Pervasive Risk Avoidance: Nursing Staff Perceptions of Risk in Person-Centered Care Delivery

Abstract

Background and Objectives

Nursing home (NH) staff perceptions of risks to residents’ health and safety are a major barrier to honoring resident preferences, the cornerstone of person-centered care (PCC) delivery. This study explored direct-care nursing staff perceptions of risk (possibilities for harm or loss) associated with honoring residents’ preferences for everyday living and care activities.

Research Design and Methods

Qualitative, descriptive design using sequential focus group (FG) methodology.

Results

Participants (N = 27) were mostly female (85%), had more than 3 years of experience (74%), and worked in NHs recently experiencing 6–12 health citations. Content analysis of 12 sequential FGs indicated nursing staff perceptions of risks may impede delivery of person-centered care. This is supported by the overarching theme: pervasive risk avoidance; and subthemes of: staff values, supports for risk-taking, and challenges to honoring preferences.

Discussion and Implications

Development of a multidimensional framework with specific risk engagement measures that account for the unique risk perspectives of nursing staff will contribute significantly to the clinical management of older adult preferences and research on the effectiveness of preference-based PCC delivery in the NH setting.

Background

The health, safety, and independence of over 1 million older adults living in U.S. nursing homes (NHs) are often compromised. Severe physical and cognitive impairments significantly affect residents’ ability to independently participate in care activities and planning (Harris-Kojetin, 2019). NH residents suffer from multiple chronic conditions, most frequently Alzheimer’s disease or other dementias (47.5%), that require assistance with at least two activities of daily living (Harris-Kojetin et al., 2019). Furthermore, evidence has shown that up to 60% of NH resident deaths result from unnatural causes including blunt-force trauma, falls, choking, drug overdose, burns, suicide, and homicide (Kennedy et al., 2014). Legal experts consider most unnatural causes of death to be avoidable harms if managed appropriately by NH staff (CNA, 2018). The high levels of chronic physical and cognitive impairments combined with high rates of avoidable harms present a critical need to improve the care and safety practices of NH staff.

Maximizing quality of care and safety of residents, the Centers for Medicaid and Medicare Services (CMS) requires preference-based, person-centered care (PCC) defined as a (2016, p. 68848): “means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.” The regulation also requires that NH care is guided by residents’ preferences that are incorporated into plans of care (CMS, 2016). Yet NH residents are not satisfied with staff honoring common care preferences (Andrew & Meeks, 2018).

Research on barriers and facilitators to delivering preference-based PCC suggests that NH staff perceive risks to residents’ health and safety, power differentials within the resident–staff relationship, high resident to staff ratios, poor staffing schedules, and organizational constraints on time significant barriers to honoring residents’ preferences for care and other activities of daily living (Abbott et al., 2016; Palmer et al., 2018; Parker et al., 2019). Common facilitators expressed by staff relate to the social environment, interdisciplinary stakeholder collaboration, and family support (Abbott et al., 2016; Palmer et al., 2018; Parker et al., 2019). These studies do not represent views of all direct-care NH staff. Licensed (Registered Nurses and Practical Nurses) and unlicensed nurses (Certified Nursing Assistants) comprise the largest portion of direct-care NH staff and have the most opportunity to deliver preference-based PCC (Gilster et al., 2018; Harris-Kojetin et al., 2019) yet the evidence suggests that only 2% of NHs effectively deliver PCC (Grabowski et al., 2014). Availability of NH staff to provide PCC is compromised by variable direct-care staffing patterns, often below CMS expectations (Geng et al., 2019).

Other complexities exist in providing preference-based PCC. First, the recent CMS (2016) regulation may artificially focus NH staff efforts on solely documenting preferences into written plans of care instead of into everyday care interactions with residents (Dellefield, 2006). As a clinical process, care planning involves interactions between individual clinicians and residents (Dellefield, 2006). However, research indicates that nurses most often experience burnout related to missed opportunities to talk with and comfort residents (White et al., 2019), indicating a focus on documentation rather than interacting with residents to clarify and honor preferences. Second, NHs employ a variety of direct-care providers with a range of professional and ethical accountabilities affecting care judgments. For example, a licensed nurse may view the importance of honoring a resident’s preference that is associated with safety and health risks differently than their nonlicensed counterparts based on public perceptions of trust (Gallup News Service, 2015), differences in credentialing and state licensure standards (ANA, 2015a; McMullen et al., 2015; The Practical Nurse Law, 1976; The Professional Nurse Law, 2009), and exposure to malpractice litigation and regulatory sanctions (Kapp, 2013; Pearce, 2016). Third, the zero-tolerance attitude for human error from NH administrators and regulators increases staff anxiety and changes staff attitudes, ultimately discouraging the adoption of PCC (Kapp, 2013). This phenomenon is exemplified in a recent case study with licensed NH staff (Registered Nurses and Social Workers) who express safety, legal, and regulatory concerns as reasons to delay honoring the commonly expressed activity preference of spending time outdoors during nicer weather (Behrens et al., 2018). Addressing practice barriers requires an exploration of direct-care nursing staff perceptions of risk associated with honoring residents’ preferences for everyday living and care activities.

Conceptual Framework

Risk in nursing care is a decision-making process that involves a cognitive recognition about self or others, and a weighting of possibilities for harm or loss associated with a risk event (Shattell, 2004). Actual harm or loss does not need to occur for risk to be present in a situation and nurses draw upon prior knowledge and/or experience with risk events to inform decision-making processes (Shattell, 2004). In psychology literature, this is known as risk perceptions (i.e., individual opinions about risk) (Slovic, 1987). Many factors underlie the complex and subtle opinions people have about risk which influences how they engage in risk events such as unconscious emotional reactions to physical threats (i.e., physical response), unconscious associations of partial information to what we already know about the threat (i.e., quick judgment), assessments of the weight of the threat to mankind, and cultural cognition (i.e., shaping ones’ views to match that of a group they most closely relate to) (Brown, 2014).

We selected the Risk and Ageing Populations model constructed by Clarke and colleagues (2006) because it offers a comprehensive view of social and cultural factors associated with risk perceptions in the context of delivering nursing care to older adults. In this model, taking risks in older adulthood is inevitable, mediates quality of life, and is culturally dependent (Clarke et al., 2006). Risk perceptions are a central construct of risk engagement in older adulthood and involve aspects of (Clarke et al., 2006, p. 172): (a) agency for the individual in terms of decision-making capacity and the ability to exercise choice; (b) “values that emanate from an individual’s biography and society”; (c) identification of hazards to safety; (d) negotiation processes between a variety of individuals; (d) safeguards in terms of “protective processes that are made to negate at least in part consequences to extreme risk-philic or risk-phobic behaviors”; and (e) risk repair in terms of “actions people take to compensate for exposure to risks that may otherwise lead to harm.” Risk engagement is subjective and considers multiple stakeholders including the older adult themselves, family, health care professionals, the organization, and the state; each with a sphere of influence or control over risk engagement (Clarke et al., 2006).

The Clarke et al. (2006) model was utilized in five studies since original publication (Clancy et al., 2014; Clarke et al., 2009, 2011; Rush et al., 2012, 2016). All studies were qualitative, with the common purpose to understand how people construct the concept of risk when caring for older adults in varied care contexts such as community-based mental health and cardiac prevention care (Clancy et al., 2014; Clarke et al., 2009, 2011; Rush et al., 2012, 2016). None of the studies were conducted in NHs or within the United States; however, this research offers contextual elements to consider when describing risk situations encountered by older adults and the care team including: perceived needs of the older adult, types of resources available, interdisciplinary team functioning (Rush et al., 2016), and individual perceptions of risk (Clancy et al., 2014; Clarke et al., 2009, 2011).

The Clarke et al. (2006) model is not comprehensive enough to examine relationships between nursing staff perceptions of risk and honoring older adult preferences, the cornerstone of delivering PCC in NHs. Thus, based on existing literature, we expanded the Clarke et al. (2006) framework to integrate constructs central to PCC delivery in NHs including resident preferences (Carpenter et al., 2000), decisional outcomes related to preference fulfillment (Behrens et al., 2018), and potential impacts on quality of life for the older adult living in the NH such as satisfaction with care (Bangerter et al., 2017) and positive affect and behaviors (Cohen-Mansfield et al., 2015; Van Haitsma et al., 2015). Figure 1 depicts the adapted model.

Figure 1.

The preference-based person-centered risk engagement conceptual model. Adapted from Clarke et al. (2006).

Risk perceptions of direct-care nursing staff remain an unexplored aspect of this model (Figure 1). Upon review of the appropriate literature, only one study addressed nursing staff perceptions of risks associated with the delivery of preference-based PCC (Behrens et al., 2018). Thus, the purpose of this study was to explore direct-care nursing staff perceptions of risk that are associated with honoring resident preferences for everyday living and care activities in the NH setting.

Method

Given the sensitive nature of exploring risks in the NH environment, this study utilized a qualitative descriptive, sequential focus group (FG) methodology (Jacklin et al., 2016; Kreuger & Casey, 2015; Sandelowski, 2000). Qualitative descriptive studies explore real-world phenomena in detail allowing for a comprehensive summary of events in the everyday terms used by the participants to describe the events (Sandelowski, 2000). Sequential FGs are a collection of FGs held with a consistent group of participants over time, related to a central topic for exploration (Jacklin et al., 2016). Supporting study credibility, this method allowed for in-depth exploration of complex and sensitive issues through prolonged engagement, resulting in deeper levels of exploration, and reflection with and among a lower number of FG participants (Jacklin et al., 2016; Sandelowski, 2000) (Table 1). Purposive sampling was used to recruit direct-care nursing staff employed in NHs experiencing a citation from state regulators indicating a potential for actual harm to residents. Safety citations served as a proxy for an environment where staff are encountering situations with residents requiring risk management. Participants fulfilled the following inclusion criteria: (a) employment as a licensed or unlicensed direct-care nursing staff; (b) 18 years of age or older; and (c) willing to attend two FGs off-shift. Participants were offered refreshments and a $50.00 gift card upon completion of both FGs.

Table 1.

Sequential Focus Group Sampling Strategy

Participant category	NH #1		NH #2		NH#3
	FG #1	FG #2	FG #1	FG #2	FG #1	FG #2
Licensed staff (RN/LPN)	n = 4–8		n = 4–8		n = 4–8
Unlicensed staff (CNA)	n = 4–8		n = 4–8		n = 4–8

Notes: CNA = Certified Nursing Assistant; FG = focus group; LPN = Licensed Practical Nurse; n = potential number of participants; NH = nursing home; RN = Registered Nurse. Sequential FGs require 4–8 participants per FG to gain a rich range of ideas on a topic (Kreuger & Casey, 2015); however, by using the same participants in multiple FGs the total number of participants needed is halved.

Sequential FGs were conducted in NHs following the end of day shift, approximately 1 week apart. Participants completed a demographic questionnaire. Using semistructured interview guides, FGs were led by a moderator experienced with running FGs with direct-care nursing staff, and a trained assistant moderator. To ensure participants where comfortable expressing their opinions, professional nurses and nursing assistants met separately (Table 1). The interview guide (Table 2) included questions about resident preferences, types of risks associated with honoring resident preferences, views and attitudes on both engaging in risk and managing risks associated with resident preferences, and stakeholder influences. These data were supplemented with field notes and debriefing forms.

Table 2.

Major Questioning Route

Main topic (framework element)	Question(s)
Focus group #1
Resident preferences	Describe an example of how you feel you have helped to do what a resident prefers.
	What preferences, if honored—that is doing what a resident prefers—do you think could lead to a positive (good) physical or emotional outcome for the resident and why?
	What preferences, if honored, do you think could lead to a negative (bad) physical or emotional outcome for the resident and why?
Risks associated with preferences	Considering the different types of preferences, you have listed, or we have talked about so far, what resident preferences do you think pose a risk to residents’ health and safety and why?
	Do these groupings accurately represent the kinds of risks to residents that you consider when attempting to honor resident preferences? Why or why not?
Risk perceptions	Do you consider yourself a risk-taker in general? Why or why not?
	How do you feel about honoring a resident’s preference that you associate with a risk to their health and safety and why do you feel that way?
	Recalling that there is no right or wrong answer, do you think there is an acceptable level of risk in helping a resident do what they prefer?
Focus group #2
Risk perceptions	When you are thinking about how to address risks to a resident what do you think about first?
Risk engagement	Please give me an example of when you were NOT able to honor a resident’s preference [request/choice].
	What actions, if any, did you take to try to minimize [lower/reduce] the risk so you could try to honor [fulfill] the resident’s preference [request/choice]?
	Please give me an example of when you were able to honor [fulfill] a resident’s preference [request/choice].
	What actions, if any, did you take to try to minimize [lower/reduce] the risk so you could honor [fulfill] the resident’s preference [request/choice]?
Stakeholder influence	Do you and your coworkers for a resident? Why do you think this is
	Would you say that your work environment is more risk tolerant [supportive of taking risks] or is more risk adverse [opposed to taking risks]? And why?

Notes: The lead author drafted the initial questions to represent key elements of the guiding framework. Once drafted, the initial guide was shared with methodology experts, and suggested edits made. The interview guides were then shared and tested with three registered nurses and edits made accordingly. The final questioning route is displayed in this table.

At the conclusion of the first FG, participants were provided a worksheet and asked to reflect and document examples of attempts to honor resident preferences and their perceptions of associated risks and barriers to preference fulfillment. Participants completed the worksheet prior to the second FG where it was used as a primer to stimulate discussion (Krueger & Casey, 2015). The FGs were audio-recorded, lasted approximately 60 min each and concluded with a review of the major themes discussed which were confirmed by FG participants (Creswell, 2014).

Verbal consent was obtained prior to starting FG activities. The study protocol and associated recruitment materials were deemed exempt status by an academic and one local site IRB prior to initiating study procedures.

Data Analysis

Conventional content analysis (Hsieh & Shannon, 2005) followed Saldaña’s (2016) first and second cycle coding procedures and was based on transcriptions of FG sessions, field notes, and debriefing forms (Krueger & Casey, 2015). Transparently viewing coding as a cyclical process with predefined analytic frameworks, implementing Saldaña’s (2016) approach in addition to the conventional content analysis reduces researcher bias and contributes to data validity. Following each FG, sessions were transcribed verbatim from the audio recording. After the first two FG sessions were transcribed by a third party and verified by the moderator, data coding began (see Supplementary Appendix 1). In the first coding cycle, two researchers (L. L. Behrens, M. Boltz) used a constant comparative method to code the data and identify themes. Descriptive coding identified the basic topic of passages in the data providing in vivo codes for how nursing staff described perceptions of risks and was followed by process coding that identified actions taken by nursing staff to fulfill preferences (Saldaña, 2016). Codes were triangulated against field notes and debriefing forms to identify similarities and differences in emerging codes and gaps in data saturation (Creswell, 2014). Preliminary coding insights were used to create a standardized codebook which was then shared with the larger research team in the second coding cycle, for refinement and expert opinion (K. Van Haitsma, A. Kolanowski, M. Sciegaj). Saturation—no new ideas offered by FG participants—was determined by expert opinion (L. L. Behrens, M. Boltz) and peer debriefing (Kreuger & Casey, 2015). Descriptive data regarding staff demographics and organizational characteristics were entered in SPSS (IBM Corp., 2017) for analysis and used to enhance transferability of study results.

Trustworthiness

Several strategies were used to ensure trustworthiness of study results. First, multiple coders followed a systematic approach to content analysis. Second, a purposive recruitment strategy and review of major themes discussed with FG participants supported credibility of results. Third, peer-reviewed criteria for reporting the results of qualitative research guided detailed data collection and transparent reporting of study results (Tong et al., 2007). Fourth, we used a written protocol to guide study implementation and an audit trail of key decision points in data collection and analysis to ensure dependability (Jacklin et al., 2016). Finally, we used data triangulation between audio recordings, field notes, and peer debriefing to reduce researcher bias in order to establish confirmability of findings (Creswell, 2014).

Findings

Twenty-seven direct-care nurses (hereforth referred to as “nursing staff”) from three NHs participated in 12 sequential FGs between March and April of 2019. With exception to one licensed nurse (not replaced), all nursing staff that consented to the first FG also completed the second FG. Self-reported characteristics of nursing staff are reported in Table 3. The NHs had 130–324 certified beds with Quality Star ratings ranging from 1 “much below average” to 5 “much above average.” Two NHs were not-for-profit, and all accepted Medicare and Medicaid reimbursement. Each NH was experiencing 6–12 health inspection citations, most frequently for deficiencies in violations to resident rights, quality of life and care, and pharmacy services. Two NHs were issued a penalty for a serious citation within the last 3 years.

Table 3.

Demographic Characteristics of Focus Group Participants (N = 27)

Characteristic	#	%	Characteristic	#	%
Age (years)			Collective experience in NHs (years)
18–29	6	22.2	1–2	3	11.1
30–39	4	14.8	3–5	4	14.8
40–49	8	29.6	6–10	6	22.2
50–59	7	25.9	11–15	4	14.8
≥60	2	7.4	16–20	5	18.5
Gender			≥21	5	18.5
Male	4	14.8	Highest degree completed
Female	23	85.2	High school/GED	6	22.2
Race			Tech/Diploma	12	44.4
American Indian/Alaskan	1	3.7	Associates degree	5	18.5
Asian or Pacific Islander	3	11.1	Bachelor’s degree	4	14.8
African American	5	18.5	Professional organizations
White	16	59.3	Yes	3	11.1
Other	2	7.4	No	21	77.7
Current role in NH (years)			No response	3	11.1
Certified Nursing Assistant	13	48.1	Professional certifications
Licensed Practical Nurse	8	29.6	Yes	14	51.9
Registered Nurse	6	22.2	No	12	44.4
Role experience (years)			No response	1	3.7
<1	3	11.1	Self-identified as risk-taker
1–2	4	14.8	Yes	8	29.6
3–5	3	11.1	No	17	63
6–10	3	11.1	Both	2	7.4
11–15	4	14.8	Risk management training
16–20	6	22.2	Yes	8	29.6
≥21	4	14.8	No	18	66.7
Employment in current NH (years)			Both	1	3.7
<1	2	7.4	PCC training
1–2	5	18.5	Yes	21	77.8
3–5	5	18.5	No	3	11.1
6–10	7	25.9	No response	3	11.1
11–15	3	11.1
16–20	4	14.8
≥21	1	3.7

Notes: GED = general education development diploma; NH = nursing home; PCC = person-centered care.

Pervasive Risk Avoidance

Nursing staff perceived risks with every type of preference for everyday living and care activities in the NH (also referred to as “risky preferences”), including food/fluid intake, showering/bathing, use of adaptive equipment, bedtime/wake-up time, medication administration, walking/ambulation, leisure activities, transfers, spending time alone, toileting, and seating location. Nursing staff commonly perceived the potential for physical and emotional harms related to honoring residents’ risky preferences including cardiovascular changes, choking and aspiration, weight gain or loss, skin breakdown, falls with injury, incontinence, general discomfort, negative moods and behaviors, loss of dignity, and negative interactions between residents.

Nursing staff predominantly described risk-averse attitudes in their individual care practices when attempting to honor residents’ risky preferences, further indicating that this attitude is ingrained in all levels of the organization. One staff member described the pervasiveness of this risk-averse attitude:

Risk is frowned upon … from anybody above the housekeeper. (FG#1_Site1_Lic4)

This prevailing and widespread attitude is exemplified in the values and beliefs of nursing staff around honoring risky preferences, along with supports and challenges they encountered within the organizational environment when attempting to honor residents’ risky preferences as expressed in three subthemes: (I) staff values; (II) supports for risk-taking; and (III) challenges to honoring preferences associated with risk. Themes and categories are presented in Table 4.

Table 4.

Identified Themes and Categories

Overarching theme	Pervasive risk avoidance
Subthemes	I. Staff values	II. Supports for risk-taking	III. Challenges to honoring preferences associated with risk
Categories	• Safety • Advocacy • Professional autonomy • Prudent risk-taking	• Negotiations • Education • Visual oversight • Communication • Personal/professional judgment	• Legal and regulatory culture • Organizational policies and procedures • Paternalistic attitudes • Resident health condition • Family Involvement

Subtheme I: Staff Values

As embodied in professional nursing ethics, nursing staff described what was important to them when faced with risky preference situations. Participants ascribed a core set of values used to guide engagement in risky preference situations that were rooted in the desire of nursing staff to mitigate risks to the physical and emotional well-being of residents including (a) safety, (b) advocacy, (c) professional autonomy, and (d) prudent risk-taking.

Safety was a priority for all nursing staff, expressed with a deep sense of professional commitment in keeping the resident free from physical injuries related to care practices and the NH environment. One nurse summed up this risk-averse attitude, stating:

I feel it is my duty to keep them [residents] as safe as possible. (FG#1_Site2_Unl3)

Safety was discussed as taking precedence over what a resident or family member may prefer in each situation. For example, if a resident does not want an alarm but has a history of falling, staff will not honor the resident’s preference, deeming it medically unsafe. Nursing staff also suggested that work environments focused on safety are risk-averse, affecting their willingness to engage in risky preference situations that are inconsistent with practice guidelines, particularly if it will result in job loss or resident injury/death. The professional commitment to safety extended beyond the work environment to social interactions between residents and family members where resident advocacy becomes important.

Advocacy was described as an important and essential role of the nursing staff, particularly when the resident is not included in the risky preference discussion such as in end-of-life care:

Again, we are in a situation, what about the patient? Where is the patient goal? What about her voice? That she is not having pain and you want to give her pain medicine, pain medicine the whole entire day? (FG#2_Site2_Lic5)

Nursing staff identified a need and responsibility to advocate on the resident’s behalf with stakeholders such as managers, the medical team, and families to promote residents’ physical safety, right to self-determination, and dignity.

However, most nursing staff expressed that they do not feel empowered by their organizations to deviate from the care plan in support of honoring resident wishes when they identify risks, representing a perceived lack of professional autonomy.

But sometimes the nurses and the supervisors hang on extremely tight, and we feel whatever family wants to do for the residents, whether it is good or not, we have to follow the resident’s families choice instead of making our own decision ... I think ... if we are working in the medical field, we should [be] given a small autonomy with our residents since they are under our medical care, instead of family care. (FG#1_Site2_Lic5)

While nursing staff thought it important to have some professional autonomy, they did not sense agency in decision making around preference-based care. Instead, they described the importance of taking on the role of a prudent risk-taker:

I would say I’m a prudent risk taker. I would only take the risk if I can predict safely what the outcome will be … (FG#1_Site2_Lic2)

Most nursing staff sensed a professional responsibility to think about and control potential outcomes of risk engagement in order to avoid harms to the resident, themselves, and the organization.

Subtheme II: Supports for Risk-Taking

Although nursing staff predominantly described risk-averse attitudes, they reported varying degrees of comfort in taking risks related to residents’ health and safety. Additionally, nursing staff reported several physical and cognitive actions they took take to facilitate honoring a resident’s risky preference. As a fundamental resident right, nursing staff actions revolved around supporting resident choices with (a) negotiation, (b) education, (c) visual oversight, (d) communication, and (e) personal/professional judgment.

Nursing staff described engaging in negotiations with residents and families to find appropriate choices to facilitate the preference and find acceptable levels of risk—described as a balance between situational harm and the resident request—resulting in a compromise that makes the situation better for everyone involved.

… like when they walk in here they’re used to so many things their way, and then we just take away from them, we have to give them something. (FG#2_Site1_Unl7)

With family, negotiations were a means to procure resources, supervision, motivation, and information about the resident, all in support of honoring the resident’s preference. The degree of family agreement and engagement influenced whether the nursing staff honored residents’ risky preferences.

Nursing staff described the need to educate residents and families about risks associated with preferences. The education should include a plan to prevent falls and other accidents in situations wherein the resident was at risk, with the goal of ensuring that the resident and family understand the risk and are ok with taking the risk.

We educated him [resident] about the safety risks and increased falling, and the fact that he’d already broken a hip and he didn’t want us helping him. He wants his independence. (FG#2_Site1_Lic1)

When residents chose independence in spite of risk, nursing staff supported residents by maintaining a continual (one-on-one) visual observation of residents provided discretely, the way the nurse would want it to be provided if s/he were in the same circumstance. This was especially true in situations where the resident preferred to be alone (i.e., bathroom or bedroom) and the nursing staff wanted to avoid physical injury:

I have one of our residents, she’s a high fall risk. She don’t want to stay out [in the dayroom] with us watching TV, … I have to honor her … I put her back after break [in her room] but I stayed there with her. I had to do the one on one with her at that time. Yes. Until she’s ready for bed. (FG#2_Site2_Unl3)

Nursing staff stressed the importance of using personal/professional judgment:

You got to honor the resident request because that’s the only thing they’re going to eat. So, it’s between honoring the request or starve the resident. (FG#1_Site2_Unl1)

and teamwork to support each other and residents when honoring risky preferences:

You try to communicate, so we try to support each other [CNAs] and try to stay on the same page so it’s easier for all of us. (FG#2_Site2_Unl1)

The health record and care plan were described as useful communication tools to manage risks, document preferences, and individualize care. While empathetic reflections (i.e., what they “would want or feel if put in the same situation”), comfort with risk-taking, and constant reevaluation of the situation were useful tools to aid nursing staff in situational decision making.

Subtheme III: Challenges to Honoring Preferences Associated With Risk

Nursing staff described obstacles encountered throughout all levels of the organization and decision-making stakeholders as negatively influencing attempts to fulfill residents’ risky preferences including: (a) legal and regulatory culture, (b) organizational policies and procedures, (c) paternalistic attitudes, (d) resident health condition, and (e) family involvement. Description of these obstacles represents the prevalence of risk-averse attitudes and behaviors commonly expressed in the NH environment.

Regarding the legal/regulatory culture of NH care, nursing staff frequently reported that they avoided honoring preferences that could worsen medical conditions or hasten death for fear of lawsuits (professional negligence):

Try and take a risk on being quick, cutting corners and [that] could possibly [lead to] death and then be sued and where’s my life then, you know? So, I would say I’m not a risk-taker. (FG#1_Site3_Unl1)

Nursing staff were also concerned that family member grievances and complaints might initiate a regulatory audit ultimately impeding their ability to provide preference-based care. For example, one nurse recalled when a family member was not happy with reduced staffing levels because it was perceived to reduce attentiveness of nursing staff to the resident’s preferred care routine; thus, they lodged a complaint with the state. In turn, this led to a state audit of the organization and a strained relationship between nursing staff and administrators.

Nursing staff also described NHs as risk-averse with zero tolerance for violations in organizational policies and procedures even when nursing staff were trying to honor resident preferences under their scope of practice for basic nursing care. Most often nursing staff indicated they were not willing to go against company policies or what is documented in care plans to honor preferences for fear of losing their jobs. As one staff member stated:

If it’s documented that that person is two assist ... If you take the risk and go in and transfer the resident by yourself knowing that okay you’ve done it before, you take that risk right on the spot, you just give away your job. There’s no tolerance for that here. (FG#2_Site2_Unl3)

Other policies and procedures cited as potential barriers to honoring preferences included those related to purchasing items for residents, food choices, self-administration of medications, personal care, activities, visitations and trips, falls management, smoking, and census-based staffing.

In addition to feeling pressure from regulators and organizational leadership to keep residents free from injury, nursing staff were concerned about residents becoming angry when risky preferences were not honored. In such cases nursing staff embraced a risk-averse, paternalistic attitude.

I can see where their [resident] agitation would come from, but they have to understand that we’re not doing it to try to upset them. It’s for their best interest and safety. (FG#2_ Site1_Lic2)

Nursing staff explained several reasons for this attitude, including competing work demands and lack of experience and skill related to handling a risky preference situation. The competing demands of caring for too many residents at one time increase anxiety in staff and residents. In response they describe a default behavior of paternalistic protectionism. Nursing staff indicated a need for more self-efficacy when approaching risky preference situations.

Factors related to residents’ health conditions were also offered as challenges to honoring a resident’s risky preference, most notably, the resident’s cognitive status.

If a resident is cognitively intact, I’m more willing to allow a risk compared to somebody who’s cognitively impaired. If they’re intact, they understand the risk and the consequences that may or may not happen. (FG#2_Site1_Lic1)

Resident cognitive status was assessed using previously documented Brief Interview for Mental Status scores, by reflecting on instances of forgetfulness, and by noting a diagnosis of dementia. Nursing staff also considered the resident’s previous treatment compliance and care refusals when evaluating whether to honor risky preferences.

Family involvement was a sensitive topic among nursing staff, especially when there were diverging family preferences. In risky preference situations nursing staff perceived family members as having unrealistic expectations for residents that contribute to health and safety risks.

The family wants her to be normal. Then they put her on a normal diet … The risk is that she can be choking, aspirating, … (FG#2_Site2_Unl2)

Diverging family preferences were perceived to cause added emotional stress on residents. In one situation, family members did not agree with a resident’s preference to go on to hospice care. The staff suggested that this caused emotional distress for the resident because the resident wanted something one of her children did not. Nursing staff recognized that family members may feel a need to advocate for their loved one to be sure they are cared for and receive what they want; however, nursing staff perceived family advocacy as creating an obstacle for nursing staff when trying to negotiate residents’ preferences.

Discussion

Despite the growing emphasis and demand for supporting preferences, nursing staff described pervasive, risk-avoiding behaviors and attitudes. The attitudes and behaviors are consistently apparent in care interactions across the daily lives of residents, are typically represented in the actions of staff at all levels, and are integrated in organizational policies and operations. This risk-phobic attitude impedes the delivery of preference-based PCC meant to honor residents’ preferences for care while maintaining their safety. This study, by describing direct-care nursing staff views on risks associated with fulfilling residents’ preferences for care and other activities of daily living, provides insight into what NH communities might consider to better implement preference-based PCC to promote independence and safety of NH residents. We discuss these insights in relationship to the current scientific literature and the guiding conceptual framework depicted in Figure 1.

Risk Engagement

Agency refers to the decision-making capacity and ability to make choices (Figure 1). In this study nursing staff did not perceive a sense of agency, instead they perceived restrictive organizational policies—especially ones that gave agency to family members over nursing staff in discussions around managing risks related to preferences. Nursing staff valued having their professional autonomy, along with the ability to advocate for the resident and keep them safe by only engaging in risk situations when they could predict the outcome. Only engaging in risk situations when outcomes can be predicted may emanate from the biography of individual nursing staff. For example, nursing staff (63%) did not self-identify as a risk-taker in their personal lives when responding to the demographic question “In your daily life do you consider yourself to be a risk-taker?”, indicating they may value prudent risk-taking outside of their formal nursing role. Our findings support the conceptual importance of considering nursing staff as significant stakeholders in managing risky preferences of NH residents (Figure 1). Consistent with the literature on the conceptual development of PCC in long-term services and support settings (Behrens et al., 2019) and risk engagement in older adult populations (Clarke et al., 2006), this study associates staff values around risk engagement as a key component to fulfilling residents’ preferences.

Consistent with the framework (Figure 1), nursing staff in this study had a keen sense of hazards that could affect residents’ safety. Many identified hazards were consistent with the literature on potentially avoidable harms such as falls and choking (CNA, 2018; Kennedy et al., 2014), indicating nursing staff are aware of and actively trying to negate these harms with their attitudes and behaviors. Results of this study begin to identify both physical and emotional hazards nursing staff associate with resident preferences for care and other activities. Future research should validate perceived versus actual risks to residents’ health and safety.

In the guiding framework, negotiation refers to a process between individuals (Clarke et al., 2006) but is not described. Nursing staff in this study described using negotiation processes to support risk-taking so that they could avoid harms to residents’ health and safety. Contextualizing the essential involvement of the resident and family in these discussions to reach an acceptable level of risk adds conceptual clarity to this key element of a risk engagement framework in the NH culture (Figure 1). Nursing staff in this study also discussed framework elements of risk repair and safeguards (Figure 1) in the thematic area of supports for risk-taking. Nursing staff used a combination of physical actions (e.g., visual oversight) and cognitive processes (e.g., judgment) to compensate and negate risks to health and safety. These findings add operational considerations for identifying risk engagement not previously described. Evidence-based strategies exist to guide discussions on how to honor preferences when they involve risk as well as documentation of risk repairs and safeguards (Calkins et al., 2018). Using this model as a fidelity indicator, future research could include such strategies as interventions to be tested for effectiveness.

Risk Perception Continuum

Risk perceptions are the subtle attitudes and behaviors people exhibit around the possibilities for harm or loss when engaging in risk activities (Shattell, 2004; Slovic 1987). In the guiding framework this is the risk perception continuum (Figure 1). Nursing staff in this study reported a range of attitudes around risk engagement, leaning more toward an attitude of risk phobia (aversion). Nursing staff in this study were experiencing a “clash in ethical principles” to do no harm and to support resident autonomy (Beauchamp & Childress, 2009). Congruent with the ANA Code of Ethics (2015b) which represents core nursing values, nursing staff reported advocating for the rights, health, and safety of the resident when discouraging risk-taking by either modifying the risks with the resident or advocating on the resident’s behalf with stakeholders but are struggling to keep residents free from adverse events or injury. This could be because of the “safety first” attitude of nursing staff. This risk-averse attitude was influenced by risk perceptions of other stakeholders as characterized in the subtheme of challenges to honoring preferences associated with risk and represented in the conceptual model as bidirectional arrows between stakeholders (Figure 1). Congruent with literature examining barriers and facilitators to honoring resident preferences in NHs (Palmer et al., 2018), this study draws attention to the critical influence that nursing staff risk attitudes and behaviors can have on fulfilling residents’ preferences. This study also adds the consideration of the critical influence of NH culture may have on preference fulfillment potentially moderated via risk perceptions of nursing staff. Evidence-based practices (Clarke & Mantle; 2016) suggests that nurses should adopt an attitude where risk becomes a necessary part of quality of life for older adults living in NHs and support or encourage appropriate risk-taking for residents, thus using risk management to promote PCC; thus, future research should include measures of nursing staff risk perceptions.

Strengths and Limitations

This study had several limitations. First, this exploratory qualitative study was limited to nursing staff in one state. Second, group think could have occurred between licensed registered and practical nurses participating in the same group. Third, although major themes were shared as part of the member-checking process, the final categories were not reviewed with participants due to scheduling challenges. Fourth, the training staff received in PCC and risk management is not known. Fifth, the resident, family, organizational, and regulator perspectives are not represented in these data. Finally, these data were purposively collected in NHs experiencing regulatory citations for poor-quality care that placed the residents at risk for injury resulting in selection bias. These limitations should be considered in light of a multitude of strengths.

First, the study methodology engaged participants over an extended period developing a trust that led to rich data collection in the natural setting. Second, this study was qualitatively rigorous using multiple coders, purposive recruitment, audit trails, data triangulation, and transparent data reporting criteria (Creswell, 2014). And third, this study represented a diverse set of NHs in terms of quality ratings and profit status, and a diverse set of participants in terms of licensure status, age range, gender, and experience.

Implications for Practice and Policy

Given the link between knowledge and quality of care outcomes, it is critical that future NH educational programs include relevant and accessible training in preference-based PCC and risk management with all direct-care nursing staff (Gilster et al., 2018). The multidimensional preference-based risk engagement model (Figure 1) could be a foundation for competencies in this training. Ideally, content would address how to assess resident preferences and associated risks, how to appropriately engage in risky preference situations, how to recognize and respond to personal attitudes about risk that they may not share with the resident or family, and how to assess if honoring the preference (or not) affects residents’ quality of life.

Knowledge gained from using this multidimensional framework (Figure 1) in research could inform national, state, and local policies. For example, nursing staff in this study reported the threat of lawsuits to the organization and themselves as a barrier to fulfilling residents’ risky preferences. Recent data suggest that NH litigation may not be effective in changing the overall quality of care delivered in NHs (Konetzka et al., 2018). NHs are sued most often for resident falls and pressure injuries and cost the NH between $146,900 and $486,000 per claim (CNA, 2018), while the addition of one registered nurse to the staff costs the NH between $92,411 and $124,880 (CMS, 2016). Money spent on legal fees may be better spent investing on improvements to the NH environment and increasing the quality and number of direct-care nursing staff. National and state policy makers could enact legislation that redirects legal costs to fund staffing and quality improvement initiatives. Additionally, policy makers could examine legislation for congruence with risk management practices that support PCC.

Conclusion

A thematic comparison of study results with the guiding conceptual framework indicated that nursing staff perceptions of risk are relevant to the management of older adult preferences that carry risks to health and safety in the NH environment. Further research has the potential to extend this model and advance our understanding of potential associations between preference-based PCC, risk management, and quality outcomes. Qualitative research with other stakeholders should further explicate factors that contribute to nursing staff perceptions of barriers and facilitators to facilitating residents’ risky preferences. Interviews with other stakeholders in the framework (Figure 1)—residents, family members, NH leadership, and state regulators—could contextualize differences in opinions about what types of preference situations carry a risk and what types of risks are acceptable to take in order to achieve preference fulfillment. It could also inform acceptable strategies to promote PCC while mitigating health and safety risks in medically complex residents. While theoretical relationships are difficult to infer from content analysis findings, future quantitative research could capture the frequency of risky preference fulfillment and its relationship to quality of life outcomes for NH residents.

Funding

This work was supported, in part, by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH) (grant UL1 TR002014); National Institute of Nursing Research Ruth L. Kirschstein National Research Service Award program (T32NR009356); and the 2019 Eastern Nursing Research Society/Council for the Advancement of Nursing Science Dissertation Award. The NIH 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; and decision to submit the manuscript for publication.

Conflict of Interest

None declared.