Relational care and older people: a challenge to accepted wisdom

‘Independence’ and ‘freedom’ are powerful concepts in modern Western society, and there’s a danger that they may become dominant ideals, casting into shadow their counterpoints of interdependence and mutuality. ‘No man is an island’, to use the words of Donne’s oft-quoted sermon, and human beings are not born for isolation but identify themselves and their own precious uniqueness through relationships with others. These aren’t only intellectual or philosophical arguments, they also have profound practical implications for daily life and particularly, I believe, for the place and peace of older people in our society.

Some few years ago, I was commissioned by The Abbeyfield Society, one of the UK’s leading charitable providers of elderly care, to undertake a study of spiritual wellbeing in their homes and housing. The intention was to understand more about what helps communities (staff, volunteers and managers as well as residents) to thrive in all ways. In the event, the findings were far more wide-ranging than we had expected and deserve consideration in planning the future and nature of residential care.  

Over 100 residents and staff were interviewed and more than 40 care settings visited during the study. Listening to the voices of older people is not only enlightening, it creates an obligation in the listener to communicate as best they can the learning they have reaped; the recently-published book Developing a Relational Model of Care for Older People: Creating environments for shared living, co-authored by James Woodward and myself, outlines the critical findings.

Central to the argument for a change of thinking, is the observation that the formation of family bonds and relationships in a home can give an increased sense of support and security to everyone, and most importantly that the family is a model for two-way relationships, based on mutual rather than uni-directional care giving. Building a family is a development from the concept of providing a home. A family is based on bonds that grow and evolve, on interdependence and on acceptance of the good and less good characteristics of others. 

When older people move into a new community – residential or housing – they have an opportunity to start a new phase of ‘belonging’. But this can only be through relationships, and these in turn rely on the right environment, one that fosters feelings of dignity, security and mutual recognition. This demands staff time and continuity, and a careful design of the built environment. People don’t want to live in beautiful hotels or hospitals, they want to live in homes that are fit for everyday life, where they can know and be known.

We need to take a transformative approach to the norms of care-giving. When we view ideas currently accepted as representing best practice through the lens of relationship-centred care, they undergo a paradigm shift.

While valuing age and respecting individuality is essential, independence can easily be another word for loneliness. At its worst, it’s a mantra that drives the practice of encouraging, and the policy of facilitating older people to linger on in a house no longer suited to their needs, listening in the night to strange noises, relying on brief visits by rushed carers and from relatives who may live many miles away.

In contrast, living in a safe setting where there are options for both privacy and company can at its best restore confidence and meaning to life. Gradually the capability to do everything for oneself fades, and then we must redefine accepted wisdom and offer the freedom to be rather than to do, and to contribute oneself and one’s own experience as valuable offerings in themselves.

Sadly, the word ‘care’ (like ‘home’) has grown to hold many negative connotations in our society. The people I met talked about love.

The conditions that enable loving care and the formation of meaningful relationships are: the right physical and relational environment to enable conversation and listening; supported, trained and valued staff; good nutrition through home-cooked food and some (not all) shared mealtimes. These things cost money – but are all the more important to provide in times of austerity because they save more public money further down the line by favouring mental and physical health. Can we be satisfied with anything less than a real change of attitude to national policy and practice? In fact, can we, as a society, afford not to make the radical shift?