The sample (N=14) comprised nine nurses (five were unit leaders), four assistant nurses, and one occupational therapist. The informants work experience in NHs ranged from 10 to 40 years, with a mean of 25 years. All informants were native Norwegians and female.
Characteristics of the NH residents staying in the included NHs have been published in earlier articles related to this implementation (2, 10, 11, 15).
The main identified categories were: (a) the characteristics of care activities before implementations of JoLNH, (b) how JoLNH influenced the care activities, and (c) challenges with the implementation of JoLNH. The findings are further elaborated with statements from the informants. The informants are numbered in parentheses at the end of each statement.
The characteristics of care activities before implementations of JoLNH
The informants gave several examples of different activities they offered to the residents to make their days meaningful, before the NH implemented the JoLNH strategy. However, the informants said the organization and planning of these activities were spontaneous, and happened by coincidence, depended on the healthcare personnel at work. One informant said they used song and music to bring forward memories and give recognition, another told that they read aloud from the newspaper during breakfast, and a third explained that they had joyful moments only by being together with the residents, laughing, walking and such like. One informant expressed the spontaneous activities like this:
There has been a lot of joy in life through one day, even if it was not planned (16)
Even though the care was characterized by spontaneous activities, the informants explained that they used life history mapping to get an overview over their residents’ prior interests and activities. However, before the implementation of JoLNH informants explained that they (the care personnel), unconsciously might have focused most on residents that could speak out about their needs and less on the residents who did not demand anything:
It was perhaps the case that the residents who were most fond of talking received the most – it might feel more naturally to sit down with them (22)
How JoLNH influenced the care activities
The second main category is supported by data on how the informants described that the JoLNH influenced the care. The informants talked about how the JoLNH lead to better planning and implementing systems for the care activities, the strategy increased their awareness on dignity, and entailed more involvement of the individual residents and their relatives, this became particularly noticeable in relation to end of life care. The informants stated that one of the requirements of implementing the JoLNH strategy was more documentation. The documentation lead to more systematic work with joy of life care activities. One informant explained how the implementation of JoLNH contributed to placing the care activities into a system. Another said that the staff had become more aware of the individual residents’ needs and worked more systematic to tailor joy of life activities to different residents’ needs. Several informants said they experienced the residents as more satisfied after the implementation.
With the JoLNH – we map all the residents about their background, what they like to do, and what they don't like to do (12)
It is positive, now everyone (the residents) get an activity program that is adapted to their needs, it is more systematic (13)
Several informants said they experienced that the residents were more satisfied after the implementation of JoLNH. They further emphasized that the residents deserved to have care activities adapted to their situation and be treated with dignity. The JoLNH also made the staff more committed to ensure that the care activities were targeted to the individual residents’ needs and executed in accordance with the plan. For some residents, the care activities could be that the care personnel sang along with the resident, had a small chat, took the resident outside to the porch for fresh air, or used music-based environmental treatment. To make sure that the residents’ individual needs were considered, the informants used each resident’s life history to plan the activities.
We create a monthly plan and then we evaluate afterwards. We should describe the resident's experiences and activities if there has been nothing positive have happened then we must report that (7)
Another positive experience related to the JoLNH implementation was that the healthcare personnel became more conscious about seeing each resident as an individual person and involving relatives. One informant emphasized the JoLNH criteria as helpful in communicating with the relatives and explained that the documentation of care activities could be printed and given to the relatives. This documentation showed what their mother or father had been doing that day and was greatly appreciated by in the relatives. Another informant told a story about an old female resident that loved flowers, and how the JoLNH strategy had made the staff more aware of this woman’s needs by letting her go outside to pick flowers.
To see the joy in the eyes of the resident then I feel we have succeeded to engage them in activities which we did not before (7).
Challenges with the implementation of JoLNH
Informants commented that even though they saw the documentation as positive, it was also challenging and difficult to perform. One informant said that the documentation was too much; it was time-consuming and difficult to remember in addition to all the other tasks they had to carry out. One informant explained that fewer specific requirements for how to document could make the documentation less time-consuming and easier to do.
All this documentation is a working task that has come in addition to everyday working tasks. I understand that we must document the experience, but objectivity is important (10)
Informants said that the JoLNH demanded for more resources if they should fulfil the JoLNH criteria and perform the JoLNH care activities. Some told that they had special JoLNH personnel that was responsible for the activities. Even though several of the informants stated that they used to carry out similar JoLNH activities before the implementation of JoLNH, they thought about the strategy as something that that demanded extra resources. One informant told that some days, it could be difficult to let all residents go outside and get fresh air. Another informant experienced some JoLNH arrangements as challenging because the unit was empty, and someone needed to stay and take care of the residents who are uneasy and not able to participate. In such situations, the informant said she often had to sacrifice the lunchbreak to make it work. Others said it was important to get people involved and to understand how important JoLNH was, and that it did not have to be so hard and time-consuming.
We struggle with having enough time, we know how the staffing situation is, there are many tasks and many times, we feel we have too little time (2)
Informants also commented that the JoLNH activities were not suited to all residents living in NHs today, because the residents are frailer than some years ago. When the residents are sicker, the informants explained that it was more difficult to develop activities adapted to their individual situation. One said the clue was to think simple. Some residents enjoyed the activities while others had opposite reactions, they could become restless and insecure. Several informants said that residents with dementia perhaps had less benefit from JoLNH activities because they needed an environment that was safe, calm and predictable.
I feel that those who are JoLNH responsible, they run around with noise and sound and events, but here in the NH 9 out of 10 residents have dementia and running around is not JoLNH for them (9)