Journal of Gerontological Nursing

Person-Centered Care 

Mapping Core Concepts of Person-Centered Care in Long-Term Services and Supports

Liza L. Behrens, MSN, RN; Gwen McGhan, PhD, RN; Katherine M. Abbott, PhD, MGS; Donna M. Fick, PhD, RN, FGSA, FAAN; Ann Marie Kolanowski, PhD, RN, FAAN; Yin Liu, PhD; Harleah G. Buck, PhD, RN, FPCN, FAHA, FAAN; Martina Roes, PhD; Allison R. Heid, PhD; Abby Spector, MMHS; Kimberly Van Haitsma, PhD

Abstract

Person-centered care (PCC) has a wide range of definitions, most based on expert opinion rather than empirical analysis. The current study used an empirical concept mapping approach to identify core components of PCC used in long-term services and supports (LTSS). The aim is to help providers and researchers develop a unified set of domains that can be used to assess and improve the quality of PCC in real-world settings. Results yielded six domains describing essential elements of PCC in LTSS: Enacting Humanistic Values, Direct Care Worker Values, Engagement Facilitators, Living Environment, Communication, and Supportive Systems; and two underlying dimensions: Intrapersonal Activities and Extrapersonal Services and Social and Physical Environment. Nurses can use the results to enhance clinical knowledge and skills around delivery of PCC. Researchers can use the results to build a comprehensive and unified measure to accelerate adoption of PCC practices shown to benefit older adults, families, and the LTSS workforce. [Journal of Gerontological Nursing, 45(2), 6–13.]

Abstract

Person-centered care (PCC) has a wide range of definitions, most based on expert opinion rather than empirical analysis. The current study used an empirical concept mapping approach to identify core components of PCC used in long-term services and supports (LTSS). The aim is to help providers and researchers develop a unified set of domains that can be used to assess and improve the quality of PCC in real-world settings. Results yielded six domains describing essential elements of PCC in LTSS: Enacting Humanistic Values, Direct Care Worker Values, Engagement Facilitators, Living Environment, Communication, and Supportive Systems; and two underlying dimensions: Intrapersonal Activities and Extrapersonal Services and Social and Physical Environment. Nurses can use the results to enhance clinical knowledge and skills around delivery of PCC. Researchers can use the results to build a comprehensive and unified measure to accelerate adoption of PCC practices shown to benefit older adults, families, and the LTSS workforce. [Journal of Gerontological Nursing, 45(2), 6–13.]

Person-centered care (PCC) is recognized as the gold standard to promote well-being among older adults receiving long-term supports and services (LTSS) (American Geriatrics Society [AGS] Expert Panel on PCC, 2016). LTSS includes services provided in assisted living, nursing homes, and home- and community-based settings (Centers for Medicare & Medicaid Services [CMS], 2016a). In the United States, approximately 5.7 million older adults live with physical and cognitive impairments requiring LTSS (Drabek & Marton, 2015). A significant proportion live with dementia, which may compromise their ability to adequately communicate (Alzheimer's Association, 2018) needs and preferences—presenting complex obstacles to effective delivery of PCC. Emerging research shows positive psychosocial benefits of PCC with the LTSS population (Kim & Park, 2017).

Although PCC is recognized as optimal, the LTSS field lacks a clear consensus conceptualization for this care paradigm. A recent literature review identified 15 different descriptions of PCC and found the term used interchangeably with patient-centered care, person-directed care, and related phrases, each with its own distinctive meaning (Kogan, Wilber, & Mosqueda, 2016b). The absence of an agreed-upon definition makes it difficult for researchers to develop tools to assess effectiveness of PCC and hinders clinicians' ability to routinely deliver and assess the quality of PCC (Gitlin, Maslow, & Khillan, 2018).

To address this issue, the 2018 National Research Summit on Dementia Care issued the recommendation to develop consistent measures of PCC for LTSS that allow for cross-study comparison (Gitlin et al., 2018). A consensus definition for PCC could lead to evidence-based practices that would help the rapidly growing number of older adults in need. The current article uses an empirical method, concept mapping, to define and distill key components of PCC for future LTSS research tool development and clinical advancement.

The current authors' review of the literature for instruments published in or before 2015 evaluating PCC among older adults receiving LTSS yielded 10 empirical tools that measure 44 domains of PCC (Coyle & Williams, 2001; Edvardsson, Koch, & Nay, 2009; Hwang, Tu, Chen, & Wang, 2012; Liss et al., 2011; “Person-Centered Practices in Assisted Living...”, 2013; Sullivan et al., 2013; Tarn, Young, & Craig, 2012; Williams, Boyle, Herman, Coleman, & Hummert, 2012; Wolf et al., 2004; Zimmerman et al., 2015). Each domain has a subset of concepts or items, many that overlap with prior definitions and others that extend beyond them (Table A, available in the online version of this article). Further empirical validation of the broad PCC construct is still needed to create a consistent operational definition of PCC for researchers and practitioners to use within LTSS settings. A rigorous understanding of PCC's most essential elements would help scientists create reliable and valid tools to evaluate PCC, test models, and conduct multi-study analysis, which would likewise help providers work to achieve consensus quality benchmarks for PCC.

Instruments Measuring Person-Centered Care in Long-Term Services and SupportsInstruments Measuring Person-Centered Care in Long-Term Services and Supports

Table A:

Instruments Measuring Person-Centered Care in Long-Term Services and Supports

Purpose

The current study used a concept mapping technique to explore the question: What are the key domains of PCC as operationalized in existing measurement tools? Concept mapping is an empirical data analytic approach that produces a visual representation of items, ideas, or concepts (Carpenter, Van Haitsma, Ruckdeschel, & Lawton, 2000; Trochim & McLinden, 2017). This approach allows for exploration of relationships among items via data visualization. It has been used for theory and model development, as well as for planning and research (Carpenter et al., 2000; Trochim & McLinden, 2017). Using concept mapping to explore the content and structure of current PCC measurement tools represents an important next step beyond expert opinion because it elicits empirically derived concepts to define PCC.

Method

Materials and Procedures

The current study used sequential data gathering and analysis steps congruent with Trochim's concept mapping method (Trochim & McLinden, 2017). First, a database was compiled of PCC measures via a literature review. To identify empirical tools that evaluate PCC from the perspective of older adults receiving LTSS, a comprehensive literature search was conducted during the first funding year of this project, 2014–2015, using multiple health care databases such as CINAHL and PubMed. The terms person-centered care and older adults, along with common derivations, were used to identify potentially relevant articles. Articles were reviewed manually to verify inclusion of the older adult population (age 65 or older) and LTSS settings. Expert stakeholders were consulted to confirm all tools had been captured.

Ten tools published from 2001 to 2015 were identified based on the following inclusion criteria: (a) the tool could be completed from the perspective of the older adult; and (b) the tool could be used in a LTSS setting (Table A). The tools comprise 44 PCC domains (major concept groupings) and 347 individual items (single concepts). For practical reasons, Trochim (1986) recommends that a stakeholder group examine less than 100 statements. Accordingly, the 44 domains became the focus of the current work (Table A).

A PCC Stakeholder Advisory Panel was convened, whose members had experience in personal or professional roles with PCC for older adults receiving LTSS. Following Institutional Review Board approval, stakeholders received an e-mail asking them to take part in an online mapping process where they would sort domains of PCC into categories. The e-mail included an informed consent document and link to the survey in OptimalSort (Optimal Workshop Ltd., n.d.), an online sorting software tool. Participants were instructed to work independently to sort domains into categories based on their perceived similarity. Domains could be placed into only one category. OptimalSort recorded the time the task took and documented each participant's domain groupings.

Data Analysis

Concept mapping in the current study was designed to synthesize qualitative data (item sorting by each participant) with multivariate statistical analyses to develop an initial understanding of areas related to PCC from older adults' perspectives, which were then represented visually through a map. The quantitative analyses included multidimensional scaling (MDS) of the sorted items, and hierarchical cluster analysis of the MDS coordinates. The visual map shows the individual items in two-dimensional (x, y) space with similar items located closer to one another and grouped into clusters.

Multidimensional Scaling. The concept mapping analysis used item sort information to construct an N × N binary matrix of similarities for each participant based on all 44 domains (Trochim & McLinden, 2017). For any two domains, a “1” was put in Xij if they were placed in the same group by a participant; a “0” was entered if otherwise. The total N × N similarity matrix Tij was generated by summing across all individual Xij matrices. Therefore, any cell in the total similarity matrix could take integer values between 0 and 17 (the number of participants who sorted the domains). The ALSCAL procedure in IBM SPSS Statistics 22 was used, which calls for a dissimilarity matrix rather than a similarity matrix as input. To generate a dissimilarity matrix, the value in each cell of the total similarity matrix was subtracted from 17 (the total number of sorters).

Solutions for different numbers of dimensions were requested during MDS. Prior research showed that interpretation would be more difficult when the number of dimensions was more than three (Carpenter et al., 2000). The statistic that can help determine the reasonable number of dimensions that concisely summarize the data is the stress value. The stress value is a percentage measure of model goodness of fit (Kruskal & Wish, 1978). The smaller the stress value, the better fit of the model (Kruskal & Wish, 1978).

Hierarchical Cluster Analysis. The x, y configuration for each item on the two-dimensional MDS solution was input for the hierarchical cluster analysis using Ward's algorithm to define a cluster (Everitt, 1980). Although no simple mathematical criterion is available to determine the number of clusters, a previous study has suggested using the coefficient from the agglomeration schedule for an ideal clustering solution (Carpenter et al., 2000). The coefficient is the squared Euclidean distance between clusters (Trochim & McLinden, 2017). One suggestion is to stop clustering at the number of clusters preceding the first most significant increase in the agglomeration coefficient (Carpenter et al., 2000). As another method for determining ideal number of clusters, Trochim and McLinden (2017) also suggest qualitatively reviewing how items are grouped in different stages of the cluster analysis. Interpretations of the concept map and clusters were based on procedures suggested by Trochim and McLinden (2017).

Results

Demographics

Seventeen participants with expertise in PCC completed the sorting procedure: older adults (n = 2), a family caregiver (n = 1), a professional caregiver (n = 1), LTSS administrators (n = 2), gerontology researchers (n = 8), a policymaker (n = 1), a dementia care policy advocate (n = 1), and a LTSS surveyor (n = 1). The professional caregiver was a RN with experience providing care to individuals with dementia in the community and long-term care. The two older adults, one man and one woman, both resided in the community and were experts in the care of individuals with dementia in LTSS settings. The investigators recruited these individuals through key stakeholder groups to include a range of viewpoints. Participants included two men (12%) and 15 women (88%), with an average age of 52.6 years (SD = 13.8 years). Participants self-identified as non-Hispanic White (94%) and Asian (6%). Fifteen participants had post-college degrees (88%); two were college graduates (12%). Average time to sort the 44 domains was 46 minutes, 50 seconds.

Multidimensional Scaling to Determine PCC Dimensions

Figure 1 shows the stress values for MDS solutions, with the number of dimensions ranging from one to six. The stress value for the two-dimensional solution in the current study was 18%, which was comparatively low among studies in the MDS literature (Carpenter et al., 2000). Although this stress value was still slightly higher than the recommended 10%, Kruskal and Wish (1978) argued that two-dimensional solutions are acceptable when they are combined with cluster analysis. Thus, a two-dimensional solution was adopted.

Stress values for multidimensional scaling solutions of different numbers of dimensions.Note. The stress value for the two-dimensional solution was 18%.

Figure 1.

Stress values for multidimensional scaling solutions of different numbers of dimensions.

Note. The stress value for the two-dimensional solution was 18%.

In the current study, the first significant increase in agglomeration coefficient occurred between a solution with five and six domain clusters, with a coefficient change at this stage of 2.226. The coefficient change prior to this stage was 0.857; the coefficient change at the next stage was 2.594. The six-cluster solution seemed to provide the best balance between statistical interpretation and detailed categorization using qualitative analysis. On the final concept map, dimensions and domain clusters were labeled using content analysis of the items included in each dimension and domain cluster (Table B, available in the online version of this article). Group consensus determined labeling (Trochim & McLinden, 2017). Figure 2 shows the two-dimensional map generated by the participant sorting and analysis. Each cluster represents a core component of PCC in LTSS, whereas each point on the map represents one of the 44 PCC domain items identified in the literature (Table A), with domain items that were sorted together in closer proximity to one another. Domain items closer to one another were rated as similar, whereas those farther away were considered dissimilar (Trochim & McLinden, 2017).

Person-Centered Care Domain Item Clusters Based on the Six-Cluster Solution from the Hierarchical Cluster AnalysisPerson-Centered Care Domain Item Clusters Based on the Six-Cluster Solution from the Hierarchical Cluster Analysis

Table B:

Person-Centered Care Domain Item Clusters Based on the Six-Cluster Solution from the Hierarchical Cluster Analysis

Euclidean distance model two-dimensional concept map from multidimensional scaling (MDS) of 44 person-centered care (PCC) domain items. Each point on the map represents one of the domain items from instruments measuring PCC in long-term services and supports (LTSS). The complete list of domain items is labeled with the letter “i” and followed by a number (see Table B for explanation). The first significant increase in agglomeration occurred between a solution with five and six domain clusters, with a coefficient change at this stage of 2.226. The coefficient change prior to this stage was 0.857; the coefficient change at the next stage was 2.594. The six-cluster solution seemed to provide the best balance between statistical interpretation and detailed categorization using qualitative analysis.

Figure 2.

Euclidean distance model two-dimensional concept map from multidimensional scaling (MDS) of 44 person-centered care (PCC) domain items. Each point on the map represents one of the domain items from instruments measuring PCC in long-term services and supports (LTSS). The complete list of domain items is labeled with the letter “i” and followed by a number (see Table B for explanation). The first significant increase in agglomeration occurred between a solution with five and six domain clusters, with a coefficient change at this stage of 2.226. The coefficient change prior to this stage was 0.857; the coefficient change at the next stage was 2.594. The six-cluster solution seemed to provide the best balance between statistical interpretation and detailed categorization using qualitative analysis.

Figure 3 shows the cluster concept map with the cluster labels:

  • Enacting Humanistic Values,
  • Direct Care Worker Values,
  • Engagement Facilitators,
  • Living Environment,
  • Communication, and
  • Supportive Systems.
Person-Centered Care Concept Map for Long-Term Services and Supports.

Figure 3.

Person-Centered Care Concept Map for Long-Term Services and Supports.

Each cluster contains a coherent set of items, from both a conceptual and statistical perspective, and reflects areas that participants considered indicators of PCC delivery in LTSS.

Enacting Humanistic Values, placed at the center of Figure 3, includes characteristics such as supporting religious or spiritual beliefs and personalizing services according to individual preferences and goals. Its central position highlights its connection to other clusters. Direct Care Worker Values includes items such as showing respect and sensitivity, which are behaviors and attitudes associated with the delivery of humanistic care. The cluster Engagement Facilitators includes items such as food and dining as well as activities that promote social connectedness. The other clusters represent communication, supportive services, and the living environment.

Figure 3 shows the two dimensions produced by the MDS configuration, following Trochim's recommended strategy (Trochim & McLinden, 2017) in which patterns among items are examined adjacent to one another and at opposite sides of Figure 2. Dimension 1 represents a continuum of dynamic activities both internal and external to the individual; accordingly, the team labeled the poles Intrapersonal Activities and Extrapersonal Services. Dimension 2 reflects a social versus physical perspective on the environment as outlined by Lawton's taxonomy of person–environment fit (Lawton & Nahemow, 1973). The poles were labeled Social Environment and Physical Environment.

Discussion

Research indicates that LTSS providers have been slow to adopt PCC practices (Applegate, Ouslander, & Kuchel, 2018; Grabowski et al., 2014). Research on the implementation of PCC practices in LTSS settings reveals that organizations ascribe unique definitions for operationalizing PCC for older adults in creating environmental culture, attributes of care, and measurement (Kogan, Wilber, & Mosqueda, 2016a). The variation in the operational definition is a reported barrier to adoption (Kogan, Wilber, & Mosqueda, 2016a). Identifying PCC's core domains offers a critical step toward creating a comprehensive, standard definition of PCC that can be used to assess and improve personalized care for older adults receiving LTSS. Conceptual clarity supports clear operational definitions and better measurement that can be used to generate rigorous evidence to encourage greater adoption of PCC practices.

The current study found two dimensions of PCC in LTSS: Intra-personal Activities/Extrapersonal Services and Physical/Social Environment. These dimensions relate to the person–environment fit (Lawton & Nahemow, 1973) commonly used to guide LTSS research and reflect the continuum of activities that occur within or happen to the person, plus aspects of the environment built around that person. Concept mapping made it possible to further aggregate the 44 PCC domains reported in the literature into a set of six domain clusters with practical implications for implementation.

The Enacting Humanistic Values domain cluster emerged from the current study as the concept most essential to delivering PCC in LTSS. This domain cluster is centrally located on the concept map, overlaps with three of four quadrants, and integrates an understanding of personhood and human values in social living environments. Accordingly, this cluster conveys the expectation for a culture of care based on an understanding of each person's values and preferences, a concept consistent with all previous definitions of PCC (AGS Expert Panel on PCC, 2016; CMS, 2016b; Fazio, Pace, Flinner, & Kallmyer, 2018; Kogan et al., 2016b; The SCAN Foundation, 2016). Domain items in this cluster address older adults' psychological needs and goals, and how staff can support older adults in pursuit of fulfilling needs or goals. Findings emphasize respect for the individual along with rights to autonomy and self-directed and personalized care; opportunities to participate in preferred forms of religious and spiritual practice; and a sense of safety, comfort, and belonging as cornerstones of quality PCC.

The Direct Care Worker Values domain cluster calls attention to the critical role of RNs, licensed practical nurses, and certified nursing assistants in PCC delivery for older adults. This domain cluster is closely connected to the Enacting Humanistic Values domain cluster and reflects direct care workers' beliefs or behaviors about what is important when attending to older adults' needs, such as respecting their right to dignity and seeking full information to allow older adults to direct their own care. However, this domain cluster relies heavily on caregiver attitudes such as concern, sensitivity, patience, honesty, active listening, encouragement, and appreciation of older adults—ingredients to building caring and nurturing relationships with older adults (Brownie & Nancarrow, 2013; Mittal, Rosen, & Leana, 2009). Current research focuses on the shortage of direct care workers and the need for improved recruitment, retention, skill development, and supervision (Gilster, Boltz, & Dalessandro, 2018). This cluster offers a key domain to consider when defining PCC and a readily available set of items that could be used to: develop job descriptions, assess applicants' desired qualities, or design training and performance evaluations to nurture staff competencies and empathic approaches in PCC delivery.

The next set of domains relates to the structure, skills, supervisory, and staffing aspects of PCC in LTSS. These domains have many thematically linked implications and outcomes.

The Communication domain cluster highlights the need for skilled communication between provider and older adult. The current results emphasize the importance of including key components of effective communication such as information exchange; open and careful listening; respect for older adults' right to autonomy and informed decision making; and responsiveness to questions, concerns, and complaints (Burgio et al., 2001). Domain cluster items describe person-centered communication as an approach in which staff show compassion and empathy and are clear and unhurried when conveying information. Studies show that clear, compassionate communication leads to positive behavioral and affective responses among nursing home residents (Gilmore-Bykovskyi, Roberts, Bowers, & Brown, 2015; Savundranayagam & Moore-Nielsen, 2015). This domain cluster, the mechanisms by which important information about individuals' values and preferences are transferred between providers and care receivers, is essential to PCC delivery in LTSS and should continue to receive prominence in definitions of PCC.

The Engagement Facilitators domain cluster describes vital social and recreational aspects of care in LTSS. The PCC domain items include: enjoyable dining; a congenial atmosphere; and varied activity offerings that are enriching, purposeful connections among residents, families, and staff. Elements of social engagement have a direct impact on physical and mental health (Umberson & Montez, 2010). Studies show that higher levels of social engagement are associated with longer survival rates, higher perceived quality of life, and psychological well-being, and serve as a mediator to physical decline and depressive symptoms in LTSS (Guse & Masesar, 1999; Kiely & Flacker, 2003; Yeung, Kwok, & Chung, 2013). Engagement facilitators can be self-reported or observed, particularly for individuals with dementia (Hill, Kolanowski, & Kürüm, 2010), and should be incorporated into PCC scale development, research, and service delivery.

The Living Environment domain cluster describes design elements that support PCC in LTSS settings. This domain cluster incorporates physical and social attributes of one's surroundings, including privacy and attractive and welcoming spaces for older adults, families, and the community. Findings highlight non-institutional design elements, such as resident rooms grouped in small-scale households rather than along institutional corridors, no overhead paging, outdoor access, and welcoming spaces for all generations. Lawton and Nahemow's (1973) seminal work on person–environment interaction in LTSS affirms the living environment as an essential element in operationalizing PCC in LTSS. Their research, along with subsequent studies, shows that well-designed, homelike settings can foster a sense of community, decrease functional dependence, promote social interaction, and provide familiarity that may allow caregivers to be more responsive to older adults' individual needs and preferences (Chaudhury, Hung, & Badger, 2013).

The Supportive Systems domain cluster refers to workplace practices, training, and leadership, which allow staff to individualize care using a collaborative process with shared decision making. A review identified key factors consistent with these findings: stable staff assignment, management support of shared decision making, PCC staff training, and innovative staffing models (Brownie & Nancarrow, 2013). The culture change movement shows that introducing PCC requires a strong, flexible, and supportive organizational leadership team (Capezuti, Taylor, Brown, Strothers, & Ouslander, 2007). Concept mapping findings emphasize that coordination among providers within and across settings, training, career development, and performance evaluation linked to culture change are necessary to individualize care and measure performance of LTSS organizations in PCC delivery.

Limitations

Findings from the current study should be interpreted with limitations in mind. First, domains for sorting were selected from 10 PCC measures used in the LTSS setting. Domain areas and measures that emerged in research published after the literature review was completed in 2015 were missed. For example, Burke, Stein-Parbury, Luscombe, and Chenoweth (2016) published the Person-Centered Environment and Care Assessment Tool, which measures dementia care services for residential care in Australia. The three domains Burke et al. (2016) developed to match the Australian Health Department–mandated standards overlap completely with the domains presented in this article (Domain 1. Organizational Culture; Domain 2. Care and Activities, Interpersonal Relationships and Interactions; and Domain 3. Physical Layout and Design). Second, study inclusion criteria focused on self-ascribed PCC measures completed from the perspective of the older adult, leaving out tools examining different aspects of dementia care, such as the environment (Fleming, 2011). Third, two of 17 raters were older adults and it is unknown whether these individuals live with impairments commonly seen in LTSS settings. In addition, 94% of participants were non-Hispanic White and primarily female. Including a more diverse group of participants may have changed the sorting outcomes. Future research should include a more diverse group of participants, as well as newly published measures and those geared toward additional care settings.

Conclusion

Delivery of PCC is a core component of achieving competency as a practicing gerontological nurse; yet, there are no evidence-based frameworks or theories to support this practice. The American Nurses Credentialing Center (2015) tests on two domains for knowledge and skill competency in PCC for board certification: communication and support. The current study expands on these domains by adding four more areas critical for knowledge and skill development when caring for older adults; namely, enacting humanistic values, direct care worker values, engagement facilitators, and living environment domains. On a practical level, nurses should consistently evaluate and incorporate the preferences and values of older adults receiving LTSS despite cognitive or physical impairment. Nurses should reflect on how their own behaviors, attitudes, and values affect the delivery of PCC to older adults receiving LTSS. Finally, nurses should provide leadership and advocacy around constructing physical and social environments for older adults receiving LTSS that promote physical and psychological well-being. Although more research is required, this study begins to provide a conceptual framework for nurses to build practice-based theory for delivering PCC and measurement tools to evaluate care delivery. Future studies can continue this work by validating the overarching constructs of PCC in LTSS settings, as well as exploring ways in which individual nursing assessments and care practices incorporate the major constructs of this framework.

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Instruments Measuring Person-Centered Care in Long-Term Services and Supports

Study (Year)InstrumentPCC Domain Items
Coyle & Williams (2001)Person Centered Inpatient Scale

Personalization (i.e., treating older adults as individuals)

Empowerment (i.e., having a say in treatment)

Information (i.e., keeping older adults informed)

Approachability/availability (i.e., friendliness and accessibility of staff)

Respectfulness (i.e., staff treat older adults as intelligent human beings)

Wolf et al. (2004)Caring Behaviors Inventory—revised version

Attending to older adults' needs (i.e., making older adults comfortable)

Showing respect (i.e., listening to/being pleasant to older adults)

Practicing knowledgeably and skillfully (i.e., staff were competent in their scope of practice)

Respecting autonomy (i.e., including older adults in their care/being honest with older adults)

Supporting religious/spiritual beliefs (i.e., staff help meet the spiritual needs of older adults)

Edvardsson, Koch, & Nay (2009)English Language Person-Centered Climate Questionnaire–Patient Version

Safety (i.e., protecting overall well-being)

Hospitality (i.e., creating a congenial environment for older adults)

Liss et al. (2011)Ambulatory Care Experiences Survey–Shortened Version

Coordination of care (i.e., organization of patient care activities between two or more health care services)

Hwang, Tu, Chen, & Wang (2012)Elderly Resident-Perceived Caring Scale

Understanding (i.e., the sensitivity of staff to emotions, language, and needs of older adults)

Accompanying (i.e., concern, patience, and honesty of staff and their willingness to share experiences with older adults and listen actively)

Assisting (i.e., the extent to which staff ensure the safety of older adults and address their needs)

Encouraging (i.e., the extent to which staff appreciate, assure, and enable older adults)

Tarn, Young, & Craig (2012)Patient Approach and Views Toward Health Care Communication Scale

Approach to interactions (i.e., staff explain things to older adults in terms that can be easily understood)

Views about physicians' health care communication (i.e., physicians read information to older adults about a new prescription, such as side effects and precautions)

Williams, Boyle, Herman, Coleman, & Hummert (2012)Emotional Tone Rating Scale

Person-centered communication (i.e., interpersonal interaction between staff and older adults is caring and/or nurturing)

Controlling communication (i.e., verbal interaction between staff and older adults may be perceived as dominating or bossy)

Sullivan et al. (2013)Artifact of Culture Change Tool

Care practices (i.e., a composite of care plans that are formatted to address meals and snacks, individualized daily routines, and bathing routines)

Environment (i.e., a composite of older adults' surroundings that includes households, private rooms, accessibility both indoors and outdoors, individualization of rooms, removal of overhead paging, bathing, and laundry)

Family/community (i.e., a composite of intergenerational families, community access, entertaining options, and reciprocity)

Leadership (i.e., a composite of the organization that includes staff attendance at conferences, including older adults and families on quality committees, older adults having a staff buddy, inclusive decision making)

Workplace practices (i.e., a composite of the workplace that includes consistent staffing, self-scheduling, staff attendance at conferences, cross training, performance evaluation tied to culture change, job development)

Outcomes (i.e., composite of longevity of staff tenure, turnover, use of agency staff, census)

Person-Centered Practices in Assisted Living: Resident Questionnaire (2013)Person-Centered Practices in Assisted Living: Resident Questionnaire

Settling in (i.e., staff provide older adults with a sense of belonging)

Planning and providing care and services (i.e., older adults receive care and services according to personal preferences and goals)

Caregiving staff (i.e., staff are caring and compassionate)

Environment and surroundings (i.e., safe, attractive, welcoming, and private space requirements are met)

Activities (i.e., older adults, families, caregivers, and staff can partake in diverse types of activities that are of interest)

Spirituality (i.e., older adults have opportunities and places to practice religious or spiritual beliefs)

Food and dining (i.e., mealtimes are pleasant and enjoyable for older adults)

Family (i.e., family members are welcomed and provided information about the activities and services for older adults)

Communication (i.e., older adults' rights are respected, concerns are answered, complaints and feedback are welcomed and addressed)

Zimmerman et al. (2015)Person-Centered Practices in Assisted Living—Staff Questionnaire

Well-being and belonging (i.e., older adults feel a sense of belonging)

Individualized care and services (i.e., older adults are involved in planning own care and services)

Social connectedness (i.e., different types of activities that are interesting to participate in)

Atmosphere (i.e., it is noisy at night)

Workplace practices (i.e., the administrator and other leaders are present and approachable)

Social connectedness (i.e., there are different types of activities that are interesting for older adults)

Individualized care and services (i.e., staff encourage and help older adults direct their own care)

Caregiver–resident relationships (i.e., staff often speak to older adults in an unclear or hurried manner)

Person-Centered Care Domain Item Clusters Based on the Six-Cluster Solution from the Hierarchical Cluster Analysis

Domain Cluster 1: Enacting Humanistic ValuesItems in this cluster represent the behaviors and attitudes that underlie humanistic care. The items address older adults' psychological needs and goals. Domain items also speak to how care partners support older adults in fulfilling those needs and goals.
LabelItem Description
i11Supporting religious/spiritual beliefs (i.e., staff help meet the spiritual needs of older adults)
i12Spirituality (i.e., older adults have opportunities and a place to practice religious or spiritual beliefs)
i13Personalization (i.e., treating older adults as whole persons)
i14Respecting autonomy (i.e., including older adults in their care/being honest with older adults)
i20Assisting (i.e., the extent to which staff ensure the safety of older adults and address their needs)
i25Empowerment (i.e., older adults having a say in their treatment)
i26Individualized care and services (i.e., older adults are involved in planning own care and services)
i28Attending to older adults' needs (i.e., making older adults comfortable)
i29Care practices (i.e., a composite of care plans that are formatted to address meals and snacks, individualized daily routines, and bathing routines)
i41Planning and providing care and services (i.e., older adults receive care and services according to personal preferences and goals)
i42Well-being and belonging (i.e., older adults feel a sense of belonging)
i43Settling in (i.e., staff provide older adults with a sense of belonging)
i44Safety (i.e., protecting overall well-being)
Domain Cluster 2: Engagement FacilitatorsItems in this cluster refer to activities within long-term services and supports (LTSS) that engage older adults in social connectedness.
LabelItem Description
i4Food and dining (i.e., mealtimes are pleasant and enjoyable for older adults)
i5Hospitality (i.e., creating a congenial environment for older adults)
i6Family (i.e., family members are welcomed and provided information about the activities and services for older adults)
i8Social connectedness (i.e., different types of activities that are interesting to do [older adults' perspective])
i9Social connectedness (i.e., different types of activities that are interesting for older adults to do [caregivers' perspective])
i10Activities (i.e., older adults, families, caregivers, and staff can partake in diverse types of activities that are of interest)
Domain Cluster 3: Living EnvironmentItems in this cluster address the environment of individuals living in long-term care. Elements of physical and social environments are included.
LabelItem Description
i1Environment (i.e., a composite of older adults' surroundings that includes households, private rooms, accessibility both indoors and outdoors, individualization of rooms, removal of overhead paging, bathing, and laundry)
i2Environment and surroundings (i.e., safe, attractive, welcoming, and private space requirements are met)
i3Atmosphere (i.e., it is noisy at night)
i7Family/community (i.e., a composite of intergenerational families, community access, entertaining options, and reciprocity)
Domain Cluster 4: Supportive SystemsItems in this cluster relate primarily to support systems. The items address workforce management and specific types of leadership needed to individualize care.
LabelItem Description
i30Coordination of care (i.e., organization of patient care activities between two or more health care services)
i31Workplace practices (i.e., the administrator and other leaders are present and approachable)
i32Workplace practices (i.e., a composite of the workplace that includes consistent staffing, self-scheduling, conference attendance by staff, cross training, performance evaluation tied to culture change, job development)
i33Outcomes (i.e., composite of longevity of staff tenure, turnover, use of agency staff, census)
i34Leadership (i.e., a composite of the organization that includes staff attending conferences, older adults and families on quality committees, older adults having staff buddy, inclusive decision making)
Domain Cluster 5: CommunicationItems in this cluster predominantly relate to care partner–resident communication. Items include verbal and non-verbal interactions that are bidirectional between care partners and residents. Items provide factors to consider at each interaction.
LabelItem Description
i17Person-centered communication (i.e., interpersonal interaction between staff and older adults is caring and/or nurturing)
i18Approach to interactions (i.e., staff explain things to older adults in terms that can be easily understood)
i19Practicing knowledgeably and skillfully (i.e., staff are competent in their scope of practice)
i21Caregiving staff (i.e., staff are caring and compassionate)
i35Approachability/availability (i.e., friendliness and accessibility of staff)
i36Caregiver–resident relationships (i.e., staff often speak to older adults in an unclear or hurried manner)
i37Controlling communication (i.e., verbal interaction between staff and older adults may be perceived as dominating or bossy)
i38Communication (i.e., older adults' rights are respected, concerns are answered, complaints and feedback are welcomed and addressed)
i39Information (i.e., keeping older adults informed)
i40Views about physician's health care communication (i.e., the physician reads information to the older adult about a new prescription, such as side effects and precautions)
Domain Cluster 6: Direct Care Worker ValuesItems in this cluster also include behaviors and attitudes associated with the delivery of humanistic care but focus on the behaviors, attitudes, emotions, and feelings exhibited by direct care workers.
LabelItem Description
i15Respectfulness (i.e., staff treat older adults as intelligent human beings)
i16Showing respect (i.e., listening/being pleasant to older adults)
i22Understanding (i.e., sensitivity of staff to emotions, language, and needs of older adults)
i23Accompanying (i.e., the concern, patience, and honesty of staff and their willingness to share experiences with older adults and actively listen)
i24Encouraging (i.e., the extent to which staff appreciate, assure, and enable older adults)
i27Individualized care and services (i.e., staff encourage and help older adults direct their own care)
Authors

Ms. Behrens is PhD Student, Dr. Fick is Elouise Ross Eberly Endowed Professor and Director of the Center for Geriatric Nursing Excellence, Dr. Kolanowski is Professor, and Dr. Van Haitsma is Associate Professor of Nursing and Director of the Program for Person-Centered Living Systems of Care, The Pennsylvania State University, College of Nursing, University Park, Pennsylvania; Dr. McGhan is Assistant Professor, University of Calgary, Faculty of Nursing, Calgary, Alberta, Canada; Dr. Abbott is Assistant Professor, Department of Sociology and Gerontology, Miami University, Oxford, Ohio; Dr. Liu is Assistant Professor, Utah State University, Emma Eccles Jones College of Education and Human Services, Department of Human Development and Family Studies, Logan, Utah; Dr. Buck is Associate Professor and Coordinator of Chronic Illness Initiatives, University of South Florida, College of Nursing, Tampa, Florida; Dr. Roes is Professor, University of Witten, Witten, North Rhine-Westphalia, Germany; and Dr. Heid is Independent Research Consultant, Ardmore, and Ms. Spector is Independent Consultant, Spector Consulting, Bala Cynwyd, Pennsylvania.

The authors have disclosed no potential conflicts of interest, financial or otherwise. Drs. Fick and Van Haitsma were not involved in the peer review or decision-making process of this manuscript.

The authors thank the 17 participants who took part in the card sorting task, and the Program for Person-Centered Living Systems of Care at The Pennsylvania State University College of Nursing for providing funding for this project.

Address correspondence to Liza L. Behrens, MSN, RN, PhD Student, The Pennsylvania State University, College of Nursing, 201 Nursing Sciences Building, University Park, PA 16802; e-mail: LLB237@psu.edu.

10.3928/00989134-20190111-02

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