Table 5 Systematic overview of interpretive categories re implementation (qualitative component)

Type‚ specialized implementation‘

Type‚ integrative implementation‘

Individual KT treatments conducted by a KT trainer (→ specialized knowledge)

individual KT treatments conducted by all nurses and nurses’ aides (→ generalized knowledge)

Conceptual focus on attentive dimensions:

Conceptual focus on physical-sensual dimensions:

‘I think that Kneipp is a conception sensitizing us for things we already do in elder care. To let us have a closer look on how we do things in care and what effect we want to achieve. For example the right nutrition, or being there for someone. Yes, it’s a holistic view on care. Everyone is talking about holistic care, but this is a hazy expression, what can you do with it? And I think that the Kneipp concept is describing what holism is.’ (head of nursing)

‘I do think that Kneipp is giving the whole thing a name, or a roof. A bit of orientation, so that the staff knows what is important to us, and the residents know it as well, their relatives, everyone knows that we have a slightly different way of working here, another kind of consciousness about care.’ (director)

‘I think what makes a difference is that care is done in a conscious manner. There are a lot of things one already does in care, but it is not done consciously, although it is at the same time a Kneipp treatment. It’s about the attention given in that moment, by the nurses. For example at lunch, when they feed someone, if you do it with ease, take a chair and sit next to the resident instead of standing and pushing the spoon in – this would also be a treatment in the Kneipp way, feeding with consciousness and ease and giving attention through it.’ (KT trainer)

‘Maybe it works so well because it’s so normal. I mean, I could just as well work with any kind of sound therapy or scents or whatever, but that’s rather special. Kneipp, instead, is down-to-earth, I do not have to explain it to the residents, they know it and they understand it.’ (director)

‘Well, it is simply part of our profession that we work here under a high tension, that we do not always have the inner calmness necessary to transfer our attention to the resident. For example, if we do not feel comfortable and calm ourselves, we could do Kneipp ten times and it would not reach the residents. No, it would only become hectic and have no effect for the resident.’ (a nurse)

‘Simply as far as skin care is concerned, or decubitus prophylaxis, Kneipp treatments are just the optimal thing. Washing with cold water and brushing the skin is but perfect, better than all those ridiculously expensive skin products we used in other nursing homes to enhance the blood circulation of the skin, we do not need those things here! We do very simple things that don’t cost anything.’ (head of nursing)

‘I think that Kneipp makes a difference about care because we have slightly more time for the residents. For example when we brush the skin, you need to take your time to brush every part of the hand or the arm, and with the washrag you always to it tatata and done. If you use the brush, it’s a little more time you give. And, after all, it’s not the same thing every day! One day you brush, one day you wash with cold water, one day you prepare a bath. And we would all get fed up with having to eat spinach and eggs every day, don’t we? And it’s the same with basic care.’ (a nurse)

Explanation of symbolic order: director, head of nursing and KT trainer

explanation of symbolic order: director and head of nursing

Keepers of specialized knowledge: KT trainer and a few nurses/nurses’ aides externally trained in KT

keeper of specialized knowledge: head of nursing (who is a trained KT trainer)

Knowledge transfer: voluntary internal schooling by KT trainer

knowledge transfer: compulsory element of job introduction for nurses and nurses’ aides

Application of KT treatments: KT trainer (according to trainer’s treatment plan)

application of KT treatments: care staff (according to residents‘ treatment plans)

Additional KT activities: care staff (voluntary, within daily basic care activities); attendants (individual attendance in daily activities); therapists and social workers (their activities are integrated into the KT concept); kitchen crew (cooking healthy menus)

additional KT activities: nurses’ aides, attendants and volunteers (group activities and individual attendance in daily activities); therapists (their activities are integrated into the KT concept)

Personalized application, complex treatments

Pragmatic application, simple treatments

KT treatments are done by the KT trainer, in a manner that stresses individual attention (giving time, serving the individual needs of the resident)

Head of nursing instructs the staff how to apply KT

Therapist applies complex, time-consuming treatments, which are popular among the residents (hot/cold baths, massages, hot rolls etc.)

Each staff member applies KT according to pragmatic instructions

Nurses and nurses’ aides are invited to apply KT as well, but do it seldom because they do not feel in a position to give the same amount of time and individual attention as the KT trainer does

Treatments are chosen that integrate well into the daily tasks and routines of care (washings, gushes, brushing, simple baths etc.)

A few nurses and nurses’ aides punctually apply single elements in basic care (e.g. brush massages) and in treatment of indispositions (e.g. herbal teas, poultices)

Residents get a fixed treatment plan compulsory for staff

Application of KT in the mode of a gift

Application of KT in the mode of a standard service

No time pressure: KT treatments can be done in a careful, individually adapted manner and therefore stress the attentive aspects. Only the KT trainer does treatments; frequency and regularity is hard to achieve.

KT treatments are done regularly, several times a week. This requests planning, offers liability for residents, and obliges staff to apply KT.

Treatments have an enchanted character; they are individual gifts of absolute attention.

Treatments have a pragmatic, everyday character; they are part of the standard services.

Treatments focus on well-being and indulging.

Focus on simplicity (cold washes, gushes) and regularity also leads to observable physiological effects; therefore, residents and staff tend to be convinced about positive long-term effects on health.

Treatments and the person of the therapist are very popular among residents.

‘Cold‘ treatments are regarded as unpopular among residents, which leads some team members to replace unpopular treatments by more appreciated ones (such as the brush massages); this brings in the gift dimension (cf. organization C).

Nurses and nurses’ aides acknowledge that ‘doing Kneipp’ is ‘something beautiful‘ they do not have the possibilities to do in their daily care work.

Residents’ agency: non-negotiable, gratitude

Residents’ agency: negotiable, a right

Residents may co-determine KT within the concrete interactions during a treatment since treatments focus on situational needs of the residents.

Residents have a therapy plan in their rooms and know what treatments they are supposed to get. Treatments are therefore part of standard services the residents have a right to.

Treatments are closely tied to the person of the therapist and tend to be experienced as personal and comprehensive ‘caring about’.

Residents may claim treatments on the basis of this plan, they may also negotiate situational changes in treatments (e.g. receiving a brush massage instead of a cold washing). They may, however, not influence who does the treatment (i.e. KT is not person-bound).

Residents have no explicit claim to receive treatments; they are perceived as occasional gifts, not regular services.

The power to define KT lies with the head of nursing (who puts up the treatment plan); the power to apply KT lies with the staff, but is negotiable for the residents.

The power to define and to apply KT treatments is not perceived to be available to residents.

‘Sometimes they treat you here as if you were a piece of wood. And Ms. X (the KT trainer) is always very kind. One day she makes me a hot roll, another day a hot-cold foot bath. And I somehow feel better afterwards.’ (a resident

‘When I came here and saw those pictures of Mr. Kneipp hanging everywhere – we had them at home as well when I was a child! Yes, Kneipp was always present at our home, and certainly this helped me get so old. Just today I had one of those cold washings – freezing it was, I thought I am not going to survive it! But now I feel so well, so warm.’ (a resident)

‘It always feels good. It’s good if you get an opportunity to relax, one feels less stiff, I can move better, blood circulation is better, this does a lot. And I like Ms. X (the KT trainer), her entire personality is good.’ (a resident)

‘Well, the dry brushing, this is great, really. It releases, and it wonderfully stimulates blood circulation, and it feels very well. I am always looking forward to this!’ (a resident)

‘Yes, one is grateful for that, if it itches at your back, if someone washes or brushes you there. And one can have such nice talks with the nurses while they’re doing it.’ (a resident)

‘Since Kneipp is so multifaceted there are so many possibilities to apply something, small but sometimes powerful. Be it with teas for example, doing small things with big effects.’ (a nurses‘ aide)

‘I am in a position to offer something to the residents, so that they feel like: Now they’re doing something special for me.” (a nurses’ aide)

‘Take for example a fever: before you grab the paracetamol, you can try to do a calf packing, which is not a big thing.’ (a nurse)

‘Well, to be honest, a contented resident also uses his bell less often.’ (a nurse)

‘And if you do some Kneipp and see how much joy they get from what you do for them, then (laughs) you want to have more of that!’ (a nurse)

‘If someone is contented, if I was able to help him or her with small things, then this helps me as well. I can stay with other work, I am more contented as well, everyone is happier!’ (a nurses’ aide)

‘When Mrs. W. gets her depressions, for example, she does not call us when she needs to go to the toilet. And when she feels well – and Kneipp is good for her psyche – she also cooperates better in care.’ (a nurse)

‘If you see reactions from residents you did not expect, it’s joyful, it’s nice, somehow. That’s the kick in nursing the elderly, it makes you happy if you get reactions, and if you get appreciation for what you do.’ (a nurse)