Resident-Directed Long-Term Care: Staff Provision of Choice During Morning Care

In a no-nonsense manual on implementing culture change in nursing homes, Bowers, Nolet, Roberts, and Esmond (2007) asked providers, “Is your facility providing person-centered care? Are you unsure if you are really providing it? What does person-centered care actually mean?” These are timely questions, for there is growing support for resident-directed care in nursing homes, with an emphasis on offering residents choices. The rationale for this focus is rooted in Ryan and Deci’s (2000) self-determination theory, for resident choice, viewed as an expression of one’s autonomy, is a central concept within this life-span theory. Specifically, this theory posits that three universal psychological needs—for competence, relatedness, and autonomy—must be met for individuals to enjoy an optimal sense of personal well-being. The theory also holds that a person’s social environment can foster attainment of these needs, such that the person thrives, or the environment can thwart these needs, to the person’s detriment. Thus, for example, nursing homes that elicit and honor resident choices help to foster residents’ sense of autonomy and, with it, their sense of well-being. Failure to attend to choice may undermine residents’ autonomy, leading to such feelings as passivity and hopelessness. In recent years, new nursing home policies and practices have emerged in line with the tenets of self-determination theory. Federal regulatory guidelines, for example, now identify choice over daily schedules as a resident right (Centers for Medicare and Medicaid Services [CMS], 2009). These guidelines instruct surveyors to ask residents if they are offered choices about daily life activities, such as bedtimes and dining, and observe whether those choices are honored by staff. Federal and state surveyors responsible for ensuring nursing home care quality can issue care deficiencies, which require a formal plan of correction from the nursing home, as part of their survey process if they determine that choice is not routinely offered to residents. Similarly, popular culture change models (e.g., Eden Alternative, Green House, Wellspring) emphasize the importance of personal choice and freedom (Bowers et al., 2007), and nursing home staff have self-reported they offer residents daily care choices such as when to get up, when to bathe, and what to eat (Doty, Koren, & Sturla, 2008). Few studies, however, have collected independent data to confirm these reports or published assessment tools that could help providers answer Bowers and colleagues’ (2007) pointed question: “Is your facility providing person-centered care?” The lack of objective data and assessment tools also has limited efforts to evaluate the impact of resident-directed care on clinical and quality-of-life outcomes. Thus, the purpose of this study was twofold: (a) to develop an observational protocol to assess the quality of staff–resident communication relevant to choice and (b) to describe staff–resident interactions in a small sample as preliminary evidence of the usefulness of the tool to assess current nursing home practices related to offering choice during morning care provision.