Friendship as Methodology?

Posted by Allan Tear on August 14, 2008

by Michael Lye and Julianne Gauron

This first phase of activity is important foundational work for the NHoF team and BIF's partners. BIF will use this deeper understanding of the experience to reveal unmet needs in the current model and help identify an initial set of target opportunities that can be tested in the lab in phase II. But understanding the day-to-day experience of the people living in a nursing home/assisted living care environment at a level of detail and accuracy that is meaningful for our purpose has raised unique challenges.

Even with good planning around trust building and introduction techniques, the team had to move in unexpected directions to make the connections they needed to gather a truly authentic first person perspective on experiences related to personal care, incontinence, mobility and mental health.

Our work in the nursing home and assisted living environment has emphasized the need for a very intimate, informal, and not highly structured observational approach. We're in the homes of the residents, not just a facility. A casual discussion style is more beneficial and productive than highly formal interviews, surveys or other typical market research methods. Even something as obvious as the gender makeup of the team has been critical to our process. With the make up of Tockwotton disproportionately female, the honesty, openness accuracy and detail of many discussions are highly dependent on the individual researcher and the relationship they have with the resident. A very high level of trust is required to openly discuss issues such as personal hygiene or showering habits if the insights are to be more than superficial.

To truly understand what is happening is resident's lives we have had to far beyond traditional ethnographic research. We needed to become part of the residents lives in a way that allows them to open up about the most intimate and profound aspects of their lives. While more traditional research methods will capture input from some of the more extremely open elderly that only covers one narrow personality type in a hugely broad continuum of personalities that make up the populations living in nursing home or assisted living units. It's easy to describe the "seniors" or the "elderly" and think of them as a homogenous group but they are no less heterogeneous population than any other population group.

Now immersed in the environment, and in some cases, creating friendships with the residents (one team member was recently invited to go "lawn bowling" with a resident), we see the experience differently than one can from the outside. We see not only the resident perspective, but the perspective of the staff and family and the intersections of these people in a variety of environments.

But to get a deeper level of detail about the more intimate elements of the experience, such as using the bathroom, getting around, eating, and relationships, the team needed to go a little deeper. For the remainder of our time in Tockwotton we will be working more closely and one-on-one with a small subset of individuals at the Home who are (to the best approximations) archetypal of the experiences faced by elders across the country.

This is how we met Larry and Esther. Larry and Esther are both residents of Tockwotton Home although they live in separate areas. Larry lives in apartment-like accommodations in the assisted living section of Tockwotton. Esther lives in the nursing home section. Larry and Esther have been married for 69 years. They just celebrated their anniversary last week. 

Larry and Esther were initially in a different home but found that they preferred Tockwotton's progressive and caring Culture Change environment. Living in separate parts of the home is difficult, but the pair tries to make the best of a challenging period of their lives.

Larry visits Esther four times a day at least, and whenever they have visitors he is physically affectionate with his kiss and hug. Larry is a vibrant man who feels strongly about the necessity of out door and physical activity. He is alert, engaged and deeply committed to helping as he can with our work. Esther has dementia and failing memory as well as significant physical ailments and can seem distant at time; she is very alert when Larry visits, under scoring the therapeutic power of interpersonal relationships.

She is in a wheel chair after two knee surgeries and a blood clot which care takers in their past home failed to catch. Their journey has been in everyway non linear, and in this way, more representative of the current experience than our cultural mythologies of aging (you get old, go to home, and pass) might suggest. Larry and Esther came to Tockwotton because one of their daughters, Lucille, was familiar with the home. Lucille's husband, who succumbed to early stage Alzheimer's, lived in Tockwotton for the last few years of his life.

Esther and Larry have proven to be great partners in our endeavor. Through their conscious effort and through our ability to observe them closely throughout the day, we have had a unique perspective on the elements of experience—both major and minor—that define the line between assisted living and nursing care. We have had an opportunity to understand how relationships work in this environment and how subtle shifts in physical and emotional needs tie to overall quality of life and care.

We are also gleaning deep insights from sisters Mary Ryan and Roberta. Roberta came to Tockwotton for nursing home care for her rapid decline with Parkinson's disease. Mary Ryan came from a senior living community to the Assisted Living side of Tockwotton to be there with her sister. Looking at these two individuals has also been a useful way to drill deeper on the nuances of the current experience.

Our last "archetype" is Bunny, who in her career was director of local and well regarded theater. Bunny is very active, still acts, leads acting class and teaches. Bunny also goes to water aerobics and theater productions whenever possible. Bunny is very driven, independent and determined to make the most of the rest of her life. In this way, Bunny is more comparable to a baby boomer than others in the home. She has higher expectations. Understanding Bunny's experience creates an important window for the team to think forward to the next generation of residents

By more closely observing these individuals and creating even deeper relationships with them, the team has (slowly) earned a level of trust that enables truly informative and candid revelations about the current experience.