed intermediate resource and private seniors’ residence (RI-RPA); and a private seniors’ residence (RPA). Our multi-site project was presented to the managers and/or owners of each residence to establish their interest in the project and determine the logistics of conducting research at the residence.⁷ Upon their agreement to support the project, the research team began recruitment for both methods employed in the project: world cafés and interviews.

World Cafés

The world café method is part of the shift towards ‘bottom-up participatory research approaches’ (Lö;hr et al., 2020, p. 2). It is a conversational method that brings together a large group of diversely positioned people within a space that has been set-up as an informal, café-style environment (Brown & Isaacs, 2005; Steiver et al., 2015). Participants in world cafés engage in small group (4–5 people) and large group (12 to 50 people) dialogues with each other based on questions posed by the host(s) of the world café. Their discussion is captured as research data through the notes participants write on white paper ‘tablecloths’ provided at each small group table; the notes taken by discussion facilitators present at each of those tables; and the notes taken by the host(s) during the large group discussions of the questions.

We conducted a world café at each of the three residences. The world cafés were between 2 to 3 hours long, and slight adaptions were made to each in light of particular organizational constraints (e.g. availability of space, human and material resources, etc.). Each world café involved small group discussions of key questions that were followed by large group discussions of the same questions. Those recruited for participation were, as our project title indicates, ‘all of the actors concerned’. Thus, everyone who lived and worked in the three residences, including informal caregivers and volunteers, was included as a potential participant. Table 1 provides a breakdown of participation in the world cafés.

Table 1.

World Café Participants.

Type of Residence¹⁴	Residents	Informal Caregivers (Family)	Care Aides	Volunteers	Nurses/Nursing Assistants/Auxiliary Nurses	Supervisor/Manager	Specialized educator/Leisure Activity Coordinator	Janitor/Cook	Total Number of Participants
CHSLD	2	1	2	1	5	2	2	2	17
RI-RPA	4	4	5	0	1	1	1	2	18
RPA	11	3	3	1	2	1	1	4	26

Interviews

Interviews were also conducted at the three residences. Unlike the world cafés, the interviews were not conducted with ‘all of the actors concerned’. Instead, our research team specifically recruited care aides⁸ for the interviews. This category of worker provides most of the direct care to residents and thus occupies a unique position with regards to understanding good treatment of older adults in residential care settings. Given this, as well as the general lack of recognition of their work (Aubry, 2017; Aubry & Couturier, 2017), our team sought a deeper exploration of their perspectives and practices. Moreover, the research literature on the world café method recommends using additional research methods to attend to the fact that power relations between world café participants can limit participation (Aldred, 2011; Löhr et al., 2020). By conducting interviews with those located at the lower end of the occupational hierarchy, we also sought to mitigate this limitation of the world café method.

The interviews conducted with the care aides were 45–90 minutes long. With the support of the owners and/or managers of the residences, they were all conducted during work hours, in private rooms within each residence. A total of 13 interviews were conducted.⁹ Three were conducted at the private seniors’ residence (RPA), four were conducted at the mixed intermediate resource and private seniors’ residence (RI-RPA), and six interviews were conducted at the long-term care residence (CHLSD).

Data Analysis

All project data were analysed according to an ethics of care theoretical perspective (Tronto, 1993, 1998). This perspective is informed by four key assumptions. The first assumption is that the attitudes, gestures, and actions of everyone who lives and works in a residence impact the care relationships therein. The second assumption is that inequities and power relations impact care relationships. A third assumption informing this theoretical perspective is that organizational, cultural, and economic contexts impact care relationships. Finally, an ethics of care theoretical perspective assumes that care is knowledge- and skills-based, and includes the skill of practicing small, meaningful gestures to meet the needs of older adults.

Based on these theoretical assumptions, and our bottom-up approach to exploring the lived experience of good treatment, an abductive analysis (Timmermans and Tavory, 2012) of the project data was conducted. The notes taken at the world cafés¹⁰ and the transcripts of the interviews were initially organized into themes that emerged from an inductive review of the data. These themes were then reviewed and reorganized according to the four theoretical assumptions outlined above. Throughout this iterative process, the research team was careful to attend to unanticipated research evidence. The data from the world cafés was also compared to that from the interviews to identify differences and similarities between these two sets of data.

Results

Meanings: Good Treatment is Relationships, Shared Responsibility and Beyond the Basics

The data from the world cafés demonstrated that the meanings our participants attributed to good treatment were quite similar to the meanings recently advanced by policymakers, though they put much more emphasis on the relational in their definitions. Indeed, our participants broadly defined good treatment as supportive of residents’ dignity, security, inclusion, and autonomy, but they also defined it as involving interactions with residents (and their informal caregivers) informed by attitudes such as mutual respect, patience, reassurance, compassion, and positivity. The world café participants explained, furthermore, that these attitudes are expressed in actions like taking time to listen and getting to know a resident, creating an environment of trust and respect, and recognizing abilities while adapting to residents’ needs. Thus, our world café participants advanced definitions of good treatment that aligned with recent policy, but extended beyond those definitions by identifying good treatment as relationship-based and grounded in everyday interactions.

The care aides who participated in interviews identified the same relational elements in their definitions of good treatment. For example, one care aide defined good treatment as ‘working with people […] good treatment is listening. I believe that it takes these qualities to perform the work […] Being compassionate, humble, gentle, patient, etc’. Along the same lines, a care aide stated that good treatment means ‘work[ing] with humans…we don’t work with machines,’ and another described good treatment as ‘attending to the person, so to smile, to be present and not solely focused on tasks’. As one care aide succinctly stated, ‘performing a task, that’s just cold […] it’s doing the task without connecting with the person, without eye contact, without touching the person’. For her and the other care aides, it was relationality with another human that defined good treatment.

In addition to aligning with the relational understandings of good treatment that were shared by world café participants, care aides included other elements in their definitions of good treatment. For instance, they expressed the idea that good treatment is collectively, not individually, accomplished. As one care aide explicitly stated, ‘everyone is responsible, not only one person, even though those who are dedicated to their work [as care aides] often carry a lot on their shoulders’. Care aides also expressed the idea that good treatment means much more than performing essential care, with one stating that it involves making sure that ‘each person has what they need but not only the necessities, [it means] offering great care and not only the basics’. In these ways, the care aides’ definitions demonstrated an understanding of good treatment as grounded in the multiple relationships that exist within a residence and as extending beyond the performance of basic tasks.

‘Ordinary’ Good Treatment Practices: Humour and ‘Little Nothings’

In response to the research questions posed about ‘ordinary’ good treatment practices, both world café and interview participants identified practices involving knowledge about residents and the skillful use of that knowledge. One of the good treatment practices they identified was the use of humour. During the world cafés, humour was described as introducing ‘lightness’ and familiarity in interactions, and as helping to defuse crises, decrease tensions and reduce discomfort in circumstances that are sometimes painful or challenging. Within the interviews, care aides elaborated on various ways that humour contributes to practicing good treatment. One remarked upon the positive impact of laughing with one another, stressing that ‘you shouldn’t think that because a person is 80 years old, they no longer have a sense of humour’. Another care aide referred to hearing laughter in the residence as ‘a form of recognition that we’ve given good care’. The care aides’ examples of humour demonstrated that its use required strong interpersonal skills and attentiveness, as demonstrated in the following explanation of good treatment of a woman living with Alzheimer’s:

She often says, ‘slimy snake’ at the end of her sentences [so] I always say ‘that slimy snake’ and she bursts out laughing, she’s in stitches. It’s little moments like that that are needed to be able to connect with them.

The participants in our study had nuanced understandings of the use of humour despite identifying it as a good treatment practice. They acknowledged that not all residents appreciate humour and that it is certainly not always appropriate, while also clearly indicating that it is a significant way to practice good treatment.

The world café and interview participants described another set of good treatment practices as ‘small gestures’, ‘little extras,’ or as one care aide put it, ‘little nothings that we do for them, that are so important, it’s incredible.’ Within the world cafés, participants identified several practices along these lines. These included simple gestures like giving a knowing smile, using affectionate terms for one another, and sharing food together, such as snacks and home-cooked dishes. They also included helping residents dress in nice clothes and put on make-up, fragrances, and jewelry as part of these practices.

Care aides identified similar ‘little nothings’ and described them as forms of spending time with residents that went beyond the time required for their job-specific tasks. In many cases, these practices involved both getting to know residents a little better and helping them look and feel good. One of our interviewees explained that ‘I take the time to speak with them and what I often do is I take that opportunity to cut their nails, get rid of their little hairs, do a half ponytail for the woman, two little barrettes and I put a little perfume on for her’. Another described how ‘sometimes we put cream on [a resident], little things like that just so that they, that they feel comfortable and we often give little compliments to make them feel good’.

Care aides’ descriptions also demonstrated that these ‘little nothings’ were tied to their deep familiarity with residents, such as ‘making the beds the way they like.’ As one explained, I know they all have a little something so… [if] I know that certain mornings, they prefer… one type of cereal I’m going to make sure to give it to them. If I know that she really likes jewelry or whatever, I’m going to try to improve her day like that.

Several care aides recognized that some of their ‘extra’ practices slightly broke the rules, particularly those concerning food regulation and professional distancing, but as one interviewee explained, ‘it’s things we shouldn’t do because well, accreditation is coming […] but they like it, it makes them feel good.’ Another similarly stated, ‘I do a lot for them. They ask me to do them a favour and I do it. Even if I’m not allowed’. These ‘small gestures’, therefore, demonstrated how care aides sought to improve residents’ quality of life through practices that went ‘beyond the job’ to create what one of them called a ‘human living environment’. At the same time, their descriptions indicated that some of these good treatment practices involved contravening mandated practices.

Conditions of Good Treatment: Complex, Nested Conditions and Time

Overall, there was a fairly marked contrast in the two data sets with respect to the conditions identified as supportive or inhibitive of practicing good treatment. World café participants identified multiple conditions as impacting good treatment. In contrast, the interview data demonstrated that care aides perceived time as the most crucial condition shaping good treatment practice.

In the world café data, the various conditions identified as supportive or inhibitive of practicing good treatment ranged from interpersonal to material to organizational factors. At the interpersonal level, for example, participants mentioned personality (in)compatibilities, family involvement, and communication and teamwork between staff as conditions that impact good treatment practices. Regarding material conditions, they identified ready access to elevators, a common room, air conditioning, and a well-decorated environment, as key. World café participants also recognized organizational condition, such as easy access to medications and the availability of a variety of adapted activities, as conditions supportive of good treatment. They also identified management as constituting a key organizational condition, specifying that good treatment involves managers’ support for ongoing staff training, their willingness to make improvements based on staff suggestions, and their toleration of good treatment practices that break other organizational rules. In identifying this range of conditions, world café participants demonstrated that good treatment is dependent on a complex and multi-faceted nest of conditions.

For the care aides who participated in interviews, time was identified as the essential condition for practicing good treatment. Indeed, being able to ‘take your time not quick quick quick’ was described as crucial by a care aide who explained that within the context of bathing,

[to] support their autonomy…even if it takes a little more time, [you must] let them wash themselves because […] the resident wants to do it alone… they don’t like to be washed by someone else.

Other care aides also spoke about needing time to better understand residents’ needs, with one stating

I really need to analyze my clients a lot and that takes time because often, they don’t speak, they hit and scream. Of course they’re in pain, but that’s just it, analyzing them [enables] me to better understand what they want.

Despite their recognition of the relationship between sufficient time and good treatment, care aides repeatedly stated that this condition was largely unmet. One care aide explained that her intentions to practice good treatment are frustrated by this lack of time, stating

I have good intentions and in terms of insufficient time, understaffing of care aides, well that can’t happen, it doesn’t work and I find that distressing. It’s a shame because the intentions are there, but sometimes, we do not have the time.

Another lamented that,

Good treatment, it’s a beautiful term that is burdensome in a structure that doesn’t provide the time [to put it into practice]. So that has to be dealt with. But the priority should be time and the number of people on the floor […] The current structure creates emergency situations, the work plans […] the timed tasks, the set tasks […] leads to unacceptable behaviours, leads to burnout.

Many others described various ways they use their own time to provide good treatment, including coming to work early, visiting on their days off, and skipping meals during their shifts. Moreover, care aides clearly identified the time available for good treatment practices as negatively impacted by insufficient staffing ratios.

Discussion

The findings from our project generally align with the assumptions that inform an ethics of care perspective (Tronto, 1993, 1998). The assumption that care is knowledge- and skills-based, and includes the practice of small, meaningful gestures, for example, was clearly evidenced in the meanings of good treatment expressed by both sets of participants, and in the specific ‘ordinary’ practices they identified as good treatment. The responses to these research questions also demonstrated that our participants identified good treatment as fundamentally oriented towards the development and maintenance of good relationships with residents and as involving ‘beyond the job’ discretionary skills.

Our findings also indicated that good treatment must be a shared responsibility, which are findings that echo the research literature on person-centred care (Caspar et al., 2019). In the interviews, care aides specifically defined good treatment as a collective responsibility. Along similar lines, the world café data revealed that good treatment is shaped by various interpersonal, environmental, and organizational conditions. In this way, our findings demonstrated that the conditions supporting good treatment practice are complex and multi-factorial, and that concerted effort is required on several fronts to ensure these conditions are put in place.

The research findings also demonstrated that good treatment is impacted by power relations operating within residential care settings, as well as by other structural factors shaping the broader residential care sector in Quebec. These constraints were most clearly exposed in the interview data. Inadequate time was the central condition care aides identified as impacting good treatment, and they recognized their lack of time as linked to insufficient staffing ratios. Those occupying the lower end of the occupational hierarchy, moreover, described experiencing distress and burnout in relation to insufficient time to practice good treatment. These health problems have been identifed in other research on care aides (Song et al., 2020; Tremblay, 2017) and demonstrate that the provision of sustainable good treatment in residential care settings is dependent on what Casagrande (2016) describes as ‘double good treatment:’ good treatment of both older adults and care staff.

Finally, misalignment between particular regulations and the ‘little extras’ care aides do to create ‘human living environments’ (i.e. homes) also highlighted key power relations and structural conditions shaping good treatment practices. Though this finding was most directly expressed in the interviews, it was also reflected in the world café data that indicated support from management is needed to engage in these non-sanctioned practices. Whereas Quebec introduced a ‘home environment approach’ (MSSS, 2003b) to the residential care sector almost 20 years ago, these findings suggest that efforts in this regard remain limited by the other regulations shaping these settings.¹¹

Conclusion

Our project explored the meanings, practices and conditions of good treatment in residential care settings in Quebec from the perspective of those with lived experience. World cafés were conducted with ‘all of the actors’ (residents, staff, informal caregivers, management, volunteers) of three different residential care settings, and interviews were conducted with cares aides due to the direct, everyday nature of their care work with residents. Our results indicate that those ‘on the ground’ identify good treatment as fundamentally oriented towards developing and maintaining good relationships with residents, as contingent upon interpersonal, material, and organizational factors, and, perhaps most importantly, as requiring (more) time. Though our findings cannot be generalized because our study was limited to three residential contexts, these results point towards the need for further research that centres ‘on the ground’ perspectives regarding good treatment in Quebec’s residential care settings.

Research on these perspectives is particularly pressing in light of the radical reform needed in Quebec’s residential care sector, as revealed by the pandemic. Indeed, though several of the Quebec Omdbudsman’s (2021) recently released recommendations¹² for residential care settings align with ideas expressed by the participants in our study, the meanings of good treatment informing Quebec’s policies, including its new residential long-term care policy, do not align as well.¹³ Further exploration of the perspectives of those ‘on the ground,’ therefore, could help inform policy change that better reflects and supports good treatment from these perspectives. As Quebec society works towards improving quality of life and care through the promotion of good treatment in these settings, the perspectives of those involved in direct care must inform these transformations.

Footnotes

Acknowledgments

The authors would like to thank the participants of this study for taking the time to discuss their views and experiences.

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Fonds de Recherche du Québec – Society and Culture [Grant No. 2019-0BTR-265747].

Ethical Approval

This study was approved by CIUSSS-CN Research Ethics Board [Approval No. MP-13-2019-1779] and the CIUSSS-CODIM Research Ethics Board [Approval No. MEO-13-2020-1969].

ORCID iD

Sandra Smele

Notes

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