In the Netherlands, as well as in other countries, nursing home care has been traditionally modeled on hospital care. However, in the last decades of the twentieth century, realization grew that, unlike hospitals, nursing homes needed to serve as literal homes to people. As a consequence, the concept of group living homes for older people with dementia has taken root.
Group living home care was originally developed in Sweden in the late 1970s (Annerstedt, 1993). In the Netherlands, the first group living homes were created in the early and mid-1980s. Its popularity increased steadily after that, but the real growth occurred in the last years of the twentieth century. Nowadays, it is estimated that at least 25% (14,000) of the Dutch population with dementia lives in at least 450 group living homes (Aedes-Actiz Kenniscentrum Wonen-Zorg, 2011).
Although matters such as a home-style environment, a small group of residents and a normal daily life are generally associated with the concept of group living home care, there are few actual definitions. In a previous study we therefore constructed a more elaborate description of group living home care (te Boekhorst et al., 2007). The “concept mapping” method was used, in which a group of experts from diverse backgrounds generated statements about the ideals of group living home care. Subsequently, the participants grouped and ranked these statements according to likeness and priority. This led to a pictorial representation – the Concept Map (Trochim, 1989). This map, which describes group living home care, depicts six clusters of statements (ranked according to priority):
1. Residents are residents for better or worse
2. Residents form a normal household
3. Residents have control over their daily life
4. Staff members are part of the group
5. Residents form a group
6. The building is an archetypical house
These six clusters describe the ideals of group living home care, but it is not known whether group living homes actually follow these ideals. In other words: do they practice what they preach? We therefore sought to explore the extent to which group living homes had implemented the ideals from the Concept Map relative to modern regular nursing homes.
An exploratory questionnaire was constructed with subscales based on the statements of the clusters of the Concept Map described above. Each subscale was to be represented by at least three statements of the corresponding cluster. Statements were chosen that were (a) highly ranked and (b) eligible for transformation into a five-point scale item. Cronbach's α was computed for each subscale. All subscales had at least an acceptable α (range α = 0.58–0.80), except the subscale “Archetypical house” (α = 0.18), which was therefore removed from the questionnaire. The questionnaire was completed by the managers of 17 group living homes (response 90%) and 16 wards of seven modern regular nursing homes (response 94%). More details on the selection of these facilities are described in te Boekhorst et al. (2009). Student's t-tests were used to establish whether group living homes and modern regular nursing homes scored differently on the items and subscales of the questionnaire.
The hypothesis was that, while modern regular nursing homes also try their best to make residents feel at home and may therefore use some of the ideals of group living home care, the ideals were practiced to a higher degree in group living homes. Results largely seemed to confirm this. Residents in group living homes lived more often in a normal household, had more autonomy in their daily lives and more often formed a group. Furthermore, staff were more often part of this group in group living homes than in modern regular nursing homes.
However, among the most notable results was the finding that, contrary to the hypothesis, group living homes did not score higher on the most important statement of the Concept Map that group living home care needs a small fixed staff. Staff in group living homes worked just as much on different units as their counterparts in modern regular nursing home care. Furthermore, group living homes scored significantly worse on the subscale “Residents for better or worse” than modern regular nursing homes. Analysis on item level showed that this significant difference was caused by the fact that many group living homes transfer residents if their care needs become too extensive or if their behavioral problems become too severe. This is remarkable since this cluster was ranked highest on the Concept Map describing the ideals of group living home care. Thus, the most central ideal of group living home care – that residents can stay “home” until they die – does not seem to be realized in group living homes. However, it is important to emphasize that some group living homes never transfer their residents, even when confronted with severe behavioral issues or care needs. Thus, the underlying causes of transfers should be studied and analyzed in closer detail. Furthermore, expertise to deal with these situations needs to be exchanged between group living homes.
In conclusion, if group living homes are able to offer their residents a permanent home and only familiar faces to care for them, they truly practice what they preach.
Note: The questionnaire “Group Living Home Characteristics” can be found at www.nkop.nl.