You know the scenario: A resident wants to eat donuts, but it will send her blood sugar skyrocketing. The staff members aren’t sure whether to let her indulge as part of person-centered care or to insist on a sugar-free alternative so that they’re not out of compliance with her care plan.
A recent study by Parker et. al examined the staff-perceived conflicts between providing services that are consonant with resident-centered care and those that are in compliance with regulations and the rights of other residents, referred to in their research as “care quality.” They made recommendations based on their findings to ease these conflicts.
They interviewed nursing home staff at 12 different Veterans Administration facilities, including senior leaders, middle managers and direct care staff, asking them questions about care such as, “Is resident-centered care implementation competing with other facility goals?”
All of the nursing homes found some level of conflict between resident-centered care and quality.
The three main areas of divergence were in 1) resident preferences versus medical care, such as issues around dietary compliance, 2) resident preferences and the rights or safety of others, such as someone disrobing in common areas, and 3) “limits on staff ability to respond, related to either time or regulations.”
The first type of conflict was the most common by far, with issues not only around dietary compliance, but also around situations such as when the resident wants to go outside to smoke but weather extremes make it physically unsafe, or residents who are in danger of falling but want to assume the risk and walk unaided.
The second area of friction was related to social or emotional health, such as roommate conflicts. Others related to concerns about physical health, such as when a resident with an infection wants to engage in activities that could put the health of others at risk.
A complicating factor in these instances was the need to explain these situations to family members who might feel that the limits being put on a loved one are not consonant with resident-centered care.
In the third category of conflict, staff members found it difficult to accommodate resident preferences when they were short-staffed, especially at mealtimes when there were multiple demands on their time.
The authors of the study made several recommendations to help minimize these conflicts in the approach to care.
• Determine how each resident feels about the balance of quality of life versus long-term survival. Assess and document the risks involved in their choices and the efforts of team members to mitigate the risks. Helpful tools and examples can be found in this Ideas Institute document, “A Process for Care Planning for Resident Choice.” McKnight’s blogger The Real Nurse Jackie wrote more about the document here.