An exploration of strategies employed by residential aged care managers to implement person

An exploration of strategies employed by residential aged care

managers to implement person-centred care

Alexander R. Zarb

RN, B. Health Management (CSU), Certificate of Gerontology

Submitted in total fulfillment of the requirements for the degree of

Masters of Nursing (Honours)

2015

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CERTIFICATE OF AUTHORSHIP ORIGINALITY

I certify that the work in this thesis has not previously been submitted for a degree nor

has it been submitted as part of requirements for a degree except as fully

acknowledged within the text.

I also certify that the thesis has been written by me. Any help that I have received in my

research work and the preparation of the thesis itself has been acknowledged. In

addition, I certify that all information sources and literature used are indicated in the

thesis.

Signature of Student:

Date: 8 July 2015

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Acknowledgements

I would like to thank my partner, Lloyd King, for his patience, support and listening to

my thoughts and ideas on this subject. We now might be able to go on holidays without

me tapping away at my laptop. Also, thank you to my children, grandchildren and

parents – you have been supportive and tolerant of my reasoning for not spending

more time together.

In particular, I want to thank my Principal Supervisor, Professor Jane Stein-Parbury,

and Co-supervisor Professor Lynette Chenoweth for your shared expertise, guidance,

perseverance and patience. Your belief in me in completing this journey is gratefully

appreciated. My thanks also go to Dr Richard Baldwin who began as my Co-

supervisor, at the commencement of this study.

My appreciation also extends to the Organisation and Managers at the centre of this

study for their cooperation in scheduling convenient times for the collection of data.

I gratefully acknowledge my work colleagues and friends who came to understand my

beliefs. For those who worked with me I appreciated your patience with our attempts

implement new practices to improve care to our residents.

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Table of Contents

CERTIFICATE OF AUTHORSHIP ORIGINALITY ...................................................... i

Acknowledgements ................................................................................................... ii

Table of Contents ...................................................................................................... iii

List of Tables ............................................................................................................ vi

List of Figures .......................................................................................................... vi

List of Appendices .................................................................................................... vi

List of Terminology and abbreviations ...................................................................... vii

Use of Italics and Quotations ............................................................................... viii

Glossary of Terms ............................................................................................... viii

Abstract .................................................................................................................... ix

Chapter 1. Introduction ........................................................................................... 1

Expectations of Residential Aged Care Providers ..................................................... 1

Study Overview ......................................................................................................... 4

Organisation of the Thesis ........................................................................................ 5

Chapter 2. Background to the project .................................................................... 7

The management context .......................................................................................... 7

Project’s Background ................................................................................................ 8

Organisation’s Project to implement PCC .............................................................. 8

Selection of residential aged care facility ............................................................... 8

Project’s methodology ........................................................................................... 9

Steering Committee ............................................................................................... 9

Chapter 3. Literature Review ................................................................................. 11

Introduction ............................................................................................................. 11

Strategies for the Literature Search ..................................................................... 11

Global Embrace of PCC .......................................................................................... 13

Person-Centred Approach to Care .......................................................................... 15

Recognition of Personhood .................................................................................. 15

Culture of Care .................................................................................................... 16

PCC in Practice ................................................................................................... 17

Implementing PCC in Residential Aged Care ....................................................... 19

A Person-Centred Care Organisation ...................................................................... 20

Organisational culture and PCC ........................................................................... 20

Staff empowerment and commitment................................................................... 22

Managerial Support for PCC ................................................................................... 23

Managers as Leaders .......................................................................................... 25

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Leadership styles and PCC ................................................................................. 27

PCC Organisational Framework .......................................................................... 29

Conclusions ............................................................................................................ 32

Chapter 4. Methodology ........................................................................................ 35

Introduction ............................................................................................................. 35

Aim and Objectives ................................................................................................. 35

Aim ...................................................................................................................... 35

Objectives ............................................................................................................ 35

Research Question ................................................................................................. 36

Study Design ........................................................................................................... 36

Sequential data collection .................................................................................... 36

Research Method .................................................................................................... 37

The four stages of Research ................................................................................ 38

Setting ................................................................................................................. 38

Study participants ................................................................................................ 38

Ethical Conduct of the Study ................................................................................... 39

UTS Human Research Ethics Approval ............................................................... 39

Organisational Access and consent ..................................................................... 40

Participant Recruitment ....................................................................................... 40

Confidentiality ......................................................................................................... 42

Risk Management ................................................................................................ 43

Data Collection ........................................................................................................ 45

PCECAT .............................................................................................................. 45

Executive and management staff interviews ........................................................ 49

Data Analysis .......................................................................................................... 53

PCECAT Data ..................................................................................................... 53

Interview Data ...................................................................................................... 53

Composite data analyses..................................................................................... 61

Triangulation of data ............................................................................................ 62

Chapter 5. Results ................................................................................................. 63

Introduction ............................................................................................................. 63

Participant Demographics ....................................................................................... 63

Manager Semi-structured Interviews ....................................................................... 64

Theme One: Thinking Differently / Changing systems ......................................... 65

Theme Two: Promoting a ‘yes culture’ ................................................................. 74

Theme Three: Changing peoples’ lives ................................................................ 82

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Aged Care Services Audit Results........................................................................... 85

PCECAT Domain Scores ..................................................................................... 86

PCECAT Field Notes – Identified Strengths and Possible Improvements ............ 87

Summary ................................................................................................................. 91

Chapter 6. Discussion ........................................................................................... 93

Introduction ............................................................................................................. 93

Leading from the top ............................................................................................... 93

Holding the vision ................................................................................................ 94

Organisational Framework to support Person-centred Care ................................ 95

Role of Steering Committee and working groups/project teams ........................... 96

Commitment of resources .................................................................................... 98

Walking the talk ................................................................................................... 99

Supporting from the bottom ................................................................................... 101

Decentralised decision-making .......................................................................... 102

Removing ‘us-them’ barriers .............................................................................. 103

Breaking routines – Changing everyday practices ................................................. 104

Reconceptualising Dining Experiences .............................................................. 105

Refocusing care planning .................................................................................. 106

Introducing the new resident to the facility ......................................................... 107

Recreational Activities ....................................................................................... 108

Reflective Practices ........................................................................................... 109

Valuing staff .......................................................................................................... 109

Supporting managers and staff to implement PCC ............................................ 110

Freeing front-line managers ............................................................................... 111

Recruitment and staffing consistency................................................................. 112

Aligning education and recruitment .................................................................... 114

Moving from compliance to commitment ............................................................... 115

Summary ............................................................................................................... 118

Limitations and Strengths ...................................................................................... 119

Limitations ......................................................................................................... 119

Strengths ........................................................................................................... 120

Conclusions .......................................................................................................... 120

Implications and Recommendations for further research ....................................... 121

Implications........................................................................................................ 121

Recommendations for further research .............................................................. 122

Chapter 7. Appendices ........................................................................................ 123

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Bibliography ............................................................................................................ 176

List of Tables

Table 1 – Ethical Risk Management............................................................................ 43 Table 2: Interview Guide ............................................................................................. 50 Table 3 - Person-centred Care Leadership - Initial Template ...................................... 56 Table 4 - Changes to the initial PCC Leadership Template ......................................... 60 Table 5 - Participant Demographics ............................................................................ 64 Table 6 - PCECAT Numerical Scores ......................................................................... 86 List of Figures

Figure 1 – Database (CINHAL and psycINFO) search outcome ................................. 13 Figure 2 – Stages of the Research ............................................................................. 37 List of Appendices

Appendix A - UTS HREC Approval ........................................................................... 123 Appendix B - Research Introductory Letter ............................................................... 124 Appendix C - Resident Information letter & Consent ................................................. 126 Appendix D - Staff Information letter ......................................................................... 128 Appendix E - Managers Information letter & consent ................................................ 129 Appendix F - Person Centred Environment and Care Assessment Tool ................... 131 Appendix G - PCECAT Qualitative Results - Unit 1 ................................................... 161 Appendix H - PCECAT Qualitative Results - Unit 2 ................................................... 165 Appendix I - PCC Leadership Template .................................................................... 170 Appendix J - Triangulation of data - PCECAT Results and Organisational PCC

Structures .......................................................................................................... 175

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List of Terminology and abbreviations

The terms ‘people living with dementia’ or ‘people with dementia’ has been used to

acknowledge the person within, over and above his or her diagnosis of dementia

related disorders. The term ‘resident’ is used to denote the person accommodated in

a residential aged care facility. In Australia, it is both customary and preferred over

other terms such as patient or client out of respect for people’s rights and expectations;

these rights are considered equal to those of anyone else who resides in his or her

own home.

Residential Aged Care Facility is a generic term for what is frequently known as

nursing homes or hostels. Some people are accommodated in these facilities for short

periods to give their carers, family or friends, respite. Otherwise, for most people it is a

permanent place to live and referred to as their home.

The term Residential aged care providers refers to the administrators of aged care

facilities representing either private operators with a for-profit interest or not-for-profit

organisations. These organisations can be affiliated with religious congregations,

community sponsored groups or government.

A term used by Tom Kitwood in the 1990s Personhood refers to the way in which one

person looks upon another within a relationship or social context; it implies respect and

trust.

The term Front-line managers has been used in this study to refer to nurse managers

who have a registered nurse background. While responsibilities vary from one

organisation to another these managers can hold titles such as Directors of Nursing,

Deputy Directors of Nursing, Care Managers, Village Managers, Facility Manager and

Nurse Unit Manager.

The term project has been used to refer to the organisation’s ambitions to implement

person-centred care within the organisation’s aged care facilities.

The term study refers to the researcher’s aim and objectives that explored the

management strategies used to implement person-centred care. Further clarification is

given, within this manuscript, by utilising the term the researcher’s study.

Square brackets [ ... ] have been used to encase words that are added to direct quotes in

order that they make sense to the reader, for example “... the resources to meet minimum

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standards of basic physical care ...[can] grind leaders down over time...[diminishing]

the personhood of those in leadership positions”

Use of Italics and Quotations

‘Single quotation marks’ without italics are colloquial phrases used to illustrate a

point;

“Double quotation marks” without italics indicate quotes from published works;

‘Single quotation marks’ with italics relate to comments and phrases frequently

used by managers that cannot be attributed to any particular person;

“Double quotation marks” with italics indicate participants’ quotes directly taken

from interview transcripts and recorded verbatim.

Glossary of Terms

ACFI – The Aged Care Funding Instrument is an aggregated tool, developed by the

Australian Government, to determine assessed needs as a means of delegating

funding to aged care providers.

Care Staff – unlicensed staff employed in residential aged care facilities to provide

personal care, industrially classified as Assistants in Nursing (AIN) or Personal Care

Assistants (PCA).

Diversional Therapist – qualified staff member who specialises in therapy often to

divert people away from boredom or to minimises states of agitation; frequently they

supervise and help staff with social and recreational activities.

PCC – Person-Centred Care refers to a model of care which respects the personhood

of people. The model focuses on getting to know and develop relationships with the

person in care.

PCECAT – Person-Centred Environment and Care Assessment Tool – self-

assessment tool to measure the degree a facility maintains person-centred care

principles.

Recreational Staff – unlicensed staff employed in residential aged care facilities to

attend to social and recreational needs, sometime known as Recreational Activity

Officers (RAO).

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Abstract

Tom Kitwood, the founder of person-centred dementia care, called for a cultural

change in care, focused on preserving the personhood of people with dementia. The

person-centred model fosters a milieu where staff can provide supportive, encouraging

and meaningful social relationships with care recipients and each other. Person-

centred care (PCC) is not only an approach to care but also a whole of system

strategy. To enable PCC, managers need to cultivate staff’s engagement with PCC;

this occurs through organisational commitment to the preservation and promotion of

personhood for residents and staff. While managers are key to promoting the

workplace conditions necessary for implementing PCC, definitive management

strategies have yet to be fully articulated. This study set out to identify management

strategies and the progress being made to implement PCC in one Australian aged care

facility.

The research question posed to focus this investigation was: “What planned

management strategies support the implementation of person-centred care in a

residential aged care facility?” The research question was answered by conducting

semi-structured interviews with senior facility managers and administering a validated

assessment tool, the Person-Centred Environment and Care Assessment Tool

(PCECAT), which was employed to assess the degree to which the facility supported

PCC principles and practices before and 12 months after the PCC implementation

process commenced.

Analysis of the manager interview data identified three main themes: Thinking

differently / changing systems; Promoting the ‘yes culture; and, Changing people’s

lives. Subthemes included: Thinking differently / changing systems, changes were

made firstly to the practices before a person came to the facility. Changing systems

involved altering of serving of meals, care planning and care practices. Additionally,

Thinking differently / changing systems extended to staffing arrangements

incorporating rosters, recruitment procedures, position descriptions and training. In

attempting to create a supportive PCC organisational culture, managers upheld the

‘yes culture’ through ‘autonomous decision-making, supporting staff, promoting

flexibility in care and developing PCC leadership’. The PCECAT results revealed that

there was an improvement twelve months after the project began in Domain 1

(Organisational Culture) and in Domain 2 (Care & Activities, and Interpersonal

Relationships & Interactions), in both care units.

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This study identified that managers shifted their major focus away from compliance to a

set of rules and showed their commitment to the values and vision of PCC. This

occurred by building a PCC organisational framework that supported PCC. This

strategy proved successful, according to the PCECAT findings.

Chapter 1 – Introduction 1

Chapter 1. Introduction

Expectations of Residential Aged Care Providers

Older Australians living in residential care deserve the best quality care (Australian

Nurses Federation 2009) where their needs are addressed with a personal approach.

With an ageing Australian population, aged care service providers cannot rely on more

of the same type of supported care that was acceptable to older people in the past,

since the expectations of future care recipients will likely require different services to

those currently in place. It is predicted that the current population in their 60s and 70s

will expect that person-centred care standards are commonplace in the supported care

accommodation that they may have need for in the future.

The demand for quality aged care services is escalating, given the high rate at which

the population is ageing and the increasing prevalence rates of people living with

dementia. In Australia, the demand for residential care will be driven by the increasing

number of people reaching 85 years and older, who are currently the highest users of

aged care services (Access Economics 2011). The latest available data reveals that for

the year 2013-4 there were 231,515 people living in residential care (Aged Care

Funding Authority 2015) with projections suggesting a further 213,000 residential aged

care places will be required by 2050 (Access Economics 2011). This increasing

demand on aged care places will be realised by 2030 as the baby boomer generation

reaches the age of 85+ (Access Economics 2011). There is demographic diversity in

the baby boomer generation; aged care providers cannot expect to offer the same

kinds of services for some older baby boomers as they have for previous and current

aged care residents. This newly ageing population group are more affluent and

educated than previous generations (Access Economics 2011). Hence, it will be a

highly segmented market, not only for aged housing and aged care but for all the

goods and services older people use (Hugo 2014). With greater financial means to

previous generations, the ageing baby boomers will be more willing to pay more for

aged care services that assist them in maintaining preferred lifestyles and living

standards (Aged Care Funding Authority 2014). As such, people in this group will be

likely to expect more from service providers.

Concurrently, the increasing prevalence of people living with dementia will also place

higher requirements on providers of care for ageing Australians (Australian Institute of

Health and Welfare 2012; Productivity Commission 2011). It is estimated there are

342,800 Australians living with dementia and that these figures will rise to 400,000 in


the next ten years, reaching an estimated 900,000 by 2050 (AIHW, 2012). Data

available from the Australian Institute of Health and Welfare (2012, p. 16) proposes

that “85,159 people (52%) of the 163,849 permanent residents who had an Aged Care

Funding Instrument appraisal at 30 June 2011 had a diagnosis of dementia”. This trend

is placing increasing pressure on aged care providers to ensure that these vulnerable

people are given the best care possible.

There is a growing call for improvements in the care for people living in residential

aged care in Australia from any different quarters: consumers, advocacy groups and

the Government. The Federal Government’s Department of Social Services (2011), the

funding body for Australian residential aged care facilities, acknowledges that

consumers and their advocates are better informed about aged care service

requirements, which has raised their expectations of service quality. Alzheimer’s

Australia recommends that better care is the way to overcome the pervasive social

negativity and stereotyping of people with dementia (Rees 2010). Strengthening this

perspective, the revised Australian Residential Aged Care and Accreditation Standards

include a more comprehensive assessment of dementia care rather than limited to the

negative perspective of behaviour management as currently exists (Aged Care

Standards and Accreditation Agency Ltd 2009). As a condition of Commonwealth

funding all Australian residential care services are required to maintain these

Standards and thereby achieve Accreditation. In the Draft Revised Aged Care

Standards (Department of Health and Ageing 2011) an additional expectation is that

aged care providers ‘maintain emotional support’ and come to ‘understand, monitor

and promote a resident’s cognitive and mental health’. From each of these quarters,

there is pressure to provide better quality aged care, particularly care that is person-

centred.

Person-centred Care (PCC) has been identified as a proven and accepted approach to

improve the quality of care for people with dementia living in residential aged care.

Numerous studies (Chenoweth et al. 2014a; Chenoweth et al. 2014b; Chenoweth et al.

2009; Cohen-Mansfield 1999; Cohen-Mansfield, Parpura-Gill & Golander 2006; Lann-

Wolcott, Medvene & Williams 2011) have identified the improved outcomes that PCC

can provide to people with dementia. PCC advocates (McCormack 2004; McCormack

et al. 2012; Nolan et al. 2004; Slater 2006) have proposed various models of practice

premised with a PCC philosophy of care. In recent years the Commonwealth

Government, through the Productivity Commission’s (2011) inquiry into the Australian

aged care system and the revision of the Aged Care Standards for Residential Care


(Department of Health and Ageing 2011), established a firm position that aged care

services needed to be person-centred in line with international standards and practice.

Governments, at all levels, are reviewing healthcare policies and incorporating a

person-centred approach to care (Kitson et al. 2013; Sharp, McAllister & Broadbent

2015; Vic Department of Health 2014; WA Department of Health 2015). The Australian

College of Nursing (2015) advised that nurse leaders will be required to develop

models of care that are person-centred. With the complexities that an ageing

population brings to the healthcare system, nursing leadership will be expected to

provide strategic direction and help drive person-centred changes within organisations

(Australian College of Nursing (ACN) 2015).

Capable nurse leaders are also required to maintain a skilled workforce if they are to

ensure quality aged care in residential facilities (Access Economics 2009; Australian

College of Nursing (ACN) 2015; Australian Nurses Federation 2009; Jeon et al. 2010a).

The findings of a report by Access Economics for the Australian Nurses Federation

(2009) recognised that the quality of aged care is potentially compromised given the

difficulties managers face with maintaining optimum aged care staffing levels. The

report revealed there is an imbalance between the increasing demands placed upon

nursing workforce, frequently taking them away from direct care, and the supply of

skilled staff in residential services (Access Economics 2009). Recruiting and retaining

appropriate aged care staff is crucial if providers are to maintain acceptable quality

services.

Maintaining a skilled workforce has been linked with organisational commitment and

job satisfaction for staff working in aged care (Chenoweth et al. 2010; Chenoweth &

Kilstoff 2002; DeCicco, Laschinger & Kerr 2006; Edvardsson et al. 2009; Jeon et al.

2011). Effective nursing leadership and management was seen to be an essential

ingredient. Similarly, leadership, mutual trust and respect, organisational support and

staff empowerment can provide positive outcomes, such as job satisfaction and

organisational commitment, for dementia care staff (Brooker 2007; Kitwood 1997a;

Langford, Parkes & Metcalfe 2006). It becomes clear, as recommended in the

Productivity Commission’s (2011) review of the aged care workforce, that staff well-

being is dependent upon improvements in management styles and, in keeping with

PCC principles, with workplace conditions.

While workplace conditions are an important aspect for managers to maintain a healthy

workforce other organisational conditions are needed to generally support the

successful implementation of PCC (Brooker 2007; Kitwood 1997a; Loveday 2013).


Introducing this approach to care requires an organisational culture that supports PCC

in every way (Kirkley et al. 2011; Kitwood 1997a). Brooker (2007) provides further

insight into the relationship between the organisation and PCC, “If we encourage

dementia care practitioners to adopt a person-centred approach without addressing the

larger organisational context, we are setting them up to fail” (p. 34). For PCC to be

effective the organisational culture must be such that care staff are empowered to

make decisions and to be flexible in their practice (Cohen-Mansfield & Bester 2006;

Kirkley et al. 2011). Kitwood (1997a) and Loveday (2013) equally concur that an

organisation needs to review its broad range of operations and systems if PCC is to be

truly effective. Top-down leadership, bottom-up consultation and a whole of systems

approach, have been found to be crucial to supporting a person-centred approach to

care (Jeon et al. 2011; Stein-Parbury et al. 2012). To address the growing expectation

of improving the quality of aged care middle managers, frequently nurse managers, will

need to be equipped with leadership skills to develop, implement and drive new models

of care, such as PCC (Australian College of Nursing (ACN) 2015; Productivity

Commission 2011).

Managers are seen to be the culture carriers whereby the way things are done in an

organisation are transferred top-down (Jeon et al. 2015). Studies have shown that

managers play an important role in providing the supportive conditions for the

implementation of PCC in residential aged care (Chenoweth et al. 2014b; Stein-

Parbury et al. 2012). Initial work has commenced on developing a clinical leadership

quality framework for middle managers to assist them and organisations to understand

the roles and expectations of managers in aged care facilities (Jeon et al. 2015). Aged

Care leadership training programs have also been trialed (Jeon et al. 2013). Yet

managers do not work in isolation. “Successful leadership and management depends

upon coherent and good organisational leadership” (Jeon et al. 2010a, p. 1). Jeon et al.

(2013) acknowledge the interconnectedness between middle managers and

organisational systems proposing that leadership training needs to be embedded in the

organisation’s governance. It remains unclear, however, what managers must do to

facilitate the adoption of PCC in residential aged care services and what organisational

structures are needed to support the implementation and maintenance of PCC across

aged care the facility.

Study Overview

This study focused on what a group of senior aged care managers put in place to

support the implementation of PCC in one residential aged care facility, using a mixed-


method sequential data collection design. Semi-structured manager interviews

obtained detail on the strategies the senior managers planned in one aged care facility

over a 12-month period. To assess how far the manager PCC strategies were

implemented and the degree to which the facility’s care services were person-centred,

the Person-Centred Environment and Care Assessment Tool (PCECAT) was

employed before the PCC change process and 12 months after it had begun.

Organisation of the Thesis

Chapter One has explained how the changing demographics of older people raises

expectations of aged care services, compelling residential aged care providers to

improve both service offering and quality. The person-centred model (PCC) was

identified as a model that elevates the standards of care, especially for people with

dementia. PCC also beckons a cultural milieu that respects the personhood of the

people living in, visiting and working in the aged care service. It was identified that

aged care facility managers are obligated to provide leadership in fostering a person-

centred approach to care, by ensuring there are sufficient staff levels, skills and

empowerment to support the model.

Chapter Two begins with a reflection of the researcher’s own experience as a

residential aged care manager, with the acknowledgement that managers don’t work in

isolation but rather in a whole system. This chapter also explains the background

organisational machinations that may be required to support the aged care manager’s

encouragement and implementation of PCC in a residential aged care facility.

Chapter Three provides a review of the literature to understand what it means to be a

person-centred aged care facility. The literature gives details on what has been

achieved to change the culture of aged care to one that respects the personhood of

people living with dementia. It also identifies that it can be difficult for aged care staff to

adopt appropriate practices that are flexible and uniquely responsive to individuals

without supportive workplace conditions. While the literature identified that managers

are the culture carriers within the workplace, it remained unclear what managers need

to do to embed PCC in residential aged care facilities.

Chapter Four describes the study’s methodology with the overall aim of understanding

what management strategies support the implementation of PCC in a residential aged

care facility. The study design and methods are described in detail, including the semi-

structured interviews conducted with senior facility managers and the facility-level data


on the quality of person-centred care services introduced during the project by the

managers, obtained with the Person-Centred Environment and Care Tool (PCECAT).

Analyses of these data are described, so as to determine which management

strategies were planned and implemented across the facility and the effect that these

strategies had on service quality.

Chapter Five outlines the results from the manager interviews and the PCECAT

findings before and after the PCC project commenced in the facility. Three major

themes, with a further seventeen sub-themes, were identified from the semi-structured

manager interviews. The PCECAT scores, collected twelve months after

commencement of the project, revealed that the PCC strategies initiated by the

managers were having a positive effect on care service quality compared to PCECAT

scores obtained prior to the project commencement. These data were confirmed by

reference to the field note data collected during administration of the PCECAT.

Chapter Six is a discussion of the study findings in relation to the links between the

manager-reported strategies and the person-centred improvements found with the

PCECAT. These management changes are discussed and attributed to organisation-

wide strategies. Links can also be made between management strategies and the

strengthened person-centredness culture and practices. Additionally, the strategies

compare favourably with workplace conditions previously identified in studies where

PCC was implemented in residential aged care facilities. The conclusions focus on

structural, system-wide strategies and hold implications for aged care organisations

wanting to successfully drive PCC as a model for quality aged care.

Chapter 2 – Background to the Project 7

Chapter 2. Background to the project

This Chapter outlines both the researcher’s personal journey as an aged care manager

while attempting to implement PCC in aged care homes, including issues that arose

and how they affected the researcher’s efforts. The researcher’s story has

consequently led to the undertaking of this study, in particular influencing the

methodology and study design. This leads onto the second part of this chapter

referring to the background to the participating organisation’s attempts to implement

PCC in one of their aged care facilities.

The management context

While working as a registered nurse and a manager in the residential aged care sector

over the last 25 years the researcher has had the opportunity to observe the way care

is provided in a variety of settings. The researcher has worked in larger aged care

organisations where the nurse manager was responsible for a number of facilities with

a deputy director of nursing in each facility. These larger organisations operated up to

40 aged care homes so each nurse manager was part of a collective of other nurse

managers and bound by policies and procedures that were developed and released

from the organisation’s corporate office. The researcher also worked in smaller aged

care homes where, without a large organisational central office developing policies, the

chief executive officer and the researcher comprised the organisation’s central office.

Working within these smaller organisations, the researcher was directly responsible for

establishing and maintaining care standards and quality. The researcher’s experience

includes working in organisations with a charitable mission and others that were

ostensibly commercial enterprises. In addition, the researcher’s employment with

government and non-government aged care homes in various roles, such as

government standards auditor and research manager, has provided an opportunity to

observe the overall management of a wide variety of Australian aged care homes.

From these varied experiences the researcher has come to realise that nurse

managers differ in the way they operate, depending on the organisation’s expectations

of their role. While the nurse manager features in all aged care homes, their titles and

scope of responsibility are variable in relation to decision-making capacities and

accountabilities (Loveday 2013). The researcher’s appraisal is that aged care homes

can either constrict or provide opportunities for the nurse manager to instil quality care.

Similarly, managers constantly struggle to balance the needs of the home with resident

care needs with the provision of a supportive and safe environment for employees


(Manley et al. 2011). The culture of the home and level of organisational support

influences the nurse manager’s creativity and flexibility to introduce PCC strategies

(Brooker 2007; Jeon, Merlyn & Chenoweth 2010; Russell & Stone 2002).

Project’s Background

The aged care organisation that agreed to participate in the researcher’s study is a

large not-for-profit organisation and a part of a large long-established Christian

denomination. While its headquarters is based in Sydney, the organisation has facilities

and community programs throughout New South Wales. Its website informs that the

organisation provides a wide choice of accommodation and service options to over

6000 residents and clients.

Organisation’s Project to implement PCC

This organisation was chosen as the focus for the current study because at a strategic

level, it had decided to implement person-centred care throughout all its residential

aged care facilities. With an executive nursing manager at the helm as the coordinator

the implementation process was described as a Project supported by a steering

committee. The implementation process used a continuous improvement methodology

incorporating a staged approach. Utilising a consultative and whole of systems

approach, teams were established to design, implement and evaluate new

interventions. The organisation’s project began with a trial in a pilot facility. The

researcher’s study focused on the strategies the organisation’s managers employed to

implement PCC in this residential aged care home.

Selection of residential aged care facility

While there are several facilities in this one location, situated in a suburb in North

Western Sydney, the facility chosen is over 30 years old, with an out-dated design

exemplified with small, shared bathrooms and narrow corridors. Managers advised of

the reasons for choosing this facility over others:

The facility managers did not have preconceived attitudes, described as

‘baggage’, and would therefore be receptive to change;

If person-centred care could be implemented in what the managers described

as a poorly designed facility then other facility managers couldn’t provide

objections when it came to their opportunity to implement PCC.


On the matter of business as usual, the facility manager was replaced from her

day-to-day responsibilities to focus on the implementation of the program.

Project’s methodology

Some of the managers highlighted this initiative as an example of the organisation’s

resource investment in the project. There had also been significant investment in

personnel’s time with literature reviews; this preparatory research led to the

development of the project’s plan and model of care. The dedication of a specific PCC

implementation Committee further exemplifies the significance of the project and the

available resources.

In its Pilot Charter, the organisation planned:

“...To realise a continuous improvement program... [that]...will

develop, identify and articulate a new model of care which is

underpinned by evidence and best practice within the concepts of

Person Centred Care (PCC).”

The project utilised an action based research methodology incorporated within the

organisation’s continuous improvement processes. There were eight project teams,

each with its own leader, where each team identified three areas of improvement

implemented in a twelve-week cycle. These teams covered: Change Management,

Dementia Specific Unit, Clinical Practice, Recreation & Lifestyle, Staffing & HR

strategy, Education, Environment and Food.

Steering Committee

The project was governed by a steering committee comprising a broad section of the

organisation’s senior managers and included a Project Manager specifically appointed

for this project. This was a supporting role to assist project team leaders on a day-to-

day basis. The project manager also liaised with supporting departments such as

Marketing and Information Technology. An external consultant worked with the steering

committee assisting and advising with the management of the project. Meeting every

six weeks, the committee’s purpose was to drive, monitor and evaluate initiatives

created for this project. With an aim to improve resident outcomes, including

satisfaction and experience, all the initiatives planned for the project were reported

back to the committee for agreement, review of progress and evaluation. Signifying the

importance the organisation felt about this project, the CEO was a member of the

steering committee. The objective to implement PCC was one of four in the


organisation’s strategic plan and, hence, reports on the project’s progress were sent to

the organisation’s board and executive on a quarterly basis.

The researcher was invited to attend the steering committee meetings as a research

student. Initially, the researcher attended four of these meetings but considered

attendance at these meetings unnecessary since the research study’s data collection

did not include what was discussed at these meetings. Attendance at these meetings,

however, provided further insight into the managers’ perspective regarding the process

of embedding PCC in their organisation. There were two occasions when this occurred.

The first involved one manager who spoke about everybody liking hot toast for

breakfast. In order to achieve the goal of serving hot toast to everybody, the project

planned to offer breakfast for extended periods. The manager presumed this initiative

would become a premise for all the organisation’s facilities when they came to

implement PCC. In response to this comment another manager on the steering

committee advised, “From the research I’ve undertaken, I could write a manual here

and now of what should be implemented to achieve PCC but that doesn’t mean it will

work in each facility”. This exchange of thoughts signified that the steering committee

was the forum for ratifying the change management process.

On the second occasion one of the executive managers expressed sentiments

referring to the time frames for implementing new initiatives. The manager stated, “If

our goal is to change people’s lives why do we want to take so long?” Responding to

this expectation, many steering committee members explained that staff, at the

coalface, could only cope with incremental change. Again, this interchange confirmed

that the change process would be taking a step-by-step process.

Chapter 3 – Literature Review 11

Chapter 3. Literature Review

Introduction

This literature review considers how a Person-Centred approach has been broadly

embraced as a suitable model of care for older people and, in particular, for people

with dementia living in residential facilities. Utilising Kitwood’s (1997a) person-centred

whole systems conceptual framework, the review is focused on the relationship

between what it means to be a person-centred organisation and how care staff are

expected to provide quality care for people with dementia within this model. The

primary aim of this study was to identify the strategies that a sample of aged care

managers employed to implement PCC in a residential aged care facility. The literature

that was reviewed on this topic includes initiatives and processes used by aged care

organisations to improve aged care service quality, and PCC initiatives employed by

managers through leadership.

Strategies for the Literature Search

To identify the most salient literature on the development of a person-centred aged

care service, the CINAHL online database was searched using a Boolean/Phrase

mode and various combinations of the following terms: personhood, dementia, and

person-centred care. The search was limited to the following parameters: research

articles, English language, aged 65+ years and publications between 2000 and 2010.

The initial search resulted in 2319 articles. When searching these articles with Smart

Text, using the terms nursing homes, residential, long term care, aged care facilities,

and (residential care and nursing homes), the number of suitable articles reduced to

448. Adding the term, dementia care helped to refine the search to 56 articles that

were suitable for review.

A second search was conducted using PsychINFO (Ovid). Utilising the same variations

of terms and applying similar limiters, the process yielded 14,296 articles, which was

reduced to 315 with an advanced search and the application of the term ‘not patient-

centred’. The results were reduced further to 144 after applying the term ‘dementia

care’.

When reading through abstracts inclusion and exclusion criteria were applied. Articles

were included because the focus of the study was on person-centred care principles in

residential aged care. These articles could be categorised into three groups: the way in


which person-centred care practices lead to improved resident outcomes; those

articles that described PCC cultural change processes in residential aged care

organisations; and where managerial practices indicated staff outcomes such as job

satisfaction. Those articles excluded from the review espoused new models for the

implementation of PCC that excluded organisational or managerial strategies. At the

completion of this process and after duplicate articles were removed 98 articles were

considered suitable for review.

RSS feeds were created with Google Reader and article alerts were retrieved from

Ebesco Host and OvidSP to continue searching for suitable literature during the course

of the study. Relevant hand searched articles were also included in the review along

with references cited in particularly relevant articles. The following review focuses on

116 articles. The strategies for the literature search are outlined in Figure 1.

Although many of the articles listed in the Bibliography appear dated and over 5 years

old the study has focused largely on the literature of three leading PCC researchers:

Kitwood (1997), Brooker (2007) and Loveday (2013). Most of the citations through the

study, particularly in the Discussion Chapter actually refer to more recent research

investigating the implementation of PCC, management and leadership training


Figure 1 – Database (CINHAL and PsychINFO) search outcome

Global Embrace of PCC

There is a global trend towards accepting PCC as the preferred model of dementia

care which is changing how care delivery is managed in a range of health and aged

care settings (Department of Health and Ageing 2011). In light of the world-wide

CINAHL Search Terms: Boolaen/Phrase – Personhood + dementia + person-centred care (2000 – 2010) (English Language, +65yrs, journal articles)

PsycINFO Search Terms: Personhood + dementia + person-centred care (2000 – 2010) (English Language, +65yrs, journal articles)

n = 2319 articles

Utilising Smart Text:

Nursing homes, residential, long term care, aged care facilities, residential care and nursing home

n = 14,296 articles

+ Advanced Search:

Not patient-centred

n = 315 articles Added Term

Dementia care

n = 200 articles

Titles and abstracts read:

Inclusion and Exclusion criteria applied

CINAHL (n=46)

PsychINFO (n=52)

Total from database search (n = 98 articles)

Excluded: (n = 62)

Duplicates: (n = 40)

Total excluded: (n – 102)

n = 448 articles

Total from database search (n = 98 articles)

RSS feeds: (n = 10)

Hand searched articles: (n = 8)

Total for review (n = 116 articles)


appreciation of PCC as a suitable care model for people with dementia, the

Productivity Commission (2011) completed a broad-ranging inquiry into the Australian

aged care system. Many of the submissions, from individuals and professional groups,

to the Commission’s review proposed the adoption of concepts consistent with a

person-centred philosophy of care. The draft report noted that future policy change

should be guided by a number of aims, one being to ensure that older Australians have

access to person-centred services that can change as their needs change (Productivity

Commission 2011).

In the United States significant improvements have been reported in long term care in

recent years, noting a culture change that “seeks to provide care within the context of

cooperative, interdependent relationships based on caregivers’ knowledge of the

residents’ personality, as well as their personal history and values” (Lann-Wolcott,

Medvene & Williams 2011, p. 90). Research and reviews have been undertaken in

Japan, the Netherlands and Belgium aiming to understand the effects of PCC on

quality of life for people with dementia (Beerens et al. 2013; de Rooij et al. 2012;

Terada et al. 2013; van de Ven et al. 2013). Brooker (2004) notes “the mark of

success” of PCC’s adoption in United Kingdom aged care homes is the inclusion of

PCC in Standard 2 of the National Service Framework. Aligning with other countries,

Sweden’s national dementia care guidelines, published in 2010, sets PCC as a priority

recommendation for the care of people with dementia (Edvardsson, Sandman & Borell

2014, p. 1). Australian governments, at all levels, have developed guidelines to assist

organisations implement a person-centred approach to care (Aged Care Branch 2011;

Vic Department of Health 2008; WA Department of Health 2015). On behalf of

Alzheimer’s Disease International, Access Economics (2006) reviewed the prevalence

of dementia in the Asia Pacific region and the responsibilities this placed on

governments. With half the world’s population living in this region Access Economics

predicted the so called ‘dementia epidemic’ had potentially devastating effects for

regional and surrounding economies (Access Economics 2006, p. vi). Setting a

benchmark, Alzheimer’s Disease International (2013) proposed PCC as the preferable

model of care to be adopted by governments and institutions around the world.

Because of PCC’s growing acceptance by the aged care sector and by the

governments of a number of countries (Access Economics 2006; Alzheimers Disease

International 2013; Beerens et al. 2013; Berkhout et al. 2009; de Rooij et al. 2012;

Edvardsson, Sandman & Borell 2014; Terada et al. 2013; van de Ven et al. 2013),

aged care providers may feel compelled to label their organisation as person-centred


(Brooker 2004, p. 215). A review of the sector in a number of countries suggests that

the PCC ideology is tokenistic limited to mission statements and aged care home

brochures advertising their services (Brooker 2013; Jeon et al., 2014).

To encourage organisations to move beyond words in mission statements,

governments around the world are setting PCC standards and inspection procedures

for residential aged care facilities (Commission for Social Care Inspection 2008;

Department of Health and Ageing 2011). Concurrently, researchers have developed

and trialed PCC measures to assist aged care providers determine the extent to which

their organisation is practicing PCC (Burke, Chenoweth & Stein-Parbury 2012b;

Edvardsson, Fetherstonhaugh & Nay 2011; Edvardsson et al. 2010).

Aligning with the Australian Aged Care Standards (2009) and Kitwood’s (1997a) whole

systems framework, the Person-centred Environment and Care Assessment Tool

(PCECAT) has been used in this study to measure the quality of PCC in the study’s

residential aged care facility. The PCECAT, a self-assessment tool for use by

residential aged care managers, draws the links between organisational culture and

the practice of PCC (Burke, Chenoweth & Stein-Parbury 2012a; Chenoweth et al.

2014b; Forbes & Fleming 2009).

Person-Centred Approach to Care

“Person-centred care is not just an ideal expressed in policy

documents for political correctness, but represents the care that

residential aged care staff want to provide” (Edvardsson et al. 2011,

p. 1211).

Credited as the founder of Person-Centred Care in dementia, Tom Kitwood’s

publications on dementia care in the 1990s promoted care practices that provide the

context and social environment for positive human relationships. His purpose in writing

these articles was to foster person-centred care and to reverse the negative care

practices associated with what he called ‘malignant social psychology’ (Kitwood

1997b). Person-centred care challenged the biomedical, diminished-capacity paradigm

in dementia care, which arose from a faulty assertion that the person is eventually lost

as a result of dementia (Adams 1996; Brooker 2004; Phinney et al. 2007).

Recognition of Personhood

Kitwood was one of the first people to raise awareness of the importance of supporting

“personhood” for people with dementia (Brooker, 2007). He defined personhood as: “A


standing or status that is bestowed upon one human being, by others, in the context of

relationship and social being. It implies recognition, respect and trust” (Kitwood 1997a,

p. 8). As such, Kitwood (1997a) identified malignant social psychology as “the repeated

failure to meet a person as Thou, and the imposition of an I-It mode of relating” (p 89),

thus objectifying the person. Continued adherence to the biomedical, diminished-

capacity paradigm, results in care staff ignoring personhood in care delivery, with the

potential to advance the progress of dementia and to perpetuate malignant social

psychology in care services (Baldwin & Capstick 2007).

Brooker (2004) further suggested that adopting an attitude of ‘dementia-ism’, where the

person with dementia is discriminated against, little value is placed on them as sentient

beings with human needs similar to others. When personhood is ignored, care staff will

be tempted to focus on the tasks to be completed for them, rather than engaging

meaningfully with the person while providing that care. If care staff and other health

providers do not recognize the person’s innate humanness, they might interact with

others and talk over the person while providing care/therapy for the person and ignore

person, as if they are not there and their needs and feelings are not of central

importance. Kitwood (1997b) observed that when physical or technical aspects of care

were not involved in service delivery, some staff-resident interactions lasted less than

two minutes and were mater-of-fact forms of communication, for example “Are you

alright? Yes, it’s nearly lunchtime I’ll be with you soon”.

When personhood is not given due priority, people with dementia can be left to wander

alone, or to sit for hours with little human contact, while staff members undertake non-

emotional and non-responsive physical care and domestic activities, rather than using

care opportunities to interact meaningfully with the person. This neglect of personhood

gives rise to and reinforces malignant social psychology. In Kitwood’s (1997a, p. 101)

experience, “Bad care devalues the person, and so puts the entire organism at risk. It

enhances anxiety, rage and grief, and these bring all manner of pathology in their

train”.

Culture of Care

To counter the effects of malignant social psychology, Kitwood called for a cultural

change in care services for people with dementia, where the main focus of care

delivery is to preserve personhood in people with dementia (Adams 1996; Baldwin

2008; Baldwin & Capstick 2007; Brooker 2004; Cowdell 2006; Edvardsson, Winblad &

Sandman 2008b; Kontos 2005; McCormack 2004; O'Connor et al. 2007). The culture

of care promoted by Kitwood (1997a) is one where ‘facilities provide a milieu’ in which


nurses, care staff and therapists provide support, encouragement, positive social

environments and meaningful relationships (Kane et al. 2003). Person-centred care

equips care/health providers with knowledge about dementia and how this impacts on

the person, the skills to communicate positively with the person, strategies for building

a mutually satisfying relationship with the person, and knowing how to approach the

person to support their unique needs (Brooker 2004; Kitwood 1997b; Kolanowski et al.

2010). This occurs when staff are given the opportunity to come to know the person

through learning about their social background and preferred ways of living, and when

they are encouraged by their managers to develop a social relationship with the person

and their family (Brooker 2007; Loveday 2013; Sharp, McAllister & Broadbent 2015).

The care relationship, therefore, involves social interaction with the person during care

and therapy events, even if this relationship can only develop through positive eye

contact, friendly gestures and touch (Kitwood 1997a). The person becomes the focus

in person-centred care, rather than the set of tasks to be undertaken (Brooker 2004;

Cohen-Mansfield & Bester 2006). In this respect, PCC moves away from restrictive

practices believed necessary to minimise risk and maintain safety for the person

(Brooker 2007; Kitwood 1997a). When implemented in a supportive managerial

environment, staff will feel free, confident and empowered to provide person-centred

care, armed with the knowledge of care approaches which are most suited to each

person (Kitwood 1997a).

PCC in Practice

Person-Centred Care refers to a philosophy of care and an approach to care. It is

frequently confused with other related care models (Brooker 2007), such as patient-

centred care (Jones, DeBaca & Yarbrough 1997), individualised care (Chappell, Reid &

Gish 2007; Papastavrou et al. 2015; Price 2006) and client-centred care (Berkhout et

al. 2009; Tellis-Nayak 2007). PCC’s purpose is to preserve personhood in dementia,

which distinguishes it from similar care models (Edvardsson, Winblad & Sandman

2008b; Slater 2006). Patient-centred care is associated with the medical model,

wherein the patient is included in decision-making between clinician and patient in

relation to treatment and care; whereas, in client-centred care the person is a service

consumer and to some extent receives care services of their own choosing (Slater

2006). It is commonly assumed that PCC is the same as individualised care. While an

important aspect of PCC, individualised care does not necessarily focus on

relationship-building in care delivery, which is a central feature of PCC. In developing

PCC with his colleagues, Kitwood (1997b) emphasised the centrality of recognizing the


person as a social being and in relationship with others. The relationship-centred care

model arose out of PCC (Adams & Gardiner 2005; McCormack 2004; Nolan et al.

2004; van Lieshout et al. 2015), focusing on the need to improve relationships between

everyone involved in the care experience. Slater (2006, p. 138) suggests, however,

that using terms such as relationship centred care ‘only muddies the waters’ since

Kitwood’s (1997b) PCC model acknowledged the need for positive working

relationships for everyone working within dementia care.

In the breadth of literature about dementia care PCC is frequently discussed, with a

number of authors exploring the nature of PCC, both as a philosophical approach and

as a model of nursing practice (Baldwin & Capstick 2007; Brooker 2004; Cohen-

Mansfield & Bester 2006; Edvardsson, Winblad & Sandman 2008b; O'Connor et al.

2007; Tellis-Nayak 2007). Although O’Connor et al.’s (2007) review of programs

counteracting Kitwood’s ‘malignant social psychology’ theory, considers that these

programs have only tenuously acknowledged personhood, focusing more on

challenging behaviours, various therapies and models of nursing practice have been

attributed to a person-centred approach to care (Brooker, Woolley & Lee 2007; Dewing

2004; Edvardsson, Winblad & Sandman 2008b; Kane et al. 2007; McCormack 2004).

Dementia Care Mapping

One method used to implement PCC is Dementia Care Mapping (DCM). Considered

by some as the gold standard PCC model (Beavis, Simpson & Graham 2002), DCM

has direct links to Kitwood and the Bradford Dementia Group, and has been broadly

used in dementia care settings since 1992 (Brooker 1995; Brooker & Surr 2006).

Kitwood (1992) considered the DCM process was the best means of implementing

PCC, using trained DCM assessors to undertake direct observations of care practices

and responses by the person with dementia over set time frames. DCM assessors

code observations using clear criteria on the quality of the person’s daily life

experiences and related care processes, according to the person’s emotional state.

Alongside these observations, the DCM assessors record staff interactions with the

person, both positive (positive events) and negative (negative detractions) (Brooker

1995). The results of the observation records and scores are fed back to managers

and staff, with the aim of informing care practices and assisting staff to reconceptualise

care approaches to be person-centred.

The DCM process has been effective in promoting organisational change through care

improvements (Brooker & Surr 2006; Chenoweth et al. 2009; van de Ven et al. 2013).


Brooker (2005, p. 15) notes that a think tank of DCM practitioners concluded that

“DCM, used within an organisational framework that supported PCC” could see

improvements in a person’s well-being and staff behavior. While effective, DCM can be

costly for aged care providers and labour intensive for DCM assessors and aged care

staff (Brownie 2013; Chenoweth et al. 2009).

In a cluster randomised control trial, comparing DCM, PCC and usual care in 15

randomly allocated aged care facilities in Australia, agitation reduced considerably in

people with dementia who had persistent agitated behaviour in aged care homes

where PCC and DCM were implemented. The care quality and positive resident

outcomes were similarly positive for DCM and PCC implementation, therefore

researchers concluded that it was not essential for DCM to be used to implement PCC

(Chenoweth et al. 2009). This study demonstrated that PCC can be delivered

effectively without the use of DCM and can make a real difference to well-being for

people with dementia when applied generally in care, and for specific aspects of care

(Alzheimers Disease International 2013; Chenoweth et al. 2009; Cohen-Mansfield,

Parpura-Gill & Golander 2006; Crandall et al. 2007; Kolanowski et al. 2010).

Implementing PCC in Residential Aged Care

“Studies have shown that the successful implementation of culture

change models [such as person-centred care] requires good

leadership and stable management; strong teamwork, efficient

communication systems; and an investment in staff training and

education about culture change.” (Brownie 2013, p. 7)

There is consensus in the international literature that PCC is a recommended model to

improve the care of people with dementia. Nevertheless, the literature reveals that, in

implementing PCC, aged care organisations must recognise and pay attention to

supporting personhood of all members of the organisation: residents, residents’ family

members, managers, staff and volunteers. This commitment creates a supportive

structure for PCC, what Kitwood (1997a) called a care organisation. This new

organisational culture calls for innovative strategies to support the implementation of

PCC in residential aged care facilities. More importantly, PCC needs to occur not only

at an individual care level, but also at an organisational level.


A Person-Centred Care Organisation

Kitwood (1997a) described a conceptual framework for the care organisation with

systems to make it function effectively and maintain standards. This framework

included: checks to maintain standards, ongoing education, constructive feedback

mechanisms, provision of timely information, management systems that supported

quality care, fair working conditions and participatory decision-making. In agreement,

Brooker (2007, p. 54) advises: “If we encourage care practitioners to adopt a person-

centred approach without addressing the larger organisational context, we are setting

them up to fail”. To be successful in operating aged care services which practice PCC,

managers need to cultivate a culture that supports PCC (Kitwood 1997a). In giving staff

the resources, systems and skills to undertake their jobs, managers become the

culture carriers for the way things are done in the organisation (Robbins & Barnwell

2006).

Organisational culture and PCC

“Some organisations describe their service as being person-centred

without the necessary cultural shift to make this a reality... Provider

organisations should ... develop a shared culture at all levels of the

organisation to ensure person-centred dementia care.” (Kirkley et al.

2011, p. 438)

Organisational culture is described as the values, beliefs and climate of the collective in

the workplace, the staff perceptions of their workplace and their managers (Langford

2009). “It influences the behaviour of all individuals and groups within the organisation.”

(Harrison & Stokes 1992, p. 1) While organisational culture and organisation climate

are viewed as two rival concepts by some scholars, in a study of 22 stratified randomly

sampled health service facilities, Braithwaite et al. (2010, p. 15) found: “a positive

correlation between organisational climate and organisational culture” As such, culture

and climate may be seen as two sides of the same coin.

Langford (2010) developed a conceptual framework to describe organisational climate

after surveying employees (n=10,021) from 876 Australian business units, including

many from large aged care organisations. The framework, described as a model,

consists of seven factors: purpose, participation, property, peace, people, progress and

passion. Listed below each of these seven factors are details of the specific

components assigned to each factor. Langford’s model links the various management

systems with organisational goals and outcomes. There are conceptual links with


Langford’s (2009) model and Kitwood’s person-centred framework (1997a), in

particular, the requirements for a whole of systems approach to person-centred care.

The management systems that Langford (2009) labelled as purpose (organisational

goals), participation (organisational systems) and property (organisational resources)

directly link with the two outcomes – progress (customer outcomes) and passion (staff

engagement). It is these management initiatives - purpose, participation and property

that result in positive outcomes for aged care recipients that, according to the model,

lead to staff commitment. The model also posits that purpose, participation and

property have links with people (motivation, talent and teamwork) and peace (wellness

and work-life balance); these final two factors (people and peace) do not directly

influence either staff passion or organisational progress, being ends in themselves.

To establish and maintain PCC in an aged care service, managers need to cultivate an

organisational culture which values respect and trust, is sensitive to staff issues and

makes important care recipient information available to staff. The broad array of

information needed by staff to provide PCC can range from the care recipient’s health,

psychological and social history and preferred lifestyle (Langford, Parkes & Metcalfe

2006), the organisation’s policy and training infrastructure (Brooker 2007; Chenoweth

et al. 2009; Lann-Wolcott, Medvene & Williams 2011) and timely advice about planned

organisational changes (Brooker 2007; Kitwood 1997a). These types of information will

enable staff to feel more empowered in their work, creating greater job satisfaction and

flexibility in providing individualised care (Laschinger & Finegan 2005).

Berkhout et al. (2009) found that the successful conditions for the introduction of what

they called resident-oriented care were on-the-job staff training and a socio-emotional

and participative leadership style. Crandall et al. (2007) found that one of the key

ingredients for successful implementation of PCC was a supportive organisational

culture. In Crandall et al.’s (2007, p. 54) study, facilities with significantly positive

practice changes “had cultures compatible with person-centred thinking”. Given the

worldwide trend towards PCC, there is a need to determine the specific organisational

conditions and support mechanisms required for its system-wide development,

facilitation and evaluation. One of the features of an organisation-wide adoption of PCC

is its potential for improving staff knowledge, skills and creativity (Chenoweth et al.

2009; Cohen-Mansfield & Bester 2006; Cohen-Mansfield, Parpura-Gill & Golander

2006; DeCicco, Laschinger & Kerr 2006; DiMaria. 2007; McCormack 2004; Tellis-

Nayak 2007; Wagner et al. 2010).


Staff empowerment and commitment

PCC can improve care for the person with dementia when a supportive culture

provides staff with the autonomy and a learning environment to make effective

decisions about care delivery (Brooker & Woolley 2007; Edvardsson, Winblad &

Sandman 2008b; Kitwood 1997a; O'Connor et al. 2007). As Yeatts & Cready (2007)

attest, staff empowerment is a component of PCC initiatives, whereby PCC gives staff

the flexibility to increase their decision-making opportunities, while honing their

dementia skills. Chenoweth et al. (2009) identified that learning the techniques of PCC

encourages staff to initiate, become involved in and take ownership of needed change.

Care staff taking ownership of change was also identified by Crandall et al. (2007)

when PCC was successfully implemented in three Oregon aged facilities. Empowered

and enlightened, care staff became aware that the introduction of changes in one

system had a domino effect on other parts of the organisation’s systems. Conversely,

when aged care facility managers find it difficult to hand over care decision-making to

nurses and direct care staff and allow staff the freedom to learn from small errors of

judgement, staff will tend to maintain known routines and focus on task-centred care

(Crandall et al. 2007). While Hughes et al. (2008) found that trust, respect and nursing

leadership are positive factors in a learning environment, further research is needed

into the leadership qualities, management skills and the well-being of staff in a person-

centred model (Chenoweth & Kilstoff 2002; Crandall et al. 2007; Yeatts & Cready

2007).

Research has identified that effective managerial leadership, mutual manager-staff

trust and respect, organisational support and staff empowerment, are linked with job

satisfaction and organisational commitment for dementia care staff (Brooker & Woolley

2007; DeCicco, Laschinger & Kerr 2006; Edvardsson, Winblad & Sandman 2008b;

Kitwood 1997a; Productivity Commission 2011). Supporting this view is the theory of

Structural Empowerment (Kanter 1979). Described as having more impact than

personal dispositions, structural empowerment comprises having access to

information, support, resources and formal and informal power, and the opportunity to

learn and grow (Laschinger et al. 2009; Wagner et al. 2010). Structural empowerment

has a direct association with respect, trust, job satisfaction, and organisational

commitment (Brooker 2007; Kitwood 1997a; Langford, Parkes & Metcalfe 2006).

A number of nursing studies have linked nurse empowerment with their commitment to

the organisation and its goals (DeCicco, Laschinger & Kerr 2006; Laschinger &

Finegan 2005). Staff members’ commitment to their workplace was assessed by


DeCicco et al. (2006) in a survey of 154 registered nurses (RNs) and Registered

Practical Nurses (RPNs) who had worked in nursing homes in Ontario, Canada, for a

minimum of 6 months. With a response rate of 60 per cent, the mail out survey

combined four different instruments to measure empowerment structures, global

empowerment, psychological empowerment and respect (2006). “Structural

empowerment, psychological empowerment and respect explained 48 per cent of the

variance in affective commitment for RNs and 40 per cent for RPNs” (DeCicco,

Laschinger & Kerr 2006, p. 49). These results concur with the findings of an earlier

study conducted with 489 nursing home staff (Steffen, Nystrom & O'Connor 1996), who

reported that nursing home administrators need to involve staff in various levels of

decision making to improve staff commitment to care service quality.

DeCicco et al. (2006) noted that staff commitment to their workplace was found to

enhance with increased job autonomy and in turn, job commitment led to customer

satisfaction. Gaining manager, nurse and care staff commitment to improving service

quality is fundamental to the PCC model, given that PCC needs to be an organisational

goal (Steffen, Nystrom & O'Connor 1996). In an Australian study (n=10,021) conducted

in a large number of aged care facilities, organisational systems were found to

influence staff engagement and organisational outcomes (Langford 2009). While links

have been made between organisational systems, staff commitment and care recipient

outcomes, there is a need for further research studies that strengthen these links in

varied care settings and for various levels of staff (Brooker 2007; Crandall et al. 2007;

Kitwood 1997a).

Managerial Support for PCC

A cultural transition to person-centre caregiving calls for caring

managers who know that the well-being of the resident is inseparable

from the welfare of the caregiver, and that the needs of the caregiver

transcend mere bread-and-butter considerations. (Tellis-Nayak 2007,

p. 53)

While PCC research has not yet identified definitive management strategies for

implementing PCC, there is some evidence for certain workplace requirements

(Chenoweth et al. 2010; Duffy, Oyebode & Allen 2009; Jeon et al. 2011; Wagner

2007). In a cluster randomised study by Chenoweth, et al. (2009) the positive

outcomes occurring with PCC training were thought to be associated with staff having

the autonomy to determine specific ways to plan personalised care. Another factor that


gave rise to direct care staff ownership and success in the change management

process was the support and commitment of the care unit manager to care staff

innovation and leadership in care planning, care delivery and evaluation of progress

being made. Crandall et al. (2007, p. 54) reported that when staff are enlightened and

empowered within a PCC organisation, “they begin to identify new areas for

improvement that further facilitate a person-centred approach to care”. Therefore,

promotion of direct care staff autonomous decision-making is a strategy that managers

can employ when implementing PCC.

In another randomised control trial using PCC as a specific intervention for lifestyle

activities in dementia care services, Cohen-Mansfield, Parpura-Gill & Golander (2006)

identified improvements in resident wellbeing when activity programs related to their

past roles were implemented. The researchers identified that nurses and therapists

required “extra time to assess role identities and to develop and implement individual-

based lifestyle activities” (Tellis-Nayak 2007, p. 53).

Extra time was also considered imperative to implementing non-pharmaceutical

interventions for the behavioural and psychological symptoms of dementia (e.g.,

aggression, agitation and wandering) in a study of people with dementia living in six

Canadian nursing homes (Cohen-Mansfield, Parpura-Gill & Golander 2006). During

focus groups, a cross-section of staff from these homes (n=35) discussed how time

featured in their work lives: time to get to know the person, time to respond, time spent

with the person, time to use certain interventions and time to get experience.

Another study (Kolanowski et al. 2010) found that flexibility in nursing care, such as

eliminating strict and ritualistic routines and accommodating residents’ chosen

timeframes, led to resident well-being and a better emotional affect. These kinds of

responsive care approaches for people with dementia were a factor of management

support and flexibility. For example, the facility manager encouraged staff to spend

time eating with residents, rather than expecting them to complete technical and

domestic tasks, such as making beds according to a strict schedule. Flexibility was

also observed in staff rostering practices to ones that accounted for individual staff

member’s personal shift requirements (Cohen-Mansfield & Bester 2006). These

studies have shown that Kitwood’s (1997a, p. 104) model requires the care service to

“...be committed to the personhood of all staff, and at all levels”. This mandate extends

to the organisation’s responsibility to the well-being of its managers and direct care

staff.


The Australian Productivity Commission (2011, p. 54) has made clear that

“opportunities for career progression, job flexibility, workplace safety, social

engagement, and the personal sense of value people get from their work” are

important contributors to the wellbeing of staff. This has practical applications for

Australian aged care providers, given recent trend analysis showing decreasing

numbers of licensed nurses working in the residential aged care sector. Future

predictions suggest that the current workforce needs in residential aged care will need

to double or triple to meet future nursing demands (Access Economics 2009; Aged

Care Workforce Committee 2005). Improved working conditions are essential to attract,

recruit and retain qualified aged care staff (Chenoweth et al. 2010; Cohen-Mansfield &

Bester 2006; Productivity Commission 2011). Cohen-Mansfield & Bester (2006)

suggest that to be adaptable to the needs of a person with dementia the organisation

needs to have an ‘unrushed pace and social ambience’ while also recognising the

needs of the employees. This inherently calls for strong leadership in the residential

aged care sector (Australian College of Nursing (ACN) 2015; Productivity Commission

2011).

Managers as Leaders

It has been asserted that some Australian nurses are ill-prepared as leaders when

appointed to management roles (Duffield 2005; Hurley & Hutchinson 2013; Jeon et al.

2010a). A clinical management leadership framework is in process for middle

managers working in the Australian aged care sector (Jeon et al. 2015; Jeon et al.

2010a). The basis for the development of the leadership framework is the pivotal role

that senior nurses play in leading and managing quality care and improving outcomes

for aged care residents (Jeon et al. 2015). Jeon et al. (2015) recommend that if middle

managers are to take up the challenge of leadership in elevating care service

standards and improving resident life experiences, the organisation needs to determine

how clinical leadership will be operationalised within the organisation’s overall

management structure.

The first steps in operationalising clinical leadership are to clarify the roles that

manager leaders play in developing quality systems. A distinction has commonly been

made between leadership and management in the quality improvement process. While

management has been described in simple terms as planning, organising and

monitoring service delivery, leadership is more concerned with creating a long-term

vision and establishing mechanisms whereby managers and their staff can collectively

and individually work towards change (Jeon et al. 2015). The Australian College of


Nursing (2015) further acknowledges that nurse managers hold formal positions within

a healthcare organisation, while nurse leaders may not necessarily have a designated

management role; this might develop as a result of changed circumstances in the

organisation, or evolve with advanced knowledge, skills and expertise. Loveday (2013)

suggests that PCC leaders can exist throughout the organisation as a result of

achieving these attributes. Adding to this perspective, Crandall et al. (2007) noted that

as greater levels of autonomy and accountability arise in a person-centered

organisation, leaders emerge from all departments and at every level in identifying new

areas for improvement that further facilitate a person-centred approach to care. Indeed,

in a person-centred organisational model, a goal will be to support leadership across

the organisation (Hurley & Hutchinson 2013; Russell & Stone 2002).

The growing literary discourse on the topic of aged care leadership reveals

interdependence between management and leadership skills (Hurley & Hutchinson

2013; Russell & Stone 2002). From their systematic review, Cummings et al. (2010)

determined that when leadership approaches are relational and people-focused, they

produce positive outcomes for the nursing workforce and the work environment, and

lead to productive and effective healthcare organisations. Good management practices

and skills also influence workplace conditions and outcomes for care recipients. Nurses

rate a ‘good’ manager or leader when he/she is visible, provide positive feedback to

their staff, and allow flexibility in work schedules (Australian College of Nursing (ACN)

2015; Cummings et al. 2010; Hurley & Hutchinson 2013).

The findings of a systematic literature review by Chenoweth et al. (2010) revealed that

the organisational ethos and a supportive environment were reasons that attracted and

retained nurses in acute, community and residential aged and dementia care services.

Leadership was cited to be an important driver for a supportive organisational culture.

In the Australian nursing workforce effective leadership is a key predictor of staff

commitment to their organisation and reduced staff turnover (Duffield et al. 2011).

Nursing leadership has also been consistently identified as a significant feature of

positive healthcare organisations. The relationship between leadership and job

satisfaction is significant, in the sense that staff satisfaction will likely have an influence

on care quality (ACN 2015). Staff job satisfaction tends to distinguish a person-centred

care organisation (Chenoweth et al. 2014c).

Nurses in all care settings have articulated the factors that give rise to job satisfaction

in care of the older person; the key factors are their ability and their manager’s support


in delivering care that meets the holistic needs of their patients, clients and residents

(Cameron & Brownie 2010; Chenoweth et al. 2014c; Jeon et al. 2013).

An issue that inhibits nurses’ opportunities to provide and/or supervise the delivery of

quality care is the inadequate levels of education and training in person-centred care of

the older person, especially the person with a cognitive impairment. Recommendations

for progressing the development of a person-centred care organisation included better

education, preparation and mentoring of all direct care staff, and ensuring sufficient

numbers of skilled nurses at the bedside as primary nurses, supervisors and mentors

(Chenoweth et al. 2014c). Instituting these foundations for PCC requires strong

managerial leadership in developing organisational policies, systems and procedures

that enable direct care staff to contribute their expertise, be part of clinical and

organisational decision-making processes and to develop leadership in optimizing care

services (Jeon et al. 2013; Rokstad et al. 2013).

The successful implementation of PCC requires aged care managers to lead and

encourage staff to contribute to achieving organisational goals, which include

improving the residents’ quality of life and well-being (Cummings et al. 2010).

Research has identified that a transformational leadership style related to managing

organisational change through engendering commitment to a vision, particularly in

“instituting changes in structure, procedure, ethos, technology, and/ or production”

(Brooker 2007; Crandall et al. 2007; Kirkley et al. 2011; Kitwood 1997a; Loveday

2013). This leadership style aligns with the requirements of introducing PCC “through a

top-down, bottom-up and system-wide approach” (Van Wart 2013, pp. 557-8). Staff

empowerment and flexibility in care regimens are also distinctive features of

transformational leadership that align with PCC principles (Jeon, Merlyn & Chenoweth

2010; Stein-Parbury et al. 2012). According to Cummings et al. (2010) transformational

leadership practices, like PCC, focus ‘on people and relationships to achieve the

common goal’, in contrast with transactional leadership, which is a task-focused

leadership style, ‘primarily managing by exception’. Importantly, in comparison to other

leadership practices, relational-based leadership styles will likely lead “to much more

frequent and encouraging outcomes” (Cummings et al. 2010, p. 378), a finding

supported by a number of other researchers (Kitwood 1997a; Loveday 2013; Van Wart

2013).

Leadership styles and PCC

It is vital to understand the leadership styles which can best assist managers take the

lead in implementing change and improve the quality of care expected of them


(Carmeli, Tishler & Edmondson 2012; Hurley & Hutchinson 2013; Hutchinson & Hurley

2013; Russell & Stone 2002; Van Wart 2013). The ‘servant leader’ approach, originally

proposed by Greenleaf (1980) and outlined by Russell and Stone (2002), proposes a

comprehensive range of leadership characteristics to accommodate varying

organisational leadership demands. Conversely, Hurley & Hutchison (2013, p. 180)

advise that while the servant leader approach is relationally based, this leadership style

tends to focus on “developing the individual as a leader and overlooks the

organisational perspective”. Best suited for non-profit organisations, a collaborative

leadership style offers a win-win perspective, to include the client’s perspective,

“emphasising the need to support the health of communities and the environment for

the good of all” (Van Wart 2013, p. 559). In keeping with this perspective, recognising

the role of the organisation’s top leadership team, Carmeli et al. (2012) identified the

significant benefits of the CEO using a relational approach when working with the

organisation’s senior managers on strategic decisions. In particular, by taking a non-

blame approach, the top management teams can learn from their mistakes.

In determining the appropriate leadership practices required to implement PCC in an

aged care facility, it appears that a combination of approaches is necessary. While

transformational leadership aligns with the ethos of PCC, the literary discourse reveals

that leaders in management positions need to adopt leadership styles that are flexible

and congruent with a particular context (Jeon et al. 2013; Kirkley et al. 2011; Shield et

al. 2014). Additionally, transactional leadership can be both complimentary and a

prerequisite to transformational leadership (Cummings et al. 2010; Hurley &

Hutchinson 2013; Van Wart 2013). Van Wart (2013, p. 558) explains further that, “the

specific and practical challenges of leadership evolve and change significantly over

time” in response to the demands placed on managers. PCC leaders are expected to

create relationships, work collaboratively to achieve the organisational goals while

balancing good management practices. With the organisational goal to successfully

implement PCC it may be simply stated that this change process will need to be,

“... led by individuals and teams who display relational skills, concern

for their employees as persons, and who can work collaboratively to

achieve a preferred future for themselves, their employees, their

patients and their organisation.” (Van Wart 2013, pp. 561-2)

While leadership style is pertinent to the implementation of PCC, managers also need

to be supported by an appropriate organisational framework.


PCC Organisational Framework

“... good leadership and effective management will tend to begin at

the organisational level, in the provision of the structural and

psychological support resources and protocols that create a healthy

workplace environment in which middle management feel supported

and empowered to more effectively lead and manage”. (Jeon, Merlyn

& Chenoweth 2010, p. 58)

As the implementation of PCC depends upon managers supported by a PCC

organisational framework (Brooker 2004; Jeon et al. 2011; Kitwood 1997a) it is

imperative to understand what are the organisational barriers or facilitators that enable

staff and managers adopt a person-centred approach to care (Kirkley et al. 2011).

Working within an organisational context, nurse managers are not fully responsible for

all the decision-making (Brooker 2007; Chenoweth et al. 2014c; Jeon et al. 2013;

Kitwood 1997a; Loveday 2013). Nurse managers are contextualised in the

organisation’s overall governance (DeCicco, Laschinger & Kerr 2006; Jeon et al.

2013). For care staff, at its essence, PCC requires them to develop relationships with

residents and uniquely responding to individuals in their care. As such, at the coalface,

care staff need to balance the needs of the individual against the wider group while

working within the organisation’s systems (Lloyd & Stirling 2015).

While managers with appropriate transformational leadership skills are the culture

carriers for change (Cummings et al. 2010), research has shown that it is the broader

organisational context that supports PCC cultural change (Brooker 2007; Brownie

2013; Edvardsson et al. 2011; Hacker, Zimmerman & Burgener 2014). By referring to

Donabedian’s Quality Framework, Hacker et al. (1966) outline that it’s the structural

resources and processes, at the organisational level, that determine the quality of care

services provided. It is important to know the explicit structural characteristics that

support PCC cultural change so that the context can be understood and compared

across research studies (Brownie 2013). Four of these characteristics have been

identified as flattened hierarchy, creation of a vision, contextualisation of PCC and a

clear process for change management.

Flattened hierarchy

Research has shown that one striking organisational structure that has been found to

facilitate PCC is a ‘flattened” organisational hierarchy (Brownie 2013; Miller et al.

2010). Described by Kitwood (1997a) as the ‘us-them’ barriers, this structural concept


decentralises decision-making. Fundamentally and practically, choice is brought to the

care recipient and his/her representative. With the proffered new hierarchical structure

decision-making is turned on its head where decisions are made closest to where the

care is provided (Crandall et al. 2007; Kirkley et al. 2011; Miller et al. 2010; Shield et al.

2014). In turn, this allows care staff to become emotionally engaged, thus more

responsive to residents’ needs as they arise (Sharp et al. 2015). Equally, their direct

managers are empowered to be supportive and enabled to make changes to the way

things are done within their care unit.

The Australian Aged Care Standards (Aged Care Standards and Accreditation Agency

Ltd 2009) propose that people living in residential aged care facilities can expect to

have the freedom to choose. Practically, however, there can be many organisational

barriers or priorities that inhibit people being given this level of decision-making (Lloyd

& Stirling 2015; Shield et al. 2014). Studies have indicated that consumers, and even

aged care managers, believe the obstacle to culture change lies with the organisations

senior managers (Kirkley et al. 2011; Miller, Mor & Clark 2010; Sharp, McAllister &

Broadbent 2015; Shield et al. 2014). This may arise because PCC has been difficult to

define (Brooker 2007), considered abstract and imprecise (Edvardsson,

Fetherstonhaugh & Nay 2011), particularly at an operational level (Sharp, McAllister &

Broadbent 2015), leading to confusion in expectations between recipients and

providers of care.

“Therefore, clear articulations of person-centred practice, from all perspectives, can

enable organisations, recruiters, managers and educators to identify and facilitate the

skills and workplace conditions necessary for clinicians to deliver person-centred care.”

(Sharp, McAllister & Broadbent 2015, p. 3)

Creation of a vision

The second organisational strategy calls for organisational leadership creating a Vision

which articulates PCC through a ‘whole-of-facility’ management system (Brownie 2013,

p. 7). Described as “warming the soil” Crandall et al. (2007, p. 54) determined that this

system-wide approach meant staff at all levels were involved in the organisation’s PCC

implementation design. With everyone informed of the incremental changes (Brownie

2013; Crandall et al. 2007; Shield et al. 2014) and aware of the PCC goals this cultural

change can create Kitwood’s (1997a) the care organisation, as has been described

already. Moving away from dictated training with top-down directives for clinicians to

practice PCC everybody, including managers, comes to understand their role and


responsibility when being person-centred. Training and supervising staff in person-

centred care generally leads to effective care practices; and this most often occurs

when there is executive support for implementing PCC organisation-wide (Crandall et

al. 2007; Kolanowski et al. 2010). Recognising its value, training is not an end in itself

(Loveday 2013; Stein-Parbury et al. 2012) but a means for cultural enlightenment

through the systems to support and sustain person-centred practice (Brownie 2013;

Crandall et al. 2007). People are then set free to be creative and spontaneous

(Crandall et al. 2007; Kitwood 1997a; Loveday 2013). There is evidence that this type

of management support and an underlying organisational culture in a person-centred

service can engender this level of staff empowerment (Cheek et al. 2004; Chenoweth

& Kilstoff 2002). Indeed, “... the importance of management support to implement PCC

cannot be underestimated” (Jeon et al. 2011, p. 516).

Contextualisation of PCC

Empowered, and with PCC embedded in the organisation’s governance, the third

strategy sees managers enabled to take the lead and contextualise PCC within their

management practice. Shield et al. (2014), in a study reviewing how nursing homes

implement PCC culture change, described the perspective of one manager who called

for people to think differently, “I really expect everybody to think outside of their own job

description, and there has to be overlap between what everybody does” (p. 750).

Importantly, Tellis-Nayak (2007, p. 52) identified that “successful managers set the

workplace environment [where] ... residents ... first and foremost are persons with a

universal human need for security, recognition, achievement and relationships”. With

kind managers care staff find their greatest satisfaction is the difference they make in

people’s lives (Tellis-Nayak 2007). In sync, research has also revealed those

managers’ initiatives where consistent assignment of staff aligns with care staff

empowered to get to know residents and, thereby, form relationships (Brownie 2013;

Loveday 2013; Shield et al. 2014). Nurturing these relationships is imperative to the

success of this culture change (Brownie 2013; Lloyd & Stirling 2015). Studies have

also elicited that managers should recruit staff that are prepared to take on a person-

centred approach to care as outlined in job descriptions (Crandall et al. 2007; Kirkley et

al. 2011; Kitwood 1997a).

Process for change management

The final strategy to consider is the change management process a concept discussed

in some detail by Brooker (2001) Kitwood (1997) and Loveday (2013). Like these


writers, studies divulge that implementing PCC is an incremental process, with small

steps and realistic goals (Shield et al. 2014, pp. 753-4). With transformative leadership

cultural change involves collaboration, consultation, delegation, flexibility and the ability

to learn from one’s mistakes(Carmeli, Tishler & Edmondson 2012; Caspar, O'Rourke &

Gutman 2009; Crandall et al. 2007; Harris, Poulsen & Vlangas 2006). In what Kirkley et

al. (2011) described as a solution-focused approach, organisations need to be flexible

if they are to sustain their ambition to meet the needs of individuals. Supported by a

culture of continuous improvement the organisation will recurrently review its practices,

policies and systems to ensure it vision for PCC is maintained (Caspar, O'Rourke &

Gutman 2009; Miller, Mor & Clark 2010). Advocates (Brooker 2007; Kitwood 1997a;

Loveday 2013) confirm to successfully implement PCC organisations need to maintain

a set of checks and balances where change is a learning experience. Loveday (2013,

p. 50) recommends,

“Leaders must give careful thought to how they can bring the team

with them through the [change] process...[providing] an awareness of

what’s currently wrong and a readiness to learn and develop, thus

leaders must foster these conditions as an essential component of

change management.”

Conclusions

This literature review has explored Kitwood’s (Kitwood 1997a) system-wide-conceptual

framework for the implementation of person-centred care. The chapter presented a

review of the relationships between the organisational culture and care staff

opportunities to implement PCC for people living in residential aged care facilities. In

practicing PCC, staff adopt a culture of care that acknowledges, respects and

promotes the personhood of each person in their care. Although the researcher’s study

does not solely focus on dementia care, the respect for personhood is particularly

important for people living with dementia. By getting to know the person and

developing a relationship, staff can be truly flexible to the needs and preferences of

each individual; enabling and empowering staff to be flexible requires supportive

organisational structures and managerial leadership.

True collaboration requires managers and staff to seek and act on advice from

residents and their families on what matters most to them (Edvardsson, Winblad &

Sandman 2008a). As well, it is essential that the voices of direct care staff contribute to

discussion and decision-making on care services, since they are the front-line arbiters


of service quality in residential aged care and in many respects, they are also the ears

and eyes of what makes for a quality care service (Chenoweth et al. 2010). Given their

major contribution to the quality of the resident’s day-to-day life, direct care staff have a

mandate to continually review routine practices and to critically reflect on decisions

they make and actions they take in supporting resident care. Wise decision-making

that aims for improved resident quality of life relies on direct care staff being able to

access, analyse and synthesise information about each resident’s personhood needs

under the guidance of qualified nurses (Chenoweth 2015).

The VIPS model (Rokstad et al. 2013) articulates the fundamental concepts which

must drive the process in achieving a person-centred organisation, and include:

Valuing: a value base that asserts the absolute value of all human lives.

Individual care: an individualised approach to care services, recognising the person’s

uniqueness.

Perspectives: understanding the world from the perspective of the person living with

dementia.

Social psychology: promoting a positive social psychology in which the person living

with dementia can experience relative well-being.

In order to support this process, a number of organisational structures must be evident

(Chenoweth et al. 2014b): the organisational executive, managers and staff are

receptive to change; stakeholders, including residents and families, are committed to

the goals and the change process; all stakeholders are engaged in the change process

from the start; an effective change model is developed to guide implementation;

adequate resources are provided to support the change process over time; Staff are

equipped with the necessary knowledge, skills and supervision to implement the

change; and policies and procedures are in place to support the use of evidence and

best-practice guidelines in making the required changes.

While identified as essential, few studies that relate to the implementation of PCC,

such as DCM, have found these essential factors remain in place over the course of

the change process. The difficulties of enacting organisational change towards a

person-centred model abound in the literature for this reason. To persuade aged care

organisations and their personnel to embrace the person-centred model, the key

stakeholders need to be convinced of its relevance to the context, and that both they

and the residents will benefit (Edvardsson, Winblad & Sandman 2008a). Nurses and

other direct care staff need strong managerial support and resources to change


traditional care practices. They also require clear guidelines on how to apply PCC to

each of the specific circumstances they are faced with (Chenoweth et al. 2014b)

Cohen-Mansfield (2014) recommends that establishing the appropriate paradigm for

determining the implementation and efficacy of PCC approaches is a topic requiring

debate, reflection and further study.

It becomes a lot easier for care and nursing staff to change their practices and

incorporate a culture of care when they work in a person-centred milieu, described as

‘warmed the soil’ (Crandall et al. 2007) for PCC. it is clear in the PCC literature

(Brooker 2007; Kitwood 1997a; Loveday 2013) that organisations need to initiate

strategic steps that create the requisite cultural milieus and participative mechanisms

for person-centred practices to be accommodated. Equally important, managers are

beholden to use appropriate leadership approaches to instil PCC friendly workplaces.

Yet these types of stratagems portray a broad-lens view of the conditions that support

a person-centred approach to care.

While research has identified a range of organisational conditions and managers’

dispositions that support PCC practice (Chenoweth et al. 2014b; Cohen-Mansfield &

Bester 2006; Crandall et al. 2007; Stein-Parbury et al. 2012) there is a void of

information regarding aged care managers’ PCC initiatives. Similar management

conditions are recommended within the PCC theoretical frameworks (Brooker 2007;

Kitwood 1997a; Loveday 2013) but they have not been examined for their

effectiveness. Even when PCC was trialled in Australian residential aged care facilities

these two large studies (Chenoweth et al. 2014b; Chenoweth et al. 2009) did not focus

on the nurse managers’ PCC implementation plans. It remains unclear, in the literature,

as to the specific, planned management strategies that comprise the necessary

change process to implement PCC.

Chapter 4 – Methodology 35

Chapter 4. Methodology

Introduction

Chapter Four outlines the methodology for the researcher’s study. The study’s

methodology encapsulates Kitwood’s PCC conceptual framework and Donabedian’s

quality framework (Donabedian 1966). To provide a level of rigour to this research

study, rather than simply relying on what managers purport to be doing to promote

PCC the study reviewed the whole of systems approach to implementing PCC,

measured by utilising the PCECAT.

Aim and Objectives

Aim

The aim of the researcher’s study was to identify, in a residential aged care facility, the

management strategies that support the implementation of person-centred care (PCC)

and determine whether these strategies are reflected in the quality of care.

Objectives

The following objectives were completed in order to achieve the aim of the study:

To explore the strategies used by managers to implement PCC;

To assess the extent to which PCC has been implemented in the aged care

facility;

To determine which management strategies support Person-centred Care by

comparing what managers say they do to the quality of PCC;

To understand staff empowerment to make decisions about the provision of

care.

To understand how residents are enabled to maintain their skills and be

supported in decision-making.

This study examined what managers say they are doing to promote PCC in an

organisation whose goal is to implement PCC across all of their facilities and services.

Because reliance on what managers say they do is insufficient in determining whether

PCC is occurring the degree to which PCC had been implemented in the study site

was assessed using a validated system-wide evaluation measure, which included

direct observation of care services, document review and interviews with different

direct care staff. The following research question framed this study.


Research Question

What planned management strategies support the implementation of person-centred care

in a residential aged care facility?

Study Design

This study was conducted in a pre/post-evaluation design over 18 months using mixed

methods and sequential data collection and analysis. Quantitative data were collected

to measure the degree to which PCC was evident in the study setting prior to (pre) and

following implementation (post) of PCC. In between the pre and post data collection

times semi-structured interviews were conducted with managers of the study setting to

ascertain strategies that they used to guide the implementation of PCC.

Sequential data collection

A mixed methods approach was employed with sequential data collection, whereby

quantitative data informed and strengthened qualitative data (Creswell 2009). Teddlie

and Tashakkori (2006, p. 15) note that “mixed methods research is defined as research

in which the investigator collects and analyses data, integrates the findings, and draws

inferences using both qualitative and quantitative approaches or methods in a single

study or program of inquiry”. Cameron (2009) asserts that mixed methods research is

utilised by a number of disciplines including organisational and management research.

Creswell et al (2004, p. 7) add that mixed methods research “holds potential for

rigorous, methodologically sound studies in primary [health] care”. Furthermore, when

both quantitative and qualitative methods are used in combination the data sets yield a

more complete analysis and complement each other (Creswell, Fetters & Ivankova

2004). The researcher’s study is comprised of the three dimensions as outlined by

Cameron (2009, p. 145): “the use of exploratory or confirmatory methods, the

integration of qualitative or quantitative data, and linking strands sequentially”.

In this study baseline facility-level data were collected with a validated Person-Centred

Environment and Care Assessment Tool (PCECAT) (Burke, Chenoweth & Stein-

Parbury 2012b) in order to determine the extent to which PCC was evident. Semi-

structured interviews were conducted with managers to obtain data on manager

initiated facility-wide plans and strategies that they were using to implement PCC. The

interview schedule for the semi-structured interviews was based on a systems

approach to the implementation of PCC as described by Brooker (2007), Kitwood

(1997a) and Loveday (2013), and included concepts such as staff empowerment,


resident enablement and decision-making. The extent to which these PCC plans and

strategies were successful was investigated at twelve months post PCC

implementation, again using the PCECAT. These two data collection methods were

employed to obtain systems-level data on the implementation of PCC across the

facility.

Overarching the PCC framework, Donabedian’s (1966) model for evaluating health

care services and quality of care was incorporated using the specific constructs of

structure, process and outcomes. In order to evaluate health outcomes, Donabedian

recommended the need to acknowledge administrative systems, buildings, equipment,

staff qualifications & training (structure), procedures and practices (process) and the

effects of health care on health care consumers (outcomes). The constructs of

structure, process and outcomes were explored through both the PCEAT and the semi-

structured manager interviews.

Research Method

Figure 2 – Stages of the Research

The study was conducted in four stages.

Stage

One

Measure practices pre PCC implementation

Stage

Two

Explore PCC managers’ plans and strategies

Stage

Three

Measure PCC practices post PCC implementation

Stage

Four

Data analysis & triangulation of data collected at stages 1,2 & 3


The four stages of Research

In Stage One the Person-Centred Environment and Care Assessment Tool (PCECAT)

was administered to measure baseline care practices against PCC standards. Stage

Two consisted of semi-structured interview with seven organisational managers to

ascertain what managers say they do to implement PCC in the facility; the interview

data was examined with a Template Analysis. In Stage Three the Person-Centred

Environment and Care Assessment Tool (PCECAT) was administered to assess the

extent to which the manager-initiated PCC intervention had been implemented in the

facility. In Stage Four all data were analysed and the Stage One and Three PCECAT

data were compared to assess the extent to which the manager-initiated PCC

implementation strategies were operating across facility services. These comparative

data were analysed in relation to the manager perceptions of PCC initiatives.

Setting

This research was undertaken in one aged care facility in the Sydney metropolitan area

that belonged to a Christian, not-for-profit, aged care organisation, selected on the

basis of its goal to implement PCC across all facility services. Like most accredited,

Australian Commonwealth Government funded homes, the facility catered for people

over 65 years of age who had been assessed by the Aged Care Assessment Team as

eligible for subsidised residential care. Having an ageing-in-place policy, the people

living there, referred to as residents, were able to continue to receive care in the same

facility when their care needs changed.

The research setting selected for the study was one of several facilities within the

complex and was built over 30 years ago. While the building offered single bedrooms,

the small, shared bathrooms and narrow corridors were features reflective of the

building’s age and created difficulties when caring for people with high care needs. On

the lower ground floor, twenty-five people living with dementia were accommodated in

a care unit that was self-contained and secure. In the care units located on the upper

two floors lodgings were provided for 113 residents who required varying levels of care.

Study participants

Study participants included residents living in the facility, registered nurses, direct care

staff, and executive and management staff. Study participants were selected on the

basis of meeting the participant selection criteria. The resident inclusion criterion was

their informed consent for the researcher to review their clinical files and to observe

how facility staff provided care to them. Managers were selected on the criterion that


they had decision-making roles for the facility in which the study was conducted. Staff

members were included in the study through convenience sampling. This meant that

staff members included were those available on the day when administering the

PCECAT. Giving their informed consent, these staff members agreed to be observed

when giving care and/or were willing to participate in individual or group discussions.

Other inclusion criteria included being permanently employed either full-time or part-

time by the facility, and being either directly involved in, or responsible for, care

services. Casual staff & staff casually employed through an external agency were

excluded, as were staff employed for domestic, administrative and maintenance duties.

Executive and management personnel who had decision-making authority within the

facility were selected for the semi-structured interviews. As Creswell (2009) notes:

“Qualitative researchers tend to collect data in the field at the site where participants

experience the issue or problem under study” (p. 175). The seven managers who

participated in the study held positions at various levels of the organisation’s

management structure. They consisted of the: chief executive officer, general manager

– operations, general manager – care, human resource manager, project manager,

village manager and clinical care coordinator. Except for the clinical care coordinator,

all these people were members of the PCC implementation project’s steering

committee. Selecting this cross-section of managers was purposeful on the basis that

they could provide different perspectives on decision-making about the strategies for

the implementation of PCC, thus providing the best opportunity to answer the question

of the study (Creswell 2009). The organisation assisted with the recruitment of these

managers, providing them with the researcher’s letter of introduction (Appendix B) and

scheduling their interviews times.

Ethical Conduct of the Study

UTS Human Research Ethics Approval

Approval for the study through the University of Technology, Sydney, Human Research

Ethics Committee (HREC) (Approval number: UTS HREC REF NO. 2012-478A)

(Appendix A).


Organisational Access and consent

As a means of introduction and outlining the researcher’s proposal the supervisors and

researcher attended the organisation’s Steering Committee meeting on 23 November

2012. Following this meeting and to gain approval from the organisation a written letter

(Appendix B) was sent to the coordinator of the PCC project, outlining the following:

The researcher’s aged care experience;

UTS ethics approval;

An introduction to the study;

The study’s aims and objectives;

Research design and data collection methods, including the process of

recruitment, informing participants and obtaining their consent.

The organisation provided approval via an email from the organisation’s project

coordinator. As such, this consent was considered to include approval to view the

organisations policies and procedures.

Participant Recruitment

Participants were recruited using a combination of purposeful and convenience

sampling. Purposeful selection was based on the requirement of a cross-section of

staff members’ views about care practices and management support of PCC. These

staff members were recruited for the purpose of collecting the required data when

administering the PCECAT (Burke, Chenoweth & Stein-Parbury 2012a). To obtain a

cross-section of staff members, the researcher walked around the facility and

approached staff asking if they were willing and had the time to speak with him. The

researcher identified the various classifications of staff as personal care staff, activity

staff, registered nurses and trainers. When collecting PCECAT data regarding

workplace conditions or their PCC practices, the researcher met with staff either in

small groups within office areas or in the common rooms within the facility. Concurrent,

convenience sampling (Schofield 2004) was incorporated where residents and/or their

relatives agreed to participate and where staff were present during the observational

component of the PCECAT assessment. The facility manager undertook the

recruitment process with 10 residents or their guardians providing consent for the

researcher to view the resident’s clinical files.

For the PCECAT data collection resident recruitment was required to allow the

researcher to view the residents’ clinical documentation. Facility managers assisted in


recruiting these residents either directly or through their relatives. Staff members were

asked, on the day of the visit, if they were available for the researcher to have an

informal talk with them. The organisation’s project coordinator outlined the

organisation’s management structure that enabled the researcher to determine the

relevant executive and management staff to participate in the interviews.

Informed Consent

Information sheets (Appendices C, D and E) describing, in general terms, the purpose,

methods, demands, risks and potential benefits of the research were provided to

residents, relatives, staff and managers. Additionally, the information sheets provided

an explanation of the security and confidentiality measures to be taken and the risk

management strategies throughout the research process.

Resident consent

Residents, their relatives or persons responsible were required to provide consent to

allow the researcher to review their clinical files. One of the facility’s managers

organised consent from a number of residents whose files the researcher reviewed.

For most residents proxy consent was given by their relative or person responsible. A

copy of the consent was left with the resident. (Appendix C - Resident Information &

Consent)

Staff consent

When administering the PCECAT, staff members were approached either individually

or in a small group. After handing them an information sheet (Appendix D – Staff

Information Sheet) the researcher outlined the purposes of the researcher’s study and

specifically what information the researcher was aiming to collect in relation to the

PCECAT. The researcher advised them that they were under no obligation and asked

if they agreed to talk to him. The researcher also advised them that the information

they provided was confidential and would have no consequences regarding their

employment. Staff consent was considered implicit by the individual’s agreement to talk

with the researcher.

Managers’ consent

The executive and management staff members who were interviewed were asked to

provide written consent prior to participating in the study. The information sheets and

consent forms (Appendix E) were sent via email to these people to enlist them into the


researcher’s study. At the commencement of each interview, the researcher asked the

participant if they had received both the information sheet and the interview guide.

Each participant was then asked if they were willing to participate in the semi-

structured interviews and asked to sign two copies of the consent form. The participant

was given a copy.

The researcher’s contact details, and those of the supervisors, were also included on

the information sheets inviting participants to seek further clarification should they wish.

The organisation’s key personnel coordinated meetings with residents, their

representatives and staff to outline the organisation’s project of implementing PCC. In

these meetings information was provided to the attendees about the researcher’s

study. While undertaking both forms of data collection the researcher attempted, as far

as possible, to create a mutual understanding between both the participants and the

researcher to allow the participants to ask questions (National Health & Medical

Research Council, Australian Research Council & Australian Vice-Chancellors'

Committee 2007).

Confidentiality

The identities of participants, facilities, managers and staff, in this study remained

confidential and were identified by codes (National Health & Medical Research Council,

Australian Research Council & Australian Vice-Chancellors' Committee 2007). This

coding remained confidential to the researcher and academic supervisors.

In order to maintain confidentiality a number of procedures were undertaken.

Transcripts of the semi-structured interviews were de-identified with respect to

participants’ names using codes for each participant. Any identifying information was

separately stored to the survey data. Information that could identify residents, their

representatives or staff, either participants or non-participants, has either been

removed or a pseudonym used to protect confidentiality. Documents, references or

data that name or identify the facility where the study took place has been removed.

All printed documents were kept secure in a designated room set aside for this study.

This room was also used when accessing computerised documents. The designated

room was secured with a coded lock on the door. Access to the computerised

documents was through a designated user name and password created for the

PCECAT assessor in this study. The program had a set lock out period as a security


measure. The researcher also logged off from the program before leaving the

designated room.

Data collected during the administration of the PCECAT was recorded on the printed

copy of the tool. This was kept with the researcher throughout the administration of the

PCECAT. Additional information such as any risky behaviour from staff was not

recorded but reported directly to the project coordinator. No person’s name was

recorded on any document. The completed assessment tool was kept in a secure

satchel within this code-locked room. After the assessment was completed all

documents have been kept secure in a locked cupboard at the researcher’s home.

The participating executive and management staff, nurses and direct care were

provided with feedback about the facility, based on the PCECAT results. A separate

meeting was conducted to provide feedback to the residents and their relatives or

guardians.

Risk Management

The identified potential ethical risks that arose in conducting the study, how they could

have affected the study and how these risks were managed are listed in Table 1.

These risks were assessed and care taken was taken when designing the study to

minimise a number of the potential risks (National Health & Medical Research Council,

Australian Research Council & Australian Vice-Chancellors' Committee 2007).

There was an occasion when information wasn’t able to be collected from a significant

staff member due to the impact of other activities occurring at the time of the

researcher’s visit. THE RESEARCHER recognised how a multitude of coinciding

events can affect the daily schedules of the facility. Data were subsequently collected

at a later date via telephone. Similarly, two of the management interviews were

postponed due the managers needing to address other priorities at that time. The other

ethical risks that were identified and managed are listed in Table 1.

Table 1 – Ethical Risk Management

Issue Risk Risk Management Resident participation

Resident shows signs of being affected by the PCECAT observations and interview

Determine if resident is negatively responding to the observation and interview process Withdraw if the Resident shows signs of distress from observations

Resident Care

The researcher witnesses adverse incidents to residents

Report witnessed incidents to Facility Management Determine if the incident fits the category of


Issue Risk Risk Management Compulsory Reporting of Abuse

Manager’s Interviews

Manager finds the interview process overwhelmingly distressful and it is impossible to complete it

Pause the interview; Determine if Manager wants to proceed; Review the interviewing process; If the interview needs to stop review the consequences to the proposed study.

Manager’s Participation

Managers refusal to participate in interview or some of the interview questions

Preventative Measures: Managers will have consented to participate in interviews as it will be a process with the ‘selection of a facility’; - If, subsequently, a manager refuses to participate this information may be collected from other personnel e.g. the educator or a more senior manager in the organisation; - If a manager refuses to answer some interview questions this will be noted against this question.

Staff member’s participation

Staff member/s refuse/s to participate in PCECAT observation and interview

Preventative Measures: All efforts will be made to ensure satisfactory amounts of information are provided to staff that will encourage their participation. - If a staff member has consented to participate and then is ‘uncooperative’ this will be noted accordingly.

Resident / representative

Resident / representative refuses to participate

Preventative Measures: Ensure explanation of research is given prior to seeking consent – include information sheets; - Talk with the facility manager / staff to help understand the resident / representative and what might help for them to accept participation - Ask representative if there is any clarification they seek which may help them reconsider their original decision;

Low response rate

Responses from either residents/representatives or staff is low

Preventative Measures Use the most appropriate procedure for administration of questionnaires – According to de Vaus (2004) face-to-face administration is good - Concerted efforts need to be employed to ensure a good response rate – explanation sessions to groups, one-to-one explanations to individuals; - Don’t leave it to other people, i.e. in the organisation, to do the explaining of the research; - Acknowledgement that response rate was low for a particular facility

Loss of data Data can be lost in various ways: - hard copies of data is lost; - electronic data is lost;

Minimising the chances of this occurring: - hard copy, completed questionnaires are electronically scanned, as soon after receipt, to the researcher’s email address; - data is entered into spread sheet upon


Issue Risk Risk Management receipt; - Spreadsheet is forwarded by email to researcher’s email address; - If data becomes irretrievably lost, data may need to be recollected ensuring to explain the reason for this happening.

Data findings Failure of data to correlate - Understand why data did not correlate; Where there other factors which may have influenced the outcomes?

- Give explanation to all people involved; - Consider what alternatives could be employed in the future - Consider if any other findings can be extracted from the available data within this research study.

Schedule of visits to facility

Facility priorities over the Research Study

- Respect facility’s priorities; - Reschedule visit for a more suitable time.

Schedule of research tasks at facility

Facility’s activities clash with scheduled research tasks

- Respect facility’s schedules; - Consider if negotiation is possible; - Determine more appropriate schedules.

Data Collection

The study data were obtained via three sources: the Person Centred Environment and

Care Assessment Tool (PCECAT) (Burke, Chenoweth & Stein-Parbury 2012a); a semi-

structured interview guide; and research field notes.

PCECAT

The PCECAT was used to measure the extent to which the care services being

provided by staff were person-centred. The PCECAT is a validated self-assessment

tool (Burke, Chenoweth & Stein-Parbury 2013) in which managers can determine the

extent to which person-centred care is practiced in their facility (PCECAT - Instrument

– Appendices F).

“It was informed by the Australian residential aged care accreditation

standards, the building quality for residential care services

certification requirements and Kitwood’s (1997) PCC principles, and

validated against the Quality Interactions Schedule (QUIS) (Dean et

al. 1993), the EAT (Fleming et al. 2001) and the Stirling Environment

Assessment Tool (SEAT) (University of Stirling 2008).” (Chenoweth

et al. 2011, p. 159)


The PCECAT was chosen as a measure of quality of care for this study because it is

consistent with the Australian Aged Care Standards (Burke, Chenoweth & Stein-

Parbury 2012a) and Kitwood’s principles (Chenoweth et al. 2014b). The 44 item

PCECAT measures a system-wide approach to care services and thus adheres to

Kitwood’s principles for the implementation of PCC (Stein-Parbury et al. 2012). This

whole of system approach is evident in the design of the PCECAT whereby the three

domains are described: organisational culture (Domain 1); care, activities /interaction/

relationships and interactions (Domain 2); and the physical layout and design of the

home (Domain 3) (Chenoweth et al. 2011). However, the PCECAT can also be used to

separately assess the quality of each of the three domains (Burke, Chenoweth & Stein-

Parbury 2012b). In this study Domain 3 of the PCECAT was excluded because the

physical environment was not the focus of this study.

Domain 1, Organisational culture, assesses the extent to which the facility executive,

managers and care staff uphold their commitment to personalised care, establish each

resident’s care needs and preferences and maintain the personhood of residents and

staff. Domain 2, Care and Activities, and Interpersonal Relationships and Interactions,

assesses whether the resident’s needs and preferences are the main focus of care and

whether there is ongoing consultation about care needs with the resident and their

family/person responsible. Also assessed is how well staff practices promote well-

being and whether work practices are sufficiently flexible to enable staff to meet

resident needs. In Domain 3, Physical layout and design, the main focus of

assessment is how well the physical environment enables the resident to feel

psychologically secure and physically comfortable.

The PCECAT has been used as a screening tool for many hundreds of aged care

facilities in Australian and international studies, including the PerCEN randomized

controlled trial (Chenoweth et al. 2011) and the IDEAL study (Agar et al 2014). Having

worked as a research assistant (RA) and a Project Manager for the PerCEN study, the

researcher was skilled in the administration of the PCECAT and have provided

supervision for data collectors using the PCECAT.

PCECAT – Psychometric Properties

The development, validation and reliability testing of the PCECAT were undertaken

over 5 stages as a PhD study utilising an expert Delphi panel. Sixteen invited national

and international health and aged care researchers and care practitioners,

gerontological scholars and researchers participated in this expert panel (Burke,


Chenoweth & Stein-Parbury 2012a). Additionally, PCECAT inter-rater reliability testing

involved a convenience sample of 15 senior and managerial staff of aged care

facilities.

While stages 1 and 2 involved the conceptualisation and construction of the first

version of the instrument, in stage 3 pilot testing at one aged care facility and a further

review by two aged care experts lead to the development of PCECAT version 2. The

Delphi panel provided advice and comments about item content, structure and scoring

(Burke, Chenoweth & Stein-Parbury 2012a). Further testing was undertaken in stage 4

of PCECAT version 3, at 72 aged care facilities, where the PCECAT data was used for

“item analysis using Kaiser-Meyer-Olkin test (Kaiser 1970), Bartlett’s Test of Sphericity

(Bartlett 1937) (p < 0.001) and Principal Components Analysis (Bartlett 1950) to

identify items for possible elimination based on weak psychometric properties” (Burke,

Chenoweth & Stein-Parbury 2012a, p. 7). In stage 5, PCECAT version 4 was tested in

a further 131 aged care facilities. Ten available Delphi members and 15

managers/senior staff who conducted PCECAT assessments, concurrently with two

study team members provided feedback regarding the relevance of items to establish

face validity.

Item analysis was undertaken on the PCECAT version 4 to determine the strength and

weaknesses of each statement utilising Principal Components Analysis; item analysis

(missing data, endorsement rates and inter-item correlations using Spearman’s

correlation (Spearman 1907)), and reliability (internal consistency and inter-rater

reliability) (Burke, Chenoweth & Stein-Parbury 2012a). Prior to conducting principle

component analysis sample adequacy was assessed with the Kaiser-Meyer-Olkin

values greater than 0.6 and Bartlett's Test of Sphericity all significant (p < 0.001).

“Reliability was determined through the calculation of internal

consistency which was measured by item-total correlation and the

Cronbach’s alpha (α) coefficient. Inter-rater reliability was assessed

using Pearson’s correlation between two raters for total for each

Domain” (Burke, Chenoweth & Stein-Parbury 2012a, p. 8)

PCECAT Procedures

The administration of the PCECAT in Stages one and three of the researcher’s study

involved collecting information from various sources to determine the degree to which

the facility provided PCC. In accordance with the PCECAT guidelines (Burke,

Chenoweth & Stein-Parbury 2012a) data were obtained by reviewing the organisation’s


policies and procedures in relation to care services and staff education and training,

resident’s clinical files and through interviews with staff members. When administering

the PCECAT, data were collected from the residents’ clinical files, care and lifestyle

plans, the organisation’s policies and procedures related to care services, the

complaints procedures and consultation mechanisms with residents and their family,

and staff education, training and supervision. The researcher requested that the project

coordinator provide the required organisational documents which included: the Mission

and Vision Statements, policy and procedure manuals, resident information handbook,

staff handbook, training packages, results of resident and relative surveys, and the

comments and complaints procedures. The clinical files of residents who were

consented into the study were accessed through the organisation’s computerised

documentation programs.

During PCECAT data collection, informal interviews were held with staff working in

different roles and having different levels of responsibility. They were asked to discuss

the requirements of individual residents and the way in which care and lifestyle

services met the resident’s unique needs. Questions also focused on the

organisational culture and staff support in their work. Staff members were approached

primarily in groups either at a prearranged time or when they were observed grouped

together in a public area of the facility. Several meetings had been pre-arranged at a

time of the day that didn’t impact on their provision of services to residents. Staff

handover sessions were ideal times to meet with a group of staff for the researcher to

verify their understanding of PCC and how well they felt supported by managers.

Similarly, the researcher talked to staff members while they were waiting for the meals

to arrive from the main kitchen.

Observations of staff providing services to residents in public areas of the facility were

also conducted to see how well the individual needs of residents were acknowledged

and addressed by staff with different roles. Assessments were undertaken by viewing

the staff members’ interactions with residents in corridors or in common areas such as

when medications were being administered. There were also opportunities to observe

staff interactions with residents while the resident participated in a recreational activity

and when meals were distributed in the dining room.

PCECAT scoring

The procedure to undertake the quantitative measure of the PCECAT a score between

0 – 3 is given for each item. These scores are added up to give a rating for each of the

three domains. In scoring each item, the tool provides a response code:


0 = Not at all

1 = Sometimes

2 = A great deal

3 = All of the time.

The assessor circles the appropriate response and writes this number in the score

column.

PCECAT Field Notes

When administering the PCECAT, at both time points, field notes were recorded on the

assessment tool against each item under review. These notes gave an explanation of

how the researcher derived the score for each item, for example, how does the

organisation’s Mission and Vision statements describe PCC. The field notes also

identified gaps and where improvements could be made with specific items. These

records were vital when making comparisons of the pre and post PCC implementation

PCECAT results. Additionally the field notes assisted with making comparisons with

the concepts identified in the Template Analysis that was used for interview data.

Executive and management staff interviews

Interviews with executive staff senior managers were planned over two days with each

participant being forwarded the interview guide (Table 2) a few weeks prior to the

scheduled interview date. Two managers could not attend their appointed interview

times so one was rescheduled for another date while the other was conducted through

a teleconference call. Another manager was interviewed over two dates as the time

allotted was insufficient to obtain all data. Thus, all seven selected managers were

interviewed.

Interview guide

The executive staff and managers were interviewed using a using a semi-structured

interview guide (Table 2 – Interview Guide) to help the participants focus on questions

important to the study, while also giving them liberty to discuss additional topics with a

bearing on the items of interest. Minichiello et al. (2004) recommend that the

researcher, knowing the topic, uses a prepared guide. In this study, the interview guide

was underpinned by Kitwood’s (1997a) conceptual framework regarding the

managerial conditions that support the implementation of PCC. The interview guide

helped to keep the interview on track and assisted to maintain consistency across all

interviews (Minichiello et al. 2004). While the interview guide was used for all the


executive and manager interviews some variations were made to glean relevant data

to the manager’s specific areas of responsibility, for example, human resource

management.

Table 2: Interview Guide

Domain Question Rationale Opening question Can you tell me about your role, here

at [name of facility]? This is an introductory question to give the manager an opportunity to speak about an area they know well. It provided an opportunity for the manager talking without feeling they were being tested.

Background knowledge of Person-centred care

Can you tell me how you first came to know about person-centred care?

Knowing how the manager came to understand PCC – how did the manager become committed to PCC?

Expected Outcomes

Why do you think it’s appropriate to implement this approach to care? (i.e., What do you hope to achieve by implementing person-centred care?)

What are the goals of implementing the [name] project? This project is PCC implementation.

Whole of systems approach

Do you plan to implement strategies that are broader than changing the way care / nursing staff provide care?

How comprehensive is this project? Are there systemic changes to be made or is it a matter of training and enlightening staff?

Organisational Culture

In your opinion, how does the current organisational culture fit with a person-centred approach to care, i.e. the approach to care you plan to implement? (Do you expect to implement changes to gear the organisational culture to a person-centred approach?)

Understanding how the person-centred approach to care fits within the organisational culture of the facility. Has the manager identified other factors that need to be addressed to bring about the expected outcomes?

Manager’s Responsibilities: PCC Competing Priorities

How do plan to implement the [name] project while maintaining your other responsibilities e.g. ACFI claims, maintaining standards, rostering of staff.

Balancing the project with the Managers’ routine responsibilities

Stakeholder cooperation

How will you gain the cooperation and/or opinions of stakeholders (e.g. staff members, residents, relatives) to the [name] project?

Is there a bottom up approach as well as a top down initiative? Does the facility manager have strategies he/she expects to implement at this level?

Recruitment and selection of staff

How will you recruit and select staff to fit with the planned introduction of the [name] project?

Drawing a line in the sand from this point, Is there recognition of the attributes / values staff will need to have to maintain the ethos of the [name] project?

Staff knowledge, skills and attributes

Have you any plans on how staff will gain knowledge and skills that are coherent with the principles of the [name] project? Do you plan to nurture people to develop appropriate attributes?

The organisation supports staff members to enable them to work within the [name] principles

Staff Job Satisfaction &

How do you encourage staff commitment to organisation’s goals

Existing staff members – Leadership skills to gain support from existing


Domain Question Rationale their organisational commitment

and their satisfaction in their jobs? staff / Leadership so staff will find understanding and satisfaction in their jobs?

Getting to know the unique person

How do staff members get to know each person in their care?

Systems to allow / inspire staff to get to know each person in their care – information to give personalised care

Meeting the unique needs of individuals

How would you expect staff to meet the unique needs of individual residents?

Is this happening now? How do you expect it to happen in the [name] project?

Planning care is individualised recognising the uniqueness of each person Is there input from the resident, family / friends? What is the process?

Decision-making Are staff members encouraged to make clinical decisions in the care planning process?

Autonomy, scope of practice, job satisfaction

Flexibility in the delivery of care

Are staff supported / encouraged to be flexible in the delivery of care e.g. showering / bathing times; choice of meals, residents’ waking and sleeping times, activity planning

Meeting the unique needs of residents staff need to be flexible when planning care; Alternatively staff members may need to follow rigid routines

Assessing comfort and satisfaction

How would you expect staff to assess that the resident is comfortable and satisfied?

Evaluation / Quality Improvement

Other areas of change

In implementing the [name] project, have you considered changes, strategies or the way things are done in the following areas? Meal service Diversional Therapy / Social & Lifestyle Chaplaincy / Pastoral Care Human Resources – duty lists, Position Descriptions Education, Training or Staff Development In any other departments

A whole of systems approach – impacts may be seen in other departments within an aged care organisation

Interview Procedures

Beginning with broad open-ended questions and using a funnelling approach

information was elicited from managers regarding strategies used to implement PCC

(Minichiello et al. 2004). The interview began with a general question to open up the

discussion: “You are the X manager - Tell me what your job entails.” Throughout the

interviews the participant’s responses were clarified and explored (Minichiello et al.

2004) employing probing questions such as, “In what way are you flexible?” Despite

advantages, the semi-structured interviews were time consuming both in organising

suitable times and procedurally (Minichiello et al. 2004).

While the interviews were guided by a set of prompts, they were also informed by the

results from the PCECAT in keeping with the sequential data collection strategy. For

example, questions were asked in relation to the classifications of staff who participate


in handovers between shifts. In addition, data collected from one interview influenced

the subsequent interviews. Through a funnelling process, the researcher explored how

other managers understood a concept raised at an earlier interview. One example was

in response to raising the concept of supporting staff through staff empowerment, one

of the managers proposed the ‘yes culture’. By exploring this concept in subsequent

interviews the researcher recognised this concept was understood by other managers.

Thus, a more comprehensive understanding of concepts raised was elicited.

All interviews were audiotaped and transcribed verbatim. Two recording devices were

used, one being a backup in the event of failure of equipment. Each interviewee was

given a brief explanation as to the procedure, gaining consent and the recording

devices explained. Time was given to ensure the interviewee was settled before

turning on the recording device. Each recording began by acknowledging the

manager’s name, their position and their own description of their role. The recording

procedures stopped if there were any interruptions or the interviewee requested a

break from the interview.

While one recording device was a standard Dictaphone the other utilised a pen

designed to record while taking notes on an electronically sensitive notepad. When

replaying the taped interview the researcher could go to any part of the interview by

using the pen to touch the written words on the notepad. Notes were recorded to

identify the managers’ physical reactions when responding to the interview questions.

These data described the observations of non-verbal communication that was

otherwise not portrayed in the typed transcript. When analysing the data from the

manager interviews the interview notes identifying the managers’ emotional responses

helped to understand the managers’ passion and commitment to any particular

intervention they were describing. As such, the manager’s emotional responses

informed the analysis when attempting to link a particular intervention with the PCC

improvements, identified in the PCECAT results.

Interview Notes

Notes were made during the interviews to capture the manager’s facial expressions

and non-verbal responses to the questions. This included laughter, clapping of hands

or clicking of fingers. These animated expressions provided an extra dimension to the

spoken word that otherwise would only be captured as transcripts. One manager, for

example, clicked his fingers to indicate that the matter being spoken about was


relevant. Another manager gave a chuckle when referring to a matter that was

considered to need improvement.

Data Analysis

PCECAT Data

PCECAT data were tabulated to show a comparison between baseline results and the

post-intervention PCECAT measurements for the two domains measured in the

researcher’s study: Domain 1 – Organisational Culture and Domain 2 – Care &

Activities, and Interpersonal Relationships & Interactions. Results for each unit, the

mainstream and the unit for people with dementia, were separately analysed. While the

totalled results for each Domain provide an immediate comparison of data, further

analysis was undertaken to determine the improvements in different PCECAT domain

scores and where gaps in service quality remained. This further analysis utilised the

field notes undertaken during the PCECAT administration in both Stages Two and

Four. A subsidiary table (Appendix G & H) provides the comparison between the

PCECAT assessors at the pre-intervention and post-intervention measurements.

These data comparisons were used in the triangulation of quantitative and qualitative

results.

Content Analysis – PCECAT Research Field Notes

These PCECAT research field notes acknowledged what was observed either from

staff members practice, discussions with staff members or from the organisation’s

documentation. These notes were recorded either directly or at a later date against the

relevant PCECAT item. To determine what piece of data supported a particular

PCECAT item reference was made to the Item’s descriptors and the PCECAT

Guidelines. This systematic classification of data against each PCECAT item is

described by Hseih and Shannon (2005, pp. 1281-2) as a “directed approach to

content analysis” and “is more structured than the conventional

approach...[by]...utilizing categories from existing theories or prior research”.

Interview Data

Template Analysis

A template analysis (King 1998) was considered to be the most appropriate way in

which to thematically analyse the data collected from the semi-structured interviews

(King 1998; Waring & Wainwright 2008). This form of analysis was particularly relevant

in this study as the aim was “to compare the perspectives of different groups of staff in


a specific context” (King 2004, p. 257). More importantly, the frameworks for PCC

implementation that have been developed (Brooker 2007; Kitwood 1997a; Loveday

2013) were used to establish a priori themes in the template. King (2012) notes that

this form of analysis has become an acceptable form of analysis in health, business

and organisational research. Like other analysis techniques, template analysis uses

codes and the coding of data (Waring & Wainwright 2008) but provides “a more flexible

technique with fewer specified procedures, permitting researchers to tailor it to match

their own requirements” (King 2004, p. 257).

There are several ways in which the template analysis can be undertaken: defining

themes, a priori, thereby constructing an initial template, based on a theoretical

position in research; developing codes after initial analysis of the data; or a

combination of these two processes (Waring & Wainwright 2008, p. 86). King (1998)

advises that when developing an initial template the a priori themes will correspond to

key concepts based on a specific theoretical question to be answered. Alternatively the

themes can be developed from the interview questions (Waring & Wainwright 2008).

Analysis from here progresses in “an iterative process of applying, modifying and re-

applying the initial template” (King 2012, p. 430). It is important, as King (1998)

cautions, to be conscious of holding too strongly onto these initial themes and

becoming reticent to alter a theme through the analysis process. Similarly, blinkered by

the initial template the researcher can overlook data that doesn’t fit into these

predefined themes (Waring & Wainwright 2008).

Developing an initial template

In this study the initial template was developed with the creation of a priori themes from

the literature (Bassey & Melluish 2012) of three leading scholars in PCC, (Brooker

2007; Kitwood 1997a; Loveday 2013). The literature produced by these scholars dates

over two decades beginning with Kitwood in 1992, reputed to be the founder of PCC.

Key concepts that relate to management and the implementation of PCC in residential

aged care were placed into the initial template (Table 3).

To explain the inter-relatedness of concepts and their hierarchical framework (King

2012) the initial themes were then clustered into three groups: structure, process and

outcome, in keeping with Donabedian’s (1966) Quality Framework. These three

constructs suggest a more comprehensive approach to assessing the quality of

medical care. As Donabedian (1966, pp. 720-1) explains “the frame of mind with which

studies of quality are approached...must be shifted ... [to] ... understanding the [...] care


process itself.” Utilizing Donabedian’s framework was considered appropriate for this

study because it is based on a whole of systems approach that has been recognized

as essential to the successful implementation of PCC (Chenoweth & Kilstoff 2002;

Jeon et al. 2011; Stein-Parbury et al. 2012). To determine which theme belonged

under each construct the following descriptions, by Donabedian (1966), were used:

Structure refers to the administrative functions that support and direct the provision of

care; Process explains the application of good practice; while, Outcome is an indicator

of quality of care.

56

Table 3 - Person-centred Care Leadership - Initial Template

Quality Framework (Donabedian 1966) Themes

Structure

Settings in which care is provided... Administrative functions that support and direct the provision of care

PCC Vision of Care Service Strategic (planning, organisational support, goal setting, stages) Organisational Culture (changes required – sensitivity to feelings, break down of divisions, positive view on interaction, spontaneity, intuition, living comfortably with faults)

HR Management Staff Selection (attitudes, willingness to learn, discernment) Employment Conditions (job satisfaction, psychological contract, pays, job designs)

Management Ethos PCC Leadership from the top (valuing all staff, sensitive to feelings, recognition of strengths, team building) Delegation (decision-making, breaking down barriers)

Quality Management PCC Continuous Improvements (review policies, care plan guide, information systems, handover guide) Value Systems (staff, risk taking support strategies, enabling residents, respecting personhood) Philosophy of Care (accredited training, specialist contracts, agreed nature of good care)

Training Structured (based on needs, includes accredited courses) Qualified Management (expertise, qualifications)

Process What is known as good practice is actually applied

PCC Vision Daily Guide (priorities set by goals, flexibility in implementation)



Big Picture (compelling, explanation, continuous referral to goals,

Staff Support Professional Acknowledgement (performance, feedback, preparedness, validation, mentoring, motivation, teamwork, consultation) Empowerment (flexibility, spontaneity, potential realised, best ways to spend time with residents, constructive feedback, information about residents) Emotional Support (support, debriefing, empathise)

Management Practice Visibility (accessibility, open door, role model, PCC demonstrated, awareness of daily practice) Leadership Style (stepped change process, delegation of decision-making & resources, staff input guided by goals, self-reflection, maximise resources, prompts to alter practice, constructive feedback, support implementation of new learning & learning from experience, enabling & facilitating, mutual trust & respect)

HR Practices Job Preparedness (psychological, skills, job match, job redesign, flexibility for up-skilling)

Training Skills (assess ill-being, dementia care, communication & interaction, clinical assessments, team training – collective knowledge) Personal Development (ongoing learning, reflective practice, unlearning task-focus practice, accredited courses,

Communication & Documentation Information available (handover to all staff, team problem-solving, rich body of information within living culture) PCC Care Plans (comprehensive, specific, positive, usable, recognises strengths and vulnerabilities, regular updates & reviews) Advocate Personhood (language, positive language, non-labelling)

Continuous Improvement



Quality Awareness (auditing, feedback of results, standards, plan of improvement, monitoring programs)

Relatives & Friends Partnerships with Staff (guidance, emotional support, trust in each other, value their knowledge, care conferences)

Care Practices Personalised Care (relationships, do with, nurturing abilities, life story informs care, recognition of person, familiar routines, consultation with daily routines, aware of comfort needs, sensitive to feelings, interactive with residents) Meaningful Activities (all staff participate in fun, occupation matches person, innovative, community participation) Personalisation (surround with personal possessions, new items similar to old ones, daily routines, risk taking)

Resident Assessments Know the person: (Life story, personality, lifestyle, health, cognition & capacity, socioeconomic gender, ethnic and cultural, reasons for difficulties, abilities, strengths, observe resident) Recognise ill-being (awareness of emotional state, difference in state of being, comfort needs

Outcome

An indicator of quality of care

PCC Vision of Care Service Vision is understood (statement is visible, priorities are explicit to staff, residents and visitors)

Staff Well-being Staff are valued and respond to clients accordingly (attitudes of inclusion, respect, affection & validations, relationships with residents, partnerships with relatives friends)

Residents Well-being Personhood is maintained (well-being, skills maintained for as long as possible, psychological needs met, confidence to live their lives, personal possessions, relationships with other residents, and family, community involvement)


While the themes in the initial template were divided into the three constructs of

structure, process and outcome, each theme had further levels or hierarchies in the

coding process (King 1998; Waring & Wainwright 2008). For example, as cited from

the researcher’s developed Template above, within Process there were other levels

each with its own set of descriptors:

Process

Staff Support

Professional Acknowledgement

performance, feedback, preparedness, validation, mentoring,

motivation, consultation

Empowerment

flexibility, spontaneity, potential realised, best ways to spend

time with residents, constructive feedback, information about

residents

Emotional

support, debriefing, empathise, stress management

Utilising the initial template a deductive analytical approach was employed (Waring &

Wainwright 2008) when coding the managers’ interview transcripts. This iterative

process involved identifying relevant data within each interview transcript and coding

the data according to each a priori theme. Upon reviewing these identified data, further

analysis was undertaken to ensure that data were coded appropriately. Concurrently,

the a priori themes were reviewed to consider whether they accurately reflected the

concept at hand.

Beginning with the transcript from Manager 1 pertinent data were underlined and

coded in accordance with each of the initial themes. Each underlined piece of data was

copied and pasted onto document; thus, data from each of the manager’s transcript

was pasted onto separate document. In this new document, the copied data were then

pasted under each of the a priori themes in the initial template. The pasted data were

referenced with the lines from which it was copied from the original transcript. Each

piece of datum was analysed and coded thus grouping the data into the relevant

themes. To assist in clustering the coded data into the three higher order constructs of

the initial template, each theme was colour coded accordingly: those pertaining to

Structure were highlighted in red, to Process in green and those related to Outcome in

blue. This enabled the clustering of data at the same time as coding. The analysis,


coding, referencing and clustering processes were repeated with each of the interview

transcripts.

The next step in the analysis involved reading through each of the selected pieces of

data and synthesising the data that reflected the essence of each theme. In this step,

the synthesised data were copied and pasted onto three new documents, each saved

as structure, process and outcome. Within each document, the pasted data were

coded under the relevant themes pertaining to each construct and referenced with the

manager’s acronym and the lines from the original interview transcript, enabling review

of the data synthesised from each manager to be listed under the relevant a priori

theme.

With all the relevant data listed under each a priori theme, it was possible to review the

entire relevant manager’s data at the one time. The researcher then identified common

threads within this set of data that related to each a priori theme. A phrase was created

to capture the common threads found in the set of synthesised data.

Changes to the initial template

King (1998) advises that after developing an initial template changes will be made to

the a priori themes during the process of analysing the interview data. A number of

changes were made to the a priori themes in the initial template to formulate the Final

Template (Appendix I). These changes are outlined on Table 4.

Table 4 - Changes to the initial PCC Leadership Template

Construct Change Rationale Structure The descriptor Leadership Potential

was added within the theme Management Ethos – Delegation.

Loveday (2013) asserted that anyone can become a PCC leader.

Added Staffing Structure under HR Management.

The data relate to the reporting lines of positions and their inclusion in teams. While it could be considered in PCC Vision of Care Service – Strategic it warrants its own classification to describe this particular management intervention.

Added the descriptor prioritising our focus under Quality Management – Value Systems

This descriptor accounts for data that explains the change of focus from completing forms to getting to know the person.

The descriptor Organisation Support was added to PCC Vision of Care Service – Strategic

To account for the perspective that this is an organisational strategy this will impact on the whole organisation and will impact on other organisational activities.

Effective management skills was added as a descriptor to Training –

To account for the data that identified the managers’ skills to problem solve beyond


Construct Change Rationale Qualified Management. the immediate problem and the ability to

see the Big Picture Process Within the theme of HR practices

the concept of Consistency of Staff was added, and the following descriptors were included: rosters that ensure continuity of care, – more full time staff / staff with greater number of hours; less agency hours.

Consistency of staff is not a concept identified by the three scholars but, after reading through the data from the management interviews, it became obvious that this would be a point of analysis.

The descriptor Stress Management was moved from the concept – Job Readiness to concept –Emotional

This construct was considered a descriptor in providing emotional support.

Under Resident Assessment the descriptor Recognise Well-being was added

Added in light of the manager’s interview question – how would you expect staff to recognise a resident is comfortable?

Staff Well-being was changed to Staff Support.

This is a better heading since staff well-being is an outcome while staff support best describes the manager’s implementation of best practice

Added Accountability as a descriptor to Leadership Style.

This acknowledges managers and other staff being accountable for the strategies they are implementing and responsive to the feedback data see Project Manager – regarding feedback of data.

Outcome There was some deliberation to include the following a priori themes: - Staff performance - Staff suitability for the job - Staff practice PCC. It was decided that they would be included as descriptors in the a priori theme PCC vision of care service.

These concepts were considered to be measures of higher-ranking outcomes – Resident well-being and PCC vision of care service.

PCC Vision of Care Service – Vision is understood as an a priori theme was deleted at one stage but reinstated.

The data from the manager’s interviews suggested that there was a need for this theme

Composite data analyses

One of the objectives of this study was to determine which management strategies

support the implementation of PCC by comparing what the managers’ report, the way

that care is implemented and whether care is assessed as being person-centred

according to the PCECAT scores.

To meet this objective the data from the post implementation PCECAT were compared

to the baseline PCECAT data, while considering the strategies implemented to support

adoption of PCC within the facility. This comparison identified improvements in the

overall scores for PCECAT domains 1 and 2. Subsequently, comparing the two sets of

data revealed where the changes had occurred and which areas required further

improvement. While improvements cannot necessarily be related to management


strategies alone, the comparison demonstrated the effectiveness of the PCC

interventions that had been instituted. In addition, during the administration of the

PCECAT the associated research field notes drew further comparison between specific

areas within each PCECAT domain item scores. This analysis process enabled a

deeper understanding of the positive changes occurring in carer services over time.

Using research field notes helped to identify the dimensions of PCC being instituted

across the facility in relation to the management strategies being implemented.

In order to meet the objective of determining whether the management strategies had

led to an improvement in the quality of care services the results from the pre and post-

intervention PCECAT were analysed. To gain a clearer understanding of how the

strategies have affected the quality of PCC there were a number of steps to this

analysis:

Identification of which areas where improvements in PCC occurred as identified

in the PCECAT scores and as reported in the research field notes;

Identification of where gaps in care service quality remained as identified in the

PCECAT scores and as recorded in the research field notes;

Comparison of the PCC improvements against relevant management strategies

– identified in the Template Analysis;

Comparison of gaps in PCC against the relevant management strategies.

Triangulation of data

To complete the data analysis comparisons were drawn between the management

strategies as identified in the Template Analysis and the PCECAT data. In order to

provide a visual comparison, the PCECAT results showing either improvements or

gaps in PCC were set alongside the management strategies (Appendix I). Accordingly,

the researcher needed to determine what PCECAT data best matched the

management strategies. In this way, links could be drawn between the management

strategies and the outcomes, whether they were improvements or gaps in PCC.

Finally, the triangulation of these two data sets with the numerical PCECAT results

provided an additional level of analysis.

Chapter 5 – Results 63

Chapter 5. Results

Introduction

Chapter 5 presents the study findings obtained from all data sources including: semi-

structured interviews with seven of the aged care organisation’s senior managers; data

obtained on the aged care organisation’s service quality with the Person-centred

Environment and Care Assessment Tool (PCECAT) before and after the

commencement of the change process; and from field notes which were recorded

when undertaking the PCECAT assessments. The study objectives were to explore, in

one aged care facility, the planned strategies that were implemented by the

organisation’s senior and middle managers to institute a person-centred approach to

care services, and to determine which of the implementation strategies were most

helpful in achieving this goal.

The study findings that relate to this research question are presented in the following

order: participant demographic characteristics; manager interview data; the PCECAT

scores and the PCECAT field notes obtained before and after the person-centred

service strategies were implemented. The manager interview and PCECAT field note data

are presented as themes, using a template analyses technique.

This technique involved examining the a priori themes, created when developing the

initial template, based on the PCC literature. After repeated template analysis of the

interview data and reflection upon the a priori themes, three major themes were

identified: Thinking Differently, Promoting a yes culture and. Changing peoples’ lives.

With further analysis subthemes emerged within each of the three major themes.

Through this thematic presentation the results can be perceived as both planned

strategies and how the themes relate to the PCC implementation conditions recognised

in the PCC literature.

Participant Demographics

The demographics of the seven managers who participated in the semi-structured

interviews are displayed in Table 5. There were nearly equal numbers of male

managers to female and a diverse spread of ages, management tenure and aged care

experience. Most managers had a nursing background, with one having worked in a

government agency and the remaining two managers coming from large private

businesses.


Table 5 - Participant Demographics

Gender Age (yrs.)

Professional Background

Aged Care Experience (yrs.)

Management Tenure (yrs.)

Manager One M >60 Non-Gov. < 5 > 10

Manager Two F 50s Nurse > 10 > 10

Manager Three M 50s Nurse > 10 > 10

Manager Four M >60 Gov. < 5 > 10

Manager Five M 40s Non-Gov. < 5 5 – 10

Manager Six F 30s Nurse 5 – 10 5 – 10

Manager Seven F 20s Nurse 5 – 10 < 5

Manager Semi-structured Interviews

Results from the initial analysis of the managers’ interview transcripts are presented in

the PCC Leadership Template (Appendix I). This Template compares the a priori

themes with the sub-themes developed during analysis; resulting in changes to some

of the a priori themes. The sub-themes represent direct responses from some

individual managers, as well as an aggregation of similar words and concepts used by

several managers. Participant reference codes are used for manager quotes when

reporting sub-theme data. Pseudonyms have been used to confide the managers’

identity.

The quotations from the managers’ interview transcripts provide a broader picture of

the managers’ responses. These responses were identified during the data coding

phase when undertaking Template Analysis of the managers’ interview transcripts. The

main themes derived using these procedures included Thinking Differently/Changing

Systems; Promoting a ‘yes culture’; and ‘Changing peoples’ lives’. A number of sub-

themes emerged from the main themes.


Theme One: Thinking Differently / Changing systems

The first theme reflects the managers’ awareness that changing systems required

different ways of thinking about service delivery. Managers described the way people

thought about their jobs and the system of carrying out their roles and responsibilities.

Changes had started at the organisation’s central office. A new way of thinking was

described in terms of a moratorium where, on Wednesdays of each week, central office

staff would not make unnecessary contact with the facilities for which they had

oversight. The aim of this decision was to allow facility managers to get on with their

job, undisturbed and without the pressure of central office seeking information for

audits or account enquiries. The rationale for this decision was to change one aspect of

the organisation’s culture of governance. Rather than being the hub of the

organisation, the central office was now to be viewed as the support centre for the

different facilities.

One manager described staff expectations and ways of thinking about their work as the

‘noise’ in the system. By noise the manager referred to the way things are traditionally

done, the established practices, as described below.

“When you look at cultural change that we are facing [we] want to get the noise

out of the system.” (Mgr. 1: line 321).

“... there’s a lot of history, there’s a lot of tradition in what we do. Many of the

people that we employ are people that have got influence. They’ve been around

for a long time. They’ve got their own ways of doing things. They’ve seen ways

pass over them before ... so we’re asking them to break out of that” (Mgr. 1:

lines, 138 – 43).

Reflecting on the planned changes for an organisation-wide implementation of a

person-centred approach to care services, this manager gave the example of changing

the central office design to an open plan design. Recognising that an open plan design

for centralised organisation administration was conducive to interpersonal interaction,

Manager 1 advised: “if that [private offices] is perceived by some people to be

inconsistent with what we’re trying to do to deinstitutionalise the place, then, we should,

we should deal with it.” (Mgr. 1: lines 311 – 2) This initiative was described alongside

others such as the decision for all staff, including senior managers, to wear the

organisation’s approved uniform and the removal of personalised parking spaces for

central office staff. Initially, this manager joked that staff would now get to work earlier

in order to obtain a parking space. Yet, when it was suggested the limited parking


spaces immediately outside the facility be designated for less abled visitors, staff

responded with “We’ve always done that” (Mgr. 5: lines 78 – 9). Manager 5 was

suggesting that staff couldn’t see the problem since they had always parked

immediately outside the facility and why were we questioning them now. “So you want

to try to remove that stuff, remove the noise” (Mgr. 1: lines 312). Seemingly symbolic in

nature, these initiatives aimed to get people to think differently about some artefacts of

the organisational culture, and to challenge traditional expectations, break down power

bases and thus, to remove the noise.

Getting rid of the noise was viewed by other managers to mean: “... [Traditionally]

we’ve built things that the market might like but we haven’t actually designed some of

the work to enable PCC ... we’ve already had a shift in culture to acknowledge that

care comes first ... we’ve moved from compliance to outcome measures and clinical

indicators, from satisfaction to the quality of life ... there’s a lot of work to do in terms of

culture at all levels...” (Mgr. 2: lines 131 – 40). Managers acknowledged the struggle

ahead: “To get it to the level we want that’s a long road” (Mgr. 5: line 66).

Alternatively, with the implementation of the person-centred approach, “the whole thing

is thinking differently and thinking outside of the square” (Mgr. 6: lines 42 – 3); “it’s also

me changing my thinking...” (Mgr. 6: line 107). “Yes ... it’s all about awareness.” (Mgr.

5: lines 68 – 70) While some accepted there was a big job ahead they recognised that,

“there were little things we could be doing.” (Mgr. 7: line 411).

“So it’s a journey ... a catalyst to make a certain change... pointing them [staff]

in a completely different direction... away from the institution ... [to] improve the

well-being and the life of the people ... rather than our own [and] on the needs

of operating of our organisation.” (Mgr. 1: lines 50 – 66)

In response to one manager’s imperative statement: “Everyone knows that everyone

loves hot toast”, another manager advised, “The evidence says that people like to have

more choice and should be more involved. It’s not [just] about how you change the

breakfast menu” (Mgr. 2, lines 543 – 5). However, the change to how meals were

served was an initiative that was implemented to change thinking about service

offerings.

Changes to how meals were served and the servery function

One of the most significant planned improvements organisation-wide centred on the

residents’ meals. During the interviews the managers began by referring to the findings


of a recent survey where aged care residents expressed their dissatisfaction with the

food provided. While there was a project team dedicated to devise ways to improve

food services, the facility managers envisioned a broad scope of ideas to make

improvements in a number of ways. When analysing the current system of meal

offerings the mangers considered that one way to support a person-centred service

was to allow the residents to have free access to the dining room, to have breakfast at

any time within a two-hour period each morning, and to have the opportunity to serve

themselves if able to.

While the imperative to provide hot toast to all residents, if preferred, was the catalyst

to changing breakfast routines, there was an all-compassing perspective on improving

choice and the meal experience, which supported this initiative. Managers

acknowledged the inhibitive practice of residents needing to wait outside the dining

room before being be allowed in at designated meal times, which were determined by

the catering staff,

“… you seem them all lined up waiting for the doors to open. It’s like herding.”

(Mgr. 2, line 304)

“We’ve run a very traditional institutional model for dining. People cue up

outside the door until 12 o’clock and then go in the doors at 12 o’clock.” (Mgr. 1:

lines 182 – 3)

“The first one [change] is opening the kitchen doors. We’re going to start with

breakfast, a two-hour open breakfast, Buffet [style]. For people to come and get

what they want, when they want it… it would be good...” (Mgr. 2, lines: 302 – 3)

Emerging from these proposals were positive concepts for enabling resident choice,

function and pleasure: “the dining experience ... building on residents’ strengths ...

freedom to choose ... more empowered ... able to do things for themselves.” (Mgr. 2,

lines: 496 – 507) Having begun with cooking meals on-site to accommodate these

changes to the mealtime experiences (Mgr. 2: line 307) other food preparation

improvements were described,

“They’re cooking with the woks and stuff; it’s bringing out the aroma so the

residents can smell it ... they’re testing things like porridge and other foods at

breakfast.” (Mgr. 6: lines 149 – 161).


A far-reaching milieu surfaced when the senior managers recognised the need to

enlighten catering staff about the organisational change in process, and the need for

the whole organisation to adopt a different way of thinking about the service they were

offering. This challenge began with leadership in the catering department: “The vision

[of] the catering department was vastly different to what we needed to happen on the

ground ... we need to walk there but there’s no running.” (Mgr. 5: lines 345 – 54) The

first plank in the change process occurred through the senior managers’ leadership in

arranging for open dining room access, two hour breakfast periods and the self-serve

buffet.

On the ground, while “great work on customer service in the dining room” was said to

have started (Mgr. 2: line 308), managers outlined the difficulties encountered: “the

servery staff are very stuck in their old ways;” (Mgr. 7: line 181) and “... they say, you’re

just serving the food [but] you’re really not; you’re really making an impact on that

resident.” (Mgr. 7: lines 187 – 191) Another manager, when working with the dedicated

food team, reiterated the need to have the catering staff focus on the residents’ needs

and preferences: “I went it doesn’t matter what we want. I’m going to take it back to the

focus group and I’ll tell you what they [the residents] want.” (Mgr. 6: lines 102 – 5)

Care practices changes

Managers envisaged how care staff practices could become person-centred even

though, at the time, they couldn’t visualise how the organisational-level changes would

come together,

“Work programs would change [although] we don’t know what the movement –

from where we are to where we would like to go” (Mgr. 1: lines 178 – 80)

Describing the care staff work schedules, this manager acknowledged that the project

team had not fully understood what developments were needed to work schedules to

accommodate person-centred practices.

Suggestions from the managers provided glimpses of a better care and social

environment, whereby residents could live: “their daily life the way they want to” (Mgr.

2: line 85). This meant looking beyond ‘the clinical day-to-day stuff’ and focusing on a

holistic approach to include ‘their spiritual needs, their social needs [and] their

relationship needs’. Meaningful human interactions were considered vital to support

resident engagement and well-being, with staff being encouraged to develop

relationships with residents. These sentiments are exemplified with one manager’s


practical description of how staff-resident interactions could be improved. During the

interview the manager recalled a positive resident-staff interaction in which she was

present and realised the unforeseen beneficial outcome:

“Well if they’re showering someone you could have a quick

conversation with that person; you could find a lot of information,

actually, in that five minutes of conversation about the resident, about

their past, about their family. And through that that’s where we get the

actual person-centred care, oh… for example a resident, yesterday,

we found out that her brother died, the Friday before, we were asking

about her headache but that’s what came out of it.” (Mgr. 7: lines 95 –

9)

Care planning changes

Another organisation-wide change that was mooted by managers was to make the

care planning process person-centred. While a computerised care-planning program

was introduced across the organisation in the previous year, the dedicated project

team had the task of improving the format of care plans, ‘hoping to come up with a

different tool’. The manager leading this team was concerned with the suggestion of

having a person-centred care section added to the standard care plan, recommending

that the person-centred approach needed to be incorporated across all aspects of care.

This view was supported by other managers, recommending that care planning was to

become holistic, by including statements on resident’s choices and articulating clearly

‘what they [the residents] want every day’. Managers also identified the goal of

integrating data collected from various departments into the one care plan document.

One manager provided insight to how this would be achieved,

“So they’re going to go and talk about the resident holistically, they’re going to

put in their aspects of the care plan and see what it looks like ...They’ve decided

to be more collaborative and put something up that covers all aspects of the

resident.” (Mgr. 2: lines 402 – 8)

It was apparent that the newly revised care plan document would become holistic.

However the managers struggled with how the information would be made available to

care providers, particularly at the bedside, “for the care staff or anyone [who] goes into

their room” (Mgr. 7: line 269). Managers expressed difficulties in creating one multi-

purpose care plan, given the practicalities of relying on a computerised system and the


system’s limitations with re-formatting data entry options. Additionally, the program was

considered to restrict the person-centred focus, when planning and reporting was

limited to allocating pre-determined responses using “drop-down boxes [rather than]

writing individual PCC responses” (Mgr. 6: line 320).

Pre-entry practices

Another important organisation-wide change considered was the pre-admission

procedures for residents and their families. Prior to a person coming to live in the

facility, the change recommended included an interview being conducted with the

resident and/or their representative. It was considered to make “a huge difference

because the resident and relative have a face before they come in” (Mgr. 6: lines 219 –

223). Otherwise, for the residents or their representatives, the only contact they had

with the facility before admission was through the organisation’s Central Intake Centre.

The Centre’s role was to liaise with various external agencies, including hospitals, to

coordinate appropriate accommodation for prospective residents. While no plans were

instituted, or any recommendations made to introduce an alternative procedure, one

manager considered that this centre be renamed in keeping with the de-

institutionalised approach the organisation was taking. “We got a horribly named

Central Intake Centre which I want to change” (Mgr. 1: lines 357 – 8).

Ensuring that the resident’s unique needs and preferences were accommodated

following admission was seen as a key change needed across the organisation.

Enabling a resident ‘to live the life they wanted to live’ was seen to begin with

‘collecting as much information as possible in the first 28 days’ of arriving at the facility.

Staff, aware of ‘not overloading the resident’, commenced with these types of

questions,

“What does the normal day look like for you? ... What can we do for

you to help you come in here? ... How can we make it easier for you

coming in here? ... The essence is the… THE person.” (Mgr. 6: lines

360 – 74)

While the process was deliberately left non-prescriptive to allow staff to be responsive

to each individual, as Mgr. 7 expressed, the advantages of this new initiative were

already being realized:

“I feel like the changes we’ve made, a little bit, has been outrageously

good ... you know now, through people’s feedback, through the


expression on their face ... [in the past with what we used to do] ...

yes you’ve made them comfortable at that minute but once you leave

the room you say: “yeah, but what do I do now? ... it’s a natural

approach. It’s very hard to write down on paper what you should be

asking ... because you’re gauging off them what they wanting to talk

about. So, you’re responsive to what they are saying. You don’t look

as if you’ve changed that much but in reality you have, and you’ve

made such a difference. So, whatever they want to focus on; every

resident is different and every relative has a different concern.” (Mgr.

7: lines 211 – 232)

This individualised supportive approach was being applied where a staff member,

working in a newly created role, became “friends with the new resident for the first

week“ (Mgr. 2: line 179). With spontaneity being the aim of this activity, the staff

member would sit with the new resident for his / her first meal to overcome the

“daunting [experience of] walking into the dining room with a hundred and so people

and you get sat in your spot” (Mgr. 7: lines 240 – 5). While the person’s relatives were

invited to join them for meals, the dedicated staff member introduced new residents to

others, and was considered to have a ‘good connection’ with the new resident. This

new staff role aimed to “align pastoral care services with lifestyle activities and care

services” (Mgr. 2: lines 187 – 99). Working with other staff the purpose of this staff role

was to meet, greet and introduce the new resident to other residents and staff. This

was one of the key organisation-wide culture change processes, which aimed to help

new residents to settle in more easily and to have an instant support person.

Encouraged to be spontaneous, the newly appointed staff member was given some

latitude to expand the role, in order to explore what additional support could be

provided to meet the resident’s needs.

Staffing arrangements

Providing the resident with quality care services, a pleasurable life experience and

encouraging their independence, were seen to begin with “... the right mix of staff”

(Mgr. 7: line 450) as they “...they don’t come from the same basket” (Mgr. 3: lines 33 –

6). At the same time, developing relationships with residents was difficult when staffing

was sporadic: “...60% [of staff] are part-timers, so in any given week a specific resident

is likely to come across 5 staff that are known to them, more than that, probably 6 – 7

staff.” (Mgr. 3: lines 553 – 6). The managers considered it to be essential for “family


members ... to see the same people all the time ... they feel comfortable they’ve built a

relationship with an individual.” (Mgr. 3: lines 490 – 3).

Consistency in staffing was considered crucial in achieving these goals. The

improvements in staffing began with the decision to allocate the same nurses and care

staff to certain sections of the facility. In suggesting reallocation to a staff member, the

manager will “ensure that they’re [staff members are] okay with it ... [stating] ... It’s your

expertise that we need here” (Mgr. 6: lines 183 – 93). Negotiations with individual staff

were described as getting ‘their buy [in] rather than [saying] this is how it is’. As well, to

help maintain staff consistency and to avoid unsettling nurses and care staff with

mooted staff reassignment, the managers described recruitment and retention

strategies which aimed to ‘get more full-time and less part-time’ staff. Through the

process of “natural attrition and the natural opportunities that arise” (Mgr. 4: lines 332 –

47), such as when a staff member resigned, it was decided that different work shifts

would not be filled immediately by casual staff, so as to recruit people who would agree

to work “a minimum of three shifts, or more, per week” (Mgr. 6: lines 229 – 30).

Recruitment procedures

Improving staff interactions with residents was considered essential to implementing

person-centred care throughout the organisation. Managers realised the need to

recruit people based on their attributes, values and strengths, and to have staff

employed who were prepared to foster these relationships, rather than focusing only on

their skills and capabilities (Mgr. 2: 60 – 1). One manager expressed satisfaction with

this new policy when observing a new staff recruit communicating positively with a

resident while assisting with her meal. Although new to aged care and potentially

lacking aged care skills, the manager reasoned that training could be provided on the

job when the right attributes were inherent to the person (Mgr. 6: line 219). Other

managers spoke about employing the right person with the right attributes from the

start: “the people who are going to work like this ... whose attributes are ... discernment

and judgement...” (Mgr. 4: lines 135 – 55) To support this new recruitment approach,

interview procedures had changed to focus on customer service, a person-centred

approach and scenario questions – “What if a person didn’t want something for lunch,

what would you do?” (Mgr. 6: line 225)

With the aim of employing the right staff for particular service roles, managers were

now permitted to directly recruit their staff with the new approaches being adopted.

Prior to this change in employment policy, managers were expected to recruit from a


central pool of staff. Staff were initially employed casually through the organisation’s

own recruitment agency that pre-screened candidates and ensured prospective staff

were suitably qualified for the work they applied to undertake. When vacancies

occurred in the facility, the casual staff were sent from the central pool. Managers no

longer had to choose permanent staff from the casual pool (Mgr. 6: lines 244 – 7).

Position descriptions

The alignment of the organisation’s goal to implement person-centred strategies

extended to human resource practices.

“The job design ... the language and the expectations in the position

descriptions actually align with the project ... [with] more emphasis on the

empathy, more emphasis on our values and a person-centred approach.” (Mgr.

1: lines 406 – 9)

“... [We’ll] inform ourselves on the ground so that will translate into the role”

(Mgr. 2: lines 178 – 80).

“Sometimes with a position ...we have a lot of latitude over the first few months

to develop the job description...” (Mgr. 2: lines 187 – 9)

Additionally, performance appraisals that were due for review, were contextualised and

rewritten to be congruent with the organisation’s mission and project objectives. This

structural change process helped all staff across the organisation to be appraised of

and achieve their role responsibilities within a person-centred framework.

Training and development

When discussing staff training with the managers it was evident that considerable

thought had gone into the subject, and changes were to be made to the current

system. A new registered nurse educator position was created, dedicated to the

implementation of the person-centred approach, who would “be able to understand all

that we are doing conceptually and to develop a personal development plan for all the

staff” (Mgr. 6: lines 286 – 6). Gaps in staff members’ preparedness for practicing

person-centred care were identified,

“They have the knowledge and the skill with the things they are doing, but the

translating that to make that information influence decisions afterwards, they

don’t have that” (MGR. 5: lines 225 – 36).


A staff education program was developed and tailored to meet the position roles and

responsibilities within the organisation. “... taken the top 20 capabilities that we think

people need to do that role in our environment and connecting with our policy and

procedure...” (Mgr. 2: lines 250 – 2). Manager 2 (lines 242 – 55) continued to explain

the extent of changes to be made with staff training and development:

“... [we’re] making a philosophical shift away from classroom and cert

III training to blended approaches ... having a personal development

plan for every staff member...based on their individual needs and

PCC and dementia care and everything else we need to do over and

above the day-to-day work ... [we’ll] walk you through the Evolve

program...you’ll have a personal development plan...based on their

[staff member’s] individual needs”.

The broad-spectrum approach to education included leadership training for managers.

“... we’ll be doing a bigger strategic platform for leadership including Transformational,

ADKAR, change and values driven...” (Mgr. 2: lines 467 – 81) The managers

expressed an intention to institute commercial packaged training courses called

ADKAR, an acronym for Awareness, Desire, Knowledge, Ability and Reinforcement.

The change management model was incorporated in one of these courses. These

education initiatives aimed to underpin the organisation’s overall change objectives.

The education philosophy adopted was based on reflective learning and personal

development plans, which would “help managers identify when they needed training as

well” (Mgr. 2: lines 485 – 6).

Theme Two: Promoting a ‘yes culture’

The second theme relates to how thinking differently and changing systems are

brought to the fore in the context of a ‘yes culture’, a concept revealed by one manager

at interview. When asked about a management philosophy Manager 1 (lines 224 – 31)

outlined:


“... [It’s what] we call the ‘yes culture’, basically a decentralised

decision-making... We are looking to a future in which the people

have got that ability to say, yes we can, okay let’s do that, I’ll stop

what I’m doing; I used to make beds at 10 o’clock, okay why do I

need to make the bed at 10 o’clock why don’t we sit down have a

chat and a cup of tea.”

Manager 1 (lines 235 – 6) continued to explain that managers needed to change their

thinking in order to practice the ‘yes culture’: It’s a different management framework,

which is going to be a bit confronting, at least challenging, personally to the managers,

frontline manager”. Other managers acknowledged the role of management in ‘giving

voice’ to staff and the ability to be ‘autonomous’. “Yes, that comes from bottom up and

top down” (Mgr. 6: lines 60 – 2). Laughing, one manager attributed the ‘yes culture’

ethos to Mgr. 1: “... it’s a big thing ... [He] wants us to say ‘yes’ to residents” (Mgr. 7:

line 312).

Encouraging autonomous decision-making

While managers didn’t explain how the ‘yes culture’ was being implemented, they did

agree that giving staff autonomy to make decisions required their support and

guidance.

“They [RNs] should have the confidence in their skills to make their decisions.

That’s something we do need to work on.” (Mgr. 7: line 312 – 6).

Supporting staff was essential so they could take ownership and actually live the

process day-to-day. “I should be saying: ‘yeah good job, good decision’ ”. (Mgr. 7: lines

317 – 322) It was argued that staff have to feel confident to take control within their

own environment and not succumb to ‘peer pressure’, in order to stop doing things the

old way. “Give them permission to not follow routines.” Mgr. 7: lines 72) Integral to this

cultural shift was giving staff the latitude to change the way they perform. “Allowing

them to say yes but also giving them more time to get control over their own tasks and

how they’re performed; I think that’s key” (Mgr. 5: lines 94 – 5). As such, managers

reasoned they would be liberating staff, “to do what they know is the right thing to do”

(Mgr. 1 lines 64 – 5).

While liberating for staff, their flexibility in how services were provided was also

perceived to have direct benefits to residents.


“It’s a very frustrating environment in which one of the people we serve says,

could I do or could I have? The person that they are asking to answer the

question, says well I’ll have to ask somebody, get approval ... it’s not in my

regulations” (Mgr. 1: lines 225 – 9).

The ability for staff to make decisions was considered to be an important aspect of a

flexible service, where meeting the needs of residents was paramount’.

“Giving freedom to act, exercising discernment in understanding the resident

and their particular needs at any one time.” (Mgr. 4: line 125)

While ‘spontaneity’ went hand-in-hand with staff autonomy, it was considered essential

that staff knew more about their residents’ unique characteristics and needs; “so with

that information I think that staff will be better informed to be able to make decisions,

those decisions on the spot.” (Mgr. 2: lines 390 – 1)

Autonomous decision-making also extended to staff enabling residents to maintain

their skills and giving them the opportunities to choose. “The evidence ...says that

people like to have more choice and should be more involved” (Mgr. 2: lines 543 – 5).

While assisting a resident, staff could involve the person in the decision-making by

stating,

“Come and help me choose what you’d like to wear today...it’s much more

meaningful than a staff member who just thinking I’ve just got to get this

resident dressed.” (Mgr. 3: lines 658 – 62)

Using this approach was considered to help staff to make the ‘culture’ shift from

wanting to help the resident and thereby ‘do everything for the resident’. Staff were

misguided not realising that “... they’re [residents were] losing their independence”.

(Mgr. 7: lines 450 – 5)

Promoting flexible care practices

Flexibility and spontaneity in care practices meant providing care in the way in which a

person expected it, or was accustomed to. “[We should] encourage much greater

flexibility in the way we respond to those needs” (Mgr. 1: lines 333 – 7). Managers

proposed the need to ‘move away from task focus’ and ‘what we want’ towards ‘doing

what they [residents] would like to do when they would like to do it’ (Mgr. 7: line 69). To

achieve this staff needed to acknowledge the way residents have lived their lives and

invest time in “... getting to understand how the resident wants to live their life [now].”


(Mgr. 2: line 378) There was an expectation that when staff knew more about the

resident’s background and life experiences, they would be more likely to respond

intuitively to the person’s preferred ways of having care and other services provided.

Flexibility was further described as,

“we ... consistently analyse who is the resident and what do they need; If we

don’t keep going back to that, we are just going to be doing the same old thing”

(Mgr. 5: lines 144 – 6).

One manager provided a practical application of a more flexible service approach,

incorporating the resident’s life story when responding to a person’s agitation:

“[It’s] something small, they’ve got a DVD player and they get

agitated at a certain time but the DVD of family, actually one resident

likes war stuff, is great and they can sit there for an hour at that time.

Xxx knows that he can pop it on and he knows they enjoy that.” (Mgr.

7: lines 224 – 238).

According to the managers, service flexibility included a move away from focusing on

the task at hand towards staff engaging with the resident’s emotions and feelings. The

approach suggested would begin with “the way in which [staff] converse with the

person [with whom] they are trying to have a relationship” (Mgr. 3: lines 86 – 99).

Managers spoke of striking up conversations during showering, or feeding assistance,

to reminisce about the person’s past, their hobbies and occupation. There were

intrinsic benefits suggested in responding in this way,

“The more we can understand and respond to the needs of people and allay

their fears and concerns the more we can improve their well-being” (Mgr. 3:

lines 677 – 80).

Additionally, the managers suggested that holding conversations with the resident

during care episodes offered the opportunity to ‘gauge if there’s something wrong from

those little nuances’. “You can’t just say oh well he’s unhappy today let’s move on.”

(Mgr. 3: lines 681 – 4) Managers considered that these improvements in care were

being realised with the change process: “the engagement with the residents – it’s

resonating with the staff” (Mgr. 5: lines 106 – 7); and staff were seen to be more

flexible and spontaneous: “one of the ladies asked one of the staff to paint her nails –

absolutely I’ll come back and do that.” (Mgr. 6: lines 66).


Care staff were also expected to be flexible and spontaneous in meeting the resident’s

social needs. Training would be provided to help these staff to provide care more

individualised ways, the focus being on meaningful activities, by recognising the

meaning of the activity for each person. Managers described a trial activity, calling it

‘pancake rage’, where care staff were given the opportunity to do an activity with

residents. They made pancakes. “They had an absolute ball.” (Mgr. 6: line 135)

To understand managers’ views on how staff could be more flexible in care delivery, a

scenario was relayed to the managers during the interview: ‘what would you expect

staff to do if a resident asked for a beer even though it wasn’t the scheduled time for

happy hour?’ There was a chorus of positive responses qualified by,

”staff can make the right decisions at the time, by knowing the person. The

families are critical influence … they know what we really need to know ... They

know … their dad likes a beer at 4 o’clock in the afternoon, in the late

afternoons. So, he’s going to get a bit grumpy if they forget.” (Mgr. 1: lines 387

– 91)

Supporting and understanding the motivation of staff members

While the focus of the interviews initially provided information on staff re-orientation

and re-education, when managers were asked if any of the planned initiatives included

rewarding staff for their involvement in the change process, one manager noted,

“... [They would be] rewarded through their role...” (Mgr. 1: lines 406 – 9] and “...

I’d like staff to feel that they have personally made a huge contribution to

someone [a resident] who says: ‘Well, I’m very grateful for, I feared coming in

here and it’s a lot better than what I thought. You’ve been so kind to me’” (Mgr.

1: line 414).

Other managers spoke of ‘acknowledging and thanking staff when they did something

well’; ‘A smile’ or saying ‘hello’, ‘all that sort of stuff’. Managers told of how staff were

starting to understand the new way and ‘they’re getting it’. Care staff were seen to be

responding according to residents’ wishes; becoming confident to defend their

decisions on how they provided care. “They know what he wants. And it’s great! And

it’s great that they challenged me. So ... which is good” (Mgr. 6, lines 71 – 2)

A new culture of care was proposed where managers supported staff with their

achievements, praised and “encouraged them for their move towards a PCC approach”


(Mgr. 3: lines 336 – 7) and when they responded to what the resident wanted.

Encouraging staff to take on a person-centred approach was described as,

“Teaching them how to engage with residents, empowering them” (Mgr. 2: lines

540 – 1); “Refining what they do (Mgr. 3: line 371); informing them there is an

alternative.” (Mgr. 3: line 389); while “It’s not beating them up; it’s understanding

your staff; [recognising that] some need more attention than others.” (Mgr. 4:

lines 374 – 6)

A reflective session, held for staff after caring for a resident with facial surgery for a

malignancy, was used as an opportunity for “providing them [staff with] that positive

feedback that you did an amazing job: We’re very lucky we’ve got you.” (Mgr. 7: lines

392 – 6) “If we’re doing that [supporting staff] well over time it creates a culture over

time” (Mgr. 4: lines 360 – 6).

For the managers this cultural shift included ‘being attuned with the realities of staff’

(Mgr. 4: line 238). At times when staff are stretched or pushed, however, some

managers realised that far more work was required to support staff: “We haven’t given

that enough attention” (Mgr. 4: lines 238 – 9). “[We] have to be sensitive to people to

pick up things ... allowing them that confidence to be able to have that chat.” (Mgr. 3:

lines 760 – 3) One manager described a situation where a staff member was reflecting

at staff handover and suddenly became very quiet, worried she had done something

wrong. Within this context the manager utilised the opportunity to facilitate a support

group for the staff member:

“So as a group we all sat there and went: yeah, it was quite

frightening what we’re talking about, and you were

uncomfortable, maybe next time we can say let’s refer it to the

Chaplain or the pastoral carer. So she said, okay, I can do that

... an open forum. It’s safe and secure with their colleagues and

they’re happy to do that ... And that’s what we say to them: we

all make mistakes”. (Mgr. 6: lines 83 – 95)

This personalised approach to supporting staff was affirmed by other managers: “It’s

understanding your staff ... some are going to need more attention than others...” (Mgr.

4: lines 374 – 6); “...they don’t come from the same basket” (Mgr. 3: lines 33 – 6).

When prompted in how they could balance staff support and the disproportionate

demands that some staff might make on a manager, Manager 4 (lines 177 – 96)


recommended that: “...the manager’s first priority is to provide care to the residents ...

[the manager has] got to make a decision and it’s going to be difficult at times; [the staff

are] going to recognise that’s a reasonable response and you’re being fair about that”.

Developing Person-centred Leadership Skills

In discussing the ‘yes culture’ being implemented with staff, Manager 1 (line 225)

outlined the challenge this concept would bring for managers: “It’s an ability of our

[front-line] managers to work successfully other than in a controlled environment”.

Inherently the ‘yes culture’ means: “we need people who are prepared to make

change” (Mgr. 2: line 55). Additionally, “They [front-line managers] also don’t have the

ability to see outside their silo.” (Mgr. 5: line 236). Considering the ‘yes culture’ to be

the management philosophy required to implement a person-centred approach across

the organisation, there was consensus that front-line managers would be confronted by

this requirement and at times, be expected to step out of their comfort zones. At

interview, Manager 2 explored the requisite leadership skills needed to help institute

person-centred care within their facility: “they actually have to work out how they

deliver it [PCC] within the constraints and idiosyncrasies of each village” (Mgr. 2: lines

441 – 456). Manager 2 qualified this perspective further by saying:

“... we [the project team] will establish some of the core

organisational things that we need to implement. We will share

those with the other managers as we learn them but every village

has got to look at the idiosyncratic ways of implementing the

concepts ... but the actual, on the ground, day-to-day work needs to

be done in every village.”(lines 224 – 8)

With the understanding that managers would need to oversee the person-centred care

approach across the organisation, and that this responsibility would be a challenge for

front-line managers, the senior managers had pondered how to develop requisite

leadership skills in facility managers. To successfully implement service changes, the

process would involve “... teaching people on the ground – this is how you make

changes, sustainable changes and sensible changes”. (Mgr. 2: lines 233 – 4) Mgr. 2

(line 234) added: “When I walk away they should have that well and truly down pat.”

Successful transformation would necessitate additional skill sets that were currently

unrealised,


“... they [the managers] have the knowledge and the skill with the things they

are doing but the translating that to make that information influence decisions

afterwards, they don’t have that” (Mgr. 5: lines 234 – 5).

To help managers develop these skills the project was developing a change

management ‘toolkit’: “My role will be to make the project to happen here; to help

develop the toolkit ongoing” (Mgr. 5: line 365). Toolkit was the term used by the

managers to describe a set of processes, trialled within this project, which would assist

managers in future change programs. Manager 5 used the opportunity to role model

how the managers could use information collected during the project, including data

collected from surveys, clinical indicators and quality assessments, to understand the

process and progress being made in implementing person-centred care as the basis

for making management decisions:

“[This process] gives the managers visibility on what’s happening as

soon as it happens so they can start to measure themselves

against the data. To feed that information back ... to show how

we’re progressing.” (Mgr. 5: lines 7 – 28) and “... people come back

to the table as a group and we work on, we discuss what we’re

doing, we analyse that and we work out a plan going forward ...

keep people accountable the whole way through.” (Mgr. 5: lines 138

– 40)

Concurrent to implementing person-centred care, front-line managers were expected to

ensure that their facilities continued to operate efficiently. At interview managers were

asked how they foresaw front-line managers balancing the daily functioning of the

facility, while also attempting to introduce the new system-wide approach to care.

Manager 4 suggested that the broad range of management skills would underpin

facilitating person-centred care:

“Good people management, good systems management,

holding people to account reasonably and fairly, staying on top

of things, procedures in place, systems in place, delegations

happening, well educated, clear expectations are set, managers

are looking at educating their own staff and recognising those

needs, I think all those things have a play in managing PCC”

(Mgr. 4: lines 209 – 27)


Theme Three: Changing peoples’ lives

The third theme reflects the managers’ realisation that thinking differently about their

own roles and responsibilities could occur when they came to acknowledge that

person-centred care can ‘change peoples’ lives’. After discussing the organisation’s

strategic plan Manager 1 (lines: 66 – 8) identified a shift in the organisation’s strategic

focus away from redevelopment of old building stock and market research to one of

putting people first. “The most important thing, in going forward over the future years,

was responding to the needs of people” (Mgr. 1: lines 17 – 8).

Organisational commitment to a vision

“Its vision... it’s fundamentally important to us; it’s the biggest challenge that we have ...

how does the service we offer go forward?” (Mgr. 1: lines 66 – 7) Signifying its

importance and guaranteeing “it’s got the wherewithal to achieve [its aims]” (Mgr. 1:

lines 68), the project’s focus on implementing a person-centred approach to care was

one of four objectives distinguished on the organisation’s strategic plan. The

organisational commitment to the project was further realised with the comment that,

“PCC can’t be taken off the shelf...Concepts would be taken, build on them

[further] and [incorporate them] into our vision, mission and values.” (Mgr. 2

lines 200 – 216)

As a means of actually getting “that off the ground that people understand that” (Mgr. 3

lines 139 – 40), the managers were asked to define their own person-centred mission

statement when they attended a change management program. Undertaking this task

prompted them to define what person-centred care meant for them, something they

hadn’t done before. Previously accustomed to accepting a textbook definition, they

were now challenged with taking ownership of the person-centred approach within their

facility, or at the organisational level. They reflected on this experience and how it

made the person-centred approach real for them, personally. Managers thought that it

would be valuable for their own staff to be given the same opportunity by identifying

what a person-centred service meant for their work.

Visibility of top down leadership

Middle managers appreciated the obvious support from the senior managers, with the

organisation’s intention to implement the person-centred model across all care

services. The visible leadership from the ‘top’ signified the prominence of this project.

The strong presence of leadership was evident as the managers identified their own


roles and responsibilities to make it happen. Two managers described their leadership

through role modelling.

“... It’s great, I’m in the position now because I can make a difference” (Mgr. 7:

lines 60 – 63); and “Mainly it comes from top down ... I myself need to be

showing them I’m providing PCC” (Mgr. 7: line 396).

The other manager referred to stretching themselves beyond the scope of their normal

role,

“An important part of your leadership role and making this work ... Absolutely,

because they see myself doing things outside my job description and outside of

my scope” (Mgr. 6: lines 142 – 3).

‘Teaching people on the ground’, having staff ‘join project teams’ and ‘getting staff to

think differently’ were examples of managers’ initiatives with the aim of “making

changes, sustainable changes and sensible changes.” (Mgr. 2: lines 234 – 5) Manager

4 further highlighted the importance of visible, top-down leadership:

“... if we haven’t got the managers on board with it and leading it locally,

and the team leaders supervisors imbibing it and leading it, the frontline

leaders, without that and the support [of] education ... there’s no way it’s

going to happen ... a clear understanding of what that means for each

particular role that they manage”. (Mgr. 4: lines 79 – 84)

Valuing the change

Realising the organisational value of making the change to a person-centred aged care

service, the project was aligned with the organisation’s continuous improvement

activities and took precedence over any other activity. “The whole organisation is going

to have to kick in and support [it].” (Mgr. 1: line 247) The manager went on to explain

how the ‘head office’ would need to see itself as the ‘support centre’. Compared to

previous attempts to implement person-centred care in different facilities this project

had “an organisational push” with its own “infrastructure”. (Mgr. 2: lines 41 – 52)

A promotional newsletter kept people abreast of what was happening: “making sure

there’s decent and consistent imagery and content around staff and resident journals”

(Mgr. 5: lines 306 –17) Depicting the newsletter sited on a resident’s walking frame this

manager anticipated its “something that people will carry around and refer to and read

at night.” Similarly, relatives would be enticed: “Promote it: they’ll jump on it: ‘This is


great!’” (Mgr. 7: lines 201 – 3). Motivation was further recognised with descriptors such

as ‘top-down approach’, a ‘bottom-up approach’ and “coaching is going to be really

important” (Mgr. 4: line 217). There was management consensus of ‘getting it right’.

Whole of system approach

The ‘organisational push’ was counterbalanced by managers’ referring to

the project as ‘an embracing gesture’, with the aim of the person-centred

approach being ‘embedded in the [organisational] structure’. “We will

establish some of the core organisational things that we need to

implement.” (Mgr. 2: lines 226 – 7) It was envisioned that the person-

centred model would be introduced across seven organisational portfolios,

taking a whole of system approach, and implemented through ‘a continuous

improvement methodology’. Improvements would be planned through:

“The seven project teams ... [focusing on] Clinical, Dementia, Food,

Environment, Human Resources, Education, Lifestyle and Spiritual”

(Mgr. 2: lines 143 – 4). “Each of them will select three priorities to

make improvements” (Mgr. 2: lines 143 – 4). “The action plans have

already been written ... I think they’re a pretty good outline of what the

staff want to do.” (Mgr. 2: lines 554 – 6).

The methodology established time frames for implementation and review,

where each team was given 12 weeks to implement the proposed

strategies in the seven portfolios. Each team undertook 3 twelve-week

‘implementation rounds’. In keeping with the organisation’s quality

framework,

“[we’ll] make sure we have all those checks and balances [before

making the proposed] strategy operational ... we’ll measure all the

way. Measure, confirm, operationalize before we begin the new

round ... there is a way of monitoring that through the process.”

(Mgr. 5: lines 368 – 407)

To overcome communication shortfalls, one manager elaborated on embedding these

changes into the system: “unless that process is explained to all, all the way through, to

all the people involved there’ll be some level of resistance.” (Mgr. 3: lines 468 – 72)


Dedicating financial and other resources to demonstrate commitment

There was further evidence of the ‘organisational push’ and supportive infrastructure, in

the form of resources and finances being allocated to the project. A project manager

was appointed with further support from other departments, such as the information

technology and publishing departments. Soon after the commencement of the project

the decision was made to allocate one of the front-line managers to assist all managers

with implementing the person-centred model across the organisation. This new role

was fully dedicated to achieving the project objectives. A replacement manager was

assigned to cover the work of this manager, to help manage ‘business as usual’. This

decision meant that the front-line manager was relieved from the day-to-day running of

the facility, which normally involved maintaining organisational systems, staff

management and financial oversight. Several managers applauded the organisation’s

resolution to commit this front-line manager to the project’s oversight.

The manager allocated to oversee and manage the project gave her personal

perspective of this decision:

“It also shows me how serious the organisation is ... putting

resources and finances ... which I think is fantastic, because I’m

very passionate about aged care and PCC ... so we can actually do

this. That’s quite comforting.” (Mgr. 6: (lines 169 – 71)

Aged Care Services Audit Results

In order to evaluate the progress being made with the person-centred changes

occurring on one of the organisation’s facilities, the quality of care services of two of

the facility’s care units was assessed with the Person-centred Environment and Care

Assessment Tool (PCECAT). As the focus of this study was not concerned with the

care units’ physical environments, data on the PCECAT’s Domain 3 (Physical layout

and design) were not collected. The PCECAT was administered prior to the change

process commencing in these care units and twelve months later, after the change

process was underway. The PCECAT procedures produced two sets of results: the

numerical scores for PCECAT Domains 1 and 2; and the field notes that were recorded

while administering the PCECAT. The field notes were documented to explain

allocated scores, to provide insight into how the person-centred approaches being

implemented had changed over time in the two care units assessed, and provided


descriptive data on the improvements that had occurred and where deficits in service

quality remained.

PCECAT Domain Scores

The PCECAT numerical results are identified in Table 6, providing a comparison of

scores for Care Unit 1 and 2 before and after commencing the organisation’s person-

centred change processes. Improvements in person-centred care practices are evident

when comparing the PCECAT numerical results. Both care units assessed were found

to have significant improvements in Domain 1 (Organisational Culture) and Domain 2

(Care & Activities, and Interpersonal Relationships & Interactions) following project

commencement. For Domain 1, Unit 1 showed a higher score of +21, while Unit 2

achieved a higher score of +30. While the before-change process scores showed only

2 points variance between the two Care Units, 12 months following commencement of

the change process there is a difference of 11 points. Before and after PCECAT scores

show that Domain 1 scores for Unit 2 (77 / 84) were higher than Unit 1 (66 / 84): 77 vs.

66 out of a total of 84 points. Domain 2 scores, Unit 2 (45 / 48) were higher than Unit 1

scores (40 / 48), 45 vs. 40 out of a total of 48 points. There were improvements for

Units 1 and 2 when comparing the before and after PCECAT scores: [Unit 1 = (+10)] ~

[Unit 2 = (+16)]. As in Domain 1 there was a minimal difference between the two care

units for Domain 2 scores before project commencement, with Unit 2 trailing Unit 1 by

1 point.

Table 6 - PCECAT Numerical Scores

Facility Stages of change Domain 1: Organisational

Culture

Range 28-84*

Domain 2: Activities, interpersonal relationships and

interactions

Range 16-48*

Unit 1

Before 45 30

12 months after 66 40

Difference Before/After +21 +10

Unit 2

Dementia Specific

Unit

Before 47 29

12 months after 77 45

Difference Before/After +30 +16

*Higher score signifies greater quality of care


PCECAT Field Notes – Identified Strengths and Possible Improvements

The field note data that were recorded alongside the PCECAT Domain 1 and 2 scores,

provide explanations for the scores allocated, comment on contextual factors that

might help to explain these scores and identify areas of strength and areas for

improvement in relation to each PCECAT Domain. Each PCECAT Domain has several

assessment criteria that nominate the data to be explored and checked. Domain 1

(Organisational Culture) has seven sub-domains (1.1 to 1.7) and 28 items within them.

There are four sub-domains for Domain 2 (Care and activities, Interpersonal

relationships and interactions) (2.1 – 2.4), comprising 16 items.

These qualitative data have been tabled against each of the PCECAT items for

Domain 1, Organisational Culture, and Domain 2, Care and Activities, and

Interpersonal Relations and Interactions. They provide insight on where improvements,

labelled as Strengths, have occurred after the PCC interventions. Similarly, the

identified gaps are listed under the heading ‘Areas for Possible Improvement’.

Appendix G lists the results for Unit 1, while Appendix H tables the results for Unit 2.

To explore how and where care services had become more person-centred following

commencement of the project in the two care units, the field note data collected 12

months after project commencement were clarified against each PCECAT Domain

Item. These data were then compared with the before-project field note data. These

data were described as either strengths or areas for further improvement. Distinctions

have been made, as necessary, when the results differed between the two different

care units assessed with the PCECAT.

Domain 1. Organisational Culture

1.1 The home’s Mission, Vision, Value Statement (or similar) states commitment to

the meeting the unique needs of the person living in the home or care unit.

This outcome spans the organisation so the findings for this item applied for both care

units. It was recommended that the organisation develop policies and procedures to

articulate person-centred principles and how they are to be applied in the services

being provided.

1.2 The person and their family/representative are aware of the home’s

commitment to a person-centred approach.


It was noted in the PCECAT assessment before the project commenced that the

resident handbook lacked information about the person-centred approach to care.

Twelve months following project commencement significant work appears to have

been undertaken to update the resident handbook, in particular the organisation

outlined its philosophy of care. The perceived outcome from this improvement is that

residents and their representatives would be armed with the knowledge that the

organisation was committed to providing individual services to residents. This initiative

was considered to be an overall improvement to the Organisational Culture and thus

an outcome for both Units.

1.3 There is regular consultation regarding the person’s individual care needs and

preferences.

Findings from the pre-change process PCECAT assessment identified that in Units 1

and 2 consultation occurred with resident and/or their families, with care conferences

being held annually. Care plans, however, did not reveal attention to the individual’s

preferences. After the commencement of change there was no commentary on this

earlier finding for Unit 1 in the PCECAT field notes. Conversely, for Unit 2, consultation

was undertaken with the residents and their representatives according to the PCECAT

field notes after the commencement of the change process. A suggestion was added to

the field notes, whereby this rapport with residents and their representatives would be

improved when staff wore name badges.

1.4 According to their ability, the person and their family/representative have the

opportunity to make suggestions and lodge a complaint

With regard to this outcome the organisation appears to have altered their position on

resident and representative satisfaction surveys. In 2013, during the PCECAT

assessment, managers spoke of how they were responding to the residents’ and

representatives’ satisfaction survey. A year later, after the commencement of the

change process, the data suggests that the organisation ought to conduct satisfaction

surveys. In the semi-structured interviews with the managers at that time, some of

them questioned the value of satisfaction surveys per se, wanting to explore more

meaningful ways of measuring resident and representative views on service quality.

Data for this outcome was similar for both Units.

1.5 Staff are aware of the organisation’s commitment to PCC services


Field note data for this construct spanned both units. Before commencement of the

change process, staff training utilised a tailor made educational program called Evolve.

At this time job descriptions made no mention of the person-centred approach to care

and staff’s requirements to support this model of care. This issue was being addressed

after the commencement of the change process, and are reflected in the post-project

PCECAT scores, where job descriptions include details on person-centred objectives.

Additionally, after commencement of change data revealed that performance

appraisals needed to be reviewed, to include an assessment that staff members have

the relevant knowledge, skills and attitude to provide services in a person-centred way.

1.6 Managers and staff demonstrate commitment to person-centred care.

For Unit 2, the PCECAT’s after commencement of change results showed

considerable improvements in some areas. Identified as a ‘strength’ staff members

were found to have ‘embraced PCC principles’ in the way they ‘support people and

attend to their needs’. They recognised “every day is different for people” and

responded accordingly to meet their needs. It was further acknowledged that staff had

‘detailed knowledge of the people they care for’ which helped to ’reduce confusion’.

These strengths were linked to the improvement in staff consistently working in Unit 2.

Subsequently, residents and relatives ‘get to know the staff’.

While some improvements were made with ‘person-centred principles’ in Unit 2, there

remained room for possible improvements for Unit 1. At the after commencement of

change PCECAT administration, staff members were considered to be ‘lacking insight

into the reason for a person’s distress’; the consequences being that staff could not

provide the corresponding ‘comfort measures’ for distressed residents. Similarly, many

staff members were found to adhere to their work schedules, rather than showing

some flexibility in their care in response to ‘a person’s needs as they occurred’.

For Units 1 and 2, the after commencement of change results showed that staff

handovers were unchanged. They were limited to clinical staff, excluding the leisure

and lifestyle staff who could otherwise augment discussions with ‘the psychosocial

aspects of each person’s life’. Staff needed the opportunities to include people’s

psychosocial issues to ‘enhance ... the person’s well-being’. In a similar vein, person-

centred practices for individual residents were not being promoted at handover.

Improvements were possible with ‘staff members [receiving] education and support’.

1.7 Staff efforts in their various roles are recognised and valued.


The PCECAT before commencement of change assessment revealed that staff did not

routinely receive direct praise for their work. This same sentiment was identified in Unit

2 after the commencement of the change process. Staff advised that receiving direct

praise for their work would make them “feel appreciated”. In Unit 1 the staff reported

facing a different issue; they felt that when they had raised matters, or made

suggestions for improvements ‘their opinion is not respected or appreciated’.

Additionally, Unit 1 staff felt there was a lack of respect shown to colleagues.

Domain 2. Care and Activities, and Interpersonal Relations and Interactions

2.1 Individual care plans support the person’s independence as far as possible

while addressing their unique needs and desires.

Care plans reviewed before the commencement of change tended to focus on the

resident’s deficits. For Unit 2 there was little evidence of strategies on how to enable

people to maintain their current skills. PCECAT assessments after the commencement

of change revealed care plans with ‘repetitive interventions’ across some care needs.

Additionally, care interventions documented did not directly relate to the staff’s

observations and care assessments undertaken for individual residents.

2.2 An individual Life History informs each person’s Recreation and Social

Activities.

Following the commencement of change in Unit 1, the field notes indicate that a newly

formed Leisure and Lifestyle team were enthusiastic about person-centred practices

and eager to implement activities to meet the individual’s interests. There remained

areas for possible improvement in Unit 1, such as incorporating the information

collected through the facility’s Culture and Lifestyle assessments in the resident’s

unique activity plan. For Unit 2 residents who, prior to the change process, had been

secluded to their own service precinct were now include in leisure activities at the

facility’s main amenity areas, such as the barbeque area and the café.

2.3 There is respect for the person’s unique identity (personhood).

Following the commencement of change in Unit 1 a number of strengths were

identified. Residents’ spiritual needs were being met through the Chaplaincy services;

particularly one chaplain who was well known and available to people regardless of

their beliefs. Through reflective practice sessions, people’s life stories were being

conveyed by residents and families to care, lifestyle and leisure staff. Cue cards were


also being used for people with communication difficulties. After commencement of the

change process an improvement in spiritual care occurred through a regular support

group meeting for family members of people past and presently living in Unit 2.

While these strengths were identified, there were areas where improvements could still

be made for Unit 1. End-of-life information did not include a person’s wishes regarding

religious and cultural rituals. Similarly, the atmosphere for people living in the home

could be enhanced through a range of activities which celebrated their cultural

diversity.

2.4 Staff maintain positive interpersonal relationships with each person.

In Units 1 and 2, after commencement of the change process, staff members were

observed to be rushing past people during their day to day work. Field notes recorded

at this time reflected that these staff could have spent more time in social

conversations with residents during their work, to help with developing trusting

relationships with their residents. Resident Satisfaction Surveys reviewed during the

PCECAT assessment following the commencement of organisational change

supported these observations, indicating a decline in residents’ satisfaction when

asked: “Staff have time to talk to me” (2013 = 84.6% compared to 2014 = 74.3%).

Summary

In summary, the strategies being planned and in some cases being actioned by the

managers involved in the organisation’s person-centred project, as described in the

semi-structured manager interviews, revealed three major themes: Thinking

Differently/Changing Systems; Promoting a ‘yes culture’; and Changing peoples’ lives.

The proposed new ways of thinking and behaving throughout the organisation was

intended as a catalyst for empowering the staff working at the ‘coalface’, by helping

them to make decisions when and where they needed to. The hope and determination

of this new way of thinking and acting was aimed at helping change the lives of the

people living in the facility.

It is clear from the change in PCECAT Domain 1 and 2 scores over the project that the

planned implementation strategies were facilitating improvements in the quality of care

services and that they were becoming more closely aligned with person-centred care

principles. The PCECAT scores reveal an average improvement, combining the two

Units, of Domain 1= (+25) and Domain 2= (+13). By reference to the field notes, the

changes revealed in PCECAT Domains 1 and 2 scores can be explained when


reviewing the detailed descriptions of the context and extent of any improvements

being made by managers and staff, where the strengths in services lay and where

there was still room for service improvement.

These study findings will be discussed in Chapter 6, to draw comparisons between the

managers’ stated plans and strategies, the PCECAT scores before and after the

commencement of the change process, and the explanations for these scores as

detailed in the field notes. The identified strengths and areas for improvement in

progressing towards a person-centred approach will be considered in light of the

theoretical models developed to assist with implementing a person-centred aged care

service. It is important to understand these links in reflecting on the progress being

made in the two care units which participated in the project. Additionally, the following

chapter will reflect on the scope and usefulness of the study methods, and identify the

study’s strengths and its limitation

Chapter 6 – Discussion 93

Chapter 6. Discussion

Introduction

“To be a person is to live in a world where meanings are shared ...

Interaction is not a matter of simply responding to signals, but of

grasping the meanings conveyed by others” (Kitwood 1997a, p. 87)

Kitwood’s statement, referring to the person being understood not merely by what they

say but what they mean to convey, resonates on many levels with the context of this

study. The immediate interpolation of Kitwood’s insight of what it means to be a person

provided the foundation for the person-centred care aged care service change process.

“Once the person is known, every interaction can be personalised...” (Loveday 2013, p.

27). It is by grasping the meaning of what a person is conveying that PCC can be truly

practiced.

In parallel to this concept of PCC practices the organisation came to understand the

meanings of the planned management strategies to implement PCC. Managers

reviewed the effectiveness of their actions comprehending the outcomes to residents.

They were committed to realise the necessary changes required to improve system-

wide practices across the organisation. The researcher’s study has identified, first and

foremost, that the process of implementing PCC practices was found to require

leadership from senior managers in all divisions of the organisation.

Leading from the top

“Leadership is about holding a vision and inspiring and guiding

movement towards it”. (Loveday 2013, p. 36)

Many studies undertaken with the aim of improving the quality of the care provided in

residential aged care facilities have identified that the degree of success is reliant on

managers’ support and leadership (Berkhout et al. 2009; Chenoweth et al. 2014b;

Chenoweth & Kilstoff 2002; Chenoweth et al. 2009; Cohen-Mansfield & Bester 2006;

Stein-Parbury et al. 2012). In Australia, the Productivity Commission (2011) recognised

the importance of management leadership skills for aged care facilities to develop and

adopt new models of care. Similarly, the Australian College of Nursing (2015, p. 4) has

recognised that nurse leadership, conversant with “a patient-centred philosophy of

nursing”, will be needed to inform “the strategic direction of Australia’s health system

and help drive the necessary changes within organisations”.


In this project, the seven senior managers were inducted and supported in the change

management process by the organisation’s CEO and its Board of Directors. Within the

organisation’s new culture, middle managers were integral to introducing PCC across

the organisation. As such, the organisation’s commitment supported all managers

when taking on their PCC leadership role. This support came in the form of a ‘step-by-

step’ (Loveday 2013) change management system together with a broader ‘whole of

systems’ view to implementing person-centred care (Jeon et al. 2011; Kitwood 1997a;

Stein-Parbury et al. 2012). While managers’ support and leadership are essential

elements to the success of introducing a person-centred approach to care it is clear

from this study that nurse managers work within a larger context and require the

backing of an organisational framework to achieve their goals (Brooker 2004). PCC

leadership needs to start at the top of the organisation (Brooker 2007). If

transformation is to occur Kitwood (1997a) recommended cultural change where

information can flow freely and staff, including managers, can be spontaneous and set

free to do their best work. The change process would not be a matter of merely giving

managers more and more duties and responsibilities (Anderson, Issel & McDaniel

2003; Jeon, Merlyn & Chenoweth 2010).

Holding the vision

It was clear that the organisation’s project was led from the top, starting with a new

organisation vision statement incorporating a person-centred philosophy of care. The

vision statement that was developed is testament to the Board of Directors’ stamp of

approval. “Valuing people has to begin at the top ... [where] those at board or trustee

level take it to underpin all their decisions. Agreeing [to] this in its vision or mission

statement means the organisation is making public its policy of promoting the rights of

people with dementia.” (Brooker 2007, p. 37). This was identified as a management

strength when the PCECAT was administered to assess progress twelve months after

the project had commenced. An example of the progress being made was the

distribution of the resident’s handbook to new residents and their families on admission

to the facility. The handbook also included new information on the person-centred care

services that were provided by the organisation. By itself, the handbook did not indicate

that services were person centred, but the information provided on service offerings

advised that the focus was on meeting individual resident needs. This was an

important step forward for the organisation because vision or mission statements

without an explanation of how these statements will be instituted in service offerings,

may appear promotional in nature (Kitwood 1997b). In regard to statements about the

person-centred nature of care services, mission/vision statements require a realistic


and practical organisational framework for implementation (Brooker 2005; Chenoweth

et al. 2014b). As Loveday (2013, pp. 37-8) notes “A vision focuses on aspirations ...

[which] to be more than words needs to be based on specific goals”. Even experienced

nurse managers who have attempted to implement a person-centred approach to care,

can struggle without organisational leadership to support their attempts (Loveday

2013). Brooker (2007, p. 35) further explains: “If a care organisation is to deliver

person-centred care in anything but a non-trivial manner...It is top-level leadership

within a care organisation that determines this.”

Organisational Framework to support Person-centred Care

The project aimed to introduce person-centred care (PCC) practices in a residential

aged care facility, beginning with leadership of one senior manager, who described

herself as the lead nurse manager in the organisation. From her examination into PCC

this manager developed and tabled a model to implement PCC, thereby setting the

tone for nursing care in the organisation (Australian College of Nursing (ACN) 2015). It

was clear that the manager’s PCC implementation plan reflected clear, strategic

thinking, and was approved by the Board of Directors, where “power and interests lie...”

(Kitwood 1997a, p. 115).

“It is never simple or easy to introduce new practices within an

organisation...One problem is how to get the organisation in a larger

sense, to accept that the proposed change is a good idea and then to

positively back it...Many good ideas are lost because of a failure of

practical (and, in a sense, political) intelligence.” (Kitwood 1997a, p.

115)

While recognising the enormity of the challenge to implement the plan, another

manager identified the project as being fundamental to providing services in the future.

His comments, together with other managers’ statements, further strengthened the

prominence of the organisation’s intention to introduce PCC organisation-wide. Taking

priority over all other projects, the senior managers did not want the PCC project to be

seen as a mere gesture of service improvement. Additionally, while the drive to

introduce PCC commenced with a management-led ‘top-down’ approach there were

reciprocal staff-driven ‘bottom-up’ expectations (Jeon et al. 2011; Stein-Parbury et al.

2012). This combined approach helped to involve as many staff as possible in the

project plan implementation. Brooker (2007) advises that all levels within the

organisation, including the Board of Directors, should be committed to implementing

and supporting PCC. At the same time, Kitwood (1997a) and Loveday (2013)


recognised that implementing PCC across the organisation and even in discrete care

units, needs to align with, and be guided by, the organisation’s overarching goals.

In the PCC project, an organisational framework was developed to support the

implementation of the different aspects of PCC in two facility care units. This initiative

represented the first step to organisation-wide care service improvement. Like Loveday

(2013), Jeon et al (2011, p. 517) identified that senior managers needed to be willing to

alter the organisational structures considered necessary to support staff’s adoption of

person-centred approaches to care. Other PCC advocates (Cohen-Mansfield & Bester

2006; Edvardsson et al. 2011; Hunter, Hadjistavropoulos & Kaasalainen 2015) concur

with the premise that organisational principles have to synchronise with PCC if its

introduction is to be successful. PCC requires a whole of system approach; creating a

workplace culture that supports residents, staff and managers to be person-centred

(Stein-Parbury et al. 2012, p. 420).

As Loveday (2013) recommends, organisational leaders must give careful thought to

how they can bring the team with them through the change process, by helping staff to

become aware of care that is not meeting resident personhood needs and helping

them to develop knowledge and professionalism. It was clear in this project that the

organisation was taking a comprehensive view to understand the range of systems,

policies and procedures that would facilitate and embody the PCC model for the

organisation. As such the senior managers leading the PCC project realised that if staff

were expected to take a person-centred approach, care service improvements needed

to be embedded within broader organisational systems, so that organisational barriers

to PCC could be addressed. “The policies, procedures and systems of the organisation

can be blocks to person-centred care” (Loveday 2013, p. 63). Prioritising the project

meant that any departmental changes occurring during the project had to align with the

PCC project’s goals. Rather than approaching any problems arising in the

implementation process with a ‘fix it’ mentality, the project team determined to

understand the causes for these issues and their relationship to the project’s overall

goals. To help gain a better understanding of problems arising, the organisational

framework established included a change management process overseen by a

steering committee.

Role of Steering Committee and working groups/project teams

The project’s steering committee comprised most of the senior organisation managers.

With secretarial support, the steering committee convened every six weeks to plan and

monitor the project’s progress. PCC was implemented through the oversight of the


steering committee, using what managers described as the organisation’s continuous

improvement methodology incorporating action plans with specific goals to be

achieved. Kitwood (1997a) promoted use of this senior management team approach,

recommending use of a common framework to progress change through a shared

consensus about the nature of good organisational practices. Concurring with this

recommendation, Crandall (2007) identified the importance of having systems in place

to support and sustain change.

With its commitment to PCC and introduction of the ‘yes culture’ the steering

committee, the executive and middle managers created a unique change management

system to implement PCC throughout the organisation. The continuous improvement

cycle became the step-by-step, staged and planned management process as

recommended by Kitwood (1997a) and Loveday (2013). While in its development stage

this process was considering the ongoing ‘toolkit’ for the implementation of PCC. One

manager used the term “toolkit ongoing” to describe the change management system.

Utilising the continuous improvement methodology, the toolkit involved a change

process which involved creativity, trials, evaluation and a process of ‘checks &

balances’ to monitor the shape and progress of change occurring (Australian College

of Nursing (ACN) 2015).

The implementation plan involved seven working groups that were accountable for

creating continuous improvement across a variety of portfolios. Each of the seven

working groups took charge of one of the following portfolios: clinical, dementia, food,

environment, human resources, education, and lifestyle & spiritual portfolios. Details on

what was needed to implement needed change emerged from initially investigating the

processes and outcomes arising for residents across these seven portfolios. Selecting

three priority improvement areas, each of the seven working groups developed action

plans which expounded the details of change objectives that were to be implemented

over twelve-week trial periods. The steering committee members evaluated outcomes

of these initiatives for the residents, allowing for a reasonable settling-in period, as

PCC advocates (Brooker 2007; Kitwood 1997b; Loveday 2013) recommend using

these approaches to PCC implementation and evaluation.

Flexibility, together with setting goals, was integral to the steering committee’s modus

operandi of developing the change management system, as advised by Loveday

(2013), “Person-centred care is highly flexible and guided by goals” (Loveday 2013, p.

42). The change management process included sharing the vision with all

stakeholders, including the residents, which is a key pillar of the PCC change


management process (Loveday 2013). The vision was not always apparent to all

members of the organisation at the start of the project, however the continuous

improvement methodology provided the “process of learning [through] experiencing,

reflecting, concluding and planning” (Loveday 2013, p. 106). Even the steering

committee members went through a process of informing themselves about the change

management process through trial and error (Carmeli, Tishler & Edmondson 2012). For

example, after creating provisional roles, the information gained during the project

helped the committee to develop better-informed job descriptions. Managers described

giving themselves this latitude as part of the learning process. The overall aim of the

change process was to establish the core elements needed to facilitate PCC

organisation-wide. These essential ingredients were shared with front-line managers

as the steering committee members developed them.

Commitment of resources

Financial and other resources were dedicated to support the project in order to achieve

its aims. This degree of input further distinguished and strengthened the organisation’s

obligation to the project. As (Brooker 2007; Kitwood 1997a) warned, ‘funding

limitations’ can be the biggest barriers to achieving the goals of PCC; a barrier normally

outside the manager’s control (Loveday 2013). The managers greatly appreciated the

resources that were made available to them in leading the PCC change process,

recognising that approval by the Board and the executive to allocate a substantial

financial outlay for the project was proof of the organisation’s commitment to the

project. These resources included the appointment of a manager to oversee the overall

project and another to specifically implement PCC within the project’s trial facility.

Although still at a conceptual stage, the organisational commitment extended to the

review of operational systems considered necessary to enhancing the quality of care

(Loveday 2013). As managers predicted, everybody within the organisation had a role

to play in progressing the project, including the Information Technology and Publishing

Departments. A newsletter was developed and distributed to disseminate updated

information about the change process to the broader organisational community,

including the residents, their families and the direct care staff. Given the extent of the

organisation’s commitment to the project, the newsletter wasn’t just a fancy brochure

advertising the project; it was as Loveday (2013, p. 28) suggests, a “vivid and

compelling image” to be articulated to everyone to create ‘drive and energy’.


Walking the talk

The managers appreciated that in order for PCC to be implemented as an

organisational change process, they would have to act in accordance with PCC

principles; that is, they needed to ‘walk the talk’ (Senge et al. 1999). Within this new

organisational ‘yes culture’ front-line managers were challenged to assume the role of

PCC leaders and to be prepared to make changes (Chenoweth et al. 2014b;

Chenoweth et al. 2009; Stein-Parbury et al. 2012). They were expected to ‘imbibe it

and lead it locally’, looking ‘beyond their silo’ and move beyond their comfort zones.

Leadership came from the senior managers with a vision to ‘change peoples’ lives’ and

‘respond to the needs of people’, with other managers recognising their leadership

roles and responsibilities within the project’s aims of implementing PCC. Loveday

(2013, p. 42) calls upon “PCC leaders to reflect on their approach to ensure it

demonstrates to staff what you want to see them doing”. Empowering the staff and

managers in this way helped to create leaders at all levels of the organisation (Hurley &

Hutchinson 2013; Loveday 2013; Russell & Stone 2002). Van Wart (2013, p. 559)

recognised that empowerment, when implemented successfully, “enhances internal

accountability, sense of ownership, professional affiliation, and buy-in with group

goals”.

One manager relished working in aged care and recognised that she was now “in a

position to make a difference”. Another admitted that, as a manager, it was “an

important part of the leadership role to make it [PCC] happen”. Furthermore, the

managers recognised that in implementing PCC they were being challenged to “think

outside the box” in becoming role models (Loveday 2013). They understood that staff

would be looking to their managers to step outside of their usual job descriptions and to

operate beyond the scope of their daily duties (Shield et al. 2014). Managers utilised

staff gatherings, such as shift handovers, to provide positive reinforcement of the PCC

processes being implemented. Positive feedback was given to the staff when

managers observed them practising PCC (Loveday 2013). This was well-accepted by

the staff, since “Providing positive feedback and leadership to staff is a critical

management skill ... [and engenders] increased organisational commitment” (Duffield

et al. 2011, p. 29). Furthermore, the managers’ invitations to different staff to represent

their working teams during focus group discussions about the project, encouraged staff

member views and suggestions in planning new strategies. These discussions also

provided the opportunity for managers to create “a vivid and compelling image of how it

will be when the goals are achieved” (Loveday 2013, p. 42). Through these


experiences care staff members were learning, on the ground, how to think differently

and how to contribute to the planning process.

The nurse manager has been found to be the ‘linchpin’ in ensuring quality services in

residential aged care facilities (Anderson, Issel & McDaniel 2003; Jeon et al. 2015;

Jeon, Merlyn & Chenoweth 2010). They are expected to play a key role in shaping the

design and delivery of new models of care, as well as “driving the changes that will be

required for their implementation” (Australian College of Nursing (ACN) 2015, p. 4).

Research undertaken by the Productivity Commission (2011) and PCC advocates

(Chenoweth et al. 2014b; Chenoweth et al. 2009; Cohen-Mansfield & Bester 2006;

Stein-Parbury et al. 2012), has identified that the success of improving aged care

services warrants strong nursing leadership and good management skills. Exhibiting

good management skills has also been found to have positive outcomes on nurses’ job

satisfaction (Cummings et al. 2010; Duffield et al. 2011). Duffield et al. (2011)

recommend that with training, mentorship and support, managers will feel more

comfortable in their role and will be able to perform well as leaders.

At interview, one of the change managers advised that implementing PCC in aged care

requires administrators and managers to be equipped with the following: good people

skills; good systems management; holding people accountable reasonably and fairly;

staying on top of things through adopting workable procedures; delegating duties with

educated and clear expectations; and understanding and meeting staff educational

needs. In acknowledging these requirements, the steering committee planned specific

training for their managers to develop, or improve, these skills.

Management Training

When setting up a plan for the uptake of PCC, Loveday (2013, p. 82) identified that

“Empowerment is integral to person-centred leadership”. With the expectation that

front-line managers would lead the change management process, these managers

needed to be empowered and equipped for their role (Loveday 2013). Management

training needs were identified, resulting in front-line managers being given the

opportunity to participate in a Transformational Leadership course. Making tailored

management courses available to front-line managers in health and aged care services

is a recommended first step to improving care services (Duffield et al. 2011;

Productivity Commission 2011). Other commercially packaged training courses were

implemented in management training, including the ADKAR (Awareness, Desire,

Knowledge, Ability and Reinforcement) course, which is a change management model.


These leadership-training courses were offered within the project’s overall

organisational PCC strategies. Jeon et al (2010b) found that providing residential aged

care managers with this level of organisational support was more effective than “relying

upon individual managers' professional development activities or motivation” (p. 9).

Research findings on aged care leadership training strengthen this perspective,

“For good leadership to be sustainable, it is essential that

organisational policies be linked to, and congruent with, leadership

development programs that can provide the necessary resources for

structural and psychological empowerment.” (Jeon et al. 2013, p. 8)

Furthermore, planned education for PCC is not intended to be an end in itself (Stein-

Parbury et al. 2012) but rather, the new learning needs to be reinforced with on-the-

ground training (Loveday 2013, p. 106). .

The managers acknowledged that they had attained knowledge and expertise within

their scope of practice, but identified a gap in their analytical skills to translate that

information into informed decision-making. Consequently, the nurse managers were

taught first-hand during the change management process to make, what managers’

described as, ‘sensible and sustainable changes’. Ultimately, before the managers

completed the training program the change processes were embedded in their

operational duties. The organisational commitment to train and support managers in

their workplaces helped to garner their motivation (Loveday 2013) and the introduction

of new responsibilities towards the PCC project helped them to progress through

important stages of learning (Berkhout et al. 2009; Chenoweth et al. 2014b;

Chenoweth et al. 2009; Stein-Parbury et al. 2012). To achieve success in implementing

PCC, staff, as well as managers, needed an organisational cultural milieu comprising a

guiding framework, while being given permission and freedom to be spontaneous and

creative in care service delivery.

Supporting from the bottom

While the organisation’s commitment to PCC had a top-down managerial approach,

managers also established bottom-up initiatives that aimed to empower staff at the

coalface (Stein-Parbury et al. 2012). One of the senior managers emphasised this

approach to change, by outlining a new direction for staff training. Organisations that

adopt PCC also recognise “the need to work by the same set of principles with their

staff” (Brooker 2007, p. 35). Direct care staff were provided with many of the skills and


capabilities that are needed to provide PCC. Encouraging this best practice model

among care staff, managers spoke of bestowing praise when they observed staff

providing PCC. Many managers spoke of having an open-door policy, where staff were

able to speak with them on any issue in the process of change, and of giving emotional

and other support to staff during PCC implementation (Loveday 2013). Direct care staff

were also included in project teams, they were invited to voice their views and make

suggestions for change at the focus group discussions, and their opinions were sought

when trialling new strategies which aimed to make care services more person-centred.

As Brooker (2007, p. 40) suggests “Staff who feel that they have been consulted over

practice are more likely to institute consultation practices with families and [residents]”.

A developing positive relationship started to arise between the resident, family and

staff, as advised by the managers who spoke of the critical influence that families

played in helping care staff to understand the residents’ needs and preferences.

Decentralised decision-making

The promotion of a ‘yes culture’ was intended to decentralise decision-making to direct

care staff, by encouraging these staff to say ‘yes’ to the residents’ simple requests,

rather than waiting for their manager’s approval to fulfil these requests. Managers

admitted that relinquishing decision-making to direct care staff in response to such

requests would ‘bring a new management framework’ and would become the new

management ethos (Brooker 2007). This new management philosophy corroborates

what Cohen-Mansfield and Bester (2006) describe as ‘flexible management principles’

where staff are enabled to determine how to interact with residents to meet their

immediate needs at the time. In Kitwood’s world (1997a, p. 103), “... the organisation

has to find a way to set each person free to do his or her best work...”. “High quality

nursing work environments empower nurses by giving them autonomy and

accountability within their scope of practice, as well as support, resources and

opportunities to grow” (Australian College of Nursing (ACN) 2015, p. 9). To improve

resident outcomes, management structures needed to move away from traditional and

authoritative top-down decision-making process (Anderson, Issel & McDaniel 2003;

Chenoweth & Kilstoff 2002; Cohen-Mansfield & Bester 2006).

Quality care outcomes are also reliant on participatory management practices that

support diversity in staff thinking and staff inter-connectedness (Anderson, Issel &

McDaniel 2003; Jeon, Merlyn & Chenoweth 2010). These participatory management

practices allow staff to problem-solve and to develop self-organising systems

(Anderson, Issel & McDaniel 2003; Cohen-Mansfield & Bester 2006). The PCC project


outcomes were similar to those occurring in another Australian PCC study, which

produced positive benefits for aged care residents and staff “where PCC was able to

be implemented as planned, there was strong management support for the [PCC]

champions, and encouragement of flexible work practices and staff involvement in

decisions regarding resident care” (Chenoweth et al. 2014b, p. 9). This randomised

control trial of PCC also found that “person-centred care needs a workplace culture

that focuses on personhood... one that attends to the needs of clients, staff, and

managers, where decision-making is a reciprocal process...” (Stein-Parbury et al. 2012,

p. 420). Recognising the importance of also supporting staff’s personhood when

implementing PCC, Kitwood (1997a, p. 111) recommended that aged care

organisations “enable each member of staff to flourish in his or her own unique way” (p.

111). This process was a feature of the organisation’s approach to the PCC change

management process.

Removing ‘us-them’ barriers

The ‘yes culture’ adopted by the project’s steering committee and the managers is

congruent with Kitwood’s (1997a) description of a care organisation where the ‘us-

them’ barriers are removed. The senior managers identified that the ‘yes culture’ would

be ‘confronting’ to some of the middle managers, since they ‘would have to be

prepared to make changes’ and work ‘outside a controlled environment’.

Corresponding to the introduction of this management ethos, structural alterations were

introduced at head office, such as removing private offices and designated parking

spaces for senior staff. With leading these changes at the executive level of the

organisation, the central, or head, office was to be viewed as the ‘support centre’ with

minimal imposition on facility managers. One manager considered that these changes

may appear to be symbolic, but ‘they were things that had to be dealt with’, in keeping

with the move to deinstitutionalise as many aspects of organisational services as

possible. “The new culture brings people of very different kinds together onto common

ground, and seeks to minimize all those us-them barriers that prevent real meeting”

(Kitwood 1997a, p. 135).

In agreement, studies have also identified that the success in implementing PCC

warrants deinstitutionalising organisations where decisions are made closer to where

care is provided (Brownie 2013; Crandall et al. 2007; Harris, Poulsen & Vlangas 2006;

Shield et al. 2014). Despite attempting to deinstitutionalise some aspects of the

organisation systems, the steering committee determined that the ‘us-them’ barriers

could be partially broken down by having senior managers wear the new staff uniform


rather than civilian clothing. This particular policy change aimed to challenge the

managers’ and staff’s expectations of the traditional bureaucratic structure of an aged

care organisation (Kirkley et al. 2011; Kitwood 1997a). To embrace a person-centred

organisational culture, all staff must be prepared to take risks and to challenge the

status quo (Kirkley et al. 2011; Loveday 2013). The new culture aimed to breakdown

the division between senior and middle managers and front-line staff, which would

otherwise engender divisions between residents, families, and staff (Brooker 2007;

Kitwood 1997a). Taking steps like changing the manager and staff uniform policy,

aligns with Brooker’s (2007, p. 34) reminder: “If we encourage care practitioners to

adopt a person-centred approach without addressing the larger organisational context,

we are setting them up to fail”.

Breaking routines – Changing everyday practices

“... Grant me the serenity to accept the things I cannot change;

courage to change the things I can; and wisdom to know the

difference” (Niebuhr 1934)

With the aim to create a new organisational culture, one manager referred to the

elimination of traditional bureaucratic expectations as ‘getting rid of the noise’.

Organisational culture is described as the values, beliefs and climate of the collective in

the workplace, and the staff’s perceptions of their workplace and of their managers

(Langford 2009). “Dementia care leaders need to be aware of the power of group

norms and conformity” (Loveday 2013, p. 48). “Long-entrenched group norms [such as]

institutionalised routines” as Loveday (2013, pp. 44-7) explains, “are barriers to PCC

which leaders need to identify and dismantle”. Targeting these entrenched institutional

norms commenced with the process of dismantling established systems, considered

important in the past, that would impede the organisational introduction of PCC

(Loveday 2013). Kitwood (1997a, pp. 113-4) warned that staff can come to an

unconscious collective agreement, where “so long as the organisational structure

remains, their defences hold”.

In implementing PCC, the managers realised that staff needed to become more flexible

in their approach to service delivery (Cohen-Mansfield & Bester 2006). Suggestions

included delaying residents’ waking times, negotiating their showering times and giving

residents a two-hour breakfast period. These flexible arrangements have been found to

give choice to people living in residential care (Crandall et al. 2007; Shield et al. 2014).

Ultimately, the new culture meant a move away from staff dictated routines to an


attitude of doing what they [the residents] would like to do, and when they would like to

do it (Kitwood 1997a). Reinforcing these changed attitudes to service delivery, was by

way of managers providing praise to staff whenever they observed staff being more

flexible in service delivery. Stein-Parbury et al. (2012) identified that the implementation

of PCC was most successful when managers encouraged staff to be flexible, allowing

them to contextualise change in their work schedules.

Managers also recognised the importance of developing positive staff-resident

relationships, most keenly identified by the way care staff conversed with the residents

during daily care. Managers postulated that staff could encourage relationship building

with and between residents by striking up a conversation during daily routines, such as

when assisting people with meals, or by encouraging them to reminisce when being

showered. By developing these relationships care staff had the opportunity of

understanding how each resident wanted to live their life day by day. Staff came to

appreciate that it was acceptable to stop what they were doing and have a chat, a hug

or a cup of tea with a resident. Forming such relationships had social benefits for the

residents. Managers recognised that when staff developed relationships with residents

they were able to gauge from the resident’s nuances if something was wrong. Rather

than staff simply acknowledging a person wasn’t happy today, managers praised staff

for taking a step forward by developing relationships with residents and attempting to

find the cause of the resident’s unhappiness. No longer were they walking away when

the basic tasks were completed (Kitwood 1997a); they were now attending to a

resident’s feelings by identifying the person’s state of well-being or ill-being (Loveday

2013). Thus, the PCC approach to care involved staff working together to understand

and acknowledge people’s feelings (Jeon et al. 2011).

Reconceptualising Dining Experiences

Managers spoke of changes that occurred across the organisation’s departments, such

as catering and laundry. The way in which meals were offered to residents was a focal

point for many managers. They were critical of the way in which residents were

expected to wait outside the dining room until permitted to enter by servery staff.

Managers outlined the difficulties encountered with the servery staff, perceiving them to

be ‘stuck in their old ways’. Managers also sensed that the servery staff thought their

role was ‘just serving the food’. Managers, however, believed that the way they

arranged and served meals had a direct impact on the residents (Bennett et al. 2014;

Reimer & Keller 2009).


While food was externally prepared and then reheated within the facility, changes to

this process included in-house cooking of vegetables in woks to bring out the aroma in

order to stimulate the residents’ appetites. In addition, an initiative that helped with

dining experiences was having a staff member sit with a newly arrived resident during

their mealtime in the first week of their stay. As well, the residents’ visitors were invited

to stay for meals so as the resident didn’t feel alone in their new surroundings. These

new approaches to dining room experiences had a very positive impact on the

residents’ well-being and satisfaction with the catering department.

Twelve months after the commencement of the organisational change project, the

PCECAT reassessments of the extent to which PCC was occurring in dining

experiences identified improvements in breakfast delivery. In Unit 1, breakfast time was

extended to two hours and residents no longer had to wait outside the dining room

before being allowed to enter by servery staff. In Unit 2, the PCECAT results show that

twelve months after project commencement, there were improvements in the dining

experience for residents and their visitors. With pleasant music playing in the

background, meals were now being offered on the balcony, allowing external dining for

residents and their families. Additionally, visitors could now make refreshments for the

residents and themselves in the kitchenette, which was newly established in the lounge

room. These positive changes to mealtime experiences occurred as a result of a

change of attitude by managers, as well as the catering and servery staff, to “value the

social aspect of meals and find ways to honour residents as individuals... Mealtimes

that are focused merely on meeting residents’ physical needs fail to support all aspects

of personhood.” (Reimer & Keller 2009, p. 328)

Refocusing care planning

Managers spoke of the new way of thinking about the purpose of resident care. Care

priorities focused on quality of life experiences, in contrast to the previous pre-

occupation with market research, property development and regulatory compliance.

“The organisation has to find a way to set each person free to do his or her best work”

(Kitwood 1997a, p. 103). The ‘yes culture’ provided the means to release nurses and

care staff from the onus to be efficient above all else. To reconceptualise the focus of

their work, they had to be prepared to make changes and get rid of this ‘noise’ from the

past.

As a next step to ‘getting to know the person’ managers spoke about how knowledge

of a person’s life story, and their abilities and preferences, was disseminated among all

staff. Importantly, the managers’ goal was to “enable staff to learn about individuals


and personalise their care” (Loveday 2013, p. 42). Managers spoke of developing an

improved format for the current care plan. The care planning process was seen as a

valid means of developing personalised approaches to meeting people’s psychosocial

needs, and has been used as a training method in studies that have introduced PCC in

residential aged care facilities (Chenoweth et al. 2014b; Stein-Parbury et al. 2012).

Two issues identified by managers regarding care planning centred on the fact that

care planning for the previous twelve months had been undertaken on a computerised

program which restricted care staff from accessing personalised resident information.

There were no electronic devices available in residents’ rooms to give care staff access

to vital care information, despite the opportunity for all these staff to obtain this

information from the centralised system. An additional difficulty of computerised care

plans was the drop-down pre-defined menu selections to assist care planning. Contrary

to a person-centred care planning process, these pre-populated options restricted staff

from developing individualised interventions in accordance with the person’s abilities,

strengths and needs (Brooker 2007; Loveday 2013).

As a result of this restrictive feature of computerised care planning, the PCECAT data

collected after the change process commenced revealed that identical documented

care approaches featured across a number of different residents’ care plans. Although

the computerised system was introduced to streamline the care planning process for

efficiency reasons (Donabedian 1966), it restricted individualising care planning. This

reliance on pre-programmed care planning processes begs the question of whether

computerised care planning programs conflict with person-centred care principles

(Dahm & Wadensten 2008). The PCECAT assessment of resident care planning

indicated that recreation/lifestyle activity plans omitted to include the residents’

personal information, which was available in other documentation systems, such as the

‘Key to Me’ profile data. Clearly, changes in care, lifestyle planning, processes and

systems were a key initiative to facilitate PCC across the organisation.

Introducing the new resident to the facility

Another new initiative focused on learning about each resident during his or her first 28

days living in the facility. Prior to a person’s arrival at the facility, an interview was

conducted with the resident and/or their representative to find out as much about the

person’s life as possible. Having this information was considered to make a huge

difference to helping settle new residents into their new home, particularly if the person

and their representative (usually a family member) were able to recognise someone

from the organisation before they were admitted to the facility. Moving away from


simply completing clinical and administrative paperwork, the admission focus changed

to getting to know the person, to understand their social and psychological needs, as

well as their physical health needs (Brooker 2007). New residents were asked what

their normal day was like since, “understanding a person’s past history is crucial to

providing person-centred care for people” (Brooker 2007, p. 58). A new staff role was

created to assist with this process, and became central to helping the new resident and

their representative to feel more at home on arrival to the facility.

On admission, the staff member’s familiar face greeted new residents, where he

oriented them to the layout of the facility, to their room and the staff who would be

caring for them. The staff member would introduce the new resident to other residents

and organise their seating in the dining room. If visitors accompanied the new resident

they were asked if they would like to stay for a meal. The staff member also dined with

the new resident for their first meal, so they wouldn’t feel alone and overwhelmed by

the group dining experience. Utilising a spontaneous approach and conscious of

making the resident feel comfortable, this staff member spent time with the new

resident and their representative to find out how the resident wanted to spend their

days in the facility. This new role became a much-valued aspect of the change

process, and it inspired other staff to take the time to get to know their new residents

and form friendships with them. Gaining information about the resident’s leisure

preferences was also a feature of this staff member’s role.

Recreational Activities

Recreational activities and how they were being offered to people was an area under

review during the PCC project. While commenting on staff titles, one manager

suggested a new approach to the naming of staff roles and questioned whether the title

‘diversional therapy’ was person-centred. These comments reveal that project

participants were raising questions in relation to recreational/diversional activities that

were provided for residents. In addition, during the project a review was conducted on

the type of personnel who were leading the recreational lifestyle activities program.

Brooker’s (2007) perspective on the value of recreation/lifestyle programs suggests

that activities which stimulate engagement and fun can be a shared responsibility

across all categories of staff, and that these programs are best not to be confined to

one particular group of staff. A study investigating the benefits of introducing humour in

aged care facilities, found that when care staff engaged in fun and laughter with

residents in their day to day care, there were positive benefits for the residents and

staff alike, and humour helped to create a more productive, enjoyable environment for


both groups (Chenoweth et al. 2014a). While there were no specific strategies

implemented for improving the Lifestyle program during the project, suggested

changes were aimed at promoting a sense of ‘spontaneity’, rather than expecting

events to be pre-planned. This is in keeping with Kitwood’s (1997a, p. 103) views

where “Caring, at its best, springs from the spontaneous actions of people who are

very resourceful and aware”. It seems that the suggested changes in approach to the

recreational activities/lifestyle programs were adopted in Unit 1, since the PCECAT

data identified a strength in the program, twelve months after the project’s

commencement, where: a newly formed recreational team were eager to further

respond to the individual needs and wishes of people living in the home.

Reflective Practices

Improved communication between staff with different roles was also identified to have

occurred 12 months after the PCC project commenced in Unit 1, according to the

PCECAT scores. One of the strengths noted on the PCECAT was that: reflective

practice sessions involving life stories of those people living in the home are being

conducted each week with care and leisure and lifestyle staff in attendance. The

reflective practice sessions were found to provide an opportunity for nurses and care

and lifestyle staff to gain greater insight into the needs and experiences of the whole

person. Yet, this positive process seems to have not been occurring at shift handovers.

The PCECAT data divulged an area for improvement relating to shift handovers,

whereby with further education, staff would learn to utilise shift handovers to share their

knowledge and discuss both the psychosocial and clinical needs of people living in the

home. At interview, one manager admitted that there had been no consideration to

include recreational/diversional staff in shift handovers. It was apparent that the

organisation’s shift handover system was clinically focused, and needed to be

reconceptualised to focus on holistic resident care and daily life activity.

Valuing staff

This organisational promotion for a new management and care philosophy was not an

end in itself, but a means of empowering nurses, care and recreational staff to be

flexible in their routines, and this was most evident in regard to a changed focus of the

shift handover (Loveday 2013). When referring to the “cultural change” one manager

expected the ‘yes culture’ liberated staff to do what they knew is the right thing to do.

He explained how staff needed to take a completely different direction in care, to one

where they did what came naturally to them when discussing the daily care and


lifestyle needs of each resident. Proffering similar views, another manager advised that

by giving staff the freedom to act with discernment, they were encouraged to invest

more time in understanding the residents’ unique needs. In doing so they would have

improved knowledge on knowing how to allay the residents’ concerns, attend to their

needs and improve opportunities for enabling resident well-being. “If a care service is

person-centred, this means that it values each and every person involved with it –

everyone matters” (Loveday 2013, p. 19). PCC advocates (Cohen-Mansfield & Bester

2006; Edvardsson et al. 2011; Kitwood 1997a; Loveday 2013) subscribe to these

sentiments, suggesting that by validating staff members’ responsibilities to ‘know the

resident’, such as by allocating sufficient time and giving guidance when conducting

shift handovers, direct care staff will be more motivated to provide a person-centred

approach to care.

Supporting managers and staff to implement PCC

Initially three key roles were created to support managers with their implementation of

PCC during the project. A registered nurse was employed to work with management to

train staff in PCC; another role was created to aid in the project’s strategy of

introducing new residents to the facility; a third position was created to free a front line

manager to focus on PCC implementation. Importantly, these new roles didn’t operate

from an individual agenda but within the strategic goals of the change project. Neither

was it a strategy dictated from the top management; rather, a team approach was used

as people in the new roles assisted and supported managers’ implementation of PCC

across the organisation. Loveday (2013) and Brooker (2007) describe how managers

can either feel stuck in a rut or overwhelmed when introducing quality programs. They

feel that more is expected of them (Jeon, Merlyn & Chenoweth 2010), Therefore,

“The ability of nurse ... leaders to balance conflicting demands and

provide effective leadership depends not only on their preparation

for leadership roles, but also on the organisational support and

recognition they are given in terms of time, resources and

personnel.” (Australian College of Nursing (ACN) 2015, p. 10)

The managers were asked at interview how they foresaw front-line managers

balancing the ‘business as usual’ with the task of implementing new strategies within

the PCC project. In their response managers appreciated the organisation’s decision to

create a position for an interim manager to take responsibility for ‘business as usual’,

replacing the front-line nurse manager who was directly involved in the project. Without


this substitute manager, the front-line manager would have been distracted from the

responsibility to introduce PCC in the two care units which elected to participate in the

first phase of the project. Her replacement by another manager during the project

relieved her from the day-to-day matters that warranted immediate attention as a front-

line manager, such as: replacing staff; collating and submitting data to central office or

funding bodies; internal and external agency audits, surveys or research; responding to

complaints; and providing systems management. Opportunities to be leaders of

change are limited by the demands that absorb managers’ time and energy (Duffield et

al. 2011; Jeon, Merlyn & Chenoweth 2010), so it was essential that a dedicated

managerial position be installed to oversee the project at an early stage.

Additionally, as previously described, a new staff role was trialled during the project

spanning across three departments ‘Leisure & lifestyle, Chaplaincy and Clinical’. It was

a brave endeavour where ‘spontaneity’ and ‘creativity’ (Kitwood 1997a) were the initial

directives assigned to the position. The person was recruited specifically for this role

was able to participate in resident support across all three portfolios. Managers spoke

about giving themselves latitude with the role, before pinning the role down to a

specific job description. This approach is in keeping with Loveday’s (2013) advice that

PCC is highly flexible, whereby staff sharing the same vision are encouraged to

explore ways of fulfilling the organisation’s goals.

Freeing front-line managers

Provided with resources and guided by goals, front-line managers were equipped with

the flexibility and freedom to adapt the PCC strategies being implemented to suit their

own facility’s requirements (Cohen-Mansfield & Bester 2006). In Australia, it is

recognised that the nurse manager role is pivotal in communicating the organisational

values and protocols (Australian College of Nursing (ACN) 2015; Jeon et al. 2010b).

Empowered through the organisation’s ‘yes culture’ front-line managers were

encouraged to be spontaneous and creative. While they were expected to implement

core organisational goals, these managers were given the opportunity to adapt the

PCC concepts to idiosyncratically suit individual care units in their facilities. This

prospect fits into ‘self-organising systems’ (Anderson, Issel & McDaniel 2003; Cohen-

Mansfield & Bester 2006). Anderson et al. (2003), (Cohen-Mansfield & Bester 2006;

Jeon, Merlyn & Chenoweth 2010) refer to ‘self-organising systems’ to explain, that in

organisations with management principles espousing the ‘yes culture’, managers and

staff are able to individualise problem solving.


The empowerment of the managers to facilitate a ‘yes culture’ helped them to

overcome what Brooker (2007, p. 36) described as, “... find[ing] the resources to meet

minimum standards of basic physical care ... [can] grind leaders down over time...

[diminishing] the personhood of those in leadership positions”. As such, “Empowered

nurse leaders who have influence within the organisation can also secure additional

resources or improved working conditions for nurses...” (Australian College of Nursing

(ACN) 2015, p. 10). Guided by the organisational goals and the change management

systems, the front-line managers reasoned they would be able to ‘self-organise’ the

implementation of PCC concepts in their own facilities. Leadership training research

shows that managers are able to embed organisational change-management

processes within a supportive PCC organisational framework if they have the support

of the senior management team.

“The development of sustainable, effective aged care leadership

and management needs to be located in collaborative,

communicative and flexible approaches, informed by systematic

communication protocols and procedures...” (Jeon et al. 2013, p. 8)

Recruitment and staffing consistency

“In order to meet the many care and support needs of older people

and their families, it will be increasingly important for aged care

services to attract, retain and effectively manage aged care

personnel, as well provide sound organisational governance. Middle

managers are pivotal to achieving these goals. Middle managers in

contemporary aged care need to be able to both lead and manage

aged care services to optimise outcomes for older people.” (Jeon et

al. 2015, p. 1008)

A significant feature of the change process that was identified in the manager

interviews was the way in which managers set about recruiting staff. As advised by the

Australian College of Nursing (2015, p. 4) “Nurse leadership will be vital to retaining

and developing Australia’s nurse workforce”. Important to the change process towards

creating a person-centred system, managers now had the autonomy to directly

interview and employ staff, as distinct from the past procedure of accepting staff

previously screened by the organisation’s recruitment agency. Selecting staff was now

based on the applicant’s attributes, including their attitudes towards older people, and

aged and dementia care, rather than merely on their previous experiences in these

areas of work (Kitwood 1997a). Although some recruits may have been new to aged


and dementia care and potentially lacking the knowledge and skills for this type of care,

the reasoning was that training could be provided on the job when the right attributes

were inherent to the person. Managers also reasoned, that very often, experienced

recruits can be equipped with attitudes contrary to a person-centred approach.

Concurring with this view, Kitwood (1997a, p. 113) warns that with “well-qualified

professionals, there is actually the task of ‘unlearning’ to be undertaken, because they

have absorbed the pathologising and distancing attitudes”. Alternatively, Kitwood

(1997a) recommended that people should be employed in dementia care work only if

they can demonstrate that they have the right attitude in caring for people with

dementia.

One manager expressed satisfaction with this new process when observing a new staff

member communicating in a person-centred way with a resident while assisting with

her meal. In determining staff applicants’ attitudes towards the people who they would

be required to care for, the managers began to utilise new interview techniques, such

as asking applicants to describe what they would say and do if a resident didn’t want

something for lunch. Referred to as the ‘psychological contract’ (Handy 1976), Kitwood

(1997a, p. 113) asserted that the ideal attainment in recruitment is where employees

and employers can develop a mutual agreement where, “... there is a match between

what the employee is wanting and expecting, the employer’s requirements, and the

real situation in the workplace”.

The new approaches in recruitment that occurred during the PCC project took into

account the organisation’s preference for staffing consistency, while also respecting

the employee’s preferences. In achieving these goals, the managers implemented

recruitment and retention strategies which aimed to ‘get more full-time and less part-

time’ staff. Attempts were made to employ people who would work a minimum of three

shifts per week and to negotiate with existing staff to take on more hours each week.

Managers wanted to move away from the current employee profile where 60 per cent

of the staff members were part-time workers, indicating that each resident was likely to

be cared for by at least six to seven different staff members in a week. In areas of care

where residents were cognitively impaired and/or vulnerable to staffing variability, the

attempt to gain more consistent staffing in individual care units was guided by PCC

principles (Kitwood, 1997).

Another strategy, also aimed to attain staff consistency, involved staff being allocated

to work permanently in particular sections of the facility, rather than being regularly

rotated through different sections. Managers believed that this strategy supported the


development of relationship-building between residents, their relatives and staff, and

between managers, staff and colleagues. As Loveday (2013, p. 55) advises where

there are organisational policies that require staff to regularly rotate around units, the

outcome is likely to destroy “the possibility of residents growing to trust and feel safe

with care staff they [get to] know”. Concurring with Loveday’s recommendation,

research has identified staff consistency as another management practice supportive

to the implementation of PCC in a residential aged care facility (Brownie 2013; Shield

et al. 2014). Additionally, while not acknowledged by managers at interview, staff

advised during the PCECAT assessments that they were more likely to be satisfied in

their work when given the opportunity to get to know their residents. In turn, they

reasoned that consistent placement would help them to develop and maintain

satisfying relationships, a workplace feature that Chenoweth et al. (2014c) discovered

frequently draws staff to work in aged care.

Aligning education and recruitment

“Too often training is seen as an end in itself... What’s important

though is not that staff are exposed to training but that they actually

learn from it... staff will benefit from training if it is one component in

a wider strategy of development, rooted in a consistent philosophy

that is reflected throughout the care service” (Loveday 2013, pp. 84

- 6).

The new educational approach to the PCC project intended to have staff understand

the importance of embedding the organisation’s goals in service delivery. To support

this philosophical shift, the new educational approach moved away from didactic

classroom training to a ‘blended’ methodology. A new PCC education program, called

Evolve, was tailored to focus on the needs of staff, addressing what was described as

the top 20 capabilities that people need to fulfil that role. Concurrently, to address

individual staff learning needs, personal development plans were introduced and skills-

training was provided on the job. The new registered nurse educator, working

alongside managers to achieve the organisational PCC goals, integrated these training

initiatives into the change process. When staff are supported with a PCC organisational

framework they are more likely to learn from their training and be enabled to implement

their learning (Brooker 2007; Chenoweth & Kilstoff 2002; Jeon, Merlyn & Chenoweth

2010; Stein-Parbury et al. 2012).

The proposed new educational philosophy and approach was aligned to the new staff

recruitment process, with both focusing on staff attributes, attitudes and capability


development. The new educator’s role was aligned with the organisation’s overall

mission whilst supporting direct care/service staff. As such, the educator had an

influential role with all direct care staff, bedding down practices that were in keeping

with a person-centred approach. Rather than focusing solely on technical skill

development, such as making beds and transferring residents, staff members were

given education and skills in how to develop relationships and to have conversations

with residents and families, and how to communicate effectively with their colleagues.

One manager described the importance of having an educator who was able to offer

training for the management team, while also understanding the learning needs of staff

members ‘on the ground’, thus ensuring that all members of the organisation obtained

appropriate education, training and learning support.

In order to achieve the PCC project goals, it was important for the organisation to

employ the right mix of staff with the right skills for the work they undertook. The newly

adopted outlook engaged the person with the right attributes and attitudes

commensurate with PCC. Training focused on individual staff needs and the

capabilities considered necessary to fulfil their different roles. One manager

emphasised the requirement of communication skills, particularly in relation to staff

learning how to develop relationships with their residents, by striking up conversations

with them during day-to-day service delivery. The language and the expectations in the

position descriptions for different staff roles were subsequently revised to align with the

change project’s emphasis on showing empathy towards residents, embedding the

organisation’s values in care practices and using person-centred communication in all

aspects of service delivery.

Moving from compliance to commitment

“... An important moral imperative [is] to ensure that our healthcare

organisations are led by individuals and teams who display

relational skills, concern for their employees as persons, and who

can work collaboratively to achieve a preferred future for

themselves, their employees, their patients and their organisation.”

(Cummings et al. 2010, p. 381)

This study has identified that the plan to implement PCC was led by the organisation’s

senior managers and given the CEO’s and the Board of Directors’ stamps of approval.

Managers recognised early in the change process that they had to ‘get rid of the noise’

and start ‘thinking differently’. Studies reveal that organisational leadership is an

essential ingredient to the successful implementation of PCC in a residential aged care


facility (Brownie 2013; Crandall et al. 2007; Jeon, Merlyn & Chenoweth 2010; Miller et

al. 2010; Shield et al. 2014). Crandall et al. (2007, p. 54) have described this

organisational culture as ‘warmed the soil’. Frequently aged care organisations advise,

that maintaining compliance with government regulations inhibits the culture change

that PCC demands (Brownie 2013; Crandall et al. 2007; Shield et al. 2014).

Conversely, consumers and health professionals perceive that the barrier to PCC lies

with organisational commitment and leadership (Miller et al. 2010; Productivity

Commission 2011; Shield et al. 2014).

In planning to implement PCC senior managers identified that the organisation had to

change its focus away from compliance to a set of rules, to strategically aiming to build

commitment to ‘change peoples’ lives. A balance needs to be achieved between

compliance, given the perennial government regulatory demands placed upon aged

care facilities (Jeon et al. 2010a), and the practicalities of introducing PCC

management strategies. PCC calls for staff and managers to be given the freedom to

be creative, spontaneous and responsive to people’s needs (Brooker 2007; Kitwood

1997b; Loveday 2013). Avoiding crisis management responses (Nelson & Cox 2003),

managers implemented creative strategies with planning and forethought. When staff

and managers made pancakes with residents, described as ‘pancake rage’, food safety

precautions were addressed in preparation for the event. In the same way, the

government’s documentation requirements to validate Commonwealth aged care

funding (Commonwealth Department of Social Services 2014) was incorporated into

changes made with reformatting care-planning. While ‘getting rid of the noise’ of

traditional ways of thinking, managers found the means to harmonise regulatory

requirements without kerbing creative initiatives. As Van Wart (2013, p. 561) notes,

“To lead change does not require charisma, but it does require

basic managerial or transactional competence, a clear sense of

what must be accomplished with the ability to let change evolve,

and the ability to distinguish among differing bottom-up, top-down,

and centre-out strategies.”

Senior managers committed themselves to tackle the intricate interactions of policies,

regulation, workforce, culture and financial stewardship to ensure a sensible balance

between compliance matters and securing PCC improvements (Australian College of

Nursing (ACN) 2015). “Effective management of complex environments requires

leadership...” (ACN 2015, p. 7). Assuring a future of checks and balances, the steering

committee utilised the organisation’s own continuous improvement methodology to


check the progress of initiatives. PCC leadership calls for repetitive reviews of the

effectiveness of interventions to understand what worked and learn why things don’t go

well (Brooker 2007; Carmeli, Tishler & Edmondson 2012; Kitwood 1997a; Love & Kelly

2011). As Crandall et al. (2007, p. 54) explains, organisational commitment to PCC

requires “systems to support and sustain practice changes … including ongoing

education, policies and procedures and job descriptions”.

In creating an organisational framework for the PCC project, partnerships were

developed across all departments, thus removing the internal silos that had previously

existed (ACN 2015). Senior managers aimed to share the organisation’s commitment

through the project’s goals (Loveday 2013). As Van Wart (2013, p. 561) advises,

“Good leaders can ill-afford to have ‘out’ groups”. By adopting emotionally intelligent

leadership approach managers can model organisational values (ACN 2015;

Hutchinson & Hurley 2013). Managers’ use of this transformational leadership style

was exemplified when they sought staff members’ ‘buy in’ to the change process and

when challenging staff to ‘think outside the square’. Collaborating in this way, through

consultation and evaluation, is linked with the mentality of leaders who are prepared to

serve (Russell & Stone 2002; Van Wart 2013). “Leaders in collaboration tend to have a

particularly strong service mentality and tend to excel at consultation and

environmental evaluation” (Van Wart 2013, p. 559).

Every senior and front-line manager within the organisation became committed to the

PCC project and recognised their leadership role in its implementation. Organisational

commitment to ‘successful change and sustainable change’, warrants managers to

‘Imbibe and lead’ the change process calling upon them to take on transformational

leadership practices (Australian College of Nursing (ACN) 2015). This relationally-

based leadership style, focusing “on people and relationships to achieve the common

goal” (Cummings et al. 2010, p. 364), is considered most suitable when introducing

organisational changes (Carmeli, Tishler & Edmondson 2012; Cummings et al. 2010;

Hurley & Hutchinson 2013; Hutchinson & Hurley 2013; Russell & Stone 2002; Van

Wart 2013). As the senior managers were committed to establish an organisational

framework to support PCC (Brooker 2004), it was imperative for them to use

transformational leadership which, as Van Wart (2013) suggests, is most appropriate

when “instituting [organisational] changes in structure, procedure, ethos, technology,

and production” (pp. 557-8). The organisation’s commitment to PCC ensured all the

managers were equipped and empowered with transformational leadership training,

embedded within the organisation’s policies and systems (Jeon et al. 2013).


As testament to the organisation’s PCC commitment the ‘yes culture’ and a variety of

training initiatives were introduced empowering staff and managers to work effectively.

Van Wart (2013, p. 561) advises that these processes, ensuring “people have what

they need to do their job”, are prerequisites for leaders intending to make

transformative organisational changes. This perspective correlates with studies

highlighting that job satisfaction and staff commitment links with ‘good’, supportive and

flexible management practices (Chenoweth et al. 2014c; DeCicco, Laschinger & Kerr

2006; Jeon et al. 2011). Importantly, Van Wart (2013, pp. 561-2) advises, “the specific

and practical challenges of leadership evolve and change significantly over time” in

response to the demands placed on managers. Managers, therefore, need to balance

good management practices, ensuring compliance with regulatory requirements, with

the transformative leadership skills to make improvements to the quality of care for

people living in residential aged care facilities.

Summary

With the increasing prevalence of people living with dementia and the prediction that

baby boomers will want improvements to the quality of residential aged care services,

organisations cannot look to a future where they provide more of the same

(Productivity Commission 2011). Across the world PCC is recommended as the most

appropriate model of care for people living with dementia (Alzheimers Disease

International 2013). Considered as stumbling blocks to the willingness of aged care

organisations becoming person-centred, consumers and governments expect these

organisations to find flexible, economical ways to balance regulatory compliance and

the commitment to continuous improvements (Shield et al. 2014). Studies have shown

that PCC is cost effective and improves outcomes to residents and staff job satisfaction

(Chenoweth et al. 2014b; Chenoweth et al. 2009; Jeon et al. 2011). Research has

provided the insight into the conditions that support person-centred practices whereby

managers and organisations have to embed PCC through a systematic approach

across the whole organisation (Stein-Parbury et al. 2012). The organisation central to

this research study was found to be committed to review their operational systems,

changing everyday practices and develop an organisational framework that supports

the organisation’s PCC Vision to change peoples’ lives.

Older Australians deserve the best quality care (Australian Nurses Federation 2009)

and this can only be achieved with a skilled and satisfied workforce (Aged Care

Workforce Committee 2005). Enriching the daily lives for people living in residential

care was achieved when staff and managers were enabled with decision-making


authority and leadership skills. Enlightened with common goals, an organisational

culture that has “warmed the soil” (Crandall et al. 2007) and a flatter hierarchical

structure (Brownie 2013), such as the yes culture described in this study, managers

and staff were freed to flexibly respond to individual resident needs and to help direct

care staff to develop relationships with the people in their care (Cohen-Mansfield &

Bester 2006). With PCC leadership and a change management process, a Continuous

Improvement methodology, nurse managers were able to lead the drive to implement

PCC models of care (Australian College of Nursing (ACN) 2015) and contextualise

PCC within each residential aged care facility (Stein-Parbury et al. 2012).

Limitations and Strengths

Limitations

The management strategies identified in this study were applied in two care units

located in one residential aged care facility of a large aged care provider organisation.

Subsequently, it is not possible to generalise the findings about the change process to

other aged care facilities that will likely have quite different organisational structures

and management systems. Additionally, since the aged care provider organisation is a

large one, it had the advantage of being able to support the change process with the

allocation of additional resources because of its economies of scale. Thus, the

organisation-wide strategies that enabled this project might not be possible for smaller

aged care facilities with reduced infrastructure support. Because the organisation was

able to release senior managers to lead the project, it was possible to have the

managers identify their plans and set in place processes for change at the

commencement of the project, which helped to embed PCC from a very early stage. In

smaller organisations where the senior managers are fully involved in the day-to-day

system operations, this might not be possible. While the PCECAT quantitative data

provided indications of improvement the identified strengths were limited to what

managers advised at the time of interview.

Another limitation was the administration of the post-intervention PCECAT by the

organisation’s own team of managers. The researcher was unable to gain direct

access to the individual PCECAT item scores 12 months after the change process

commenced, even though the summary domain scores were made available to him.

This subsequently limited full analysis of individual PCECAT item scores that had

changed 12 months after the change process had commenced. Qualitative analysis of

field note data was, thus, limited to some PCECAT items, and were constrained by

manager-collected reports of changes occurring.


Strengths

This study provides important insights to the change management processes actioned

by one aged care organisation in their goal to embed person-centred principles into key

areas of care services. As noted, the organisation had seven project teams tasked to

develop priority improvements. These project teams comprised, Food, Human

Resources, Clinical Care, Dementia Care, Recreational/Lifestyle therapy, Environment,

and Spirituality. The process continues for this organisation, whose senior managers

remain fully committed to this goal and their mission to make services align with the

changing needs of individual residents and the changed expectations of aged care

communities. In this study, interview data were obtained from senior managers at one

point of time in the organisation’s project, and augmented by data obtained on service

quality in two of the organisation’s care units with the Person-Centred Environment and

Care Assessment Tool (PCECAT) and associated field notes. These different sources

of data provide a good view of how an aged care management team can lead change

across an organisation by embedding a philosophical approach to care services in

many different aspects of the organisations’ operations.

This investigation of change towards a person-centred system allows an examination

of the multi-layered structural factors that need to be negotiated at a system-level to

enable organisational change. As there is much speculation on how to embed

evidence into practice, this study gives some clear indicators of how this might occur.

Changes that were made not only required executive approval, cooperation and policy

changes, but also required middle manager and staff cooperation and a willingness to

reconceptualise staff roles and responsibilities. The evidence of success in addressing

the many factors that potentially prevent organisational reform, as identified with the

PCECAT assessments, indicates that many of the project’s novel innovations were

effective. While this study was unable to continue beyond 12 months, follow-up

communication with the managers involved in the PCC project suggests that the reform

process and positive outcomes are continuing. Where research has acknowledged

management responsibility in promoting person-centred practices this study has

provided the managers with a voice to express what strategies they used to implement

PCC.

Conclusions

This study of planned management strategies to support the implementation of PCC in

a residential aged care facility has provided insight into the actual management


strategies that support PCC practices in a residential aged care facility. The managers’

strategies have been linked with PCC quality improvements. It is clear that the call for a

“culture of care” was much easier to achieve when PCC is launched with organisational

leadership embedding PCC within an organisational framework. Although PCC

advocates for leadership at all levels, the best intentions and enthusiasm from

managers and staff will face a battle without the broader organisational support.

Direct care staff and managers were empowered and enabled to be responsive to

peoples’ needs with a new organisational culture strategy described as the ‘yes

culture’. Organisational leadership was exemplified with the steering committee

creating a toolkit change process through a continuous improvement methodology.

Continuous improvement oversaw structural changes in the organisation’s systems,

processes and procedures.

It is clear that in order to successfully and sustainably implement PCC in a residential

aged care facility, this organisation made a commitment beyond words in a brochure.

There was a strategic decision to develop a supportive PCC framework across all its

systems; a move away from the fixation of complying with a set of rules and a market-

responsiveness approach. Everyone in the organisation was asked to think differently

and adopt a vision for a future where, through addressing peoples’ needs, they were

bold enough to believe they would change peoples’ lives.

Implications and Recommendations for further research

Implications

With residential aged care organisations expected to improve the quality of their care

services, PCC is considered a viable, gold standard model to care for people living with

dementia and within residential facilities. As witnessed in this study the successful

embedding of PCC warrants organisational commitment to resources and operational

changes. This will involve reviewing structural factors, such as policies, procedures and

systems, across the whole of the organisation’s services with the aim of assisting in

person-centred practices.

If organisations want to be truly committed to person-centred care they ought to

enhance the organisational culture where decisions can be made as close to the

residents as possible. Direct care staff should be given the capabilities to discern

what’s right for the person in their care. Training opportunities will accompany

organisational systems in order to optimise staff empowerment.


Managers are considered the culture carriers in organisations. In order for managers to

promote person-centred principles, organisations should equip their managers with

leadership skills and the legitimate authority to flexibly introduce the necessary

changes in their residential aged care facilities. Concurrently, managers should adopt

human relation based leadership styles to cultivate a satisfied workforce that

consequently reaps collaboration and commitment.

Recommendations for further research

With the aim to understand the management strategies that support person-centred

care in a residential aged care facility, this study was conducted in one facility in a

relatively large aged care organisation. Future research with similar aims is

recommended where studies are undertaken in smaller organisations or over a number

of residential aged care facilities. In this way, the implications gleaned from such

research could be generalised across a broader range of facilities. It would also be

beneficial for the residential aged care community that studies are trialled over longer

periods thereby assisting to further understand the effectiveness of management

strategies that promote person-centred care.

Chapter 7 – Appendices 123

Chapter 7. Appendices

Appendix A - UTS HREC Approval

From: Ethics Secretariat <[email protected]> Date: 14 February 2012 4:49:26 PM AEDT To: Prof Jane Stein-Parbury <[email protected]> Cc: Mr. Alexander Raymond Zarb <[email protected]>, Ethics Secretariat <[email protected]> Subject: Eth: HREC Approval Letter - UTS HREC 2011-478A Dear Jane and Alexander, Re: "Management strategies that support person-centered care in residential care" Thank you for your response to the Committee's comments. Your response satisfactorily addresses the concerns and questions raised by the Committee, and I am pleased to inform you that ethics clearance is now granted. Your clearance number is UTS HREC REF NO. 2012-478A You should consider this your official letter of approval. If you require a hardcopy please contact the Research Ethics Officer ([email protected]). Please note that the ethical conduct of research is an on-going process. The National Statement on Ethical Conduct in Research Involving Humans requires us to obtain a report about the progress of the research, and in particular about any changes to the research which may have ethical implications. This report form must be completed at least annually, and at the end of the project (if it takes more than a year). The Ethics Secretariat will contact you when it is time to complete your first report. I also refer you to the AVCC guidelines relating to the storage of data, which require that data be kept for a minimum of 5 years after publication of research. However, in NSW, longer retention requirements are required for research on human subjects with potential long-term effects, research with long-term environmental effects, or research considered of national or international significance, importance, or controversy. If the data from this research project falls into one of these categories, contact University Records for advice on long-term retention. If you have any queries about your ethics clearance, or require any amendments to your research in the future, please do not hesitate to contact the Ethics Secretariat at the Research and Innovation Office, on 02 9514 9772. Yours sincerely, Professor Marion Haas Chairperson UTS Human Research Ethics Committee C/- Research & Innovation Office University of Technology, Sydney Level 14, Tower Building Broadway NSW 2007 Ph.: 02 9514 9772 Fax: 02 9514 1244 Web: http://www.research.uts.edu.au/policies/restricted/ethics.htm UTS CRICOS Provider Code: 00099F DISCLAIMER: This email message and any accompanying attachments may contain confidential information. If you are not the intended recipient, do not read, use, disseminate, distribute or copy this message or attachments. If you have received this message in error, please notify the sender immediately and delete this message. Any views expressed in this message are those of the individual sender, except where the sender expressly, and with authority, states them to be the views of the University of Technology Sydney. Before opening any attachments, please check them for viruses and defects. Think. Green. Do. Please consider the environment before printing this email.


Appendix B - Research Introductory Letter

Anglican Retirement Villages – Farrer Brown Court, Castle Hill December 2012 Research Details: Title: Management Strategies that support the implementation of person-

centred care in residential aged care.

Student: Alex Zarb, UTS Masters (Honours)

Supervisors: Professors Jane Stein-Parbury & Lynn Chenoweth

Student’s background:

In 1985 I began my career in residential aged care working as a registered nurse. Since then I have held various management and education positions in both large and small charitable aged care organisations. Additionally, I worked as a Commonwealth Nursing Officer and in 2008/9 I assisted Lynn Chenoweth (Chief Investigator) at UTS as the research project manager for the PerCEN study. Currently I am the full time Director of Nursing for two aged care facilities with a total of 133 beds at HarbisonCare, a community organisation in the Southern Highlands of NSW.

UTS Ethics Approval

In February 2012 the UTS Health Research Ethics Committee study approved the proposed study (HREC Approval Reference - UTS HREC 2011-478A). Approval letter is available upon request.

Introduction to the Study

Person-centred care (PCC) has been shown to be effective in promoting well being for people living in residential aged care facilities (Chenoweth et al. 2009). PCC is not simply how individual carers relate to residents but requires a ‘whole of system’ approach that is supported by an organisational culture and management practices (Brooker 2007). However it is unclear what exact management practices are needed to promote and support a PCC approach. Therefore, research is needed in this area.

Aim and objectives:

The aim of this study is to explore management systems and strategies that support PCC in residential aged care facilities.

The objectives to meet this aim are to:

Select a residential aged care facility that is in the process of implementing PCC Assess the extent to which the services offered to the residents are person-centred; Explore management strategies, which support the implementation of Person-

centred Care through interviews with the managers of these facilities.

Benefits to the organisation and its staff


All staff working in the organisation will be provided with feedback in relation to the extent that their care and environment is person-centred. This feedback includes suggestions for improvements in person-centred care. Aged care managers will benefit by a clearer understanding of practices that support a PCC care environment.

Research Design and Data collection The sequence of data collection and analysis is as follows:

1. A purposive sample of one aged care facility (Farrer Brown Court) will be selected for the study based on the organisation’s intention to implement PCC principles and practices.

2. Semi-structured interviews with managers will be conducted to explore the support strategies that they plan to use in the implementation of PCC at this facility.

3. Person Centred Environment and Care Assessment tool (PCECAT) will be used to determine the extent to which the organisational culture and care practices are person-centred. (PCECAT & Guidelines – Appendices A & AA)

4. Data analysis will compare what managers say with the results of the PCECAT.

5. Steps 2, 3 & 4 will be undertaken at the start of the project and, again, 12 months after implementation of PCC at Farrer Brown Court. The managers will be interviewed every 6 weeks during the implementation period.

Selection Criteria & Consents Facility

ARV has selected Farrer Brown Court as the facility in which to implement a PCC approach. This study will form a part of the ARV Rhythm of Life project.

Staff

To complete the PCECAT the researcher will informally speak with staff members who are willing and available at the time. (Staff Information Sheet – Appendix B)

Residents, Relatives and/or Guardians

In using the PCECAT, the clinical documentation will be observed and reviewed. The clinical files will be selected based on those residents where consent has been gained to do so (Resident, Relative, and Guardian Information Sheet & Consent – Appendix C)

Managers

Managers will be selected who are directly responsible for the facility. In line with the ARV management structure, the managers to be interviewed will include:

Facility Manager, Clinical Coordinator, General Manager Care Services, General Manager Operational and CEO. (Managers Information Sheet & Consent)

Reference List


Appendix C - Resident Information letter & Consent

INFORMATION LETTER – Resident / Relative / Guardian

The Management Strategies that support Person-centred Care

Dear Resident, Relative or Guardian

My name is Alex Zarb and I am a research student at the University of Technology, Sydney, completing a Master of Nursing (Hons).

I am conducting research into the management strategies that support a person-centred approach to caring for people living with dementia in residential aged care facilities. The research will involve undertaking semi-structured interviews with the facility manager and his/her managerial colleagues.

This facility has been chosen to participate in the study because the Senior Management at Anglican Retirement Villages has decided to implement person-centred care in Farrer Brown Court. As such, I am interested to learn managers’ strategies that support a person-centred approach to caring for people living with dementia.

Following the interviews with managers I will assess the person-centred approach by using the validated assessment tool known as the Person Centred Environment and Care Assessment Tool (PCECAT). The information gathered from the PCECAT will provide an assessment to determine the extent to which person-centred care is provided in each unit. In undertaking the PCECAT assessment I will be observing staff practices, their documentation and the general environment of the facility. I will then compare the manager’s responses with the data collected from the PCECAT assessment.

Should you wish to be involved I will ask you to sign a consent form so that I can access the clinical record of selected residents. I will be assessing care strategies, not personal information about individual residents. At the end of the study, I will provide feedback of the results to the Executive, managers and staff in each facility.

No individual resident, manager or care staff member will be identified in the data collected.

If you would like further clarification you may contact me, using my email listed below. Alternatively you can contact my supervisors –

Professor Jane Stein-Parbury Nursing, Midwifery & Health UTS - Building 10, Jones St, Broadway, NSW 2000 Email: [email protected] Phone No: 0418 287 241

Professor Lynn Chenoweth Nursing, Midwifery & Health UTS - Building 10, Jones St, Broadway, NSW 2000 Email: [email protected] Phone No: 02 9514 5710

Yours sincerely,

Alex Zarb, Masters of Nursing (Honours) student, [email protected]


Resident, Relative or Guardian Consent Form

Management Strategies that support Person-centred care

I ___________________________________ (Resident’s, Relative’s, Guardian’s name) agree to participate in the research project - Management strategies that support person-centred care – (UTS HREC approval reference no: UTS HREC 2012-478A) being conducted by Alex Zarb, (Student Number: 10951895; [email protected]) of the University of Technology, Sydney for his degree - Masters of Nursing, Honours. He is being supervised by: Professors Jane Stein-Parbury, [email protected] / 0418 287 241, and Lynn Chenoweth [email protected] / 02 9514 5710 from the University of Technology, Sydney.

I understand that the purpose of this study is to identify the management strategies that support a person-centred approach to caring for people in a residential aged care facility.

I also understand that the researcher will be using the Person Centred Care and Environment Tool (PCECAT) to measure the extent to which person-centred care has been implemented in the facility. This assessment will involve reviewing the organisation’s policies, procedures and clinical documentation. Staff interactions and relationships with residents will be assessed through observation and staff interviews.

I understand that I am being asked to give consent for the researcher, Alex Zarb, to observe and review the clinical documentation related to the resident:

______________________________________________ (Resident’s Name)

Resident’s and staff member’s identity will be coded and all confidential information will be kept secure.

I am aware that I can contact Alex Zarb or his supervisors Professors Jane Stein-Parbury or Lynn Chenoweth if I have any concerns about the research. I also understand that I am free to withdraw my participation from this research project at any time I wish, without consequences, and without giving a reason. This will not affect current or future care for this resident, or in any way alter the relationship that I have with this facility.

I agree that Alex Zarb has answered all my questions fully and clearly.

I agree that the research data gathered from this project may be published in a form that does not identify me in any way.

________________________________________ ____/____/____ Signature (participant) ________________________________________ ____/____/____ Signature (researcher or delegate) Please retain a copy for your own record NOTE: This study has been approved by the University of Technology, Sydney Human Research Ethics Committee. If you have any complaints or reservations about any aspect of your participation in this research that you cannot resolve with the researcher, you may contact the Ethics Committee through the Research Ethics Officer (ph: +61 2 9514 9772 [email protected]) and quote the UTS HREC reference number. Any complaint you make will be treated in confidence and investigated fully and you will be informed of the outcome.


Appendix D - Staff Information letter


Dear Staff Member


I am conducting research into the management strategies that support a person-centred approach to caring for people living with dementia. The research will involve undertaking interviews with the facility manager and his/her managerial colleagues.

Following the interview I will assess the person-centred approach by using the validated assessment tool known as the Person Centred Environment and Care Assessment Tool (PCECAT). The information gathered from the PCECAT will provide an assessment to determine the extent to which person-centred care is provided in each unit.

In completing the PCECAT I will also speak, informally, with individual staff members about various aspects of the residents’ care and the practices at your facility. These talks will take no more than 20 minutes of your time. I understand that you may be interrupted through the talk to attend to your care responsibilities. Each time I approach you, I will seek your consent and you may refuse to talk to me, without giving a reason, and with no consequence to your current or future employment. You may feel uncomfortable because you think your care is being evaluated; that is not the intention of this research and you can stop the interaction at any time.

This facility has been chosen to participate in the study because the Senior Management at Anglican Retirement Villages has decided to implement person-centred care in Farrer Brown Court and this research is an aspect of the evaluation of the initiative. As such, I am interested to learn your manager’s strategies that support a person-centred approach to caring for people living in residential aged care.

I will compare the manager’s responses with the data collected from the PCECAT assessment.

No individual resident, manager or care staff member will be identified in the data collected.

At the end of the study, I will provide feedback of the results to the executive, managers and staff in each facility.

If you would like further clarification you may contact me, using my email listed below.

Alternatively you can contact my supervisors –



Yours sincerely,

Alex Zarb, Masters of Nursing (Honours) student [email protected]


Appendix E - Managers Information letter & consent

INFORMATION LETTER – Managers


Dear Manager


I am conducting research into the management strategies that support a person-centred approach to caring for people living in a residential aged care facility and would welcome your assistance. The research will involve undertaking a semi-structured interview with you and your managerial colleagues. The nature of a semi-structured interview is that l will come with some prepared questions and that I may also ask questions based on some of your responses.

You have been chosen to participate in the study because the Senior Management at Anglican Retirement Villages has decided to implement person-centred care in Farrer Brown Court. As such, I am interested to learn your management strategies that support a person-centred approach to caring for people in residential aged care.

Following the interview I will assess the person-centred approach by using the validated assessment tool known as the Person Centred Environment and Care Assessment Tool (PCECAT). The information gathered from the PCECAT will provide an assessment to determine the extent to which person-centred care is provided in each unit. I will compare the manager’s responses with the data collected from the PCECAT assessment.

No individual manager or care staff member will be identified in the data collected.

At the end of the study, I will provide feedback of the results to the Executive, managers and staff in each facility.

If you are interested in participating, I would be glad if you completed the consent form, overleaf, place it in the provided envelope, seal it and leave it with your Research Facilitator for me to collect. If you would like further clarification you may contact me, using my email listed below. Alternatively you can contact my supervisors –



You are under no obligation to participate in this research.

Yours sincerely,

Alex Zarb, Masters of Nursing (Honours) student, [email protected] NOTE: This study has been approved by the University of Technology, Sydney Human Research Ethics Committee. If you have any complaints or reservations about any aspect of your participation in this research that you cannot resolve with the researcher, you may contact the Ethics Committee through the Research Ethics Officer (ph: +61 2 9514 9772 [email protected]) and quote the UTS HREC reference number. Any complaint you make will be treated in confidence and investigated fully and you will be informed of the outcome.


Manager Consent Form

Management Strategies that support Person-centred care

I ____________________ (Manager’s name) agree to participate in the research project - Management strategies that support person-centred care – (UTS HREC approval reference no: UTS HREC 2012-478A) being conducted by Alex Zarb, (Student Number: 10951895; [email protected]) of the University of Technology, Sydney for his degree - Masters of Nursing, Honours. He is being supervised by: Professors Jane Stein-Parbury, [email protected] / 0418 287 241, and Lynn Chenoweth [email protected] / 02 9514 5710 from the University of Technology, Sydney.

I understand that the purpose of this study is to identify the management strategies that support a person-centred approach to caring for people in a residential aged care facility.

I understand that I have been asked to participate in this research because I have management responsibilities in an aged care facility. As a manager, I will be able to provide the researcher with information about the strategies I have implemented to support person-centred care (PCC) in a residential aged care facility. My participation in this research will involve the researcher conducting a semi-structured interview with me, and my managerial colleagues. In the interview I will ask some prepared questions and some additional questions to clarify the manager’s responses and to seek further information from the answers provided. It is anticipated that this interview may take up two hours but no longer. The interviews will be audio recorded and transcribed for analysis. While there may be some risk that I may feel I am being judged about my performance as a manager the researcher will take all efforts not to judge my responses. If I feel that the interview is affecting me emotionally I can advise the researcher that I wish to pause or stop the interview.

I also understand that the researcher will be using the Person Centred Care and Environment Tool (PCECAT) to measure the extent to which person-centred care has been implemented in the facility. This assessment will involve reviewing and discussing with me the organisation’s policies, procedures and clinical documentation. Staff interactions and relationships with residents will be assessed through observation and staff interviews.

My identity will be coded and all confidential information will be kept secure.

I am aware that I can contact Alex Zarb or his supervisors Professors Jane Stein-Parbury or Lynn Chenoweth if I have any concerns about the research. I also understand that I am free to withdraw my participation from this research project at any time I wish, without consequences, and without giving a reason. This will not affect my current or future employment.

I agree that Alex Zarb has answered all my questions fully and clearly.

I agree that the research data gathered from this project may be published in a form that does not identify me in any way.

________________________________________ ____/____/____ Signature (participant) ________________________________________ ____/____/____ Signature (researcher or delegate)

Please retain a copy for your records

NOTE: This study has been approved by the University of Technology, Sydney Human Research Ethics Committee. If you have any complaints or reservations about any aspect of your participation in this research which you cannot resolve with the researcher, you may contact the Ethics Committee through the Research Ethics Officer (ph: +61 2 9514 9772 [email protected]) and quote the UTS HREC reference number. Any complaint you make will be treated in confidence and investigated fully and you will be informed of the outcome.


Appendix F - Person Centred Environment and Care Assessment Tool

Person-Centred Environment and Care Assessment Tool

(PCECAT)

Chanel Burke

October 2011


Contents Page Introduction 2 The purpose and aim of the Person-Centred Environment and Care Assessment Tool (PCECAT) 2 Why adopt a Person-Centred approach to care 3 Why is a Person-Centred Care environment so important? 3 What is Person-Centred Care? 4 Instruction on the use of the Tool 5 Section A Characteristics of the Home or Care Unit 8 Section B Domain 1. Organisational Culture 10 Domain 2. Care and Activities, and Interpersonal Relationships and Interactions. 16 Domain 3. Physical Layout and Design. 20 Total Scores 24 Section C New Quality Strategies 25 References 27

“ © The PCECAT measure is the property of the University of Technology Sydney (UTS). Permission to use the PCECAT must be granted by UTS. PCECAT cannot be used for commercial purposes. PCECAT must not be reduced, added to, or altered in any way without agreement of the instrument developers C. Burke, L. Chenoweth and J. Stein-Parbury, UTS”


Introduction

Person-Centred Care recognises that each person is a unique individual resulting from their past history of relationships, achievements

and experiences. When providing person-centred care, the focus is on the person’s strengths, remaining capabilities and distinct

characteristic, while acknowledging their preferences and what is meaningful in their life (Kitwood 1997, Brooker 2007, Alzheimer’s

Australia 2007). By also facilitating choice and involvement in decision making, aged care service providers help in maintaining the

uniqueness of the person with dementia. The independence and quality of life of the person can also be improved by characteristics of

the home’s environment.

In utilising the Person-Centred Environment and Care Assessment Tool managers and staff of residential services will not only be able to

demonstrate how the environment supports Person-Centred services and that care provided is Person-Centred, they will be able to

demonstrate continuous quality improvement in service provision in accordance with the Aged Care Residential Standards

(Commonwealth Department of Health & Family Services 1998).

The purpose and aim of the Person-Centred Environment and Care Assessment Tool (PCECAT)

The purpose of the Person-Centred Environment and Care Assessment Tool (referred to as PCECAT) is to assist managers and staff

(Directors of Nursing, Managers, Deputy Directors of Nursing, Nurse Educators, Enrolled Nurses etc.) of aged care homes, providing

services for people with dementia, conduct a self-assessment of care practices and the environment of the Home or Care Unit.

The aim of the self-assessment is to determine if the environment supports Person-Centred approach to care and if services offered to

people living with dementia in the Home or Care Unit are Person-Centred. The accompanying Guidelines to the Person-Centred

Environment and Care Assessment Tool (referred to as the Guidelines) can be used in conjunction with the PCECAT during the self-

assessment to assist in gaining a clear understanding of each question. “ © The PCECAT measure is the property of the University of Technology Sydney (UTS). Permission to use the PCECAT must be granted by UTS. PCECAT cannot be used for commercial purposes. PCECAT must not be reduced, added to, or altered in any way without agreement of the instrument developers C. Burke, L. Chenoweth and J. Stein-Parbury, UTS”


In conducting the assessment of the Home or Care Unit, the following domains are reviewed:


Domain 2. Care and Activities, Interpersonal Relationships and Interactions

Domain 3. Physical Layout and Design of the Home.

While the self-assessment can utilize the whole PCECAT, each domain can be addressed separately. The Manager is able to choose the

manner in which the PCECAT is used depending on the identified needs of the home.

Why adopt a person-centred approach to care?

People living with dementia are entitled to a quality lifestyle where their worth and dignity is respected and maintained (Kitwood 1997). No

matter how frail, physically or mentally disabled, or psychologically vulnerable the person may be, service providers and staff have a

responsibility to protect their rights to life, privacy, confidentiality and security. Each person also has a right to expect to receive high

standards of care in a home that meets their individual needs.

By adopting a Person-Centred approach the focus is on the person rather than how dementia is affecting the person (Alzheimer’s Society

2005). Such recognition acknowledges the unique qualities of each person (Kitwood 1997) and that people with dementia are not one

homogeneous group (Marshall 1997). As the Australian Residential Care standards (Department of Health & Family Services, 1998) rests

upon these fundamental principles, managers and staff of residential aged care homes will not only be able to comply with these

Standards, they will also focus on maintaining the individual’s personhood, which is essential to well-being.



Why is a Person-Centred Care environment so important? In addition to the neurological damage that occurs to people with dementia, they are also affected by factors around them, such as the

physical structure of the home, the care staff’s attitudes towards them, the way they are treated and the way staff treat each other. By

offering a quality environment where the person’s right to privacy is respected, their independence is maximized and their opportunity to

contribute and participate in community life continues, staff will be able to assist the person to make best use of their capabilities. As a

result, the quality of life of a person living with dementia can be improved.

For an organisation to adopt a Person-Centred approach to service delivery, it is essential for a “whole of organisation” approach, driven

by senior managers and supported by direct care staff who require sound knowledge and communication capability, sensitivity and the

ability to develop empathy (Loveday and Kitwood, 2000). Providing Person-Centred Care has an overarching ethical code that not only

guides all practices within the organisation, but also encompasses all relationships and interactions involving the person living with

dementia, their families and the organisation’s staff. By embracing the ethical code all members of the organisation acknowledge the

individuality of each person, attempt to see situations from their perspective and recognize the interdependence of all those involved

(Loveday and Kitwood 2000, Brooker 2007).

What is person-centred care? The principles of personhood have clearly informed the ten guidelines to providing Person-Centred Care developed by Loveday and

Kitwood (1998, p. 10-21), which state, if “well understood and consistently applied in any care environment , the quality of life of the

majority of persons in it would improve dramatically…as they take us back to some universal aspect of personhood”. According to

Loveday and Kitwood (2000) the ten guidelines of Person-Centred Care are:

Attend to the whole person, See each individual as special and unique, Give respect to the past,



Focus on the positives, Stay in communication, Nourish attachments, Create community, Maximise freedom; Minimise control, Don’t just give; receive as well, Maintain a moral world.

These principles of a Person-Centred approach are supported by the Aged Care Act 1997, the associated Accreditation Standards and

the 1999 Certification Assessment Instrument as follows:

The right to be treated with dignity is recognized and respected, and enhanced through the relationship between the person and the caregiver.

The right to privacy and confidentiality is acknowledged and respected. Religious and cultural backgrounds of the person are valued and fostered. Quality, individualised care that meets physical, social, and emotional needs of the person is provided. Support and encouragement to enable self-determination and individuality is offered and enhanced through partnership

between the person and the caregiver The right to security and safety in a comfortable environment (Commonwealth Department of Health and Family Services

1998,). “ © The PCECAT measure is the property of the University of Technology Sydney (UTS). Permission to use the PCECAT must be granted by UTS. PCECAT cannot be used for commercial purposes. PCECAT must not be reduced, added to, or altered in any way without agreement of the instrument developers C. Burke, L. Chenoweth and J. Stein-Parbury, UTS”


Instructions for using the PCECAT The PCECAT consists of THREE sections:

Section A: Characteristics of the Home or Care Unit – addresses information relating to the demographic features of the Home or Care Unit. This section is available for those homes wishing to undertake comparative studies when there are a number of homes in their organisation.

Section B: Culture, Care Practices and Environment of the Home - addresses the three Domains of the PCECAT. Each Domain commences with the principles of Person-Centred Care relating to that Domain and demonstrates the links to the relevant Aged Care Residential Standards Expected Outcomes (Commonwealth Department of Health and Family Services 1998).

Section C: Staff strategies to improve care practices and the environment - provides an opportunity to use the PCECAT as a means of staff developing strategies to improve care practices and the environment. These strategies may be incorporated into the home’s plan for continuous quality improvement in accordance with the Aged Care Residential Standards.

To gain the most benefit from the self-assessment, it is important to involve as many staff as possible, with representation from all major work areas. It is also necessary to be as objective as possible. Therefore, before you start using the PCECAT it is advised to spend time walking through the home becoming aware of the environment including different noises and odours, the nature of interaction between staff and people living in the home, the involvement of people in activities, the manner in which staff relate to each other and the inclusion of family members in activities and decision making. While it is important to listen to what staff tell you about the way they conduct their work, it is essential to confirm their comments through:

Chapter 1. observing staff performing their duties;

Chapter 2. having conversations with people living in the home and their family/representative about staff’s performance; and

Chapter 3. reviewing appropriate documentation on resident assessment, care planning and care outcomes.



Procedure for completing the PCECAT: Try to answer each question as accurately as you can. Your responses will then be a true reflection of the degree to which the environment supports Person Centred-Care and if services offered to people living in the home and those with dementia are Person-Centred.

Step 1. Completing each question

Make sure you answer each question in the specific way the questions ask you to. That is by either:

entering data, for example

How many permanent residents are in the home on the day of assessment?

(Questions requiring data to be entered are found only in Section A of the PCECAT)

By placing a circle around the relevant response associated with the question, for example, the statement

The Home’s Handbook states a positive commitment to providing Person-Centred Care and states how this is provided in the home.

By using the response code indicated, that is 0 = Not at all 1 = Sometimes 2 = A great deal 3 = All of the time

Place a circle around the score which most accurately reflects the practice in the home, i.e., if “All of the time” 3 will be circled.

Some questions require an estimation, for example,

Staff demonstrate that they assess all potential reasons for the person’s distress

While there is no set percentage of staff required to enable a score to be determined, it should be remembered that the staff sample size should be large enough to reflect an accurate picture of the practice (Burns & Grove 2005).



Step 2. Calculating the score for each question

The score associated with the response that has been circled is entered into the “Score” column, (for example, if a circle is placed around 3, the score 3 is entered in the corresponding “Score” column). The “Comments” column may be used to record action you have undertaken to address the statement/question.

Step 3. Calculating the Sub-total Score At the completion of the questions associated with each domain add the numbers in the “Score” column and enter the sum as the sub-total score.

The total scores and associated ratings will enable you to determine your progress in developing an environment that supports Person-Centred Care practices and offering a Person-Centred approach to care.



Person-Centred Environment and Care Assessment Tool (PCECAT) SECTION A Characteristics of the Home or Care Unit. 1. Indicate whether the Home or Individual Care Unit is being assessed (Circle correct response).

Home: Yes / No Care Unit: Yes / No

2. Identification code of the home/care unit______________________________________ Date assessment was

undertaken______________

3. What is the total number of people who can live in the home or care unit being assessed? ___________

4. How many people permanently live in the home or care unit on the day of assessment? ___________

5. How many people are living in the home or care unit for respite on the day of assessment? ___________

6. How many people have dementia as their primary diagnosis? _______ number out of ______ (total number of

people)

7. How many people have a “high level approval” (nursing home)? ___________

8. How many people have a “low level approval” (hostel)? ___________

9. What is the total number of bedrooms in the home or care unit being assessed? ___________

9.1 How many are single bedrooms? ___________

9.2 How many bedrooms accommodate two people? ___________

9.3 How many bedrooms accommodate three + people? ___________

9.4 How many “couples” bedrooms (i.e. two adjoining rooms with an interconnecting door) are there? ___________

10.1 What is the ratio of toilet to people living in the home or care unit? _______ number of toilets to ________ number of people living in the home or care unit. “ © The PCECAT measure is the property of the University of Technology Sydney (UTS). Permission to use the PCECAT must be granted by UTS. PCECAT cannot be used for commercial purposes. PCECAT must not be reduced, added to, or altered in any way without agreement of the instrument developers C. Burke, L. Chenoweth and J. Stein-Parbury, UTS”


10.2 What is the ratio of showers to people living in the home or care unit? _______ number of showers to ________ number of people

living in the home or care unit.

10.3 How many ensuite bathrooms to single bedrooms are there? _______

11. What are the total number of paid hours worked by employed staff (permanent, part-time, contractual and casual) each week in each

of the following roles? Permanent Full Permanent Part Contracted Casual

Staff involved in direct care of people living in the home or care unit: Time Time Staff Staff

11.1 Care Coordinator / DDON ____ ____ ____ ____ 11.2 Registered Nurse ____ ____ ____ ____ 11.3 Enrolled nurse ____ ____ ____ ____ 11.4 AIN / PCA / CSE ____ ____ ____ ____ 11.5 Physiotherapist / Physiotherapy Aid ____ ____ ____ ____ 11.6 Diversional therapist/recreation officer ____ ____ ____ ____ 11.7 Pastoral care staff / Welfare staff ____ ____ ____ ____ 11.8 Total hours = ____ ____ ____ ____ 12. In the month prior to this assessment with the PCECAT, what was the total number of hours worked by agency staff in the home or

care unit in direct care roles? _______hours

13. How many nurses and care staff have resigned from the home or care unit in the past 6 months?

Manager _______ Nurses (RN, EN and EEN) _______ Care staff (AIN, PCA, CSE) _______ “ © The PCECAT measure is the property of the University of Technology Sydney (UTS). Permission to use the PCECAT must be granted by UTS. PCECAT cannot be used for commercial purposes. PCECAT must not be reduced, added to, or altered in any way without agreement of the instrument developers C. Burke, L. Chenoweth and J. Stein-Parbury, UTS”


SECTION B Domain 1. Organisational Culture

Principles of Person-Centred Care relating to organisational culture Accreditation standards (Expected outcomes) relating to organisational culture

Commitment of the organisation / home to a culture where the person comes first.

1.3 Education and staff development 1.5 Planning and leadership 1.6 Human resource management 1.8 Information systems

Staff work practices acknowledge, respect and support the uniqueness of the person, including their culture, background, and care needs

2.4 to 2.17 Expected outcomes (See Appendix A, p.25 to 27) 3.4 to 3.9 Expected outcomes (See Appendix A, p.27 to 28)

Managers and staff continually improve practice to enhance the life of the person, working in consultation with the person’s family/representative.

1.1, 2.1, 3.1 and 4.1 Continuous improvement 1.4 Comments and complaints 3.4 Emotional support 3.5 Independence 3.6 Privacy and dignity 3.8 Cultural and spiritual life 3.9 Choice and decision making 4.4 Living environment 4.8 Catering cleaning and laundry

Staff are respected and supported in their role/s and have access to appropriate training and professional development for the role/s.

1.6 Human resource management 1.8 Information systems 1.3, 2.3, 3.3 and 4.3 Education and staff development




Rate your organisation’s current status regarding a Person-Centred Care culture using the scale below.

The comments column can be used to record any action that has been taken to achieve the specific indicator.

0 = Not at all 1 = Sometimes 2 = A great deal 3 = All of the time

Organisational culture indicators that support a person-centred approach to care

Response Score Comments

1.1 The Home’s Mission, Vision, Values Statement (or similar) states a commitment to the meeting the unique needs of the person living in the Home or Care Unit.

A The Home has a policy relating to the use of a Person-Centred Care

philosophy that is underpinned by respect and dignity.

0 1 2 3

B

The Home has procedures outlining how Person-Centred Care is

performed.

0 1 2 3

1.2 The person and their family/representative are aware of the home’s commitment to a person-centred approach.

A Prior to admission, the home provides information regarding services

and practices to the person and their family/representative.

0 1 2 3

B The Home’s Handbook states a positive commitment to providing

Person-Centred Care and states how this is provided in the home.

0 1 2 3



Organisational culture indicators (cont.)


Response Scale: 0 = Not at all; 1 = Sometimes; 2 = A great deal; 3 = All of the time

C Within the first week following admission there is an orientation to the

home and its Person-Centred services for the person and their

family/representative.

0 1 2 3

1.3 There is regular consultation regarding the person’s individual care needs and preferences.

A The individual preferences and desires of the person are obtained prior

to the development of their Care Plan.

0 1 2 3

B Relevant to their level of capability, the person and his/her

family/representative are given the opportunity to collaborate with staff

in determining all aspects of the person’s Care Plan (in person or via

telephone).

0 1 2 3

C Staff gain information on the end-of-life beliefs of the person, their

wishes and preferred practices and what is meaningful in their life.

0 1 2 3

D Throughout their stay in the home, there is ongoing consultation with

the person and/or their family/representative prior to taking action for

specific care needs.

0 1 2 3

E Independent and anonymous feedback is sought from the family /

representative about aspects of care they observe.

0 1 2 3



Organisational culture indicators (cont.) Response Score

Comments


1.4 According to their ability, the person and their family / representative have the opportunity to make suggestions and lodge a complaint.

A On admission to the home, information about the complaints and

suggestion system outlining avenues available, process, timeframe

and feedback is given to the person and their family/representative.

0 1 2 3

B The home seeks independent and anonymous feedback from families/

representatives about their satisfaction with how

complaints/suggestions are addressed.

0 1 2 3

1.5 Staff are aware of the organisation’s commitment to providing Person-Centred Care services.

A Staff position descriptions highlight the responsibility to provide

Person-Centred Care.

0 1 2 3

B Staff orientation fully explains principles of Person-Centred Care

practices and how these are applied in everyday care.

0 1 2 3

C Staff have received training in Person-Centred Care as part of their

professional development.

0 1 2 3






D Staff have formal annual performance appraisals to identify Person-

Centred skill development.

0 1 2 3

1.6 Managers and staff demonstrate commitment to Person-Centred Care.

A Managers/senior staff can explain how Person-Centred Care is

implemented through care systems.

0 1 2 3

B Staff can provide detailed knowledge of the background, needs,

desires and preferences of persons they regularly care for.

0 1 2 3

C Shift overlap and staff handovers occur where all staff receive up-to-

date information about each person’s needs and their current health

status.

0 1 2 3

D There are opportunities at shift handover for staff to discuss with each

other how they are implementing Person-Centred Care.

0 1 2 3

E Staff regularly provide care services for the same person (for a

minimum period of 3 months)

0 1 2 3

F Work practices are sufficiently flexible to enable staff to respond to the

person’s needs as they occur.

0 1 2 3

G Staff demonstrate that they assess all potential reasons for the

person’s distress.

0 1 2 3






H When a person is distressed staff offer comfort in keeping with the

person’s preferences and needs.

0 1 2 3

1.7 Staff’s efforts in their various roles are recognized and valued.

A Staff confirm they are offered the educational support specific to

Person-Centred Care that they need to undertake their roles.

0 1 2 3

B Staff are satisfied that issues/concerns they raise in care delivery are

acted upon by their supervisor/relevant person.

0 1 2 3

C Staff confirm their managers acknowledge/praise their achievements in

using person-centred approaches in caring for the person.

0 1 2 3

D Staff confirm there is a culture of respect for all staff.

0 1 2 3

Add scores to obtain subtotal for this section

Subtotal =

Organisational culture



Domain 2. Care and Activities, and Interpersonal Relationships and Interactions.

Principles of Person-Centred Care in care and activity programs Accreditation standards (Expected outcomes) relating to each person’s care and activities

The person is respected and valued.

2.4 to 2.17 Expected outcomes (See Appendix A, p.25 to 27) 3.4 Emotional support 3.6 Privacy and dignity 3.9 Choice and decision making

Care and activity programs recognize the person’s individuality while reinforcing their strengths, personal attributes and remaining skills.

2.4 Clinical care 3.4 Emotional support 3.5 Independence 3.7 Leisure interests and activities 3.8 Cultural and spiritual life 3.9 Choice and decision making

The social environment supports the psychological needs of the person: the need for love, attachment, comfort, identity, occupation and inclusion.

3.4 Emotional support 3.5 Independence 3.7 Leisure interests and activities 3.8 Cultural and spiritual life 3.9 Choice and decision making

There is a commitment to maintaining the person’s independence, allowing choice and involvement in decision-making.

3.5 Independence 3.8 Cultural and spiritual life 3.9 Choice and decision making 4.4 Living environment

Staff have the ability to engage with the person in their uniqueness through openness, flexibility, creativeness and compassion.

2.4 Clinical care 3.3 Education and staff development 3.4 Emotional support 4.4 Living environment



Domain 2. Care and Activities, and Interpersonal Relationships and Interactions.

Rate your organisations status in providing a Person-Centred approach in care and activity programs, interpersonal relationships and

interactions using the scale below. The comments column may be used to record any action that has been taken to achieve the specific

indicator.

0 = Not at all 1 = Sometimes 2 = A great deal 3 = All of the time Care and Activities, and Interpersonal Relationships and

Interactions demonstrate a person-centred approach to care Response Score Comments

2.1 Individual Care Plans support the person’s independence as far as possible while addressing their unique needs and desires.

A Prior to the development of the Care Plan comprehensive

assessments are conducted, including medical, functional (physical,

cognitive, social and psychological), emotional and spiritual domains.

0 1 2 3

B Assessments are conducted for specific areas of care (e.g. mobility,

risk of falls, continence – bowel and bladder and behavior)

0 1 2 3

C The Care Plan focuses on how to support the person’s abilities (their

strengths) more than how to compensate for their disabilities (their

deficits).

0 1 2 3



Care and Activities, and Interpersonal Relationships and Interactions demonstrate a person-centred approach to care.

Response Score

Comments


2.2 An Individual Life History informs each person’s Recreation and Social Activities.

A The person’s Life History/profile is taken into consideration when

developing their unique Activity Plan.

0 1 2 3

B The person has input to developing their unique Activity Plan at the

level of their ability.

0 1 2 3

C The person’s Activity Plan is reviewed in conjunction with their Care

Plan.

0 1 2 3

D The person participates in recreational and social activities that match

their interests and needs.

0 1 2 3

E The person provides staff with feedback, both positive and negative,

on their Activity Plan at the level of their ability.

0 1 2 3

2.3 There is respect for the person’s unique identity (personhood)

A Staff use each person’s Life History/profile to gain information on their

personal beliefs and what is meaningful in their life.

0 1 2 3

B There are avenues available for the person to express their individual

spirituality in meaningful ways.

0 1 2 3



Care and Activities, and Interpersonal Relationships and Interactions demonstrate a person-centred approach to care.

Response Score

Comments


C The backgrounds of people from culturally and linguistically diverse societies are appreciated and acknowledged through provision of preferred food, music, activities and celebrations.

0 1 2 3

D Staff use language-specific or symbolic cue cards (or similar) to enable

communication with the person if required.

0 1 2 3

E Staff respect the person’s choices (e.g. foods, activities, time of getting out of bed etc.), or alternative choices are negotiated if unable to be fully met.

0 1 2 3

F Staff use the person’s preferred memorabilia (photos, objects) to assist them in maintaining communication and relationships with family and close friends.

0 1 2 3


A Staff meet the person’s need for personal interaction by engaging with

them in meaningful social conversation.

0 1 2 3

B Staff engage in culturally appropriate and preferred physical contact with the person e.g. touch, signs of affection and personal care.

0 1 2 3

Add scores to obtain subtotal for this section Subtotal =

Care and Activities, Interpersonal Relationships and Interactions



Domain 3. Physical layout and design

Principles of person-centred physical layout and design of the home

Accreditation standards (Expected outcomes) relating to the physical layout and design of the home

The physical layout and design of the home supports the people living in the home to feel psychologically secure and physically comfortable. (Alzheimer’s Australia 2003).

3.4 Emotional security 4.4 Living environment

The physical environment of the home supports people to

maintain their memory and independence through appropriate stimulation and cueing, and engage in activities in a safe environment.

2.14 Mobility, dexterity and rehabilitation 3.5 Independence 4.4 Living environment 4.5 Occupational health and safety

Physical environmental factors such as noise, warmth, visual stimulation are regularly reviewed to ensure the comfort of people living in the home.

4.4 Living environment 4.5 Occupational health and safety



Domain 3. Physical layout and design

Rate your organisation’s status in providing a physical layout and design that supports person-centred approach to care using the scale below. The comments column may be used to record any action that has been taken to achieve the specific indicator.

0 = Not at all 1 = Sometimes 2 = A great deal 3 = All of the time Person-centred physical layout and design indicators

Response Score Comment

3.1 The Home or Care Unit has features that assist to maintain the person’s memory, functioning and independence

A There is an accessible courtyard / garden area with discrete security

fencing and gating in place to ensure safety of the person using the area.

0 1 2 3

B The courtyard / garden area has familiar objects that encourage usual

activities of daily living, e.g. walking paths, clothes line, raised garden

beds, rakes and brooms, letter box.

0 1 2 3

C The courtyard / garden area has sufficient seats in shaded areas for the

person to sit and rest if they wish.

0 1 2 3

D There are clearly defined walking areas for the person throughout the

home that do not stop in “dead-ends”.

0 1 2 3

E There are grab rails in public areas to enable free and safe movement of

the person using these areas.

0 1 2 3



Person-centred physical layout and design indicators



F There are grab rails for the person to use in private and shared

bathrooms and toilets.

0 1 2 3

G The person has an item of choice on the door or immediately outside

their room to assist in room recognition, e.g. photo/s, number, name,

picture, memorabilia.

0 1 2 3

H The person is assisted to find their way around the care unit by the use of

pictures, signage, artworks, colours or recognizable objects.

0 1 2 3

3.2 The Home or Care Unit has architectural/design features that create a domestic, rather than institutional, environment.

A There are private areas available apart from the person’s

bedroom/bedroom space for the person to meet with family and friends.

0 1 2 3

B The kitchen/kitchenette available for the person and their families/friends

to make a snack has appropriate safety features (e.g. discrete positioning

of hot water taps, lockable draws containing sharp instruments)

0 1 2 3

C There are small dining areas to provide opportunities for people to eat in

small groups (4-6) including family and friends, if they wish

0 1 2 3

D The person has a pleasant view of the outside when sitting in a chair in

their bedroom.

0 1 2 3



Person-centred physical layout and design indicators



E The furniture in public areas is arranged in clusters to enable the person

to socialize if they wish.

0 1 2 3

3.3 A familiar and homely atmosphere is created in the home

A Furnishings and decor of the home are in keeping with the person’s age

and past memory.

0 1 2 3

B The person is able to personalize their bedroom / living space in the

manner they choose.

0 1 2 3

C The person is able to bring personal items into shared areas of the home

to assist in making the area familiar to them.

0 1 2 3

D The person has access to a phone where they can make, or are assisted

to make, and receive calls from family/friends.

0 1 2 3

3.4 Safety and security in the Home.

A Hallways are kept free of obstacles (e.g. wheelchairs, cleaning

equipment, lifters) to enable maximum movement of the person

throughout the home.

0 1 2 3



Person-centred physical layout and design indicators Response Score Comment


B Staff can adequately supervise the person in both public and private

areas of the home.

0 1 2 3

C All windows are restricted in the extent they can be opened, thus preventing the person from climbing out while still allowing fresh air ventilation.

0 1 2 3

D There are good levels of natural lighting supplemented by artificial lighting during the daytime.

0 1 2 3

E There is sufficient lighting at night, either at floor level or in the ensuite, to guide the person to the bathroom.

0 1 2 3

F Entrances to areas that pose danger to the person (e g Dirty utility room with contaminated materials, medication storage, and chemical storage areas) are disguised.

0 1 2 3

3.5 Effects of noise levels in the home

A People scream or call out for help. 0 1 2 3

B Staff call or shout to gain attention. 0 1 2 3

C Noises from recreation activities enjoyed by others intrude on the person’s quiet or sleep time, e.g. television, radio, music program...

0 1 2 3

D Noises from equipment and electronic devices intrude on the person’s quiet or sleep time, e.g. vacuum cleaner, metal trolleys, call bells, intercom system.

0 1 2 3

Add scores to obtain subtotal for this domain Subtotal = Physical layout and design



Ratings

For each domain list the subtotal of the scores recorded Maximum

score

Domain 1: – Organisational Culture: Subtotal score = (84)

Domain 2: – Care and Activities, and Interpersonal Relationships and Interactions: Subtotal score = (48)

Domain 3: – Physical Layout and Design: Subtotal score = (81)

Total Score = (213)

LIKE CONTINUOUS QUALITY IMPROVEMENT, PROVIDING SERVICES THAT ARE PERSON-CENTRED IS AN ONGOING PROCESS. THROUGH YOUR HARD WORK THE BENEFITS WILL BE EXPERIENCED BY PEOPLE LIVING IN THE HOME, THEIR FAMILIES AND STAFF.



SECTION C.

New Quality Strategies

In reviewing each of the three domains, what new strategies can be developed in the home/care unit assessed to improve Person-Centred Care, and/or create a Person-Centred Environment?

Domain 1: - Organisational Culture

i) ____________________________________________________________________________________________________

ii) ____________________________________________________________________________________________________

iii) ___________________________________________________________________________________________________

iv) ___________________________________________________________________________________________________

v) ____________________________________________________________________________________________________

Domain 2: - Care and Activities / Interaction between staff and each person living in the Home

i) ____________________________________________________________________________________________________

ii) ____________________________________________________________________________________________________

iii) ___________________________________________________________________________________________________

iv) ___________________________________________________________________________________________________

v) ____________________________________________________________________________________________________

Domain 3: - Physical Layout and Design of the Home.

i) ____________________________________________________________________________________________________



ii) ___________________________________________________________________________________________________

iii) ___________________________________________________________________________________________________

iv) ___________________________________________________________________________________________________

v) ____________________________________________________________________________________________________

Reference Source: Aged Care Standards and Accreditation Agency. 2005 Results and processes in relation to the expected outcomes of the Accreditation

Standards. Aged Care Standards and Accreditation Agency Ltd, Parramatta.

Alzheimer’s Australia. 2003. Quality Dementia Care Position Paper No. 2 Australasian Journal on Ageing. Vol. 22 No 4. pp 203-205

Alzheimer’s Australia. 2004. Dementia Care and the Built Environment. Position Paper 3.

Alzheimer’s Society. 2005 Quality Dementia Care in Care Homes. Person-centred Standards. Alzheimer’s Society London.

Brooker D 2007 Person-centred Dementia Care. Making Services Better. Jessica Kingsley Publishers London.

Brooker, D. & Surr, C. 2005 Dementia Care Mapping. Principles & Practice. Bradford Dementia Group, Bradford. United Kingdom.

Calkins M.1998. Risk Management in Environmental Design. Dementia Care: Can we afford the risk? Mixing independence, choice, rights

and risk minimization in care.

Department of Health & Ageing 2003 Building Quality for Residential Care Services Certification. Australian Government Department of

Health and Ageing, Canberra.

Department of Health & Family Services. 1998. Standards and Guidelines for Residential Aged Care Services Manual. CanPrint

Communications Pty Ltd, Kingston ACT.

Edvardsson D., Winblad B. & Sandman P.O. 2008 Person-centred care of people with severe Alzheimer’s disease: current status and

ways forward. Lancet Neurology. Vol 7 April. P. 362-367. “ © The PCECAT measure is the property of the University of Technology Sydney (UTS). Permission to use the PCECAT must be granted by UTS. PCECAT cannot be used for commercial purposes. PCECAT must not be reduced, added to, or altered in any way without agreement of the instrument developers C. Burke, L. Chenoweth and J. Stein-Parbury, UTS”


Fleming R., Forbes I, & Bennett K. 2005 Adapting the Ward for people with dementia. Woodhead International, Sydney (Referred to as

“Fleming et al. 2005”)

Institute for Caregiver Education. 2003. Culture Change Indicators Survey. Guide to Assessing Progress on the Culture Change Journey.

Institute for Caregiver Education Chambersburg, PA 17201. Kitwood, T. 1997. Dementia Reconsidered. The person comes first. Open University Press, Buckingham.

Kitwood T. & Bredin K. 1992 Towards a theory of dementia care: personhood and wellbeing. Ageing and Society. 12:269-287

Loveday B. & Kitwood T. 2000 Improving Dementia Care. A Resource for Training and Professional Development. The Journal of

Dementia Care. Hawker Publications Ltd London. Marshall M. & Tibbs M. 2006 Social Work and People with Dementia. Partnership, Practice and Persistence. The Policy Press, United

Kingdom.

Moos, R.H. & Lemke S. 1996. Evaluating Residential Facilities. The Multiphase Environmental Assessment Procedure. Sage

Publications United Kingdom.

Sloane, P. & Mathews, L. 1991. Dementia Units in Long Term Care. John Hopkins University Press, Baltimore.

Sloane, P.D., Mitchell C.M., Weisman G., Zimmer S., et al 2002 The Therapeutic Environment Screening Survey for Nursing Homes

(TESS-NH): An Observational Instrument for Assessing the Physical Environment of Institutional Settings for Persons with Dementia.

Journal of Gerontology Social Sciences. Vol. 57B, N



Appendix G - PCECAT Qualitative Results - Unit 1

PCECAT Items January 2013

Pre PCC Intervention Gaps identified

January 2014 Post PCC Intervention

Strengths Areas for Possible Improvement Domain 1 – Organisational Culture

1.1 The home’s Mission, Vision, Value Statement (or similar) states commitment to the meeting the unique needs of the person living in the home or care unit.

The home does not have procedures that indicate how person-centred care is provided.

Procedures – The organisation’s policies and procedures need to clearly articulate person-centred principles and how they are to be implemented when providing services to people in the home and their families.


The resident handbook does not provide information about how person-centred care is provided in the facility. Managers advised that there were meetings provided to residents and/or their representatives to inform them of the intention of the facility to introduce person-centred care. One of the residents was observed to have a newsletter about the PCC project.

Welcome Handbook – significant work has been undertaken to produce a document which reflects the philosophy of the organisation, while also including information relevant to each home. Having knowledge of the commitment of the home to provide services aimed at meeting individual needs and preferences will assist in offering support, comfort and reducing the level of anxiety of a person and their family.

1.3 There is regular consultation regarding the person’s individual care

While care plans are developed and annual care conferences are held the individual care plans were clinically and process driven and lacked individual preferences.





Strengths Areas for Possible Improvement needs and preferences. 1.4 According to their ability, the person and their family/representative have the opportunity to make suggestions and lodge a complaint.

Resident / relative surveys are undertaken on an annual basis; the survey results are collated and analysed through an external provider. Managers advised that information from these surveys were being used to guide their interventions / actions in the upcoming project.

Suggestions/complaints/compliments/praise: this process could be enhanced by seeking independent and anonymous feedback through the organisation’s satisfaction surveys.


Job descriptions did not provide information to staff about PCC. Staff training in PCC was about to be launched through the Evolve program

Position descriptions are currently being reviewed to ensure they emphasise the organisation’s expectation that staff are responsible for providing services in a person-centred way. Performance appraisals need to demonstrate links to the specific position description while also demonstrating that staff members have the relevant knowledge, skills and attitude to provide services in a person-centred way.


Some of the more regular staff had a reasonable knowledge of people’s background but the use of agency meant these staff members lacked knowledge. Handover occurred between all shifts however they were not representative of all staff e.g. Leisure & Lifestyle & therapy staff. The handover between afternoon / night staff and night / morning staff occurred in two steps. The care staff initially received the handover who then passed it onto the RN later during the night shift or at 8

Handover could be enhanced by the regular attendance of leisure and lifestyle staff to assist in the discussion of the psychosocial aspects of each person’s life in addition to clinical needs. Staff members require education and support to understand the importance of shift handover in promoting person-centred practices. As the needs of older people constantly change occasions for staff to share their knowledge and discuss both the psychosocial and clinical needs of people living in the home, will enhance opportunities to improve the person’s well-being.





Strengths Areas for Possible Improvement am for the morning shift. There are no procedures for staff to discuss how they provide PCC to individual residents. There was little consistency of staff on each wing. Staff filled in for others on wings. After talking with staff and observing documentation there was little evidence that staff used people’s background to understand why resident’s displayed certain behaviours

For many of the staff, adherence to work schedules dominates the way care is provided to people living in the home, rather than adopting flexible practices to address people’s needs as they occurred. Staff need to take the time to explore reasons for a person’s distress and provide appropriate comfort immediately.


At the time of the assessment staff had received a talk about the introduction of PCC. Some staff advised that they didn’t receive direct praise for the work they did.

Staff require knowledge and appreciation of the whole person, including their past life, relationships, employment, needs and preferences in order to provide person-centred care and improve the well-being of the person. Some staff feel that when they raise matters of concern or make suggestions as to where improvement can occur, their opinion is not respected and valued. Some care staff feel that there is a lack of respect shown by staff to each other.

Domain 2 – Care and Activities, and Interpersonal Relations and Interactions 2.1 Individual care plans support the person’s independence as far as possible while addressing their unique needs and desires.

Comprehensive assessments are completed for all residents. These assessments directly feed into the development of Care Plans. There was little identification of people’s abilities. Lifestyle care plans were more positive focused although they weren’t consistent in this approach.

2.2 An individual Life

The resident’s life story was identified in a document called “Key to me”. A

There is a newly formed leisure and lifestyle team who were very

There needs to be greater connection between the information collected by care and leisure and





Strengths Areas for Possible Improvement History informs each person’s Recreation and Social Activities

resident’s interests were picked up in the proposed activities for the resident. Other details of the life story were not always utilised in the care plan.

enthusiastic about person-centred practices and eager to further respond to the individual needs and wishes of people living in the home.

lifestyle staff from people living in the home and families for the Key to Me and Social and Cultural and Spiritual Care Plan to be used in the development of each person’s unique activity plan.


Following discussions with staff members of varying classifications the staff members didn’t display knowledge of resident’s back grounds or life story. Feedback from residents / relatives indicated that they weren’t satisfied with the activities to meet people’s culturally diverse backgrounds. While staff spoke of the availability of cue cards the cards were not being used. There was no evidence of staff utilising resident’s memorabilia to assist with communication or to develop relationships.

The spiritual needs of people living in the home are well accommodated through the very active role of the Chaplain who is well known and available to people regardless of their faith belief. Reflective practice sessions involving life stories of those people living in the home are being conducted each week with care and leisure and lifestyle staff in attendance. Cue cards are being used as required to enhance communication with people who experience difficulties with speech or understanding due to reduced cognitive ability, speech impairment or those from CALD groups.

End of Life - Information gained on end-of-life beliefs, their wishes and what is meaningful in the life of a person needs to be extended to reflect person-centred principles...No other information regarding their wishes, for example, religious or cultural ritual, the physical environment with music playing, was found. This knowledge will assist staff in ensuring a person-centred approach occurs and the wishes of the person are respected. The needs of people from different cultural and linguistic diverse backgrounds could be enhanced through appropriate activities, music and culturally specific events as there is need to recognise and celebrate the unique cultures of the people living in the home. The use of cues cards would assist with communication where a person is unable to express their needs due to cognitive impairment or where English is the person’s second language.


There was little evidence of staff having conversations with residents. Some incidents with residents were very negative: “you are wet” and telling the resident to go to their room.

Some staff members need to spend more time in social conversation with people rather than rushing past them. Such conversations not only acknowledge the importance of the person but also assist in developing a trusting relationship between the staff and the person. This is evidenced through the results of Resident Satisfaction Survey addressing “Staff have time to talk to me” with 84.6% satisfaction in March 2013 dropping to 74.3% in February 2014.

Chapter 7 – Appendices

165

Appendix H - PCECAT Qualitative Results - Unit 2




Strengths Areas for Possible Improvement

Domain 1 – Organisational Culture

1.1 The home’s Mission, Vision, Value Statement (or similar) states commitment to the meeting the unique needs of the person living in the home or care unit.

The home does not have procedures that indicate how person-centred care is provided.

Procedures – The organisation’s policies and procedures need to clearly articulate person-centred principles and how they are to be implemented when providing services to people in the home and their families.


The resident handbook does not provide information about how person-centred care is provided in the facility. Managers advised that there were meetings provided to residents and/or their representatives to inform them of the intention of the facility to introduce person-centred care. One of the residents was observed to have a newsletter about the PCC project.

Welcome Handbook – significant work has been undertaken to produce a document which reflects the philosophy of the organisation, while also including information relevant to each home. Having knowledge of the commitment of the home to provide services aimed at meeting individual needs and preferences will assist in offering support, comfort and reducing the level of anxiety of a person and their family.

While consultation occurs with people living in the unit and their relatives, these relationships would be further enhanced if all staff wore name badges to enable families to remember their names.

Chapter 7 - Appendices 166





1.3 There is regular consultation regarding the person’s individual care needs and preferences.

While care plans are developed and annual care conferences are held the individual care plans were clinically and process driven and lacked individual preferences.

1.4 According to their ability, the person and their family/representative have the opportunity to make suggestions and lodge a complaint.

Resident / relative surveys are undertaken on an annual basis; the survey results are collated and analysed through an external provider. Managers advised that information from these surveys were being used to guide their interventions / actions in the upcoming project.

Suggestions/complaints/compliments/praise: this process could be enhanced by seeking independent and anonymous feedback through the organisation’s satisfaction surveys.


Job descriptions did not provide information to staff about PCC.

Staff training in PCC was about to be launched through the Evolve program

Position descriptions are currently being reviewed to ensure they emphasise the organisation’s expectation that staff are responsible for providing services in a person-centred way.

Performance appraisals need to demonstrate links to the specific position description while also demonstrating that staff members have the relevant knowledge, skills and attitude to provide services in a person-centred way.







Some of the more regular staff had a reasonable knowledge of people’s background but the use of agency meant these staff members lacked knowledge.

Handover occurred between all shifts however they were not representative of all staff e.g. Leisure & Lifestyle & therapy staff. The handover between afternoon / night staff and night / morning staff occurred in two steps. The care staff initially received the handover who then passed it onto the RN later during the night shift or at 8 am for the morning shift.

There are no procedures for staff to discuss how they provide PCC to individual residents.

There was little consistency of staff on each wing. Staff filled in for others on wings.

After talking with staff and observing documentation there was little evidence that staff used people’s background to

Staff members have embraced person-centred principles in the way they support people and attend to their needs. There is acknowledgement by staff that every day is different for people and accordingly, meet their needs as they arise.

There is consistency with the care staff working in the unit, thus enabling staff to have detailed knowledge of the people they care for, and in turn, reduce confusion and enable both the people living in the unit and their families the opportunity to get to know the staff.

Handover could be enhanced by the regular attendance of leisure and lifestyle staff to assist in the discussion of the psychosocial aspects of each person’s life in addition to clinical needs.

Staff members require education and support to understand the importance of shift handover in promoting person-centred practices. As the needs of older people constantly change occasions for staff to share their knowledge and discuss both the psychosocial and clinical needs of people living in the home, will enhance opportunities to improve the person’s well-being.






understand why resident’s displayed certain behaviours


At the time of the assessment staff had received a talk about the introduction of PCC.

Some staff advised that they didn’t receive direct praise for the work they did.

Some staff members feel that management could offer greater acknowledgement of the work they undertake, thus making them feel appreciated.

Domain 2 – Care and Activities, and Interpersonal Relations and Interactions

2.1 Individual care plans support the person’s independence as far as possible while addressing their unique needs and desires.

Comprehensive assessments are completed for all residents which feed into the development of a care plan. The documentation focused on residents’ inabilities rather than on their strengths. While some care plans described how a resident is sociable and likes to keep active there was no description as to how to enable residents to maintain their skills.

Some care plans reviewed contain a level of repetition across a number of fields e.g. mobility, physiotherapy and pain management. There also needs to be stronger links between observation/assessments and appropriate interventions.

2.2 An individual Life History informs each person’s Recreation and

While the “Key to me” assessment provided a comprehensive history the

People living in Unit 2 are included in activities that occur in other parts of the home, such as






Social Activities details from the residents’ life story wasn’t utilised in the development of care plans. The resident’s interests identified in their life story did marry with the planned activities but this was limited to the staff providing the activities.

visiting the café and bar-b-q area.


Staff members were able to describe a resident’s background yet they couldn’t explain how they used this information in their day-to-day interactions with the resident. There was little evidence of how staff member maintained people’s culturally diverse backgrounds. Staff members weren’t seen to be using cue cards to assist these residents.

There is a support group available for the family members of people past and presently living in Unit 2 that meets regularly.

The needs of people from different cultural and linguistic diverse backgrounds could be further enhanced through appropriate activities, music and culturally specific events. Cue cards need to be available to assist staff communicate with people who have speech impairment and for those who have little or no speech due to English being their second language.


Staff members were seen to be grouped together and there was little evidence that staff had developed relationships with residents.

Some staff members need to spend more time in social conversation with people rather than rushing past them. Such conversations not only acknowledge the importance of the person but also assist in developing a trusting relationship between the staff and the person. This is evidenced through the results of Resident Satisfaction Survey addressing “Staff have time to talk to me” with 84.6% satisfaction in March 2013 dropping to 74.3% in February 2014.


Appendix I - PCC Leadership Template

Quality Framework (Donabedian 1966)

Template Analysis Themes Codes from Interview Data References

Structure Settings in which care is provided... Administrative functions that support and direct the provision of care

PCC Vision of Care Service Strategic (planning, organisational support, goal setting, stages)

Change management methodology with aligning strategies; Organisational commitment & infrastructure

Mgr. 2, MGR. 5, Mgr. 1 All Managers

Organisational Culture (changes required – sensitivity to feelings, break down of divisions, positive view on interaction, spontaneity, intuition, living comfortably with faults)

Get the noise out of the system; An embracing gesture: Consistency with the organisation’s vision and value; Embedded in the structure

Mgr. 1 Mgr. 3, Mgr. 4, Mgr. 6, Mgr. 3 / Mgr. 2

HR Management Staffing Structure (positions created in line with PCC aims and objectives)

Latitude to explore new roles to support the model of care

Mgr. 2 / Ops, Mgr. 7, Mgr. 6, Mgr. 1

Staff Selection (attitudes, willingness to learn, discernment)

Attributes – people able to learn and work with discernment and judgement

Mgr. 3, Mgr. 4,

Employment Conditions (job satisfaction, psychological contract, pays, job designs)

Role descriptions align with organisation’s values; Balanced relationship between employer and employee

Mgr. 4, Mgr. 3, Mgr. 6 Mgr. 4, Mgr. 6,

Management Ethos PCC Leadership from the top (valuing all staff, sensitive to feelings, recognition of strengths, team building)

Engaging, role modelling, understanding, confronting, challenging & supportive

Mgr. 1, Mgr. 3, Mgr. 2, Mgr. 4, Mgr. 5, Mgr. 6

Delegation (decision-making, breaking down barriers)

Autonomy to decide discerningly at the local level while strategically supported


Quality Management PCC Continuous Improvements




(review policies, care plan guide, information systems, handover guide)

A PCC quality framework which is contextualised within the organisation’s systems

Mgr. 2, Mgr. 4, Mgr. 5

Value Systems (staff, risk taking support strategies, enabling residents, respecting personhood)

Investment in knowing and enabling people; Staff scope of decision-making; change of focus from Compliance


Philosophy of Care (accredited training, specialist contracts, agreed nature of good care)

Focus on relationship to change people’s lives; Broader than physical care; The model is on the table

Mgr. 1, Mgr. 2, Mgr. 3, Mgr. 4, Mgr. 6

Training Structured (based on needs, includes accredited courses)

Training specialising on the predetermined capabilities for each role


Qualified Management (expertise, qualifications)

Leadership training for managers

Mgr. 2

Process What is known as good practice is actually applied

PCC Vision Daily Guide (priorities set by goals, flexibility in implementation)

Comprehending how it will appear on a day-to-day basis; Different in each village; A toolkit; Integrating spirituality & pastoral care

Mgr. 1, Mgr. 2, Mgr. 3, Mgr. 5

Big Picture (compelling, explanation, continuous referral to goals,

Enable people to understand the goals; Day-by-day ownership


Staff Support

Professional Acknowledgement (performance, feedback, preparedness, validation, mentoring, motivation, teamwork, consultation)

Acknowledging accomplishments;

Mgr. 1, Mgr. 4

Empowerment (flexibility, spontaneity, potential realised, best ways to spend time with residents, constructive feedback, information about

Liberating staff to be flexible & spontaneous with people; Give voice & ownership to staff; Ability to say ‘yes’ at the local level

Mgr. 1, Mgr. 2, Mgr. 3, Mgr. 4, Mgr. 5, Mgr. 6,




residents) Mgr. 7 Emotional Support (support, debriefing, empathise)

Attuned to staff feelings at the time; Facilitating forums for debriefing


Management Practice

Visibility (accessibility, open door, role model, PCC demonstrated, awareness of daily practice)

Being available and picking up things


Leadership Style (stepped change process, delegation of decision-making & resources, staff input guided by goals, self-reflection, maximise resources, prompts to alter practice, constructive feedback, support implementation of new learning & learning from experience, enabling & facilitating, mutual trust & respect)

Leading and teaching people using a team approach to implement change; Self-reflection


HR Practices

Job Preparedness (psychological, skills, job match, job redesign, flexibility for up-skilling)

Personal development to ensure they’re capable to give PCC Mgr. 2, Mgr. 3, Mgr. 4, MGR. 5, Mgr. 6, Mgr. 7

Consistency of Staffing (rosters that ensure continuity of care – more full time staff / staff with greater number of hours; less agency hours, )

Regular staff to build relationships

Mgr. 2, Mgr. 3, Mgr. 4, Mgr. 6, Mgr. 7

Training

Skills (assess ill-being, dementia care, communication & interaction, clinical assessments, team training – collective knowledge)

Learning to engage with residents

Mgr. 2,

Personal Development (ongoing learning, reflective practice,

Development plan for each staff member to refine how they

Mgr. 2, Mgr. 3, MGR.




unlearning task-focus practice, accredited courses,

practice; Know their limitations

5, Mgr. 6, Mgr. 7

Communication & Documentation

Information available (handover to all staff, team problem-solving, rich body of information within living culture)

Collaboration between all groups of staff to obtain and share holistic information


PCC Care Plans (comprehensive, specific, positive, usable, recognises strengths and vulnerabilities, regular updates & reviews)

Develop a care plan that’s easily accessible and that articulates what the resident wants each day


Advocate Personhood (language, positive language, non-labelling)

Staff member is enabled to advocate for the person

Mgr. 3

Continuous Improvement Quality Awareness (auditing, feedback of results, standards, plan of improvement, monitoring programs)

Project teams developing action plans to address the following areas: clinical, dementia, food, environment, human resources, education, lifestyle and spiritual; Outcomes are measured and results fed back to indicate progress; Strategies implemented: admission process and gathering information about – what’s your typical day?

Mgr. 2, Mgr. 5, Mgr. 6, Mgr. 7 Mgr. 5 Mgr. 2, Mgr. 5, Mgr. 6, Mgr. 7

Relatives & Friends

Partnerships with Staff (guidance, emotional support, trust in each other, value their knowledge, care conferences)

Families are a critical influence to inform staff


Care Practices Personalised Care (relationships, do with, nurturing abilities, life story informs care, recognition of person, familiar routines, consultation with daily routines, aware of comfort needs, sensitive to feelings, interactive with residents)

Respond to ensure people can live out their unique day; meaningful interactions





Meaningful Activities (all staff participate in fun, occupation matches person, innovative, community participation)

Staff are supported to understand how to socialise with residents


Personalisation (surround with personal possessions, new items similar to old ones, daily routines, risk taking)

Flexibility in care to allow them to live their daily life


Resident Assessments

Know the person: (Life story, personality, lifestyle, health, cognition & capacity, socioeconomic gender, ethnic and cultural, reasons for difficulties, abilities, strengths, observe resident)

Through conversation we get to know the little nuances to bring better fulfilment


Recognise ill-being (awareness of emotional state, difference in state of being, comfort needs

Understand & respond to people’s feelings


Outcome

An indicator of quality of care

Staff Well-being

Staff are valued and respond to clients accordingly (attitudes of inclusion, respect, affection & validations, relationships with residents, partnerships with relatives friends)

Staff are positively engaging with residents

Mgr. 5, Mgr. 6

Residents Well-being

Personhood is maintained (well-being, skills maintained for as long as possible, psychological needs met, confidence to live their lives, personal possessions, relationships with other residents, and family, community involvement)

Residents taking up what’s being offered

Mgr. 6, Mgr. 7


Appendix J - Triangulation of data - PCECAT Results and Organisational PCC Structures

PCECAT Qualitative Results – Strengths Organisational PCC Structures

Welcome Handbook – Organisation’s PCC Vision PCC Vision

Organisational Framework

Breakfast available – 2 hour period

Spiritual Support – Chaplain available & known Staff empowerment & flexibility

New Leisure & Lifestyle staff – enthusiastic re PCC Managers’ empowerment

Dementia Support group – emotional & educational PCC Leadership

Cue cards – cultural recognition

Care staff – PCC informed & uniquely responsive Change management process

Consistency of staff – forming relationships CI methodology

Contextualising PCC

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