As world life expectancy rises, the number of people who are aged 60 and over is projected to increase (United Nations Department of Economic and Social Affairs Population Division, 2015; He et al, 2016). The average life expectancy in Ireland rose to 81.8 years in 2016 (European Commission Directorate-General for Economic and Financial Affairs, 2017). Thus older adult services need to prepare for increased demand (Ling and McGann, 2018). Adults over the age of 65 are more likely to have complex care needs (Kogan et al, 2016). In Ireland, over 23 000 older adults over the age of 65 reside in long-term care settings (Central Statistics Office, 2017).
Person-centred approaches are a central feature of older adults' care (Broderick and Coffey, 2013; Wilberforce et al, 2016). This is a multidimensional concept without one global definition. Recently, the American Geriatric Society (AGS) Expert Panel on Person-Centered Care described it as meaning that an individual's values and preferences are elicited to guide all aspects of their health care, while supporting their health and life goals (AGS, 2016). In Ireland, the National Standards for Safer Better Healthcare place person-centred care and support on the agenda in the delivery of healthcare services (Health Information and Quality Authority (HIQA), 2012).
The provision of person-centred care that is responsive to the multifaceted needs of older adults is central to collaborative healthcare delivery (AGS, 2016). This collaborative approach shifts away from the traditional biomedical model towards supporting individual choice and autonomy in healthcare decisions to the extent that the individual desires (McCormack and McCance, 2010; The Health Foundation, 2014; Yoon et al, 2015; Kogan et al, 2016; Ling and McGann, 2018). Person-centred care is synonymous with high-quality care provision (Li and Porock, 2014; AGS, 2016). The National Quality Standards for Residential Care Settings for Older People in Ireland aim to ensure that the safety and wellbeing of older adults is promoted through safe staffing, good management and effective clinical governance in the residential care setting (HIQA, 2016). However, the delivery of quality health care from the residents' perspective is more than a reduction of adverse events or the presence of standards and guidelines (Edvardsson et al, 2017).
A review identified a small number of published tools that measured person-centred care from the patient's perspective (Edvardsson and Innes, 2010). Two measures assessed to what extent the patients' view the psychosocial environment of hospital settings to be person centred; the Person-centered Climate Questionnaire-Patient (PCQ-P) (Edvardsson et al, 2009) and the Person-Centred Inpatient Scale (Coyle and Williams, 2001). The Client-Centred Care Questionnaire measures the extent to which older people living at home experienced professional nursing care as being person centred (de Witte et al, 2006).
The PCQ-P has demonstrated reliability and validity to assess the levels of person-centredness in diverse care environments (Edvardsson et al, 2009; Parlour et al, 2015). The Norwegian, Swedish and English versions of the PCQ-P showed reliability and validity to measure the perceptions of older adults of the person-centred climate of long-term care settings (Yoon et al, 2015, Bergland et al, 2015, Nordin et al, 2017). In particular, the English version identified hospitality, safety and everydayness as crucial dimensions of a person-centred environment (Yoon et al, 2015):
Aim
The aim of this study was to explore the perspectives of Irish residents in a long-term care setting about the person-centred climate of the setting.
Method
A cross-sectional quantitative design was used to explore the perceptions of adults aged 65 years of age and older about the person-centred climate of their long-term care setting.
Sample, settings and participant recruitment
Between February and May 2014 a purposive sampling procedure was used to recruit participants from one older adult setting, which comprised five wards, in the south-east of Ireland. Inclusion criteria were to be aged 65 years or older, to be cognitively able to respond to the questionnaires as assessed by the clinical nurse manager, have the ability to communicate verbally and be able to consent to participate in the study. Residents who did not meet these criteria were excluded. Individuals who met the inclusion criteria were informed about the study by a member of the research team during information sessions. Interested participants were given a questionnaire and an envelope that was returned to a sealed box in each ward area. The questionnaires were anonymised to protect participants' confidentiality. Overall, 56 residents completed the questionnaires and were included in the analysis.
Development of PCQ-P
The PCQ-P is a 17-item tool that measures to what extent the psychosocial environment of healthcare settings is perceived to be person-centred. The development of the tool was based on findings from a qualitative study exploring the meaning of the psychosocial environment for patients. The tools then underwent initial testing among Swedish participants (Edvardsson et al, 2008). The PCQ-P was translated into English and demonstrated validity and reliability among Australian day-surgery recipients (Edvardsson et al, 2009).
The tool is rated on a 6-point Likert scale (ranging from 1 = no I disagree completely to 6 = yes I agree completely). The scale describes three dimensions of person-centred care: safety, everydayness and hospitality (Edvardsson et al, 2008). Scores range between 17 (a climate that is not very person-centred) to 102 (a very person-centred climate). Demographic characteristics were also collected, comprising gender, age and length of stay in the long-term care setting.
Data collection and ethical considerations
Data were collected from five long-stay wards (two male, two female and one mixed ward). The study was approved by the relevant research ethics committees and was conducted to international ethical research guidelines. Returning the completed questionnaire implied participant consent.
Analysis of the results
Participants were given a study identifier to maintain confidentiality. All survey data were coded in SPSSv24.0. The analysis included descriptive and chi-squared analysis. Positive resident perceptions of the person-centred climate of the care setting (Yes, I agree and Yes, I agree completely) were categorised for chi-square analysis. The groupings of age and length of stay were chosen as being above or below the mean value for the variable. Residents were compared by gender (male versus female), mean age (aged 83 years or older versus 82 years of age or younger), and mean length of stay (37 months or less versus 38 months or more) (Table 1). Cronbach's alpha and item-total coefficients were conducted for the whole scale and each of the three subscales: hospitality, safety and everydayness.
| Characteristic | Frequency (%) | Mean (SD) | |
|---|---|---|---|
| Gender | Male | 28 (53) | |
| Female | 25 (47) | ||
| Age (years) | <65 years | 2 (4) | 82.87 (7.17) |
| 65-74 years | 7 (14) | ||
| 75-84 years | 23 (41) | ||
| >85 years | 23 (41) | ||
| Length of stay (months) | ≤6 months | 14 (27) | 37.72 (41.28) |
| >6 ≤12 months | 6 (11) | ||
| >12 ≤36 months | 15 (28) | ||
| >36 months | 18 (34) | ||
SD = standard deviation. Respondents did not complete all fields and some information is missing (gender = 3, age = 1, and length of stay = 3)
Results
Demographics
Similar numbers of male and female residents participated (52.8% male versus 47.2% female). The mean age was 82.87 years of age (SD=7.17). The average length of stay was 37.72 months (SD=41.48). Of these residents, the majority (94.6%) were in long term care, while the others were utilising respite care (Table 1).
Reliability analysis
The cut-off point for the Cronbach alpha coefficient was satisfactory for the whole scale (0.89). All but one of the subscales, safety, reached the cut-off point of 0.7 (Pallant, 2010) (Table 2). Because it was important to measure residents' perceptions of safety, the subscale was retained because the overall Cronbach's alpha level was greater than 0.7. The corrected item-total coefficients varied from 0.349-0.724, which indicates a moderate correlation (>0.20) (Streiner et al, 2014).
| Person-centered Climate Questionnaire Patient (PCQ-P) statement | Mean (SD) | |
|---|---|---|
| Hospitality | A place where I feel welcome | 5.75 (0.552) |
| A place where it is easy to talk to staff | 5.64 (0.754) | |
| A place where staff are knowledgeable | 5.62 (0.733) | |
| A place where staff talk to me so that I can understand | 5.51 (0.858) | |
| A place where staff make extra efforts for my comfort | 5.45 (0.789) | |
| A place where I can make choices, eg what to wear, eat | 5.31 (0.960) | |
| A place where staff take notice of what I say | 5.22 (1.01) | |
| A place where I get that ‘little bit extra’ | 5.20 (0.989) | |
| Safety | A place that is neat and clean | 5.89 (0.366) |
| A place where I feel safe | 5.80 (0.483) | |
| A place where I receive the best possible care | 5.52 (0.934) | |
| A place where staff come quickly when I need them | 5.50 (0.809) | |
| A place where staff seem to have time for patients | 5.21 (0.967) | |
| Everydayness | A place that feels homely | 5.53 (1.067) |
| A place where people talk about everyday life and not just illness | 5.11 (1.121) | |
| A place that has something nice to look at | 5.04 (0.898) | |
| A place where it is possible to get unpleasant thoughts out of your head | 4.89 (1.155) | |
| Reliability analysis | Whole scale: Cronbach's alpha = 0.89 |
|
Climate of person-centredness
Overall, residents rated the person-centred climate very highly in terms of being a hospitable environment in which they were made to feel welcome, and a safe environment that was kept neat and clean. The mean (SD) total score for the whole scale was 5.39 (0.520). The mean scores in the hospitality subscale ranged from 5.20 to 5.75; in the safety subscale they ranged from 5.21 to 5.89; and in the everydayness subscale they ranged from 4.89 to 5.53 (Table 2).
Female residents were significantly more likely to mention that the environment felt homely compared with male residents (100% v 85.7%, P=0.49) (Table 3). Almost one-quarter of female residents did not perceive that they received the best care possible (24%), or that the staff took notice of what they said (28%), or that the staff seemed to have time for them (28%), although statistical significance was not reached when compared with males.
| Statements | Gender (n=53) | Age (n=55) | Length of stay (n=53) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Male % (n=28) | Female % (n=25) | Significance | ≤82 years % (n=24) | ≥83 years % (n=31) | Significance | ≤37 months % (n=18) | ≥38 months % (n=35) | Significance | |
| Staff knowledgeable | 89 (25) | 87 (21) | 0.841 | 91 (21) | 87 (27) | 0.627 | 88 (30) | 89 (16) | 0.944 |
| Best care possible | 93 (26) | 76 (19) | 0.87 | 83 (20) | 87 (27) | 0.695 | 83 (29) | 94 (17) | 0.238 |
| Feel safe | 93 (26) | 100 (25) | 0.173 | 92 (22) | 100 (31) | 0.102 | 100 (35) | 89 (16) | 0.044 * |
| Feel welcome | 93 (26) | 96 (24) | 0.621 | 100 (24) | 90 (28) | 0.117 | 91 (32) | 100 (18) | 0.201 |
| Staff easy to talk to | 89 (25) | 96 (24) | 0.356 | 87 (21) | 97 (30) | 0.189 | 94 (33) | 89 (16) | 0.481 |
| Staff notice what I say | 86 (24) | 72 (18) | 0.219 | 67 (16) | 90 (28) | 0.030 * | 80 (28) | 78 (14) | 0.850 |
| Staff come quickly | 82 (23) | 84 (21) | 0.857 | 75 (18) | 90 (28) | 0.128 | 80 (28) | 89 (16) | 0.414 |
| Staff talk to me | 86 (24) | 92 (23) | 0.471 | 87 (21) | 90 (28) | 0.739 | 87 (31) | 89 (16) | 0.972 |
| Place neat and clean | 96 (27) | 100 (25) | 0.340 | 100 (24) | 97 (30) | 0.375 | 97 (34) | 100 (18) | 0.469 |
| Staff have time for patients | 82 (23) | 72 (18) | 0.378 | 71 (17) | 84 (26) | 0.246 | 74 (26) | 83 (15) | 0.456 |
| Something nice to look at | 74 (20) | 84 (21) | 0.381 | 74 (17)** | 81 (25) | 0.556 | 82 (27) | 72 (13) | 0.426 |
| Feels homely | 86 (24) | 100 (25) | 0.049 * | 96 (23) | 90 (28) | 0.435 | 91 (32) | 94 (17) | 0.694 |
| Rid of unpleasant thoughts | 63 (17) | 84 (21) | 0.087 | 58 (14) | 87 (26) | 0.018 * | 69 (24) | 83 (15) | 0.248 |
| Talk about everyday life | 79 (22) | 76 (19) | 0.823 | 67 (16) | 87 (27) | 0.069 | 86 (30) | 67 (12) | 0.105 |
| Staff make extra effort | 89 (25) | 84 (25) | 0.570 | 75 (18) | 97 (30) | 0.016 * | 80 (28) | 100 (18) | 0.042 * |
| Make choices | 79 (22) | 84 (21) | 0.614 | 75 (18) | 87 (27) | 0.249 | 83 (29) | 78 (14) | 0.654 |
| Get a little bit extra | 68 (19) | 72 (18) | 0.743 | 62 (15) | 77 (24) | 0.227 | 71.4 (25) | 67 (12) | 0.721 |
Note:
denotes statistically significant associations at the p<0.05 level;
out of 23 respondents
Older residents were significantly more likely to perceive that staff took notice of what they were saying (90.3% v 66.7%, P=0.030) and that they made extra efforts to ensure the residents' comfort (96.8% v 75.0%, P=0.016) compared with younger residents (Table 3). Younger residents were significantly more likely to report that they perceived the setting as a place where it was difficult to get unpleasant thoughts out of your head (58% v 87%, P=0.018) compared with older residents (Table 3).
Residents who had resided in the long-term care facility for more than 37 months (maximum length of stay 13.5 years) were significantly less likely to feel safe in the environment (89% v 100%, P=0.044) compared with those residents who had lived in the facility for 37 months or a shorter period (minimum residence 1 month) (Table 3). Conversely, longer term residents were significantly more likely to report that staff made an extra effort to ensure that they were comfortable in their environment (100% v 80%, P=0.042) compared with those with a shorter length of stay in the care facility (1-37 months).
Discussion
Person-centred care was developed to promote a person's wellbeing and quality of life in contrast to treatment driven by health professionals (McCormack and McCance, 2010). Person-centredness is now regarded as a central component of any high-quality long-term care service for older people (Yoon et al, 2015; Wilberforce et al, 2016). Patients in older people's care settings may prioritise different facets of person-centredness, or require them to be achieved in a different manner to patients in other healthcare settings (Wilberforce et al, 2016).
In the current study, the Cronbach's alpha coefficient for the whole scale was 0.89, which demonstrated a satisfactory internal consistency for the PCQ-P. This is a consistent finding with two previous research studies that used the PCQ-P among nursing home residents, indicating Cronbach's alpha values of 0.89 and 0.84 in the US and Norwegian versions respectively (Yoon et al, 2015; Bergland et al, 2015). The results also supported the three dimensions of a person-centred climate: hospitality, safety and everydayness reported in the US study (Yoon et al, 2015).
Everydayness incorporates a homely environment where people talk about everyday things, and do not focus on cognitive and physical decline. It also helps residents to get unpleasant thoughts out of their head through the maintenance of personal identity and their usual routines (Kitwood, 1997; Edvardsson et al, 2008). Previous research has shown that, given the extended length of stay in nursing homes, fostering an atmosphere of everydayness through the provision of a homely and deinstitutionalised environment contributes to the residents' perception of living in a more person-centred care setting (Edvardsson et al, 2008; Yoon et al, 2015; Nordin et al, 2017). In the present study, the lower mean values detected in the everydayness subscale (5.53-4.89) have demonstrated that everydayness is also a significant aspect of person-centred care provision for residents in Irish nursing homes that needs further attention by care providers.
In particular, younger male residents who had lived in the long-term residential setting for less than 3 years were more likely to report that they did not perceive the setting as a place where you could get unpleasant thoughts out of your head. A recent randomised controlled trial highlighted that depressive symptoms may also be observed among aged care residents (Lok et al, 2017). Many residents have difficulties adjusting to their loss of independence and routine, and many of the residents feel over-challenged and unable to cope with the new situation (Thakur and Blazer, 2008; Riedl et al, 2013; Bhar, 2015,). Care providers need to address these concerns to enhance the person-centred climate in long-term residential settings.
Women are more likely than men to require long-term care and for longer durations (Feder and Komisar, 2012). In the current study, more female residents were dissatisfied with the time that staff had to spend with them and also perceived that staff did not take notice of what they said when compared to male residents. However, both male and female residents equally endorsed the statement that it was crucially important for care providers to create an environment where people talked about everyday life and not just about illness. Recent research in person-centred care and practice development in older adult residential care settings undertaken by Buckley et al (2018) suggests that spending time with residents needs to be based on the residents' priorities, and not driven by care provider task allocation. One way of doing this is to prioritise the creation of ‘communicative spaces' such as a lounge area with seating for staff and patients, leading to meaningful communication between care provider and residents (Buckley et al, 2018). Conceptually, communicative spaces provide a discursive arena in which people's voices can be heard. Physically, it is a space participants are familiar with and comfortable in (Bevan, 2013).
Satisfaction with the hospitality culture in care settings for older adults, encompassing feelings of comfort, reliable delivery of services by knowledgeable staff, and where individuality is respected and fostered, has been found to support residents to live actively in their later years (Lee and Severt, 2017). In terms of hospitality, older Irish residents in the present study perceived that staff needed to pay more attention to assisting them to make choices about their day-to-day living, to actively listen to and respond to what they have to say, and to make an extra effort to doing a little extra to understand the person and build a unique individualised relationship.
Older adults in long-term care settings are likely to need assistance in multiple activities of living, to have functional decline in the physical and cognitive domains, and to be chronically frail. Long-term care settings must strive to find a balance between preserving maximum independence and promoting the safety of an increasingly frail population, taking into account the context of care, the resident characteristics, and the resident mix, including long and short stay and staffing levels (Simmons et al, 2016). In this study, residents rated the overall safety of the environment quite highly, which echoes the international findings of Yoon et al (2015) and Bergland et al (2015). However, older adults (>83 years of age) who are ageing in the long-term care setting as their full-time place of residence for a longer period of time (>38 months) were less likely to feel safe there. The PCQ-P could also be used to gather the perspectives of longer term residents and residents who are availing themselves of respite care in such settings to help the staff to deliver high-quality, person-centred care for both groups.
Owners and managers of long-term older adult settings need to keep pace with the changing landscape in the healthcare industry (Negrea, 2016). There is clear scope for improvements in approaches to Irish older adult long-term care delivery to provide greater person-centred care and support based on the individual's right to self-determination, mutual respect and understanding (HIQA, 2016; Browne, 2016).
Limitations
Several limitations of this study need to be acknowledged. This study was conducted in a single long-term residential setting in one geographical location using a purposive sampling frame. This affects the generalisability of the results and may not be representative of older adults residing in long-term care settings across Ireland. A cross-sectional design only captures a snapshot of the perspectives of the residents at that particular time. Future research studies should gather PCQ-P data at a number of timepoints to allow for comparison of the person-centred climate in the long-term older adult care setting over time.
The inclusion of the clinical nurse manager in the recruitment process introduced a possibility of selection bias, in that they may have been more likely to select residents who were more likely to respond favourably to queries about the person-centred climate of the setting. The questionnaire response rate was poor (56%) and data were not collected on the non-responders (44%). As a result of the poor response rate, and consequent low sample size, an assessment cannot be made about the perceptions of the person-centred climate of the long-term care setting for non-responders, which limits the generalisability of these results beyond this sample of residents in this long-term care setting.
Conclusion
This study contributes to the literature by supporting the reliability and validity of the PCQ-P with regard to measuring the perceptions of older adults in long-term care settings. This study showed that the English version of the PCQ-P had satisfactory reliability among cognitively intact residents of long-term residential care settings in Ireland. The research also supported the three dimensions of a climate of person-centred care: hospitality, safety and everydayness, as identified in recent international research. Overall, the climate of person-centred care in the long-term care residential setting was appraised highly by the residents. There is a need for larger scale studies to explore the person-centred climate of long-term and respite residential settings.