The answer to this question can help organizations develop approaches to assess resident preferences, engage in care planning, and strategically allocate staff time for ongoing and effective person-centered care practices.
This tip sheet is designed to help communities use best practices to respond to consistency as well as changes in resident preferences and to be responsive to shifts in health and function that occur over time. These recommendations are derived from recent studies that used the Preferences for Everyday Living Inventory to explore the consistency of resident preferences, as well as reasons preferences may change.
Overall, the research1 shows that nursing home residents’ preferences generally remain stable for at least a three-month period, allowing for reliable and predictable care planning. The findings suggest that, for the vast majority of preferences, care plans formed initially will continue to reflect authentic resident wishes for care for at least 90 days. Of course, customizing care is a continuous process. It is important to remain sensitive to changes that occur between quarterly care planning meetings and to communicate them to all relevant care team members.
Evidence-Based Recommendations for Providers
- Investing staff time in assessing resident preferences is worthwhile. Although we know preferences can and do change, everyday preferences tend to be stable across three months.This finding suggests that for most residents, there is no need for formal reassessments more frequently than quarterly unless there is a change in the person’s physical or psychological health, functional ability or life circumstances.
- Consistent assignment is beneficial because the most stable preferences relate to involving others in care. These preferences include: having staff show that they respect and care about you; choosing your own medical professional; and choosing those you would like involved in discussions about your care.Therefore, staff familiar with resident preferences for care can work more efficiently and effectively.
- Assessing and integrating preferences for care at move-in helps residents transition and adjust to living in a new community with new routines and new caregivers. When staff take the time to understand and honor preferences, they help a new resident feel comfortable and cared for, and build the foundation for ongoing positive and trusting relationships.
- Providers can select from among the PELI items and can be confident the questions measure preferences important to nursing home residents. In the research study1 (described below), a majority of nursing home residents endorsed more than 90% of the PELI items as important.
- Providers seeking ways to move toward preference-based, person-centered care can examine the range of PELI items and choose a subset as a focus for clinical activities. Providers do not have to use all 72 PELI items: each has been tested as a stand-alone item. One option is to start with the 16 PELI items that also are part of the MDS-Section F. Over time, the community can build capacity to address the wider, full range of preferences covered in the PELI-NH (For further item selection ideas, see the How to Get Started PELI tip sheet.)
- From a quality improvement perspective, providers also can begin by using a subset of PELI items, such as the MDS 3.0 Section F, and adding as staff progress in their ability to assess and honor preferences. (For further details on quality improvement, see the PELI tip sheet, Using the PELI for Your QAPI Program.)
When Residents Change their Preferences
While research shows that nursing home residents’ most important preferences generally remain stable, it is natural that residents change their minds from time to time. In a 2016 study, nursing home residents talked with us about the variety of reasons their preferences shift. Sometimes it’s a matter of personal circumstances – family members might visit, a medical appointment is scheduled, the individual’s physical health changes, or the resident just doesn’t feel like attending an activity that day. Other circumstances also come into play and include the social context (whether the resident is satisfied with the quality of social interactions and programs that are offered), and external factors (weather, current events and special occasions such as a birthday or holiday).
How can care teams respond to changing preferences?
First and foremost, it is important for staff to check in with residents about their specific choices every day. Consider asking questions such as: “What do you want to wear today?” or “Would you like your usual granola and yogurt for breakfast or something else?” These conversations have several benefits:
- Daily inquiries nurture connections between residents and staff, cultivate a more personal and responsive home-like atmosphere, build a sense of community, and enhance resident autonomy, independence and satisfaction.
- Care teams have the chance to catch the moment when a resident wants to try something new — for example, when a resident who gives low priority to “spending time with children” decides spontaneously to join an intergenerational group.
- While consistency is important for residents, continue to offer choices, novel and spontaneous experiences that honor how change is an essential part of the human experience. Invite residents to participate in new, potentially engaging activities and programs on topics of interest to stimulate learning and contribute to quality of life.
- Sometimes staff learn that that a resident’s physical health or emotional wellbeing is changing, such as when a resident declines favorite activities or meals. When a resident says that a once important preference now seems unimportant, the care team should follow up by asking “why?” Residents may reveal reasons they have lost interest or feel unable to fulfill a preference – and staff can begin to address any barriers. For example, concerns about incontinence can be a barrier to participation – and non-verbal cues, such as wanting to sleep longer, may be a sign of depression. The team may need to modify an activity to meet a resident’s changing functional abilities and keep the person engaged in meaningful and enjoyable experiences (see PELI tip sheet on Integrating Preferences Into Care Plans).
Whether staff learn about preference changes from a daily conversation, or through a care planning meeting, it is critical to communicate the information across team members and shifts to assure continuity of person-centered care.
In the press of day-to-day life in the nursing home, staff might view residents who change their minds negatively—as “unreliable,” “unpredictable” or “picky.” At these moments, it is important to remember that all of us change our minds depending on our mood, the weather, competing demands on our time and a host of other considerations. Change is simply a part of our daily lives and nursing home residents are no different. As a care community, we need to support residents by understanding that the importance of preferences may alter as a resident’s abilities, life circumstances, and interests shift.
The bottom line: Asking about preferences, and incorporating them into care plans and practices, sends a powerful message to residents: “We will do all we can to enhance your sense of success and quality of life.”
How the Research was Conducted
The information in this tip sheet is based on three studies conducted by the Preference Based Living team. A 2018 study1 explored the change in resident preferences over a three-month period. Participants (n=255) lived in 28 nursing homes in the suburbs of a major metropolitan area. All were interviewed using the Preferences for Everyday Living Inventory-Nursing Home (PELI-NH), which asks respondents to rate the importance of 72 preferences. Interviews took place at the beginning and the end of the three-month period. An earlier2 study also used the PELI-NH to test the consistency of community nursing home resident’ everyday preferences over a one-week period. To provide further context, a 2016 project3 conducted in-depth interviews with residents (n=39) to understand why they may change their minds about the importance of their preferences or why their preferences may be restricted.