Evaluation of the Test Phase of the “Program GIFT in Residence”: Results from a Pilot Participatory Action Research

Abstract

Despite the negative effects on older adults, resident-to-resident aggression (RRA) remains a complex and understudied problem. Few interventions exist that address this issue by promoting goodwill. Using the intervention mapping approach, the evaluation of the test phase of the pilot Program GIFT in private seniors’ residences (PSRs) (Quebec, Canada) was conducted through qualitative interviews with 25 residents, 21 staff members, and 4 managers. The results indicate that the program achieved its objectives of promoting goodwill, although the strategies to manage RRA and intervention tools were more difficult to integrate into the PSRs’ culture. Obstacles and facilitators were reported. Recommendations were identified to enhance the program’s content, promote it more effectively, and ensure long-term sustainability. This research is the first endeavour to develop, test, and evaluate the test phase of a pilot program co-created with residents, staff members and managers of PSRs, aiming simultaneously at promoting goodwill and countering RRA.

Résumé

Malgré ses conséquences pour les personnes aînées, la maltraitance entre résidents demeure un problème complexe et peu étudié. Peu d’intervention aborde ce problème en promouvant la bienveillance. Utilisant l’intervention mapping, l’évaluation de la phase test du Programme BIEN en résidence (Québec, Canada) a été réalisée par des entretiens qualitatifs avec 25 résidents, 21 membres du personnel et 4 gestionnaires. Les résultats indiquent que le programme a atteint ses objectifs de promotion de la bienveillance, bien que les stratégies de gestion et les interventions en situation de maltraitance aient été plus difficiles à intégrer dans la culture des résidences privées pour aînés. Des obstacles et des facilitateurs ont été rapportés. Des recommandations ont été identifiées pour améliorer le contenu du programme, le promouvoir plus efficacement et assurer une implantation optimale. Cette recherche est la première à développer, tester et évaluer la phase test d’un programme cocréé avec des résidents, membres du personnel et gestionnaires de RPA, visant simultanément à promouvoir la bienveillance et à lutter contre la maltraitance entre résidents.

Elder abuse, or mistreatment of older adults, is characterized as a single or repeated act, or lack of appropriate action, occurring in any relationship where there is an expectation of trust that leads to harm or distress to an older person, as defined by the World Health Organization (WHO, 2023a). Elder abuse (both violence and neglect) takes place within community and institutional settings, and can be physical, psychological, sexual, financial or material, organizational in nature, and can also be in the type of ageism or violation of rights. The Government of Quebec, in Canada, has taken concrete action to counter mistreatment of older adults since 2010, with the introduction of the first Governmental Action plan to Counter Mistreatment of Older Adults 2010–2015 (Government of Quebec, 2010). In 2022, the Government of Quebec adopted its third Governmental Action plan to Counter Mistreatment of Older Adults 2022–2027: Recognizing and Acting Together (Government of Quebec, 2022) and revisited the Act to Combat Maltreatment of Seniors and Other Persons of Full Age in Vulnerable Situations (Compilation of Quebec Laws and Regulations [CQLR], Chapter L-6.3) (Government of Quebec, 2017a), initially adopted in May 2017. This act included mandatory reporting of mistreatment of older adults in private seniors’ residences¹ (PSRs).

Resident-to-resident aggression (RRA) is a prevalent form of mistreatment of older adults that occurs worldwide within congregate residential facilities.² Approximately 19.0 per cent of residents and 41.0 per cent of nurses in PSRs for independent and semi-independent older adults have reported experiencing or observing RRA (Trompetter et al., 2011). The proportion of residents involved in RRA is similar (20.2%) in long-term care centres³ for older adults requiring constant care (Lachs et al., 2016). Moreover, an overwhelming majority of staff members (97.0% and 88.8%, respectively) in these establishments have observed RRA (Botngård et al., 2020; Castle, 2012).

RRA is defined as ‘negative, aggressive and intrusive verbal, physical, sexual, and material interactions between long-term care residents that in a community setting would likely be unwelcome and potentially cause physical or psychological distress or harm to the recipient’ (McDonald et al., 2015a, p. 157). RRA has various consequences on the well-being, safety, and health of those involved (McDonald et al., 2015b). These can take the form of psychological (e.g., insecurity, anxiety), physical (e.g., sleep disorders), and social (e.g., social isolation) consequences (Beaulieu & Leboeuf, 2019; Falardeau et al., 2022; Goodridge et al., 2017). In general, research has identified that new arrivals and those with physical and psychological challenges are the residents most susceptible to being targets of RRA (Beaulieu & Leboeuf, 2019; McDonald et al., 2015b). In PSR, residents with atypical physical appearance and those less fortunate (Beaulieu & Leboeuf, 2019) are equally more susceptible to being targets. Men, residents with physical or cognitive challenges, or with particular personality traits are the ones more prone to committing RRA towards their peers (Beaulieu & Leboeuf, 2019).

RRA usually manifests when new residents arrive at the residence (Beaulieu & Leboeuf, 2019; Jain et al., 2018; Pillemer et al., 2012), because of changes associated with aging (e.g., diminished self-confidence stemming from physical or cognitive decline) (Beaulieu & Leboeuf, 2019), and when one desire to attain control over a particular area, like a game room or a dining table (Beaulieu & Leboeuf, 2019; Pillemer et al., 2012). In long-term care centres, additional contributing factors encompass a reaction to disruptive behaviour (Jain et al., 2018; Pillemer et al., 2012) or a sense of being enclosed by the overpopulation of residents (Benbow, 2016). In PSRs, elevated employee turnover rates and limited physical surroundings (e.g., limited access to elevators or insufficient corridor width) (Beaulieu & Leboeuf, 2019) may also cause RRA.

In Quebec, the second edition of the Governmental Action plan to Counter Mistreatment of Older Adults (Government of Quebec, 2017b) introduces the term ‘well-treatment’, a synonym of wellness care and goodwill, and promotes it as a central part of countering and preventing mistreatment of older adults. According to the government, well-treatment:

is about fostering the well-being and showing consideration for the dignity, self- fulfillment, self-esteem, inclusion and safety of a senior. It is expressed through attentiveness, attitudes, actions and practices that are respectful of the values, cultures, beliefs, life journeys, uniqueness and rights and freedom of that individual. (Government of Quebec, 2017b, p. 38)

Programs exist to counter bullying among older adults (Madsen et al., 2020) or to manage RRA in long-term care centres (Ellis et al., 2014) outside of Quebec. Tools or activities have been developed to counter RRA (Teresi et al., 2013) or to promote wellness care among older adults (Strom and Strom, 2017; Theurer et al., 2014), an approach helping to counter RRA (Falardeau et al., 2022). However, none of these initiatives include in the same program a dual approach of promoting goodwill and countering RRA, by grouping multidimensional modules and proposing various tools and activities for all PSRs’ actors, nor have they been developed in partnership with older adults and PSRs. Furthermore, the Governmental Action plan to Counter Mistreatment of Older Adults 2022–2027: Recognizing and Acting Together (Government of Quebec, 2022) has no specific measures to address RRA, and few actions are taken to counter RRA or promote goodwill in PSRs, despite the fact that 18.4 per cent of older adults live in this type of congregate residential facilities, a significantly higher proportion than other Canadian provinces and territories where the rate varies between 5.0 and 10.0 per cent (Canadian Mortgage & Housing Corporation [CMHC], 2020).

This study aims to bridge these gaps by presenting the results of the evaluation of the test phase of a pilot program developed with the dual purpose of countering RRA and promote goodwill in Quebec’s PSRs. Using participatory action research (Aner, 2016; Blair & Minkler, 2009), the research was carried out in three phases: (1) conducting a needs study with residents who experienced RRA, and staff members and experts who intervened in RRA; (2) developing and testing a program to address RRA and promote goodwill; and (3) evaluating the test phase of the pilot program. The intervention mapping (Bartholomew Eldredge et al., 2016), which has proven effective for planning and its adaptability for social research, was used to guide program development, testing, and evaluation. The results of the needs study (step 1) (Beaulieu et al., 2021; Falardeau et al., 2021; Falardeau et al., 2022) and the detailed development of the pilot program (step 2) (Beaulieu et al., 2022) were published previously. The Research Ethics Board of the Université de Sherbrooke (Lettres et sciences humaines) approved this research (2019-2444).

Program GIFT in residence: development and testing through a participatory action research approach

The Program GIFT in residence, aimed at promoting goodwill and countering RRA, was developed within the framework of a participatory action research with four PSRs in two regions in Quebec, Canada (Eastern Township and Montérégie). In fact, the corporation of PSRs based in Canada contacted the research team to study the phenomenon in their PSRs after observing social problems between residents: lack of respect, verbal and physical aggressive or violent behaviours, bullying, etc. The participatory action research was then created with the corporation and four of their PSRs. The participatory action research approach facilitated ongoing collaboration between the research team and the practice community (Aner, 2016; Blair & Minkler, 2009). Throughout the project, the research team worked closely with three committees (steering committee, advisory committee, and working committee)⁴ bringing together residents, staff members, and managers of PSRs, and experts working to counter RRA and promote goodwill between older adults. This, among other things, enabled older adults to actively participate in the development of a program designed to improve their well-being and quality of life.

The program’s content was co-created in partnership with the working committee regrouping three residents and three employees, in addition to three members of the research team (MCF, MB, and HC), between December 2020 and September 2021, during the COVID-19 pandemic. Five meetings of two hours were held by videoconference to discuss the objectives of the program, target clientele, and tools and activities to include in the program. In between meetings, the research team developed the content based on the committee’s recommendations, which was then presented to its members for validation.

During meetings with the two other committees, the progress of program development was presented to its members to collect impressions and comments. For instance, it is by working closely with the committees that the name of the program was selected: the Program GIFT in residence, GIFT meaning ‘Goodwill against Intolerance For Togetherness’. The terms ‘goodwill’ and ‘intolerance’ were proposed by residents, staff members, and managers during a first phase of the project, as the most representative terms to characterize the positive and negative relationships between residents (Beaulieu & Leboeuf, 2019, Leboeuf et al., 2022). These terms were used throughout the pilot program. For the purpose of this article, the terms ‘goodwill’ and ‘RRA’ will nevertheless be used.

As mentioned, the Program GIFT in residence has a dual objective: to promote goodwill and to counter RRA. It consists of a variety of tools and activities for individuals involved in the PSR: residents, staff members, and managers. The main idea behind it was to create a multidimensional program that caters to all actors within the PSRs and to develop strategies to engage the majority of people living or working there. The program includes three modules that meet four objectives, based on the needs studies carried out in previous phases of the research (Beaulieu & Leboeuf, 2019; Falardeau et al., 2022):

1. 1. Facilitate the adaptation and integration of new residents into the residence (module 1)

2. 2. Clarify the process for managing RRA (module 2)

3. 3. Propose intervention tools to counter RRA (module 2 and module 3)

4. 4. Promote goodwill between residents (module 3)

Module 1 seeks to facilitate the integration of new residents into the residence through a peer-to-peer pairing system with established residents in the PSR. Additionally, welcoming activities are proposed to prevent situations of RRA, which newcomers may be the target of. This module is designed for residents, but it is essential that those responsible for its implementation understand the foundations of the material for an optimal use.

Module 2 encompasses various tools and activities to effectively manage and address situations of RRA. It is intended for staff members and managers of PSRs, and includes: five training capsules, each lasting approximately six minutes, a compilation of existing training resources, a structured approach to managing RRA consisting of a decision chart, a documentation form and a checklist of steps to be taken upon observing RRA, and a list of available resources.

Module 3 is intended for residents and aims to promote a positive atmosphere between residents and in the living environment and raise awareness about RRA. It comprises a repertoire of existing conferences, an awareness poster campaign, information on the establishment of residents’ representation bodies to encourage goodwill among them such as a residents’ committee and a goodwill’s committee, as well as the collaborative creation of a goodwill charter and various group and individual activities. Further details about the committees and the theoretical foundations underlying each tool and activity within the program can be found in Beaulieu et al. (2022).

The pilot program was tested between October 2021 and July 2022 to improve its content. During the pilot testing, the program’s tools and activities were adjusted based on residents, staff members, and managers of PSRs’ feedback. Although all the modules were presented to the managers by the project coordinator, they were free to test the ones that met the PSR’s needs (see Table 1). For example, the residence 3 (R3) wanted to improve their welcoming protocol and acted in creating a welcoming committee with employees and residents to pair a new resident with a peer. In the residence 1 (R1), the lifestyle and program manager was interested in diversifying the group activities and conferences for residents, which led R1 to test many. The research team ensured that all tools and activities were tested at least once. During the testing, meetings and follow-ups were held with the managers of PSRs and the lifestyle and program managers, while communication activities aimed to inform the residents and employees. More information regarding the support offered by the research team can be found in Beaulieu et al. (2022).

Table 1. Content of the Program GIFT in residence tested in each residence (R)

The test phase was conducted in the context of the COVID-19 pandemic, which posed various challenges, including limited in-person activities due to mandatory vaccination passports, COVID-19 outbreaks, and staff shortage. However, these challenges were taken into account and addressed to capture the reality of PSRs for adequate program development.

Method: evaluation of the pilot

The evaluation of the test phase of the pilot program was carried out according to the intervention mapping approach (Bartholomew Eldredge et al., 2016) in the context of a participatory action research (Aner, 2016; Blair & Minkler, 2009). The intervention mapping (Bartholomew Eldredge et al., 2016) was selected for its foundations in effective planning and its adaptability to social research. This method also allows for quantitative and/or qualitative evaluation to better improve a pilot program. Developed in the 1990s, this method consists of six steps: (1) developing a model of the problem based on a needs assessment; (2) developing program objectives and goals; (3) developing a plan of the program, including its scope, sequence, and practical applications; (4) producing program content, and testing the pilot program; (5) planning the implementation of the program, its adoption and sustainability; (6) evaluating the overall implementation of the program. Steps 1 to 4 were completed previously. Part of step 4 also involves evaluating the pilot program, in this case a qualitative evaluation, which is the main focus of this article. In conclusion, steps 5 and 6 will be discussed.

Between May and August 2022, qualitative semistructured individual and group interviews were conducted with residents, staff members, and managers of the participating PSRs. The semistructured interview method was employed to address predetermined themes while allowing participants the freedom to discuss parallel issues relevant to research (Creswell & Poth, 2018). Twelve individual interviews and nine group interviews were conducted, lasting an average of one hour. In total, 50 participants were interviewed, including 25 residents, 21 staff members, and 4 managers of PSRs. All participants had to have contributed to the testing of the program, its tools or activities. Residents were required to possess the cognitive capability to participate in discussion during the interview as determined by the research team.

A convenience sample and snowball sample were used to recruit participants, two common strategies used in qualitative research in gerontology (Wagner et al., 2018). Lifestyle and program managers and managers of PSRs who had worked on the development of the program were initially approached by the research team. Managers of PSRs suggested staff members to be interviewed. The interviewer, a trained research assistant, coordinated the interviews with the managers of PSRs, which took place during the staff members’ working hours. Residents who expressed an interest in participating in the evaluation process were requested to leave their contact details with the lifestyle and program manager, the manager of their PSR, or a member of the research team at any moment during the trial.

The themes discussed during the interviews aimed to assess the program’s achievements in meeting its objectives (e.g.: does this tool/activity helps in practice? If so, how? If not, why?), the facilitators and obstacles encountered during the testing (e.g.: how was the testing of the program? What problems did you observe?), and the strategies or change needed to improve the program and its content (e.g., what did you appreciate most/least about that activity? How could it be improved?).

The research team produced the interview framework by operationalizing the objectives of the pilot program into questions for each group of participants. The audio interviews were transcribed by a research assistant and uploaded in the QSR NVivo 12 software. Analytical questioning (Paillé & Mucchielli, 2021) was selected since this type of analysis is appropriate in evaluative research where project objectives are well defined, clear, and necessitate specific questions to be answered. To achieved analytical questioning, the research team used the questions of the interview framework to create new questions to analyze the data. The aim of analytical questioning is not to generate ‘conceptualizing categories or themes, but rather direct responses in the form of statements, observations, remarks’ (Paillé & Mucchielli, 2021, p. 214, free translation). It also leaves a space for new elements introduced by the participants. The tree code generated by analytical questioning was validated by the research team and two research assistants and was then presented to the three committees included in this participatory action research for comments and feedback.

Results: evaluation of the test phase of the pilot program

Table 2 shows that the majority of participants were women. This reflects the reality of these environments, in which a majority of women live and work, according to the numbers provided by the partner of this project, the corporation of PSRs (73.6% on average of women living in the PSRs, and 71.9% of women working in the PSRs in 2021). The staff members hold different positions within the PSRs: dining room attendants, personal care attendants, reception attendants, care team leaders, housekeeping attendants, cooks, lifestyle and program managers, auxiliary nurses, and administrative assistants. The average age of residents was 77.2 years old, and they have lived in the PSR for a little over three years. Most participants had French as their principal language spoken, reflecting a similar proportion (82.2% in 2021) of the first official language spoken of the Quebec population (Statistics Canada, 2023). Table 2 also shows a diversity of education levels among participants, and within the same group of participants, allowing for more chances of obtaining a variety of points of view.

Table 2. Characteristics of participants (n = 50)

SD, standard deviation; NA, not applicable

Achievement of objectives

According to the 50 participants interviewed, the material developed in the program is relevant to address RRA and promote goodwill. Furthermore, the objectives of promoting goodwill and improving the welcome process for new residents were achieved. However, some objectives were partially achieved mainly the ones related to the information on intervention tools (Table 3).

Table 3. Level of achievement of objectives

The first objective, which is to facilitate the integration of new residents into the residence (module 1), is considered to have been achieved according to the participants. Among other things, the PSRs either had a body to facilitate the residents’ integration or they created one with the help of the guidelines provided in the program. Both managers of PSRs (M) and residents (R) agreed that pairing a new resident to one already living in the residence is necessary, but must be overseen by management:

The pairing process is great for us. For a resident, it’s too much. You have to understand that the average age is 86 here. So it’s always going to go through management. (M2)

We’re not going to take responsibility. We didn’t want to take on the responsibility of pairing people up as such, but we were willing to do that part to accompany them on visits. (R12)

The PSRs also integrated activities to enhance social relationships between residents at the time of their arrival, which were well received by residents.

In regard to the second objective, which refers to clarifying and defining a process to manage RRA (module 2), results showed that the integration of these tools was more challenging. In fact, as Table 1 shows, the tools and activities included in the process of managing RRA (decision chart, documentation form, and checklist on actions to take) were only in part tested in the four PSRs and interviews informed that no sustained follow-ups were made from PSRs managers with their staff members. Furthermore, although staff members and managers reported understanding the relevance of having guidelines to manage RRA, it was not documented by all of them. According to a PSR manager, the tool was integrated late in the test phase and there are few RRA situations requiring it. The citation below also indicates that the form was forgotten by them, and therefore not used in an optimal manner:

I haven’t really had an event [of RRA]. But speaking to you, it reminds me of an event, a lady that came to me. […] I will use it. But it will be the first time I will use this form. (M3)

For the research team, this led to identifying that staff members and PSRs managers did not develop attitudes to document RRA (Table 3). Below, obstacles to the program’s testing are presented, as identified by the participants. Some factors, such as limited human resources in PSRs, heavy workload, and the COVID-19 pandemic, can help explain why staff members were unable to fully execute documentation, despite the recognition of RRA management being considered important.

Referring to the third objective, the program presents a good potential to make PSRs’ actors aware of RRA with training capsules for staff members and group activities for residents (modules 2 and 3). On the one hand, staff members (SMs) appreciated the short training capsules and understood their relevance:

I watched the five capsules and read the PDF on goodwill. It was very interesting. The capsule on cognitive problems was my favorite. If only I’d been able to watch these capsules when I started working with older adults, with some of them losing their autonomy! It was my first experience of working with older adults and I really didn’t know how to react at first when some were aggressive. I didn’t realize that their anger wasn’t directed at me directly but that in some cases, it had been provoked by an argument with another resident. (SM8)

On the other hand, residents learned about RRA and goodwill during the conferences and activities (module 3). A resident (R) explained how the activities of the program allowed them to better understand how to manage RRA:

The activities were a great revelation. […] Sometimes we see situations, especially in the cafeteria and during activities. We don’t know how to fix things. [The program] gave us a guideline. (R10)

At last, the fourth objective is also considered to have been achieved. For example, PSRs created or reinforced a body representing residents to increase their voice in their living environment. Participants also reported promoting a culture of goodwill in the residence and understanding its importance, in accordance with the program’s objective, as explained by this resident:

It’s a village here. […] I decided to edit and publish a book [in the PSR] during the pandemic so that people would be less bored. I thought, “people have a lot of time on their hands in their apartment. They have time to reflect on their life.” […] So I published a book based on their life stories. And I had a lot of support from management. We sold 110 books in two days! (R7)

Nevertheless, results show that continuous education is needed regarding the various issues related to RRA for all actors.

Obstacles and facilitators

The pilot program encountered organizational and social challenges. One concern stems from the limited human resources in PSRs, which led to a high staff turnover rate. Consequently, those who remained experienced a heavy workload, making it difficult for them to engage in new initiatives. Furthermore, the managers and staff responsible for testing the pilot program had limited time for it, requiring important support from the project coordinator, and some felt that their implication was unrecognized by their superiors. These difficulties were exacerbated by the COVID-19 pandemic as it resulted in constant closures of activities, making it hard to maintain continuity, as explained by one manager (M):

In the last two years, it has been a constant struggle with the pandemic and the constant closures of activities. We just reopened on March 4 […] I had two outbreaks one after the other. […] I think this is the ugly part; it’s hard to have a common thread. Every time, we must re-explain everything to everyone. (M1)

These obstacles underscore the need for a sustainable approach that considers the dynamic environment in which PSRs operate.

Another significant impediment was limited social in-person participation, as 10 per cent of residents typically attended the program’s group activities. Despite applying various methods, reaching a significant number of residents remained a challenge, especially those who perpetrate RRA. For instance, residents who participated in activities noted that the perpetrators were absent, rendering these activities less effective and highlighting the need to broaden strategies to reach this audience:

The people who take part in projects and activities are not the troublemakers. We need to find ways to reach them. (R22)

Residents who are present [at the activities] say: “The people who do this [RRA] aren’t here. They’re never here” (M3)

On the other hand, a lifestyle and program manager considered this level of social participation as excellent for any kind of group activity in PSRs. Being aware of limited participation to in-person group activities, the program was designed with a range of tools and activities to reach out to residents who may be less involved in such activities, for example, the awareness poster campaign and the individual activities. Another lifestyle and program manager (SM) explains how they publicized the individual activities, such as the crossword puzzles, resulting in reaching the individuals less keen on participating in group activities:

At some point, we were in lockdown because of COVID. […] I had the crossword puzzles that I could print. So I made copies and hung them to every door. (SM13)

Volunteer recruitment was also an issue. Few residents volunteered or had time to do so. Some were present for specific activities, but those resident volunteers who served as ‘program ambassadors’, for instance, the residents sitting on the project committees, contributed significantly. In this case, a more thorough recruitment strategy to identify and mobilize various individuals is needed.

A facilitator of the program was the inclusion of goodwill promotion in its objective, making it more attractive to residents. If the focus were solely on RRA, it would have been harder to garner residents’ interest, according to an interaction between some of them:

When we talk about mistreatment, residents don’t want to get involved. (R4) No. They don’t want to get involved. They get scared. (R6) They get suspicious. (R8)

Additionally, the adaptability of the program, particularly in allowing for customization to fit a specific PSR, was a crucial facilitator. The relevance of the tools and activities also enhanced program acceptance. For example, several activities can be organized on a recurring basis and can be adapted to the residents. Others were appreciated because they were special activities or conferences presented by well-known public figures or experts. These observations demonstrate the importance of co-creating program design that considers the unique characteristics of the target population.

The pilot’s success was also dependent on managers, staff, and those who tested it, acting as key facilitators of the program. Without their support, the program would not have been tested. The importance of their contribution implies the need to harness these actors’ efforts better and provide training support for program deployment. Finally, the research team’s support was also critical to implementers’ success:

You did a great job. […] You gave us everything on a silver platter. It was really fun to be part of it and contribute to it with you. (M1)

In summary, the obstacles that impeded the pilot program’s testing and success required multifaceted solutions that considered the challenges and opportunities in PSRs. As a result, a training offer was developed in partnerships with the Quebec Federation of Recreation in Institutions to support those involved in deploying the program.

Recommendations

The recommendations put forward by the participants to enhance the program align with the objectives and target the content, promotion, and sustainability of the program. Participants requested more communication activities to be carried out in the PSR to increase awareness of the program and reach a greater number of residents. The activities proposed include holding information kiosks and distributing information pamphlets to each resident. Moreover, participants suggested using various communication channels to reach different groups of residents and staff members. Despite including most of these activities during the pilot, the recommendations highlight the need for repeated communication efforts to inform all residents and staff members, particularly during staff rapid turnover, as a resident explains (R):

I don’t think the project as such had been properly presented to the residents by the [first] manager to attract them. Because I’m sure the director who left knew that. But there seemed to be no desire to repeat that [by the new manager]. So in my opinion, not everyone in the residence was aware of the project. (R14)

This resident refers to a specific context that happened during the trial period of the program, specifically the change in manager of a PSR during the already challenging COVID-19 pandemic. Despite the complexity of the circumstances, the resident’s remark underlines the importance of ongoing efforts to ensure a smooth transition of the program during staff turnover. In this regard, it was suggested that staff training be implemented to facilitate the comprehension of the program’s fundamentals, among other aspects. Furthermore, to sustain the program in PSRs, participants recommended appointing a person or committee to oversee the program in each PSR and to integrate the program’s objectives within the organizational goals. Participants then suggested broadening the target audience to include families and non independent older adults.

Recommendations for tools and activities aimed to improve the program by adding scenarios to the training capsules, reformulating statements in board games, and changing the activities’ titles to better represent their content. An staff member displayed how they adapted the program to their PSR and used activities like the game “Tell us about you!” to enhance the residents’ well-being during COVID-19:

[During COVID, I was questioning myself:] “How am I going to do this? It’s a board game. So, I made copies of the game. Everyone had their pawn, their dice, and their [copy of the] game board in front of them. They found it amusing. And then I gave them the game. Some told me that they played with their family. (SM13)

The recommendations proposed by participants contributed to the improvement of the Program GIFT in residence as the research team considered them when aligning with the program’s objectives. They highlight, among other things, that a better dissemination of information must be perpetuated to reach a greater number of residents and staff members, and that the program’s content must be adaptable for the PSR use based on its needs.

Discussion

The present study evaluated the test phase of the pilot Program GIFT in residence designed to promote goodwill and counter RRA in PSRs through individual and group interviews with residents, staff members, and managers. More specifically, the study aimed to assess the program’s achievements in meeting its objectives, the facilitators and obstacles encountered during the test phase, and strategies for improvement.

The program’s dual objective and multidimensional modules made it easier to integrate the tools and activities with the dimension of goodwill, which was well received and indirectly addressed RRA, validating the explicit and primary needs found previously (Falardeau et al., 2022). The dimensions associated with RRA management for staff members and interventions found in this evaluation are also in line with the implicit and secondary needs that emerged from Falardeau et al. (2022). In fact, the program’s content was created using diverse tools and activities to reach many individuals living, working, or managing in PSRs. Being aware that, in concordance with other in-person activities in PSRs, an average of 10 per cent of residents would attend each group activities, and other tools were used to reach more residents, such as the poster campaign available throughout the PSRs or the list of help resources provided to each resident. For the research team and the committees involved, it was evident throughout the project that reaching all residents and SMs was utopia. In PSRs, there is a frequent turnover of staff members, managers, and residents. This is why it was also planned that members of each of these three groups collaborated all through the process to develop and test the pilot program to ensure an ongoing involvement. During the next phases of implementation and sustainability, this will always be a challenge, even if the program is incorporated into the organizational structure of the corporation of PSRs.

The findings from this study consolidate the importance of setting up a structure for sustainability and support to the implementation of the program. Results show, for example, that staff members and managers reported understanding the relevance of having guidelines to manage RRA, but that actions were not fully taken in that sense. There may be reasons for this discrepancy, such as the limited human resources in PSRs, the heavy workload or the COVID-19 pandemic, and the time it takes to introduce and support changes in practice. Nonetheless, training can enhance the integration of concepts and interventions (Teresi et al., 2013). In a planned change framework (Bartholomew Eldredge et al., 2016; Cummings & Worley, 2014), the process of progressing to the change is equally, if not more, important than the outcome itself. Based on the results, it can be hypothesized that the importance of the process, more than the results, was not fully understood or emphasized. For the intended adopters and implementers, training would provide a deeper understanding of the program’s foundations and process. As a result, a training offer has been created to optimize the understanding of the program and its implementation in PSRs.

In line with the participatory action research approach (Aner, 2016; Blair & Minkler, 2009), the research team used the feedback received through interviews to improve the program. The evaluation served as a basis for making revisions, such as improving the content of the poster campaign and adding scenarios in the training capsules. In continuity with Blair and Minkler’s (2009), the study found that involving older adults in the program’s development generated empowerment among them, and most residents sitting on committees took on the role of ambassadors in their PSRs. In fact, other programs dealing with RRA or the promotion of goodwill exist, but to our knowledge, these were not developed in partnership with a committee of residents and employees of PSRs (Madsen et al., 2020; Theurer et al., 2014). This program captures the benefits of collaborating with actors in the field; it is imperative that they must be given the opportunity to contribute to the development of programs that are geared towards them to create personal involvement (Blair & Minkler, 2009).

The Program GIFT in residence designed for PSRs is innovative as it combines a dual objective of promoting goodwill and countering RRA, in contrast to existing programs that either address RRA or a similar form of abuse (Ellis et al., 2014; Madsen et al., 2020), or the promotion of goodwill (Strom & Strom, 2017; Theurer et al., 2014). The intervention mapping (Bartholomew Eldredge et al., 2016) has proven relevant to the development of the program with its structured framework, yet adaptable, allowing for program development planning grounded in the reality of the intended actors. Furthermore, programs are often developed without being tested and evaluated prior to implementation. The intervention mapping contributed to defining a clear and iterative process to enhance the program before large-scale implementation. Indeed, by allowing for a qualitative evaluation, this approach has facilitated the identification of necessary improvements to the program based on the feedback from both intended recipients and intended adopters and implementers, prior to its final version. Finally, intervention mapping emphasizes the importance of a large-scale implementation and its evaluation to measure its reach and effects. These steps were not completed in this project but are underway.

This program proposes the utilization of prevention and intervention strategies, out of the four practices prioritized in Quebec: prevention, tracking, intervention, and coordination (Government of Quebec, 2016). The prevention strategy includes the employment of tools and activities to promote positive relationships between residents, while the intervention strategy aims to enhance the management of RRA. Some other measures may serve as prevention or intervention approaches, such as acquiring the necessary skills and knowledge to handle such situations. Although the research team initially considered using tracking as a third practice, the needs study (Falardeau et al., 2022) and present evaluation do not support its use. Even though some tools and activities may facilitate the recognition of RRA, such as the training capsules, there is no existing initiative to enable the identification of residents susceptible to being targeted by RRA. Further research is needed to investigate the reasons behind this gap and the potential adaptation of existing tools from other living facilities to Quebec PSRs (Kim et al., 2019).

The program is novel on an international level due to its dual objective designed for independent and semi-independent older adults dwelling in PSRs. Other practices in use globally either focus on promoting goodwill or countering RRA (Caspi, 2015; Strom & Strom, 2017; Theurer et al., 2014; Winningham & Pike, 2007) and are applicable mainly to long-term care centres (Ellis et al., 2014, Teresi et al., 2013). In light of the expected surge in the percentage of older adults, expected to increase from 12 per cent in 2015 to 22 per cent in 2050 (WHO, 2023b), future research should explore the possibility (if and how) of testing and implementing the Program GIFT in residence in other regions and other types of congregate residential facilities.

Strengths and limitations

The Program GIFT in residence is the first, to our knowledge, to advocate for a dual objective of promoting goodwill and countering RRA through a participatory action research. The program integrates multidimensional modules and provides diverse tools and activities for all actors involved in PSRs. This innovative project facilitates active participation of PSR residents, staff members, and managers. Furthermore, the program is specifically designed for PSRs, where RRA is understudied (Falardeau et al., 2022).

The pilot program underwent a qualitative evaluation, which aimed to enhance its tools and activities among other things. While it helped understand the participants’ experience, it is impossible to quantitatively measure the program’s impact on all actors living or working in PSRs. This area requires further investigation, for example during a larger-scale implementation of the program, which is currently underway.

This project took place amid the COVID-19 pandemic, which complicated the research process considerably. The research project was subject to government guidelines and regulations to limit the spread of the virus. This resulted in cancelled or postponed events and limited participation in conferences or activities. Despite these difficulties, the participatory action research approach motivated all stakeholders to persevere and complete the project.

Implications

The research findings have specific implications for policy and practice:

1. 1. As the proportion of older adults increases, more programs are necessary to tackle RRA and improve the quality of life of residents, and policy makers must strategize accordingly;

2. 2. Practices developed to counter mistreatment of older adults, and therefore RRA, should include the promotion of goodwill;

3. 3. Continuous training of managers and staff members must become part of a global strategy to improve the management of RRA;

4. 4. Rapid staff and resident turnover must be considered when developing a program for congregate living facilities; therefore, training has to be offered on an ongoing basis and the program offered on a recurrent basis (ideally, each year);

5. 5. Including older adults in program development designed for them is beneficial to give them a voice and anchor the program in their reality;

6. 6. Researchers must maintain an ongoing international dialogue on knowledge and best practices concerning RRA and goodwill.

Conclusion

The Program GIFT in residence was developed through a participatory action research approach with PSR corporation in Quebec. The program underwent a pilot evaluation of its test phase to enhance its content and create a framework promoting the program’s sustainability. The evaluation of the test phase was carried out according to the intervention mapping (Bartholomew Eldredge et al., 2016) in the context of a participatory action research approach and contributed to assessing the achievement of the program’s objectives.

The PSR corporation is in the process of integrating the program’s content into its existing structure while ensuring adequate assimilation of tools and activities among all its PSRs. The program is actually available in French and English. Training for managers of PSRs and lifestyle and program managers has been created and is now available. More information can be found via the following link: https://maltraitancedesaines.com/en/trainings/__trashed/.