Summary

Relationship-based care (RBC) is a care delivery model that the ASSTSAS introduced about ten years ago in residential care facilities through the training of trainers. The goal of RBC is to improve not only the quality of resident care but also the occupational health of caregivers. This research is exploratory (the very first study of RBC) and collaborative, a partnership involving a decision maker (ASSTSAS), the 17 residential care facilities that took part in the research and the Steering Committee which not only guided the research but validated and publicized the results.

In the first phase of the research, which involved completed RBC implementation projects, three studies were conducted: 1) An analysis of questionnaires completed by caregivers (n =392) one month after taking part in RBC training showed that they perceived the principles and techniques taught to be useful, though they felt some aspects were difficult to integrate in practice. Work team support proves to be the key element in transfer of learning in care situations. 2) A survey of 17 key informants from 17 different institutions and representing some 70 units where RBC was instituted showed the following: after basic training given by ASSTAS, the approach was introduced in all institutions and is still considered active in 14; its implementation in care settings is estimated in most cases at 5 to 7 on a scale of 10 (median = 6); when implemented, the impact of RBC is perceived as positive by caregivers as well as residents. 3) Based on analysis of focus groups that included 32 people (consultants, managers, project leaders, caregiver-trainers and  caregiver-trainees) from nine of the institutions where RBC was introduced, a model of influencing factors at the micro level (caregiver/resident dyad), the meso level (team, unit, institution) and the macro level (sociopolitical and economic environment) was developed.

The second phase of the research involved real-time analysis of an implementation project in an institution based on the activities of the project advisor/coach and the point of view of internal stakeholders, with data collected at two points in the implementation process. The analysis showed the difficulties encountered by the internal stakeholders (not only in organizing the training but also in the follow-up required to maintain the approach) as well as the strategies used to overcome them. The study also showed that the setting (changes to care and work organization in particular) is a source of difficulties for implementation.

The third phase of the research involved caregivers implementing RBC in the work setting. Two studies were conducted: 1) In an ergonomic work analysis involving observation and interviewing (115 hours) of nine orderlies and two nursing assistants in seven care units, 164 acts of assistance with meals and hygiene were documented. The results showed that in providing the assistance the caregivers tried to find a compromise between RBC objectives and elements such as protection of the resident, respect for the resident’s preferences and autonomy, and their own protection as a caregiver. They also showed that the caregivers developed a variety of strategies, individually and as a team, that helped to implement RCB: changes to the delivery of care and the shift to adapt to the characteristics of the resident; search for information about the resident; and sharing within the team. Though the focus of the RBC was hygiene care, the results show that the caregivers also applied the principles of RBC to assistance with meals. A number of factors seem to facilitate the implementation of RBC, including availability of equipment, compact space arrangements and flexible work organization. The second study of this phase was designed to explore, through observation of the resident/caregiver dyad during assistance with hygiene and dressing, the correlation between use of RBC and the behaviours of residents during the assistance. Fourteen residents and five caregivers from two institutions were studied by two independent observers without any connection to the institution. Application of RBC was estimated at 86.6% based on RBC use scores obtained with the help of a 23-item checklist developed for the study, comparable to a mean score of 86.3% that caregivers gave themselves for RBC application during the care provided. The data from observations of the residents suggest that agitated behaviours were present but varied from one resident to the next. Positive behaviours were more frequent, particularly nonverbal behaviours, than problem or agitated behaviours. To our knowledge, this is the first time residents’ positive behaviours have been taken into account.

The research contributes in many ways to the advancement of scientific knowledge. It suggests that introducing a person-centred approach to care, like RBC where the primary focus is the relational aspect of care, is a culture change that demands, in addition to the training of caregivers (which was much appreciated), that certain conditions be met. A project to implement the approach is the starting point for this culture change. However, maintaining the change is compromised by the high turnover of caregivers as well as the many projects carried out at the same time in the institutions that seem to run counter to the approach. In terms of methodology, a number of promising tools were developed, among them the checklist for scoring application of the approach and a tool to assess residents’ positive behaviour. A number of recommendations are made to policy makers, the healthcare community and the ASSTSAS to promote RBC as a tool for balancing the technical and relational aspects of care.