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http://dem.sagepub.com/content/early/2011/09/14/1471301211421188The online version of this article can be found at:

 DOI: 10.1177/1471301211421188

published online 20 September 2011DementiaPatrick J. Doyle, Kate de Medeiros and Pamela A. Saunders

living settingNested social groups within the social environment of a dementia care assisted

  

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Article

Nested social groups withinthe social environmentof a dementia care assistedliving setting

Patrick J. DoyleUniversity of Maryland, USA

Kate de MedeirosMiami University, USA

Pamela A. SaundersGeorgetown University, USA

Abstract

The social environments of people with dementia are complex and still not fully understood.

Investigating how residents in a dementia care setting navigate and participate within social groups

is critical as the therapeutic benefits of social engagement are unequivocal. An ethnographic study

of social environments within a dementia care residence revealed that there is active socialization

and even strong and lasting friendships formed between people with dementia. Many of these

relationships were observed to be a part of groups, ‘nested’ within the larger social environment.

These ‘nested social groups’ had unique dynamics and their structuring was often influenced by

outside factors (e.g. physical environment and staff preferences). The existence of these groups

has implications for the experiences and quality of life of the residents in long-term care. Nested

social groups will be defined and their function within the social environment will be discussed.

Keywords

dementia, long-term care, nested social groups, social environment

Introduction

People who enter long-term care (LTC) settings experience a radical transition from theirpast to the new experiences that now constitute their lives. The ‘person’ is now a ‘resident’;their home is now a LTC setting (at least in the view of others); and their family and friends,some of which are new, now exist mainly within the context of this new environment.

Corresponding author:

Patrick J. Doyle, Department of Sociology/Anthropology, University of Maryland, Baltimore County, 1000 Hilltop Circle,

Baltimore, MD 21250, USA.

Email: pdoyle1@umbc.edu

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DOI: 10.1177/1471301211421188

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The residents of many assisted living (AL) settings and nursing homes (NHs) often have littleexposure to the outside world. All of the necessary elements of life are provided within theconfines of the LTC complex, thus making trips outside one’s ‘home’ no longer a requiredpart of the older adult’s life. In essence, entering a LTC setting is like entering a new world –with an amalgamation of the norms, rules, practices, and other social and cultural elementsbrought in by the different people living and working in the setting (Morgan et al., 2011).The new culture that forms within the LTC setting is often different from that which definedthe previous life of the resident. The transition to a LTC facility from one’s home isrecognized as a major life transition by older adults (Aminzadeh, Dalziel, Molnar &Garcia, 2009). Being uprooted from one’s home can be jarring. The adjustment to thenew setting can be difficult. In fact, moving to a LTC setting has been associated withnegative outcomes such as depression, isolation, and poorer psychological, social andhealth outcomes (Aneshensel, Pearlin, Levy-Storms & Schuler, 2000; Gaugler, Zarit& Pearlin, 1999).

It can be inferred that this transition into a LTC setting is most difficult for people withdementia. The person with dementia enters the new and unfamiliar environment, usually notby choice, that is filled with other people, few of whom the resident thinks he/she recognizes,acting in ways that are difficult to understand. All of the exit doors that can potentially allowthe person out of this unfamiliar place are locked or lead to another area that the persondoes not recognize. The person with dementia now lives in a place that he/she struggles tounderstand. These factors can further complicate adjustment to the setting. Understandably,residents often express feelings of confusion concerning the place and people who surroundthem. Over time, such feelings of being out-of-place may dissipate and many residents maybecome comfortable and resolved to being in the setting.

Our main focus in this paper is on how people with dementia integrate into the socialenvironment and the social structures that form as a result of this integration. The dynamicsof social life are extraordinarily complex and this is only compounded when examining theinteractions and relationships among people living in a dementia-specific LTC facility. Byapplying and building on previous theoretical and empirical research on socialization andsocial networks, we will describe the concept of ‘nested social groups’ and demonstrate thevarious ways in which the composition of the social environment is influenced by individualresidents’ characteristics and the physical and organizational environments that exist in theLTC residence. Understanding patterns of interactions and how they are influenced isimportant because of the strong benefits that social engagement can have on the qualityof life for people with dementia (de Rooij, Luijkx, Declercq & Schols, 2011; Miranda-Castillo et al., 2010; Steeman, Godderis, Grypdonck, De Bal & De Casterle, 2007).

Benefits of social engagement

The value of social relationships throughout the life course, regardless of a person’s abilitiesor limitations, is well established. Friendships have been linked to psychological andemotional well-being and better physical functioning for older adults (Avlund, Lund,Holstein & Due, 2004; Krause, 2010). Conversely, there are negative consequences (e.g.poor perceived health, depression) associated with losing friendships and having one’ssocial networks decrease (see Krause, 2006 for an overview of this body of literature).Two of the many life events that have been linked to significant changes insocial networks and friendships are (1) a transition into LTC from the community

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(Dupuis-Blanchard, Neufeld & Strang, 2009) and (2) a decline in cognitive functioning(Kiely, Simon, Jones & Morris, 2000).

There is a vast literature in multiple disciplines about friendships in old age (as reviewedby Adams, 1989) and more specifically within the broad context of LTC environments(Eckert, Zimmerman & Morgan, 2001; Powers, 1991; Retsinas & Garrity, 1985). Thisliterature has established that cognitive abilities are critical to the formation andmaintenance of friendships. Memory (both shared long-term memory and short-termmemory), recognition (of people and objects), greetings, and conversing are among therelevant abilities often affected by dementia. Although these factors can interfere with theability of the person with dementia to establish friendships, research on how friendships areestablished and maintained throughout the course of dementia has been described as lacking(Hubbard, Tester & Downs, 2003) and, unfortunately, this description is still correct.

Diaz Moore’s 1999 study remains one of the few published works which focused on thesocial environment of people with dementia in LTC. Diaz Moore identified a range of socialrelationships that were observed between residents with dementia (e.g. congenial friendships,cliques, and confidant relationship) and demonstrated that these social relationships areaffected by factors such as an organizational drive to maintain task efficiency, a conceptrelevant here and which will be further discussed in this paper. Diaz Moore (1999) and someof the other research focused on the social environments of people with dementia (e.g.Cohen-Mansfield & Marx, 1992; McAllister & Silverman, 1999; Phinney, Chaudhury &O’Connor, 2007; Teitelman, Raber & Watts, 2010) have begun to elucidate the greatcomplexity in these environments, but additional work is needed to understand fully theextant dynamics of social relations. What is clear from this previous research is that peoplewith dementia remain fully capable of participating in and forming social relationships,communities, and groups.

One of the relevant research questions that remains unanswered in this area is, ‘Canpersons with dementia overcome some of the dysfunction in cognitive and physical abilitythat could potentially impede social functioning within a LTC unit?’ The present studysought to examine the social and physical environment in one LTC setting, and to learn ifand how people with dementia form social groups within the setting. This paper will focus onhow the social environment was structured, the groups of residents that formed, and howsocialization occurred among the residents. Before discussing the social structure of thissetting, however, a few conceptual clarifications are necessary to understand better themeaning of nested social groups.

Social structure

It is important to distinguish between a social group and a social network so as not toconfuse them and the corresponding literature discussed in this paper. In its most basicsense, a social network refers to a ‘specific type of relation linking a defined set of people,organizations, or communities’ (Trotter, 1999). Social networks are composed of multiple,intertwined social relationships that have specific meanings, purposes, and configurationswithin and beyond the immediate network (White, Boorman & Breiger, 1976).

However, although sociological theory and research have continuously refined andexpanded the concept of social networks as distinct from ‘groups,’ many theorists havepointed to the closeness of the two concepts in regard to the analysis of their meaningand structure (Fine & Kleinman, 1983; Fuhse, 2009). The concept of ‘social group’ was

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used in early interactionist perspectives on society and was developed as a unit ofmeasurement to look at the culture of small social groups, membership therein, and theinteractions that occur within them (Blumer, 1969; Fine, 1979). The major distinctionbetween these two concepts, network and group, is the boundedness or degree to whichthe individuals within a particular cluster of people are isolated from others outside thecluster (Fuhse, 2006). The term ‘network’ describes a loose binding or interlinking amongindividuals as sets of people that can extend beyond the immediate social environment toconnect multiple clusters. For example, a person may belong to many social networks andtherefore connect many sets of people through network membership. Unlike networks, asocial ‘group’ is more tightly bound or restricted. Members of a group are understood tohave more direct and immediate connectedness within a primary context than networks.The concept of ‘groups’, bound within one context, is more descriptive of the social structureof the residential dementia care environment we observed because this type of setting limitsthe residents’ abilities to extend beyond their immediate surroundings, and, thus, restrictstheir interactions to the people living, working, and visiting in the residence. However, evenwithin this one environment residents are often bound within distinct clusters of people.

Method

Data for this paper were collected as a part of a larger ethnographic research projectexamining the social environment of one dementia-specific LTC setting, Cedar Hill. CedarHill provides assisted living and skilled nursing levels of care to a total of 126 residents.Assisted living describes a level of care in which residents are usually able to ambulate withlittle assistance and complete many tasks of daily living with minimal help from staff.Residents needing skilled nursing care generally are unable to ambulate without awheelchair or require other direct assistance (e.g. eating). Cedar Hill’s explicitorganizational commitment to providing person-centered dementia care to all residentswas reflected in its operating mission statement and marketing materials. Residents weresplit among three AL houses with 20 residents in each and two skilled nursing care housesfor 66 residents. Data collection focused on Magnolia House, one of the three AL houses.Over the course of 12 months (2009–2010), observational and interview data were collectedfrom both resident and staff participants in Magnolia House. This study was reviewed andapproved by the Johns Hopkins University School of Medicine’s Institutional ReviewBoard.

Participants

Thirty-one residents living in Magnolia House participated in this study. All of the residentswere staying long term in Cedar Hill and each had a legally authorized representative whogave consent for the person to be approached to participate in research. When the residentsgave assent, a battery of measures was administered to evaluate each resident’s cognitive andphysical functioning (see de Medeiros, Saunders & Doyle, 2011 in this issue, for a detaileddescription). Although these scores will not be used systematically in this paper to evaluatethe effect of functioning on social participation, some of these data will be used to makeinferences about the potential role that an individual resident’s characteristics can have ongroup formation and social interactions. Some of the residents (n¼ 12) were also interviewedregarding their perspective on friendship and the relationships that they had with other

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residents (if they said they had any). At the beginning of the study, staff participated informal interviews that focused on the social environment and their perspectives of theresidents’ relationships and how much each resident got along with other residents. Audiotaping was done as a part of the interviews with residents and staff members. In addition tothe interviews, informal, off-the-cuff, conversations with the participants were used as a partof the observations to clarify further the elements of the social environment or residents’relationships.

Observations of the social environment were completed during the morning, afternoon,and evening, and focused on the resident-to-resident interactions that occurred and howother factors within the environment influenced the social relationships. A research teammember also participated in the day-to-day activities in the setting by casually talking withand/or helping the residents or staff (e.g. telling a resident where they can find something,helping to pass meals in the dining room, etc.). Observations were documented in multipleways: (1) detailed ethnographic field notes; (2) digital audio recording of residentparticipants’ conversations with each other; (3) video recording of specific residents’ socialgroups; and (4) social mapping (recording the location of residents sitting in a specificlocation at different periods of time).

On average, 5 hours of field observations were completed by the research team each week.While in the field, the researchers wrote short notes that were later used to trigger memorywhen writing full field notes after leaving the house (Bailey, 1996). The majority of the datawere in the form of field notes, but there were also approximately 20 hours of video andaudio recordings of the residents in their social groups. The observations were concentratedin the common areas of the Magnolia House (dining room, parlor area, television enclaves,and hallways). Private domains, such as residents’ rooms, were entered only if the researcherwas invited by the resident.

Analytical approach

To assess how the residents’ social environment was nested within the physical environmentof Cedar Hill, the field notes and social maps (52 maps of resident rooms; 113 maps of thecommon areas) collected over 12 months were analyzed. These data were used to place theresidents spatially within the physical environment, to determine the locations in whichresidents were intermingling, and to identify residents who interacted with each other.

It is important to note that for the purposes of this paper, these data were not used toperform a systematic evaluation of the social interactions within this environment, but ratherto provide some insight as to the unique structure in which people with dementia socializeand interact within this small environment. The goals of this analysis were to: (1) examinecritically the structure of the social environment of a dementia care facility as observedthrough ethnographic fieldwork; and (2) use these observations to contribute to theextensive theoretical work in sociology, psychology, and gerontology in regard to socialnetworks and groups.

To analyze the patterns of the data, the data were first reviewed by research assistants toidentify the sections where interactions between residents occurred. These interactions werethen coded by the research team through the use of a detailed codebook containing criteriafor each code. First, the interactions were coded as positive, negative, or neutral and thenwere thematically analyzed through the use of inductive coding in which a selection oftranscripts were reviewed to establish a list of common themes (e.g. joking, information

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seeking, helping, mutual interest, social norm/custom, and environment). Analysis was doneusing a mix of individual and team coding where at least two research team members eachcoded a transcript, compared their codes, and reconciled any discrepancies (58% ofobservational data were team coded). As is typical with analysis of ethnographic data, theresearch team formally and informally reviewed and discussed the data as collected duringthe fieldwork. The ongoing analyses examined the observational and interview data forpatterns, which were then used to guide additional data collection to clarify elements ofthe environment (Miles & Huberman, 1994). Presented in this article is one of the centralpatterns of the social environment of Magnolia House: nested social groups.

Results

In this section, we will describe the specific meaning of nested social groups, the factors thatinfluence their formation (e.g. physical design barriers and organizational preferences), anduse specific residents to illustrate the complexities of the Magnolia House socialenvironment.

Nested social groups

The concept of nested social groups refers to the clusters of residents who were frequentlyobserved in close proximity to each other and interacting with one another. These groupswere ‘nested’ within the larger physical environment of Magnolia House. The concept ofnesting was borrowed from the social ecology model (Bronfenbrenner, 1977).Bronfenbrenner proposed that environments should be understood and examined asmultiple-level structures nested within each other. These levels are referred to as beingnested because although they are thought of as having distinct elements, each levelinfluences the other. For example, according to this theory, the microlevel of anenvironment includes interactions between individuals, but these interactions are directlyinfluenced by macrolevel patterns of the culture in the environment (e.g. institutional rules).Thus, relationships among people are nested within the local cultures of the setting and bothlevels interact and influence each other (Bronfenbrenner, 1979).

A similar structure of the residents’ social environment was observed, thus making thenesting concept applicable. Distinct social groups among residents were formed and theseindividuals had patterns of interactions that were specific to the others in the group. Groupsvaried in size as did the frequency, quality (e.g. positive or negative), and types ofinteractions among the residents within them. The social interactions of many residentswere limited to the other residents who were part of their immediate group. Outside eachgroup of residents was a larger social environment containing other residents, direct-careworkers, family members, scheduled activities, and sections of the building with additionalsocial groups. The environment’s physical design, the setting’s organizational factors, andthe characteristics of residents influenced the plasticity (or degree to which groupcomposition changed over time) of the nested social groups. These elements of the largersocial environment directly affected the experiences of the small groups of residents (as wewill describe below) even though the direct interactions between them were limited. As such,the small groups of residents that formed were nested within the larger social environment(see Figure 1 for a diagrammatical representation of the social group ‘nesting’). Interestingly,the degree to which a group and/or a resident engaged with the surrounding social

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environment varied both within and between these clusters of residents. This variation willbe described further when examining the factors that influence the formation of these nestedgroups.

Although most residents restricted the majority of their social engagement to the othermembers of their group, some residents were observed interacting with residents and staffmembers outside the primary cluster of people with whom they associated most often. Theseresidents will be called bridging residents. The bridging residents were able to overcome theorganizational, physical design, and individual characteristics that were identified as barriersto social relations with other residents from other groups. The barriers described in thispaper are factors that affect a resident’s social opportunity structure. The social opportunitystructure consists of those elements of the social and physical environment that impede orfacilitate residents’ socialization with others as individuals and with certain compositions ofthe nested social groups within Cedar Hill. In discussing the barriers observed in this setting,we will integrate how some of the bridging residents were able to overcome obstacles andalso show how LTC organizations, researchers, and direct-care workers can minimize theeffect of barriers in the social environment.

Factors influencing nested social group formation: physical and organizationalenvironments

Physical environment. Many of the factors influencing residents’ opportunities to interactwith other residents were related to the physical environment. It has long been establishedthat there is a dynamic interplay between a person and his or her environment and that thenature of this relationship is largely dependent on the ‘fit’ between the individual’scompetence (as variously defined) and the structure of their environment. Especiallyrelevant to the present study is the assertion that one’s physical environment becomesmore salient and often more restricting as the competency to navigate one’s surroundingsdeclines (Lawton & Nahemow, 1973; Lawton & Simon, 1968). Much of the recent work inthis area has focused on the interplay between the environment, the person, and the structure

Figure 1. Nestedness of the Cedar Hill social environment.

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of his or her social world (Calkins, 2001; Wahl & Lang, 2003). Accordingly, in this sectionwe focus on two elements of the physical environment of Cedar Hill to demonstrate theirdirect impact on the structure of the social environment and the interactions that do and donot occur between the residents, specifically: (1) the demarcation of houses by locked doors;and (2) the physical layout of Magnolia House.

Demarcation of houses by locked doors. Although all the residents and staff members ofCedar Hill were contained within one building owned and operated by a single company, thesetting was physically divided between the AL and skilled nursing levels of care, which wereseparated by locked doors. The three AL houses were located on the left side of the building;skilled nursing on the right and on a basement level. Administrative offices were locatedbetween AL and skilled nursing care sections. The only time that residents from theAL section interacted with skilled nursing residents was during optional weekly religiousservices or other rare, formal activities.

Within the AL section, a walking loop connected the three AL houses, a suite of staffoffices, and a public gathering room that included a fireplace, chairs, and couches. Althoughdoors between the three houses were often locked, preventing residents from walking morethan a few hundred feet on the walking loop, the doors were occasionally opened, dependingon the staff on duty. When access to the walking loop was available, the fireplace room couldbe considered a sort of social ecotone: a tension and transition area between two or moreadjacent social environments. Many residents, staff, and family members who walkedaround the loop passed through the fireplace room and occasionally would interact witheach other. Such an ecotone between distinct social environments (e.g. two differentAL houses) could be a possible way to create a bridge between nested social groups andexpand the social connectedness in the dementia care setting.

The doors, which when locked impeded the residents’ movement between houses andspaces, held a great deal of power over the possibility of socialization. We note that gettingto the other houses while the doors were locked was possible for a few residents. Theseresidents’ abilities (such as, walking unassisted and conversing with others) helped themovercome the barrier of the locked doors to interact with other AL social groups(bridging groups). One bridging resident, Madeline, would seek out a staff member whenthe doors were locked and ask that they be opened, which they often were. There were manyreasons why Madeline was able and permitted to bridge her environment whereas otherscould not. The first was her ability to walk freely without assistance, remember her wayaround the building, and verbally communicate her wishes to others. In addition, Madelinehad a well-known interest in the facility’s cat, which lived in a staff member’s office, andwould express her desire to visit the cat, which most staff members would facilitate. Whenasked why they would almost exclusively grant Madeline access to the other houses when thedoors were locked, staff said they knew that Madeline would always come back shortly andthat they would not have to spend time looking for her if they needed her. Based on this andother cases, it eventually became clear that the staff’s motivations regarding the doors had agreat deal to do with organizational factors such as the need to maintain task efficiency, suchas passing out medicines, and reduce burdensome work, such as looking for residents.

The physical layout of Magnolia House. Magnolia House was ‘U’-shaped, with10 residents’ rooms comprising each side of the ‘U’ and the kitchen, common dining area,and main door at the bottom of the ‘U’. The large, enclosed kitchen, located at the center of

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the dining room, constituted approximately one-quarter of the entire dining area, and,because of its size, split the dining room into two distinct halves. There was a large parlorroom to the left of the dining room with multiple armchairs, recliners, and couches. Thisparlor area was often the site of smaller staff-initiated organized group activities in theafternoon and early evening within Magnolia House. This concentration of formalactivities brought increased flow of Magnolia House residents to this common area in thetime between meals. Although it was highly variable based on the time of day, most residentsdid not stay in their rooms, but rather spent most of their time in the dining room and theparlor room and it was in these areas where we observed the nested social groups. Aligningwith previous research in dementia care settings (e.g. Diaz Moore, 1999), the majority ofsocial interactions happened during mealtimes and although sitting at the same dining roomtable did not automatically lead to conversations, it increased their likelihood. The frequencyof interactions in this environment may have been due to the close proximity of residents, theinherent social nature of eating with others, the availability of conversational topics, or anumber of other factors.

We did observe what seemed to be an imaginary division between the left and the rightside of the house. For example, the majority of the residents who lived on the right hallwaysat on the right side of the dining room whereas those who lived in the left hallway sat on theleft side of the dining room. This division seemed to be largely a consequence oforganizational practices, which will be discussed later, but there was also a perceptionamong some of the residents that the dining room was concretely divided by the kitchen.When we asked residents about this separation in seating and social interactions, somedescribed the other side of the dining room as if it were a world away. When asked ifshe talked to any of the residents who sit on the other side of the dining room, oneresident, Patricia, said ‘Yeah because I knew them before that [the kitchen] was put up’.Patricia went on to indicate, however, that she no longer went to the other side of the diningroom since the kitchen was remodeled, creating a more distinct division between the twosides. Patricia saw her social environment as the area limited to her side of the dining roomand pointed to the large kitchen in the middle of the room as a barrier to getting to the otherside.

The differences in peoples’ ambulatory ability influenced the impact of such physicalstructures as the kitchen. Those residents who could not easily walk, like Patricia, whoneeded assistance with her walker, were often restricted to the side of the dining roomclosest to their room. Although residents could, in theory, choose their own seats, staffmembers were observed guiding them to seats that they (the staff) had selected. Patriciawas essentially limited to a nested social group of two. She was helped each day to a two-person table. Bessie, her tablemate, had great difficulty with hearing, making communicationbetween the two unsuccessful and leading to misunderstandings and negative interactionsbetween the two women (e.g. arguing and yelling). The reasons that this seating arrangementwas continued were observed to be strongly linked to organizational factors (e.g. focus ontask efficiency). These will be discussed in greater detail in the next section.

Unlike Patricia’s situation, there were many residents who walked without difficulty andoften made their own choice regarding where they sat. Interestingly, residents who sat on theside of the dining room that was opposite to where their room was located, or who buckedthe left/right trend of dining room seating, were the residents who were more physically andsocially active, again pointing to additional influences that individual factors (such asphysical and cognitive) have on the composition of nested social groups.

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Organizational environment. The organizational environment, specifically choices made bystaff, had a great deal of influence on some nested social groups. To continue with theprevious example of tablemates, Patricia and Bessie, staff members we interviewed saidthat the two were not a good match and that Patricia, who enjoyed talking with otherresidents, was not able to be socially engaged while sitting next to Bessie. When askedwhy the two continued to be seated at the same table, some said it was the easiest placeto put the two and that, because of Patricia’s tolerance of Bessie’s loud coughing, Patriciawas the least likely to cause problems for the staff with this arrangement. Despite thenegative personal aspects of this nested social group, staff found the seating locations tobe easy to manage. The table was near the hallway to the residents’ rooms and it took onlyminimal effort to guide the two women to their seats. In this and other cases, ease of taskcompletion rather than optimal resident engagement guided staff decisions regardingresidents’ seating and therefore influenced the composition and quality of some nestedsocial groups such as Patricia and Bessie’s. At times, when there was an empty seat at anearby table, Patricia would attempt to sit elsewhere, but her seat near Bessie was consideredby staff to be Patricia’s seat. The case of Patricia and Bessie hints at the underlyingorganizational factors that also influence the residents’ groups.

Two nursing assistants were assigned to Magnolia House for each shift and they wereresponsible for the care of the residents on one side of the house. One of the nursingassistants in the building stated that seating residents together on one side of the diningroom allows one to ‘keep an eye on your residents’. Also, with residents close to their rooms,it makes it easier for staff members to take the residents back to their rooms quickly if theyneed to use the toilet after lunch. This did not apply to residents who could walk well orresidents who were continent because in these cases the staff member was not affected by theresidents’ location in the dining room. This reinforces the crucial role that a resident’s abilityto act independently of the staff members has on the composition and size of the residents’social world.

Another example of the primacy of task efficacy shaping group composition was betweenAbigail and Doris who had a nested social group based on their perceived abilities to helpand to receive assistance. Abigail, who sat at Doris’ table, helped Doris eat and takemedications. This behavior was not perceived as ‘helping’ by the nursing aides working inthe dining room, but was instead perceived as hindering the aides’ ability to feed and givemedications to Doris. One of the nursing assistants said that Abigail’s ‘mothering’ needed tostop and the next day the two residents were separated at lunch. Abigail remained in hernormal dining room seat but Doris was moved to a different section of the dining room. It isof note that Doris, who was unable to move without assistance, was the person who staffdecided to move. Although moving Doris decreased the number of interactions betweenthese two residents, it did not sever the relationship. After the move, Abigail continued tohelp Doris by walking to her new table and again trying to convince her to eat her food. Theinteractions decreased over time as Abigail’s ability to walk well decreased. This act of staffoverriding residents’ preference to sit next to each other is an example of what Kitwoodcalled imposition – ‘forcing a person to do something, overriding desire or denying thepossibility of choice’ (Kitwood, 1997). This type of interaction between staff andresidents, as well as 16 others, has been identified as ‘malignant’ to a person withdementia as it can negatively affect the person’s self-esteem, well-being, and quality of life(Kitwood, 1997; Sabat, 1994; Sabat, 2001). There were many additional examples of staffpreferences dictating seating arrangements, interactions, and, in turn, the composition of the

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nested social groups. As such, the powerful role of staff decisions on a resident’s immediatesocial environment is certainly something that needs to be considered. This relates back tothe concept of nesting as it demonstrated the interlinking between groups and thesurrounding environment. The staff were not members of these social groups but theirdecisions and actions regarding the completion of tasks influenced the socialization andthe agency of these residents.

Completion of tasks was not the only organizational factor that influenced groupcomposition. The biases of nursing assistants regarding who should sit together also cameinto play. One specific example was the ‘men’s table’. The staff members in Magnolia Housefrequently talked about how all the men should sit together because they often interactedand were all friends. This perspective, however, did not align with the actualities of theinteractions in this nested social group. Interactions between the residents at the men’stable were infrequent and these men actually held more meaningful and regularconversations with people outside their dining group. The men did not often socializewith each other. In spite of this fact, however, and because they were men, staff membersbelieved that the best social environment for these residents would result from their sittingtogether during meals. Even though the male residents did not frequently talk to each other,this perception of the strong friendships between the men continued and this groupcomposition was never reassessed by the staff members in Magnolia House.

Continuity of nested social groups

Our final observation regarding nested social groups is the continuity of these groups indifferent environmental contexts. As was demonstrated in the previous sections of this paper,nested social groups were often formed within the dining room and influencing theirordering principles were a number of organizational and physical design factors.Although formed and maintained by the interactions occurring in the dining room ofMagnolia House, these nested social groups extended beyond the dining room. Residentswho sat and interacted with each other during meals would often congregate outside of thedining room during both formal and informal activities. Even when residents were broughtoutside of Magnolia House to the garden room for an activity, the people within the nestedsocial groups most often sat next to each other. This was a consequence of both the personalchoice of the residents and staff influence.

Those people who could walk to the activities independently would often seek out theother residents whom they recognized in the group of people and sit next to them duringthe activity. Also, many times the residents of a given nested social group would walk to theactivity together because they were already near each other when they were asked by theactivities person if they would like to attend the event. In essence, there was a ripple effect ofdining room seating, except in the case of those at the men’s table. Because activities wereoften held after meals, the residents sitting together were frequently brought to the activitytogether and sat together. By remaining proximate, the residents of a nested social groupwere encouraged to continue moving through the environment together. As for theindividuals who could not get to the activity independently, it was at the discretion ofthe staff member to seat them where he or she thought best. Observations demonstratedthat this was often near the people with whom they sat in the dining room.

Notably, this trend of continuity between the dining room and social groups that formedduring activities was not as strong for the male residents who sat at the men’s table.

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For example, Bob sat at the men’s table every day and was often observed greeting the othermen when they arrived for meals. However, when he attended the activities, he often sat nextto Madeline (the bridging resident who was a part of the women’s group). Bob and Madelineformed a strong and lasting nested social group that existed only outside the MagnoliaHouse dining room. There were also two other men (John and Ed) who frequently wentback to their rooms after meals in lieu of attending the activity. It was unclear why thisdining room nested social group broke down in other parts of the building. It is possible thatthe pressure from staff on certain male residents to sit together during meals did not extendoutside these times leading to the residents to choose to interact with people outside themen’s table group. Clearly, it was a choice on the part of the men not to be with one anotherwhen they had the opportunity to make the choice – something that they did not have in thedining room where they seem to have been ordered, or at the very least strongly encouraged,to sit together.

Discussion

The existence of nested social groups is integral to the social life of people with dementialiving in LTC homes and social interactions are important factors affecting their quality oflife. This paper addressed some of the factors that influenced the formation and compositionof these groups, including those in the physical environment and those involving the actionsof staff members.

In regard to the physical environment, the placement of locked doors restricted themovement of residents within the larger social environment and for some residents thekitchen in the middle of the dining room was even seen as a barrier to mobility betweennested social groups. To many residents the physical environment restricted theiropportunity to interact with other people in the social environment. The spectrum of theenvironmental influences on social engagement supports the environmental docilityhypothesis, which states that people with lower competence (e.g. people with significantcognitive impairment and/or limited mobility) are more prone to the effects ofenvironmental press (Lawton & Simon, 1968). In other words, people with lower abilityto navigate their environment will exhibit less agency than they would if they had increasedability or facilitative help by staff. In essence, residents within this setting with lowercompetence had less choice and responsibility when it came to determining their groupmembership. This lack of choice not only affects the quality of residents’ socialinteractions (as in the situation with Patricia and Bessie), but could also lower theresident’s perceived well-being and participation in the environment (Langer & Rodin,1976; Martin & Younger, 2000).

In Magnolia House, there were both intended and accidental barriers created in thephysical environment. The kitchen redesign was done by the organization to improve theaesthetics of the house (even though this was largely unsuccessful) and had only accidentalconsequences on some of the residents’ ability to interact with each other. On the other hand,the locked doors were intentionally used by certain staff members to restrict the residents’movement to the inside of the house. The negative effects that intentional barriers have onthe residents’ social experiences should be assessed by LTC organizations and caregiverswhen making decisions regarding the social environment. The residents’ wishes to movesafely throughout the environment should be considered as being of equal importance tothe sometimes conflicting needs of the staff members to achieve task efficiency. This focus on

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task efficiency and the staff members’ incorrect beliefs regarding residents’ relationships werealso barriers to some of the residents in this setting. Regardless, decisions about activitiesand setting lay-out made by staff were made without awareness or recognition that residentsdevelop social relationships with other residents on their own and that these relationshipsuse and preserve their remaining cognitive and social capacities. Lack of such awareness istherefore tragic and unproductive.

The findings presented in this paper also illustrate the central role that staff members haveon the formation of nested social groups and the residents’ ability or inability to interact withother people in the environment. Staff members can directly force some residents to sit withother residents (e.g. moving Doris to a new table) and they can indirectly restrict certaininteractions by implementing some barriers between people (e.g. locking the doors). Nestedsocial groups that are compelled and do not have positive social dynamics can result inongoing negative or non-stimulating social interactions between residents (e.g. men’s table).Negative social interactions, such as these types of pairings, have been shown also to havenegative consequences for the residents’ well-being and the types of behaviors they manifest(Kitwood, 1997). However, purposeful seating based on perceived compatibility could bebeneficial for the residents and may be an easy path to facilitating friendships betweenresidents. Encouragement to meet other people and join other dining room tables couldopen the door to the development of friendships between people who otherwise would nothave crossed paths. Although purposeful seating could be beneficial in principle, it wouldhave to be borne out by the staff members’ observation of a positive interactions between theresidents and not based on the convenience of other people in the environment.

Bridging residents, like Madeline, who was a part of the women’s group, were able tobreak down the physical and organizational barriers and essentially fell outside the model ofnested social groups interacting with residents throughout the entire AL section of CedarHill. However, Patricia was restricted by the barriers and, in turn, was isolated from many ofthe other residents, even those in different sections of Magnolia House. The majority ofresidents had very limited social networks and were limited almost exclusively to their nestedsocial groups, thus making the group dynamics all that more important to them. It is in thesecases where attending to the quality of interactions and changing the nested social groups ifnecessary can improve the social engagement of residents and could produce a better socialexperience for a person with dementia living in a LTC setting.

Limitations of the present study

The concept of nested social groups and the barriers that influence their formation wereidentified within one dementia care facility and, as such, no attempt at generalization is beingmade in this study. Regardless of the lack of generalization, this study identified a specificsocial structure (nested social groups) and described the social context in which these peoplewith dementia lived. Future research will determine the degree to which the present findingsapply to other LTC homes.

Another limitation of this research was that it was not able to assess and incorporate themeaning that the residents attributed to the relationships and interactions that they had withthe people in their nested social group. Social network research has moved beyond focusingprimarily on the structure of the relationships in networks to describe the cultural andinterpersonal complexities (such as shared meanings) of these relationships and groups(Fuhse, 2009; Yeung, 2005). Examining the meanings that residents, staff, and family

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assign to nested social groups is a topic that should be addressed in future research.However, this type of research in a dementia care facility may present many difficulties.

The decision not to examine fully the meaning structure (shared meanings andexpectations between people) of these social groups was made for multiple reasons. First,the type of data available for analysis would not have been sufficient to assess fully thiselement of social groups because the resident-to-resident conversational data (availablethrough audio or video recording) was limited in number of hours and the documentedfield notes were not used to collect these data systematically. Also, even if the qualitativedata were collected to examine the meaning structure of the nested social groups, therewould have been, for a number of reasons, a great deal of difficulty in determining themeanings of the relationships between people with dementia.

One reason is that many residents experience some difficulty verbally communicating withothers and as such it could be difficult for the researcher to determine the nature of somerelationships or interactions. Also, even if communicative ability remains intact for thepeople in the observed groups, the meanings they assign to their relationships may differfrom others in the group (lack of shared meaning and reciprocity) or they may changedrastically over time. These meanings may shift with a resident’s perception of who theothers in the group are and the environment around him or her. A person’s perception ofthe surroundings can change daily or even in a matter of an hour. The ephemeral nature ofperceptions of an environment, including the social environment, presents a challenge toexamining the creation and reproduction of meaning in a relationship between two peoplewith dementia in a LTC home. More audio, video, and written data focusing onthe meanings assigned to nested social groups would help to examine more deeplythe complexities of these groups. Future research should build on this study and use thenested social group as a unit of measurement to examine the meaning structures in thesegroups and also how altering their composition could influence the residents’ socialengagement and quality of life.

Acknowledgments

The authors would like to thank the editors of this special issue and Dr Robert Rubinstein for their

thoughtful input regarding this paper, Amanda Mosby and Laura Girling for their efforts helping to

collect and analyze the data, and the people within the focal long-term care setting who shared their

time and experiences throughout the project.

Funding

The research presented was supported in part by a grant from the Alzheimer’s Association (grant

number NIRG-08-91764).

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Patrick J. Doyle, MA, is a doctoral candidate in Gerontology at the University of Maryland,Baltimore County. His research has focused on how caregiving practices, physicalenvironments, and social interactions influence the lived experience of people withdementia residing in long-term care settings. In his dissertation research, he is examininghow a person-centered model of care is interpreted and applied by various stakeholderswithin a dementia-specific long-term care setting.

Kate de Medeiros, PhD, is Assistant Professor of Gerontology in the Department ofSociology and Gerontology, Miami University, Oxford, Ohio. Her research focusesbroadly on the construction of selfhood in old age and includes work on friendships andself-expression/performance through autobiographical writing for a variety of olderpopulations. She has published work on the complementary self in old age, narrativeexplorations of selfhood, neuropsychiatric symptoms in dementia, and the meaning ofsuffering.

Pamela A. Saunders, PhD, is an Associate Professor in Departments of Neurology andPsychiatry at Georgetown University School of Medicine. Her research focuses on thepreserved, communicative abilities of persons with dementia. In addition, she teachesmedical students how to communicate in clinical settings. She is the author of multiplearticles on language, communication, and dementia as well as medical education.

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