Abstract
In residential care communities (CCs), implementation strategies can improve the use of person-centered approaches for residents’ behavioral symptoms of distress. We examined staff perceptions of how well their organizational goals for achieving person-centered care (PCC) were met following implementation of the strategy, Evidence Integration Triangle for Behavioral and Psychological Symptoms of Distress. We also identified organizational characteristics and indicators of staff adoption associated with perceived goal attainment. Goal attainment was evaluated by staff using goal attainment scaling (GAS) at the completion of the implementation trial in 26 CCs. Correlations, t tests, and linear regression were used to determine which factors were associated with goal attainment. Total time spent with the research facilitator, stable staff group membership, and presence of a survey deficiency during the study period explained 63% of the variance in goal attainment. Staff can set achievable organizational goals to improve PCC for residents’ behavioral symptoms of distress.
Behavioral symptoms of distress, such as aggression, agitation, depression, and anxiety, are common in people living with dementia. Up to 90% of residents in care communities (CCs), settings that have traditionally been referred to as nursing homes, exhibit these symptoms and are at high risk for impaired function, exposure to inappropriate use of antipsychotics, and greater cost of care (Kales et al., 2015). The Centers for Medicare & Medicaid Services (CMS) National Partnership to Improve Dementia Care and Reduce Antipsychotic Use in Nursing Homes requires that care for residents living with dementia be delivered using person-centered approaches, including strategies that are targeted to the needs, situations, and preferences of the resident (Lucas & Bowblis, 2017). Despite regulatory requirements, staff struggle to consistently implement these approaches because they lack the knowledge, skills, and/or resources to meet national expectations (Lemay et al., 2013). There is evidence that practice change in CCs can be facilitated when an implementation strategy is used to promote uptake (Mitchell et al., 2020).
GOAL SETTING AND ATTAINMENT WITHIN AN IMPLEMENTATION STRATEGY
We tested the effectiveness of an implementation strategy for helping staff use person-centered approaches for behavioral symptoms of distress in 55 CCs: the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Distress trial (Resnick et al., 2021). A critical component of most implementation strategies is setting and evaluating how well goals that support the attainment of improved care have been met (Mohr, 1973). When goals of care broadly affect all individuals served by a CC, these goals should be set collectively by staff to maximize successful implementation (Mohr, 1973). Prior research has shown that when staff are involved in the process of goal setting it promotes a work environment where they are empowered and motivated to contribute to positive resident outcomes (Karrer et al., 2020; Kottke et al., 2008).
In addition to shared decision making, other factors can affect successful achievement of organizational goals. In their study of residential care for frail older adults, Bravo et al. (2006) found that three variables were associated with organizational goal attainment: the educational level of the manager; the manager’s perception of care quality; and the research team’s ability to establish a partnership with staff. In another study of health care service organizations, expert judges examined case studies and evaluated factors they believed contributed to organizational goal attainment (Glaser & Backer, 1980). Successful goal attainment was more likely in situations where there was evidence that: goals were well-integrated into practice; goals represented a well-defined need of the organization; there was flexibility in implementation; goals reflected staff values; there was a champion who continued to support goal attainment; and staff were involved in the planning and implementation process (Glaser & Backer, 1980).
Research on factors associated with organizational goal attainment in CCs is limited but other literature indicates factors that may impact practice change in these settings. Characteristics of the CC, such as bed size, non-profit status, staffing levels, stable leadership/ownership, and fewer survey deficiencies, have been associated with better overall quality care (Castle & Engberg, 2006; Coleman & Whitelaw, 2020; Harrington et al., 2020). Also important to practice change is the degree to which the administration and staff invest in the practice change initiative, including the number and type (i.e., discipline) of staff engaged in the initiative and the time devoted to achieving the organizational goal (Coleman & Whitelaw, 2020; Kottke et al., 2008).
PURPOSE
We used data from our clinical trial (Resnick et al., 2021) to characterize organizational goal attainment in CCs. Three aims guided the study:
Describe goals set by CC staff to achieve the use of person-centered approaches for behavioral symptoms of distress.
Identify the types of goals that are attained most often as rated by staff.
Identify characteristics of the organization and indicators of staff adoption that are associated with successful goal attainment.
METHOD
Implementation Study
The study was approved by a University-based Institutional Review Board and was registered on clinicaltrials.gov (NCT03014570). The protocol for the study has been published (Resnick et al., 2018). Briefly, 55 CCs and 553 residents from two states were enrolled in the study. The 12-month implementation strategy that was tested in the study included a four-step process delivered by research facilitators working with staff who set organizational goals to overcome barriers to the delivery of person-centered care (PCC).
Setting and Sample
To be eligible, the CC had to: (a) have 100 beds or at least 50 beds if there was a dedicated memory care community; (b) identify a staff member to be a champion who worked with the research team in the implementation process; and (c) be able to access email. For analyses reported here, only treatment CCs who completed the evaluation were included (n = 26 of 28 treatment CCs).
Procedures and Implementation Strategy
CCs were randomized into treatment (multi-component strategy to enhance uptake of person-centered behavioral approaches for symptoms of distress) and control (usual care) groups. As a first step in the implementation approach, each treatment CC formed a working group and selected a champion to partner with a research facilitator (i.e., a member of the research team with expertise and experience in the use of person-centered behavioral approaches in long-term care settings). The working group comprised staff in the CC who volunteered and who could affect or be affected by the implementation strategy (e.g., director of nursing [DON], nursing home administrator, staff nurse, social worker, activities director, direct caregivers). The size of the working group varied by CC and depended on individuals’ ability to participate over the 12-month study. Champions were any staff member who expressed a desire to work with the research facilitator and staff to make a practice change. Together they identified barriers to PCC and worked toward resolution.
The staff working group, champion, and research facilitator met monthly for 12 months to enact the components of the implementation strategy. At their initial meeting, the research facilitator used a brainstorming approach that empowered the group to identify specific goals for improving the use of person-centered approaches for behavioral symptoms of distress. The group was initially asked to identify all barriers to PCC in their CC and then to identify the barrier(s) that was/were primary driver(s) of poor outcomes and that could be successfully resolved within the 12-month study period. Based on that discussion, goals for removing primary barriers were set. Goals were specific to each CC and included such things as enhancing the environment to promote resident wayfinding, improving staff retention, promoting staff empowerment, improving staff knowledge of dementia and community resources, identifying resident preferences for everyday living, reducing staff burnout, and improving communication among interdisciplinary staff.
Four steps were used over the 12-month study period to help staff use approaches to prevent and manage behavioral symptoms of distress and meet their individual organizational goals: (1) assessment of each CC’s physical environment and policies related to management of behavioral symptoms; (2) education of staff on PCC approaches; (3) ongoing assistance with development of PCC plans; and (4) real-time mentoring and motivating of staff on use of PCC approaches for behavioral symptoms of distress. These steps were implemented by the champion with coaching from the research facilitator. During each monthly meeting, the staff working group, champion, and research facilitator discussed progress toward meeting organizational goals and the use of evidence-based and/or practice-informed approaches for reducing behavioral symptoms. These approaches were available on three websites developed by the investigators: www.nursinghometoolkit.com; www.functionfocusedcare.org; and www.preferencebasedliving.com.
At the completion of the project and during the final meeting, the champion and staff working group used goal attainment scaling (GAS) to assess the degree to which each of the goals set in their initial meeting was achieved.
Measures
Measures for the current study were obtained by trained research assistants and research facilitators.
Demographics.
Sex, race, and staffing role were recorded for each staff member engaged in the implementation process.
Organizational Characteristics.
Profit status, bed size, the number of staff hours (RN, licensed practical nurse [LPN], certified nursing assistant [CNA]), and overall star rating were obtained at baseline from the Medicare Nursing Home Compare website (access https://www.medicare.gov). Profit status was rated as for-profit (1) or not-for-profit (0). Overall star rating ranged from 1 to 5 stars (higher star rating indicates better quality performance). In addition, the research facilitator recorded any change in DON, change in ownership, and/or receiving a survey deficiency during the study period. A designation of yes (1) or no (0) was made.
Indicators of Staff Adoption.
During implementation, indicators of staff adoption were tracked at each monthly meeting by the research facilitator. These indicators included the number of meetings held by the group, time spent with the research facilitator (in hours), number of disciplines engaged in the group, number of staff attending meetings, if there was a change in champion, and if there was a change in group membership. At the end of the study period (12 months), total number of meetings held, total time spent with the research facilitator, number of disciplines attending meetings, and average number of staff attending meetings were tabulated. A designation of yes (1) or no (0) was made for a change in champion or staff working group membership.
Goal Attainment Scaling.
GAS is an evaluation technique typically used at the individual level to assess attainment of individual goals of care (Kiresuk et al., 1994). In the current study, it was used as the metric to evaluate organizational goal attainment, the outcome variable in our regression analysis. Each CC set their own specific goals at the initial group meeting. At the final meeting, staff were asked to use a 5-point Likert scale (0 to 4) and come to a consensus on the extent to which each of their CC goals were met (0 = much less than expected, 1 = less than expected, 2 = as expected, 3 = more than expected, 4 = much more than expected). GAS has been used with geriatric interdisciplinary teams working on facility-wide issues that require an individualized approach and is a reliable, valid, and responsive method to quantify outcomes (Bravo et al., 2005; Rockwood et al., 2003).
Data Analyses
Frequencies of staff demographic characteristics were tabulated. To address our first aim, the goal data were analyzed with a conventional content analysis conducted by four researchers (M.B., L.B., K.R., C.M.) who independently coded and categorized the goals set by each CC in the initial meeting. The lead researcher (A.K.) categorized the goals and developed preliminary labels, which were reviewed by the research team who came to consensus on the categorization. Basic descriptive statistics were run to examine the distributions and frequencies of types of goals developed by CCs.
To address our second aim, goal attainment data were dichotomized to goal attained (1) or goal not attained (0). Attained was defined as being rated as: as expected, more than expected, or much more than expected. Not attained included goals rated as much less than expected or less than expected. Average GAS was computed across goals within each category. To compare mean-level ratings of GAS across goal types, we used independent samples t tests.
To address our third aim, we followed a series of steps. First, average GAS scores were computed for each CC. Average score was determined to be the most illustrative of the CC’s ability to achieve the goals set, as CCs set different numbers and types of goals. An average score of 1, for example, indicated a low level of attainment, whereas an average score of 3 or 4 represented a high level of attainment of goals set. Second, correlations (continuous constructs) and tests of mean difference (t test; dichotomous constructs) were run to examine the association of organizational characteristics and indicators of stakeholder adoption with average goal attainment for CCs. We tested the following organizational attributes: bed size, profit status, RN hours, LPN hours, CNA hours, overall star rating, change in DON, change in ownership, and receiving a survey deficiency. We tested the following indicators of staff adoption: number of meetings held, time spent with facilitator, number of disciplines attending meetings, average number of staff members attending meetings, change in champion, and change in working group membership. Third, taking the variables that showed an association with average goal attainment scores, we examined pairwise correlations among them. We then used a stepwise linear regression, first accounting for total time spent by the research facilitator, as this variable represented the effort expended by the research team during implementation. We then tested the incremental impacts of the number of disciplines attending meetings, a change in group membership, and any survey deficiency during the study period to determine which variables uniquely explained variance in goal attainment scores. Constructs not significantly contributing unique variance were trimmed from the final model in favor of parsimony.
RESULTS
During the final meeting, 93 staff across 26 CCs participated in assessing goal attainment using GAS. Most were non-Hispanic, White (74.2%), female (91.4%), and represented various staff roles including: administrators (n = 4), DONs (n = 13), nurses (n = 18), CNAs (n = 4), social workers/social service staff (n = 8), recreation therapists/activity staff (n = 13), and others, such as pharmacists, nutritionists, culinary staff, or fitness instructors (n = 33).
Description of CC Goals
Each CC established between one and four goals (mean = 2.73, SD = 0.87). Across 26 CCs, a total of 72 goals were set. These 72 goals fell into one of five categories: staff capacity, education, communications, improved resident outcomes, and physical environment. Staff capacity included goals aimed at processes or actions designed to enhance the ability of staff to deliver PCC through staff retention, empowerment, sensitivity to resident needs, self-care, or interdisciplinary teamwork. Education included goals centered on transferring evidence-based dementia care knowledge to improve PCC. Communications goals aimed to improve patterns of, and systems for, information exchange to promote positive resident outcomes. Improved resident outcome goals focused on improving specific resident outcomes, such as function, behavior, or mood. Physical environment goals included remodeling or re-using physical space in a more productive way to support resident and family psychosocial needs. Table 1 provides descriptions of each goal type and the percentage of goals that fell into each category. Staff capacity (35% of goals) and education (32% of goals) were the goals set most frequently.
TABLE 1.
Summary of Care Communities’ Goals: Types, Percentage Attaineda, and Mean Level of Attainment (N = 26)
| Goal Type | n (%) | GAS, Mean (SD) |
|
|---|---|---|---|
| Goals Set | Goals Attainedb | ||
| Staff capacity | 26 (35) | 20 (77) | 2.27 (1.28) |
| Education | 23 (32) | 12 (52) | 1.52 (1.16) |
| Communications | 15 (21) | 9 (60) | 1.60 (1.30) |
| Improved resident outcomes | 4 (6) | 2 (50) | 1.75 (0.96) |
| Physical environment | 4 (6) | 1 (25) | 1.00 (0.82) |
Note. GAS = goal attainment score (range = 0 to 4, where 0 = much less than expected, 1 = less than expected, 2 = as expected, 3 = more than expected, 4 = much more than expected).
Attained was defined as: as expected, more than expected, or much more than expected.
If goal was set.
Goal Attainment
We found that 22 (85%) CCs achieved at least one goal during the 12-month period. For staff capacity goals, 77% were attained; whereas for education only 52% were rated as attained (Table 1). Physical environment goals were rarely set (6%) and rarely attained (25%). We found a significant difference between average level of goal attainment for staff capacity (mean = 2.27, SD = 1.28) and education goals (mean = 1.52, SD = 1.16; t[47] = 2.13, p = 0.039). In other words, CCs realized higher levels of goal achievement when they addressed staff capacity goals than when they addressed educational goals. No differences were found between staff capacity and communication goals or between communication and education goals. We were unable to compare improved resident outcome and physical environment goals to the other goals because of insufficient sample size in these two categories.
Factors Associated With Goal Attainment
Table 2 outlines the associations of organizational attributes and indicators of staff adoption with average goal attainment scores. The only CC organizational characteristic associated with goal attainment was the documentation of a survey deficiency during the study period (yes/no); those not experiencing a survey deficiency during the intervention achieved lower levels of goal attainment (mean = 1.58, SD = 0.86) than CCs experiencing a survey deficiency (mean = 3.07, SD = 0.48). Regarding indicators of staff adoption, more time spent by the research facilitator with CC staff in meetings and a greater number of disciplines attending those meetings were associated with greater goal attainment. In addition, CCs that did not experience a change in their staff group membership reported higher goal attainment (mean = 2.32, SD = 0.85) than those that experienced a change (mean = 1.46, SD = 0.99).
TABLE 2.
Associations of Care Community Organizational Attributes and Indicators of Staff Adoption With Average Goal Attainment Scores
| Attribute | n (%) or Mean (SD) (Range) | Goal Attainment |
|---|---|---|
| r/p Value or t(df) | ||
| Organizational Characteristics | ||
| Bed size | 142.27 (76.08) (63 to 412) | −0.24/0.237 |
| Profit status | t(24) = 0.95/0.350 | |
| For profit | 14 (54) | |
| Not for profit | 12 (46) | |
| RN hours | 48.96 (15.7) (23 to 80) | 0.08/0.708 |
| LPN hours | 49.24 (13.14) (22 to 74) | −0.31/0.129 |
| CNA hours | 135.96 (20.96) (100 to 173) | −0.03/0.900 |
| Overall star rating | 3.62 (1.2) (1 to 5) | −0.18/0.375 |
| DON change | t(24) = 0.81/0.428 | |
| No | 19 (73) | |
| Yes | 7 (27) | |
| Ownership change | t(24) = 1.01/0.321 | |
| No | 24 (924) | |
| Yes | 2 (8) | |
| Survey issues during studya | t(22) = –3.68/0.001 | |
| No | 19 (73) | |
| Yes | 5 (19) | |
| Indicators of Stakeholder Adoption | ||
| Count of monthly meetings over 1 yearb | 10.54 (1.73) (7 to 12) | 0.17/0.400 |
| Total time spent by research facilitator within staff working group meetings (hours) | 11.82 (5.38) (3 to 22) | 0.61/0.001 |
| Total number of disciplines engaged in staff working group meetings over 1 year | 4.46 (1.82) (2 to 9) | 0.43/0.029 |
| Average number of staff members attending meetings over 1 year | 4.65 (1.63) (2.38 to 8.22) | 0.29/0.151 |
| Change in champion | t(8.61) = −0.37/0.723 | |
| No | 18 (69) | |
| Yes | 8 (31) | |
| Change in composition of staff working group membership | t(24) = 2.35/0.027 | |
| Yes | 14 (54) | |
| No | 12 (46) | |
Missing data for two nursing homes.
Excludes meetings held with just the champion.
Table 3 reports inter-item correlations among the constructs showing associations with average goal attainment. Total number of disciplines engaged across meetings was positively associated with time spent by the research facilitator and presence of a survey deficiency during the study.
TABLE 3.
Correlations Among Characteristics With Significant Associations With Average Goal Attainment Scores
| 1 | 2 | 3 | 4 | |
|---|---|---|---|---|
| 1. Total time spent by research facilitator with facility in meetings (hours) | — | |||
| 2. Total number of disciplines engaged in staff working group meetings over 1 year | 0.48* | — | ||
| 3. Change in composition of staff working group membership | −0.08 | −0.15 | — | |
| 4. Survey deficiency during study | 0.44* | 0.04 | −0.15 | — |
p < 0.05.
Table 4 outlines regression results. We found that total time spent with the research facilitator was significantly and positively associated with average goal attainment scores. After accounting for this association, we also found that a survey deficiency during the study was positively associated and change in staff working group was negatively associated with average goal attainment scores. The three variables together explained 63% of the variance in goal attainment scores. Total number of disciplines attending meetings was not uniquely predictive in the models after accounting for total time spent with the research facilitator and was dropped from the final model.
TABLE 4.
Regression Results of Organizational and Implementation Strategy Variables Associated With Average Goal Attainment Scores
| Variable | Model 1 |
Model 2 |
||||
|---|---|---|---|---|---|---|
| B | SE | β | B | SE | β | |
| Constant | 0.50 | 0.39 | — | 1.05* | 0.37 | — |
| Total time spent by research facilitator in staff working group meetings (hours) | 0.12*** | 0.03 | 0.64 | 0.08** | 0.03 | 0.44 |
| Change in composition of staff working group membership | — | — | — | −0.57* | 0.27 | −0.29 |
| Survey issues during study | — | — | — | 0.92* | 0.37 | 0.38 |
| F | 14.98*** | 11.3*** | ||||
| R2 | 0.41 | 0.63 | ||||
| ΔR2 | — | 0.22 | ||||
Note. SE = standard error.
p < 0.05
p < 0.01
p < 0.001.
DISCUSSION
This is one of the first studies to evaluate organizational goal setting for managing behavioral symptoms of distress in CCs. In the current study, staff from 26 CCs identified a total of 72 goals. The number and breadth of these goals indicate that staff are aware of the myriad factors that drive resident outcomes, and importantly, those they perceive to be specific to their community. From the point of view of staff, the goals they developed reflected a clear pattern of viewing system-level issues as the main barriers to PCC delivery. This finding has been corroborated by other nurse-led dementia implementation research (Karrer et al., 2020).
Building staff capacity through retention, staff empowerment, sensitivity to resident needs, self-care, or interdisciplinary teamwork was the most frequently identified method for removing barriers to PCC (35% of total goals). These goals were also attained at a higher rate than other types of goals and significantly more so than educational goals, which were the second most common type of goal identified.
Staff empowerment, an aspect of staff capacity, has long been a theme voiced as central to the broader culture change movement in nursing homes (Koren, 2010). Empowerment of nursing staff, especially CNAs, in long-term care has improved resident outcomes related to social engagement and clinical outcomes, as well as better staff outcomes, including increased job satisfaction and decreased burnout and turnover (Barry et al., 2005; Berridge et al., 2018; Kostiwa & Meeks, 2009; Rajamohan et al., 2019).
In a recent summation of common challenges to implementing PCC practices, the Alzheimer’s Association Dementia Care Provider Roundtable pointed to the importance of providing staff with education in “applying a specific person-centered approach to address dementia-related expressions” via experiential training opportunities (Fazio et al., 2020, p. 1584). The centrality of good communication and effective information sharing systems has also been shown to dramatically affect the perceived ability of staff to deliver PCC (Kolanowski et al., 2015). Our findings support that staff understand the need for education and communication systems to implement PCC.
Goals related to improved resident outcomes and the physical environment were set less often and achieved less frequently than the other three types of goals, making it difficult to conduct any statistical comparisons. In a recent national panel study of culture change practices in 1,584 U.S. nursing homes, only 22% of facilities were able to demonstrate improvements in the physical environment over a 7-year period (Lima et al., 2020). The nursing homes that improved had greater resources compared to facilities that did not improve. Improving the physical environment is more durable than, for example, staffing levels, but takes a large initial capital investment, something many CCs lack. In that same study, improvements in PCC were achieved by 44% of nursing homes, but there was evidence that the adoption of those care practices depended on continual buy-in from leadership and staff (Lima et al., 2020).
The regression analysis indicated that organizational characteristics and indicators of staff adoption were associated with goal attainment. CCs that were experiencing survey deficiencies, those that had a stable staff working group, and those that spent more time with the research facilitator were more successful in meeting their goals. Having a survey deficiency may have incentivized CCs to improve the care they delivered to residents. By participating in our research study, staff were provided with an opportunity to learn and demonstrate improved resident care. Having a stable staff working group and leadership provided by the research facilitator may have worked to produce the continual buy-in needed for practice change (Lima et al., 2020). Strong leadership and low staff turnover are among the important elements that support quality improvement.
IMPLICATIONS FOR NURSING PRACTICE
This implementation study was designed to engage CC staff in a process where they identified barriers to PCC and then, collectively, set goals to reduce those barriers and improve the quality of care delivered to residents. Shared decision making motivates staff to take an active role in implementing practice change (Karrer et al., 2020; Kottke et al., 2008) and has been shown to have a positive effect on many of the barriers to PCC identified by staff in the current study. The American Nurses Credentialing Center Pathways to Excellence Program is an example of a framework for a practice environment that builds on shared decision making (access https://www.nursingworld.org/). CCs that have adopted this program report less staff turnover, greater job satisfaction, greater resident satisfaction, and better resident outcomes (White et al., 2020). Our experience during the current study supports that a culture of shared decision making is a critical component of PCC and should be adopted by CCs because it has the effect of aligning strategies that not only support regulatory compliance but build a qualified and stable workforce.
LIMITATIONS AND STRENGTHS
There are limitations to the study. Members of the staff working groups were volunteers and their perception of goal attainment may not represent the perception held by staff not involved in the monthly meetings. A larger and more geographically diverse sample may yield different results. There may be other factors that impact goal attainment that were not considered in this study. There are also strengths to the study. The use of GAS empowered staff to identify and specify actions to address the specific issues that were driving outcomes in their CCs. Research assistants and facilitators were well-trained and had experience working in CC settings.
CONCLUSION
PCC is the standard for quality care but many CCs struggle to implement practices that would make it a reality. In the current study, staff were able to set specific goals to improve PCC. Successful goal attainment was realized in those CCs that received a survey deficiency, had a stable staff working group, and had greater input from the research facilitator.
Funding:
The study was supported by the National Institute of Nursing Research (NINR) (grant 1R01NR015982-01A1). The National Institutes of Health/NINR had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Footnotes
Disclosure: The authors have disclosed no potential conflicts of interest, financial or otherwise.
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