Staff-perceived Conflict between Resident-centered Care and Quality in the Skilled Nursing Facility: Are Both Possible?

ABSTRACT

Objectives: The purpose of this study was to understand if and how Veterans Affairs (VA) nursing home (CLC) staff experience difficulty in providing care that is both resident-centered (RCC) and concordant with quality standards.

Methods: Twelve VA CLCs were selected for site visits, stratified based on rankings on a composite quality measure (calculated from various indicators) and resident-centered care (RCC) progress (based on a culture change tool). Staff were interviewed about efforts and barriers to achieving goals in RCC and quality, and the interview transcripts systematically analyzed for themes.

Results: We interviewed 141 participants, including senior leaders, middle managers, and front-line staff. An emergent theme was conflict between RCC and quality, although participants varied in their perceptions of its impact. Participants perceived three conflict types: 1) between resident preferences and medically indicated actions; 2) between resident preferences and the needs or safety of others; and 3) limits of staff time or authority.

Conclusions: CLC staff perceive conflicts between RCC and care consistent with quality imperatives.

Clinical implications: Variation in perceived RCC-quality conflicts suggests that policy clarifications and additional training may provide guidance in dealing with such dilemmas. It may be prudent to clearly communicate to what boundaries exist to RCC in the evolving CLC environment.

KEYWORDS:

• Health care
• quality indicators
• resident-centered care
• skilled nursing facilities

Acknowledgments

This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research & Development Service (VA HSR&D IIR 11-356; Jenny Sullivan, PI). We thank the interviewees at the sites for their engagement in the interviews; we also thank Emily Rose Lopez and Omonyêlé Adjognon for providing project management during the study. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Additional information

Funding

This work was supported by the Health Services Research and Development [VA HSR&D IIR 11-356].