Person-centered care (PCC) is the gold standard for health care delivery in the United States and abroad, which is further reinforced by the Affordable Care Act and Centers for Medicare & Medicaid Services (CMS) (White House Conference on Aging, 2015). PCC means to “focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives” (CMS, 2016, p. 8) and it is achievable through “a dynamic relationship among individuals, others who are important to them and all relevant providers” (American Geriatrics Society [AGS] Expert Panel on Person-Centered Care, 2016, p. 16). Studies have identified tailoring the care processes to meet the particular needs and preferences of residents as an important element in providing PCC (Abbott, Heid, & Van Haitsma, 2016). Although much has been published on eliciting preferences and the perspective of nursing home residents and staff, less attention has been given to how assisted living facilities provide PCC from either the resident or staff perspective.
A growing body of literature has identified facilitators and barriers, such as facility policies and resident characteristics, to fulfilling nursing home residents' preferences based on staff perspectives (Abbott et al., 2016). Additional studies have focused on how health care professionals in nursing homes, especially nurses and certified nursing assistants (CNAs), contribute to PCC. These studies also stressed the inclusion of all staff in the flow of communication, especially CNAs, and the development of educational programs that are responsive to staff learning styles and time constraints (Kolanowski, Van Haitsma, Penrod, Hill, & Yevchak, 2015). However, most PCC education and training are provided only to clinical staff, such as direct care staff (e.g., CNAs). For example, the Staff Training in Assisted Living Residences (STAR) is effective in reducing the levels of affective and behavioral distress among residents with dementia; however, training is provided only to the direct care staff (Teri, Huda, Gibbons, Young, & van Leynseele, 2005). Similarly, the Person-Centered Practices in Assisted Living was developed for use with assisted living residents and staff in response to concerns that assisted living is not person-centered (Zimmerman et al., 2015). But, only clinical staff were involved in the development of this measure (Zimmerman et al., 2015). Although some have advocated for the inclusion of all personnel (AGS Expert Panel on PCC, 2016), there is little evidence of studies that explicitly discussed the contribution of non-clinical professionals to PCC. Therefore, the purpose of the current study was to explore the contributions of non-clinical professionals, such as housekeepers and maintenance mechanics, in promoting PCC of older adults residing in assisted living.
Paid personnel of an assisted living organization (licensed for 80 residents) having daily interactions with residents who spoke English were eligible to participate. The second author (K.M.A.) presented the study at a staff meeting and answered questions. Participating staff were scheduled to be interviewed during their work hours at a time of their choosing.
A semi-structured interview guide was developed as part of a study exploring social networks and health among residents in assisted living. Staff were asked to reflect on their observations of resident-to-resident interactions as well as resident-to-staff interactions. Some of the questions included: “Could you describe your responsibilities with regard to residents?” and “How do you and other staff promote positive relationships between residents and other staff members?” Interviews were audiorecorded, transcribed verbatim, and checked for accuracy by the authors.
A convenience sample of eight staff members from administration, housekeeping, concierge, and maintenance participated. Transcripts were coded and categorized using Dedoose® software based on four a priori themes from Edvardsson, Varrailhon, and Edvardsson (2013) (Table). Themes identify how staff promoted PCC based on a sample of 436 staff providing nursing care from 26 Swedish long-term care facilities (Edvardsson et al., 2013). Discrepancies in coding were discussed and reconciled through consensus during weekly meetings between the coauthors. The study was approved by the Office of Regulatory Affairs, and informed consent was sought prior to the interview.
Ways Nursing Staff Facilitate Person-Centered Care
Three housekeepers, two maintenance mechanics, one administrative assistant, and two individuals who worked as the concierge across first and second shifts participated in the study. The concierge had similar responsibilities to a front desk receptionist (i.e., allowing individuals into the locked building, signing residents in/out, answering phone calls, and distributing mail) with a desk located at the main entrance. The concierge is also the first point of contact for guests and family who are trying to locate residents inside the community. Participants were mostly female (75%) and non-Hispanic (75%), with the majority between ages 41 and 59 (87.5%), and had worked in the assisted living facility for an average 2.9 years. Staff mentioned various ways in which they contributed to PCC across the four domains (Table).
Examples of how non-clinical staff facilitated PCC were found for all categories except for one sub-category (i.e., involving residents in everyday tasks and activities). In addition, a new sub-category was identified related to promoting pleasurable living called “navigating the organization.” This theme was not represented in the original categories but was an important way non-clinical staff facilitated PCC. Below are example quotes from participants that reflected the major domains of PCC.
Promoting Decision Making
Offering Resident Choices. The concierge explained that providing information about activities to residents proved helpful in encouraging residents to attend activities. For example, some residents ask “What are we going to do today?” or “What is there for me to do?” and the concierge would remind them of the schedule. Sometimes the concierge would offer suggestions by saying “Why don't you play Scrabble®?”
Respecting Resident Choices. A maintenance mechanic described an interaction in which a male resident wanted to test another resident's scooter:
He was actually thinking of getting one of those scooters. He wanted to know how it feels to sit in the scooter. So, this lady who got it, let the man sit on it and showed him around the place. It's just good to watch that but we have to be aware and see if he falls or she falls.
Promoting a Meaningful Living
Creating Activities That Match Residents' Needs and Interests. An example of how staff help match resident interests is when residents are looking for other residents. Residents ask where their friends are, such as “Where's Ruth?” and one of the housekeepers responded by suggesting, “Would you like me to go get her for you?” or “Do you want to take a walk and see where she's at?” In addition, a housekeeper said that she is aware of life events and tries to be attentive to residents' needs. For example, “Let's say somebody dies. And you see one of the residents crying, we go up to them, comfort them.” Another sub-theme under this category was promoting a meaningful living; however, examples of non-clinical staff involving residents in everyday tasks and activities were not found.
Promoting a Pleasurable Living
Facilitating Experiences of Grooming. Facilitating the grooming experience gives staff an opportunity to “get involved with them [residents],” and to let them know that “they can come to us for anything.” Staff also described how complimenting residents on their outfits is a way for them to be “courteous and kind.” A concierge stated:
A lot of times a resident will come to me and say, “How do I look?” I come from behind the desk and tell her how nice she looks and just rearrange her necklace for her, or sometimes she'll bring her earring and ask me if I would put her earring on for her.
Creating Festivities for Residents. A maintenance mechanic explained, “We even do karaoke at times and they [residents] pick me to sing their best song. They know that I know Spanish and they say that you know how to sing that song.” A housekeeper added that she and her team “dance and sing to give them [residents] energy. They love it, and say that they have energy now.”
Navigating the Organization. The sub-category of navigating the organization was not originally a part of the Edvardsson et al. (2013) themes. This sub-category was added after hearing from non-clinical staff about how they assist residents throughout the day by “more or less facilitate them getting an answer by directing them to the appropriate person or by asking for them…. I help them with times and locating people. More or less I almost know where the residents are all the time.” In addition, a concierge expressed that “I help them navigate the organization more or less.”
Seeing the Resident as a Valuable Person. A concierge expressed that she greets residents “because we are the first one that they [residents] see when they come in by saying good morning.” Staff believe that it is just a way “to make them feel comfortable.” A maintenance mechanic described how he sought to make residents feel seen and acknowledged. He explained, “I walk in the hallway and I can tell 90% of the residents' names and I call them by their names. I know if they want to be called Mr. or Mrs. or just their first name or just the last name.” Staff also described how they strive to put aside tasks they were involved in when noticing that their presence and interaction could benefit residents. One maintenance mechanic expressed:
What I do anytime I have a job, I always ask them how is everything going. I want to be really nice to them if there is anything that I can do for them besides what I am sent there to do. I say anything you need while I am here, make their day better, and make them happy.
Listening to Residents' Life Stories. The concierge highlighted that “you have to actually show that friendliness, that love, and concern where they [residents] will open up to you about anything.” Learning about a resident, his/her experiences, and emotions is crucial to provide PCC and a housekeeper expressed that listening to their life stories helps her provide better care, stating, “That's how you learn about them; how they feel, how they act, the emotions, so that's what I like, that's how you understand a person better when you talk to them.” The administrative assistant also had a similar thought and explained:
The more you talk, the more you can get out of them, so you know that there are similarities. A woman yesterday told me that she went to Sunny View High School. Well, so did I. And she'll say, “Oh do you remember Mr. Smith?” Oh yes, I remember Mr. Smith and then the conversation started. …That's how we interact together.
Assisted living non-clinical staff gave examples of how they provide PCC without ever using the words PCC. These staff members supported a person-centered culture through promoting personhood, decision making, meaningful living, and pleasurable living in a similar way to nursing staff. Non-clinical staff explained ways in which they fostered pleasurable living by creating festivities for residents such as dancing or singing. Residents' choices were respected, but staff were always nearby in case they were needed. Finally, non-clinical staff explained how they helped residents navigate living in a large community.
Previous literature has focused on the ways direct care workers have promoted PCC (Edvardsson et al., 2013). However, the current study identifies ways in which staff in supporting roles contribute in similar ways to person-centered practices. Examples of ways staff promote personhood were found for all categories except involving residents in everyday tasks and activities. One reason why this could have occurred is that saturation was not reached with the sample. Additional studies on PCC need to include non-clinical personnel to advance the understanding of their role. Another possibility is that assisted living staff in these roles may not include residents in everyday tasks. Most assisted living residents pay privately for care and may not wish or expect to be included in housekeeping or maintenance tasks.
In addition, a sub-category to promoting a pleasurable living emerged from the data regarding helping to navigate the organization. This finding is reflective of the unique role of non-clinical staff. Helping navigate the organization was not just about helping residents find their way, but was also about connecting residents to other residents, staff, or departments who can meet their needs.
The implication of the current work is to encourage assisted living providers to include all personnel having direct interactions with residents in person-centered education, training, and implementation. Non-clinical staff can play a role in identifying important preferences for everyday living, such as preferred activities or interests among residents. Using additional staff members to contribute to the organization's understanding of the background and history of a resident would help relieve pressures felt by clinical staff. In addition, such understanding can help in promoting positive resident–staff relationships as well as increasing job satisfaction among staff (Payne, 2010). Including non-clinical care team members in the overall PCC mission could aid in creating a team approach to care for the improvement of PCC plans and creative solutions to problems. This team approach would also facilitate the promotion of a sense of belonging and fulfillment among staff, leading to a working environment that feels less clinical.
As with all studies, the current study has limitations. It is a secondary analysis based on the voices of a small convenience sample of assisted living staff, who are part of a private pay organization on the East Coast. Findings may not be reflective of similar staff members in other locations and settings. For example, it was surprising that non-clinical staff were not more involved in everyday tasks and activities. In addition, PCC was not the purpose of the original study and was not specifically discussed and not all categories of staff provided examples for all domains equally. Additional examples of ways non-clinical staff promote PCC could have been determined had more direct questions been asked.
Non-clinical staff members have a vital role to play in facilitating assisted living organizations' PCC goals. Non-clinical staff explained how they promote PCC culture through promoting personhood, decision making, meaningful living, and pleasurable living. Including non-clinical staff in the organization's PCC education, training, and implementation can support a team approach to care.
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Ways Nursing Staff Facilitate Person-Centered Care
|Promoting decision making|
Offering resident choices
Respecting resident choices
|Promoting a meaningful living|
Involving residents in everyday tasks and activities
Creating activities that match residents' needs and interests
|Promoting a pleasurable living|
Facilitating experiences of grooming
Creating festivities for residents
Navigating the organization
Seeing the resident as a valuable person
Listening to residents' life stories