Perceptions of Care in Residential Facilities According to Functional Dependency: A Phenomenological Approach Centred on Older Adults’ Dignity

Abstract

Population ageing and the increase in life expectancy have heightened the demand for long-term care in residential facilities. In Spain, it is projected that by 2054 the functional dependency rate among those aged 65 and over will exceed 53.0%, posing significant challenges for person-centred care. This study aims to examine institutionalised older adults’ perceptions of care in relation to their functional dependency, and how these perceptions shape their dignity and participation in residential life. A qualitative study with a phenomenological approach was conducted in a residential facility located in the north-east of Andalusia, Spain, involving eight residents with varying degrees of autonomy and dependency. Data were collected through individual semi-structured interviews and analysed using Colaizzi’s phenomenological method. The findings revealed that, as dependency increases, care is perceived as more impersonal, generating feelings of diminished dignity and greater exclusion. In addition, limitations were observed in communication and participation in residential life. Respect for privacy and personal preferences was particularly relevant for women. The study concludes that the care received is conditioned by the degree of dependency and the resources available. It is recommended to enhance staff training, increase staffing levels, and promote the active participation of residents.

1. Introduction

Population ageing and the increase in life expectancy have led to a significant rise in the demand for long-term care, particularly in residential settings [1]. In this context, the quality of care and the treatment that older adults receive in care homes has become a matter of growing concern and interest for the research community, healthcare professionals, and policymakers. The ageing of the population in Spain is a clear and significant trend. According to projections from the National Statistics Institute, the proportion of the population aged 65 and over, which currently stands at 20.4% of the total, is expected to reach a peak of 30.5% around the year 2055 [2].

According to the World Health Organization (WHO), an older person or older adult is defined as someone aged 60 years or over. However, for this definition, it should not be limited solely to chronological age, but should also take into account other factors such as physical, functional, mental, and health conditions [3]. Considering these multiple variables that influence the ageing process makes it possible to identify the specific needs of each group, as well as their level of dependency. In Spain, it is projected that the dependency rate of the population aged over 65 will reach 53.41% by the year 2054 [4].

Functional dependency in care is defined as the reduction in individuals’ ability to meet their self-care needs and the requirement for support from others. According to the Spanish Act on the Promotion of Personal Autonomy and Care for People in a Situation of Dependency, this condition is characterised by the need for the assistance of another person or persons, or substantial aids, in order to carry out basic activities of daily living (hereinafter BADLs) [5]. This support may be provided either by professionals or by informal carers, mainly family members, who play a crucial role in the provision of care for dependency [6]. This situation is particularly relevant in the case of older adults, who often experience a gradual loss of autonomy as a result of chronic illnesses and the physical and psychological changes associated with ageing [7].

In the context of residential care, autonomy refers to the opportunities available to older adults to make their own decisions about their daily lives [8]. This is a crucial aspect of their wellbeing and quality of life, as residents particularly value the possibility of maintaining their previous lifestyle after admission and retaining control over their own autonomy. This involves having genuine options in daily routines, respect for their independence and privacy, participation in decision-making, receiving visits without time restrictions, having a private space, and being able to decide on their everyday activities [9]. The preservation of this perceived autonomy not only enhances residents’ satisfaction, but also contributes to maintaining their dignity and sense of identity within the institutional environment [10]. Many institutionalised older adults highlight positive aspects such as the care and protection they receive, but also point out significant limitations related to the daily routine and the lack of meaningful activities, which affect their perception of care and their sense of autonomy [11].

The present study focuses on a crucial yet often overlooked aspect in research on the care of older adults: the subjective perception of residents regarding the treatment they receive in residential settings. This research seeks to explore how residents interpret and experience the care provided to them, taking into account their individual circumstances and specific care needs. While numerous studies have addressed objective mistreatment in residential environments [12,13], there is a significant gap in understanding how residents themselves interpret, justify, or normalise certain behaviours that could be considered negative or even abusive from an external perspective.

Elder abuse is defined as a single or repeated act, or the failure to take appropriate action, occurring within any relationship where there is an expectation of trust and which causes harm or distress to an older person [14]. This type of violence constitutes a violation of human rights and includes physical, sexual, psychological, and emotional abuse; financial and material exploitation; abandonment; neglect; and a severe loss of dignity and respect [15]. The prevalence of mistreatment in long-term care settings is alarming. Studies have revealed that up to 33.4% of residents in institutions have reported psychological abuse, 14.1% physical abuse, and 11.6% neglect [16]. These data underline the urgency of addressing this problem in a comprehensive manner.

It is important to highlight that the normalisation of mistreatment or neglect in long-term care settings is a worrying phenomenon. Previous research has identified a “culture of neglect” that can lead to the acceptance of poor care practices as normal [17]. This process of normalisation can have serious consequences for residents’ physical and mental health, as well as for their overall quality of life [18].

At the international level, many studies have reviewed the literature on mistreatment in long-term residential care and report significant rates of psychological and physical abuse, as well as neglect [19]. They also highlight figures showing that 20.1% of residents experience some form of mistreatment, with verbal abuse being more common than physical abuse, at 9.1% and 5.2%, respectively [20]. In the case of Spain, although there is less specialised evidence on the mistreatment of older adults in residential settings, the available literature similarly indicates concerning rates [21]. These findings underline the urgency of further investigating how residents perceive and justify the treatment they receive, which could provide new insights for improving care and dignity in residential environments.

By exploring how older adults perceive and justify the treatment they receive according to their level of dependency, this study aims to contribute to a deeper and more nuanced understanding of the experience of life in care homes. The relevance of this study lies in its potential to reveal patterns of thinking and justification that residents use to make sense of their experiences. Understanding these mechanisms can provide valuable information for improving sensitivity in care and in the management of treatment in residential settings. Furthermore, this approach may shed light on how residents’ perceptions influence their overall wellbeing and sense of dignity.

2. Materials and Methods

2.1. Purpose, Objective, and Research Questions

Following the phenomenological orientation of this research, the study was guided by a clear purpose: to explore how older adults living in a residential facility perceive the treatment and care they receive in relation to their degree of functional dependency, with particular attention to their dignity.

For this purpose, the present study established a single objective: to analyse residents’ subjective perceptions of care according to their functional dependency, in order to understand how these perceptions, shape their sense of dignity and participation in residential life.

To operationalise this objective, the following research questions were formulated:

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How do residents perceive the care they receive according to their level of functional dependency?

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In what ways do these perceptions influence their sense of dignity and participation in the residential setting?

2.2. Study Area

This research was carried out in a residential care facility for older adults located in the north-east of Andalusia, Spain. This facility was selected due to the accessibility and representativeness of the target population of the study, providing an ideal context in which to explore the life experiences of these individuals.

2.3. Study Design

This study followed an interpretative phenomenological design [22] to investigate the lived experiences of older residents. Interpretative phenomenological analysis is a methodological approach that seeks to understand how individuals experience and make sense of their experiences [23]. This method focuses on the interpretation of narratives provided by participants, including any non-verbal aspects, which allows for a deep understanding of their experiences and interpretations regarding a lived phenomenon or event [24].

2.4. Recruitment and Sample

An intentional sampling strategy, also known as purposive or judgement sampling, was employed in this study in order to ensure diversity in terms of gender and levels of dependency.

The inclusion criteria for participation were as follows:

(I) Availability: older participants who were willing and available to take part in the interview were sought; (II) Diversity in levels of functional dependency: participants with different levels of functional dependency were selected, ranging from those with greater independence in daily activities to those requiring assistance in various areas, such as mobility, personal care, or daily tasks. This allowed for broad representation of experiences across different degrees of autonomy, without focusing on specific ranges of the Barthel Index and Lawton and Brody scales already applied by the care home staff, to which access was provided; (III) Age: only individuals aged 60 years or older were included, following the definition of “older person” established by the WHO, which considers this threshold as a reference criterion for identifying the ageing population in global contexts; and (IV) Gender: four women and four men were intentionally selected to ensure balanced representation.

Residents who were unable to participate in interviews due to significant health problems or severe cognitive impairment preventing comprehension or participation in the study were excluded.

2.5. Data Collection and Procedure

With the support of the management of the facility, a call for participation was made to residents who were duly informed. Data were collected during April 2025 through semi-structured interviews. The interviews were conducted individually, in a private setting where the older participants could feel comfortable speaking, either in their own room or in the psychology office, and lasted between 30 and 40 min.

An interview guide was developed in accordance with the main aim of this study, following phenomenological principles [25], which allowed for the detailed collection of participants’ testimonies. The preparation of the semi-structured interview was based on a prior review of the scientific literature on the perception of treatment in care homes according to the degree of functional dependency. This review made it possible to identify key dimensions and relevant factors that influence how residents interpret the care they receive, serving as the basis for the formulation of the questions. From this process, an interview guide consisting of eight main questions was designed to explore different dimensions and perceptions related to the phenomenon under study. Apart from the sociodemographic questions, which were closed-ended, these eight main questions were open-ended, allowing participants to freely express their experiences, interpretations, and points of view.

To ensure the validity of the interview guide, a structured internal table was created with four sections for each question (see Supplementary Table S1). The first section contained the literal wording of the question, drafted in clear and accessible language to facilitate understanding by the participants. The second section defined the specific objective of the question within the overall framework of the study. Thirdly, a brief definition of the key concept that the question sought to explore was included. Finally, the section on theoretical justification provided the scientific basis for including each question, supported by references to international evidence. This systematic procedure ensured coherence between the guide and the research objectives, and strengthened the methodological rigour of the study.

All interviews were audio-recorded after reading the “participant information” section at the beginning of each session. At that time, participants were given the option to accept or decline both the recording and their participation in the interview. The recordings were subsequently transcribed verbatim in order to preserve the integrity of the narratives and their analysis. These were supplemented with field notes taken during the interviews, aimed at capturing elements of non-verbal language and other meaningful expressions. Participants were also informed about the anonymity and confidentiality of their responses, in line with ethical recommendations for qualitative research.

2.6. Data Analysis

The interview transcripts were subjected to a comparative analysis across the different profiles of participants, paying particular attention to issues related to the self-perceived treatment according to the level of functional dependency. The information was organised into thematic findings. The procedure was guided by the steps of Colaizzi’s phenomenological method [26]: (1) familiarisation with the data through the researcher’s preparation and reading of the interview transcripts; (2) identification of significant statements by extracting relevant quotations or recurrent phenomena considered worthy of further exploration; (3) formulation of meanings, in which the phenomena under investigation were linked to their associated meanings; (4) clustering into themes; (5) exhaustive description, through a rich and comprehensive elaboration of the phenomenon based on the themes considered to be central; (6) formulation of the fundamental structure; and (7) verification with the participants. In this final step, the aim was to confirm whether the description faithfully reflected their experience by reading to them the results obtained and explaining how their ideas had been incorporated into the text.

The coding of the data was carried out manually using an open approach, allowing themes to emerge directly from the testimonies, in line with Colaizzi’s phenomenological methodology. This approach enabled a more faithful capture of the participants’ lived experiences.

This study was designed in accordance with the guidelines set out in the Standards for Reporting Qualitative Research (SRQR) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [27], in order to ensure compliance with the four fundamental principles of qualitative research proposed [16]: (1) credibility, (2) transferability, (3) dependability, and (4) confirmability.

To ensure (1) credibility of the results, the researcher adopted a reflexive stance throughout the process, being aware of how her professional experience as an occupational therapist in care homes could influence the interpretation of the data. The participants’ responses were analysed with constant consideration of their individual context and level of functional dependency, avoiding assumptions and reviewing potential personal biases.

(2) Transferability was addressed by providing a detailed description of the participants’ characteristics (age, gender, level of functional dependency according to the Barthel Index and Lawton and Brody scales, length of stay in the care home, frequency of visits, level of activity, etc.). In addition, verbatim excerpts from the interviews were included to illustrate the findings.

(3) Dependability was reflected in the clear and orderly description of the steps followed during data analysis. The process included a first reading of the responses to identify key ideas, a second reading to group common themes, and the verbatim transcription of the interviews to familiarise with the terminology used by participants. The entire procedure was recorded in a straightforward manner to ensure that, if another person followed the same steps, they could reach similar conclusions.

Finally, (4) confirmability of the results and manual coding of the data was carried out in two phases, separated by two weeks. This allowed for comparison of the results obtained in both analyses and for the identification of possible inconsistencies or subjective interpretations. In this way, the aim was to ensure that the conclusions were grounded in the experiences and testimonies of the older participants, rather than in the expectations or beliefs of the researcher.

2.7. Ethical Considerations

This research was approved by the Human Research Ethics Committee (CEIH) of the University of Jaén, protocol code: 20250125/FEB.LIN2. Prior to data collection, each participant received a detailed information sheet explaining the objectives of the study, its voluntary nature, the possible risks and benefits of participation, and their right to refuse or withdraw at any time without negative consequences. All participants signed a written informed consent form.

To protect the privacy of the interviewees and ensure the confidentiality of the information and their responses, transcripts were anonymised using alphanumeric codes, and no identifying data were linked to the recordings or the transcripts. The interviews were conducted in private and safe settings, and particular care was taken to minimise any emotional discomfort, especially when addressing sensitive issues. When necessary, verbal support was offered, and participants were reminded at all times of their right to take breaks or interrupt the interview without the need for any justification.

3. Results

3.1. Sociodemographic Characteristics

The participant group of this study ultimately consisted of eight institutionalised older adults, whose demographic and clinical characteristics provided a better understanding of both their functional profile and their care needs. The age variable reflected an advanced mean age, typical of the geriatric population, which implies a higher likelihood of requiring assistance in conditions associated with dependency. The gender balance contributed to the representativeness of the results. Functional assessment using the Barthel Index and the Lawton and Brody scale made it possible to identify different degrees of autonomy in BADLs and IADLs. Although mild and moderate levels of functional dependency predominated, diversity was observed in the capacity for autonomy, which affects both the need for support through technical aids such as walkers, wheelchairs and walking sticks, and the possibility of social participation in the activities, workshops, celebrations and events offered by the facility. Participation in these activities showed a moderate average level, but with heterogeneous results, as three participants were in the 0–25% range, three in the 26–50% range, and two in the 75–100% range.

Cognitive assessment, interpreted through the results of the Pfeiffer questionnaire and accessed through the residents’ records, indicated that most participants maintained normal cognitive functioning, although the presence of a case of mild impairment highlighted the importance of continuous monitoring of this dimension in the residential context. Social support, measured by the frequency of visits or contacts, was a key indicator of integration and wellbeing.

Overall, the analysis of these variables offers a comprehensive view of the biopsychosocial profile of the participants in this study (see

Table 1. Characteristics of the Participants (P).

Variable	Category	N (%) or Mean (M)
Age (years)	Range between 61 and 70 years	1 (12.5%)
	Range between 71 and 80 years	1 (12.5%)
	Range between 81 and 90 years	4 (50.0%)
	Range between 91 and 100 years	2 (25.0%)
	Mean (years)	84
Gender	Female	4 (50.0%)
	Male	4 (50.0%)
Barthel Index	Mild dependency	5 (62.5%)
	Severe dependency	3 (37.5%)
Lawton and Brody Index	Independent	1 (12.5%)
	Moderate dependency	7 (87.5%)
Pfeiffer	M	9.3
	Normal cognitive function	7 (87.5%)
	Mild dementia	1 (12.5%)
Assistive devices	Walking stick	1 (12.5%)
	Walker	3 (37.5%)
	Manual wheelchair	3 (37.5%)
	Powered wheelchair	1 (12.5%)
Social support	Weekly	4 (50.0%)
	Monthly	2 (25.0%)
	Fortnightly	1 (12.5%)
	Yearly	1 (12.5%)

Note. In what follows, the abbreviation P refers to each participant, followed by their identification number (e.g., P1, P2). Gender is abbreviated as M = Male.

), which is essential for interpreting the study findings and for guiding future strategies for personalised care and the promotion of autonomy within the residential environment.

3.2. Results of the Thematic Analysis

In order to conduct the analysis of the results obtained from the interviews and to address the aim of the study, the analysis revealed the following themes, which are summarised in

Table 2. Coding Framework.

Themes	Categories	Relevant Codes
Treatment received: between care and haste	Differences according to the degree of functional dependency	- Hurried care
		- Lack of tact
	Hurried and impersonal care	- Inhumane treatment
	Lack of time and insufficient staffing ratios	- Resignation
		- More satisfactory treatment for residents with greater autonomy
Autonomy, dependency and dignity: emotional and social impact	Feelings of vulnerability associated with visible dependency	- Tremors, choking, abrupt movements - Misunderstanding by staff
	Perceptions of insufficient recognition of care needs	- Not being believed
		- Care perceived as rushed or dismissive
	Emotional impact on dignity and safety	- Frustration - Discomfort - Feeling undervalued
	Positive perceptions linked to greater dependency	- Gratitude for help - Appreciation for attentive responses
The role of gender and privacy in the care experience	Gender preferences in intimate care	- Preference for female caregivers (linked to modesty/embarrassment)
		- Indifference towards caregiver’s gender (quality of interaction prioritised) - Positive experiences with male caregivers (gentleness, empathy)
	Differences in perception according to gender and modesty	- Modesty and embarrassment as decisive factors - Comfort linked to respectful treatment over gender
	Adaptation to individual preferences	- Diversity of positions (no uniform pattern) - Person-centred care (PCC) as guiding principle - Ethical reflection on equality and fairness in staff assignment
Communication, listening and participation: feeling that their voice is heard	Perception of being listened to	- Lack of active listening - Lower perception of being listened among people with a higher degree of dependency
	Communication	- Lack of time
		- Minimization of demands - Need for spaces for dialogue
	Participation in everyday decisions	- Limited influence on organisation - Partial and conditional participation opportunities

Note. Each theme includes both negative and positive perceptions, reflecting the diversity of experiences among residents according to their degree of autonomy, gender, and personality.

.

3.2.1. Theme 1: Treatment Received: Between Care and Haste

This theme focuses on how resident participants perceive the daily treatment they receive from the staff working in the care home, particularly in relation to their level of autonomy or dependency. Most participants reported that the treatment received varies significantly according to the amount of assistance they require for performing basic activities of daily living (BADLs) such as showering, personal hygiene, dressing, transferring, among others. Hence, the discourses reflect relevant differences in the experience of treatment according to the level of dependency, with greater levels of dissatisfaction evident among residents with higher care needs. For instance, those who, due to their situation, require constant and ongoing assistance with these basic activities described the care as more hurried and, at times, impersonal. Accordingly, most participants with reduced mobility (P 2, P 3 and P 8) described interactions marked by haste and even a lack of tact:

“Terrible. Because they do not welcome us. They do not treat us as human beings. We feel as if we were made of papier-mâché.”

(P 2-F)

(P 2) explained that they have bruises caused when being put into bed or taken out with the hoist, due to the lack of time available to settle so many people, without the patience and time that they deserve. Other participants also perceived haste as a constant element. Therefore, there are clear signs of a normalisation of neglect in the daily treatment and care of residents.

“I see them nervous. So fast, whoever they are. They make mistakes; I can see it.”

(P 7-M)

In contrast, this perception was not shared by residents with greater autonomy and less need for care and assistance from the staff. Some felt that the staff were indeed approachable and attentive, with a neutral or positive assessment of the treatment received, albeit with exceptions

“Very good. Maybe now and then… but no, no bad treatment.”

(P 1-F)

“I think I receive normal treatment. I mean, and sometimes… but no, we have never been treated badly.”

(P 6-M)

However, even among those who positively assessed the treatment, complaints about lack of time and speed. In this regard, it is worth noting that both residents who perceive good treatment from the staff and those who report neglect refer to terms such as ‘stress,’ ‘overload,’ ‘nervousness,’ ‘rush,’ and ‘lack of time,’ among others, when speaking about the caregivers’ work, expressing resignation in the face of this situation. Those who have been at the facility longer highlight a considerable worsening of these issues due to staffing ratios.

“But no, they fail. They fail a lot. They come down far too fast. You don’t even have time to turn over. (…) But at least let them dedicate a minimum to me.”

(P 7-M)

“The problem many times is the time; they have to get 10 people up as if they were targets and not people who may take more or less time to get up, and they rush around.”

(P 6-M)

In most cases, negligent care is associated with -and even justified by- a lack of personnel. Throughout the interviews, both explicitly and implicitly, repeated references are made to unsustainable ratios between staff and residents, where lack of time and the impossibility of working any faster lead to curt responses, “inhumane” treatment, or a lack of empathy on the part of staff, with a particularly strong impact on residents with a high level of dependency.

3.2.2. Theme 2: Autonomy, Functional Dependency and Dignity: Emotional and Social Impact

This theme examines how residents’ perceptions of professional care, in the context of their functional dependency, shaped their sense of dignity and everyday autonomy within the residential environment. Participants frequently associated respectful and unhurried care, together with the opportunity to make small daily decisions (for example, the timing of personal care, preferred positioning, or requests for assistance), with feeling valued and retaining a certain degree of autonomy.

In addition to these positive experiences, several residents described feelings of vulnerability in their treatment related to visible manifestations of dependency (such as tremors, choking, or abrupt movements), which they perceived as being misunderstood by staff:

“Maybe they get annoyed that I have spasms, they think I do it on purpose, so they try to avoid me, or they ignore me, or sit far away or whatever. In fact, there are times when I feel that I should leave the home …”

(P 5-M)

This perception emerged with particular intensity among residents with reduced mobility, who recounted care experiences that generated discomfort:

“Giving me a squeeze, using the hoist, with the hoist and with their fingers, because of the rush.”

(P 2-F)

In this regard, it was noted that the intensity of care could become a burden for the staff, which was reflected in the quality of attention. Residents also recounted occasions when their need for assistance was not fully recognised, particularly when appearances (for example, walking during physiotherapy) could be interpreted as a sign of greater independence. Such situations were perceived as not being believed or taken seriously, and as undermining their dignity and safety:

“Many, many, many times they had to help me, and they haven’t, because they tell me to stop being silly. The problem is that they see me moving; they see me walking with the walker in the afternoon with the physiotherapist because she forces me to, to keep a bit of strength in my legs. But it’s because she is there, supporting me every 2 metres. Alone I can’t; I fall, and now what? I can’t, but they don’t believe me.”

(P 7-M)

“When I have needed to go to something, they have said to me, here we go again. Are you at it once more?”.

(P 2-F)

It can therefore be inferred that staff exhibit attitudes characteristic of the stigmatisation of dependency, as perceived and subjectively reported by the participants. Accordingly, some participants also pointed out differences in the way fellow residents with lower levels of autonomy were treated, calling for a more humane and respectful approach. In this way, the residents reveal an association established by the professionals between dependency and a perceived “deservingness” of poorer quality treatment, expressing a contrary stance toward that association.

“That they treat her with affection and with the respect she deserves. She is heavy and repeats things many times, but she should be treated as a person, just like me.”

(P 3-F)

By contrast, other testimonies—sometimes even from the same participants—linked higher levels of dependency with more attentive responses, which were interpreted positively:

“If you need more help and they do everything for you, of course the treatment is different, and I am completely fine with that.”

(P 3-F)

Taken together, these accounts illustrate that functional dependency shaped residents’ lived experiences of dignity in multiple ways: at times generating perceptions of insufficient recognition, and at other times fostering appreciation for the support and attentiveness received. The impact was not only social, affecting their sense of inclusion in the home and their ability to make everyday decisions, but also profoundly emotional. As one participant expressed:

“It bothers me when they rush me, because they see me as fine and think I am doing it just to get at them.”.

(P 6-M)

This testimony underscores how misinterpretations of dependency may generate frustration and vulnerability, while also shaping residents’ sense of dignity and their place within the social environment of the home.

3.2.3. Theme 3: The Role of Gender and Privacy in the Care Experience

This theme explores how the gender of both residents and caregivers influenced perceptions of care and the experience of privacy in intimate situations, such as personal hygiene. The accounts collected reveal a diversity of positions rather than a uniform preference. Some women reported feeling more comfortable when assisted by female staff, citing modesty or embarrassment as their main reasons:

“I told them, the one who came twice, that he shouldn’t come again because I had never undressed in front of a man and this colleague of yours came, and no, no, no, such embarrassment, I blush just remembering it (…) And I told the social worker both times and they changed me to another carer.”

(P 3-F)

Others, however, expressed indifference to the caregiver’s gender, emphasising that the quality of the interaction was more relevant than the sex of the person providing assistance:

“Well… I have also been showered sometimes by men. And the same. And they have attended to me just like the women. I mean, the embarrassment is natural. But they do it with care.”

(P 4-F)

There were also testimonies that inverted the assumed preference, highlighting positive experiences with male caregivers:

“This dark-skinned lad, very good, very kind, he takes my hand until I get to the shower, he takes my hand when I come out of the shower, he dries me, normal, like another girl.”

(P 1-F)

“I think it’s the same, but there is something that boys do better, and that is that they have more heart than girls. Girls have bathed me and hurt me more than my mother, and boys have bathed me and been much more gentle in everything: washing me, dressing me, applying cream, in everything, and I used to think that, because boys are rougher…”

(P 2-F)

For their part, male participants unanimously expressed indifference, stating that both male and female staff carried out their tasks competently:

“No, the treatment is the same, whether it’s a man or a woman.”

(P 7-M)

These narratives show that gender preferences in intimate care are heterogeneous, context-dependent, and shaped by personal histories rather than by a generalised pattern among residents. While for some women gender was a decisive factor in comfort and privacy, others prioritised respectful treatment regardless of who provided it.

This heterogeneity underscores the importance of a PCC approach, where the preferences of residents are acknowledged and accommodated as far as possible. However, the findings also invite critical reflection: adapting staff assignments exclusively on the basis of gender could risk reinforcing discriminatory practices against caregivers. Therefore, rather than a prescriptive rule, gender preferences should be considered within a broader ethical framework that balances residents’ comfort with principles of equality and fairness in the workplace.

3.2.4. Theme 4: Communication, Listening and Participation: Feeling That Their Voice Is Heard

Finally, this fourth theme focuses on how residents perceive communication with the staff and their capacity to express needs, be listened to, and participate in everyday decisions within the care home. The interviews revealed that feeling listened to and being able to communicate concerns or preferences is fundamental to wellbeing and the perception of respect in daily life. Participants reported very heterogeneous experiences in this regard.

Some residents explained that, when they expressed their needs, staff responded appropriately, even if they had to insist repeatedly:

“If I ask for it, yes, they come and attend to me […] I tell them to put cream on me, they put cream on me, but you have to tell them every day, or when I run out of pads, I have to ask for them, even though they know I have none left because they tidy my room, but only when you ask is when they pay attention.”

(P 1-F)

Others highlighted more attentive responses, emphasising the importance of kindness in everyday interactions:

“Yes, because, well, when I need help, I call someone and they always come and help me, always, and in a nice way.”

(P 8-M)

However, some accounts reflected a lack of active listening and response on the part of the staff, especially in situations of greater dependency or when the resident requires more time to explain what is happening to them:

“They keep telling me to wait all the time and I say to them: oh, you know, you have me waiting all the time. And they answer: you don’t realise, you have no idea what we have to do.”

(P 2-F)

This sense of not being heard was confirmed by her roommate, who described the emotional toll of witnessing these interactions:

“Look, with (P 2-F), it’s horrible. She’s my roommate, and it’s horrible how they treat her, because I hear it and the poor thing often cries, and then I go and give her a hug and spend some time with her, but they treat her terribly, they shout at her, and they don’t give her… I don’t know, something that she asks for a lot, and she has to depend on everything.”

(P 3-F)

She herself, with a lower level of dependency than her roommate and fewer difficulties, normalises the lack of time and speed as part of life in the care home, something that does not affect her personally since she is not in the same situation as (P 2-F), saying:

“At the beginning they spent more time with me and did what I needed, now everything is quick.”

Other participants also noted the difficulty of being attended to and the tendency to minimise their demands:

“Because they don’t have the time, and for me, who needs help but tries very hard, they think I don’t need their help and say ‘here, carry on, I’ll be back later, finish it yourself… I’ll be back’, and with all the rushing…”

(P 7-M)

“Sometimes they rush a lot. Sometimes they have said they are leaving in the morning, when I am going to the shower, and they spend five minutes with me and then leave so that I do the rest myself, and honestly, I would manage better with a bit more help.”

(P 3-F)

Participation in the life of the care home was a recurring concern for residents, shaping their sense of agency and belonging within the home. While some valued opportunities to choose activities or express preferences, others emphasised that these chances were limited, fragmented, and often lacked a real impact on the organisation of daily life.

One resident explicitly proposed the need for collective spaces to make their voices heard:

“Maybe one thing that could be done to improve this would be to have more meetings between everyone to foster respect, where we make people aware that this is important, isn’t it? To respect.”

(P 5-M)

Others described how their suggestions were disregarded or responded to only partially, undermining their sense of recognition:

“Things you ask for, things they don’t give you. However, you say it. Look, please, could you bring me this? Could you bring me a tablet for my headache? They won’t give it to you.”

(P 2-F)

Beyond specific requests, residents associated participation with two different but connected ideas: on one hand, the ability to preserve small aspects of everyday autonomy. For instance, the lack of responsiveness to minor preferences was felt as neglect of their personhood; on the other hand, participation was also linked to the experience of being taken seriously. Some residents pointed out that even when they attempted to express their views, their words were downplayed:

“When you say something, sometimes they think it’s not important, like you’re exaggerating, and then nothing changes.”

(P 3-F)

By contrast, there were also positive accounts in which residents recognised that their voices were acknowledged in specific situations:

“Yes, because, well, when I need help, I call someone and they always come and help me, always, and in a nice way.”

(P 8-M)

These accounts reveal that participation was often partial and conditional, mediated by staff availability and organisational priorities rather than established as a consistent practice. While some residents felt listened to, others perceived that their ability to influence decisions—whether about daily care or the collective environment—was minimal.

This highlights the need to reconceptualise participation not as isolated opportunities to express preferences, but as a systematic practice of inclusion, in which residents’ voices are actively incorporated into everyday routines, care planning, and communal decision-making. For older people living in residential settings, being listened to and involved in decisions was closely tied to their dignity, autonomy, and sense of belonging.

Differences in the perception of listening and communication depending on the degree of dependency and the personality of each resident were considered particularly relevant. Some, due to their character or physical condition, find it more difficult to express their needs or be heard, which can generate frustration and a feeling of invisibility. This can be understood as a consequence of work overload, lack of time, and the tendency to prioritise physical tasks over conversation and emotional care. This may be due both to the organisational structure and functioning of the care home, perceived as a rigid organizational structure, and to staff training, which is often more oriented towards physical care than communication and emotional support.

In summary, communication, listening, and genuine participation in the life of the care home emerge as key factors for older adults to feel respected, valued, and active members of their environment. Fostering spaces for dialogue, listening, and shared decision-making could be a crucial opportunity to move towards more person-centred care and a better quality of life, for which it is crucial to overcome the current care systems characterized by organisational rigidity.

4. Discussion

This study explored the perception of the treatment received by older adults living in a care home, analysing how their level of autonomy and dependency shapes these experiences. The findings indicated that functional dependency directly influences the quality of the treatment perceived, a result consistent with previous research linking the loss of autonomy to greater vulnerability to negligent or discriminatory practices [8,19].

Work overload and staff shortages in care homes limit the capacity to provide individualised care, particularly for residents with high levels of dependency. This is reflected in the accounts of participants, who describe hurried or impersonal interactions, a phenomenon that the international literature associates with a “culture of neglect” in long-term care [17,18]. The passive acceptance of inadequate treatment by some residents corresponds with what has been observed in studies showing that a significant proportion of institutionalised individuals tend to normalise psychological mistreatment, possibly as an adaptive mechanism to institutionalisation, in line with the concept of “learned helplessness” applied to residential settings [20,21]. Furthermore, the literature highlights that the normalisation of mistreatment or neglect in long-term care environments is a concerning phenomenon, with serious consequences for the physical and mental health of residents, as well as for their overall quality of life [10,28].

Regarding gender differences in intimate care, the study reveals that a significant proportion of women prefer to be attended to by female carers in situations involving personal hygiene, while men show greater indifference. This finding is consistent with research that emphasises the importance of respecting individual preferences in care as an essential principle of the PCC model, although the actual implementation of this model remains limited in many residential contexts. The literature also highlights that adapting protocols to individual preferences is still an unresolved issue in most institutions, which has an impact on residents’ satisfaction and wellbeing [29,30].

This study contributes to the scientific literature by providing a qualitative perspective focused on the subjective experience of residents themselves, revealing internalised mechanisms of justification, such as the association between dependency and a perceived “deservingness” of poorer quality treatment. In this way, it broadens previous findings on institutional mistreatment by incorporating the phenomenological dimension of lived experience. In addition, it identifies dynamics of exclusion and social hierarchies based on functional ability, where the more autonomous residents have access to better interactions with staff, a phenomenon that has been scarcely explored in the Spanish literature. The findings also show that rigid schedules and protocols, such as the limited time allocated for personal care, generate a perception of dehumanisation, which supports the need to implement flexible models that prioritise autonomy and participation, in line with recommendations from the WHO and recent studies on quality of life in care homes [31]. Moreover, in accordance with a recent systematic review on the subject [32], limitations are evident regarding opportunities for genuine resident participation in the design of activities carried out in the centre, in channelling demands and suggestions, and in the development of internal protocols where residents should be protagonists of change and not mere recipients.

The findings suggest the need to implement concrete actions to improve care in residential facilities, such as the personalisation of care through individualised plans, staff training in therapeutic communication and the detection of institutional abuse, and the creation of residents’ councils to participate in the co-design of activities and protocols. For future research, the development of longitudinal studies is recommended to analyse the evolution of perceptions of treatment during the institutionalisation process, comparative research between residential models, and cost–benefit analyses of increasing staffing levels, considering the relationship between staff-to-resident ratios and quality of life.

This study highlights that the quality of treatment in care homes is shaped by structural factors such as work overload and organisational rigidity, as well as by socio-psychological factors such as the normalisation of neglect and the stigmatisation of dependency. While progress has been made in terms of physical care, challenges remain in preserving the dignity and autonomy of residents. The results reinforce the urgency of moving towards care models that prioritise the voice of older adults, in line with international guidelines on person-centred care. Future interventions should integrate scientific evidence to ensure that care homes are places to live rather than mere service-providing facilities, with the primary objective of promoting dignity and wellbeing in later life.

4.1. Strengths and Limitations

This study offers a number of relevant strengths that reinforce the validity and interest of its findings. Firstly, the application of an interpretative phenomenological approach stands out, as it allows an in-depth exploration of the subjective experience of older residents according to their level of dependency. This methodological approach makes it possible to capture not only their assessment of the care received but also the ways in which they justify, accept or normalise certain behaviours on the part of staff, thereby enriching the understanding of the phenomenon beyond the objective standards of what constitutes good or poor care. In addition, the sample selection achieved a balance in terms of gender and diversity of levels of autonomy and dependency, thus enhancing the representativeness of different profiles regarding the perceptions gathered. Data collection through semi-structured interviews, conducted in private settings and adapted to the capacities of each participant, together with the observation of non-verbal language, has made it possible to obtain rich and contextualised accounts. The data analysis, carried out following Colaizzi’s phenomenological method and supported by the verification of findings with the participants themselves, ensures rigour and fidelity to the narrated experiences. Finally, the findings of the study provide practical contributions for improving residential care, emphasising the importance of personalised treatment, active listening and adaptation to individual preferences, which can contribute to raising awareness of the need to advance, consolidate and strengthen the person-centred care model in residential care settings, as a key element for enhancing the dignity of institutionalised older adults.

On the other hand, this study has certain limitations that should be taken into account when interpreting its findings and their applicability. The first is the small sample size, limited to only eight participants, and the fact that all were selected from a single residential care facility where care is provided by the same staff team. Furthermore, the exclusion of people with severe cognitive impairment means that the voices of a particularly vulnerable sector of the residential population, characterised by high levels of dependency, were not included, which restricts the range of experiences explored. Testimonies from family members and professionals—key actors in the care ecosystem whose perspectives are essential for understanding the reality and functioning of institutions, and therefore the care provided and received—were also not considered. In addition, the study did not examine in depth structural variables such as staffing ratios or institutional policies, both of which have been identified as determinants of care quality. Moreover, as the interviews were conducted within the residential facility, some participants may have downplayed negative experiences for fear of reprisals.

It should also be noted that the data collection was carried out at a specific point in time, without addressing the potential evolution of perceptions over time or in response to organisational changes or changes in the health status of the residents. All these considerations highlight the need for further studies in other contexts and with larger and more diverse samples, including a broader spectrum of dependency profiles, in order to gain a more comprehensive understanding of the experience of older adults in residential care.

4.2. Implications for Clinical Practice, Policy, and Future Research

To clearly and visually synthesise the implications derived from this study on the perception of care in residential facilities according to the level of individual dependency, the following table presents an integrated summary of the repercussions for clinical practice, policy, and future research, thereby facilitating overall consultation and understanding (

Table 3. Proposals and Implications for Clinical Practice, Policy, and Research.

Area	Recommendations	Relation to Findings
Clinical practice	Specialised training in PCC and empathetic communication	Implement training programmes for professionals focused on empathetic communication skills, time management, and respect for autonomy
		Develop protocols that prioritise privacy and individual preferences, such as the choice of caregiver’s gender for intimate tasks, a concern frequently highlighted by female interviewees
	Strengthening active listening through psychosocial interventions	Establish structured dialogue spaces where residents can express their needs and take part in daily decision-making, thus avoiding the feeling of invisibility
	Improving staff-to-resident ratios and time management to avoid rushed care, particularly for residents with high levels of functional dependency	Reduce the perception of “hurried” care by adjusting task distribution and increasing staffing during critical shifts (e.g., mornings), identified as a key factor in dissatisfaction
Policy and institutional management	Implementation and monitoring of individualised care plans, with a review of funding models	Increase resources to ensure adequate staff-to-resident ratios, given that most participants with severe dependency linked their dissatisfaction to staff work overload
	Promotion of regulations that safeguard dignity, rights, and autonomy, in line with the principles of the PCC model	Regulate the mandatory implementation of personalised care plans in residential facilities, in alignment with the Law on Personal Autonomy and a rights-based approach to older adults
		Promote “ageing-in-community” policies with support for sheltered housing and programmes aimed at preventing social exclusion within residential settings
Future research	Conduct longitudinal and multicentre studies on the evolution of perceptions of care according to levels of dependency and cognitive impairment	Analyse how perceptions of care evolve as functional and cognitive impairment progresses, using validated assessment tools (e.g., Barthel Index, Lawton and Brody scales) with larger and more diverse samples
	Research on the impact of organisational culture and management models on the quality of care	Explore the relationship between residential management models and the normalisation of negligent practices, as identified in a substantial proportion of the participants’ narratives
	Evaluation of technological interventions to enhance communication and autonomy without replacing human contact	Assess the role of digital tools, such as personalised alert systems, in improving communication and autonomy while ensuring that these do not substitute meaningful human interaction
	Intersectional analyses combining gender, functional level, and sociocultural context	Investigate how factors such as gender, socioeconomic status, and functional diversity moderate perceptions of care, an area that remains underexplored in the present study

). The table illustrates how each line of action is linked to the findings and needs identified, and how it can guide both the improvement of care and the development of policies and new research.

5. Conclusions

This study has provided an in-depth understanding of how older adults living in a long-term care facility perceive the treatment they receive, taking into account their level of autonomy and dependence. The findings indicate that the degree of functional dependency is a determining factor in residents’ daily experiences. Thus, the study confirms that care provision is not homogeneous, but varies according to the amount of assistance required. Those with a higher level of autonomy reflect: (1) more positive experiences and care satisfaction, (2) higher level of social and emotional integration within the institution, and (3) better interactions with other residents; than those with higher level of dependency.

The analysis of the narratives reveals that the loss of autonomy not only impacts the relationship with staff but also affects social integration within the facility, leading to dynamics of exclusion and the emergence of invisible hierarchies between more autonomous residents and those with greater dependence. This phenomenon (invisible hierarchy), which has been scarcely explored in the national literature, offers a novel perspective on the complexity of residential life and underscores the importance of tailoring care to individual needs and preferences, thereby providing further support for the person-centred care model.

The study also highlights the relevance of respecting privacy and individual preferences, particularly in intimate care where the gender of the caregiver can influence wellbeing, especially for female residents. Communication and meaningful participation in daily life within the residence emerge as key factors for wellbeing and perceived dignity, yet these are currently constrained by limited time and resources. These findings reinforce the need to move towards person-centred models of care that ensure autonomy, dignity, and the active participation of residents in decision-making processes affecting their daily lives.

From a knowledge contribution perspective, this research provides a qualitative, experience-centred view from the residents themselves, expanding the understanding of how the care received is justified and normalised according to the level of dependency. The inclusion of direct narratives makes it possible to identify mechanisms of adaptation and resignation in the face of rushed or depersonalised care, as well as strategies used to preserve self-esteem and dignity in contexts of vulnerability.

In terms of practical implications, the findings point to the need to strengthen staff training in person-centred care, improve staffing ratios, and foster residents’ participation in decision-making processes. At an institutional level, it is essential to implement protocols that respect residents’ autonomy, privacy, and diversity, and to establish formal mechanisms for the continuous evaluation of care quality. Moreover, it is recommended to create structured spaces for dialogue and active listening, enabling older adults to express their needs and expectations, thereby contributing to the construction of a more inclusive and respectful environment.

Ultimately, in line with the present research, it is essential to continue advancing and updating knowledge of the challenges inherent to the residential care system for older adults, with a view to transforming traditional models of care and consolidating approaches that focus on the person, their needs, their dignity, their life history, and their individual preferences, with the ultimate aim of enhancing their quality of life.