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Oldfield - You have to wait - Time as an Instrument of Power in a North American Nursing Home - Preprint, 2019

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Abstract

In this article I explore three types of time in the daily life of a North American nursing home. The first type is institutional time, the dominant force structuring daily life for both staff and residents. The second type is residents’ time, which is how residents would prefer to structure their daily lives. Both the first and second types can be measured by clocks. The third type is dementia time, the unquantifiable, fluctuating timescape of people with cognitive impairments, who comprise the majority of nursing-homes residents. Based on a critical ethnography of a North American nursing home and using a narrative approach, I show how the three types of time intersect and, in their intersection, how institutional time becomes an instrument of power. I then discuss alternative practices and structures that may lessen the power imbalances observed in the critical ethnography. Finally, I reflect on challenges with this type of time research and suggest how they may be addressed through qualitative methodologies. Note: part of this article was published by Review of Disability Studies International in July 2021 (Vol. 17, No. 2) as "Nothing About Us Without Us": Involving People with Dementia in Qualitative Research. The article is available at https://rdsjournal.org/index.php/journal/article/view/1034
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Note: part of this article has been published:
Oldfield, M. (2021, July). "Nothing about us without us": Involving people with dementia in
qualitative research. Review of Disability Studies International, 17(2).
https://rdsjournal.org/index.php/journal/article/view/1034
The article is also available on Margaret Oldfields ResearchGate page:
https://www.researchgate.net/profile/Margaret-Oldfield
“You Have to Wait!”: Time as an Instrument of Power in a North American
Nursing Home
Margaret Oldfield
Abstract:
In this article I explore three types of time in the daily life of a North American nursing home. The first
type is institutional time, the dominant force structuring daily life for both staff and residents. The
second type is residents’ time, which is how residents would prefer to structure their daily lives. Both
the first and second types can be measured by clocks. The third type is dementia time, the
unquantifiable, fluctuating timescape of people with cognitive impairments, who comprise the majority
of nursing-homes residents. Based on a critical ethnography of a North American nursing home and
using a narrative approach, I show how the three types of time intersect and, in their intersection, how
institutional time becomes an instrument of power. I then discuss alternative practices and structures
that may lessen the power imbalances observed in the critical ethnography. Finally, I reflect on
challenges with this type of time research and suggest how they may be addressed through qualitative
methodologies.
Key words: critical ethnography, dementia, dementia time, disability, institutions, institutional time,
nursing homes, power, residents’ time, time research
1. Introduction
Helen,
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a member of my family, lived in her own apartment until her late 80s. After she was
labeled with dementia, she was ably cared for by a long-time friend and neighbor, who subtly
fit caregiving into their intersecting life rhythms for seven years. I began interviewing Helen
during that period because, being a generation younger, I wanted to apply her philosophy of
aging to my own life. I also observed how the dementia label changed the way Helen’s other
family members and friends regarded her (see OLDFIELD & HANSEN, in press). Three
years ago, at 87, Helen fell at home and was moved to a nursing home. Being a researcher
working within critical disability studies, in which dementia is coming to be viewed as much
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All names are pseudonyms.
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as a disability as a disease (SHAKESPEARE, ZEILIG, & MITTLER, 2017), visiting her in her
new location was also an opportunity to observe power relations inside an institution. My
reflective participant observations of her nursing home became an informal critical
ethnography, which has continued over the three years since Helen was moved into the
nursing home. The ethnography is guided by critical disability studies, which looks at power
relations from the perspective of people with impairments.
Critical ethnography “takes us beneath surface appearances, disrupts the status quo, and
unsettles both neutrality and taken-for-granted assumptions by bringing to light underlying
and obscure operations of power and control” (MADISON, 2005, p.5). In critical ethnography,
power is viewed as a social force, evident in, for example, having to conform to rules and
regulations or expectations (ROSS, ROGERS, & DUFF, 2016)such as those in nursing
homes. Data for the ongoing ethnography include not only the observations and reflections
that I audio-record during bimonthly, week-long visits to the nursing home, but interviews with
Helen about her experiences in the home and local-government care standards for nursing
homes.
During each visit I meet informally with the nurse-manager of Helen’s floor as well as family
members and friends of other residents. My audio-recorded field notes on informal meetings
with these people become data for the ethnography. At the beginning of the ethnography, to
understand the institutional context, I also informally met with the directors of nursing and
social work in the nursing home. To learn about related research, I read on an ongoing basis
academic and gray literature about long-term care, dementia care, and nursing-home reform
(See References list).
To gain others’ perspectives on the ethnography’s findings and thereby increase their
trustworthiness and potential resonance, I took the following measures. First, I co-wrote a
publication with another researcher who did not know Helen (OLDFIELD & HANSEN, in
press). Second, I presented on the ethnography at conferences in the disciplines of critical
disability studies and gerontological nursing. Third, I compared my findings to academic
literature on nursing-home reform. Fourth, I sought feedback on a draft of this article from
readers within critical disability studies and nursing.
In this article I explore three types of time: institutional time, residents’ time, and dementia
time through stories about daily life in Helen’s nursing home drawn from my reflective
participant observations. Although I endeavor to take the standpoint of Helen and her fellow
residents, I acknowledge that the stories are filtered through my observational lens as a
family member who lives elsewhere and is a generation younger than Helen. My aim is to
show how the three types of time intersect and, in their intersection, how institutional time
becomes an instrument of power. The use of institutional time as an instrument of power is
often unintentional and based on unexamined social assumptions about power relations
between staff and residents. In demonstrating how institutional time becomes an instrument
of power, my intent is not to blame the institution’s staff or cast its residents as victims, but to
recognize power imbalances between the two groups of people and the way power works.
Within the analysis supported by evidence from the ethnography, I discuss alternative
practices and structures that may lessen the power imbalances that the stories evidence. At
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the end of the article, I reflect on challenges with this type of time research and suggest how
they may be addressed through qualitative methodologies, particularly ethnography.
2. Three Conceptualizations of Time in Nursing Homes
By institutional time, I mean time as measured by and displayed on clocks and calendars that
prioritizes the institution’s needs. A key feature of clock time is that it can be both counted
(EGEDE-NISSEN, JAKOBSEN, SELLEVOLD, & SØRLIE, 2012) and therefore accounted
for. It structures workers’ shifts, and their tasks within shifts, inside institutions, such as
hospitals, schools, prisonsand nursing homes.
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In nursing homes, institutional time is
reflected in daily routines, workers’ time sheets, resident-care logs, and reports to regulators.
Institutional time in nursing homes is itself structured and often constrained by staffing levels,
workloads, regulatory requirements, how time is allotted among tasks (MALLIDOU,
CUMMINGS, SCHALM, & EASTABROOKS, 2013), and among staff members
(MCCLOSKEY, DONOVAN, STEWART, & DONOVAN, 2015). Institutional time prioritizes
“routine practices that manage residents’ bodies at any given time based on nursing home
policies and schedules” (MALLIDOU ET AL., 2013, p.1234). Privately owned nursing homes
often experience pressure to keep costs down to maximize profits for shareholders
(HARRINGTON, SCHNELLE, MCGREGOR, & SIMMONS, 2016). For them, institutional time
is a cost. In non-profit or publicly owned homes, funding constraints and low staffing levels
have a similar effect. With corporate time-management practices being applied to both
private and non-profit nursing homes, not only do routine body-oriented tasks take priority but
workers are expected to do them faster (ARMSTRONG, 2013).
By residents’ time, I mean how nursing-home residents would prefer to structure their time if
they had the choice. This might include eating when they are hungry, going where they want
to when they want to, going to the toilet when they feel the need to, and going to bed when
they are sleepy. For people over 75 who live in institutions, although not necessarily for
people living independently, time slows down (DROIT-VOLET, 2016). This slowing down of
residents’ time is not due to slower cognitive function with age; rather, it arises from the
residents’ awareness that their lives have changed, that the best times of their lives are
behind them, and their resignation to this change (DROIT-VOLET, 2016). The author found
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the retrospective judgment of the passage of time was not linked to individual
psychological traits but rather results from the conscious awareness of being in a
retirement home and that life has therefore definitively changed, with the best being in
the past and not the future. This is consistent with works on the well-being of elderly
people and the feeling of resignation they experience when they have to live in a
retirement home. (p.19)
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Depending on the government jurisdiction, these are also called long-term residential care, long-term
care facilities, or skilled nursing centers.
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Time passes quickly when old people are happy, and more slowly when they are sada
condition more likely among nursing-home residents (DROIT-VOLET, 2016). Therefore,
residents’ time can be much slower than institutional time.
Because dementia-related cognitive impairments can alter the perception of time, it is
important to understand how residents with dementia experience time differently from staff,
family members, and residents without dementia. Social scientists have developed a new
concept, dementia time, to describe this unquantifiable, fluctuating timescape, which
challenges the linear order and quantifiable nature of institutional and residents’ time.
As YOSHIZAKI-GIBBONS (in review) explains, Individual moments may be…intermittent,
irrational, and idiosyncratic” (p.7). Dementia time, unlike linearly ordered time, can be
conceptualized as flat, in that past, present, and future may occur in the same plane. As
MITCHELL, DUPUIS, AND KONTOS (2013) explain,
The person before you is a unity of everyone they have been over a life span. Past,
present and future are experienced together…Older people also describe a greater
connection with the cosmos; connecting and reconnecting with loved ones and
memories; and redefinitions of time, space, life, and death…the disappearing
boundaries of time, place, person [that are] currently designated as symptoms of
brain disease and dementia, may in fact be markers of a natural transformation that
occurs with aging. (p.10)
3. A Day in the Life of the Second Floor: Conflicts between Institutional Time,
and Residents’ and Dementia Time
This section contains narratives from the critical ethnography that illustrate conflicts between
the three types of time. These conflicts illuminate how the dominant type, institutional time,
becomes an instrument of power over residents. The stories combine my reflective
participant observations from multiple days and times and are generally organized
chronologically to follow a day in the life of the institution’s second floor, where Helen lives.
Within the analysis I discuss alternative practices that may reduce conflicts between
institutional, residents’, and dementia time.
3.1 Setting the scene
I exit the home’s elevator on the 2nd floor of the 16-storey building. To the left of the elevator
is the nursing station, with the nurse-manager’s office and the staff room. These rooms are
behind a counter on which sit two computers, with a third facing a wall to the side. Behind the
counter is a bookcase full of thick binders, one for each resident on the floor. The nursing
station is at the bottom of the U-shaped floor, which houses 40-50 residents, some in rooms
within view of the nursing station and others in rooms on the two wings. Staff wear hospital-
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style uniforms (scrubs for the care workers and white coats for professionals), with name
badges.
The rooms are identical: each has two hospital beds separated by curtains surrounding each
bed. Each room contains a sink and mirror, two small closets, two night tables, two TVs, two
small dressers, and a door to a room with a toilet and sink that is shared with one other
resident room. Beside each room’s entrance is a number and the names of both residents.
Some rooms have a chair or two for visitors; others do not. To Helen, it looks like a hospital.
As she asks me every so often, “Why am I still in the hospital? I’m not sick.”
I check to see if Helen is in her room. She is not. It is after lunch, so she may be in the dining
room. I turn left, walking to the end of the hall. On the way, I wave hello to a couple of men
sitting in wheelchairs outside their rooms. Other residents are weaving their wheelchairs
through the hallwaynegotiating the narrow space with the cleaner and his cart, care
workers, and other staff. Some exchange hellos, nods, or waves.
The massive medication cart blocks one of the dining room’s doorways, while the licensed
practical nurse (LPN) dispenses medications. I go in the other door. I look to my right and
see Helen, sitting quietly alone in her wheelchair behind a table in front of the window.
Helen’s roommate, Rosa, snoozes in her wheelchair at another table in the large room. This
is the afternoon routine every time I visit Helen. Arriving after lunch, I find her in the dining
room at the same table, usually by herself. The routine exemplifies institutional time, which
prioritizes the needs of the institution not the residents.
3.2 Afternoon jail
Opposite the dining-room entrance sits a silent care worker, whose role appears to be
watching the dozen or so residents in the room. As far as I have observed, care workers in
this role do not talk to the residents, except to order them to “Sit down!” when they try to rise
from their chairs. This is likely an effort to prevent residents from falling and injuring
themselves. Falls must be documented and reported to the government. These residents,
perhaps labeled with dementia and thereby “at risk of wandering,” are not allowed to leave
the dining room in the afternoon unless they are accompanied by recreation staff or family
members. The TV is ontoo loud to allow conversation. Most residents sit silent and alone.
The scene closely resembles the nursing home studied by MALLIDOU ET AL. (2013). As
they describe, “Residents were quietly sitting, passively waiting, watching television that
(most of the times) was on all day long, or sleeping, showing no interest of [sic] what was
happening around them” (p.1234).
Although the dining room does not look like a jail, it functions like one. Residents are
prevented from leaving by the care worker stationed in the room, who guards their
movements by shouting at them from a distance. Other researchers have used a similar
analogy to describe life in nursing homes. HEGGESTAD, NORTVEDT, AND SLETTEBØ
(2013) reported that residents in their studies described their nursing home as “a prison
without bars”. In ARMSTRONG AND BRAEDLEY’S (2016) study, a care worker described
residents as “feel[ing] like they’re in a cage” (p.79). It is important to remember that nursing-
home residents are adults, not small children to be kept in line. Controlling adults in this way,
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in response to institutional time and needs, infantilizes them (OLDFIELD & HANSEN, in
press).
I go over to Helen, who is surprised to see me and looks up with a big smile. I ask her
whether she would like to visit other parts of the building with me. Once we leave the second
floor, we will be able to enjoy the afternoon on residents’ time: ogling the views from the
beautiful recreation room or the physical therapy room, buying a snack in the cafeteria,
relaxing in the family room, or having Helen’s hair cut at the home’s salon. But, for Helen to
leave the dining room, I must accompany her and tell staff at the nursing station that we are
leaving the floor. If we want to leave the building, we must get a written pass, signed by the
LPN. The pass requires me to agree to return Helen to the floor by a certain time or risk
losing the privilege of taking her out. This would hurt Helen far more than me. Without a
signed pass, the security guard at the building’s exit will not let Helen leave.
Although part of the institution’s risk-management strategy, the written pass evinces the
institution’s power to determine residents’ movements according to institutional time, not their
own. The pass system also makes clear that the building is not the residents’ home. As
(TUFFORD, LOWNDES, STRUTHERS, & CHIVERS (2018) remark, “Who holds power to
determine access and exiting through doors, locks and codes is crucial to the tension
between home and institution” (p. 38).
Before Helen and I leave the dining room, Suzie, another resident, asks me if there’s
somewhere quiet that she and her neighbor Esther can go. I tell them about the cafeteria and
suggest we all go together. Esther says she needs to get her money from the nursing station.
We all go over there, and I explain that I would like to take Suzie and Esther, along with
Helen, to the cafeteria. “You can’t do that! How can you take more than one person?” the
LPN on duty says to me. She turns and yells, “Esther, go back to the dining room!” I
apologize to Suzie and Esther, and Suzie wearily thanks me for trying.
According to the LPN, I cannot take responsibility for three residents, only the one who is my
family member. Her reaction was likely based on a rapid assessment of risk, which clearly
takes priority in institutional time over the physical and mental benefits that Suzie and Esther
might have gained (TUFFORD, ET AL., 2018) in leaving the afternoon jail, under residents’
time (how nursing-home residents would prefer to structure their time if they had the choice).
So Suzie and Esther must switch back to institutional time, as enforced by the LPN.
Underpinning the afternoon jail and the pass system is the institution’s overriding concern
with resident safety. Institutional time spent on issuing passes, fall prevention, and other risk-
mitigation practices is shaped by government regulations, by societal attitudes about risks for
elderly people, by media scandals (TUFFORD, ET AL., 2018), and by family members’
expectations that institutions are safer for their relatives than living at home.
One perceived risk in traditional North American nursing homes is allowing residents
(especially those with dementia) to go wherever they like, whenever they like—on residents’
time. Yet, in Europe and in some North American nursing homes, there are no locked floors.
The Re-imagining Long-term Residential Care project (http://reltc.apps01.yorku.ca) describes
nursing homes that allow residents (including those with dementia) to roam around the
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building on their own time. Examples include unlocked kitchen and laundry rooms, unlocked
doors to fenced-in gardens, and doors locked only at night when there are fewer staff to keep
track of residents (ARMSTRONG & BRAEDLEY, 2016). Project researchers note that, where
residents have freedom to move through unlocked doors, they are less agitated in the more
relaxed atmosphere. The researchers advocate balancing risk reduction with providing
stimulation and autonomy for residents:
LTRC homes with open living areas that allow residents with advanced dementias
and those with other chronic conditions and frailties to meet, mingle and enter various
home areas may be considered by some to be less safe than homes in which they
are locked into separate, secure home areas. However, this assessment does not
consider the benefits gained for residents who remain physically active and socially
integrated. (ARMSTRONG & BRAEDLEY, 2016, p.78)
In addition, reducing agitation among residents by incorporating residents’ time into the
physical environment will likely reduce the amount of institutional time spent calming
residents.
3.3 Fun on institutional time
Sometimes when I arrive after lunch, Helen is at an event in the top-floor recreation room. A
recreation staff member announces each event on the building’s loudspeaker, and then
recreation staff go to each floor asking residents if they want to attend. Because many
residents use wheelchairs and each of the two service elevators only holds six, it takes a
long time to bring residents up and take them back to their floorsabout as much or more
time than a 1-hour event. When I attend these events with Helen, of which many are musical,
I note that she and other residents smile and sing along when invited. While this opportunity
for fun on institutional time benefits residents, only those who feel up to going when the event
is scheduled, who can communicate that they want to go, and who can fit into the room, can
partake.
There are also opportunities for fun on the second floor that do not require residents to leave
it. A few mornings a week, recreation staff come to the second floor to deliver music therapy
or other programs. However, like activities in the recreation room, they are scheduled on
institutional time. If residents do not feel like partaking in these programs, they miss out on
the fun. Although there is a cupboard in the dining room containing materials for arts and
crafts, I have not observed residents accessing the materials for spontaneous fun on
residents’ time. Nor have I observed residents spontaneously playing cards or organizing
other fun on their own time. Fun appears to be offered and controlled by institutional time
alone.
One way of enabling fun unstructured by institutional time (i.e., whenever residents prefer to
engage in it) would be to make craft materials, playing cards, books, and free newspapers
visibly available to residents and easily accessible in the dining room. For residents unable to
move about on their own, an assortment of recreational materials could be put on each table.
Instead of putting these materials away in a cupboard, to be accessed only when
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recreational come to the floor for programs on institutional time, residents could be
encouraged to take recreational materials to their rooms. Particularly during the afternoon
jail, opportunities for spontaneous fun might alleviate the boredom of residents not allowed to
leave. If more than one care worker was assigned to guard the residents, that person could
converse with them and perhaps facilitate fun.
3.4 Moving around
Although some residents using wheelchairs can move around the second floor using their
feet or hands to move their chairs, those needing staff assistance cannot move around the
floor on their own, whenever and wherever they like. Instead, they must abide by institutional
time and wait until care workers can assist them. HEGGESTAD ET AL. (2013) report that,
when staff “don’t have the time,” as several of their resident participants remarked, immobility
reinforces residents’ feeling of being in a “prison without bars.
Mobility benefits residents by reducing depression, increasing functional independence, and
quality of life (MALLIDOU ET AL., 2013). Residents time—walking slowly with support from
an arm or being watched while using a walkerconsumes institutional time. In contrast,
having residents use wheelchairs makes it quicker for staff to move them from room to room
under the constraints of institutional time. In these ways, institutional time becomes an
instrument of power over residents’ mobility. As relayed above in the story of my role in
getting Helen out of the afternoon jail, institutional time becomes an instrument of power over
visitors’ mobility as well. TUFFORD, ET AL. (2018) point out that institutional time’s power
over residents’ mobility distinguishes institutions from private homes, in which residents have
agency to go where they want when they want, as they would on residents’ time.
Residents’ and institutional time can align, however, when physical therapists take residents
outside to practise “walking in the community,” as Helen’s therapist referred to it. One
gorgeous spring day, he took her outside and invited me to tag along. We had a wonderful
time in the warm air of the park that is right across the street from the institution. Because
accompanying residents as they move around the building and out in the community is part
of the therapist’s job, in this case institutional and residents’ time align. However, in the case
of care workers, the two types of time rarely appear to align. Perhaps it is because care
workers are expected to serve more residents on their shifts than therapists.
3.5 Going to the toilet
Power imbalances between institutional and residents’ time can seriously affect residents’
health. Being left in wheelchairs for long stretches of time without going to the toilet increases
incontinence (TUFFORD, ET AL., 2018), as does being unable to void when needed
(SALSBURY LYONS, 2010). Government nursing-home standards recognize this problem:
“Loss of bladder (and bowel) control is a significant problem for nursing home residents that
often results from poor or inadequate care” (MOLOTT, 2018, p.32).
For Helen, the conflict between institutional and residents’ time has led to painful skin
damage, because she has to wait for assistance in getting to the toilet and, being incontinent,
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is not changed as often as she needs to be. Although the nurse-manager has tried to ensure
that Helen is checked every couple of hours, care workers may not have the institutional
time. They have other duties and other residents to care for, and the institution is short
staffed. As an example, an evening care worker told me that she has 8-10 residents to serve
during her shift. At a Family Council meeting I attended, family members noted the high
number of residents assigned to each care worker on other floors. On Helen’s floor, the
supervising nurse spends much of her institutional time doing administrative tasks. She may
not have enough time to ensure that care workers carry out her instructions.
Helen’s roommate Rosa asks an LPN working on a computer behind the counter to take her
to the bathroom. The LPN replies, “That’s not my job. You have to wait until your care worker
comes.” She does not explain why she cannot take Rosa to the toilet. Rosa asks again,
repeatedly. The LPN gets annoyed. She tells Rosa, “You have to wait!” It seems that the
division of labor among staff, and the consequent power differential among them, may get in
the way of institutional time accommodating residents’ time.
Many reasons have been reported for poor continence care in nursing homes. The most
cited are “inadequate knowledge and staffing, employee attitudes, and ineffective leadership”
(SALSBURY LYONS, 2010, p.336). Although external solutions such as clinical guidelines,
regulatory enforcement, and quality assurance programs are often proposed, SALSBURY
LYONS argues that these efforts to change care-provider behavior are not sufficient. They
must be preceded by an understanding of the social, cultural, and organizational contexts
that affect care provision, and their relationship to time.
3.6 Whose reality?
Helen’s description of her daily life reflects dementia time. It seems that, in her mind, past
activities continue in the present. Helen often talks about going outside as part of her daily
routine. She tells me, “I walk every day. I go to my church.” A few moments later, she talks
about living in a city far away with her family. Between visits, when we talk on the phone
about when I’ll visit next, Helen often points out, “I won’t be here. I’m going home tomorrow.”
Although Helen’s dementia time may be a way of coping with a painful present (YOSHIAKI-
GIBBONS, 2017), I believe it is as real to Helen as calendar time is to me. So I try to honor
Helen’s dementia time, telling her “OK. I’ll find you.”
Helen’s dementia time also melds a lifespan into one flat plane. Although she recognizes me,
Helen is not always sure about my relationship to her and asks me what it is. Sometimes she
talks about being a generation younger than me and about her parents being alive. I see no
point in forcing Helen into calendar time by “correcting” her, as I have seen family members
do with other residents, since this dementia time is her reality in the moment. At another
moment, it may change. On one visit, an LPN, turning her face towards mine and away from
Helen, asked me, “Is she confused?” I have heard other staff use this term, which equates
dementia time with confusion, as a euphemism for dementia. As far as I have observed, we
are the only two people on Helen’s floor who converse in dementia time, challenging the
linear order and ‘factuality’ of institutional time. Calendar-based time dominates.
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Engaging with residents in dementia time is about connecting emotionally, validating, and
affirming what residents experience in dementia time (YOSHIZAKI-GIBBONS, 2017). Being
able to be truly present without correcting or judging people with dementia (MITCHELL ET
AL., 2013) can improve residents’ physical and mental health and may even be more
important than workers’ skill in physical care (MALLIDOU ET AL., 2013). Enhanced mental
health may alleviate the depression and boredom of living in an institution.
Because dementia time may fluctuate from day to day or hour to hour, incorporating it into
physical tasks on institutional time requires remaining flexible as needs change in the
moment (YOSHIZAKI-GIBBONS, 2017). For example, a care worker who appreciates
dementia time, instead of saying “But a minute ago you said you wanted this,” might say
“Right, I’ll do that.” The government nursing-home-care standards in Helen’s jurisdiction give
another example of how to incorporate dementia time:
A resident with dementia may be attempting to exit the building with the intent
to meet her/his children at the school bus. Walking with the resident without
challenging or disputing the resident’s intent and conversing with the resident
about the desire (tell me about your children) may reassure the resident.
(MOLOTT, 2018, p.19)
Appreciating dementia time requires creativity in adapting to alternate realities (YOSHIZAKI-
GIBBONS, 2017). Although conceptualizing time creatively could be part of staff training, it is
not only an issue of changing workers’ attitudes. Incorporating dementia time in nursing
homes also requires structural change; for example, in work organization, in the ownership of
institutions, in philosophies of carein short, enabling care workers to incorporate dementia
time into their work days, which are structured by institutional time.
3.7 Dinner: Residents’ time for socializing
Toward the end of our afternoon together, Helen asks me for the clock time. She wants to
ensure that we return to the dining room by 5:00, to wait for dinner. I used to point out that
dinner is not served until 6:00. I recently realized why Helen wants to get to the dining room
well ahead of time: residents gather beforehand and chat. Sitting at Helen’s table, the most
vocal (as one of her tablemates describes it), feels to me like being at a casual dinner party.
At other tables, though, there is little conversation. Mealtimes seem to be highlights of
residents’ days, as they are in many nursing homes (LOWNDES, DALY, & ARMSTRONG,
2018), because then the group comes together and there are opportunities to socialize with
each other, verbally or not. This is an important part of the dignity of belonging
(HEGGESTAD ET AL., 2013). Meals are a time for connecting with others (KELLER ET AL.,
2018) and also provide opportunities for care workers and residents to get to know each
otherto build relationships (KELLER ET AL., 2014).
About an hour or so before dinner arrives, residents who walk or move their wheelchairs on
their own begin to enter the dining room. Care workers begin to wheel other residents in.
They put a paper bib on each resident and try to resolve any disagreements about who sits
where in the dining room. A couple of family members arrive to help them eat. This
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institutional-time-consuming preparation enables residents to interact with each other,
verbally or otherwise; in other words, to socialize.
Once the food trays arrive on carts from the central kitchen, care workers put each person’s
tray in front of them. They speak little to residents, sometimes encouraging them but more
often directing them to eat. Although I have observed care workers socializing with each
other during dinner, I have not observed them socializing with residents. Institutional time
and residents’ time seem to operate separately in the same room: care workers focus on
getting everyone to finish their food, and residents focus on socializing. Later in the meal,
care workers ask each resident if they have finished eating, then remove their trays. To clear
the room so the cleaner can come in, care workers move people in wheelchairs into the
hallway, where they put the wheelchairs in a line. Residents’ time for socializing is quickly
snuffed out in favor of institutional time.
More than half of nursing-home residents are malnourished for a variety of preventable
reasons associated with individuals and the dining environment (KELLER ET AL., 2014).
One reason is the organizational practice of closing dining rooms after meals, which can
result in rushing residents to finish eating (KELLER ET AL., 2014) and favors institutional
time over residents’ time. This power imbalance not only shortens the time residents have
available for eating, it shortens the time staff have available for residents who need help
eating. According to LOWNDES ET AL. (2018), this takes at least 20-30 institutional-time
minutes per resident. Both adequate time for residents to eat and adequate time for care
workers to assist them are crucial to reducing the high rate of malnutrition in nursing homes
(SLAUGHTER ET AL., 2017).
On the second floor in Helen’s home, there is a sign on the door to the small kitchen that
says ‘Staff Only. Residents wanting food outside of mealtimes have to ask staff to bring it to
them from the kitchen. Retrieving food for residents takes institutional time and limits
residents from eating on their own time when they are hungry. Although allowing residents to
enter the kitchen may be perceived as risky, other cultures assess risk for residents
differently. For example, in a German care home, residents have access to fully equipped
kitchensto refrigerators, kettles, knives, and stoves. They participate in meal preparation,
which enables physical activity and socializing (TUFFORD ET AL., 2018). LOWNDES ET AL.
(2018) suggest having kitchens open for snacks and drinks between meals or at night, so
residents can help themselves. Giving access to kitchens incorporates residents’ time into
the institution’s operations, so that residents can eat when they are hungry and do not need
to wait until designated mealtimes.
Another recognized way to reduce malnutrition is to increase the social interaction of
residents at mealtimes (SLAUGHTER ET AL., 2017).Changing food-service practices can
not only increase food consumption, it can increase opportunities for residents to socialize.
An alternative to care workers serving food on trays to each seated resident, buffet-style
meals, has been found to encourage residents to eat more (LOWNDES, ARMSTRONG, &
DALY, 2015). This format could also allow residents to chat while serving themselves and
moving to and from a buffet.
12
In the dining room at Helen’s institution, the TV is usually on during meals. Turning down the
volume, or turning the TV off, would recognize the importance of mealtimes to socializing in
residents’ time.
3.8 Evening jail
In the next part of the daily routine, care workers wheel some residents, including Helen and
Rosa, to their room and place them beside its door, facing the nursing station. From there, a
staff member watches them and other residents until the care worker assigned to them is
ready to put them to bed. Although staff allow Helen to get up when she is readyor to stay
in bed if she does not feel well—going to bed is determined by institutional, not residents’,
time.
Residents confined to the evening jail are not allowed to go into their rooms (for example, to
watch their choice of TV channels). Rosa asks me several times to take her into the room,
but the staff member at the nursing station tells me no, she has to stay outside. Helen tells
me she would like to lie down in bed. I help her use the toilet as she asks, watch while she
transfers herself from her wheelchair onto her bed, and help her change into her nightgown.
We watch TV together for a while. Then the care worker who has been assigned to put Helen
to bed arrives. “Who put her into bed?” she demands. I explain that Helen told me she
wanted to go to bed, so I helped her get there. It seems, in responding to Helen’s residents’
time, I have transgressed institutional time priorities.
Underlying the surveillance over residents and restraint of their mobility in the evening jail
may be an institutional effort to prevent falls; yet fall-prevention practices often lead to loss of
mobility (TUFFORD, ET AL., 2018). In the jurisdiction where Helen lives, falls are used to
rate the quality of care provided by nursing homes, and these ratings are publicized on a
government website. This may in part explain the attention to fall prevention at Helen’s
privately owned nursing home, which competes with others for residents. Risk mitigation may
dictate why, in the evening jail as well as the afternoon jail, institutional time overrules
residents’ time.
3.9 Institutional time as an instrument of power in daily life on the second floor
As explored in the analysis above, institutional time conflicts with residents’ time when it
prevents the residents on Helen’s floor from leaving the afternoon jail, improvising their own
fun, moving around the floor when they want to, going to the toilet when they feel the need
to, taking as much time as they need to eat dinner and socialize with fellow residents, and
going to bed when they are sleepy. Other than in conversations between Helen and me,
dementia time appears to have no place on the second floor. These conflicts demonstrate
how institutional time becomes an instrument of power over the other two types of time and
thereby diminishes residents’ quality of life. On the second floor, residentstime must
generally give way to institutional time, which orders daily life in the nursing home. Those
who transgress institutional time are directed, even ordered to conform.
13
Critical disability studies scholars have begun to document life for younger North Americans
with cognitive impairments (also called developmental or intellectual disabilities) who were
segregated from other children in institutions and remained there for the rest of their lives
(BURGHARDT, 2014). Although some of these institutions still exist, more often today
children with cognitive impairments grow up in their families. As adults, they may have
access to community-based supportive housing, such as group homes and supported
apartment living. These alternatives came about through the deinstitutionalization movement
that, beginning in the 1960s, aimed to close the institutions (PANITCH, 2008). One of their
defining features was institutional time as an instrument of power. As demonstrated in the
stories earlier in this article, this power continues to control and confine residents in
traditional North American nursing homes.
Daily life on the second floor resembles that of a North American institution housing people
with developmental disabilities that only recently closed. As MALACRIDA (2015) argues,
The dehumanizing qualities of the institution…were entrenched in the ways
that inmates’
3
days were organized…long, painfully dull stretches of time
interrupted by brief, intense bursts of activity…The simple human bodily
needsto eat when hungry, to drink when thirsty, and to use a toilet when
fullwere routinely denied because of the rigidity of the schedule, or delayed
because of the necessity of finding an available and willing staff member.
(pp.75-77)
The impact of institutional time as an instrument of power on residents’ quality of life is
similar as well to the institution for people with developmental disabilities that MALACRIDA
(2015) studied. As she explains,
Routines operated to control inmates’ bodily functions were also established
as a way to facilitate staff efficiency…the predictability and regimentation of
daily routines made the management of all these bodies possible…This need
to control inmates’ bodies, while not necessarily intentionally degrading,
nevertheless did operate in dehumanizing ways, subordinating inmates’
natural bodily functions and needs to institutional efficiency. (p.78)
We need to ask why frail North American elders and people with dementia continue
to be segregated in institutions, when this practice is no longer widely accepted for
younger people with cognitive impairments. North Americans governments have
found ways to create supportive housing integrated within communities for the latter
group of people.
There are many lessons from the deinstitutionalization movement that could be
applied to the much newer North American efforts to make traditional nursing homes
3
Malacrida purposely refers to residents as inmates, arguing that the institution was modeled on a
prison.
14
more humane and to create non-institutional alternatives. One example is the Green
House model. These are small homes housing 9-12 residents in which care workers
are able to spend more time engaging with residents (SHARKEY ET AL., 2011).
According to WILLIAMS ET AL. (2016), although community-based, high-support
housing for elders exists, it does not meet the demand for care that prevents
institutionalization. Instead, government policy still prioritizes expanding the number
of nursing-home beds, based on the hospital model. Key to the success of the
movement to make high-support elder care more humane is reducing the power of
institutional time over residents’ and dementia time.
4. Structural Changes that May Reduce the Power of Institutional Time over
Residents’ and Dementia Time
In this section, I discuss structural changes to traditional nursing homes that might reduce
the power of institutional time over residents’ and dementia time. As Helen expressed, these
changes involve “Holding someone else’s time.” The changes are the philosophy of relational
care and its recognition in government regulations, improving continuity of care, and giving
care workers more flexibility and autonomy. These structural changes could complement the
alternative practices discussed in the previous section.
4.1 Relational care can incorporate residents’ and dementia time into institutional time
Relational care comprises “relational or relationship-centered approaches that emphasize
interpersonal connections and strong, mutually beneficial relationships between and among
persons in need of care, their family members and friends, and paid workers” (BARKEN &
LOWNDES, 2017, p.62). With its focus on care in relationship, relational care holds potential
for incorporating residents’ time into institutional time. Helen gave an example of this melding
of the two types of time. When I asked her what comprised good care, she described it as
follows:
They take themselves to you in a nice way…the really good ones are with you
from beginning to end…it’s putting two female bodies together…And some
people are just so open to you…they’re gathering you, and if you need
another moment, they will join you in that…Especially the ones who’ve had a
lot of experience, they know if you know that there’s something that you could
do, that they don’t have to do for you…they find out a lot about the people,
how they can manage stuff that you don’t— [So, it’s knowing what each
person can do, what they can manage, and what they need help with?]
Yeah…And some people have long conversations all through the
thing...Because maybe you do something that they don’t really want you to be
doing, and they want something else. [It’s working together.] Yes, it is.
Helen’s phrases “they take themselves to you” and “two female bodies together”
15
express institutional time slowing down to allow her to proceed according to her abilities, in
her residents’ time. This slowing down allows her to be not just an object of care, but a
participant.
Relational care particularly benefits residents with dementia. In a number of efforts to change
nursing-home culture (see, for example, RONCH, 2005; https://uwaterloo.ca/partnerships-in-
dementia-care/our-philosophy), care workers are encouraged to spend more time with
residents who have dementia. Relational care not only provides more compassionate
environments for residents, it reduces staff turnover because staff are more satisfied with
their jobs (WELSH, 2018). This, in turn, reduces the need to use institutional time to hire and
train new care workers.
I have observed relational care in action a few times on the second floor. Once when I was in
Helen’s room, a care worker arrived who was from francophone Africa. Both Helen and I
spoke to her in French. All of us enjoyed the encounter, and I hope that it began building a
mutually beneficial relationship between Helen and the care worker for their future
encounters.
In another example of relational care that creatively incorporated dementia time, a research
colleague told of how she observed an LPN dispensing medication in a hallway. A resident
approached her, angrily shouting. The LPN scooped the resident in her arms and danced
with her down the hallway. The resident was no longer angry, and the LPN went back to her
work on institutional time. It took all of a minute, said the researcher (J. Struthers, Centre for
Critical Qualitative Health Research seminar, January 16, 2019).
Although relational care may reduce conflicts between institutional time, residents’ time, and
dementia time, to allow for the time needed to build and enhance relationships between
residents and care workers, regulators need to recognize relational care as part of
institutional time.
4.2 Recognizing relational care in regulations and adequate funding
Relational care takes time: time for care workers to know residents intimately (MCCLEARY
ET AL., 2018), learn their preferences and, for people with dementia, how they communicate
without words. Building mutually beneficial relationships (MCCLEARY ET AL., 2018)
between residents and workers requires time for them to get to know each other as
individuals not just roles.
The difficulty of countingand thereby accounting forinstitutional time spent in relational
care is a key issue. Government care standards for nursing homes evolved from standards
for hospitals, which are based on set amounts of time to perform physical tasks and do not
include relational care.
4
Documentation of physical care consumes institutional time that
4
Nonetheless, it is possible to track relational care. GRASP software allows hospital nurses to
document psycho-social and emotional support as part of their workloads (Personal communication,
C. Lee, February 18, 2019).
16
could be spent in relational care (LOWNDES ET AL., 2015). For example, efforts by care
workers to gather biographical information from residents (BANNERJEE & ARMSTRONG,
2015), part of building relationships, do not count. A nursing professor wrote to me: “As a
health services researcher, I find the key problem has to do with how quality care is poorly
defined by governing bodies. Sadly, it is all about bed sores and quantifiable items at this
point. A smile does not count” (C. Lee, personal communication, January 2, 2018).
A second factor impeding relational care is inadequate government funding for nursing
homes, which keeps staffing levels low (BANNERJEE & ARMSTRONG, 2015). Institutions
looking to cut costs do so by reducing care staff. Although family advocates promote
government-regulated minimum staff-resident standards as a solution to short staffing, as the
family council at Helen’s institution does, staffing minimums are not enough, in part because
they are not well enforced (HARRINGTON ET AL., 2016). In addition, staffing needs vary
according to the acuity of residents’ needs, the design of institutions (e.g., large units or
those with single-occupancy rooms require staff to spend more institutional time walking).
Therefore, minimum-staffing standards need to take these differences into consideration
(MCCLOSKEY ET AL., 2015). Attending to how care tasks are allocated among levels of
staff (RNs, LPNs, and care workers)and the time each of these groups spend providing
direct care to residentsis important, too (MCCLOSKEY ET AL., 2015).
There are ways to increase the number of people providing relational care without hiring
more staff. For example, a German home hosts an apprenticeship program that essentially
doubles the staff complement (TUFFORD, ET AL., 2018). In another example, an American
nursing home sits next to a religious college, where students are required to volunteer in the
nursing home as part of their courses. In this way, the institution gains volunteers and its
residents benefit from teaching the young people about spirituality (ROTH, 2005). In cities
with nursing homes, colleges and universities in close proximity, nursing homes can recruit
volunteers for relational care from among students doing practicums in nursing, social work,
and allied health professions.
4.3 Continuity of care that incorporates residents’ time
The scheduling of staff on the second floor of Helen’s institution impedes incorporating
residents’ time into daily life. The nurse-manager is the professional model for care workers
in relating emotionally to residents, a skill essential to providing relational care on residents’
time. Some care workers have this skill, and others do not. However, on the nurse-
manager’s weekday 9:00 a.m.-to-6:00 p.m. schedule, administrative duties periodically take
her off the floor and she has paperwork to do in her office, minimizing her institutional time to
supervise care workers. On evenings, during the night, and on weekends, there is no nurse-
manager on the floor. Although a supervisor who covers three floors is on call for
emergencies, she is not on the second floor, modeling professional care.
The staffing schedule also impedes continuity of care; that is, the same care workers are not
assigned consistently to the same residents, allowing each pair to form a relationship. In
addition, regular full-time care workers, who are unionized, may get first pick at shifts. Other
workers who float among floors in the building and casual workers provided by temporary
agencies fill in the spots that regular workers do not want, or are called in when full-time care
17
workers are sick. These floaters and casuals are less likely that full-time staff to be aware of
residents’ preferences, because they seem them irregularly, so continuity of care suffers
(ARMSTRONG, ARMSTRONG, & CHOINIERE, 2015). They are more likely to follow
institutional time than residents’ time.
A change in staff scheduling (e.g., hiring a nurse-manager to supervise care workers on
evenings and weekends; pairing care workers and residents consistently) may not only
increase the incorporation of residents’ time into more continuous care, it may increase job
satisfaction among care workers. MALLIDOU ET AL. (2013) note that care workers who are
permanently assigned to certain residents, rather than being rotated among them, are more
likely to be satisfied with their jobs. This structural change could benefit not only care workers
but nursing home administrators. As with relational care, more job satisfaction reduces
institutional time spent on hiring and training new staff. Enabling care staff to spend more
time with residents builds trust and empathy between them (MALLIDOU ET AL., 2013). Staff
who have long-term relationships with the residents to whom they are assigned can tune into
residents’ time and, in turn, perform physical-care tasks only when residents want them to.
By accommodating residents’ time in this way, care workers may experience less resistance
from residents who trust themreducing the need to institutional time overcoming residents’
resistance to care.
4.4 Flexible institutional time and more autonomy for care workers
Giving care workers time flexibility and more autonomy in organizing their tasks, by not
having to synchronize them with the tasks of other workers (EGEDE-NISSEN ET AL., 2012),
may allow care workers to better incorporate residents’ time. This includes delaying physical-
care tasks until residents are ready, rather than physically forcing them to fit into institutional
time (ØYE, FADNES JACOBSEN, & ELIN MEKKI, 2016). Better incorporating residents time
into more flexible institutional time could enable more agency for residents; for example,
choosing what clothes to wear rather than care workers picking the clothes out of a closet or
dressing residents in what they wore the day before. More flexibility could help residents
maintain their strength by allowing them the time they need to dress, brush their hair, or get
ready for bed.
When institutional time allows care workers more autonomy, they can apply their capacities
for communication, presence, humor, and empathy (BANERJEE & ARMSTRONG, 2015).
More autonomy can also allow snippets of time for socializing with residentsduring care
tasks and mealtimes for exampleand thereby building relationships that enhance relational
care.
5. Investigating the Intersections between Institutional, Residents’, and
Dementia Time in Nursing Homes
In this section, I discuss five challenges with investigating time in the particular setting of a
nursing home: gaining access to the time-research setting, informed consent from
participants with dementia, researching dementia time, and the emotional impact on
researchers of observing situations where institutional time trumps residents’ and dementia
18
time. For each challenge, I discuss how it might be addressed through qualitative
methodological approaches. At the end of the section, I focus on one methodology,
ethnography, which is particularly appropriate for investigating time in nursing homes.
5.1 Gaining access to the time-research setting
As a member of Helen’s family my access to the institution is unquestioned, although I must
sign in and out at the security desk as every other visitor and staff member does. For those
who do not have a family member living in a nursing home, gaining access to investigate the
power relations between institutional, residents’, and dementia time could be more difficult.
Researchers without access as family members would need to first build trusting
relationships with administrators to gain permission to access not only the institution’s
spaces, but to recruit participants. Without permission to move freely about, researchers
cannot observe the three types of time in interaction. Where permission is attainable, it is
more likely to be from institutions who want to showcase how they recognize residents’ and
dementia time in their culture change, rather than from more traditional institutions who risk
being critiqued by researchers investigating the power relations of time. In the landscape of
North American long-term residential care, where many facilities are privately owned,
competition for business may prevent corporate owners from risking scandals and damaged
reputations by allowing researchers in.
5.2 Informed consent from participants with dementia
It is crucial to include the lived experiences of people with dementia in dementia research
(NYGÅRD, 2006). Nonetheless, they are often excluded (NOVEK & WILKINSON, 2017).
Instead, healthcare professionals or family members are often asked to speak on behalf of
people with dementia, even if they are verbal and articulate. This is problematic, because
accounts other than those directly from people with dementia may be filtered through
dominant ideas about dementia, such as that it is a tragedy to be feared (VAN GORP &
VERCRUYSSE, 2012).
One reason for excluding people with dementia is the assumption that they cannot give
informed consent. MOORE AND HOLLETT (2003) challenge conventional measures of
determining competence to consent as applied to potential research participants. They argue
that research participants are not required to be competent in making decisions about all
areas of life but only a specific decision in a specific context.
NYGÅRD (2006) recommends that researchers build relationships with participants with
dementia well before requesting informed consent. During the research, researchers should
remind participants who the researchers are, the purpose of the research, and that they are
temporary visitors. MOORE AND HOLLETT (2003) add that ensuring that participants
understand the researcher’s role is essential to continuing consent. Because relationships
are so important in dementia research, researchers should plan if and how they will withdraw
from the relationship (MOORE & HOLLETT, 2003).
5.3 Researching dementia time
19
As explained above, people with dementia are often excluded from research on dementia.
Although family members and care workers may be able to observe dementia time and
reflect on their observations, they do not directly experience the phenomenon. If researchers
want to fully understand dementia time, it is crucial to engage with and interview people with
dementia. This may require adapting research methods to take into account the needs of
participants with cognitive impairments.
The SCOTTISH DEMENTIA WORKING GROUP (2014), an advocacy organization of people
with dementia, has produced guidelines for working with research participants who have
dementia. Several of the guidelines directly address aspects of time. The Group advises that
researchers should:
be empathetic, unpatronizing, and tolerant
communicate in inoffensive language that participants will understand
find out the best time for participants to meet, how they each keep track of time and
want to be reminded of meetings
ask participants if they would like to have someone with them
ask about participants’ emotional and physical safety needs at each meeting
offer access to counseling or emotional support
recap previous conversations at each meeting
give participants time to reflect and respond to questions
offer regular breaks
be cautious about asking participants to recall unhappy times, as they may trigger pain
not stay longer than agreed, unless invited to.
Dementia researchers suggest ways to adapt interview techniques for participants with
dementia. These include scheduling interviews for when participants are mostly likely to
experience the study phenomenon (MOORE & HOLLETT, 2003). An unstructured interview
format may be most adaptable (NYGÅRD, 2006), in addition to fostering co-construction of
knowledge. It also allows participants to direct the conversation to issues that matter to them
(MOORE & HOLLETT, 2003). Photo-elicitation can be used to make interviews more
concrete, as can asking questions about the participant’s daily life, ones that do not require
recalling events or feelings (NYGÅRD, 2006) and focus on participants’ strengths (MOORE &
HOLLETT, 2003). The photo-voice technique (DASSAH, ALDERSEY, & NORMAN, 2017)
giving cameras to participants and asking them to photograph aspects of their lives that are
important to themcould provide material for participants to discuss during interviews.
Although interviews can be adapted for people with dementia, they usually rely on verbal
communication. Interviewing participants who communicate differently, without words,
requires a nonconventional approach. TEACHMAN, MISTRY, AND GIBSON (2014)
developed such an approach for interviewing youth who communicate nonverbally using eye
gaze, gestures, facial expressions, and technology. Their methods include observation,
photo-elicitation, face-to-face and electronic interviews. The researchers are assisted by
family members in becoming familiar with participants’ communication modes.
BOURBONNAIS AND DUCHARME (2010) used a triad methodology to explore the
language of screams among people with dementia in a nursing home. Each triad comprised
20
a resident with dementia, a family member, and healthcare professional or a paid caregiver
who knew the resident well.
Besides interviews, participants with dementia can be involved in participant observation.
Informally interviewing someone while accompanying them for discrete periods of time in
their daily life enables questions to be more concrete and prompted by things that both
researcher and participant observe in the same moment (NYGÅRD, 2006). Participants can
also demonstrate what they mean (NYGÅRD, 2006), adding to the richness of data. These
go-along interviews (CARPIANO, 2009) also facilitate the co-construction of qualitative data
between each interviewer/participant pair. Photography can be used to document the
locations visited and what was observed. The photographs can then be used to remind
participants about the go-along experiences in later interviews, where the time shared by
interviewer/participant pairs can be explored.
Analysing data on dementia time and interpreting findings may require adaptation of data-
analysis techniques as well, since researchers may not have experienced dementia time
directly. It may help to create an advisory committee of people with dementia from outside
the study setting, perhaps recruiting committee members through advocacy organizations of
and/or for people with dementia. Committee members could participate in data analysis and
interpretation. They could also guide development of research questions during planning of
studies of dementia time. In addition, adapting member-checking techniques for participants
with dementia might facilitate checking whether the findings resonate with their experiences
of dementia time. Visual methods (e.g., putting themes on cards and asking participants to
arrange them in order of resonance with their lived experience) might work for member
checking and could also be used to involve participants with dementia in data analysis.
Similarly, researchers could draw conceptual diagrams or mental maps exploring aspects of
time, in collaboration with participants.
5.4 Emotional impact on researchers of observing situations where institutional time
trumps residents’ and dementia time
Doing critical ethnography may put researchers at risk of emotional distress. The SCOTTISH
DEMENTIA WORKING GROUP (2014) recommends that researchers “become aware of
their own ‘safe zones’ and know where to go/not go” (p.683). Individual researchers will, of
course, interpret emotional safety differently according to their personal history and
circumstances. What I offer here are suggestions for emotional safeguards when researching
the intersections of institutional, residents’, and dementia time in nursing homes.
In a seminar I attended, a nursing-home researcher talked about the upsetting emotions she
felt in observing low-quality care (J. Choinere, Centre for Critical Qualitative Health Research
seminar, January 16, 2019). I have certainly experienced distress in witnessing how
institutional time impinges on quality of life for Helen and her fellow institutional residents.
Over the 3 years of my ethnography, I have developed relationships with some of them. A
few others who I did not get to know have died. To let go of the anger I feel witnessing how
institutional time becomes an instrument of power, I find it helpful to audio-record my
participant observations and reflections as soon as possible after making them. As a family
21
member, I am very careful not to criticize the institution or its staff. I strive to maintain
pleasant relationships with them, not only to avoid being the recipient of defensive reactions
and to prevent being admonished for transgressing institutional time, but to protect Helen.
Discussing my observations with Kim, the family member of Helen’s roommate Rosa,
somewhat alleviates my distress because Kim is very familiar with the institution, coming
daily to help Rosa eat dinner. This informal peer support is one of the strategies
recommended by DICKSON-SWIFT, JAMES, KIPPEN, AND LIAMPUTTONG (2008), who
also advise researchers investigating emotionally sensitive topics to look beyond peer
support. They recommend that researchers leave time between data-collection episodes to
process emotions, develop guidelines for ending research relationships and strategies for
dealing with participant death, and have someone else transcribe interviews to avoid reliving
traumatic experiences.
5.5 Qualitative approaches to research on time in nursing homes
Although quantitative research approaches are well suited to investigating countable
institutional time, qualitative approaches, such as ethnography, are better suited to
investigating residents’ and dementia time because the latter two are less easily counted or
unquantifiable. A focus on the quality of time is therefore more appropriate, particularly for
nonlinearly ordered dementia time. Ethnography also involves researchers building
relationships with participants over time. This time can increase ethnographers’
understanding of the worlds of residents and people with dementia, in turn giving researchers
access to their sense of residents’ and dementia time.
As a qualitative methodology ethnography enables time researchers to draw on multiple data
sources and participant standpoints to answer their research questions. This multiplicity may
help round out the challenges in tapping participants’ lived experiences of residents’ and
dementia time. Using interviews and participant observation in the same study enables
researchers to locate similarities and differences among data from different sources and use
one method to flesh out findings from another (NYGÅRD, 2006). For example, during
interviews researchers can follow up themes from their analysis of observational data, or vice
versa (HEGGESTAD ET AL., 2013). Ethnography also allows the study of the participants’
situations in context, which can be investigated using other ethnographic methods, such as
document analysis. Because one way to adapt research for participants with dementia is to
schedule multiple, short interviews, working with the same participants over time may
facilitate data interpretation (NYGÅRD, 2006). Ethnography allows for such longitudinal
research, involving multiple interviews and observations with participants at different times
and perhaps in different contexts.
6. Where do we go from here?
Because traditional North American nursing homes are both residences and highly regulated
workplaces, conflicts between institutional time, residents’ time, and dementia time are likely.
These conflicts show how institutional time becomes an instrument of power in the lives of
nursing-home residents. However, there are alternative practices and structural changes that
22
may lessen conflicts between the three types of time and shift the balance of power slightly in
favor of residents.
The research presented in this article took place in a novel setting, a nursing home. Although
there is substantial research on time in educational institutions (SCHILLING, KONIG, &
O’NEILL, 2018), there is little English-language literature on non-institutional time in nursing
homes.
The typology of time developed in this article (institutional, residents’, and dementia time) has
potential for guiding further research. The typology could be used as a conceptual framework
for studies of time in nursing homes. Administrators of nursing homes and their directors of
nursing could use this framework to understand the culture of their institutions by examining
the intersection of the three types of time. Gerontology researchers studying culture change
in elder care could use the typology to compare traditional nursing homes with non-
institutional alternatives. Critical gerontologists could use the time typology to study power
relations in elder care and the impact of institutional time’s dominance on residents.
It is hoped that the typology of time explored in this article can accelerate nursing-home
reforms by providing a new evaluative lensthe intersection of three types of timefor
researchers studying the effectiveness of changes in practice and structure. In evaluation
research, examining the impact of reforms on residents’ time and dementia time could
expand cost-benefit analyses. Incorporation of residents’ and dementia time into the daily life
of nursing homes and non-institutional alternatives could be used to qualitatively assess
changes in practice and structure. The ultimate effectiveness-outcome measure would be
improved health and quality of life for frail elders and people with dementia.
Acknowledgments
I am most grateful to Helen for sharing her experiences with eloquence and humor and to
Kim for supporting me emotionally in this research. I thank Charlotte Lee, Rona Macdonald,
Carol Nash, and Hailee Yoshizaki-Gibbons, whose comments on a draft of this article
substantially improved it. Thanks are due as well to the peer reviewers and editors of this
special issue for their improvements.
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Author
Margaret Oldfield, a social scientist, received her PhD in rehabilitation science from the
University of Toronto. Her research focuses on changing workplaces and policy to enable
people with chronic illnesses to stay at work. She also uses the lens of critical disability studies
to explore the experiences of people with dementia who live in institutions commonly called
nursing homes. Dr. Oldfield has published her research in academic and trade journals, and
books, and presented it at numerous conferences and webinars. Her work can be viewed on
Research Gate and Google Scholar.
Contact:
Margaret Oldfield
407-550 Ontario Street, Toronto, Canada, M4X 1X3
Tel.: 01-416-975-5199
E-mail: margaret.oldfield@alum.utoronto.ca
ResearchGate has not been able to resolve any citations for this publication.
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