Chapter 9. Conceptualizing Person-Centred Care for Ethnocultural Minority Residents in Long-Term Care Homes: Adaptation of a Person-Centred Practice Framework

Within long-term-care (LTC) settings, the needs and concerns of ethnocultural minority older adults are often ignored and unmet. Many of these individuals receive substandard care, reinforcing the common perception that life in LTC settings is lonely, boring, and helpless (Li & Porock, 2014, 1396). Person-centred care (PCC) has been widely recognized as a fundamental way to promote a more humanistic approach: policies, programs, and services incorporating elements of PCC can foster a better quality of care for older adults and create a more supportive LTC setting promoting autonomy, independence, and dignity (Rantz & Flesner, 2003).

PCC approaches to improve quality of life and resident experience can enable public, private, and non-profit sectors to deliver improved care and services for all residents of LTC settings, including ethnocultural minority older adults. For example, PCC centres the individual needs of older residents by shifting the focus of healthcare providers from task-oriented activities to person-oriented activities (McGilton et al. 2012; Rantz & Flesner, 2003). In theory, PCC enables LTC residents to live more meaningful lives with an improved quality of life and overall wellbeing (Brownie & Nancarrow, 2012). However, few studies have explored how the principles of PCC can be effectively translated into care practices that are appropriate for ethnocultural minority older adults.

The term “ethnocultural minority older adults’” refers to older individuals whose culture, ethnicity, race, and/or religion differ from those of mainstream Canadians (Statistics Canada, 2018b). It includes older individuals who immigrated to Canada in later life, as well as immigrants who may have arrived as children and have aged in Canada (Statistics Canada, 2018b). In 2016, older immigrants represented 31 percent of the total older adult population aged 65 and over in Canada, and racialized minorities made up 22 percent of Canada’s population (Statistics Canada, 2019). Canada’s immigration patterns have been changing, with a shift away from European immigrants to more immigrants from Africa, Asia, and Middle East, making Canada more ethnoculturally diverse (Statistics Canada, 2018a). The heterogenous nature of their experiences, based on the intersection of gender, race, class, and other social identities, shape their health and wellbeing, as well as their aging and care expectations.

Research suggests that changes in cultural values, combined with work and life demands, make it challenging for the family members of ethnocultural minority older adults to take on the role of primary caregiver (Chappell, 2003; Lee & Mjelde-Mossey, 2004; Ujimoto, 1995). As a result, many ethnocultural minority older adults must depend on LTC services. More research efforts are now focusing on the experiences of ethnocultural minority older adults in LTC homes as they relate to cultural changes, as well as the provision of innovative types of housing and care, but very few studies have focuses on PCC as it related to minority older adults living in LTC settings.

The COVID-19 pandemic has brought concerns about quality of care in LTC settings to the forefront. More research is needed, especially given the increasing populations of ethnocultural minority older adults in LTC settings. Specifically, a careful examination is needed to assess the relevance and application of PCC approaches in LTC settings, and how PCC approaches can be effectively incorporated into practice, policy, and programs. This chapter presents a conceptual PCC framework that can provide a comprehensive perspective. It draws from McCormack and McCance’s (2017) person-centred practice framework (PCPF), complemented with elements from intersectionality, life course theory, and integrative model of place. The guiding research question is: How can PCC models be adopted and implemented to meet the needs of ethnocultural minority residents in LTC settings?

Person-centred Care

The core concepts of PCC are personhood and person-centredness. Kitwood defined personhood as “a status that is bestowed upon one human being by others, in the context of relationship and social being. It implies recognition, respect and trust” (1997, 8). Personhood represents the inner feeling individuals have that guides them as persons; each individual has a unique inner perspective that shapes their being in the world (Leibing, 2008). Sabat (2002) argued that personhood is linked to three different understandings of “the self”: Self 1 involves personal identity and is autobiographical in nature, focusing on how individuals relate to their being in the world; Self 2 involves the physical and mental characteristics of individuals (height, weight, beliefs, religion); and Self 3 involves the various social identity that individuals form in different circumstances.

McCormack and McCance (2017) suggested that person-centredness includes four central means of being: being in relation, being in a social world, being in place, and being with self. Being in relation involves significant relationships and interpersonal practices that have healing benefits. Being in social context aligns with Merleau-Ponty’s (1989) theory of how individuals are interconnected with their social world, continuously reconstructing meaning through being in the world. Being in place refers to the importance of built environment and its influences on care experiences: places are strongly linked with each individual’s memories, emotions, and histories. Being with self emphasizes the need for individuals to be self-aware: they must recognize their own values and beliefs in order to engage in authentic relationships that stimulate person-centred practices. Research about person-centredness and its elements is constantly evolving (McCormack & McCance, 2017), so procedures and processes intended to foster quality of life in LTC settings necessitate continuous monitoring, re-evaluation, and revision.

Person-centred Practice Framework

McCormack and McCance’s (2017) developed their PCPF based on empirical research in a nursing context; it serves as a practical guide to foster PCC in healthcare settings. Its philosophical underpinning is rooted in the human sciences, and it consists of four main interrelated domains: prerequisites, care environment, care processes, and person-centred outcomes. Successful person-centred outcomes require first addressing prerequisites, followed by the care environment, and then by person-centred processes. This framework also recognizes influences occurring at the macro level.

The first domain, prerequisites, involves ensuring that healthcare providers can deliver effective PCC. For example, healthcare providers must be professionally competent, have interpersonal skills, be self-aware of their own beliefs and values, and be committed to their job. All of these attributes are important and indicative of a PCC provider who can successfully handle the challenges of a frequently changing environment. The second domain, the care environment, refers to the context in which care is being delivered: the facilitation of PCC is contingent on the care environment regardless of the healthcare provider attributes stated in the prerequisites. The provision of care is closely linked with the third domain, person-centred processes, which involve a series of activities that operationalize person-centred practice. Activities may include working with the individual’s beliefs and values, sharing decision-making, engaging authentically, being sympathetically present, and providing holistic care.

Person-centred processes lead to the fourth domain, person-centred outcomes. Successful person-centred outcomes include good care experience, involvement in care, feeling of wellbeing, and a healthy environment and culture within the healthcare setting. Good care experience entails both objective evaluations of the care provided and the subjective views of the care received. Involvement in care speaks to the decision-making process where individuals are active contributors in planning and monitoring their own care. Feelings of wellbeing entail both the care recipient and the care providers feeling valued. Finally, a healthy environment supports collaboration among staff members, pioneering practices, shared decision-making, and transformative leadership. These PCC outcomes are about more than just accomplishing the goals and tasks related to the individual’s medical needs: they promote collaborative care, shared decision-making, and an individualized approach to care.

Strengths and Limitations of the Person-centred Care Framework

McCormack and McCance’s (2017) PCPF expands on their earlier theoretical model and functions as a guide to cultivate practical knowledge about person-centred approach, transforming PCC from philosophy to practice. As a theoretical framework, it offers a clear description of PCC’s core concepts and their synergistic relationship, which informs research and contributes to further theory development. Person-centred outcomes detailed in this framework are informed by evidence and provide direct targets for evaluating PCC approach by including the perspectives of care professionals, individuals receiving care, and their family members. This framework also recognizes the significance of the care environment and other contextual components (e.g., attitudes and moral beliefs of involved parties), which are fundamental in implementing and fostering PCC.

However, while the PCPF stresses the importance of considering each individual’s beliefs and values, the care environment, and other contextual components, the complexity of person-centred practice, and the implications of attributes among care professionals (McCormack & McCance, 2017; Santana et al. 2017), it does not explicitly include the perspectives of diverse individuals and communities such as ethnocultural minority older adults in LTC settings. Personal attributes extend beyond values, beliefs, and personality, and a broader perspective is needed to include the influences of characteristics such as age, gender, ethnicity, and culture, all of which affect person-centred processes and outcomes. Life history and experiences also shape how both healthcare professionals and residents foster connections and engagements that facilitate PCC. Moreover, the PCPF stresses the role of staff (e.g., nurses) in the implementation of person-centred practice, which can understate the mutually inclusive relationship between care professionals and residents that is imperative for achieving person-centred outcomes. The next section explores how to address these gaps and conceptualize PCC for ethnocultural minority residents in LTC settings, by incorporating complementary theories and concepts such as intersectionality, the life course, and the integrative model of place.

Complementary Theories and Concepts: Intersectionality, the Life Course, and the Integrative Model of Place

Many scholars have drawn from intersectionality to highlight the important relationships between multiple social positions, e.g., race, gender, age, ethnicity, religion, and class (Crenshaw, 2009). The concept of intersectionality stems from post-structuralist feminist debate, feminist critical movements, and political movements (e.g., Black feminisms). Post-colonial, Latina, queer, and Indigenous scholars have contributed to scholarly discussions on the multi-dimensional processes that influence human lives (Bunjun, 2010; Collins, 1990; Hankivsky, 2014; Van Herk et al. 2011). The nature of intersectionality remains open for discussion among scholars: it has been  interpreted as a theory, a methodological approach, and a practice (Hankivsky, 2014), but these are not mutually exclusive.

McCall (2005) identified three approaches to address the complexity of intersectional analysis: anti-categorical (rejecting categories and advocating for inclusion and exclusion mechanisms); intra-categorical (examining intersecting categories to identify the social location of a disadvantaged group); and inter-categorical (supporting the strategic use of analytical categories). Other scholars have stressed the importance of considering the collective influence of many social locations, because oppression and inequities are not the outcomes of single isolated elements, but rather result from the intersections of social positions, power relations, and experiences (Crenshaw, 2009; Hankivsky et al. 2015). Intersectionality can complement the PCPF by capturing and exploring multiple identity markers – of ethnocultural minority older adults and healthcare providers – and thus facilitating a person-centred approach.

The concept of the life course, or life history, originates from Elder’s (2000) work on the diverse dimensions that influence an individual’s life from birth to death. It integrates cultural, social, and historical factors and highlights four paradigmatic principles that play a critical role in shaping the life course of each individual: lives in time and place, timing of lives, linked lives, and human agency in choice making and actions. It can be used as a method to collect data, specifically a chronology of events and activities. Life history can provide valuable information on LTC residents; for example, information about birth, marriage, education, work, family, and retirement can be gathered through archival documents or interviews involving a life calendar or age-event matrix.

The integrative model of place draws from work by Weisman, Chaudhury, and Moore (2000). For example, the multifaceted and dynamic relationship between an older resident and a LTC setting is influenced by numerous contextual factors including organizational, sociological, architectural, and psychological systems.

A New Conceptual Framework: PCC for Ethnocultural Minority Older Adults in LTC Homes

Figure 9.1 presents a novel framework to help conceptualize the implementation of PCC to best serve the needs of ethnocultural minority residents in LTC settings. It draws from McCormack and McCance’s (2017) PCPF, complemented by the incorporation of concepts including intersectionality, the life course, and the integrative model of place. It acknowledges the multiple attributes and experiences of both residents (ethnocultural minority older adults) and caregivers (care aides and nurses) and elucidates a set of care processes that are necessary to ensure PCC and positive care outcomes. It is rooted in person-centred processes and outcomes, while incorporating Weisman, Chaudhury, and Moore’s (2000) integrative model of place to acknowledge the contextual factors of LTC settings that affect overall PCC processes and outcomes.

The new framework offers a clear description of the activities that operationalize PCC, along with desired outcomes; it can be used to assess whether effective person-centred practices have been achieved. Activities related to person-centred processes include sharing decision-making, engaging authentically, being sympathetically present, and providing holistic care (McCormack & McCance, 2017). These activities interrelate with one another and can function simultaneously to foster person-centred outcomes including good care experience, involvement in care, feeling of wellbeing, and a healthy environment (McCormack & McCance, 2017). Bi-directional links between person-centred processes and outcomes represent the interrelationships between them.

Person-centred processes involve activities that require ongoing collaboration between care practitioners and older adults in LTC settings. The conceptual framework clearly identifies caregivers and residents to illustrate the interactions – and personal attributes – that can affect care processes and outcomes (McCormack & McCance, 2017). This focus on interactions aligns with the main tenets of relationship-centred care, which should involve engagement between a group of care professionals, the older resident, and those who are significant to the older resident (McCormack & McCance, 2017; Nolan et al. 2004). Partnerships are at the core of person-centred processes, and person-centred outcomes can in turn influence and inform caregivers, residents, and broader PCC processes.

McCormack and McCance’s (2017) framework includes working with each individual’s beliefs and values as one of many processes. In contrast, our framework centres this as a guiding principle that overlaps with all of the activities happening in the care processes, ultimately affecting person-centred outcomes. In addition to centring the beliefs and values of individuals, our conceptual framework incorporates the attributes of both caregivers and residents. By drawing from elements of intersectionality, care providers can start to understand the multiple social positions of an ethnocultural minority resident (age, gender, ethnicity, and culture) and how these affect their values and beliefs. Caregivers can learn to utilize strategies that allow differences between and within groups, and do not diminish individuals to a single category (Crenshaw, 2009; Torres, 2015). This can help prevent ‘othering’ and generalizing individuals who share similar identity markers.

Another important component of our framework is life history, which complements the intersectionality lens because it helps healthcare providers understand how life experiences over time (e.g., pre-, during, and post-migration) affects identity, interests, and what is important to each individual (Elder, 2000; Ferrer et al. 2017). For example, the values and beliefs of an older Southeast Asian adult who immigrated to Canada in the later stages of life will likely be different from an older Southeast Asian adult who arrived in Canada as a child and grew older in Canada: these individuals share the same ethnicity but may require very different care approaches. This example helps demonstrate the interplay among life history and social identity markers such as age, gender, culture, and ethnicity, and how cultural values, beliefs, and lifestyle are unique to each individual. An intersectional and life course approach acknowledges the interactions between various identity markers and life events and can be utilized to customize and sensitize care practices in LTC homes. It is also important to recognize the various identity markers of healthcare providers, because their values and beliefs strongly affect their ability to facilitate PCC (McCormack & McCance, 2017). It is also important to note that while our conceptual framework specifies identity markers such as age, gender, culture, and ethnicity, other identity markers may apply to ethnocultural minority residents and healthcare providers and should be incorporated as necessary, e.g., religion, disability, race, nationality, and sexual orientation.

Finally, our conceptual framework illustrates how social, organizational, and physical factors can affect healthcare providers and residents, as well as overall PCC processes and outcomes. The theoretical framework developed by Weisman and colleagues (2000) serves as useful guide to illustrate how the quality of care practices and quality of life among LTC residents are influenced by contextual environmental factors. Social factors refer to the overall social setting: how residents, various staff groups, and other involved parties interact and affect the care practices and social relations within in the LTC setting. Organizational factors refer to internal and external components and influences that shape processes and practices within the LTC setting: internal factors might include the values, culture, and policies at the LTc, and external factors might include funding, staffing models, and regional policies/regulations. Physical environmental factors are defined by the geographic area of the care home and its built environmental features. The interplay of organizational, social, and physical environmental factors affect how person-centred practices are facilitated in LTC settings for all residents, including ethnocultural minority residents.

Conclusion

Our novel conceptual framework offers new insights into how PCC processes are influenced by various attributes and experiences of diverse individuals, healthcare providers, and communities. We drew from McCormack and McCance’s (2017) PCPF and incorporated elements from intersectionality, the life course, and the integrative model of place to develop a helpful theoretical model for exploring how practices related to PCC can contribute to the overall wellbeing of the ethnocultural minority aging population. Limited research has focused on the implications of PCC for ethnocultural minority older adults, and this framework provides a starting point to conceptualize the person-centred approach in ways that can meet the unique needs of ethnocultural older adults in LTC settings. In addition to contributing to theory, this framework will extend opportunities to develop a research agenda to identify, implement, and facilitate person-centred processes for ethno-specific older adults in LTC homes.

Our new framework was designed for the LTC context, but it can be modified to accommodate other healthcare settings. It is not intended to be a one-size-fits-all approach, as the dimensions and context of care will vary. More empirical research will be necessary to validate, adapt, and refine our framework to serve the evolving nature of theory and practice related to person-centred care.

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