Enhancing Person-Centered Care in Long-Term Care

Fellow Clinical Gerontologists,

As the Associate Editor of Long Term Care for Clinical Gerontologist (CG), I am pleased to introduce this special issue on Long-Term Care (LTC) to the CG readership. Although CG has long been published in cooperation with Psychologists in Long Term Care and tries to consistently include articles by a variety of disciplines on this special setting, CG has had a number of excellent submissions over recent years that touched upon similar themes in LTC whereby we thought a special issue was warranted. I am especially happy to introduce this issue because it reflects some of the major priorities of CG in that all articles focus on some aspect of person-centered care for LTC residents. The six articles that make up this series collected data in five different countries reflecting our ever increasing international focus and revealing how factors associated with humane care are a constant in the world.

The article by Law and colleagues, “Staff factors contributing to family satisfaction with long-term dementia care: A systematic review of the literature” sets the stage for a discussion of person-centered care (Law, Patterson, & Muers, 2017). The authors identified 14 well-designed studies in their review and found family-related factors (e.g., relationship reciprocity between staff and family; effective communication; emotional support from staff), staffing-related factors (friendly and approachable staff; adequate one-on-one time; consistent & educated staff), and client-related factors (kin-like relationships; staff familiar with residents; understanding unique resident preferences). It is great that the research literature has progressed beyond a focus on symptom relief and has embraced the idea of quality of life. Law and colleagues’ recommendation to cultivate relationship-centered models of care is a creative way to end a review that I expect will be referenced for years to come.

Konnert, Speirs, and Mori’s article (Konnert, Speirs, & Mori, 2017) on the use of the daily diary method (via telephone) with nine family members to explore family–staff conflict and how such conflict might be related to mood fluctuations in nursing home residents is a methodological advance in the LTC literature. This method yields findings suggesting that “poor resident care, lack of information, and staff attitudes” spark conflict. These factors associated with conflict reflect bureaucratic, institution-focused, insensitive, rote execution of job duties, i.e., the opposite of person-centered care. As recommended by the authors, guided by conflict generation and resolution theory, we need to target conflictual family–staff relationships by implementing interventions informed by the daily diary method findings.

Using interviews with 10 nursing home staff, Aeling and Vacha-Haase explored the perceptions of LTC nurses regarding hospice and resident experiences of hospice (Aeling & Vacha-Haase, 2017). LTC nurses almost uniformly have had positive experiences with hospice, viewing it as a setting of additional emotional support for those who are dying. However, they perceive that nursing home residents fear it as a place of imminent and even hastened death. I agree with the authors’ conclusions that a didactic-based intervention to dispel myths of hospice may lead to improved quality of life for those residents (and their family members) who are in the last stage of life.

Harper and colleagues address an issue that has long been neglected in LTC settings, i.e., the use of PRN medications (Harper, Reddon, Hunt, & Royan, 2017). Conducting chart reviews and interviews of nurses in two units of a geriatric psychiatric hospital, the authors clearly show how documentation of the behaviors targeted and the rationales employed for PRN usage were “sub-optimal.” Even more troubling, in both of the units half or more of the nursing staff indicated that PRN medications were appropriate for physical aggression, agitation, and even verbal aggression; in one unit, the main alternate to use of PRN medications was restraints! These findings have dramatic resonance regarding initiatives to reduce anti-psychotic medication in nursing homes and underline the urgent need to systematically teach LTC staff how to manage disruptive behavior non-pharmacologically.

Tosangwarn, Clissett, and Blake (Tosangwarn, Clissett, & Blake, 2017) describe the development of the Thai Internalized Stigma Scale for nursing home residents. The authors note that the stigma of being a nursing home resident can result in “lowered self-esteem, social isolation, self-harm and depression.” Once again, education may be the key regarding informing the public about how frail older adults living in these settings are still to be accorded the rights of all living beings to a good quality of life.

Cesetti, Vescovelli, and Ruini’s article focuses on the promotion of the well-being of nursing home residents via a narrative intervention utilized with 30 nursing home residents that integrates aspects of life review with those of fairy-tale telling (Cesetti, Vescovelli, & Ruini, 2017). This creative gero-specific group treatment tries to resolve some of the mixed results of the life review reminiscence treatment literature. Specifically, it encourages a positive fairy-tale ending to address concerns that some residents may wallow in depressive misery when conducting a traditional life review thereby triggering negative outcomes. This brief four-session intervention was found to improve well-being and sleep. It may be that benefits are reaped because the shared social activity involved in creating a group fairy tale stimulates both interpersonal affirmation and intrapsychic integration. The take-away message from all of these articles in this special series is to foster interventions to support LTC residents and their families to improve staff–family relations, reduce conflict with staff, promote a sense of personal and social integration in residents, reduce misuse of medications, and confront myths of hospice and nursing home care that lower the expectation that older adults might enjoy and even flourish in LTC environments.

Also included in this issue are four original research articles on family caregiving. Paulson and colleagues’ (Paulson, Bassett, Kitsmiller, Luther, & Conner, 2017) survey of labor force participation—in particular reduction in time spent at work—found weekly care demands exceeding 20 hours to be the sole determinant of labor force participation. Their article is especially interesting in its comparison of planned behaviors and actual behaviors. Kim and Knight’s survey of 114 caregivers compared with 114 non-caregivers (Kim & Knight, 2017) to test the “MORE” wisdom resource model of caregiving. They found that openness to experience, sense of mastery, and emotional regulation were key “wisdom resources” associated with life satisfaction in caregivers. Liu, Lu, and Lou’s survey of 754 caregivers in urban China (Liu, Lu, & Lou, 2017) found that more involvement in physical care and more cognitive impairment in the care recipient were associated with higher burden, among other findings. Grossman and Gruenewald’s (Grossman & Gruenewald, 2017) analysis of 3,814 participants from the MIDUS (National Survey of Midlife Development in the United States) sample found caregivers reported more negative affect, less positive affect, but higher generativity, highlighting positive aspects of caregiving.