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Examining the quality of interactions between nurses and cognitively impaired residents in long-term care facilities

Power dynamic between staff and clients can play a crucial role

By Christine Meng
January 8, 2024
Social interaction and engagement are critical for the overall well-being of people living with dementia. Health-care professionals should prioritize opportunities for engagement to mitigate the negative effects of measures that limit socializing.

Takeaway messages

  • Most relations between nurses and people in long term care are hierarchical, with nurses having positional power. This affects the quality of the interactions they have.
  • Cultural issues, socio-political factors, and workplace policies and realities can have significant impacts on how nurses interact with others.
  • Nurses should reflect on the power dynamics inherent in interactions they have with clients and be mindful of the impact that these dynamics can have on the quality of care provided.

The incidence of dementia in Canada is anticipated to nearly double between 2020 and 2038 (Horne, 2021). People living with dementia are almost inevitably placed in long-term care (LTC) facilities as the disease progresses and the required care cannot be successfully fulfilled at home. According to Willemse et al. (2015), nursing staff members’ ability to interact with LTC residents with dementia to meet their psychological needs generates long-term positive effects on their quality of life. Indeed, the COVID-19 pandemic underscored the importance of providing meaningful engagement to people in LTC.

Social interaction and engagement are critical for the overall well-being of people living with dementia. Health-care professionals should prioritize opportunities for engagement to mitigate the negative effects of measures that limit socializing. This area warrants ongoing research and intervention to enhance the quality of life of this vulnerable population.

In this analysis, I offer some insights, which were discovered through a literature search I conducted, on the power relations and cultural issues between LTC nurses and residents with dementia. These findings shed light on the nature of the interactions between these two groups. I also propose two recommendations for future research examining interactions with these residents and ways of improving nursing practices.

Discussion of power relations and cultural issues

Based on my review of articles,1 most of the power relations between LTC facility nurses and people living with dementia are hierarchical; staff in nursing homes have positional power, which affects the quality of the interactions they have with residents. However, the articles I reviewed also revealed that some staff members and residents did occasionally form equal partnerships.

Due to the residents’ dependency on LTC staff, they were hesitant to criticize the care they received (Forsgren, Skott, Hartelius, & Saldert, 2016). For example, one staff member from a study stated, “[I]magine if you [as a resident] get some staff you’re not comfortable with, what do you do then? As an old person, what do you do? They [residents] are completely at our mercy. They are completely in our hands and have no control over how we treat them” (Forsgren et al., 2016, p.115). Although residents with dementia were found to be able to exercise power, they were not consistently able to do so in collaboration with nurses. Instead, nurses’ level of authority was frequently exploited to dominate these residents, such as when nurses managed client care without client involvement; therefore, decision-making was not always shared between nurses and clients (Lung & Liu, 2016; Oudshoorn, Ward‐Griffin, & McWilliam, 2007).

However, it is essential to note that nurses operate within complex and often challenging work environments, and their actions may reflect systemic constraints rather than individual intentions.

One of the most significant issues that I discovered during the article review was the role of culture during interactions between LTC staff and residents living with dementia. Rather than contributing to clients’ powerlessness, culture provided an opportunity for nurses to combat unfair conditions. To make this opportunity a reality, the articles suggested that nurses must acknowledge their power in client interactions and reflect on how they employ it by examining their style of client interaction (Chuang & Abbey, 2009; Oudshoorn et al., 2007).

For example, in one study, nurses opted to not force their expectations on their clients, thus liberating them from an unequal power dynamic. One study nurse participant stated, “There is no ‘shoulds’…. [W]e always have a tendency to say, ‘Well,…I should do this, we should do this,’ and the minute I hear anyone saying ‘should’ I say, ‘Oh, let’s forget that word” (Oudshoorn et al., 2007, p. 1440). It is important to note, however, that professional autonomy exercised by nurses can be subordinated to system power. Therefore, cultural issues, such as the emphasis on the quality of interactions with residents with dementia, must be adjusted and improved at an organizational level. Where necessary, socio-political factors should be included in the consideration to improve residents’ quality of life.

These findings aligned with the discovery in the reviewed articles that staff members do not always involve clients in care activities. Therefore, minimal or neutral interactions were sometimes reported.

One of the reviewed articles revealed a specific cultural influence on power relationships: Chinese culture viewed staff members as professional, and it was deemed inappropriate to challenge or question staff members during interactions in the LTC facility. In addition, most of the reviewed articles mentioned the importance of LTC staff members’ knowledge of the power they have when interacting with residents; few of these articles, however, assessed this knowledge.

Conclusions and recommendations

This short analysis aims to offer a starting point to examine the quality of interactions between nurses and residents with dementia living in LTC settings. There were several limitations in the articles I reviewed. For example, geographical areas and participants in some studies were limited to U.S. nursing homes or Whites and females (Paudel, Resnick, & Galik, 2020; Sherwin & Winsby, 2011). Therefore, the conclusions could be inadequate and biased. When discussing the findings from an epistemological standpoint, I noticed that most of the articles were dominated by biomedical results that emphasized quantitative data, such as observations and questionnaires from staff members, rather than qualitative data from residents themselves (Jao et al., 2018; Paudel et al., 2020). This means the findings from these articles may not represent a comprehensive understanding of the phenomenon.

Another limitation of writing this analysis is the inclusion of a mixture of study participants. While the analysis aims to explore the relationships between nurses and people living with dementia, it also includes other health-care professionals, such as personal care workers and residential care aides. Therefore, the findings may not fully represent the nursing profession. Future studies could focus on narrowing down the participant pool to a single health-care role to improve the specificity of the analysis.

This analysis sheds light on the issue that most of the power relations between nurses and LTC residents with dementia in terms of the quality of interactions are hierarchical as staff members in a nursing home have positional power. The analysis also exposed one of the most significant cultural issues discovered in the reviewed articles: the emphasis on care-related interactions between nurses and these residents.

Therefore, I propose two recommendations for consideration by nursing researchers and practising health-care professionals.

For nursing researchers

Conduct studies that examine the quality of interactions between health-care professionals and people living with dementia in LTC facilities at various levels while considering socio-cultural factors such as autonomy awareness from the perspectives of these residents. This will broaden the assessment of interactions beyond a purely biomedical framework and facilitate a more comprehensive understanding of the factors that impact these interactions.

For practising health-care professionals

Reflect on the power dynamics inherent in interactions with people living with dementia and to be mindful of the impact that these dynamics can have on the quality of care provided. By taking a more balanced and harmonious approach to care, health-care professionals can better understand the needs of their clients and offer solutions that are more attuned to their unique circumstances.


Custers, A. F. J., Westerhof, G. J., Kuin, Y., Gerritsen, D. L., & Riksen-Walraven, J. M. (2013). Need fulfillment in the nursing home: Resident and observer perspectives in relation to resident well-being. European Journal of Ageing10(3), 201–209. doi:10.1007/s10433-013-0263-y

Chuang, Y.-H., & Abbey, J. (2009). The culture of a Taiwanese nursing home. Journal of Clinical Nursing18(11), 1640–1648. doi:10.1111/j.1365-2702.2008.02698.x

Forsgren, E., Skott, C., Hartelius, L., & Saldert, C. (2016). Communicative barriers and resources in nursing homes from the enrolled nurses’ perspective: A qualitative interview study. International Journal of Nursing Studies54, 112–121. doi:10.1016/j.ijnurstu.2015.05.006

Horne, F. (2021, June 3). Increases in dementia will drive long-term care reform. Policy Options. Retrieved from term-care-reform/.

Jao, Y.-L., Loken, E., MacAndrew, M., Van Haitsma, K., & Kolanowski, A. (2018). Association between social interaction and affect in nursing home residents with dementia. Aging & Mental Health22(6), 778–783. doi:10.1080/13607863.2017.1304526

Lung, C.-C., & Liu, J. Y. W. (2016). How the perspectives of nursing assistants and frail elderly residents on their daily interaction in nursing homes affect their interaction: A qualitative study. BMC Geriatrics16, 13. doi:10.1186/s12877-016-0186-5

Oudshoorn, A., Ward‐Griffin, C., & McWilliam, C. (2007). Client–nurse relationships in home‐based palliative care: A critical analysis of power relations. Journal of Clinical Nursing16(8), 1435–1443. doi:10.1111/j.1365-2702.2006.01720.x

Paudel, A., Resnick, B., & Galik, E. (2020). The quality of interactions between staff and residents with cognitive impairment in nursing homes. American Journal of Alzheimer’s Disease & Other Dementias35, 1533317519863259. doi:10.1177/1533317519863259

Sherwin, S., & Winsby, M. (2011). A relational perspective on autonomy for older adults residing in nursing homes. Health Expectations14(2), 182–190. doi:10.1111/j.1369-7625.2010.00638.x

Willemse, B. M., Downs, M., Arnold, L., Smit, D., de Lange, J., & Pot, A. M. (2015). Staff–resident interactions in long-term care for people with dementia: The role of meeting psychological needs in achieving residents’ well-being. Aging & Mental Health, 19(5), 444–452. doi:10.1080/13607863.2014.944088

1 An online database search of the literature was conducted and further narrowed to eight research articles published between 2007 and 2020. Literature searches were conducted using ScienceDirect, Ovid, CINAHL, and Google Scholar to achieve these aims. The search process mainly used the following keywords: “interactions,” “nursing home,” “long-term care,” and “staff members.”

Christine Meng, RN, MN, is a PhD student at the University of British Columbia. Her research focuses on engaging older adults living with dementia in long-term care facilities. She also works as a casual RN in a nursing home.