Providing cost-effective and high-quality long-term care is becoming one of the major societal challenges in the western world, due to the aging population and the consequential long-term burden imposed on care systems. The long-term care sector faces challenges in terms of recruiting and keeping a competent workforce, as negative societal images exist toward care of older people, and significant labor shortages are projected (Vernooij-Dassen et al., 2009). Long-term care is also challenging from a resident and family perspective, as life in long-term care often is connected to loneliness and boredom, partly through media highlights of sub-standard care that has been limited to completing care tasks and/or providing monitored containment of residents (Cohen-Mansfield & Bester, 2006; Doyle et al., 2012; Slama & Bergman-Evans, 2000). However, contemporary research and best practice exemplars illustrate how best practice long-term care of older people involves activities to promote quality of life and thriving, and that it is imperative to support experiences of the good life for residents despite institutionalization (Bergland & Kirkevold, 2006; Cooney, Murphy, & O’Shea, 2009; Zingmark, Sandman, & Norberg, 2002).
There is evidence to suggest that resident quality of life can be improved by participating in familiar household activities such as cooking and doing laundry (Funaki, Kaneko, & Okamura, 2005), being engaged in various hobbies and interests (Drageset et al., 2009), or partaking in other personally meaningful domestic activities (Cooney et al., 2009; Murphy, O’Shea, & Cooney, 2007). In addition, participating in everyday activities has been described as promoting a continuation of self and normality for residents (Edvardsson, Fetherstonhaugh, & Nay, 2010) and as representing and defining people as persons through suggesting that we are what we do (Davis, Byers, Nay, & Koch, 2009). Thus, it seems that providing individually tailored, meaningful everyday activities can contribute to a culture shift in long-term care toward a person-centered practice (McCormack, Karlsson, Dewing, & Lerdal, 2010; McKeown, Clarke, Ingleton, Ryan, & Repper, 2010). Such increasing person-centeredness is recurrently described in contemporary literature as underpinning high quality, best practice care of older people (Edvardsson, Sandman, & Rasmussen, 2012; Kitwood, 1997; McCormack & McCance, 2010). Emerging from a phenomenological life-world understanding of illness and its consequences for the person and family, person-centeredness has been described to involve collecting and using knowledge about the person’s needs, hopes, and wishes to promote a continuation of self and normality despite illness, to enable shared decision making, and to facilitate experiences of comfort, joy, and meaningful experiences of life (Brooker, 2007; Edvardsson et al., 2010; McCormack & McCance, 2006). The academic literature into person-centeredness in care of older people has largely focused on delineating the conceptual content, implications for policy and management, and future directions for research (Edvardsson, Winblad, & Sandman, 2008; McCormack & McCance, 2006; Morgan & Yoder, 2012), and less research has highlighted how nursing staff can actually facilitate this somewhat elusive concept in practice. This study aimed to fill this knowledge gap by exploring how nursing staff promote person-centeredness in long-term care.
Design, Sampling, and Participants
The study utilized an anthropological free-listing approach to data collection (Lindqvist et al., 2012; Tishelman, Lövgren, Broberger, Hamberg, & Sprangers, 2010) and qualitative content analysis (Graneheim & Lundman, 2004) to analyze the resulting written self-report descriptions of how staff facilitated person-centeredness in long-term care practice. The study drew upon a sample of Swedish long-term care staff that participated in an in-service program on improving care of older people and people with dementia. Staff that attended the in-service sessions were provided information about the study at the end of the sessions. A procedure of implied consent to participation was employed, whereby staff who were willing to participate agreed to provide anonymous written descriptions of how they facilitated person-centeredness in their work with residents. In total, 436 staff from 26 long-term care facilities agreed to participate, representing an 83% response rate from the 526 members of staff attending the in-services. Participating staff consisted of the following categories: personal care workers (little or no education), assistant nurses (high school–level education), RNs (university-level education), unit managers (university-level education), and unspecified others.
Self-reported staff data were collected using a free-listing approach derived from anthropology (Lindqvist et al., 2012; Tishelman et al., 2010) to identify issues of importance to participants uninfluenced by researchers’ assumptions. This anthropological free-listing involved asking the study participants to provide written descriptions of how they facilitated person-centeredness in long-term care. The participants were also asked to provide demographic information such as age, gender, profession, and work experience in care of older people. No personally identifiable information was collected. Time and space for data collection was allocated in the end of the in-service sessions, and written responses from participating staff were collected anonymously in a box on site. The resulting self-report descriptions varied in length between single sentences to several paragraphs. All data were collected in March 2012.
The written descriptions were transcribed verbatim, collated into a single Microsoft Word® document, and subjected to qualitative content analysis (Graneheim & Lundman, 2004). The qualitative content analysis was performed in three steps. First, the texts were read through as a whole, to gain an overall understanding of the content. Second, emerging conceptual themes were constructed from the content of the text, and text descriptions were sorted into themes on the basis of its content. Third, the themes and content were subjected to comparative analyses to ensure that thematic labeling and content had an inherent logic, and that themes were mutually exclusive to the largest extent possible. During this stage, conceptual labeling and thematic content were sorted and rearranged to clarify the defining characteristics of each theme. These three steps were jointly performed by all members of the research team.
The study was conducted in accordance with the Declaration of Helsinki and received approval from the participating organization. No ethically challenging issues were identified from the study respondents’ point of view, as participation or withdrawal was completely voluntary. A voluntary return of a written description implied consent for participation in the study.
The final study sample of nursing staff (N = 436) consisted mostly of women (95%), with a mean age of 45 (SD = 11.6 years), and an average work experience of 17 years (SD = 9.5) in long-term care. The participants consisted mainly of personal care workers (48%), assistant nurses (35%), unit managers (5%), RNs (5%), and unspecified others (7%).
The analyses resulted in four themes that illuminate how staff described facilitating person-centeredness in their daily work with residents. These themes indicate that staff largely used a variety of activities to facilitate person-centeredness, namely: Promoting Decision Making, Promoting a Meaningful Living, Promoting a Pleasurable Living, and Promoting Personhood. Each theme and its content is presented below and organized by an initial description of each theme followed by an outline of its properties and content.
Promoting Decision Making
Staff recurrently described how they engaged residents in different activities to facilitate resident involvement in decision making, and this theme surfaced as central to supporting person-centeredness for residents. Promoting resident decision making had two properties: (a) offering resident choices and (b) respecting resident choices.
Offering Resident Choices. Staff described that they made efforts to become aware of how residents preferred to organize their day and their activities of daily living, and also to know the extent to which residents needed and wanted assistance. Staff also described how they were offering choices of how and when to perform personal hygiene, presenting a variety of clothes for residents to choose from, and offering a variety of foods to choose from to facilitate resident involvement in decision making. One of the participants described how she offered choices to residents: “I always ask the person what she wants and how she wants it done. In the shower, for example, what does she do, what do I do, and in what order? It all needs to be on her terms.”
Staff also expressed that they described to residents the type of activities that were being offered within the unit that day and that they sometimes gently guided resident decision making so that residents were not forced to make choices that exceeded their abilities. Residents’ previous life histories were described as important sources of knowledge of preferences, especially in relation to residents with communication difficulties. However, staff also described that residents’ preferences could change, and that they were careful not to assume that previously stated preferences were continuously valid without ongoing evidence.
Respecting Resident Choices. Staff also described how they respected resident choices by listening and accepting their point of view. Respecting choices from residents involved for example respecting lifestyle decisions such as watching television throughout the day, staying up late and sleeping in, having wine or beer when preferred, having irregular meal times, and being allowed to perform personal hygiene in a personal manner and extent, even if this deviated from the shared norms and routines. One of the participants elaborated, “Respecting their decisions is important for us, for example, when they prefer getting in and out of bed. We need to listen to what is important to them.”
Being open for individual variation and not being judgmental about how residents wanted to live their lives emerged as a latent meaning in this theme, and staff described the possibility of making decisions and having these respected as being central to facilitating person-centeredness.
Promoting a Meaningful Living
Participating staff also outlined that promoting a meaningful living for residents was another aspect of supporting person-centeredness. Individually targeted activities were described as providing a meaningful content to the day, but also as means to confirm residents as individuals by continuing to do the things they enjoyed. Promoting a meaningful living had two properties: (a) involving residents in everyday tasks and activities and (b) creating activities that match residents’ needs and interests.
Involving Residents in Everyday Tasks and Activities. It was repeatedly described how staff involved residents in daily tasks and household activities that had to be done in the unit, such as cooking, cleaning, watering plants, and/or arranging the laundry. Thereby, staff could complete such tasks while still facilitating a meaningful occupation for residents through their involvement, and participating in such activities were described as having the added benefit of supporting and developing residents’ functional capacity. One staff member stated, “I’ll often get one of the residents to help me setting the tables, washing up, and keeping it tidy. She loves it when being asked to help us, being needed and important.”
Also, activities to support physical health and function in residents were described, and these could range between gymnastic exercises and uncomplicated ball games. It seemed that a cornerstone for person-centeredness was involving all residents in some form of everyday activity, irrespective of cognitive or physical function, and that such activities needed adaptation to resident cognitive and functional ability as well as to personal interests and routines.
Creating Activities that Match Residents’ Needs and Interests. Creating activities that matched residents’ needs and interests were also described as important to facilitate person-centeredness, and this required a shared knowledge about residents previous and current biography among staff. A wide range of activities were described by staff such as playing games, listening to music, singing, watching movies, reading for residents, looking in photo albums, sewing, playing games, solving crossword puzzles, dancing, and watching soccer. Having the appropriate space and equipment was essential to creating such activities that matched residents’ needs and interests. As one staff member described, “We try to build their everyday life with them, based on what they can and want to do and try all we possibly can for them to participate in life, go on excursions and having fun.”
Creating activities that matched residents’ needs and interests also involved activities relating to psychosocial and emotional needs, and staff described how they held residents’ hands; gave hand, foot, or back massages; or hugged residents who were known to appreciate touch and bodily contact. However, staff also reiterated the necessity to be attentive to those residents who would not appreciate bodily contact.
Promoting a Pleasurable Living
Staff also described how they used activities to facilitate experiences of pleasure and enjoyment for residents to increase the person-centeredness of long-term care. This often involved doing “little extras” that staff knew residents would appreciate, and staff described how such activities created expressions of joy and delight and could make the residents’ day a bit better than expected. Promoting a pleasurable living for residents had two properties: (a) facilitating experiences of grooming and (b) creating festivities for residents.
Facilitating Experiences of Grooming. Staff described how they put in extra efforts to transform the task of grooming to an experience of grooming as being person centered and pleasurable. Facilitating beauty, pampering, pleasure, and pride as defined by each individual resident was central to grooming as an experience, and not grooming as only a task. Facilitating experiences of grooming could involve doing residents’ hair extra carefully, offering an old-school barber shave for residents, applying makeup carefully and offering a manicure, dressing residents in their most beautiful clothes, or assisting with jewelry and accessories. Staff described how they perceived a strong sense of pleasure and pride among residents when being extra well-groomed, especially among those residents who throughout their lives had been well-groomed and careful with their appearances. Facilitating experiences of grooming was also described to influence staff well-being, as they reported feeling good when seeing residents look good. One of the participants stated:
It makes me happy to see the residents happy, and many of them really appreciate when you care for their appearances and help them to look their best. One woman in particular, I assist her every day with putting lipstick on, and selecting the best looking dress for today.
Creating Festivities for Residents. Staff also described how they organized festivities and happenings for residents, as a part of increasing the person-centeredness of the long-term care facility. Such activities included organizing formal and ornamented dinners with fine cutlery, porcelain, serviettes, and wine, sometimes with themes such as “dinner dances” and “Nobel Prize dinners,” where small encouragement awards could be awarded to residents, and celebrations of national traditions or cultural events. Staff described that residents needed and deserved to experience the good in life, as they were still in need of pleasures even though living in an institution. One staff member narrated:
We have festivities every other month, often with wines and aperitifs. It can be barbecues or Nobel dinners or similar. Our philosophy is to let them enjoy life’s dessert. They have all worked really hard for what our country is today, and we need to reward these efforts with some remaining pleasures.
It seemed that the latent meaning of creating festivities for residents was to exceed resident and family expectations, by making life a bit more pleasant with satisfaction and joy for residents and family as well as for staff.
Staff repeatedly described how they engaged in activities to promote the personhood of residents through highlighting resident life stories and through meaningful interaction. Promoting personhood was described as being at the core of facilitating person-centeredness in long-term care facilities. This theme had two properties: (a) seeing the resident as a valuable person and (b) listening to residents’ life stories.
Seeing the Resident as a Valuable Person. Staff described how they actively tried to make residents feel seen and acknowledged through establishing eye contact and always using residents’ names, and by systematically greeting and acknowledging each resident when beginning a new shift. Staff also described how they strived to put aside tasks they were currently involved in when noticing that their presence and interaction could benefit residents. Other activities to facilitate seeing the residents as individuals included creating space for interaction and small talk through shared meals, coffee times, or snack sessions that brought residents and staff together, and as such created a culturally appropriate and familiar space for small talking and sharing of space and moment. One staff member described:
I try to do something special for each particular resident every morning, making him or her feel like a valuable person. For this one resident, for example, a sailor, I prepare by listening to the sea report on radio so that I can tell him the expected winds, currents, and conditions at sea today. For another resident, this is unimportant, and I need to find out what is valuable to her to establish a relationship. This is my responsibility as a staff member.
Listening to Residents’ Life Stories. Staff also described the importance of engaging in activities that could highlight or relate to resident life stories, through asking questions and conversing about residents’ lives and significant life events. This was highlighted as a starting point for meaningful conversations and staff perceived these conversations as highly appreciated by residents, as they were given the opportunity to tell their stories. Conversing around residents’ life stories was not only described to create meaning for residents, it also assisted staff in becoming knowledgeable about the person and thus increasingly person centered. Staff described how this facilitated person-centered moments and gave them valuable biographical information about residents that could influence future activities, interactions, and conversations. As one staff member stated:
I try to spend as much of my time as possible being with residents, to interact, listen, and build relationships. I do not want to get stuck in routines or tasks, I’d rather be flexible and creative and focus on closeness with and support to residents.
The aim of this article was to explore how nursing staff promote person-centeredness in long-term care. The findings outlined four themes that illuminate that staff largely used a variety of everyday activities to facilitate person-centeredness: promoting decision making, promoting a meaningful living, promoting a pleasurable living, and promoting personhood. The findings also indicate that biographical knowledge of the resident provided the fundamentals for a conscious use of individually tailored meaningful everyday activities to facilitate person-centeredness, and to support experiences of being a person with possibilities to make valid decisions and experience meaningfulness, pleasure, and joy.
First, the findings highlighted that promoting decision making was one way to facilitate person-centeredness in practice. This theme contained activities to offer choices for residents but also to respect these choices even if they deviated from the norm or the routines of the setting. Previous research has described that shared decision making builds on human rights of residents and is fundamentally about offering activities, interventions, and management strategies that are most consistent with the person’s preferences and values (Légaré et al., 2010). Shared decision making has been highlighted as a central part to person-centeredness (Edvardsson et al., 2012; Kitwood, 1997; McCormack & McCance, 2010), even if the practices of frontline nursing staff to actually operationalize shared decision making has received less attention and description. It seems that person-centeredness is well underway in any setting if and when residents can make respected decisions. However, issues of decision making deserve careful and reflective application in long-term care due to the high prevalence of diagnosed and undiagnosed cognitive impairment and the legal/ethical issues that comes with such conditions (Smebye, Kirkevold, & Engedal, 2012; Wolfs et al., 2012).
Second, the findings highlighted that promoting a meaningful living was another way for staff to facilitate person-centeredness. These findings resonate with previous results that have outlined the importance of participation in familiar daily activities, hobbies, interests, and other personally meaningful activities to support resident well-being (Cooney et al., 2009; Drageset et al., 2009; Funaki et al., 2005; Murphy et al., 2007). Previous work has indicated that participation in everyday activities can have existentially meaningful dimensions to support a continuation and explication of self (Cooney et al., 2009; Davis et al., 2009). This study provides support to that suggestion in that such activities were used by frontline nursing staff in long-term care to facilitate a person-centered practice supportive of individuality, engagement, and continuation of self. Further development and studies of the role, meaning, and outcomes of everyday activities as nursing interventions to support existential at-homeness and personhood in long-term care would be valuable.
Third, the findings indicated that staff conducted various activities to promote a pleasurable living for residents. Pleasure and pleasurable experiences may not be among the first things connected to life in long-term care, even though pleasure is central to life in society at large. Somewhat surprisingly, pleasure and grooming have not been well explored at all in long-term care research. Searches in relevant databases such as PubMed and CINAHL reveal a very limited scholarly attention to these issues. There is a dearth of studies exploring the prevalence, content, and meaning of pleasure for older people in long-term care. Arguably, older people in long-term care are no different than the rest of society, in that being free of pain, constipation, falls, and pressure ulcers is merely the expected baseline of living, whereas having possibilities to look one’s best and experience the little extras that give personal pleasure are things that add meaning and value to life. The issue of pleasure and its role for nursing theory and practice in optimizing health deserves further exploration and application in clinical practice, research, and education. It seems that pleasure has huge potential to benefit gerontological nursing as a research theme central to a health-promoting aged care approach.
Some would argue that grooming residents is a minimal expectation of a long-term care position and part of regular duties, and that this does not necessarily have anything to do with person-centeredness. Thus, grooming may not be an activity seen as fundamental to person-centeredness, and it could even be viewed as somewhat alarming to see descriptions of ensuring good hygiene and grooming for residents (e.g., clean-shaven face) considered person-centered care. However, to qualify as a dimension of person-centeredness, promoting resident grooming had to go beyond the expected task of grooming, to incorporate the little extras valued and further experienced by each particular resident. By going beyond the expected and the ordinary and by creating an experience of pleasure through the aesthetic and existential aspects in feeling beautiful, grooming became a manifestation of person-centeredness as opposed to another task that needed completion before lunchtime.
Lastly, the findings described a number of activities that staff performed to promote the personhood of residents, and how this was important in enhancing the person-centeredness of care in the setting. The issue of promoting personhood has been at the nucleus of person-centered care ever since the emergence of the concept (Brooker, 2007; Edvardsson et al., 2008, 2010; McCormack & McCance, 2006; Morgan & Yoder, 2012), even though this issue has been difficult to describe from a practice perspective. The importance of “small talk” as a basis for promoting personhood emerged in this study, and this has previously been illustrated as a caring practice within palliative care (Lindqvist et al., 2012). Emerging in this study as a way of promoting personhood and as a systematic collection of biographical data, referring to such an important nursing phenomenon with a derogatory term such as “small talk” risks reducing its meaning. Further exploration and conceptualization of this phenomenon and its role in gerontological nursing can forward our understanding of the unseen and undervalued ways in which essential aspects of nursing are planned, conducted, used and evaluated.
Although it was important for presentation purposes to make mutually exclusive categories, all of the described activities work in concert for person-centered care to be fully realized. For example, resident choice about clothes is not sufficient to represent person-centered care, and neither is an occasional involvement of residents in everyday activities. To interpret the findings of this study holistically, they indicate that person-centeredness is more a philosophy than particular interventions, a creative and playful culture of ethics that celebrates life and manifests individuality, dignity, beauty, meaningfulness, and pleasure in its doing and being.
The study is limited by being based on a convenience sample of long-term care recruited from a local area of Sweden, and thus the sampling procedure as such cannot support transferability of the findings. Readers are invited to assess for themselves the extent to which these findings are transferable to settings beyond the study and how clinically applicable they are in other contexts. Further study of these themes in other settings and samples are needed and invited. The study is also limited by relying on self-report written descriptions, which sometimes were brief and not overly elaborative. This means limited possibilities to make far-reaching interpretations of the meaning, significance, and/or prevalence of the reported activities as it remains unknown to what extent staff actually do what they said they do.
Conclusion and Implications for Practice
Despite its limitations, this study contributes to the literature by providing concrete descriptions of how the abstract person-centeredness concept can be operationalized and facilitated in everyday long-term care practice. The findings indicate that person-centeredness is more a culture and a philosophy rather than singular interventions, and that person-centeredness thrives from manifestations of individuality, dignity, beauty, meaningfulness, and pleasure in both the doing and being of care, individually and collectively. Hopefully, the findings can contribute to move the understanding of person-centeredness from the philosophical, policy, and conceptual domains, toward practice implementation. The study also contributes by suggesting that promoting pleasure for residents is a dimension central to person-centeredness and to health-promoting gerontological nursing at large, and that “small talk” is a potentially powerful nursing phenomenon that deserves more research attention.
The findings are relevant to clinical practice as they provide concrete examples of ways in which person-centeredness can be facilitated. The themes and their content can be used by nurses and managers to critically audit and discuss the extent to which their own clinical practice values and devotes purposeful attention, time, and resources to activities promoting person-centeredness. For example, to what extent do staff offer and respect choices for residents, involve residents in daily tasks and household activities, provide individually tailored activities and pleasurable experiences, and promote being seen and acknowledged? To what extent do direct care staff engage in small talk with residents, is this acceptable among peers, and is this encouraged by nursing leaders in long-term care settings? It seems imperative that leaders initiate reflective discussions on how to increasingly promote person-centeredness in the clinical setting and that they lead the way in creating a philosophy and culture of care that value and prioritize engaging in small talk, facilitating everyday pleasures, and promoting personhood and not only the completion of tasks. This seems urgently needed if the concept of person-centeredness is to be brought from policy to practice.
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