Implementing Person Centered Care in Nursing Homes Public Deposited

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  • August 29, 2022
  • Rosemond, Cheryl A.
    • Affiliation: Gillings School of Global Public Health, Department of Health Behavior
  • Nursing homes are likely the most complex of all the healthcare organizations in the United States. Charged with caring for frail and disabled elders, nursing homes operate under high regulatory scrutiny and low public opinion. Despite efforts to improve, many nursing home residents receive poor care. By focusing on residents' needs and preferences rather than operational efficiency, person centered care represents an innovation in nursing home care. This dissertation applies innovation implementation theory to understand what might help or hinder the implementation of person centered care in nursing homes. The theoretical framework posits that the constructs of management support, financial resources, implementation policies and procedures, and implementation climate are positively related to the implementation effectiveness of the innovation. Because of factors specific to the nursing home setting, the framework was adapted by adding four constructs: 1) innovation characteristics; 2) organizational stability; 3) innovation-values fit; and 4) innovation-operations fit. Data for this research come from the Person Centered Care (PCC) Program, conducted by The Carolina's Center for Medical Excellence and funded by the Centers for Medicare & Medicaid Services. Eight North Carolina nursing homes participated in the PCC Program from Sept 2004 to August 2005. Using complementary methodologies, two studies were carried out. Study 1 used 24 semi-structured interviews and content analytic methods to understand direct caregivers' views about the climate for the implementation of person centered care in their nursing home. Study 2 employed a multiple case study design and pattern matching logic to determine why some nursing homes were more effective than others in implementing person centered care. Rival hypotheses were tested to examine if the presence of electronic communications or if knowledge experts' and nursing homes leaders' confidence to accomplish PCC Program goals were associated with implementation effectiveness. Implementation effectiveness was positively associated with one aspect of implementation policies and practices - management communications. Implementation effectiveness was also positively associated with implementation climate as viewed by direct caregivers. Counter to theoretical predictions, implementation effectiveness was positively associated with an innovation characteristic - scope of the project. Implementation effectiveness was not associated with the presence of financial resources, management support, organizational stability, or other implementation policies and practices, including the amount of time and training offered to workers to learn about person centered care. Rival hypothesis testing demonstrated that knowledge experts' and facility leaders' confidence to achieve PCC Program goals was associated with implementation effectiveness. This research demonstrates that implementation was more effective when characteristics of the innovation fostered smooth operations in the daily routines of direct caregivers, the worker group most responsible for the implementation of person centered care. Implementation was also more effective when leaders communicated about the innovation in a way that demonstrated cultural sensitivity to the attributes of key worker groups. Based on their confidence to achieve PCC Program goals, knowledge experts and facility leaders could accurately forecast their homes' implementation effectiveness early in the change process. This finding suggests that a more fine-grained understanding of implementation effectiveness may lie in understanding leaders' and workers' perceptions about their organization's readiness and capacity to implement broad-based change.
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  • ... in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Health Behavior and Health Education in the School of Public Health
  • Ennett, Susan
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  • University of North Carolina at Chapel Hill

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