Care Provider Perceptions of Person-Centeredness in Geriatric Care

Applications of Study Findings

• Concepts identify barriers that can be addressed to change organizational structures and care practices to promote person-centered care

Design and Methods

Initially, a search was conducted of the peer-reviewed and gray literature, including a focus on the healthcare workforce. The PubMed search engine was used to query peer-reviewed sources; an internet search engine (Google) was utilized to identify gray literature. Search terms for person-centeredness included “person centered care,” “person directed care,” “individualized care,” or “personalized care.” Search terms related to the workforce included “caregiver,” “worker,” “administration,” “direct care worker,” “provider,” and related terms. Sources were limited to the past 20 years. The review was presented to the steering committee of LINC-AD (Leveraging an Interdisciplinary Consortium to Improve Care and Outcomes for Persons Living with Alzheimer’s and Dementia), a national network convened by the Alzheimer’s Association. Based on the literature, the steering committee identified four summative topics for in-depth exploration: definition of person-centeredness, person-centeredness from a systemic perspective, person-centeredness and technology, and person-centeredness in relation to care and the healthcare workforce. This paper reports the results related to person-centeredness and the workforce.

We employed a series of two meetings with long-term care staff and two facilitated think tank discussions with national experts in the summer of 2022 to explore perspectives on person-centeredness as it relates to the healthcare workforce and to identify factors that facilitate or impede the implementation of person-centered practices. Each lasted 90–120 minutes and was facilitated by a trained moderator, with a separate project team member assigned as note-taker. The two in-person meetings included: (a) 11 staff members (including nursing, direct care, and dining staff) from a Maryland assisted living community, and (b) 10 members of the Alzheimer’s Association Dementia Care Provider Roundtable. Participants for the virtual sessions were selected through literature review and professional networking to ensure representation from diverse disciplinary and professional backgrounds. Virtual think tank participants included:

• A senior policy maker and administrator of a state center on aging

The discussion facilitator was provided a series of open-ended questions to stimulate discussion. The questions included prompts such as “How does the concept of person-centeredness relate to you in your work? How does it apply to health care workers in general and in your setting? Does person-centered care need to be taught? What kind of care is easiest/hardest to deliver in a person-centered way? What does administrative support for person-centered care look like?” The semi-structured question framework was used flexibly, allowing participants to introduce additional topics and perspectives beyond prepared questions.

All meetings were audio-recorded and transcribed verbatim. For each session, the designated note-taker prepared a written summary within 24 hours, which was subsequently reviewed and revised by the project team to ensure accuracy and completeness.

An exploratory thematic analysis was conducted, with materials analyzed by the study team using a qualitative iterative process. Concepts were elaborated by group consensus and refined iteratively to incorporate perspectives across all project components and participant groups. For this report, representative quotations were selected from the transcripts to illustrate each concept. Quotations were chosen based on their ability to capture perspectives expressed by multiple participants.

Issues Identified

Overall, discussion elucidated three key concepts: person-centeredness varies by care setting due to differences in organization and client/patient needs; person-centeredness is not considered standard care; and person-centeredness variably consists of an interplay between leadership and care providers. Each topic is presented with illustrative quotes in the material that follows.

Discussion

Person-centeredness has become increasingly championed as a key principle of quality healthcare; however, its application to the fourth aim of quality healthcare—the persons providing that care—has received little attention. This paper describes a series of discussions related to person-centeredness based on the perspectives of those who oversee or provide that care. Through these discussions, three observations emerged: person-centeredness varies by care setting due to differences in organization and client/patient needs; person-centeredness is not considered standard care; and person-centeredness variably consists of an interplay between leadership and care providers. The commonality across these observations is the variability of person-centeredness in geriatric care.

As became clear from our discussions and literature review, care practices differ by care setting, related in part to the primary focus of the setting and the organization of care (Table 1), which suggest that approaches to person-centeredness at the provider level will vary by setting. By definition, home care allows individuals to age in place, which is considered person-centered; and, although hospitalization aims to return patients home quickly, doing so is sometimes at the expense of patients feeling care is too rushed (Stempniak, 2019). In all care settings, facilitators of and barriers to person-centeredness are present at the patient level, care provider level, and organizational level (Marulappa et al., 2022), many of which are common across settings (e.g., limited time to provide care, procedural-based care, and attention to regulatory compliance). Therefore, all settings should seek to find an operational balance that optimizes person-centeredness within the parameters of appropriate treatment.

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Table 1.

Person-Centeredness Across Different Care Settings

Care setting	Primary focus	Facilitators of person-centeredness	Barriers to person-centeredness
Home care	Variable care needs	- Allows client to age and receive care in place - Structured to facilitate one-on-one interactions between care provider and client - Clients have control regarding their preferences (e.g., diet, medication administration, care providers) (Caldwell et al., 2023)	- Procedure-based care limits ability to individualize care - Large client load limits time for essential interactions to build meaningful relationships and learn care preferences (Caldwell et al., 2023) - Inconsistent staffing prevents actualization of care preferences - Large amount of required documentation inclines care plans to prioritize medical status and undermine preferences (Caldwell et al., 2023)
Residential long-term care	Functional and cognitive support; also palliation and end-of-life care	- If in effect, consistent assignment may allow relationship building - Market demand (in assisted living) may promote individualized care - Some models expressly incorporate direct care workers and residents in care planning (Zimmerman & Cohen, 2010)	- Staffing shortages - Organizational cultures lean towards regulatory emphasis of safety and focus on prescribed quality measures - Negative attitude towards nursing home care (Sperber et al., 2021) - Administrative decisions based on economic/workforce scarcity - Hierarchical view of care teams
Post-acute nursing home care	Rehabilitation and functional support	- Medicare and/or private insurance funding - Less rigid structure versus automatic and procedural, allows staff to be more responsive to needs (Sperber et al., 2021) - Patient and caregivers have goal to return patient to the home (Sperber et al., 2021)	- Medicare funding limits patient stay to a strict time frame - Variable communication by care providers with the family
Acute care hospital	Curative treatment of acute health conditions	- Certain roles (e.g., patient navigators, volunteers) employed to fill gaps in person-centeredness and customer service culture - Relatively rapid care for an acute problem returns patients quickly to preferred/appropriate setting (Sperber et al., 2021)	- Length of stay is minimized; patients at times feel discharged too early (Stempniak, 2019) - Specialty and role stratification can lead to miscommunication and patient sense of lacking control (Sperber et al., 2021) - Rigid organizational structures are acceptable from the patient’s perspective (Alharbi et al., 2012)
Hospice	Palliation	- Full federal funding for public palliative care services; patient can opt for private palliative care - Consistent communication with family and patient to the extent possible - Advance care planning allows patient to have a sense of greater control and quality of life (Thomas & Gray, 2018)	- Federally regulated - Setting differences across in-patient hospital, residential long-term care, outpatient hospice facility, home - Limited time with hospice staff and patient’s death during transition to palliative care (Midtbust et al., 2018)

Another clear although disappointing finding was that person-centeredness is rarely the standard of care. In provision of home and community-based services, for example, barriers to person-centeredness include a medicalized care planning process that often marginalizes both the patient and the direct care provider, language and racial differences, and lack of coordination between multiple providers (Caldwell et al., 2023; McPherson et al., 2024). In long-term care settings, barriers to staff performing with person-centeredness exist at the person-level, team-level, and organizational level (Backman et al., 2024), and institutional realities such as staffing shortages, financial limitations, and even the survey/certification process itself work to limit person-centeredness (Travers et al., 2022).

Despite the many limitations, staff have innumerable options to provide person-centeredness in daily interactions, ranging from encouraging a nursing home resident to select their clothes for the day, to providing preferred food, to providing care for activities of daily living in a way that is sensitive to preferred practices (Sloane et al., 2004; Zimmerman et al., 2020). Given the many barriers, however, person-centeredness involves building relationships that go beyond standard care models so as to develop more person-centered trust and understanding between the individual and care provider (Bishop et al., 2008; Kelly et al., 2019). However, not all providers find it easy to build meaningful relationships with their patients/residents/clients; traits associated with those who are most successful include strong interpersonal skills, working holistically, belief in shared decision-making, authentic engagement styles, and flexibility (Vareta et al., 2023); so identifying effective teaching and supervisory structures to enhance such skills, and applying them to person-centeredness, may be indicated (Roets-Merken et al., 2016).

A large and expanding body of literature indicates that high staff turnover and low job satisfaction are improved by organizational changes that support and encourage staff to be person-centered (Austrom et al., 2016; Bishop et al., 2008; Brooker, 2003; McCormack & McCance, 2006). However, participants in the discussion groups noted that encouragement of person-centeredness by healthcare leaders and managers is not consistent, in part because of concerns meeting quality indicators that ostensibly run counter to person-centeredness. Management style is critical as well; evidence indicates consensus-driven leadership—a style that embodies person-centeredness by soliciting and acting on employee input, as opposed to more authoritarian approaches, is associated with higher quality care, increased staff satisfaction, and lower staff turnover (Castle & Decker, 2011; Donoghue & Castle, 2009). Another component of person-centered administrative practice is to provide time and flexibility for care workers to develop relationships and tailor care, because delivering care that is flexible and relationship-focused is a prime source of satisfaction among care providers (Kelly et al., 2019; Myers et al., 2018; Rodríguez-Martín et al., 2013).

Implications for Practice, Policy, and Research

Person-centeredness, as a desirable key element of health care quality, depends on high-performing, satisfied care providers; and viewing person-centeredness from the perspective of caregivers identifies several elements that must be considered and addressed. For one thing, the optimal degree and essential components of person-centeredness will differ depending on the setting. In addition, efforts to improve person-centeredness should consider patient-level, team-level, and organizational factors, identifying both barriers and facilitators to improvement. Finally, because person-centeredness is rarely considered standard care, its promotion needs conscious and ongoing education and quality-improvement efforts that aim to increase support for person-centeredness at the organizational level, foster such traits as interpersonal skills and flexibility among staff, and improve the overall worker experience.

Finally, we note that the observations emanating from our discussion groups are but the beginning of a conversation to better understand and promote person-centeredness in geriatric care by those individuals responsible for the care. The commonality across the observations can enable frank discussion about the root cause of the variability, especially if it is examined in the context of a “just culture” that balances accountability for individuals and the organization as a whole to improve care (Boysen, 2013).