PERSON-CENTERED CARE AND THE RESIDENT-CARE AIDE

A Thesis

Presented to the faculty of the Department of Graduate and Professional Studies

in Education

California State University, Sacramento

Submitted in partial satisfaction of

the requirements for the degree of

MASTER OF ARTS

in

Education

(Curriculum and Instruction)

by

Katrina Kym Pimentel

SPRING

2014

ii

© 2014

Katrina Kym Pimentel

ALL RIGHTS RESERVED

iii

PERSON-CENTERED CARE AND THE RESIDENT-CARE AIDE

A Thesis

by

Katrina Kym Pimentel

Approved by:

__________________________________, Committee Chair

Porfirio Loeza, Ph.D.

__________________________________, Second Reader

Cheryl Osborne, Ed.D.

____________________________

Date

iv

Student: Katrina Kym Pimentel

I certify that this student has met the requirements for format contained in the University

format manual, and that this thesis is suitable for shelving in the Library and credit is to

be awarded for the thesis.

__________________________, Graduate Coordinator ___________________

Albert Lozano, Ph.D. Date

Graduate & Professional Studies in Education

v

Abstract

of

PERSON-CENTERED CARE AND THE RESIDENT-CARE AIDE

by

Katrina Kym Pimentel

This thesis focuses on the person-centered care approach delivered to older adults

residing in assisted living with an emphasis on dementia-care. Of particular importance in

the provision quality dementia-care is the critical role of the Resident-Care Aide (R.C.A)

and the challenges and opportunities within the organization was highlighted using Albert

Bandura’s self-efficacy theory juxtaposed leadership. The research design used methods

of ethnography which included participant-observation visits, a survey, and informal

interviews with staff at an assisted living community with Memory Care in Northern

California. The participants of this study included (N=7) R.C.A’s and the residents they

cared for in the Memory Care neighborhood. Five substantive themes emerged from the

research findings which include: consistent assignment equates to greater resident-

knowledge and relationship; understanding the dining program improves

vi

the dining experience; embracing emergent leaders within the organization; ambiguity

leads to lower family and staff satisfaction; and Resident-Care Aides find meaning in

their work.

_______________________, Committee Chair

Porfirio Loeza, Ph.D.

_______________________

Date

vii

DEDICATION

This thesis is dedicated to my daughter Shawna Skye and son Jonathan Batiste; may they

be inspired to reach their full potential and aspire to be an agent for change in their

respective educational endeavors.

viii

ACKNOWLEDGEMENTS

I would like to thank Dr. Porfirio M. Loeza for his phenomenal mentorship and

support he has given to me throughout this thesis process. Under his guidance, I have

been challenged to think critically about the issues discovered in doing this research and

has heightened my overall learning experiences as his graduate research assistant. He is

not only my mentor, but has become a friend. I would also like to thank Dr. Cheryl

Osborne, in the Gerontology program for introducing and fostering my love for aging and

demanding excellence by providing a rigorous academic program and rich service-

learning experiences which highly influenced my engagement in the coursework and as a

discipline. I would like to thank Nancy Shier-Anzelmo for her impressive knowledge

and expertise in dementia and person-centered care. The introduction to the world of

dementia was instrumental in inspiring in me the drive to also be an advocate for change

in dementia. I would also like to thank Don Lewis, Bereavement and Volunteer

Coordinator at University of California, Davis Hospice Program for providing me with a

transformational year-long internship shadowing the interdisciplinary team of social

workers, nurses and the chaplain to the homes of terminal patients. It was in one of these

visits that my interest in providing dementia-education was born. I must thank Professor

Barbara Grigg, my faculty advisor during this internship; her support, encouragement and

kindness was touching. In addition to these five influential figures, I must say thank you

to my partner, Richard; my two children, Shawna and Jonathan; and their grandmother,

Roseann, for supporting me throughout my academic endeavors and future pursuits.

ix

TABLE OF CONTENTS

Page

Dedication………………………..………………………………………………………vii

Acknowledgements……………………………………………………………………..viii

Chapter

1. INTRODUCTION………………………………………...…………………...……….1

Statement of the Problem…. ……………………………………………………...5

Significance the Study …………………………………………………...…….....7

Methodology………………………………………………………………………8

Research Questions………………………………………………………………..9

Limitations………………………………………………………………...............9

Delimitations………………………………………………………………………9

Theoretical Basis for the Study…………………………………………………..10

Definitions of Terms……………………………………………………………..11

Organization of Thesis…………………………………………………….…. …14

Background of Researcher……………………………………………………….15

2. REVIEW OF LITERATURE……..…………………………………………………16

Introduction………………………………………………………………………16

Person-Centered Dementia-Care………………………………………………...17

Assisted Living and the Resident-Care Aide…………………………………….31

Person-Centered Care in the Organization………………………………………38

Summary…………………………………………………………………………50

x

3. METHODOLOGY…………………………………………………………………..51

Overview…………………..……………………………………………………..51

Research Design and Data Collection……………………...……..……………...51

Research Questions………………………………………………………………53

Research Instruments…………………………………………………………….53

Research Participants…………………………………………………………….56

Research Setting……………………………………………………………….....56

Data Analysis Procedures………………………………..………………………57

Summary…………………………………………………………………………58

4. FINDINGS AND ANALYSIS OF THE DATA…………………………………….. 59

Overview…………………………………………………………………………59

Findings & Analysis…………………………………………………….. ……...61

1. Consistent Assignment Equates to Greater Resident-Knowledge and

Relationship………………………………………………………………….64

2. Understanding the Dining Program Improves the Dining Experience………67

3. Embracing Emergent Leaders within the Organization………………..…….75

4. Ambiguity Leads to Lower Family and Staff Satisfaction……………..……79

5. Resident-Care Aides Find Meaning in Their Work………………………….84

Summary…………………………………………………………………………88

5. SIGNIFICANCE………………………………………………………………………90

Introduction………………………………………………………………………90

xi

Discussion of the Findings…………………………………………..…………...91

Implications………………………………………………………………………94

Limitations……………………………………………………………………….96

Recommendations………………………………………………………………..97

Conclusions………………………………………………………………………99

References………………………………………………………………………………100

1

Chapter 1

INTRODUCTION

Nearly 5.4 million American’s are affected by dementia, a condition marked by

irreversible loss of brain function that causes problems with memory, thinking, language,

judgment, and behavior (Dementia Initiative, 2013). There are many different forms of

dementia that affect the elderly, but Alzheimer’s disease is the most common and

accounts for 60 to 80 percent of all dementias (Williams, et. al., 2010) and is the sixth

leading cause of death in the United States and the fifth leading cause of death in

California (Alzheimer’s Association, 2013). Unfortunately, with the first wave of the

baby boomer cohort reaching the legal age of retirement this past year, the demand for

elder care and the incidence of dementia is only going to skyrocket over the next thirty

years. In fact, “the worldwide prevalence of dementia [was] estimated to be 35.6 million

in 2010, with the number exceeding (…) 115 million in 2050, making it a pressing global

health concern” (Williams, et. al., 2010, p. 13).

Dementia care significantly impacts the long-term care systems, family and, or,

care givers. The long-term care needs of this population are costly in terms medical care,

as this population is hospitalized two to three times more than individuals without

dementia, and for daily supervision (NAPA, 2010). “In 2005, the direct cost to Medicare

and Medicaid for care of people with Alzheimer’s disease and other dementias was $111

billion” (Williams, et. al., 2010, p. 14) and was expected to reach $140 billion in 2012

and projected to reach $1.2 trillion in 2050 (Alzheimer’s Association, 2013).

2

In addition to monetary impacts, persons with dementia pose complex challenges

as a result of cognitive and communication impairments caused by the dementia. While

the decision to place loved ones with dementia in institutional care is not always an easy

or preferable choice for family to make, it often becomes necessary in order to ensure

their safety. Institutional care givers may be employed at hospitals, nursing homes,

assisted living communities, and skilled nursing facilities. This research focuses on care

provided at assisted living communities with memory care.

The face of institutional dementia care is changing. Prior to the late 1980’s

individuals housed in nursing homes and other long-term care settings did not fare well.

This is because the long-term care management models used were developed based on

hospitals, which are paternalistic and use a hierarchical style of management and where

task-completion is valued over relationships (Kendall, 2011). This resulted in terrible

neglect and poor outcomes for those who needed institutional care. In an effort to

improve resident-quality of life, the nursing home reform act, under the Omnibus Budget

Reconciliation Act (OBRA), of 1987, was passed which mandated that long-term care

settings deinstitutionalize their practices and to provide “services to attain or maintain the

highest practable physical, mental, and psychosocial well-being” (Social Security Act,

1986). This holistic approach marked the start of the culture-change movement in long-

term care. Under this act, Medicaid home- and community-based waivers were also made

available to those individuals who wanted to remain in the community, but were in need

3

of assistance with the activities of daily living, such as dressing, bathing and grooming.

Assisted living falls under this category of the policy.

Assisted living offers residents with a home-environments and supportive

services to allow the older adult to remain as independent as possible. Assisted living

settings may be apartments or houses, or rooms, with varying levels of care. Some

assisted living communities (ALC) have special Alzheimer’s care units, referred to as

Memory Care which provides specialized care and supervision to older adults with

advancing dementia (Alzheimer’s Association, 2013). These communities embrace a

resident-centered approach which considers the physical, social, spiritual, and

psychological needs of the resident. Other terms such as person-centered or patient-

centered, have been used to describe the same approach and depends on the setting and

governing body’s philosophy. This thesis uses person-centered care to focus on the

individual living with dementia.

Person-centered dementia care is an “evidence-based nursing theory founded on

the principle that all human beings are of absolute value and worthy of respect, no matter

what their disability, and on a conviction that people with dementia can live fulfilling

lives” (Epp, 2003, p. 10). It is a model of care increasingly being recognized as the best

practice in dementia care (Dementia Initiative, 2013). The American psychotherapist and

humanist, Carl Rogers (1951) applied what was first called non-directive therapy, and

later changed to client-centered therapy, to the counseling setting. Rogers developed this

approach from his extensive research on personhood and was heavily influenced by

4

Abraham Maslow‘s hierarchy of needs and believed that in order to facilitate growth the

focus of therapy needed to be on the client, as a whole person; and that the role of the

therapist was to express genuine concern, have an acceptant attitude, hold the client with

unconditional positive regard and experience the moment with the client with empathetic

understanding (Rogers, 1967). Carl Rogers’ work inspired Professor Tom Kitwood,

British social psychologist and founder of the Bradford Dementia Group at the University

of Bradford, in the U.K., who applied this approach to his work with dementia which

shifted the focus of dementia-care from a disease focus to a quality of life focus.

Since its inception, this person-centered care has largely been philosophical,

rather than prescriptive, leading to variances and ambiguity. However, a recent

whitepaper published by the Dementia Initiative (2013) defined the consensus reached by

experts in the field. The core values and philosophy of this approach include:

1. “Every person has his/her own meaning of life, authenticity (personality,

spirit and character), history, interests, personal preferences, and needs to

continue to experience life at all stages of dementia. The person is not

their dementia illness; rather the condition is only one aspect of their

current status.

2. Focus on the strengths of the person living with dementia rather than on

what

abilities and capabilities have been diminished or lost.

5

3. Enter the world of the person living with dementia to best understand,

communicate with, and interpret the meaning of his/her behavioral

expressions

from their perspective” (p. 14).

The quality of person-centered care is dependent on the provision of eight structural

elements which are interconnected and essential for supporting operational care practices

and include:

1. Relationships and Community (belonging)

2. Governance

3. Leadership

4. Care Partners/Workforce (Resident-Care Aide)

5. Services

6. Meaningful Life and Engagement

7. Environment

8. Accountability (CEAL, 2010, p. 9).

Statement of the Problem

The person-centered care approach is increasingly being recognized as the best

practice in dementia care as it has shown to not only improve resident-care outcomes, but

the job-satisfaction among the direct-care staff (Resident-Care Aides) who care for them.

This is critical because aides in assisted living have turnover rates as high as 200 percent

annually, with many leaving within their first year working (Chou, 2012). When aides are

6

constantly leaving the workforce, the person with dementia does not fare well as new

staff will not be familiar with the personalized communication and preferences and

increases the likelihood that they will have unmet needs. According to the need-driven

dementia-compromised theory of behavior, individuals will attempt to express

themselves using whatever form of communication intact, which is often through

behaviors which may include agitation, aggression or withdrawal (Gitlan,Winter,

Earland, Herge, Chernett, Piersol & Burke, 2009) and which complicate care giving.

Understanding the meaning behind behaviors is learned in culture and which develops

through relationship and overtime (Dementia Initiative, 2013). Therefore, good dementia

care is dependent on a stable care staff and individualized care, both of which are key

principles of person-centered care.

With the ever-growing population of older adults aging, the demand for assisted

living care and other aging services is also increasing. This makes older adults and their

family prime marketing targets for senior products and services; and person-centered care

is a very attractive service. But, like all products and services, the quality of the person-

centered care delivered is likely to vary depending on the provider and cost. However, in

order to provide quality person-centered care it is imperative that all eight structural

elements needed to support operational care practices are secured and maintained.

Otherwise, only fragmented person-centered care will be delivered (Dementia Initiative,

2013), making the person with dementia vulnerable to inferior care and the incidence of

turnover among the Resident-Care Aides high.

7

Therefore, the purpose of this study is to conduct qualitative research at one ALC

with Memory Care which provides person-centered care. The intent of this research will

be to experience the nature of the care environment, the care provided and the effect it

has on the residents and staff. Using methods of ethnography, the researcher will make

visits as a participant-observer, conduct a survey, and make inquiry through informal

interviews with staff. This research is important because “the culture of a social group

[is] a shared way of viewing the world, its definitions of what is real and true; what is

important in pursuing; sense of history, and the personal qualities that are to be

esteemed” (Kitwood, 1990, p. 164) and will emerge in the organizational practices,

interactions among staff and with residents, and in the care practices despite marketing

approaches.

Significance of the Study

The baby-boomer cohort is aging which indicates that the demand for elder care is

increasing. As recently as 2005, Teri, et. al., identified that there are more than one

million older adults residing in ALCs; and the CEAL (2010) reported that more than 50

percent of residents in assisted living are affected by dementia. Because these

communities are licensed and regulated by the state as non-medical, Residential Care

Facilities for the Elderly, they are not required to hire professional-level care staff.

Instead, they employ Resident-Care Aides, who are not required to have prior experience

working with older adults. They receive ten hours of training, which they have four

weeks to complete (Social Security Act, 1886) and which rarely prepares them for the

8

complex challenges that cognitive and communication impairments pose. Inadequate

understanding of aging-related issues and dementia subjects these Resident-Care Aides to

turnover.

Turnover is costly in terms of recruiting and training new staff. According to

Coogle, Parham and Rachel (2011) “the estimated staff turnover cost for each [Resident-

Care Aide] is approximately between $1750 and $5000” (p. 521). The CEAL (2010)

“estimated the annual cost associated with 67 staff and an average turnover rate of 73

percent, to be approximately $84,537” (p. 18). These costs are alarming and must be

addressed. The person-centered care approach seeks to decrease turnover of aides by not

viewing them “as simply people being paid to accomplish tasks, but as integral to the

success of the entity in general and for individualized person-centered dementia care”

(Dementia Initiative, 2013, p. 20).

Methodology

The purpose of this study was to conduct qualitative research at one ALC with

Memory Care which provides person-centered care. The intent of this research was to

experience the nature of the care environment, the care provided, and their effect on the

residents and staff. Using methods of ethnography, the researcher made three visits as a

participant-observer, conducted a survey, and made inquiry through informal interviews

with staff.

9

Research Questions

While ethnographic research requires the researcher refrain from having a

predetermined hypothesis, some guiding parameters for this research include:

Primary Research Question

1. In what ways are the qualities of person-centered care expressed, or not expressed, in

the staff-staff and staff-resident interactions? (i.e., nutrition, mood, behavior,

socialization, and therapeutic activity, teamwork, support, feedback, etc).

Secondary Research Question

2. In what ways are the qualities of satisfaction mitigated and/or displayed in specific

settings or contexts.

Limitations

There are limitations to this study. First, the observational data may be skewed by

the fact that staff were aware that the researcher was a visitor in the care environment.

Also, anytime staff is requested to take part in an employee satisfaction survey they may

not always respond honestly for fear that they may be identified by their employer. To

decrease this fear, the researcher remained on-site to retrieve the surveys from the

Resident-Care Aides. One other limitation to this study is that due to the qualitative

nature of the study, replication cannot occur.

Delimitations

To protect the working relation between the assisted living organization and the

direct care staff, the survey will exclude questions regarding wages and benefits.

10

Theoretical Basis for Study

The theoretical framework for which person-centered care was developed is based

on the work of humanists Abraham Maslow and Carl Rogers, and paired with Albert

Bandura’s self-efficacy theory. Maslow, referred to as the father of humanistic

psychology, “stood for human dignity and humanistic values; he advocated a psychology

that studied healthy people and which trusted and placed the unique potential of each

person at the core of its concerns” (DeCarvalho, 1991, p. 45). His work which he is most

known for is his theory of hierarchy of needs which posits that human behavior is

motivated to fulfill needs. These needs include: biological and physiological needs; safety

needs; social needs; esteem needs; and self-actualization needs (McLeod, 2007); these

needs are hierarchically arranged with the lowest level being physiological needs and the

highest level being self-actualization needs” (Maslow, 1998, p. xx). Carl Roger’s applied

these humanistic values to the therapy setting and developed the client-centered care

approach. Rogers believed in order to promote growth in the client, the focus of therapy

needed to be on the client, as a whole person; and that the role of the therapist was to

express genuine concern, have an acceptant attitude, hold the client with unconditional

positive regard and experience the moment with the client with empathetic understanding

(Rogers, 1967). With these values, the person-centered care approach for the frail,

elderly and disabled individuals was formed. The person-centered care organization

strives to honor and meet the needs of the residents in assisted living and the workforce

11

that cares for them; thereby promoting high quality care and high performing and

satisfied staff (Maslow, 1965).

This thesis highlights the challenges affecting the Resident-Care Aide in assisted

living and places particular emphasis on the staffs need for safety and esteem. However,

Albert Bandura’s self-efficacy theory will provide the framework for attending to these

needs within the organization. Self-efficacy is a cognitive regulating process in which

one’s perceptions of their abilities affect their level of motivation, goal-setting and actual

performance (Bandura, 2012). In general, “people who have a high assurance in their

capabilities approach difficult tasks as challenges to be mastered rather than as threats to

be avoided” (Bandura, 1989, p. 731) and therefore, perform higher (Brockner, 1988).

Having an understanding how self-efficacy is developed can provide the organization

with the insight needed to raise the self-efficacy of the Resident-Care Aide; thereby

increasing job-satisfaction, performance and quality of dementia care.

Definitions of Terms

Assisted Living Communities: establishments that provide permanent housing to senior

citizens who need some help with activities of daily living, such as bathing,

dressing, and taking medication, but that do not need the round-the-clock nursing

care provided in a nursing home. Many people choose ALC’s as their senior

living option because of their focus on independence and dignity.

Behavioral Expression: term preferred by the Dementia Initiative experts rather than

“behavioral problem.” Included are behaviors such as agitation, anxiety,

12

aggression, and screaming. It is important to understand the root cause of

behaviors as they are often expressions of unmet needs, such as pain, hunger,

thirst, boredom, loneliness, or an underlying medical condition that the person

with dementia is challenged to communicate to a care partner or to address him or

herself.

Care Partners: people actively engaged in providing care and/or support such as family

members and others known through a personal relationship and formal caregivers.

Cognitive Impairment: refers to any loss of cognitive ability beyond what is expected as a

part of the regular aging process. Dementia and Alzheimer’s disease are common

causes of cognitive impairment in the aging population. Senior living communities

often offer special services for patients suffering from cognitive impairment.

Consistent Assignment: The same caregiver is assigned to the same residents.

Dementia: a loss of brain function that occurs with certain diseases. It affects memory,

thinking, language, judgment, and behavior.

Direct-Care Staff: people who care for individuals of all ages who have disabilities or a

chronic illness and need their assistance. In this case, they are the staff members

who provide care for older adults residing in assisted living and memory care

communities (Resident-Care Aide).

Job-Satisfaction: the degree to which people like their jobs.

Long-Term Care: refers to the services delivered to aging individuals who need help

with activities of daily living. It can be administered at home, in senior living

13

communities, or in skilled nursing facilities. Patients in assisted living facilities,

home-health situations and nursing homes all receive long-term care.

Memory Care Neighborhood: specialized living arrangements for people who struggle

with cognitive impairment, and who can benefit from extra protection in an assisted

living or nursing home environment. While some facilities specialize exclusively in

memory care services, many senior living communities have special memory care

units or floors that offer special services and care for those with dementia,

Alzheimer’s and other forms of cognitive impairment.

Perseveration: repeated or prolonged action, thought, or utterance. People with

dementia often carry out the same activity, make the same gesture, or ask the

same question or repeatedly.

Person-Centered Care: person centered practice for older persons is treatment and care

provided by health services that places the person at the center of their own care

and considers the needs of the older person’s care. Person-centered practice is

treating patients/clients as they want to be treated. This might include considering

concepts such as dignity and respect.

Person-Centered Mentoring: With person-centered issues, mentoring helps individuals

gain insights into their own behavior and interaction with others.

Staff Turnover: the percentage of direct care employees that terminate employment, either

voluntarily or involuntarily, over the course of one year. The equation to measure

turnover is terminations in a year divided by the total number of staff members.

14

Structural Elements: The eight structural elements constitute the building blocks for

person-centered dementia care.

Organization of Thesis

This chapter provided an overview of the issues related to dementia and their

caregivers and the person-centered care approach based on theoretical work of Abraham

Maslow and Carl Rogers. The significance between the inverse relationship between staff-

stability and quality dementia-care which warrants this thesis research was also outlined and

will be further explored using Albert Bandura’s self-efficacy theory juxtaposed leadership.

This chapter also outlined the methodological strategies for collecting the qualitative data

sought in this research study. The next chapter, Chapter Two, outlines the key research

literature on the person-centered dementia care approach, the challenges affecting the

Resident-Care Aide in assisted living, and organizational supports essential for developing

their knowledge, skill, and efficacy in order to provide quality dementia care. In Chapter

Three, the full methodological approach for collecting the data needed for this ethnography

research study is delineated. In Chapter Four, the findings from the participant-observational

visits, the surveys and the informal interviews are presented in terms of major themes which

emerge from the data. The final chapter, Chapter Five, provides a discussion regarding the

significance of the findings, their implications, and recommendations for improving the

delivery of person-centered care.

15

Background of Researcher

The researcher of this thesis is moving mountains to attain a higher education. As a

twice teen parent and ninth grade dropout, her academic journey has been one of both

cognitive and personal growth. She first earned her G.E.D, and then enrolled at Sacramento

City Community College before transferring to CSUS. In 2012, she graduated with a B.S.

degree in Gerontology with an interest in dementia. Through the M.A. Teacher Education,

Curriculum and Instruction program, the researcher has been able to incorporate the values

of each program through this thesis which focuses on educational issues of dementia-care.

Despite the rich opportunities the researcher has and continues to be afforded, she remains

humble and appreciative and is invested to pay it forward to equally if not more deserving

academic scholars.

16

Chapter 2

REVIEW OF LITERATURE

Introduction

This thesis focuses on the person-centered dementia care approach provided in

assisting living and the challenges which threaten its quality with special attention to the

paid-care partner. “Dementia is a loss of cognitive abilities in multiple domains that

results in impairment in normal activities of daily living and loss of independence

(Williams, et. al., 2010, p. 13). Currently, there are more than 5.4 million people in the

United States affected by dementia and this number is expected to rise to 16 million by

the year 2050 (Alzheimer’s Association, 2013) which means that the demand for

dementia-care is going to be astronomical. Caring for persons with dementia “strains the

health and long-term care systems as they use a disproportionate amount of health care

resources; for instance, they are hospitalized two to three times as often as people the

same age who do not have the disease” (NAPA, 2010).

The effects of dementia pose real challenges for Care Partners with “up to 50

suffering from significant psychological distress” (Williams, et. al., 2010, p. 13). In the

organizational setting, when care partners are under-supported or lack the skills needed to

provide effective care, their level of satisfaction with their job goes down and the

incidence of staff turnover increases (Chou, 2012). The person-centered dementia care

approach recognizes and appreciates the valuable role that care partners have resident-

wellbeing and views them as integral to the successful delivery of person-centered care

17

(Dementia Initiative, 2013). When all structural elements are implemented and

maintained this approach is intended to provide the necessary supports needed to improve

job-satisfaction and decrease turnover (Chou, 2012).

This chapter defines the person-centered dementia care philosophy and core

values and all eight structural elements needed to support operational practices. This

chapter also highlights the critical role and challenges affecting the care partner in

assisted living, referred in this thesis as the Resident-Care Aide, and the responsibility of

the organization in order to raise their efficacy and skills. Because person-centered care is

multifaceted, the review of literature within this chapter has been grouped into three

sections in order to improve coherency. These sections include:

1. Person-Centered Dementia Care

2. Assisted Living and the Resident-Care Aide

3. Person-Centered Care in the Organization.

Person-Centered Dementia-Care

Person-centered care is a philosophy of care which considers the needs of the

whole person, rather than de-compartmentalizing a person’s health and well-being. The

language and aspects of whole person care was written into the Omnibus Budget

Reconciliation Act (OBRA) of 1987. This policy mandated that long-term care settings

deinstitutionalize the care practices for frail, elderly and disabled persons by taking the

appropriate measures to enhance quality of life by providing “services to attain or

maintain the highest practable physical, mental, and psychosocial well-being” (Social

18

Security Act, 1986). This policy also guaranteed residents the right to free-choice, the

right to be free from restraints, the right to privacy and confidentiality, and the right to

voice grievances (Social Security Act, 1986). This reform policy started a culture-change

movement in long-term care in which paternalistic practices are being transformed

towards an approach in which elders direct their own care and are treated with respect

and dignity, and reside in home-like environments (CEAL, 2010). The strides of the

culture-movement are not slowing. Recently, with the enactment of the Affordable Care

Act, all community-based care must also be delivered in a “person-centered manner

through a whole person orientation, with coordinated and integrated care, and the

provision of safe and high-quality care through community-based health teams”

(PPACA, 2009).

The person-centered dementia care approach acknowledges the person first, not

the disease, and believes that persons with dementia can lead fulfilling lives (Kitwood,

1997). This philosophy allows caregivers to provide the persons with dementia with a

continuation of their identity which is so important when so much of their selves are lost;

not only to the disease, but through the social disintegration that occurs once given a

dementia diagnosis (Hashmi, 2009).

The theoretical framework for the philosophy was developed by the work of

Humanists Abraham Maslow and Carl Rogers, both of which conducted extensive

research on personhood. Maslow (1943) focused on human behavior which he posited

19

was goal-driven to fulfill needs which are hierarchically-arranged; this is his most

popular theory and which is referred to as: hierarchy of needs and includes:

1. Biological and Physiological needs: air, food, drink, shelter, warmth, sex,

sleep.

2. Safety needs: protection from elements, security, order, law, limits,

stability, and freedom from fear.

3. Social needs: belongingness, affection and love, -from work group,

family, friends, romantic relationships.

4. Esteem needs: achievement mastery, independence, status, dominance,

prestige, self-respect, and respect from others.

5. Self-Actualization: realizing personal potential, self-fulfillment, seeking

personal growth and peak experiences (McLeod, 2007).

The biological and physiological needs are at the base of the pyramid and the self-

actualization needs are at the peak. Although these levels are interdependent, the basic

premise is that people whose basic need for a food and water are unmet, are not likely to

want anything else; but once that need has been satisfied, higher needs emerge (Maslow,

1943) with the highest drive towards maturity and growth (McLeod, 2007). Using these

foundations, Carl Rogers (1951) applied what was first called non-directive therapy, and

later changed to client-centered therapy, to the counseling setting. Rogers believed that

in order to facilitate growth the focus of therapy needed to be on the client, as a whole

person; and that the role of the therapist was to express genuine concern, have an

20

acceptant attitude, hold the client with unconditional positive regard and experience the

moment with the client with empathetic understanding (Rogers, 1967).

The work of Rogers inspired Professor Tom Kitwood, British social psychologist

and founder of the Bradford Dementia Group at the University of Bradford, in the U.K.,

who applied the approach to his work with dementia. This revolutionized the way the

world sees dementia. Whereas prior dementia research focused on the neurological

pathology of the disease, Kitwood‘s research, like Rogers and Maslow, focused on

personhood which he says is “a standing or a status that is bestowed on one human being

by another in the context of relationship and social being” (Kitwood, 1997, p 8). He

asserts, that “although dementia challenges assumptions about what it means to be a

person, a person is always a person” (Woods, 1999, p. 35); and a person is “someone who

is worthy of recognition, who legitimately belongs to a community of responsible agents;

and who merits treatment with respect” (Kitwood, 1990, p 46). The recognition that each

person possesses a physical, social, psychological, and spiritual dimension promotes

morality and brings the person to the forefront of a disease that inhumanly robs aspects of

personhood. Kitwood (1997) believed that “people with dementia have only one all-

encompassing need—for love, which is met through the provision of the five great needs:

for comfort, attachment, inclusion, occupation and identity” (p. 19). This belief was

based on Maslow (1959) who found love to be a curative agent in treating the mentally-

ill, and which he says is “established through the rapport of empathy, sympathy,

21

kindness, and mutual trust between the patient and the therapist and the placing of the

patient in a social climate free from inner and interhuman conflicts” (p. 8).

Providing quality dementia-care requires a clear understanding of the core values

and philosophy of person-centered care and the provision of eight structural elements

needed to support person-centered care practices. The consensus reached by experts in

the field were recently published in a white paper by the Dementia Initiative (2013) and

includes:

1. “Every person has his/her own meaning of life, authenticity (personality, spirit

and character history, interests, personal preferences, and needs to continue to

experience life at all stages of dementia. The person is not their dementia illness;

rather the condition.

2. Focus on the strengths of the person living with dementia rather than on what

abilities

and capabilities have been diminished or lost.

3. “Enter the world” of the person living with dementia to best understand,

communicate with, and interpret the meaning of his/her behaviors from their

perspective” (p. 22).

The eight structural elements are interconnected and essential for supporting the

operational practices of person-centered care and include:

1. “Relationships and Community (belonging)

2. Governance

22

3. Leadership

4. Care Partners/Workforce (Resident-Care Aide)

5. Services

6. Meaningful Life and Engagement

7. Environment

8. Accountability” (CEAL, 2010, p. 9).

Person-centered care can be provided at home, in senior living communities, or in skilled

nursing facilities; therefore, not all structural elements will apply to all settings

(Dementia Initiative, 2013). However, this thesis focuses on care provided in assisted

living (senior living communities) where all elements do apply. However, for

organizational purposes this section will focus on the resident and person with dementia

in order to highlight the values directing this care approach and will explore the elements:

Relationships and Community; lightly introduce Care Partners/Workforce, Services,

Meaningful Life and Engagement, and Environment. The remaining structural elements:

Governance, Leadership, Workforce and Accountability will be discussed in the section

entitled Person-Centered Care in the Organization.

Relationships and community. “For persons living with dementia, relationships

and belonging are especially important as it as adds familiarity, comfort, meaning, and

context to daily living” (Dementia Initiative, 2013, p. 20). Unfortunately, Hashmi (2009)

found that persons with dementia often suffer a death of human interaction which Jootun

and McGhee (2011) affirm can lead to deprivation, isolation and detachment. Most

23

often, a lack of knowledge about dementia and communicating with persons with

dementia or how to respond to their behavioral expressions (Perry, Galloway, Bottorf, &

Nixon, 2005) has been identified as a problem. However, according to the need-driven

dementia-compromised theory of behavior, individuals will attempt to express

themselves using whatever form of communication intact, which is often through

behaviors which may include agitation, aggression or withdrawal (Gitlan,et. al., 2009).

However, Rogers (1967) stresses the need for having unconditional positive regard for

the person at the center of care; and Kitwood (1997) identified this as a requisite for care

partners since persons with dementia cannot rationalize their own behaviors. Close

relationships with persons with dementia allows care partners to know the person well,

which enables them to look for the root causes of behaviors and learn the meaning of

these expressions by paying close attention to their non-verbal forms of communication,

which Jootun and McGhee (2011) state “accounts for 93 percent of communication in

humans” (p. 42). In fact, Hadley, Brown and Smith (1998) asserted that emotional

intensity is strongly congruent with facial expressions which are universal, and therefore,

can provide care partners with valuable insight as to how the individual is feeling or

might need. The more the care partner knows about the person with dementia the greater

their understanding and competency in responding to their needs will be (Kitwood, 1997)

as only through relationship is this information transmitted and learned. Additionally, the

Centers for Excellence in Assisted Living (CEAL) (2010) reported on a study which

found that close relationships with care partners slowed the rate of the clinical

24

progression of dementia and is another reason for why retaining a stable care staff is so

valued, as these relationships and connections take time to develop. Therefore, the

“operational practice to support these relationships (…) is a culture that ensures staff has

time to spend with residents in order to form, nurture, and maintain these relationships”

(Dementia Imitative, 2013, p. 22).

Care Partners/Workforce. Person-centered care acknowledges the incredible

role that the caregiver has in providing quality care. Without them, the structural element:

relationship and community cannot be sustained. Therefore, the caregivers, or care

partners, are not viewed “as simply people being paid to accomplish tasks, but integral to

the success of the entity in general and for individualized person-centered dementia care”

(Dementia Initiative, 2013, p. 20). In assisted living, care partners have the unique

opportunity to form close emotional bonds with residents which serves as psychic

income, which Chou (2012) asserts makes an otherwise undesirable job meaningful.

Therefore, it is imperative that workforce practices support the relationship-building

between the person with dementia and the care partner through consistent assignment and

having the appropriate number of staff on shift each day and by providing effective

education and supervisory support (Dementia initiative, 2013). In this thesis, the paid

care partner in assisted living will be referred to as the Resident-Care Aide and will be

further explored later in this review.

Services. Person-centered care requires personalized services and should reflect

the persons “values, lifestyle choices, and needs to support his/her unique rhythms of

25

daily living” (Dementia Initiative, 2013, p. 20). This requires a comprehensive holistic

assessment which assesses for “cognitive health, physical health, physical functioning,

behavioral status, sensory capabilities, decision-making capacity, communication

abilities, personal background, cultural preferences, and spiritual needs” (Tilly & Reed,

2006, p. 5) and is used to direct the care plan for each person with dementia. According

to Tilly and Reed (2006) “an effective care plan builds on the resident’s abilities and

incorporates strategies such as task breakdown, fitness programs and physical or

occupational therapy to help residents complete their daily routines and maintain their

functional abilities as long as possible” (p. 6).

Providing personalized care preserves personhood and allows the person with

dementia to remain an agent in their own life, despite failing mental powers (Kitwood,

1997). This requires persons with dementia to be seen “not as an object, not as a

vegetable, not an empty body, not a child, but an adult, who, given support, might

exercise choices and respond to a respectful approach” (Woods, 1999, p. 35). The

personal biography provides a wealth of information for care partners to act as proxy

agents on their behalf (Bandura, 2001). For example, the daily routines the person with

dementia had for eating, bathing and sleeping, and the activities and social interests they

engaged in throughout their life can be used to personalize care and honor choice.

Meaningful life and engagement. Having dementia does not mean the need for

a meaningful life diminishes. In actuality, it may become more important. The construct

of what it means to have a meaningful life is multifaceted and is personal. This is why

26

collecting the biographical information for the personalization of care services is so

important as it allows care partners to individualize their experiences as much as possible.

Just as the person with dementia’s daily routines and social interests are used for

developing services for the care plans, the personalization adds to a meaningful life. As

for engagement, it is important to note that “people have different needs for solitude and

socialization, what is purposeful and meaningful for each individual is unique to them”

(Dementia Initiative, 2013, p. 21). However, in general, persons with dementia benefit

from:

Everyday social interactions, including brief positive interactions with casual

acquaintances and care partners, [as it] fosters a sense of well-being. Laughing,

singing, or simply being with others can exert a calming or energizing influence.

Knowing that one is part of a social community larger than oneself can provide a

reassuring context when a person is feeling particularly lost or upset. (Dementia

Initiative, 2013, p. 31).

For elders with early stage dementia, Chung (2009) found they benefited greatly from

opportunities to reminisce with younger generations. This is because “remote memories,

especially those with a personal reference (autobiographical memories), are relatively

spared until advanced stages. Reminiscence is about remembering, putting things

together and communicating meaning (…) and represents one of their spared cognitive

strengths” (Chung, 2009, p. 259) which provides a continuation of their identity and adds

meaning to their life. The family is also integral to the success of the process and as

27

valuable resources for acquiring personal items such as photographs and other

memorabilia of the person with dementia during childhood, adolescence, and adulthood

(Boise & White, 2004). Displaying these items in the person with dementia’s personal

spaces is a powerful way to trigger episodes of ‘rementia (Epp, 2003) and personifies

them to the care partner.

Having an occupation is integral to a meaningful life as it adds purpose and

enjoyment to daily life and fosters emotional health and can reduce the occurrence of

distressing behavioral expressions (Dementia Initiative, 2013). Although “persons with

dementia may no longer have the cognitive skills necessary for long-term projects or

activities that require a lot of memory, judgment or planning” (Kitwood, 1997, p. 20)

there are many activities that can be modified and still enjoyed. In fact, research suggests

that for individuals with a cognitive impairment “activity may fill a void, maintain social

roles, enable positive expression, reduce frustrations, and enhance continuity of self-

identity and feelings of connectedness” (Gitlan, et. al., 2009, p. 429).

Environment. The structural elements in person-centered care are

interconnected. Perhaps the clearest example of this connectedness is through the

structural element environment. Good dementia-care requires a supportive physical and

social environment. In the absence of this support persons with dementia may not feel

safe enough to engage or trusting enough to develop close relationships with care

partners and others and detracts from a meaningful life. Providing a safe physical

environment requires special attention to “create effective designs for indoor and outdoor

28

spaces, colors, lights, sounds, furniture, and furnishings that blend to create a warm,

comfortable, orienting, safe place to be” (Dementia Initiative, 2013, p. 21). This is

essential if the person with dementia is “to achieve maximum functioning, comfort,

functionality, safety, and well-being” (Dementia Initiative, 2013, p. 24). Institutional-

style common rooms with loud televisions and cafeteria-style seating are not therapeutic

for persons with dementia and can actually result in the occurrence of distressing

behavioral expressions such as agitation or withdrawal (Weitzel, et al., 2011).

The social environment has a significant impact on the wellbeing of persons with

dementia. The social environment includes the language used; the attitudes; behaviors

expressed; which reflects the culture of the environment. Unfortunately, persons with

dementia are prone to stigmatization and stereotyping by others which detracts from a

supportive environment (Gavin, 2011). This is because in everyday life, “people select,

collect, and store a large amount of information from their encounters with others (…)

and then make some condensed summary descriptions in the form of ascribed traits”

(Kitwood, 1990, p. 186). This tendency leads to the ascription of labels based on the

behavioral traits expressed by persons with dementia. For example, persons with

dementia may become disoriented and confused and wander off, leading to them being

labeled a wanderer. Such labels degrade personhood and further alienate them from

others (Kitwood, 1993). In person-centered care, person-first language is embraced and

the person who wanders is reframed as person who enjoys being active; this reframing,

29

Fazio (2001) says, “helps people recognize positive aspects [of the person] which were

previously viewed as only negative” (p. 88).

Reframing not only of words but of attitudes, perceptions, and beliefs about

dementia is required for a person-centered culture. In fact, Tietleman, Raber and Watts

(2010) warn that “both professional and informal [care partners] need to be aware of the

power that their attitudes and behaviors have in shaping the social environment” (p. 330).

According to Kitwood (1995) a supportive social environment is where “individuality is

respected, agency is maintained, feelings are validated, abilities are exercised; there is a

celebration of life, with much to give pleasure to the senses, and support [is] provided in

times of distress” (para. 29). The social actions which promote a supportive environment

and well-being include:

1. “Recognition- being acknowledged as a person affirmed in one’s own

uniqueness.

2. Negotiating- being consulted about preferences, desires and needs, in a way

that takes into account anxiety, so that even the most dependent person have

some degree of choice.

3. Play- being safe enough for play, to have spontaneity and self-expression.

4. Timalation- honor personal or moral boundaries and stimulation in a non-

sexual contact.

5. Validation- validating one’s experience so that the person with dementia can

feel more alive, more connected and more real.

30

6. Holding- proving safety, security and comfort so that a painful emotion will

pass and not cause disintegration to the psyche.

7. Facilitation- when a person’s sense of agency is depleted, enabling of

interaction to get started, to amplify it, so that meaning can develop”

(Kitwood, 1997).

The social psychology of the care environment ventures into every aspect of care

giving and throughout the organization. For example, poor nutrition can lead to

increased infections, slower wound healing, greater risk of falls and fractures, and lower

health-related quality of life (Reimer & Keller, 2009). While the nutritional intake of

older adults often declines with age due to physiological changes such as a reduced

appetite and taste alterations (Reimer & Keller, 2009), Hung and Chaudhury (2011)

found that when care partners provide a supportive social psychology, both nutritional

intake and positive person-centered care outcomes increase. This is because “eating is not

only essential to physical survival, but is important for emotional and social needs of

human life” (Hung & Chaudhury, 2011, p. 1). According to Reimer and Keller (2009)

pleasant dining experiences are created when staff value the social aspect of meals and

find ways to honor residents as individuals, holistically, otherwise feeding could become

task-focused, rushed, or stopped too soon” (p. 330).

Providing a supportive social environment encompasses many things and to list

them would be endless. However, music programs and activities can contribute to the

creation of a supportive environment as it has a strong impact on human emotion.

31

“According to Dr. Oliver Sacks, Professor of Neurology at New York University School

of Medicine, music can lift us out of depression or move us to tears — it is a remedy, a

tonic, orange juice for the ear. But for many of my neurological patients, music is even

more — it can provide access, when no medication can, to movement, to speech, to life

(Dementia Initiative, 2013, p. 26). This was supported when a qualitative study was

conducted by Gotell, Brown and Ekman (2007) in which music was incorporated into

care giving of nine persons with severe dementia. The results revealed that compared to

no music, the persons with dementia whose care partners played background music

during meals and dressing proved to enhance mutuality and increase their sense of

playfulness. For the care partner who merely sang, or hummed, it enhanced a sense of

sincerity and intimacy between them and the person with dementia. The structural

element of environment is connected to the structural element of relationships and

belonging by the connectedness and sincerity which also adds to a meaningful life.

Assisted Living and the Resident-Care Aide

The Omnibus Reconciliation Act of 1987 was the turning point in the culture-

change movement in long-term care. Not only did this act mandate that long-term care

settings deinstitutionalize their of care practices for frail, elderly and disabled people, but

provided Medicaid home- and community-based waivers to individuals who need some

assistance with the activities of daily living such as dressing, bathing and grooming but

want to remain in the community (Social Security Act, 1986); assisted living falls under

this category of the policy. While the concept of assisted living-type of housing was not

32

entirely new, the term first appeared in 1978, along with a housing model consisting of

three of key principles which include:

1. “Residential environments with both private and public spaces;

2. Health services for both routine, unplanned, and specialized care; and

3. An operating philosophy which emphasizes resident-choice regarding the

resident’s time, space, possessions, and contacts in his or her private space, as

well as the choice to accept or reject medical or health-related care and

services” (Wilson, 2007, p. 10).

Today, assisted living can range from small personal board and care homes to

large apartment-complex housing models with some being privately owned and others

with not-for-profit status (Kane & Wilson, 1993). Some are located adjacent to nursing

homes or independent living quarters or have specialized memory care living quarters

which provide additional services and supervision for persons with advancing dementia

(Wilson, 2007). Prior to this, nursing homes were the most popular choice and the

predominant form of public long-term care (Wilson, 2007). However, today, a move to a

nursing home in order to receive 24-hour care costs an estimated $78,000 per year

(NAPA, 2010); whereas “the national average cost for basic services in an assisted living

facility is $41,724 per year (Alzheimer’s Association, 2013). Currently, assisted living is

“home to more than one million of the U.S.’s older adults in 36,000 settings nationwide,

filling the gap between independent living and nursing home care” (Harris-Wallace, et

33

al., 2011, p. 98) and the demand for this type of housing will only increase with the vast

number of baby boomers who are now and will be reaching the age of retirement.

The development of assisted living provides consumers with a greater selection of

community-based home care options but is not without problems. Because they are

licensed by the state as non-medical, Residential Care Facilities for the Elderly; and

despite the fact that more than 50 percent of residents present with dementia (CEAL,

2010), they are not required to hire professional-level nursing staff. Instead, they employ

Resident-Care Aides to assist the residents with performing the activities of daily living.

While, Ball, Leproe, Perkins, Hollingsworth and Sweatman (2009) found that it was their

“values for helping elders and care giving jobs stemmed from past family experiences

which attracted them to assisted living” (p. 41), Resident-Care Aides are not required to

have a nursing background, high school diploma, or prior experience working with older

adults. Unlike nursing homes, which require aides to be certified by completing 75 hours

of training and pass an exam (Social Security Act, 1986), aides in assisted living receive

just ten hours of training in which they have four weeks to complete, with four hours of

additional training each year (Social Security Act, 1986).

According to California’s state regulations for RCFE’s the curriculum provided to

Resident-Care Aides covers:

1. “The aging process, physical limitations, and special needs of the elderly

34

2. The importance and techniques of personal care services, including, but not

limited to: bathing, grooming, dressing, feeding, toileting, and universal

precautions

3. Residents’ rights and personal rights

4. Medication policies and procedures

5. Psychosocial needs of the elderly (e.g. recreation, companionship,

independence, etc.)

6. Recognizing the signs and symptoms of dementia in individuals” (Residential

Compendium, 2007, pp. 3-39).

For “[Resident-Care Aides] caring for residents with dementia in a community that

advertises or promotes dementia special care, programming, or environment receive extra

training. In addition to other staff training, they must complete six hours of resident care

orientation within the first four weeks of employment (…) with an additional eight hours

of in-service training per year” (Compendium, 2007, pp. 3-36). The training encompasses

the following:

1. “Hydration;

2. Skin care;

3. Communication;

4. Therapeutic activities;

5. Behavioral changes;

35

6. Environment;

7. Assisting with activities of daily living;

8. Recognizing symptoms that may create or aggravate dementia behaviors;

9. Recognizing the effects of medications commonly used to treat the symptoms

of dementia;

10. Responsiveness to the general security and supervision of dementia residents”

(Residential Compendium, 2007, pp. 3-39).

Despite the appearance of a comprehensive aging and dementia care curriculum,

it rarely prepares Resident-Care Aides for the multiple and complex challenges they are

likely to experience on the job. As a result, it is imperative that Resident-Care Aides

receive effective supervisory support with on-the-job coaching and feedback on their care

performance. Without it, the Resident-Care Aide is prone to feel that their responsibilities

exceed their abilities, resulting in role overload (Chou, 2012). This is when a malignant

social psychology seeps in and depletion, disillusionment and burnout ensues (Kitwood,

1995). Burnout is a leading cause of turnover and is characterized as “exhaustion and

reduced interest in tasks or activities (…) and can result not only from work overload but

role ambiguity, role conflict, limited job autonomy and client demands” (Gray-Stanley &

Muramatsu, 2011, p. 1066) as well. The burnout of staff can result in the provision of an

un-therapeutic social environment for residents. Kitwood (1993) coined an un-therapeutic

social environment as a malignant social psychology, which is the direct opposite of a

supportive social psychology described earlier; they are the negative actions by staff that

36

can occur as a result of burnout and that can significantly impact the resident’s health and

wellbeing. These actions include:

1. “Treachery- using dishonest representation or deception to obtain compliance.

2. Disempowerment- doing for a dementia sufferer what they can do for

themselves.

3. Infantilizing- implying the persons with dementia has the mentality of a baby

or young child.

4. Condemnation- blaming the person with dementia of behaving with malicious

or seditious intent.

5. Intimidation- use of threats, commands, or physical assaults; the abuse of

power.

6. Stigmatization- turning the dementia sufferer into an alien, a diseased object,

an outcast, especially through verbal labels.

7. Outpacing delivering information or instruction too fast for the person with

dementia to process.

8. Invalidation- ignoring or discounting the person with dementia’s subjective

state, especially in feelings of distress or bewilderment.

9. Banishment- removing the person with dementia from human surroundings,

either physically or psychologically.

10. Objectification- treating the person like a lump of dead matter; something to

be measured or pushed around” (Kitwood, 1997).

37

Unfortunately, this population of workers has one of the highest turnover rates. In

fact, while the direct care staff in all long-term care settings experience similar staffing

challenges, the aides in assisted living have rates as high as 200 percent annually with

many leaving within their first year of employment (Chou, 2012). Turnover is costly in

terms of hiring and training new staff. One study revealed that “the estimated staff

turnover cost for each [Resident-Care Aide] is approximately between $1750 and $5000”

(Coogle, et. al., 2011, p. 521); the Centers for Excellence in Assisted Living (CEAL)

(2010) estimated “the annual cost associated with turnover in a typical assisted living

residence with 67 staff and an average turnover rate of 73 percent, to be approximately

$84,537” (p. 18). Reducing staff turnover is critical for improving satisfaction among

residents and their family members. When staff is stable, the Resident-Care Aide

benefits from knowing the person with dementia well, and therefore, is better able to

respond to their communicated needs, spoken and behaviorally expressed. For family

this knowledge is priceless as they can rest knowing their loved one is in good hands; on

average, “when turnover decreased by 20 percent, resident and family satisfaction

increased by 30 percent” (Chou & Roberts, 2008, p 209). With the vast number of

assisted living options on the market today, ensuring that family is satisfied is indicative

that person-centered care is effective and that the organization develops a reputable

reputation (Lee, 2012).

The costs associated with turnover are alarming and raise an interesting question.

If resident-aides voluntarily seek employment in assisted living and find the residents the

38

most satisfying part of their jobs, why then, is turnover among this population of workers

so high? Chou (2012) credits this phenomenon directly to how satisfied the aide is with

their job; which he asserts is the outcome of the measure and quality of the presenting

stressors and the availability of workplace support. Person-centered care, when all

structural elements are secured and maintained, is designed to provide the necessary

supports needed to improve satisfaction and decrease staff turnover (Dementia Initiative,

2013). The following section will explore the remaining structural elements of person-

centered care within the organization.

Person-Centered Care in the Organization

The same human-oriented frameworks used for guiding person-centered

dementia-care are the same frameworks applied to the organizational setting and

treatment of staff. Recall, Maslow’s theory of hierarchy of needs posits that human

behavior is goal-driven to fulfill the following hierarchically-arranged needs:

1. “Biological and Physiological needs: air, food, drink, shelter, warmth,

sex, sleep.

2. Safety needs: protection from elements, security, order, law, limits,

stability, and freedom from fear.

3. Social needs: belongingness, affection and love, -from work group,

family, friends, romantic relationships.

4. Esteem needs: achievement mastery, independence, status, dominance,

prestige, self-respect, and respect from others.

39

5. Self-Actualization: realizing personal potential, self-fulfillment, seeking

personal growth and peak experiences” (McLeod, 2007).

Of particular importance for the Resident-Care Aide, and consequently persons

with dementia, are the safety and esteem needs. Going back to the structural element of

environment, the social psychology of the organization significantly impacts work

performance and resident-care. A supportive organization is essential, with each person

respected and properly supported, for the delivery of quality person-centered care. The

remaining structural elements: governance, leadership, workforce, and accountability are

essential for supporting and sustaining the mission, culture, and practice of person-

centered care; each of these will now be reviewed.

Governance. The successful delivery of person-centered care in assisted living is

dependent on the governing bodies. As the “ultimate decision-makers, (…) the owner,

operator, and the board are essential to establishing, implementing, and sustaining the

operational culture within their organization; without their active involvement and

commitment, and person-centered dementia care cannot be created or sustained”

(Dementia Initiative, 2013, p. 20). This means that they are responsible for ensuring that

all structural elements are secured and producing desirable outcomes. Unfortunately,

however, “resistance from senior leadership is the most frequently cited barrier to

adopting culture change, followed by perceived cost and concern about compliance with

regulatory requirements” (Brownie & Nancarrow, 2013, p. 8). This is because the

commitment to provide quality person-centered care is a value-base” (Kirkley, et. al.,

40

2011, p. 442) and “medically oriented institutions may not value the time required for

staff to attend to the personhood needs of persons with dementia and may not recognize

that the approach can save time and money in the long run by decreasing disruptive

behaviors of dementia sufferers and decreasing staff turn-over” (Thornton, 2011, p. 11).

Fortunately, Rogers (1967) asserts that “values are not held rigidly, but are

continually changing” (p. 21) and “are subject to reappraisal in the light of new

experience” (Kitwood, 1990, p. 57). New experiences can come from making the

commitment to be a learning-organization and by providing effective, organization-wide

education in both dementia and person-centered care. Consequently, in order to create an

“institution of great depth and quality, the board must undergo a radical shift in how they

approach their roles” (Spears, 1996, p. 2) due to the flattening of the management

hierarchy that elicits the participation of Resident-Care Aide’s in the collaboration and

planning related to resident-care. And, as a result, Tilly and Reed (2006) affirm that

“administrators have the critical role of evaluating facility policies and procedures to

ensure that they support the [Resident-Care Aide] decision making during real-time

interactions with residents” (p. 8) and must re-design those policies and procedures that

do not support staff decision making (Dementia Initiative, 2013).

Leadership. Strong organizational leadership is essential for providing the

successful delivery of person-centered care because it is a radical shift from traditional

long-term care management models. "Leadership refers to the head of an organization

and executive and managerial staff positions; [they] are the key communicators and

41

supporters to ensure that person-centered operational practices are implemented,

achieved, and sustained” (Dementia Initiative, 2013, p. 20). Because of the holistic

nature of person-centered care it is imperative that the leadership-style also reflect the

values of person-centered care. Traditional long-term care management models use an

authoritative-style of management where tasks are valued over relationships (Kendall,

2011). Inconsiderate leaders have been described by Bass (1960) to “frequently demand

more than can be done, who criticize subordinates in front of others, who treat

subordinates without considering feelings, who ride subordinates for making mistakes

and who frequently deflate the self-esteem or threaten the security of subordinates by

acting without consulting them, refusing to accept suggestions, and refuse to explain

actions” (p. 99). Poor leadership “has consequences for staff in terms of demoralization,

burnout and stress, lower work satisfaction or job clarity, lower psychological wellbeing

and high workforce turnover” (Brooker & Wooley, 2007, p. 379). This does not help the

vision of person-centered care move forward, nor does it create a supportive social

environment.

Two leadership styles which have been found to promote the safety, esteem and

retention of the Resident-Care Aide are the transformational leader and the servant-

leader. The transformational leader is someone who understands the values of the

organization and “[models] a set of behaviors that motivate followers to achieve

performance beyond expectations by changing followers' attitudes, beliefs, and values as

opposed to simply gaining compliance” (Yucel, McMillan, & Richard, 2014, p. 2). It is

42

someone who “inspires and mentors their subordinates and has strong communication

skills, is a good listener, possesses teamwork skills, effectively develops others through

mentorship and coaching, and is be able to articulate a shared vision” (Isaac, Grifin, &

Carnes, 2010, p. 544). The servant leader is committed to “teamwork and community;

involving others in decision making; is strongly based in ethical and caring behavior; and

to enhancing the growth of people” (Spears, 1996, p. 1). While both styles are very

similar, however, Stone, Russell and Patterson (2004) denote “the difference is the focus.

The transformational leader's focus is directed toward the organization, and his or her

behavior builds follower commitment toward organizational objectives, while the servant

leader's focus is on the followers, and the achievement of organizational objectives is a

subordinate outcome” (p. 1). A healthy combination of both leadership-styles is the best

practice for a healthy person-centered care environment. Leadership, like the social

environment, ventures into all aspects of care and throughout the organization.

Therefore, the following section will apply leadership with respect to developing a strong

workforce.

Workforce (Resident-Care Aide). The Resident-Care Aide in assisted living is

integral to the successful delivery of person-centered care (Dementia Initiative, 2013).

Therefore, it is the responsibility of the governing officials and members of the leadership

team to ensure that the Resident-Care Aide is “effectively oriented, trained and mentored

[in order] to build person-centered care skills and competencies” (CEAL, 2010, p. 15).

When considering the challenge of staffing and its impact on the quality of the dementia

43

care, it is imperative that the organization devote attention to the third and fourth level of

Maslow’s hierarchy of needs which includes the need for: safety and esteem. According

the McLeod (2007) esteem needs include the need for achievement mastery,

independence, status, dominance, prestige, self-respect, and respect from others;

attending to employee self-esteem within the organizational setting has proved good

results. Brockner (1988) asserts that “self-esteem typically refers to a global construct

that taps individual’ self-evaluations across a wide variety of situations” (p. 14).

The extent at which the organization can influence a Resident-Care Aide’s global

construct is variable, but raising their evaluations of their care giving abilities may

profoundly affect their commitment, satisfaction, and retention with the company. This

is because, as Huang, Shyo, Chen and Hsu (2009) assert, care giving behaviors largely

depend on the care partners’ perceived self-efficacy. Self-efficacy is a cognitive

regulating process in which one’s perceptions of their abilities affect their level of

motivation, goal-setting and actual performance (Bandura, 2012). In general, “people

who have a high assurance in their capabilities approach difficult tasks as challenges to

be mastered rather than as threats to be avoided” (Bandura, 1989, p. 731) and therefore

perform higher (Brockner, 1998). Having an understanding of how self-efficacy is

developed can provide organizations with opportunities to raise the care giving efficacy

of the Resident-Care Aide and can significantly impact job-satisfaction and retention.

Therefore, this theory will now be applied to the Resident-Care Aide with respect to

leadership, safety and esteem.

44

The first way self-efficacy is developed is by mastery experiences (Bandura, 2012).

This is “the most dependable source of efficacy expectations because they are based on

one’s own personal experiences. Successes raise mastery expectations; repeated failures

lower them” (Bandura, 1977, p. 80). Therefore, the governing policies and leadership must

enable others to act, as an exemplary leader “enlists the support and assistance from all

those who must make the project work (…); they know that those who are expected to

produce the results must feel a sense of ownership” (p. 12). This is why person-centered

care flattens the hierarchy and involves the Resident-Care Aide in the planning,

collaborating and decision-making processes regarding resident-care because it validates

their valuable role and allows them to develop and use all of their knowledge and skill

(Koren, 2010). For example, one of the most effective means of addressing behavioral

expressions not associated with an unmet need, such as pain, hunger or thirst, is therapeutic

recreation (occupation). Gitlan, et. al., (2009) developed and tested a Tailored Activity

Program (TAP), which consisted of 170 prescribed activities and was assigned to 60 persons

with dementia and their care partners who were trained on how to use the prescribed

activities. The results revealed that not only did the program promote wellness in persons

with dementia, but it had a profound, positive effect on caregiver self-efficacy “with 86 %

saying that they had enhanced skills and 93% saying they felt they had more [confidence]

that they could diffuse challenging behaviors” (Gitlan, et al., 2009, p. 429).

The second way self-efficacy is developed is through social modeling (Bandura,

2012). According to Bandura (1977) “seeing others perform threatening activities without

45

adverse consequences can create expectations in observers that they too will succeed if

they intensify their efforts; they persuade themselves that if others can do it, they should

be able to achieve at least some improvements” (p. 81). There are a number of people

within an organization who can serve as models for the Resident-Care Aide the person-

centered care giving behaviors needed to enhance the effectiveness of their skill;

however, according to Kouzes and Posner (1995) “the three most important are mentors,

immediate supervisors/managers, and peers” (p. 329). Mentors can be formal or informal

persons within the organization and can help the Resident-Care Aide “navigate the

system, make introductions, and point [them] in the right direction” (Kouzes & Posner,

1995, p. 329). This is important because Resident-Care Aide’s in assisted living receive

as little as ten hours of initial training with six additional hours each year after (Social

Security Act, 1986). This means that much of the learning that Resident-Care Aides

acquire comes from on-the-job experience and guidance from supervisors and other staff.

The CEAL (2010) supports the use of work teams as they correlate to higher performance

and reduced turnover and allow for role modeling and the sharing of creative care giving

interventions by more experienced staff. Likewise, mangers have a crucial role in the

practical skill development of the Resident-Care Aide and can do so by providing hands-

on-training, coaching and feedback, with the goal of inspiring excellence in care. Kouzes

and Posner (1995) assert “the best ones challenge us, trust us, are willing to spend time

with us, and are consistent in their behavior” (p. 330).

46

Educational resources can also provide Resident-Care Aides with vicarious

learning experiences. Training programs which employ a variety of experiential and

interactive teaching methods such as on-the-job coaching, role playing, case studies, and

self-reflective assignments (Boeitcher, Kemeny, DeShon & Stevens, p. 2004) have been

found to be more “productive and beneficial than lecture and video trainings, [and]

recognizes that people have different learning strengths; some learn best visually, others

by hearing information and still others by doing” (CEAL, 2010, p. 19). Role-playing is

an educative process designed to bring about a change in attitude, set, and behavior of

trainees” (Bellows, 1959, p. 227) “by allowing them to act out solutions to problems

without a script, promoting transference from learning situations to performance on the

job” (Bass, 1960, p. 216).

The third way self-efficacy is developed is through social persuasion (Bandura,

2011). According to Bandura (2011) “if people are persuaded to believe in themselves they

are more perseverant in the face of difficulties, [as] resolve increases the chance of success”

(p. 13). However, this manner of efficacy expectation is weak and short-lived as it can

create expectations without providing an authentic base for them” (Bandura, 1977, p. 82).

Therefore, leaders must “pay attention to be sure they observe followers doing the right

things and doing things right and compliment workers on their successes, encouraging their

hearts through verbal recognition to keep working toward the vision” (Boone & Makhani,

2012, p. 19), coupled with practical models of success to provide needed reinforcements.

47

Understanding the barriers to staff buy-in allows for better leadership to emerge and

social persuasion to occur. For example, Bellows (1959) asserts that “people resist change if

they do not see a need or if they feel they are being pushed into it” (p. 226). Therefore, the

leader must communicate and inspire a shared vision as “visions seen only by leaders are

insufficient to create an organized movement or a significant change in the company (…);

leaders cannot command commitment, only inspire it. (…) To enlist support, leaders must

know their constituents and speak their language” (Kouzles & Posner, 1995, p. 11). They

must “display an individualized consideration and to develop a high quality dyadic

relationship with each [Resident-Care Aide], paying particular attention to their special

needs and wants, and provide the information and resources needed for successful

completion of tasks” (Tse & Chiu, 2014, p. 2829). This conveys to staff that they are truly

valued members of the team and integral to the success of person-centered care and the

organization (Dementia Initiative, 2013). Additionally, “people resist change if there is lack

of visible reward for changing” (Bellows, 1959, p. 226). Not only do people seek out and

stay at organizations that offer the rewards they want or are lacking at other companies

(Bass, 1960), but rewards can reinforce the behaviors valued by the organization and

increase their willingness to support the values and goals of the organization (Bellows,

1959). Therefore, good leaders “take care to recognize both individual contributions and

team achievements through rewards, awards, gifts, and thank-you’s of many types;

presenting a plaque, naming an employee-of-the-month, or honoring a retiree are

opportunities to [highlight staff’s] successes and to reinforce the community’s shared values

48

and vision” (Boone & Makhani, 2012, p. 19). While initially the Resident-Care Aide may be

motivated by the reward, in time and with practice the real reward will come when they see

the benefits of person-centered care which equates to overall-wellbeing of the residents and

satisfaction in their jobs.

The fourth way self-efficacy is developed is through physical and emotional

states (Bandura, 2012). According to Bandura (1977) when evaluating self-efficacy

“people rely partly upon their anxiety and vulnerability to stress; because high arousal

usually debilitates performance, individuals are more likely to expect success when they

are not beset by aversive arousal than when they are tense, shaking, and viscerally

agitated” (p. 82). Dementia-care poses complex challenges that make the Resident-Care

Aide prone to experiencing states of stress. However, leaders within person-centered care

organizations must recognize that “no one does their best when they are feeling

incompetent or alienated” (Kosner & Posner, 2005, p. 12) and therefore, provide their

workforce with effective instrumental and emotional supports needed to develop their

knowledge and skill (Chou, 2012). In doing that, leaders must also recognize that if the

Resident-Care Aide’s is to learn and thrive, they have to attend to the safety needs of staff

by ensuring that the structural element social environment is effective, as Rogers (1951)

asserts:

Only in an atmosphere of safety, protection, and acceptance, the firm boundaries

of self-organization relax (…) [enough to] explore his perceptual field more and

more fully. He discovers faulty generalizations, but his self-structure in now

49

sufficiently relaxed so that he can consider the complex and contradictory

experiences upon which they are based (…) and is able to assimilate this

contradictory experience into a new revised pattern a process of disorganization

and reorganization. (p. 193).

With new gained knowledge and with leadership’s support the Resident-Care Aide “can

gain confidence in [their] ability to handle the stresses, anxieties, and problems”

(Maslow, 1959, p. 127) associated with care giving.

Accountability. Person-centered care is multifaceted and requires the full

commitment and action by those in governance and leadership positions within the

organization. It is this structural element which ensures that the integral components of

person-centered care are in place and producing desired outcomes. Accountability, refers

to “a system [to] regularly evaluate the performance (culture, operations, processes,

systems) and be collected through internal and external means, including resident, family,

and staff satisfaction surveys” (Dementia Initiative, 2013, p. 24). The goal is to ensure

that all components are functioning and maintained so that quality dementia care can be

provided; where staff receive the necessary supports to perform their jobs effectively,

which above all else entails the development of close bonds with residents, which is at

the heart of person-centered care. Therefore, the operational practice for accountability is

“ensuring that all of the person-centered dementia care practices and processes are, in

fact, producing intended outcomes” (Dementia Initiative, 2013, p. 24).

50

Summary

This chapter outlined the key research regarding dementia care with respect to the

provision of person-centered care approach, and in assisted living. As was presented,

dementia poses multiple and complex challenges for caregivers which are integral to

success of resident-care. The person-centered care approach was developed using the

theoretical framework of Abraham Maslow’s hierarchy of needs and Carl Roger’s client-

centered therapy and is collectively concerned with preserving personhood and

promoting the growth of all people within the organization. As was discussed, it is the

role and responsibility of governance and members of the leadership team to ensure that

that a person-centered culture is created, achieved and maintained (Dementia initiative,

2013). Leadership was juxtaposed the structural element workforce (Resident-Care Aide)

and was examined through the lens of Albert Bandura’s self-efficacy theory. This pairing

allowed for a better application of the leadership needed to meet the safety and esteem

needs of the Resident-Care Aides employed in the organization. The next chapter, chapter

three, will explain the methodology used in this research study which focuses on the

person-centered care provided in assisted living community.

51

Chapter 3

METHODOLOGY

Overview

An assisted living community (ALC) is “home to more than one million of the

U.S.’s older adults in 36,000 settings nationwide filling the gap between independent

living and nursing home care” (Harris-Wallace, et al., 2011, p. 98). While ALC’s are

licensed by the state as non-medical, Residential Care Facilities for the Elderly, more

than 50 percent of residents present with dementia (CEAL, 2010); and with the aging of

the baby-boomers the demand for this type of housing and the prevalence of dementia

will only increase over the next thirty years (Alzheimer’s Association, 2013). This will

only complicate current staffing challenges that affect the assisted living industry and

place greater demands on the Resident-Care Aide. Staff turnover has negative

implications for both the organization and for persons with dementia. For the

organization, staff turnover results in high costs in terms of hiring and training new staff;

for the person with dementia, turnover can result in unmet needs (Gitlan, et al., 2009) as a

new staff member may not be familiar with their preferences or understand the meaning

behind their behavioral expressions (Dementia Initiative, 2013). For these reasons, the

assisted living industry must find a way to retain a stable workforce.

Research Design and Data Collection

This study uses ethnographic research methods to collect qualitative data from the

selected research site for this study. “Ethnographic research is grounded in field work that

52

enables the researcher to study the activities of people in their everyday setting” (Palmer,

2001, p. 301) in order to discover what daily life is like for the members of that group.

This research is important because “the culture of a social group [is] a shared way of

viewing the world, its definitions of what is real and true; what is important in pursuing;

sense of history, and the personal qualities that are to be esteemed” (Kitwood, 1990, p.

164). Culture emerges in verbal exchanges, attitudes, behaviors, and through workforce

practices despite marketing resources which may state otherwise. The ethnographic

research approaches used in this study included participant-observation visits, surveys,

and informal interviews with staff as questions arise during these visits to the assisted

living community.

The procedure for distributing and collecting the survey instruments will take

place during the participant-observation visits that has been approved by the community.

During these visits I will follow/shadow the Resident-Care Aides as they carry out their

daily routines caring for residents and record my observations in a field note book.

During this face-to-face interaction, the researcher took the opportunity to request that the

Resident-Care Aides participate in the study which entailed taking the paper-based

survey instrument on-site and agree to an informal interview as questions arise. The

researcher provided written information on their rights as voluntary research participants

and had them sign the prepared consent form and then give them my survey. Between

the data gathered from the participant-observation visits, informal interviews and survey

53

responses a rich source of information for answering the research questions was expected

to be obtained.

Research Questions

The intent of this research study was to keep an open-mind and not bring

assumptions about what the researcher expected to find. However, in light of the literature

reviewed in Chapter Two, the following research questions were developed to guide the

research design:

Primary Research Question

1. In what ways are the qualities of person-centered care expressed, or not expressed, in

the staff-staff and staff-resident interactions? (i.e., nutrition, mood, behavior,

socialization, and therapeutic activity, teamwork, support, feedback, etc).

Secondary Research Question

2. In what ways are the qualities of satisfaction mitigated and/or displayed in specific

settings or contexts.

Research Instruments

The research instrument to be used in this research study was a qualitative survey

that assisted the researcher to answer the research questions. The researcher developed a

survey that collected data about the participant’s care giving background, person-centered

care values and workforce practices, and their level of satisfaction with their job and the

organization. The survey use a five-point rating scale for responses with designated

spaces after each question that will allow staff the option to expand or explain any of

54

their survey responses. Four of the eleven survey questions included four caregiver

background questions which include:

1. How long have you been caring for older adults?

2. Please indicate the age group you belong to (optional)

3. Please share the ethnicity you identify with (optional)

4. How long have been working for this organization?

By asking these questions it allowed the researcher to look for anomalies/correlations

between years of experience, duration of employment, age and ethnicity which will

permit me to better analyze the survey and observational data gathered during the

participant-observations visits.

The additional seven questions are delineated here in two clusters with respect to

their relationship to the above stated research questions. The first cluster of questions is

related to the job-satisfaction, which is the degree to which the Resident-Care Aides like

their jobs. These questions include:

1. Do you and your coworkers work well as a team?

2. Does your supervisor provide you with helpful feedback on the care you provide

to residents?

3. How meaningful do you find your work to be?

4. If you were to change jobs, how likely would it be caring for older adults?

5. In what areas of resident-care is most challenging?

55

These questions are important for assessing qualities of staff job-satisfaction which Chou

(2012) asserts is the outcome of the measure and quality of the presenting stressors and

the availability of emotional and physical workplace support. Workplace emotional

support can be “acts of caring, such as showing concern, respect, and trust, or listening

sympathetically (…) while instrumental support can be offering tangible assistance such

as materials and resources necessary for the job, guidance or knowledge needed to

complete a task or actual physical aid” (Chou & Robert, 2008, p. 209). The last question

regarding the most challenging aspect of resident-care was the only question on the

survey that was designated to be an open-ended question with the intent to see if the

challenges they experience is mitigated by other factors in the organization, leading to

satisfaction.

The second cluster of questions is related to resident-care, and asks:

1. How beneficial do you think outdoor activities are in relation to resident mood

and behavior?

2. How often in the past month have you spent time outside with residents?

3. What types of activities did you engage with residents outside?

4. During mealtimes do you sit down with residents and engage them with

conversation?

5. How beneficial do you think music programs are in relation to resident mood and

behavior?

6. How often are musical activities enjoyed by the residents?

56

The basis for asking these questions is that they are indicators of the practice of person-

centered care in relation to resident-wellbeing. In particular, two of the questions are

asking for the Resident-Care Aide’s value-base in regards to the effectiveness of outdoor

activities and music programs on mood and behavior; and two of the questions are asking

for the frequency in which they actually engage in those activities. The question

regarding mealtimes is critically important in relation to person-centered care which

strives to provide pleasant and supportive dining experiences because it promotes well-

being and quality life for residents.

Research Participants

The primary focus of this thesis is the Resident-Care Aide employed in assisted

living. This focus was selected in acknowledgement of the incredible role they have in

resident-care and the high turnover rates that plague this population of workers which

detracts quality dementia-care. The participants in this research design are the Resident-

Care Aides employed at the selected research site. These Resident-Care Aides split their

time between assisted living community and the specialized Memory Care neighborhood.

To protect their confidentiality they will be given pseudonyms, or fictitious names, in the

findings of this research study.

Research Setting

The setting for this research study was one ALC with a specialized Memory Care

neighborhood located in Northern California. This site was selected because of its

commitment to providing person-centered care to its aging residents. The Director of

57

Quality and Compliance was more than welcoming of my research study and allowed me

to select the level of care which best suited my study design. The options were: assisted

living or Memory Care program. Because this thesis is centered on dementia-care, the

Memory Care program was selected because it will allow me to observe the

organizational practices and the interactions between staff-staff, staff-resident, and

resident-resident in a community where all of the residents have severe enough dementia

that they can no longer live without secured, 24-hour supervision.

Data Analysis Procedures

The qualitative data sought in this research study was analyzed in terms of distinct

major themes or subject areas worthy of discussing that emerged from the data collected.

By examining the survey data and field notes collected during the participant-observation

visits and informal interviews, the researcher hoped to assess the Resident-Care Aides

care giving experience, perceived adequacy of ongoing support and training, and their

level of job-satisfaction. Upon this investigation and from the data collected assertions

about the data collected were made which the researcher found to be substantive. These

claims were supported with the qualitative data provided as well as an analysis of that

data. The findings of this research are presented in ethnography format. An ethnography

is “a style of social science writing which draws upon the writer’s close observation of

and involvement with people in a particular social setting and relates the words spoken

and the practices observed or experienced to the overall cultural framework within which

they occurred” (Watson, 2011, p. 205) Therefore, the qualitative information gained

58

through the interviews, surveys and participant-observations were thoughtfully reflected

on and presented as a story of how things work in this organization (Watson, 2011).

Summary

This chapter provided information regarding methodology used in this research

study which focuses on the Resident-Care Aides employed in the research site. Through

participant-observations visits, surveys and informal interviewing the researcher hoped to

gain insight into their experience as an employee at this community as well as to the

experience of residents in the Memory Care neighborhood. The information gathered

from these rich data sources were analyzed for emerging themes and were presented and

supported in a written ethnography in Chapter Four.

59

Chapter 4

FINDINGS AND ANALYSIS OF THE DATA

Overview

This research study took place at an assisted living community, with specialized

Memory Care, in Northern California. The community is situated in the beautiful,

country-side surrounded by nature and open-air. In exploration of the grounds, the

researcher was pleased to hear the beautiful chirping of the birds against the backdrop of

the sound of running water from the seven rock gardens through the property. Along the

perimeter of the property, visible low-hanging bird-feeders and park-like seating are

inviting and peaceful. Inside, the community was beautifully decorated with inviting

houseplants and an aviary with two canaries, and two beautiful fireplaces which were

being quietly enjoyed by several residents, as soft symphonic music played in the

background, creating a pleasing environment. To the side there was an open coffee and

pastry bar available for the residents to enjoy. To the other side there is a community

library and a family dining room which provide residents with reading materials and a

place for an intimate dining experience with friends and family.

Towards the rear of the building, behind a code-secured entrance, lies the

specialized Memory Care neighborhood. Inside this community, the wall art are enlarged

pictures of the memory care residents which immediately provides an intimate

experience. Outside of each of the resident’s rooms, hangs a personal biography of each

resident, which provides care givers with unique information about their past experiences

60

and preferences which are what person-centered care plans are based. Within the

memory care neighborhood, are two dining halls, one large and the other, small. There is

also a common activity and television room which are used for various scheduled

activities and programs. In the middle, is the nursing station, where the medication

technician stores and prepares for distribution the resident’s prescription medications and

supplements. The researcher’s overall evaluation of the esthetics of the community was

that it was pleasing and comfortable place to be.

The participants in this study included seven Resident-Care Aides and the

residents they care for within the memory care neighborhood. In this community the

Resident-Care Aides are referred to as R.C.A.s. All seven of these R.C.A.s were female

and were between the ages of eighteen to forty-seven years and older. The demographics

identified by these R.C.A.’s fell into three ethnic groups: three were Caucasian; two were

African American; and two were Hispanic. All seven R.C.A.’s reported having prior care

giving experience, with one aide reporting one to two years of experience; two aides

reported having three to four years of experience; one aide reported having five to six

years of experience; and three aides reported having ten or more years of experience.

The length of their employment with this particular ALC reported by these R.C.A.’s

varied as well, with two of the aides reporting being employed there for 90 days or less;

two aides reported being employed for six months or less; and three aides reported to

having been employed there for one or more years. While it was not one of the available

61

options on my survey, two of the R.C.A’s shared with me that they had been employed

with this assisted living community for ten years.

Findings & Analysis

Upon completion of the research at the Memory Care neighborhood and after

analyzing the data, the researcher was able to find five overarching themes or major

subject areas which were substantive and which can be connected to the structural

elements of person-centered care. These include:

1. Consistent Assignment Equates to Greater Resident-Knowledge and Relationship:

Because of the memory and communication impairments caused by dementia,

persons with dementia need care partners who know them well, otherwise they

may have unmet needs. Therefore, in order to develop this knowledge it is

important that the same care partners are assigned to the same residents which is a

factor of the structural element four: Workforce; however, it is ultimately

connected to the structural element three: Leadership as they are responsible for

“ensuring that workforce practices are based on personal interactions and

relationships” (Dementia Initiative, 2013, p. 20).

2. Understanding the Dining Program Improves the Dining Experience: In order to

provide a person-centered dining experience it is important that staff be educated

on all aspects of the company’s adopted dining program and be given the

rationale behind it so that staff can see the benefits of following it, as opposed to

being forced into something they see no need for. This finding correlates with the

62

structural element three: Leadership because it is the responsibility of leadership

to “ensure that person-centered operational practices are implemented, achieved,

and sustained (…) [and that staff] are oriented and trained in person-centeredness

and dementia-care competencies” (Dementia Initiative, 2013, p. 20).

3. Embracing Emergent Leaders within the Organization: Because of the costs

associated with turnover, it is important that organizations hire the right people

for the job. For leadership positions, it is critical that the person have leadership

qualities or potential. The first place the organization should look is at the talents

of their current staff. Those that have such attributes should be given a pathway

and training into a leadership position. This finding correlates with the person-

centered care structural element three: Leadership, and structural element four:

Workforce as “investing in staff by fostering a continual learning environment

(…) and promoting staff members who are good at their jobs into leadership

positions” (CEAL, 2010) are ideal as Coogle, Parham and Rachel (2011) found

that the development of new skills and career ladders were found to be important

for career commitment and the greatest deterrent of turnover.

4. Ambiguity Leads to Lower Family and Staff Satisfaction: People prefer the full-

disclosure of information. In assisted living, family members are paying for a

service and expect that a quality service will be rendered; and the Resident-Care

Aides are the providers of that service. If pertinent information is not given, either

to staff or to family, their level of satisfaction with the organization decreases.

63

Therefore, in order to raise satisfaction effective education and support and

decentralized communication is important for conveying the right information to

the right people. This finding correlates with the structural element eight:

Accountability, which refers to the “practice of ensuring that desired person-

centered outcomes are actually being achieved and is effective. Such evaluative

data can be collected through internal and external means, including resident,

family, and staff satisfaction surveys” (Dementia Initiative, 2013, p. 21).

Resident-Care Aides Find Meaning in Their Work: Providing care to older adults

and persons with dementia pose many challenges for care partners. However,

despite these challenges the Resident-Care Aides in this study were able to

identify positive attributes of their job that outweighed the challenges. When

people find their work to be meaningful they are more likely to remain in that job.

For quality dementia-care, job-stability of the care partner is essential. This

finding correlates with the structural element three: Leadership as they must

“continually recognize and appreciate staff work efforts through genuine praise

and encouragement [as well as] take the time to periodically recognize and

celebrate successes that can be easily identified through regular monitoring and

evaluating outcomes” (CEAL, 2010, p. 14) which is connected to structural

element eight: Accountability.

Each of these themes are further described and supported with evidence from the

data collected from the participant-observational visits, survey instrument and informal

64

interviews of this study to support these claims along with pertinent research from the

review of literature outlined in Chapter two. The participants in this study have been

assigned pseudonyms in the presentation of these findings to protect the confidentiality of

their identity.

1. Consistent Assignment Equates to Greater Resident-Knowledge and

Relationship.

The person-centered care approach values the relationship-building between the

R.C.A. and person with dementia. The more the care partner knows about the person

with dementia, the greater their understanding and competency in responding to their

needs will be (Kitwood, 1997). Therefore, the quality of the person-centered care is

dependent on a stable care staff as relationships and person-knowledge develops

overtime.

The qualitative data collected for this study revealed that an ideal relationship

between a care partner and a person with dementia had been formed between long-term

employee, Ashley, and resident, Jane. Ashley is an R.C.A in her early 40’s and has been

employed with the company for ten years. Jane has late-stage dementia, uses a wheel

chair, and requires full assistance during meals. And, although Jane cannot engage in

dialogue, per se, she communicates through verbal perseverations and clearly asserts her

agency to unwanted care. The knowledge Ashley has about Jane is evident in the

following interactions between Ashley and Jane:

Ashley: Hello, good morning! Do you want to sleep longer?

(Ashley kneels down on her knee next to Jane’s bed).

65

Ashley: I like to get down to their level and make eye contact with them. They

may not always understand what you are saying, but they know tone of voice,

body language and hear movements.

Ashley is aware that although Jane does not have the capacity to understand all of her

words, she knows that by making eye contact, adjusting her tone and monitoring her body

language are modes of communication still intact for Jane.

(Jane’s eyes open; however, she has eye problems which cause her eyes secrete a

discharge that hardens during the night)

Ashley: I know, I will wash your face for you. Let’s get you up and see if you

need to use the bathroom. The water takes forever to get warm so I turn it on

right away so it will be warm by the time I am done helping her use the restroom.

(Ashley pulls down Jane’s blankets to get her out of bed)

Ashley: Oh, the morning shift must have already gotten her up. Oh I wish I could

have shown you how I like to get her dressed. I love dressing her in pretty clothes.

Oh well, let me help her use the bathroom. Jane, hi! Let’s go to the bathroom.

Ashley: Can you shut the door to the room? I like to give them privacy. We

would.

Ashley and Jane’s morning routine is well versed. She knows that Jane’s eye condition

makes it hard to see and that the water takes time to warm to a comfortable temperature.

She also looks forward to dressing her for the day and enjoys making her look pretty.

She also respects Jane as a person and affords her with the privacy that most people

prefer while dressing or using the restroom.

Ashley: I think Jane really needs a bed rail because she has been falling and that

is how she got that bruise.

(Ashley points to the huge bruise on the side of Jane’s face)

She used to use a walker but she is too weak now. But sometimes she will just

want to get up and try to stand like she did with her walker.

Because Ashley has been a consistent employee with the company and knows Jane well,

she has seen her decline and knows the measures that need to be taken to prevent her

66

from future injuries in bed. She also has the background knowledge about Jane’s previous

use of a walker that allows her to rationalize her attempts to stand.

Ashley: Hello Jane, how are you? You were just sleeping away.

(Ashley smiles at Jane)

Ashley: I love my job because I like to be a family member for them. I like to talk

to all of the residents each day. I love it when they smile, just like with my own

kids.

Having a positive regard for persons with dementia is key to person-centered care.

Ashley’s regard for Jane and the other residents is high as they are like family members

to her; she enjoys being in relation with them as she likes to talk to them and see them

smile.

Ashley: Ok Jane, can you hold onto the bar for me?

(Jane grabs the bar with two hands and stands up)

Good Job! You did it!

Ashley: Now can you sit down on the toilet?

Jane: No! No! No!

Ashley: Ok, you don’t need to go to the bathroom? Well let’s put a fresh depend

on for you then and wash your face.

Ashley: Good job!

Ashley is supportive and encourages Jane to participate in her activities of daily living

which allows her to employ the functional abilities that are she still intact for her. She

also respects Jane as an agent by welcoming her expressions to unwanted care and

accepting her as the authority of her toileting needs.

Jane: (perseverating)

Ashley: Did you know Jane sings? That’s what I call it. I love it. If she wasn’t

making that sound, I would be worried something was wrong.

(Ashley takes a small blanket off of the bed and folds it and hands it to Jane)

Ashley: Here Jane! I like to give her the blanket because she likes to hold onto it

and it makes her calmer; otherwise she tries to hold onto everything and becomes

more stressed.

67

Ashley: Jane, I will be right back I am going to get you some yogurt ok?

Ashley has developed unique insights about Jane. She has learned Jane’s specialized

form of communication that allows her to monitor Jane’s disposition and needs. She has

learned that providing Jane with a blanket makes her experience less stress and to feel

more secure.

The person-centered care approach values the relationship-building between the

R.C.A. and person with dementia. The more the care partner knows about the person

with dementia, the greater their understanding and competency in responding to their

needs will be (Kitwood, 1997). Ashley clearly knows Jane well. She has developed the

insight needed to better meet Jane’s needs. She is also very attentive to Jane’s experience

and engages in non-verbal forms of communication by adjusting her tone, maintaining

eye contact and caressing her face often. According to Jootun and McGhee (2011) these

behaviors are appropriate in dementia-care because “non-verbal communication accounts

for 93 percent of communication in humans” (p. 42); and Hadley, et. al., (1998) found

that emotional intensity is strongly congruent with facial expressions and is universal.

Ashley’s attentiveness, compassion and regard for Jane, indicates that her position in the

Memory Care neighborhood is both warranted and essential for the delivery of quality

person-centered care.

2. Understanding the Dining Program Improves the Dining Experience.

It is imperative that Resident-Care Aides be given education on the organization’s

adopted dining program if a person-centered dining experience is to be provided.

68

Otherwise, in the absence of this knowledge, or without the buy-in from staff, an un-

therapeutic dining experience is likely to occur.

This study revealed two very different dining experiences; one dining service was

near ideal for person-centered dining, and the other was less supportive. A lack of

knowledge about the dining program, or a lack of assertion of that knowledge by other

staff, was responsible for the less than ideal dining service. The supportive dining

experience was a lunch service. The dining room was bustling with the sounds of

silverware hitting plates and residents busily eating and conversing with one another.

Ashley, the R.C.A. that cared for Jane, was as attentive and knowledgeable about other

residents as she was with Jane and is evident in the following dialogue:

Ashley: I like to get a smaller plate for “Ms. B” (Ashley retrieves a small plate

from the cupboard and takes it to Mrs. B, a resident who appears uninterested in

eating) because if there is too much on her plate she won’t eat. But if there is only

one thing at a time she eats a lot! I think she gets overwhelmed.

Ashley: Here you go, Mrs. B. (Ashley sits close to Mrs. B, putting one item on

the plate at a time; and Mrs. B begins to eat each food item Ashley puts on the

plate).

Kat: Do you always sit down with the residents and eat with them?

Ashley: Yes, we sit down and eat with them and encourage them to eat. They

won’t if you are not eating.

Ashley knows that Mrs. B gets overwhelmed during meal times but has learned that by

placing one food item on the plate at a time, it allows Mrs. B to better manage the

experience and increases her nutritional intake. Because Ashley understands the dining

program and the rationale for it she knows that dining is much more than merely the

intake of food; it is also a very social experience. By eating with the residents and

69

providing the necessary resident-support she is able to provide a supportive social dining

experience.

During the lunch service, the researcher observed Marie, another R.C.A. who has

been with the company for ten years, in a small dining room with a small group of

residents. The researcher inquired about it to Ashley:

Kat: What is Marie doing in there?”

Ashley: Oh, that’s the hospice feeding room. You can go in there if you want.

Kat: Thank you.

Hospice is end-of-life care. In dementia, as it progresses, feeding becomes a challenge

and therefore, food must be mechanically chopped or pureed to prevent choking.

The researcher approached the small dining room and observed Marie dining with

five residents. Four of the residents’ meals were chopped (carrots, chicken, and corn

bread), except for a leg of barbeque chicken; and one resident, Jane’s, was pureed and

needed direct feeding assistance. The researcher knocked on the door and the

conversation went as follows:

Kat: Hi, can I sit in here with you?

Marie: Sure.

Kat: What do you do in here?

Marie: I am the hospice feeder, I help the residents who need their food chopped

or pureed, or feeding assistance. Except sometimes they don’t eat the food

because it doesn’t look like a carrot or sandwich. I saw this video called Dining

with Friends and the top chefs make their food actually look like the food they are

supposed to look like.

Kat: How long are meals?

Marie: I like to give them a lot of time, so they can let their food settle and they

don’t have to feel rushed. But they usually take an hour.

70

Marie understands the dining program and the aspects related to dining which affect

interest in and the consumption of food. Rather than a rushed, task-focused dining

experience, Marie allows ample time for residents to eat, socialize, and let their food to

settle which equates to a more pleasant dining experience. She is also aware of the dining

program’s potential as she has seen a model by top chefs who prepare appetizing meals

for persons needing chopped or pureed foods.

Marie stands up to get the desserts; a white cake with a whipped cream topping.

Marie takes the diabetic (sugar-free) dessert, which looks exactly the same, and sets it in

front of Shirley. Shirley does not hesitate to partake in the delectable treat with her

fingers; Marie makes the following comment about Shirley:

Marie: Shirley likes finger foods. That’s how she prefers to eat, so when the food

is chopped she can’t do that as well. And she loves sweets.

(Shirley looks up and makes a huge grin as she licks her fingers).

Marie has developed the knowledge about each of the residents in the small hospice

dining hall. She knows Shirley’s preferential mode of eating is with her hands and that

she likes sweet desserts.

Towards the end of the meal, Ms. W, the youngest and only Asian resident,

begins to engage in the repeated folding of her cloth napkins on the table. The dialogue

regarding this experience is as follows:

Ms. W: Sorry, we are all booked up.

Marie: Ms. W is very fidgety. She likes to stay busy.

(Ms. W gets up and takes the napkin in front of me and folds it perfectly).

Ms. W: No, bank is closed today.

(Marie hands Ms. W. a napkin from a resident who had finished eating and Ms. W

returns to her chair to fold it)

71

Kat: Do you know her background? Maybe she owned or worked in a restaurant

before?

Marie: I think so…for sure, because she seems like she used to wait on tables or

something.

(Marie gives her another napkin to fold)

Marie: She is doing so much better. When she first came she was not doing good

and never wanted to come out and be with the other residents.

Kat: What do you think was the change?

Marie: She started a new medicine and she is doing so good. She is so pretty too.

(Marie stops and smiles adoringly at Ms. W).

Person-centered care seeks to find the meaning behind expressed behaviors and holds the

person with dementia in a positive regard. Marie has found ways to honor each resident

in the hospice dining hall. She respects that Ms. W. prefers to stay busy and so she

provides her with napkins to fold that are not being used by other residents. She also has

seen the progress to Ms. W.’s health since coming to the Memory Care neighborhood and

strives to provide a therapeutic social environment for her.

The lunch dining experience was near ideal and beautifully captured the values of

person-centered care. The success of the service can be attributed to the fact that both of

the R.C.A.’s on duty understood and conveyed their knowledge about the dining program

and the importance of providing a supportive environment. Only in my absence could it

have been improved as the time and attention they gave to me would have been solely the

residents. However, throughout the meal Ashley and Marie remained attentive to the

residents. The small dining room afforded Marie with a small ratio of residents to care for

which was one R.C.A. to five residents. This provided an effective seating arrangement

that allowed for greater visibility of the resident’s facial and bodily expressions which

allowed her to better monitor the residents in her care.

72

The second dining service I observed was dinner and proved to be a less

supportive dining experience. I attribute this experience to the evening shift’s lack of

knowledge about the dining program by newer R.C.A.’s and a lack of assertion of this

knowledge by more experienced staff. This claim is evidenced in the following dialogue

with Amy, a newly hired R.C.A. prior to the dinner service:

(The kitchen staff entered with the food; she first turned on the lights to the small

dining room, and then proceeded to the large dining hall to begin serving the

residents).

Amy: I wonder what’s going on in there.

Kat: Oh, that’s for the residents who need feeding assistance.

Amy: Oh, ya…I hate that room. It doesn’t make sense to have them separated

over there when we all fit in here. I say just keep everyone in one room.

(We all enter the same dining room and everyone takes a seat).

Amy: See, we all fit in here. And look they are all eating just fine.

Amy had been employed with the company for 90 or less days. In that time, she had not

acquired knowledge about the company’s dining program or the rationale for the hospice

feeding room. And, consequently, she did not see a need for holding separate dining

services.

During the dinner service the R.C.A.’s engaged in light socialization with the

kitchen staff and each other. During this time, Mary, a resident who staff cited as the

community’s more challenging resident, and who was seated at a table in the back of the

room, engaged in a dispute with another resident, Ms. T. The dialogue is as follows:

Mary: Oh my God. Oh my God. I don’t feel good! I am going to throw up!

Ms. T: Can you please stop saying that?

Mary: Bastard, Crap! I’ll go kill myself.

(Mary takes her glass and pours it on Ms. T’s shirt).

Ms. T: Why did you do that?! She poured that cup right on my shirt!

Mary: No I didn’t! I put my cup right in front of me!

73

Ms. T: No you did it on purpose!

(Ms. T leaves the room to change her shirt).

Mary: Oh my God. Oh my God. I don’t feel good! Bastard, Crap! I’ll go kill

myself.

Amy: Mary can you stop talking like that it is upsetting people.

Mary: What did I say?

Amy: You really upset her.

Mary: How?

Amy: Never mind. It’s ok, just eat your food.

Mary’s use of foul language is upsetting to the other residents. Her disturbing behavioral

tendencies and aggressiveness towards others deems it necessary to seat her in a location

in which she and others around her can be closely monitored.

In the confusion caused by the dispute and because the residents on hospice were

dispersed throughout the dining room, the kitchen staff almost caused a dietary mishap

during her distribution of the desserts and is evidenced in the following dialogue:

(The kitchen staff passes out the desserts, placing one in front of Shirley)

Kitchen staff: Oh that was close! I forgot she is a diabetic.

(The kitchen staff quickly grabs the plate and switches it with a sugar-free

dessert).

Amy: Good catch!

The kitchen staff almost distributed a non-diabetic dessert to Shirley, the resident with

diabetes from the hospice feeding room. If the residents on hospice were seated closer

together, the kitchen staff may have experienced less confusion.

Near the end of the dinner service, Ms. W., the resident from the hospice room

who prefers to stay busy, had taken off one of her shoes and began roaming from table to

table taking the napkins of residents who had not finished eating yet. The staff’s response

to this occurrence is as follows:

74

Amy: She does that all of the time. By the end she will have no shoes on.

In the short time that Amy has been employed with the company she has come to accept

Ms. W.’s after-dinner behaviors as the norm. While her acceptance is respectful to Ms.

W., allowing her to roam from table to table is inconsiderate of the other residents who

also deserve to have a pleasant dining experience.

The dinner staff chose for all residents to dine together in the large dining hall.

Although Amy was well-intended she did not see a need for separate dining and

consequently the outcome was a less supportive dining experience. The researcher

attributes this provision to a lack of knowledge, or assertiveness of knowledge, about the

organization’s adopted dining program. While Amy had only been employed with the

company for a short time, there were two other R.C.A.s on-shift that evening: Ana,

another employee of 90 days or less, and Sandra, a ten year employee with the company.

Although Sandra was busy attending to resident-needs outside of the dining hall during

the service, the researcher was surprised that she did not assert her knowledge of the

program to the newer staff when she saw them dining in one hall. Consequently, the

residents that required feeding support were dispersed throughout the large dining hall,

making monitoring the resident’s needs difficult. Moreover, because the dinner staff was

engaged in their own conversations with the kitchen staff rather than with adjacent

residents, it made monitoring the social environment impossible. As a result of this

laxity, Shirley almost received a non-diabetic dessert; Mary poured a drink on Ms. T; and

75

Ms. W. took her shoe off and took the napkins of her fellow resident’s before they

finished dining.

Caring for persons with dementia and older adults in group-settings pose complex

challenges for Resident-Care Aides that are not completely preventable. However, good

social interactions could be better encouraged by appropriately grouping residents at

tables in the dining room, making dining together more possible. For example, Reimer

and Keller (2009) reported that it has been hypothesized that there should be four

different groupings for meals to allow for closer monitoring and support interventions

and include: “residents who are aware of their social environment and usual social

boundaries; residents with less awareness of social boundaries; residents with greater

tendencies for disruptive behavior; and residents who respond to stimuli but have no

awareness of their social environment” (p. 336). These seating arrangements will

contribute to the overall goal of person-centered dining, which Hung and Chaudhury

(2011) assert is to provide a pleasant dining experience for all residents as it significantly

impacts nutritional intake and overall well-being.

3. Embracing Emergent Leaders within the Organization.

Turnover is costly in terms of hiring and training new staff. Therefore, it is

important that organizations employ the right people for the job they are seeking to fill.

To fill leadership positions, the first place human resources should look is at the natural

leadership talents of staff in the organization and to develop the skills of those with

leadership potential.

76

Marie is an R.C.A. who has been employed with the company for the past ten

years. Observing her in action as she cared for residents was very impressive, as was her

ethical assertions regarding her position within the company. Throughout the

researcher’s time with Marie, she remained busy attending to resident-care needs. The

following dialogue is evidence of these ethical assertions and leadership qualities:

Marie: My job is to take care of the residents. I shower them; I help them go to

the bathroom. I ask them how they are feeling, if they are in pain. And to report!

And I talk to them.

(Marie walks down the hall and enters each room to check on the residents)

Marie: I go up and down the halls and make sure everyone is taken care of. I do

everything right! It is really hard for me to sit long, so I do more work than I have

to. It is supposed to be housekeeping that takes care of cleaning the trash bins out,

but I usually take care of it. But if I see that their (residents) floor needs

vacuuming, housekeeping needs to come and do their job.

Kat: Does that cause you problems?

Marie: I don’t care who hears. I am not afraid. I am here for the resident. The

other staff don’t always like me because I make them do their job right. And

management plays favoritism; if they like you, you get scheduled better. But I am

hoping that the new manager, which is also African American, will be fairer. And

not be on my side or anything but just be fair.

Marie is confident in her role as an R.C.A. and is efficacious in her work performance.

However she is expressing a desire for justice and equity in the workplace by other staff

and by the management team.

Marie: I want to be a trainer some day because all the problems that do come up

boil down to a training issue.

Kat: I definitely could see you doing that. You would be a good trainer!

Marie understands that most challenges within the workplace can be remedied with

training. She also expressed an interest to provide such training to others in the future.

77

Marie’s ethics were further evidenced in the hospice dining hall when she noticed

a safety issue of the prepared meal. The following is her assertion:

Marie: Look at this! (Marie points to the chicken) I am going to have to say

something about this. That’s the only way to get things to happen, is if you ask

questions. I mean, there are bones in the chicken and someone could choke. What

were they thinking?

Resident-safety is a top priority. Because Marie works closely with residents on hospice

and serves their food, she is in a prime position to communicate these concerns with the

kitchen and supervisory staff. Her acting on that concern is further evidence of her

leadership potential.

Marie is very certain of her role as an R.C.A. and clearly understands the roles

and responsibilities of others in the organization. This allows her to specify her concerns

and to give positive attributes where the organization’s performance is strong while

holding people accountable for their roles and responsibilities. This is evidenced in the

following assertions:

Marie: But I give them (the assisted living company) an “A” plus-plus for the

outings they do. They go to restaurants like Subway. A lot better than where I

used to work. But if I see something wrong I am going to say something because

my duty is to observe and report. If they take a bowel, or don’t. If they shower, or

refuse. Like at 2:00 pm. is when the shift change is and we meet so that the next

shift will know of any problems or issues so they can be there for the resident. I

can’t stand it when someone knows something happened and then they don’t let

the next shift know because it takes away from the resident.

Communication and shared decision-making are hallmarks of person-centered care.

Marie values the communication and collaboration between the day and evening shift

staff because it allows her to provide more effective care to the residents.

78

Marie also believes in taking precautionary measures to keep residents from harm

and is evidenced in the following statement:

Marie: That is why I am a good R.C.A. I am all for prevention. Like I put

Desitin on with every diaper change...so that they don’t get a rash in the first

place; like I do for my babies. I care for the residents like I do for my kids.

Marie regards the residents as family members and takes the same preventative measures

as she would for her own children. Marie attributes having these qualities to what make

her a good R.C.A.

Marie has a solid understanding of what would detract from being a good R.C.A.

and is evidenced in her following statement:

Marie: But the biggest problems are with management. And you are not

supposed to be understaffed. I don’t say it…the State says it. And with staff… do

your job! I don’t do no favors for no one. Like if a resident is supposed to have

oxygen, I am not authorized to do it. Do your job!

Again, Marie is expressing a desire for equity and accountability within the ALC and to

abide by the rules and regulations of the state. Marie’s ethics regarding for her role, her

coworker’s role, and the responsibilities of the organization provide clear examples of her

leadership potential.

Marie has been with the company for the past ten years and has expressed her

desire to become a teacher. She understands her duty as an R.C.A. is to observe and

report. She knows how important it is that the day and evening shifts communicate and

collaborate on any changes in resident-health and/or behaviors during shift-change

meetings. According to Spears (1996) she embodies the values of a servant leader as she

is committed to “teamwork and community; involving others in decision making; is

79

strongly based in ethical and caring behavior; and to enhancing the growth of people” (p.

1). These qualities make her, what Kitwood (1998) refers to as, a moral agent which is

someone “who can engage consistently in the right action, even in the face of

countervailing pressures; moral character is learned primarily through practice, by facing

up to real opportunities, difficulties and dilemmas” (para. 1). Because Marie has these

qualities and consistency, it warrants investing in her leadership training for a leadership

position within the company. According to CEAL (2010) when leaders emerge from

within the organization, like Marie, they possess a thorough understanding of the

organization’s values and practices and bring with them invaluable insight on the needs

and challenges affecting the Resident-Care Aide. This is ideal as Coogle, et. al., (2011)

found that the development of new skills and career ladders were found to be important

for career commitment and the greatest deterrent of turnover.

4. Ambiguity Leads to Lower Family and Staff Satisfaction.

The Resident-Care Aide learns much of their skill on-the-job which can create

problems within the organization and lead to lowered staff-, family-, and resident-

satisfaction. The following dialogue exemplifies how ambiguity can lead to family

and staff frustration:

Family member: Excuse me, how do I talk to the nursing supervisor?

Amy: The nursing supervisor? Uh, good question.

Family member: What do you mean? You don’t know?

Amy: I haven’t met her myself yet?

Family member: You mean the nursing supervisor has not met the staff yet?!

Amy: Well she just started today. Go to the end of the hall and ask the med-tech!

(Amy points to the end of the hall).

80

Amy’s lack of knowledge about the new nursing supervisor and poor communication

with family was upsetting to both Amy and the resident’s family member. However, her

response itself was genuine as Amy had not met the supervisor and seemingly had not

been instructed in how to respond to family inquiries on this matter.

The frustration Amy experienced as a result of lacking this information about the

nursing supervisor spilled into the care environment and is evident in the following

dialogue between Amy and the more experienced R.C.A., Sandra:

Amy: Oh my God! That lady was like “where is the nurse supervisor?” and I said

I didn’t know, and she said “what do you mean you don’t know?” and I said well

she just started today!

(Sandra looks confused but uninterested in getting involved),

Sandra: Oh, well I have to get the maintenance man to bring the big scale over

here.

Despite Sandra’s ten years of experience, she did not provide Amy with helpful feedback

about how to work with families or emotional support to diffuse or redirect her

frustrations.

Amy’s lack of knowledge was further evidenced in the following conversation with

Sandra regarding the purpose or procedure for weighing the residents:

Amy: For what?

Sandra: To weigh the residents.

Amy: Weigh the residents?

Sandra: Ya, every first of the month the residents have to be weighed.

Amy: Oh…how are you going to do that with the wheelchairs?

Sandra: It’s a big one; and wheel-chair accessible.

Amy: Oh.

In Amy’s short-time with the company she had not seen the process of weighing the

residents, nor did Sandra offer Amy a rationale for the purpose of weighing the residents

81

each month which represents a missed mentoring opportunity. Weighing the residents

every month is mandated by state regulations as it provides key information regarding

their nutritional intake and health-status.

Amy’s dissatisfaction with the family member continues to bother her and is

evident in her statement to me after Sandra left to go get the scale:

Amy: But I do not like dealing with the family members. They are barely ever

here and when they are they want to find all of the things wrong.

Amy does not have the insight to see the validity of the family member’s discontent.

This detracts from person-centered care which views family members as integral to the

care planning process and their satisfaction as key for the resident’s continued residency

at the assisted living and Memory Care neighborhoods.

The R.C.A.s at this community expressed having lowered satisfaction with the

extent and supportiveness of their initial training with the company and is evident in the

following dialogue:

Kat: Do you like working here?

Amy: Yes, I mean the positives outweigh the challenges.

Kat: How was the training for the job?

Amy: Terrible! It was barely any at all. I think it was two days in memory care

and three days in assisted living.

Gina: For me it was more like two days in memory care and one day in assisted

living.

Ana: Well see for me it was different! I started in assisted living and just moved

over here. So this is all new to me. And my whole thing is I want to do a good

job. And over there (in assisted living) they tell you (because the residents are

more cognizant).

Amy: Yes, but the thing for me is they never even gave you a radio over there (in

assisted living) so you were just running all over the place. Then you would get to

a residents room and you didn’t have what they needed so you would have to go

82

all over the place. I mean put me where you put me, but give me a radio so I can

know what I am supposed to do or need to know!

Sandra: Yes, they didn’t give me a radio over there either.

These three R.C.A.s reported not having the proper training, equipment and support to

learn and perform their jobs effectively. They all stated that having access to a radio

during that initial training period would have permitted them to communicate more

effectively with management regarding resident-care and would have improved the

quality of care they provided to the community’s residents.

Further ambiguity by the R.C.A.s was discovered through question two of the

administered survey, which asks: Does your direct supervisor provide helpful feedback

on your job performance? Of the seven study participants, 57% responded that they

sometimes receive helpful feedback on their performance; and two of the R.C.A.s added

the following comments to this survey question:

Marie: Right now we don't have one, this lady works from her house she's not

with the company but she is still in charge of our day's job and status.

Amy: If you ask.

When Resident-Care Aides perceive themselves to be under-supported or lack helpful

supervisory support, their satisfaction with their job and the organization is lowered and

they are unable to improve the effectiveness of their care interventions.

Resident-Care Aides learn much of their knowledge and skill on-the-job, often

through trial and error. The R.C.A.s in this study expressed great ambiguity regarding

their role and responsibilities with the company during their initial training period which

lowered their care giving efficacy. They also expressed dissatisfaction with the lack of

83

support from their supervisors and from not being given the tools needed to do their jobs

effectively, which was having access to the radio so that they can communicate more

efficiently with management regarding resident-care. Staff satisfaction was also lowered

due to a lack of knowledge regarding the organization’s protocol for communicating with

family and in the absence of clear instructions. The CEAL (2010) reported that Resident-

Care Aides “are put in situations that require unusually sophisticated interpersonal and

communication skills,” (p. 18) which they often lack at the start of their employment.

Because of Amy’s short duration with the company and limited experience working with

families, she lacked the insight needed to understand the reasonability of the family

member’s inquiry and so became upset and frustrated with them, lowering her

satisfaction and the satisfaction of the family member. Family members want to know

that their loved one is well taken care of and not knowing who is supervising the care

warrants their lowered satisfaction. Unfortunately, Sandra, who has been with the

company for ten years failed to assert her knowledge to the newer staff. This represents a

missed mentoring opportunity, as Chou and Robert (2008) found that “job-satisfaction

(…) was positively associated with supervisor instrumental and emotional support and

coworker emotional support” (p. 208). Sources of emotional support can be “acts of

caring, such as showing concern, respect, and trust, or listening sympathetically (…)

while instrumental support can be offering tangible assistance such as materials and

resources necessary for the job, guidance or knowledge needed to complete a task or

actual physical aid” (Chou & Robert, 2008, p. 209).

84

Person-centered care recognizes that “no one does their best when they are feeling

incompetent or alienated” (Kosner & Posner, 1995, p. 12). Believers in the approach

understand that “people rely partly upon their anxiety and vulnerability to stress. [And]

high arousal usually debilitates performance; [especially when they are] tense, shaking,

and viscerally agitated” (Bandura, 1977, p. 82). Therefore, it is imperative that the

governance and members of the leadership team provide these aides with the training and

support needed to improve the effectiveness of their job-performance and satisfaction

with the company. This is critical because when family- and staff- satisfaction goes

down, the organization is vulnerable to a poor reputation and high turnover. However,

Chou and Roberts (2008) assert that “when turnover is decreased by 20 percent, resident

and family satisfaction increases by 30 percent” (p. 209).

5. Resident-Aides Find Meaning in Their Work.

Despite the many challenges facing Resident-Care Aides they are able to find

meaning in their work. The one open-ended question on the survey asked the R.C.A.s:

What is the most challenging aspect of your job? The following are their responses:

Ashley: Memory care and physical changing.

Marie: Well there is a lot of redirecting to do that comes with the job.

Amy: Dealing with care for combative residents.

Sandra: Dealing with resident’s family.

Gina: For me it would have to be the loss of the ones I care so much for.

Ana: Communication with residents in memory care.

These responses reflect the evidenced-based literature regarding the challenges

experienced by direct care staff. However, despite these challenges, and as also stated in

the research, Resident-Care Aides are able to find meaning in their work. This was

85

evidenced in this study by the R.C.A.s responses to question nine of the survey which

asks: How meaningful do you find your work to be? All of seven participants reported

they found their work to be extremely meaningful. The following dialogue was gained

through the informal interviews and the additional comments provided on this question

on the survey and support the claim that these R.C.A.s do find meaning in their work:

Amy: I mean you have to love your job if you are going to change diapers all of

the time. And it’s even worse over on the assisted living side because they can do

things by themselves, but will be extra needy. Like there is this one man who you

can tell not only pooped his diaper but try to make it messier than it needs to be.

Here (memory care) they don’t know they are being hard, but they (residents in

assisted living) know what they are doing. Gotta have compassion and enjoy what

you do.

Marie: I care, that’s what it takes to be a good R.C.A. and you have to listen.

Leslie: My language (Spanish) makes it hard to care for the residents. But I want

to do a good job for them. But I like to play Bingo with them and eat ice cream

and donuts with them.

Gina: I absolutely love what I do. My residents are my second family. I love each

one of them!

Ana: I wanted to be a nurse when I was seven years old.

These Resident-Care Aides identified factors which they find brings meaning to their

jobs. The residents and their compassion to care mitigated the stress they experienced

caring for residents’ hygiene needs or behaviors.

Question ten on the survey asked the R.C.A.s: If you were to change jobs, how

likely would it be caring for older adults? Of the seven participants, 43% said it is would

be extremely likely; 43 % said it would be very likely; and one said that it would be not at

all likely. Two of the R.C.A.s which stated it would be very likely provided the following

comments:

86

Gina: I want to go back to school and get my nursing degree.

Marie: I say that because I rather teach.

Collectively, all of the R.C.A.s were able to find meaning in their work. When

Resident-Care Aides find their work to be meaningful they tend to stay with the

organization, despite the stressors of the job. In fact, although the one R.C.A. stated it

would be not at all likely that she would work with older adults if she were to change

jobs, she has remained employed with this company for ten years and reported on the

survey to that she found her work to be extremely meaningful. However, while this

correlates with the literature, organizations should not take this gift for granted. They

must build on this ability and ensure that workforce practices support their relationship-

building between the staff and residents and that the social environment to validate what

is meaningful to them.

Person-centered care values the incredible role that the Resident-Care Aide has in

providing quality dementia-care, and therefore, views staff not “as simply people being

paid to accomplish tasks, but integral to the success of the entity in general and for

individualized person-centered dementia care” (Dementia Initiative, 2013, p. 20). The

believers in the approach recognize that it was Resident-Care Aides “values for helping

elders and care giving jobs stemmed from past family experiences which attracted them

to assisted living” (Ball, et. al., 2009, p. 41) and understand that “all human beings prefer

meaningful work to meaningless work” (Maslow, 1951, p. 29). They recognize and

support the close emotional bonds that these R.C.A.’s are able to make with residents

because they understand that it serves as psychic income bringing meaning to their job

87

(Chou, 2012) and therefore develop workforce practices which support these

relationships.

Due to the critically important role of the Resident-Care Aide in resident-care, it

is important that leadership “take care to recognize both individual contributions and

team achievements through rewards, awards, gifts, and thank-you’s of many types to (…)

reinforce the community’s shared values and vision” (Boone & Makhani, 2012, p. 19).

Likewise, it is important that leaders “display an individualized consideration and to

develop a high quality dyadic relationship with each [Resident-Care Aide], paying

particular attention to their special needs and wants, and provide the information and

resources needed” (Tse & Chiu, 2014, p. 2829). Marie, has been with the organization

for ten years, has demonstrated leadership qualities, and has expressed her desire to teach.

Developing this pathway is an opportunity for both Marie and the organization, as

Coogle, et. al., (2011) found that the development of new skills and career ladders were

found to be important for career commitment and the greatest deterrent of turnover.

Person-centered care is founded on the belief that all people want to feel safe and

that they belong. Close relationships with caregivers allow persons with dementia to be

well cared for and to thrive. Knowledge of person-centered care and the adopted dining

program allows staff to provide a therapeutic social and physical environment. Due to

their integral role in providing this care, the organization must show the Resident-Care

Aides that they are valued by providing them with effective training and helpful

supervisory support. Embracing the meaning that Resident-Care Aides find in their work

88

and developing the natural leaders within the organization is an opportunity for both the

company and Resident-Care Aides as it can raise self-esteem and caregiver efficacy;

thereby improving the challenges associated with turnover.

Summary

This chapter provided ethnography of the information collected from one ALC in

Northern California. Through my participation-observation visits, informal interviews

and survey data, the researcher was able to find five distinct subjects that are of great

importance with respect to dementia-care provided in assisted living and Memory Care.

The first theme that was discussed was: consistent assignment equates to greater

resident-knowledge and relationship. As was supported, the more knowledge the

Resident-Care Aide has about dementia and about the resident, the more therapeutic their

care giving interventions will be. The second theme that was discussed was:

understanding the dining program improves the dining experience. This theme is

extremely important because the dining experience significantly impacts resident

nutritional intake and overall well-being. The third theme that was discussed was:

embracing emergent leaders within the organization. This theme focused on cultivating

the leadership talents within company which is organizational efficiency in terms of job-

satisfaction and turnover of staff. The fourth theme that was discussed was: ambiguity

lowers family and staff satisfaction. When people do not have the information or

resources necessary to do their jobs, satisfaction is significantly lowered and leads to high

turnover and a poor reputation. The final theme that was discussed was: Resident-Care

89

Aides find meaning in their work. This theme depicted and supports the literature that

despite the many challenges experienced by the Resident-Care Aide, they want to provide

good care to residents and the positives of the job outweigh the negatives, which raises

satisfaction. The following chapter, Chapter Five, provides a discussion regarding the

significance of the data revealed from this research and their implications in relations to

person-centered care and the assisted living industry, as well as identifies the limitations

of this study and recommendations for future areas of research.

90

Chapter 5

SIGNIFICANCE

Introduction

This thesis focused on the person-centered dementia care approach. As was

discussed, person-centered care requires a thorough understanding of the values and core

philosophy of the approach, as well as all eight structural element needed to support

person-centered operational practices. To review, the consensus philosophy, by experts in

the field, includes:

1. “Every person has his/her own meaning of life, authenticity (personality, spirit

and character history, interests, personal preferences, and needs to continue to

experience life at all stages of dementia. The person is not their dementia illness;

rather the condition.

2. Focus on the strengths of the person living with dementia rather than on what

abilities

and capabilities have been diminished or lost.

3. “Enter the world” of the person living with dementia to best understand,

communicate with, and interpret the meaning of his/her behaviors from their

perspective” (Dementia Initiative, 2013, p. 22).

Also to review, the eight structural elements essential for supporting the operational

practices of person-centered care include:

1. “Relationships and Community (belonging)

91

2. Governance

3. Leadership

4. Care Partners/Workforce (Resident-Care Aide)

5. Services

6. Meaningful Life and Engagement

7. Environment

8. Accountability” (CEAL, 2010, p. 9).

This thesis focused on the delivery of person-centered care in assisted living and

Memory Care. It highlighted the critical role of the Resident-Care Aide in resident-health

and well-being and identified the challenges they experience on the job. Due to the

limited formal education Resident-Care Aides receive, quality dementia care is dependent

on the organization’s provision of all eight structural elements. Without them, person-

centered care cannot be created or sustained and the Resident-Care Aide remains

vulnerable to lowered satisfaction and the incidence of turnover will continue to be high.

Discussion of the Findings

In Chapter Four, the findings of this research study were provided in an

ethnography using five distinct themes worthy of discussion in relation to person-

centered care. The survey instrument, informal interviews with staff and from the

participant-observations visits during real-time interactions with residents and staff

revealed a rich source of information for understanding the challenges and opportunities

that are presented to the Resident-Care Aide in this assisted living. Because person-

92

centered is multi-faceted, all of the findings are connected to one or all eight of the

structural elements of person-centered care. However, for the purposes of clarity of the

discussion, the issues discovered from the findings are issues connected to the third

structural element: Leadership and ultimately an issue which must be identified and

addressed through the structural element: Accountability.

The findings of this study provided evidence that there was a disparity of person-

centered care knowledge between the morning and evening shift staff and a lack of

person-centered care mentoring of the newer staff. Both Ashley and Marie from the day-

shift had a strong understanding of the importance of providing a supportive dining

experience, and therefore, were able to provide a therapeutic environment and add

sincerity to their care giving. Marie was able to find ways to honor Ms W.’s preference to

stay busy in the hospice dining hall without compromising the dining experience of the

other residents by providing her with napkins, not being used, to fold. In contrast, the

evening staff members, Amy and Ana, had only recently been hired and were not

knowledgeable, or did not assert their knowledge, on the purpose of the hospice dining

hall. Unfortunately, these newly hired staff lacked mentorship from the more

experienced staff. In particular, despite her ten years of employment with the company,

Sandra did not assert her knowledge of the dining program when she saw that residents

were seated together in one dining hall, nor did she impart coworker support to diffuse

Amy’s frustration when her lack of knowledge regarding the new supervisor upset a

resident’s family member. Consequently, the evening dining service was ridden with

93

distractions which nearly led to Shirley, the resident with diabetes, to be given a non-

diabetic dessert; permitted Mary, the more challenging resident, to disrupt the meal by

pouring her drink on Ms. T.; and Ms. W., the resident that prefers be active, to roam

around the dining hall with one shoe and disturb the other residents before they had

finished dining. While separated dining does not guarantee a distraction-free dining

experience, it does allow staff to better monitor the residents and the provision of dining

support. These issues are connected to structural element three: Leadership as it is their

responsibility “to ensure [that staff] are oriented and trained in person-centeredness and

dementia-care competencies” (Dementia Initiative, 2013, p. 20).

The findings also provided evidence that ambiguity lowers satisfaction. Some

staff members reported they were under-supported during their initial training and lacked

supervisory support. They stated that not having access to the radio prevented them from

communicating efficiently with management and from providing quality resident-care.

Both Amy and a resident’s family member experienced lowered satisfaction when Amy

lacked knowledge about the new supervisor and in the absence of mentorship by her

more experienced co-worker, Sandra. These issues, in addition to their connection to

leadership, are connected to the eighth structural element: Accountability. Family and

care partners are key stakeholders in person-centered care and therefore their satisfaction

is essential for the success of the business and quality dementia-care.

Despite the challenges and stressors facing the Resident-Care Aide each day, the

findings of this study also revealed that the close relationships they have with the

94

residents, which are viewed as extended family members, mitigates the dis-satisfaction

and brings meaning to their work. These dispositions represent opportunities for the

company in terms of structural element two: Leadership and structural element four:

Care Partners in terms of staff-retention and stability. Ashley, the R.C.A. who shared an

intimate relationship with Jane, has been with the company for ten years. In that time she

has developed a strong understanding of person-centered care and is dedicated to finding

ways to honor the residents she cares for, making her an asset to the Memory Care

neighborhood. Likewise, Marie, also a ten year employee, has gained a wealth of

knowledge about the organization’s practices and state regulations and is dedicated to

providing ethical care, team work and collaboration between shifts, and has aspirations to

teach one day which is the qualities of servant leadership which are needed in person-

centered care organizations. These qualities indicate her leadership potential and which

should be cultivated by the organization into a leadership or mentorship position.

Harnessing such talents promotes the development of the company’s workforce and their

satisfaction and retention with the company.

Implications

The success of person-centered care is dependent on the provision and

maintenance of all eight structural elements. In particular importance with respect to the

findings discovered in chapter four, is the need for leadership. Because of the limited

initial training that these Resident-Care Aids receive, without strong leadership they

cannot develop their knowledge and skill of caring for older adults and persons with

95

dementia in person-centered ways. Not having access to such supervisory and leadership

supports is a major contributing factor in the high turnover rates among this population of

workers. Turnover is costly in terms of hiring and training new staff. Coogle, et. al.,

(2011) “estimated that the staff turnover cost for each [Resident-Care Aide] is

approximately between $1750 and $5000” (p. 521); and the CEAL (2010) estimated “the

annual cost associated with turnover in a typical assisted living residence with 67 staff

and an average turnover rate of 73 percent, to be approximately $84,537” (p. 18). In

addition to monetary costs, turnover compromises the quality of the care provided as new

staff lack the individualized knowledge needed for meeting the needs of persons with

dementia.

There is no dispute, even among the best care communities, that Resident-Care

Aides receive minimal formal training. This coupled by the challenges they experience

on the job and often limited supervisory support, increases their vulnerability to

experiencing role overload, burnout and lowered job-satisfaction (Chou, 2012).

Therefore, it is the responsibility of the governing officials and members of the leadership

team to ensure that the Resident-Care Aides are “effectively oriented, trained and

mentored to build person-centered care skills and competencies” (CEAL, 2010, p. 15).

This means that leaders must model “behaviors that motivate followers to achieve

performance beyond expectations by changing followers' attitudes, beliefs, and values as

opposed to simply gaining compliance” (Yucel, et. al., 2013, p. 2). For Amy, who did not

see the need for separate dining, it is the leadership’s responsibility to help her see the

96

benefits or rewards for changing (Bellows, 1959); which in this case is a reduction of

resident-conflicts and negative behavioral expressions and improvements to resident’s

nutritional-intake and overall well-being. By taking advantage of the natural leaders

within the organization, like Marie, to provide person-centered care mentoring to newer

staff, would fulfill both Amy’s need to learn and Marie’s need to teach and is a positive

contribution to the organization.

Reducing staff turnover and developing critically important aging and dementia

knowledge and skill needed for communicating effectively with residents, staff and

family is vital for improving the satisfaction of stakeholders. When staff is stable, the

Resident-Care Aide benefits from knowing the person with dementia well, and therefore,

is better able to respond to their communicated needs, spoken and behaviorally

expressed, which raises job-satisfaction. For family, this knowledge is priceless as they

can rest knowing their loved one is in good hands, and raises their satisfaction. Raising

their satisfaction is essential because family members are often the deciding persons who

determine the housing placement they see as best for their aging loved one. This is

important because Chou and Roberts (2008) reported that on average, “when turnover

decreased by 20 percent, resident and family satisfaction increased by 30 percent” (p.

209).

Limitations

The research conducted in this thesis provides a unique insight to the nature of

one assisted living community in Northern California. Despite the rich information

97

acquired, there were limitations to this study. The first limitation was the limited number

of visits to the community. It would have been interesting to have made an additional

visit after the newly hired supervisor had time to assume and adjust to her position within

the Memory Care neighborhood to see if the dynamics of the work teams improved

between the day and evening shift and within the same work team. Another limitation

was the survey instrument itself. Due to the busy schedule that the Resident-Care Aide’s

are responsible for following and because of potential language barriers of the staff, my

survey was designed using closed-ended questions with a five point rating scale for

responses. A closed-ended question prevents a richer picture from being discovered and

limits the range of responses that an open-ended question can elicit.

Recommendations

Strengthening the workforce and raising the satisfaction of all stakeholders is

essential for delivering quality dementia-care and attaining a reputable reputation.

However, the degree of improvements that can be made in an organization is dependent

on structural element one: Governance. Governing officials include “the owner, operator,

and the board, and are essential to establishing, implementing, and sustaining the

operational culture within their organization; without their active involvement and

commitment, and person-centered dementia care cannot be created or sustained”

(Dementia Initiative, 2013, p. 20). They must ensure that workforce “policies and

procedures support the [Resident-aide] decision making during real-time interactions

with residents” (Tilly & Reed, 2006, p. 8) and re-design those policies and procedures

98

that do not support staff decision making (Dementia Initiative, 2013). It is imperative the

workforce practices support the relationship-building between the person with dementia

and the Resident-Care Aide by having the appropriate number of staff on shift each day

(Dementia initiative, 2013).

Likewise, it is the responsibility of structural element three: Leadership to ensure

that all Resident-Care Aide are “effectively oriented, trained and mentored to build

person-centered care skills and competencies” (CEAL, 2010, p. 15). In recognition of the

valuable role of the Resident-Care Aide, they must be given the education and resources

needed to enable them to act (Kouzles & Posner, 1995). This means ensuring a more

supportive initial training and ongoing person-centered care mentoring of newer staff by

supervisors and the more experienced, in order develop person-centered care and aging

knowledge needed for raising satisfaction; this is critical for reducing the incidence of

turnover among this population of workers. It is also important that companies cultivate

the talents of the natural leaders within the organization by creating career ladders into

leadership positions for which they can aspire to attain as it is the highest deterrent of

turnover (Coogle, et. al., 2011).

While all components’ are integral the success of person-centered care, the

procedures for the eighth structural element: Accountability are crucial to ensuring that all

of the structural elements, are secured, maintained and producing desired outcomes

through both internal and external methods for analyzing performance (Dementia

Initiative, 2013). This means that family, staff and the resident’s satisfaction is valued,

99

considered and aligned with the core values and philosophy of person-centered care; and

if they are not, governance must take the necessary measures for correcting or realigning

those factors.

Conclusions

Currently, there are more than one million older adults residing in assisted living

communities (Teri, et al., 2005) and more than 50 % of them are affected by dementia

(CEAL, 2010). This coupled by the projection that the incidence of dementia is going to

rise to sixteen million people by the year 2050 (Alzheimer’s Association, 2013), signifies

that the need for both dementia care and assisted living will be astronomical.

Consequently, the need for competent, ethical and stable Resident-Care Aides will be

essential for the provision of quality care. Therefore, it is the responsibility of, and

requires, the commitment of governing officials who are dedicated to ensuring that all

eight structural elements of person-centered care are in place, maintained and producing

desired outcomes (Dementia Initiative, 2013).

100

References

Alzheimer’s Association. (2013). Alzheimer’s disease facts and figures. Retrieved from:

http://www.alz.org/alzheimers_disease_facts_and_figures.asp.

Ball, M., Leproe, L., Perkins, M., Hollingsworth, C. & Sweatman, M. (2009). “They

are the reason I come to work”: the meaning of resident-staff relationships in

assisted living. Journal of Aging Studies, 23, 37-47.

Bandura, A. (2001). Social cognitive theory: an agentic perspective. Annual Review of

Psychology, 52(1), 1-26.

Bandura, A. (1977). Social learning theory. Prentice-Hall, Inc., Englewood Cliffs, N.J.

Bandura, A. (1989). Regulation of cognitive processes through perceived self-efficacy.

Developmental Psychology, 25(5), 729-735.

Bandura, A. (2012). On the functional properties of perceived self-efficacy revisited.

Journal of Management, 38(9), 9-44.

Bass, B. (1960). Leadership, psychology, and organizational behavior. Harper &

Brothers: New York.

Bellows, R. (1959). Creative leadership. Prentice-Hall, Inc., Englewood Cliffs, N.J.

Boeitcher, I., Kemeny, B., DeShon, R. & Stevens, A. (2004). A system to develop staff

behaviors for person-centered care. Alzheimer’s Care Quarterly, 5(3), 188-196.

Boise, L. & White, D. (2004). The family’s role in person-centered care practice

considerations. Aging Matters, 42(5), 12-19.

101

Boone, L. & Makhani, S. (2012). Five necessary attitudes of a servant leader. Review of

Business, 33(1), 83-96.

Brockner, J. (1988). Self-esteem at work: research, theory and practice. Lexington,

MA: Lexington Books.

Brooker, D. & Wooley, R. (2007). Enriching opportunities for people living with

dementia: the development of a blueprint for a sustainable activity-based model.

Aging & Mental Health, 11(4), 371-383.

Brownie, S. & Nancarrow, S. (2013). Effects of person-centered care on residents and

staff in

aged-care facilities: a systematic review. Clinical Interventions in Aging, 8, 1-10.

CALA (2010). Assisted living employees: trained for success. Retrieved from:

http://www.caassistedliving.org/web/pdf/resources/staff_training.pdf.

Center for Excellence in Assisted Living. (2010). Person-centered care in assisted living:

An informational guide. Retrieved from:

http://www.theceal.org/assets/PDF/personcentered%20care%20in%20assisted%2

0living.pdf.

Chou, R. (2012). Resident-centered job satisfaction and turnover intent among direct care

workers in assisted living: a mixed-methods study. Research on Aging, 34(3),

337-364.

Chou R. & Robert, S. (2008). Workplace support, role overload, and job satisfaction of

direct care workers in assisted living. Journal of Health and Social Behavior,

49(2), 208-222.

102

Chung, J. (2009). An intergenerational reminiscence programme for older adults with

early dementia and youth volunteers: values and challenges. Scandinavian

Journal of Caring Science, 23, 259-264.

Coogle, C., Parham, I. & Rachel, C. (2011). Job-satisfaction and career commitment

among Alzheimer’s care providers: addressing turnover and improving staff

empowerment. American Journal of Alzheimer’s Disease & Other Dementias,

26(7), 521-527.

DeCarvalho, R.J. (1991). The growth hypothesis in psychology: the humanistic

psychology of Abraham Maslow and Carl Rogers. EMText: San Francisco.

Dementia Initiative (2013). Dementia care: the quality chasm. Retrieved from:

http://www.ccal.org/wp-content/uploads/DementiaCareTheQualityChasm_2-20-

13-final.pdf.

Ejaz, F., Noelker, L., Menne, H. & Bagaka’s, J. (2008). The impact of stress and support

on direct care workers’ job satisfaction. The Gerontologist, 48(1), 60-70.

Epp, T. (2003). Person-centered dementia care: a vision to be refined. Canadian

Alzheimer’s Disease Review, 14-18.

Fazio, S. (2001). Person-centered language is an essential part of person-centered care.

Caregiving Challenges, 2(2), 87-90.

Gavin, J. (2011). Exploring the usefulness of a recovery-based approach to dementia care

nursing. Contemporary Nurse, 39(2), 140-146.

103

Gitlan, L., Winter, L., Earland, T., Herge, E., Chernett,N., Piersol, C. & Burke, J. (2009).

The tailored activity program to reduce behavioral symptoms in individuals with

dementia: feasibility, acceptability, and replication potential. The Gerontologist,

49(3), 428-439.

Gotell, E., Brown, S. & Ekman, S. (2007). The influence of caregiver singing and

background music on vocally expressed emotions and moods in dementia care: a

qualitative analysis. International Journal of Nursing Studies, 46, 422-430.

Gray-Stanley, J. & Muramatsu, N. (2011). Work stress, burnout, and social and personal

resources among direct care workers. Research in Developmental Disabilities, 32,

1065-1074.

Hadley, C., Brown, S. & Smith, A. (1998). Evaluating interventions for people with

severe dementia: using the positive response schedule. Aging & Mental Health,

3(3), 234-240.

Harris-Wallace, B., Schumacher, J., Perez, K., Eckert, K., Doyle, P., Beeber, A. &

Zimmerman, S. (2011). The emerging role of health care supervisors. Seniors

Housing & Care Journal, 19(1), 97-108.

Hashmi, M. (2009). Dementia: an anthropological perspective. International Journal of

Geriatric Psychiatry, 24, 207-212.

Huang, H., Shyo, Y., Chen, S. & Hsu, W. (2009). Caregiver self-efficacy for managing

behavioural problems of older people with dementia in Taiwan correlates with

care receiver’s behavioural problems. Journal of Clinical Nursing, 18, 2588-2595.

104

Hung, L., & Chaudhury, H. (2011). Exploring personhood in dining experiences of

residents with dementia in long-term care facilities. Journal of Aging Studies

25(1), 1–12.

Isaac, C., Grifin, L. & Carnes, M. (2010). A qualitative study of faculty members’ views

of women chairs. Journal of Women’s Health, 19(3), 553-546.

Jootun, D. & McGhee, G. (2011). Effective communication with people who have

dementia. Nursing Standard, 25(25), 40-46.

Kane, R. & Wilson, K. (1993). Assisted living in the United States: a new paradigm for

residential care for frail older persons?

Kendell, B. (2011). Culture change in long-term care services: Eden-greenhouse-aging in

the community. Educational Gerontology, 37(6), 506-525.

Kirkley, C., Bamford, C., Poole, M., Arksey, H., Hughes, J. & Bond, J. (2011). The

impact of organisational culture on the delivery of person-centered care in

services providing respite care and short breaks for people with dementia. Health

& Social Care in the Community, 19(4), 438-448.

Kitwood, T. (1990). Concern for others: a new psychology of conscience and morality.

London; New York: Routledge.

Kitwood, T. (1993). Person and process. International Journal of Geriatric Psychiatry,

8(7), 541-545.

Kitwood, T. (1995). Positive long-term changes in dementia: some preliminary

observations. Journal of Mental Health, 4(2), 133-144.

105

Kitwood, T. (1997). The experience of dementia. Aging & Mental Health, 1(1), 13-22.

Kitwood, T. (1998). Professional and moral development for care work: some

observations on the process. Journal of Moral Education, 27(3), 401-411.

Koren, M. (2010). Person-centered care for nursing home residents: the culture-change

movement. Health Affairs, 29(2), 312-317.

Kouzes, J. & Posner, B. (1995). The leadership challenge: how to keep getting

extraordinary things done in organizations. Jossey-Bass Publishers: San

Francisco.

Lee, D. (2012). The role of transformational leadership styles in the home health care

industry. Home Health Care Management Practice, 24, 169.

Maslow, A. (1943). A theory of human motivation. Psychological Review, 50, 370-396.

Maslow, A. (1959). New knowledge in human values. NY: Harper & Brothers,

Publishers.

Maslow, A. (1965). Eupsychian Management. Richard D. Irwin, Inc. and the Dorsey

press.

Maslow, A. (1998). Maslow on management. Wiley, John & Sons, Incorporated.

Mcleod, S. A. (2007). Simply Psychology; Maslow | Hierarchy of Needs. Retrieved from:

http://www.simplypsychology.org/maslow.html

NAPA. (2010). U.S. Department of Health & Human Services. Retrieved from:

http://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf.

106

Palmer, C. (2001). Ethnography: a research method in practice. International Journal of

Tourism Research, 3, 301-312.

Perry, J., Galloway, S., Bottorf, J. & Nixon, S. (2005). Nurse-Patient communication in

dementia: improving the odds. Journal of Gerontological Nursing, 31(4), 43-52.

PHI Facts (2013). Quality care through quality jobs. Retrieved from:

http://phinational.org/sites/phinational.org/files/phi-facts-3.pdf.

PPACA. (2010). HR .3590. Retrieved from: http://www.gpo.gov/fdsys/pkg/BILLS-

111hr3590enr/pdf/BILLS-111hr3590enr.pdf.

Reimer, H. & Keller, H. (2009). Mealtimes in nursing homes: striving for person-

centered care. Journal of Nutrition for the Elderly, 28(4), 327-347.

Residential Compendium. (2007). Residential care facilities for the elderly (RCFEs):

Title 22, Division 6, Chapter 87100-87730. Retrieved from:

http://aspe.hhs.gov/daltcp/reports/2007/07alcomCA.pdf

Rogers, C. (1951). Client-centered therapy: its current practice, implications, and theory.

Boston: Houghton Mifflin.

Rogers, C. (1967). On becoming a person: a therapist's view of psychotherapy. London:

Constable.

Social Security Act, 1986, 101 STAT.1330-165.

Spears, L. (1996). Reflections on Robert K. Greenleaf and servant-leadership. Leadership

& Organization Development Journal 17(7), 33-35.

107

Stone, G., Russell, R. & Patterson, K. (2004). Transformational versus servant

leadership: a difference in leader focus. Leadership & Organization Development

Journal, 25(4), 349-361.

Teri, L., Huda, P. Gibbons, L. Young, H. & Leynseele, J. (2005). STAR: a dementia-

specific training program for staff in assisted living residences. The Gerontologist,

45(5), 686-693.

Thornton, L. (2011). Person-centered dementia care: an essential component of ethical

nursing care. Canadian Nursing Home, 22(3), 10-14.

Tietleman, J., Raber, C. & Watts, J. (2010). The power of the social environment in

motivating persons with dementia to engage in occupation: qualitative findings.

Physical and Occupational Therapy in Geriatrics, 28(4), 321-333.

28(4), 321-333.

Tilly, J., & Reed, P. (2006). Dementia care practice recommendations for assisted living

residences and nursing homes. Chicago: Alzheimer’s Association.

Tse, H. & Chiu, W. (2014). Transformational leadership and job performance: a social

identity perspective. Journal of Business Research, 67, 2827-2835.

Watson, T. (2011). Ethnography, reality, and truth: the vital need for studies of ‘how

things work’ in organizations and management. Journal of Management Studies

48(1), 202-217.

108

Weitzel, T., Robinson, S., Barnes, M., Berry, Holmes, J., Mercer, S., Foster, T., Allen, L.,

Victor, D., Volmer, C., Steinkruge, K., Fredrich, L., Plunket, D. & Kirkbride, G.

(2011). The special needs of hospitalized patients with dementia. Academy of

Medical-Surgical Nurses, 20(1), pp.13-8.

Williams JW, Plassman BL, Burke J, Holsinger T, Benjamin S. (2010). Preventing

Alzheimer’s disease and Cognitive Decline. Evidence Report/Technology

Assessment No. 193. (Prepared by the Duke Evidence-based Practice Center under

Contract No. HHSA 290-2007-10066-I.) AHRQ Publication No. 10-E005.

Rockville, MD: Agency for Healthcare Research and Quality.

Williams, K., Harris, B., Lueger, A., Ward, K., Wassmer, R. & Webb, A. (2011). Visual

cues for person-centered communication. Clinical Nursing Research, 20(4), 448-

461.

Wilson, K. (2007). Historical evolution of assisted living in the United States, 1979 to

present. The Gerontologist, 47(11), 8-22.

Woods, B. (1999). The person in dementia care. Generations, 23(3), 35-39.

Yucel, I., McMillan, A. & Richard, O. (2014). Does CEO transformational leadership

influence top executive normative commitment? Journal of Business Research,

65(6), 1170-1177. Retrieved from: http://dx.doi.org/10.1016/j.jbusres.05.005

Zimmerman, S. Williams, C., Reed, P., Boutansi, M., Pressier, J., Heck, E. & Sloane, P.

(2005). Attitudes, stress, and satisfaction of staff who care for residents with

dementia. The Gerontologist, 45(1), 96-105.