Person-Centered in Letter or Spirit?: A Review of Three Articles on Applications of Person-Centered Care with Older Adults in Long-Term Residential Care Facilities

By Adam J. Pearson

1. Introduction: Person-Centered Care in Residential Settings for Older Adults

In recent years, researchers have critiqued medical bureaucracies and institutions’ tendencies to reduce short-term patients and long-term residents alike to numbers, depersonalized medical problems, statistics, chunks of time, waitlist positions, or mere occupiers of beds to be discharged as soon as possible (Abraham, 2011; Youngson, 2008). The negative impacts of this alienating approach have been equally well-documented. Particularly in the case of care for older adults, biomedical approaches that value ‘efficiency’ above all have ironically led to increases in acuity, vulnerability, institutional mortality rates, and patient dissatisfaction with care; indeed, as Clarfield, Bergman, and Kane (2001) note in their study of Israel, Canada, and the United States, the problem has become a truly “international concern.” In its attempt to respond to this institutional crisis, the person-centered care (PCC) model has gained support as a best-practice approach to improve quality of care (Slater, 2006). In contrast to the biomedical model, person-centered care aims to offer care that is individualized, personal, holistic, grounded in an enriching social milieu, and respectful of client wishes and values, (Morgan & Yoder, 2012). However, critics of the model claim that it is all too often vague, ideologically sloganistic, inconsistently applied, ineffectual, and overly individualistic (Packer, 2003; Nolan et al., 2004).

Is person-centered care as poorly-defined and ineffectual as these critics allege, or is the model more clearly-articulated and empirically effective than they realize? This paper will attempt to formulate a tentative answer to this question based on a comparative analysis of three articles pertaining to person-centered care. To assess the claim that the term has no consistent and coherent conceptual and methodological meaning, a concept-analysis of the term by Morgan & Yoder (2012) will be analyzed. In addition, in order to assess the quantitative effectiveness of the model in practice in the long-term residential care of older adults, two empirical studies by Brownie and Nancarrow (2013) and Edvardsson, Fetherstonhaugh and Nay (2010) will also be reviewed. Structurally, the paper will begin by summarizing the three articles, will comparatively analyze their findings, and will conclude by exploring advocacy and intervention roles that social workers can play in the practice of person-centered care in health and social service contexts.

2. Surveying the Terrain: Summaries of Three Views of Person-Centered Practice

In the first article, Morgan & Yoder (2012) attempt to unpack the conceptual meaning and effects of person-centered care in a comprehensive concept analysis. Their incisive article can be subdivided into two main sections: first, a definition of person-centered care and its main attributes from a conceptual perspective and second, an analysis of some of the consequences of implementing the approach that have been discussed in the lecture.

In the first section, Morgan & Yoder (2012) define PCC as a holistic bio-psychosocial-spiritual approach to deliver care that is respectful, individualized, allows negotiation, and offers choice through a therapeutic relationship where people are empowered to be involved in health decisions at the level the care receiver desires. The researchers then proceed to define the approach as having distinct attributes, which give it a clear and unified conceptual meaning. According to Morgan & Yoder (2012), PCC is holistic (by recognizing how health issues impact the person’s biological, social, psychological, and spiritual dimensions), individualized (to the person’s values, culture, capacity, and life activities), respectful (of client choices), and empowering (that is, encouraging autonomy and self-confidence through education, support, communication, and negotiation).

In addition, the authors see PCC as acknowledging the impact of a care environment that displays vision and commitment (by drawing on symbols, images, metaphors, and resources to show respect for staff and clients) and shared governance (using less hierarchical and more team-based decision-making that values input from beside workers). In the second section, Morgan & Yoder (2012) suggest that PCC is designed to produce definite consequences. These include improved quality of care (responsive, respectful, timely, and customized to the person) and increased client care satisfaction (through honouring individual needs and choices). Morgan & Yoder (2012) close their article by suggesting that caregivers can use the attributes of PCC to guide their beside practice and measure its outcomes to validate the PCC philosophy.

In the second article, Brownie & Nancarrow (2012) diverge from the previous article’s theoretical focus to undertake a systematic review of the empirical effects of person-centered care and staff in residential care facilities for older adults.  The authors analyze 7 different studies of the impact of PCC on workers and clients in aged-care facilities. The researchers note that person-centered culture interventions tend to incorporate several features including environmental enhancement (e.g. with plants or animals), opportunities for social stimulation and fulfilling relationships (e.g. more visits from family and interaction with other residents and staff), continuity of care (e.g. by assigning residents to the same care staff), changes in management approaches (e.g. to introduce democratized or shared decision-making), changes to staffing models (e.g. focusing on staff empowerment), and individualized care philosophies (rather than institutionalized) (Brownie & Nancarrow, 2012).

The authors concluded that most of the studies they analyzed had design weaknesses like a lack of randomization or selection bias, which limit the inferences that can be generalized from their findings. However, they also found that that despite these limitations, PCC interventions in residential aged-care facilities were associated with psychosocial benefits to residents and staff. These included significant reductions in residents’ levels of boredom, helplessness, and depression and significant increases in staff’s satisfaction in their confidence and ability to provide high-quality individualized care. However, some of the studies found that giving residents more autonomy of movement led to a higher risk of falls and some PCC-implementing facilities seemed to experience higher staff turnover, although the reasons for the increase were unclear from the studies. Brownie & Nancarrow (2012) also found that to be successful, PCC culture changes require good leadership, strong teamwork, efficient care systems, and an investment in staff training about PCC. On the other hand, resistance to implementing PCC models tended to come from senior staff preferences for their existing practices, followed by perceived costs and concerns about conforming with regulatory requirements. The researchers closed their article by suggesting that PCC models should include more concern for residents’ safety before aiming to meet their higher needs.

In the third article, Edvardsson et al. (2010) focus their analysis of PCC implementations even more than the last article to examine their impacts on people with dementia in particular, as well as their family members and the staff who care for them. The researchers interviewed 37 staff working in aged care, 11 people with early-onset dementia, and 19 family members of clients with dementia and conducted a content analysis on their results. The authors found that these respondents reported that the PCC practices of helping staff get to know the person of the client, welcome the family, and provide meaningful activities all promoted what the researchers call a “continuation of self and normality” (Edvardsson et al., 2010, p. 1). Residents reported that being in a personalized environment and experiencing continuity and flexibility of care helped support them as progressive dementia eroded their conceptions of selfhood and accustomed routines of daily life. They appreciated being spoken to respectfully, acknowledged as valuable, and offered opportunities to do likeable things (e.g. listen to music, or participate in parties, barbecues, or celebrations) and make decisions about when to get up from bed, what to eat, and whom to spend time with.

Staff members emphasized the importance of using knowledge about client preferences and life histories to make customized decisions about activities, routines, including small extras (e.g. a coffee or time in the sun), or develop personalized symptom management strategies. Family members reported feeling welcomed when staff frequently communicated changes and significant events to them, and created opportunities to incorporate family members’ intimate knowledge of their loved ones into the care plan. Both family members and residents reported that places that looked pleasant with beautiful interiors, exteriors, and surroundings made them feel more comfortable. Views from the window and interior gardens supported feelings of connection to nature and homeliness. Finally, Edvardsson et al (2010) found that successfully implementing PCC requires low staff turnover to encourage trust and prioritizing quality time with residents over task-completion.

3. Analyzing the Perspectives: Thoughts and Observations on the Issue and the Articles

Taken together, these three articles offer us some helpful insights with which to begin to evaluate the claims of critics of PCC that the model lacks conceptual coherence, is ineffectual, and is overly individualistic as both Packer (2003) and Nolan et al. (2004) had claimed. I will tackle these three charges one at a time using each of the 3 articles in turn as analytical tools.

First, against the claim that PCC lacks conceptual coherence or is only vaguely-defined, the Morgan and Yoder (2012) article provides ample counterevidence. As the authors reveal, the concept can be articulated in very specific terms and conceptually coherent terms. First of all, it is biopsychosocially and even spiritually holistic. In my own work in a long-term care CHSLD facility working with older adults, I have found that the spiritual aspect, which often gets neglected by the biomedical model, is respected and honoured as a source of strength, client value, and coping for residents. This willingness to mobilize the clients’ values is part of the respectful, personalized, individualized approach that conceptually defines PCC (Morgan & Yoder, 2012).

Second, the approach’s prioritization of maximizing client autonomy by incorporating their values, strengths, and choices into care plans and democratizing and sharing governance and decision-making power is yet another defining feature of the approach. I have seen this integrated in practice in respecting clients’ wishes to refuse or request alternate treatments, modify their institutionally-administered diets at will, have input on care schedules so that they can sleep in late if they wish, and make decisions about which activities they would like to attend in the residence. This aspect of PCC powerfully distinguishes it from the top-down, hierarchical, task-oriented, and doctor-dominated traditional biomedical model. Finally, as Morgan & Yoder (2012) reveal, effectively-implemented PCC can increase quality of care and client care satisfaction; this has indeed been my experience in working with clients, who often tell me that they enjoy feeling like their ideas, values, and concerns are integrated into their care plan. Thus, PCC is far more conceptually coherent than its critics claim.

Second, contrary to Packer’s (2003) claim that, as commonly-implemented, the PCC approach tends to be ideologically sloganistic—that is ‘person-centered’ only in name rather than in practice—and ineffectual, Brownie & Nancarrow’s (2012) article reveals that the approach can produce real change within health care institutions. Far from merely a nominal approach, a facility-wide rolling out of PCC involves concrete and multifaceted interventions. Brownie & Nancarrow’s (2012) review of the 7 studies they analyzed showed that these interventions can include enhancing the residents’ environment, boosting recreational and interactional activities, increasing continuity of care, democratizing and sharing decision-making power, and empowering staff. These concrete actions move the approach from merely stating positive slogans to making changes to clients’ daily routines and physical and social environments to improve their well-being.

At the two long-term care residences at which I have worked, I have seen cases in which the nursing team went out of their way to honour residents’ requests for certain foods, sleeping at specific times, or even getting access to coffee at unconventional hours, such as late at night. The idiosyncracies of clients were celebrated and honoured rather than repressed and controlled and as a result, they reported feeling heard and seen as people. Brownie & Nancarrow’s (2012) research also showed that with strong leadership and teamwork, operationalizing the PCC model can lower clients’ boredom, helplessness, depression, and even the agitation of residents with dementia. The dangers posed by giving residents more freedom—such as the higher risk of falls the authors point out—can indeed be mediated by making adaptations to the living spaces through which clients move. For instance, at my workplace, residents who are prone to falling out of bed have cushioning anti-fall mats installed under their beds to protect them without taking away their autonomy through restraints. Thus, PCC can be measurably effectual.

Third, while Nolan et al. (2004) claim that PCC can be overly individualistic to the detriment of considerations of the well-being of the client’s family or community as a whole, the article by Edvardsson et al. (2010) paints a different picture based on the experiences of older adults with dementia, their family members, and the staff who care for them. Far from being overly individualistic, these researchers found that the PCC approach’s personalizing of care for the client and regularly communicating with the client’s family led the family to feel more included, integrated, and happy with the care their loved one was receiving. Personalizing care for the client had the added benefit of giving other clients in the same facility more opportunities in regards to types of recreational and therapeutic activities that were offered to foster their autonomy (Edvardsson et al., 2010). This, in turn, led to a stronger sense of rapport within the community of residents and a culture in which respect for individual differences is fostered. While biomedical hierarchy and ‘efficiency’-driven models tend to increase social isolation and withdrawal among residents, the PCC approach was found to foster increased closeness and in-group togetherness. Thus, the surprising effect of personalizing care by treating clients as individuals was that it led to the very increases in collective health that critics denied.

4. A Role for Social Work: Advocacy and Intervention Roles for Social Workers

While, as these articles point out, the PCC approach can have numerous benefits for residents, family members, and the staff that serve them, social workers can do a great deal to ensure that the approach is consistently implemented in the best interests of clients. First, since policy and higher-organizational expectations to increase efficiency at all costs can threaten the resources, space, and time that properly implementing the PCC approach requires, social workers can serve a key role at the macro-systemic level in advocating for and helping craft policies that support rather than discourage the success of the PCC model. This is particularly the case since, due to their size, large bureaucracies like Quebec’s MSSS and CIUSSS system are constantly at risk of falling into a breakdown of communication between their various structural levels (Viens et al., 2005). As a result, organizational and managerial choices can be made at the higher levels that are out of touch with the frontline realities on the ground; social workers can play a role in combating this tendency with advocacy within and without their organizations, participation in policy-drafting and advisory committees, and writing letters and reports to higher officials.

Second, at the meso-level of intervention, social workers can play a role in building programs that are person-centered and consistent with the PCC philosophy for caregivers and family members. They can also draw on clients’ expresses wishes and interests for programming to design groups to fill in the gaps in service delivery within their organizations. In this way, they can ensure that the care approach is authentically respectful and individualized at the meso-scale.

Third, on a micro-level, even though the PCC model is developed with the best of intentions and aims to amplify the voices of clients in decision-making and the role of their wishes in care plans, in practice, the biomedical model continues to be a dominant force in the life of clients (Abraham, 2011). Doctors often still wield dominant sway over care decisions and high demands on the time of nurses may lead them to be unable to spend enough time with clients to hear their concerns and answer their questions (Youngson, 2008).  As a result, social workers can play a vital role at the micro-level of facilitating communication between clients and other professions within the care team such as nurses, occupational therapists, dieticians, and physical and rehabilitation therapists.

One of the key roles I play within the context of PCC within the residence at which I work is to listen to clients’ questions and concerns sand then frame and communicate them in ways that are tailored to the professionals best equipped to respond to them. I can also help clients who may have reduced communication skills due to cognitive deterioration to negotiate for additional adaptations or individualized consideration with the key team members with the power to make those decisions. Thus, at the micro-level, social workers can play a key role in getting to know clients’ life histories and psychosocial experiences on a more in-depth level than other professionals and voicing these to the team to support PCC.

5. Seeing Personhood Over Quantitativity: Concluding Words in an Ongoing Discussion

In conclusion, the person-centered care model arose as attempt from the nursing field and other professions to rectify the problems created by the biomedical model’s fixation on statistical efficiency as the ultimate good. As it turns out, this model is perfectly consonant with the social work profession’s valuation of client dignity, self-determination, and maximizing well-being for individuals, communities, and families. Although the model is not without its limitations and pitfalls, as Morgan & Yoder (2012), Brownie & Nancarrow (2013), and Edvardsson et al. (2010) all suggest, it nonetheless offers workers in the helping professions a powerful theoretical lens and practice model through which to view, not the person as a number, but the client as a person.

References

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Brownie, S., & Nancarrow, S. (2013). Effects of person-centered care on residents and
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Clarfield, A. M., Bergman, H., & Kane, R. (2001). Fragmentation of care for frail older people—An international problem. Experience from three countries: Israel, Canada, and the United States. Journal of the American Geriatrics Society, 49(12), 1714-1721.

Edvardsson, D., Fetherstonhaugh, D., & Nay, R. (2010). Promoting a continuation of self and normality: Person‐centred care as described by people with dementia, their family
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Morgan, S., & Yoder, L. H. (2012). A concept analysis of person-centered care. Journal of
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Nolan, M. R., Davies, S., Brown, J., Keady, J., & Nolan, J. (2004). Beyond ‘person‐centred’
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Packer, T. (2003). Turning rhetoric into reality. In Community Mental Health Nursing and Dementia Care: Practice Perspectives (pp. 104-119). Buckingham: Open University Press.

Slater, L. (2006). Person-centredness: A concept analysis. Contemporary Nurse, 23, 135–144.

Youngson, R. (2008). Compassion in healthcare: The missing dimension of healthcare reform? London: NHS Confederation.

Viens, C., Lavoie-Tremblay, M., Leclerc, M. M., & Brabant, L. H. (2005). New approaches of organizing care and work: Giving way to participation, mobilization, and innovation. The health care manager, 24(2), 150-158.

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