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What is person-first care?

An interview with Nancy Tischer, Director of Education at Saint John’s

What does “person-first” mean?
The principle of personhood and dementia care was first introduced in the early 1980’s at the University of Bradford UK by Dr. Thomas Kitwood, founder of the Bradford Dementia Group. Kitwood defines personhood in his book Dementia Reconsidered as: “…a standing or status that is bestowed upon one human-being, by others, in the context of a relationship and social-being. It implies recognition, respect, and trust.

Person-first is a set of principles that honor the person before the task. These practices provide the basis for: creating a daily life worth living; striving to nurture the mind as well as the spirit; and promoting growth and development for all.

How is this different from the “old model of care?”
For generations, the nursing home “way of life” has been a strong medical model where elders no longer control such basic pleasures and rights as when they wake up in the morning, what they eat, how they spend their time and when they go to sleep.

Often when elders lose their abilities to care for themselves, caregivers focus only on the elder’s physical comfort and safety. Caregivers also save time by doing everything for the elder rather than allowing them to help themselves. The medical model also has a traditional departmental structure, very hierarchical, where decisions are made by management and carried to staff through in-services, memos and instructions. The bulk of decisions are made by department heads, administrators and leadership team based on efficiencies and the ease of monitoring.

Saint John’s is working to transform this institutional approach to nursing home care into a community or social model. It focuses on individualized care rising from the individual needs of each person and allowing them to direct their own care. Megan Hannan, MS, an associate with Action Pact, a consulting group devoted to culture change for elders in long-term care, and creator of the “Person First” dementia care model, provided train-the–trainer sessions for Saint John’s employees. In Person-First, the aim of caregivers is to honor elders by finding ways for them to participate and help the caregiver. Hannan explains in her training that many believe incorrectly that people afflicted with dementia cannot participate in self-directed care or decision making. In our learned experience with small community circles and through a document called “Windows into the Past, Present and Future,” where caregivers get to know the resident’s story or life history, caregivers help residents to communicate and gain more control of their own care. In a culture change transformation, the decision making is further from the top and closer to the residents. This model empowers the residents and caregivers to help make decisions. The leadership is brought closer to the residents and the traditional hierarchical organizational structure becomes flattened.

Why was it developed?
This model was developed because of a crisis within the Nursing Home industry at large. Approximately four years ago, Saint John’s and other homes in the country, were experiencing excessive staff turnover rates, exorbitant outside nursing pool bills and severe staff and resident dissatisfaction. The leadership team felt something needed to change and that’s when we began researching how to create a better work environment for staff and a better way of providing nursing home care and service to residents.

How have residents reacted to this new model?
Saint John’s was a fortunate to receive a grant from the Retirement Research Foundation to help develop our social or neighborhood model. The research component was completed by Barbara Bowers, PhD, RN, University of Wisconsin-Madison School of Nursing. The research results can be summarized in the following lists:

Medical Model-Resident Outcomes:
• Sad, withdrawn
• Loss of privacy
• Isolated and deserted
• Loss of choice/too many rules
• Lack of interest, spiritless
• Low expectations/complacent

Social Model- Resident Outcomes:
• Happy, socially engaged
• Valued as a person
• Included, attached
• Empowered

How is “person-first” beneficial to their health?
Saint John’s health care philosophy focuses on the strength and wellness of an individual in contrast to focusing on illness. Our care-giving team no longer wears uniforms because traditional hospital scrubs or white nursing uniforms imply illness. This has made a difference in how residents feel about themselves in their environment. Waking up each day in a place they call home, where relationships between residents, family, and staff are the foundation for the Saint John’s community and where each person can and does make a difference would be of benefit to any individual’s health.

Can you give examples some examples of “person-first” choices made by caregivers?
One of the most dramatic choices given to residents by caregivers is the opportunity to rise naturally. There was a time, not so long ago, when we rousted residents out of bed as early as 5 AM in order for them to be in the dinning room, dressed and ready to receive their breakfast tray by 7:30 AM (tray meaning no choice). Now residents can get up whenever they wish, have breakfast anytime they wish, and breakfast is made right in the kitchen next to the dinning room in the neighborhood, where a variety of choices are available each and every day.

Food is an important part of the resident’s daily life. If a resident expresses a desire for a certain food, it is not unusual for a staff member to run out to a local restaurant to pick up the food of choice whether it is fried chicken, a hamburger, Chinese or barbeque ribs.

Another example of “person-first” is choice in how care is delivered. The nurses enter into a care-giving relationship with the resident and family. If a resident chooses a course contrary to medical advice, the nursing staff will follow the resident’s wishes at all costs.

What is the most exceptional example of “person-first care you have witnessed?
There have been many; however, this example in particular comes to mind. One of our residents was attending a party with musical entertainment, sitting side by side next to his wife holding hands. Their free hands were tapping to the music on their outside knees. Both husband and wife were truly engaged in the music and each other. The dentist came up to the neighborhood and asked the staff to bring the husband down for a dental appointment. This was not the usual time for scheduled dental appointments. Before “person-first” we would not have questioned the dentist and told the resident that the dentist wanted to see him and whisked him away to the dental office in the lower level. However, one of our values within our new model is that the person comes before the task. After further questioning, we learned from the dentist that the appointment was scheduled for later in the day. Since he was in the neighborhood anyway he decided to see his patients earlier and without prior notice. This was a turning point. We did not cave to a professional doctor and we held true to our value system by asking the dentist to keep his scheduled appointments and please give our residents the same courtesy he gives the residents living in independent living. He is still practicing as our house dentist, understands our philosophy quite well now, and an incident like this has not occurred again.

How have the staff reacted to this change?
Research conducted by the UW research team resulted in these outcomes:

Medical Model- Staff Outcomes:
• High turnover and absenteeism rates
• Lack of caregiver empowerment
• Lack of resident-bonding
• Distant family/staff relationships
• Task oriented
• Provides hospital environment

Social Model-Staff Outcomes:
• Confident
• Teamwork
• Empowered
• Communicating and building relationships
• Taking risks
• Learning and growing
• Providing home

What differences have you seen at Saint John’s as a result of “person-first care”?
The most dramatic differences I have seen at Saint John’s as a result of “person-first” have been the change within our management team. Our traditional management roles of superiority and control developed into leadership roles of respect and trust. Partnerships were formed with Action Pact of Milwaukee and Alder Associates of Washington, D.C. to create team alignment, adopt operating promises, and become a true community. With team leadership developing healthy practices of team-building and modeling respect and trust to employees, this healthiness filtered down. As author Tom Kitwood writes, “The manager’s role is thus much more one of enabling and facilitating than of controlling, and this involves giving a great deal of feedback to staff.”

This new way of interaction created an environment that broke down the system of powerlessness and low self-esteem felt by residents and caregivers to a new climate of empowerment and self-determination. Spirits are rekindled, and voices are being heard.

Nancy Tischer has a BS degree in nursing and has worked half of her 30 year career in acute care and the later half in long term care. Nancy notes, “I have always wanted to make a difference in some capacity in the field of nursing, no matter how small it might be considered. I believe I have found my passion, working as the Director of Education at Saint John’s, advocating for deep system change in how elders are treated, served and cared for in our society.”

What is

Essay by Megan Hannan

»Interview with Nancy Tischer


Additional resources

What is person-centered care?

Transforming: The Way Work is Done (PDF)

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