Ensuring Resident Choice

Benefits of Resident Choice

Choice is a basic right for every person. Research shows that the positive feelings associated with choice and autonomy boost physical and mental well-being among individuals of all ages, and in particular among older adults. Studies indicate that nursing home residents with greater choice about their care experience a deeper sense of purpose and control over their lives and report higher levels of satisfaction, a key indicator of quality. Consumers and their families, provider organizations, and government regulatory agencies increasingly value resident-directed care as an important component of quality.

This tip sheet identifies ways to support and assure that nursing home residents can state their preferences and direct their care as much as possible. This resource reflects best practices among nursing home staff and administrators to overcome logistical and cultural challenges to respect individual preferences for daily schedules, activities and interactions.

Cultivating a Culture to Ensure Resident Choice

Organizational leadership sets the stage to create a community that respects and honors resident choice. Key steps are:

• Make a top-level commitment to prioritize and honor resident choice. Communicate this priority to the entire organization.
• Cultivate a culture that empowers residents to voice their opinions, and ensures staff are receptive and responsive.
• Invest resources in training all staff — including volunteers, activity and social service professionals, nursing assistants, housekeeping, nutrition, transportation and office staff — to listen carefully to residents, honor their preferences, and convey respect through every interaction. Keep the learning going – at team meetings, invite staff to share examples of how they are meeting resident choices. Celebrate success!
• Promote understanding that residents usually are realistic in their requests. Contrary to popular stereotype, residents generally do not make extraordinary or unreasonable demands (“for surf and turf every night”).
• Empower staff to identify and overcome obstacles to resident choice – for example, through flexible scheduling to allow waking and bathing times that align with individual preferences.
• Empower your resident council to find new ways to promote resident choice.

Strategies to Ensure Resident Choice

Practical ideas that have worked successfully in communities include:

• Encourage your staff to use a tool such as the Preferences for Everyday Living Inventory (PELl) to ask residents about their preferences and document the information so that it is available to the full care team (See PELI Tip Sheets: How to Get Started and Interview Tips). Along with nurses and social workers, encourage certified nursing assistants with consistent assignment to complete the PELI with residents.
• Systematically incorporate resident preferences and choices into care plans. For example, use “I” statements when discussing a problem and goal in care planning. Include preferences, such as “I like having coffee with cream and sugar immediately when I wake up at 6 a.m.” or “I don’t like to get dressed until I see the newspaper and have breakfast.”
• Work diligently and creatively in partnership with administrators, staff, residents and families to resolve challenges to meeting resident preferences.
• Offer choices and activities that are meaningful to residents and tailored to their strengths and abilities (e.g., it may not be possible to play baseball, but a resident can play on the Wii).
• Start a Quality Assurance and Performance Improvement (QAPI) initiative to track organization-wide data about resident preferences and the extent to which they are met. Consider using tools to track progress in matching care to resident preferences, such as the PELI, Advancing Excellence Campaign for America’s Nursing Homes Person-Centered Care (PCC) Goal, or Match Quality Indicator.
• Invite resident council members to share how they would prioritize options for community improvements (e.g., adding a butterfly garden or outdoor thermometer, labeling trees and flowers, and notifying residents when someone in the community passes away).
• Work with families to help them understand that residents drive decision-making. While families may disagree with a loved one’s choice, the resident is in control. For example, families often want their relative to be more involved in activities, yet the resident may decline to participate (see PELI Tip Sheet: Working with Proxies).
• For individuals whose ability to communicate is limited due to cognitive or other impairment, encourage family members to weigh in on likely preferences. Also, ask staff to observe residents’ responses to care, tasks and activities to identify clues, such as a smile or laugh, indicating that a preference or choice is being honored (see the EPASS tool and PELI Tip Sheet: Working with Proxies).
• Create PCC huddles for staff to share positive stories about their experiences promoting resident choice.
• Create a preferences kiosk for staff, and use flip charts or electronic tools to communicate resident preferences for daily living.
• Create a process for reassessing preferences periodically, particularly if the resident is experiencing depressive symptoms, pain, or anxiety.
• Ask staff to bring examples of preferences that are difficult to fulfill to team meetings. As a group, brainstorm solutions.

We gratefully acknowledge support from 
The Patrick and Catherine Weldon Donaghue Medical Research Foundation