Culture Changes When Elders Make Decisions About Their Daily Lives

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The framework that we are about to outline illustrates the differences along the journey from a traditional, institutional PROVIDER-DIRECTED organizational culture to one that is PERSON-DIRECTED, supporting autonomy and enhancing well-being and quality of life.

As we move along, you will see how this Continuum of Direction illustrates the differences between a STAFF or PROVIDER-DIRECTED and a PERSON-DIRECTED culture.

This Continuum of Person-Directed Culture was developed by Susan Misiorski and Joanne Rader, of the Pioneer Network.

Care Assignments

Now let’s take a look at how the practice of Care Assignments changes as an organization moves from being PROVIDER/ or STAFF-DIRECTED to PERSON-DIRECTED.

In a Provider-Directed Culture Management makes most of the decisions with little conscious consideration of the impact on elders or staff. Elders accommodate staff preferences; they are expected to follow existing routines.

Think about where your organization fits within this. Is your organization provider directed, staff centered, person centered, or resident directed? Knowing where you are now helps you envision how to continue moving forward.

PROVIDER-DIRECTED Care in Action: Care Assignments


The nursing assistants punch in at the time clock and check the bulletin board next to the time clock for their scheduled unit. The scheduling coordinator posts this daily schedule each morning. Upon reporting to their posted units, the charge nurse gives each nursing assistant their assignment after giving report.

We gradually move from a LOW Person-Directed Culture to HIGH Person-Directed Culture.

In a Staff Centered culture, staff consult elders or put themselves in elders’ place while making the decisions. Elders accommodate staff much of the time —but have some choices within existing routines and options.

STAFF-CENTERED Care in Action: Care Assignments

STAFF-CENTERED Care Assignments

The nursing assistants always work on the same unit. Upon reporting to their usual unit, the nurse gives them their assignment of residents for the day, which is often different from the day before.

In a Person-Centered culture, Elder preferences or past patterns form the basis of decision making about some routines. Staff begin to organize routines in order to accommodate Elder preferences —whether articulated or observed.

PERSON-CENTERED Care in Action: Care Assignments

PERSON-CENTERED Care Assignments

The nursing assistants always work with the same group of elders/residents. The nursing assistants themselves are responsible for evaluating how their assignments are going and they communicate regularly with each other to ensure the elders’ needs are met in a fair and equitable way. Each elder has a primary aide and an alternate who cares for them when the primary aide has a day off.

In a Person-Directed Culture, Elders make decisions every day about their individual routines. When not capable of articulating needs, staff honor observed preferences and lifelong habits. Staff organize their hours, patterns and assignments to meet elder preferences.

PERSON-DIRECTED Care in Action: Care Assignments

PERSON-DIRECTED Care Assignments

The Certified Nursing Assistants (CNAs) hold team meetings to coordinate their self-scheduling and consistent assignments. They learn from the elders/residents on their neighborhoods (no longer called “units”) what time they want to wake up, eat, etc. The CNAs create their own schedules based upon their own availability and the times the elders need their support. They create their assignments based on their existing relationships with the elders, and the elders are a part of deciding who will care for them.

Where does YOUR organization fit within this framework?


Knowing where you are NOW helps you envision how to continue moving forward.

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