This study examined the current status of SDM and identified the personal characteristics of care providers and the care environment characteristics that influence SDM among long-term care facility staff. The study employed a person-centered nursing framework and identified the experience of person-centered care education, person-centered attitude, communication behavior, and person-centered climate as key factors influencing SDM.
The mean score of SDM in this study was 35.78, which was slightly higher than the mean score observed among physicians in primary care clinics in Japan (31.65) using the same measurement tool [26]. This difference could be attributed to the increased emphasis on reflecting the values and preferences of residents in long-term care facilities, where care services are closely related to the daily activities of residents, such as having a meal and urinating. In another study conducted in Japan using the same instrument among a sample of home care staff, the mean scores for Items 4 and 7 were the lowest [27]. These findings align with the present study, where the mean scores of Items 7 and 8 were the lowest. Notably, the score for Item 7 (My care receiver (or family) and I thoroughly weighed the different care options) was low in both studies. This implies that despite engaging in discussions regarding care options with the care receiver or family, various care methods are not being comparatively assessed adequately. Furthermore, the score of Item 8 (My care receiver (or family) and I selected a care option together) was low in the current study, indicating that the final decision regarding the care option is highly likely to be made by the care provider. Hence, it is crucial to develop effective strategies that promote greater engagement of the care receiver or family in the selection of care options.
Regarding the general characteristics analyzed in this study, the experience of person-centered care education was found to have a significant impact on SDM. SDM is a communication approach based on the philosophy of person-centered care, which emphasizes incorporating the preferences of the care receiver, addressing their physical, psychological, and social needs, and promoting their engagement [11, 28]. Therefore, education on person-centered care could have a positive impact on the practice of SDM. Nevertheless, it is worth noting that in this study, only 63.8% of participants had experienced person-centered care education, and approximately one-third of the participants had no experience in this area. It is thus necessary to reinforce person-centered care education for staff in long-term care facilities to promote SDM.
Regarding the personal characteristics analyzed in this study, both person-centered attitude and communication behavior were found to significantly influence SDM. Person-centered attitude encompasses the care receiver’s sense of agency, belief in their competency for psychosocial engagement, and respect for personhood [22]. Of these, attitude toward agency, in particular, can have a significant impact on SDM as it reflects the care provider’s belief in care receiver`s ability to make decisions regarding their own actions. A study implementing a person-centered dementia care education program, which included curriculum components focused on ‘valuing people’ and ‘personal perspectives’ for the staff at nursing homes, demonstrated improvements in person-centered attitude [29]. Notably, it is necessary to improve person-centered attitudes by providing person-centered care education through various approaches such as incorporating videos or images [29], ICT technologies such as touchscreen technology [30], and role-playing strategies [31], subsequently enhancing SDM practices.
Effective communication behavior in care providers involves considering and accommodating the care receiver’s communication impairments and needs [23]. By engaging in appropriate communication behavior, care providers can gain a better understanding of the values and preferences of care receivers and their families, facilitating the expression of opinions and promoting effective interaction. In addition, demonstrating empathy can enhance the interaction between care providers and care receivers. In a previous study, as the person-centered communication by the staff increased, the positive reactions of residents at care facilities increased [32]. Hence, it is crucial to provide educational programs for care providers that focus on improving their communication skills [33].
In addition, as most residents in long-term care facilities may experience cognitive decline and have difficulty expressing their opinions, it is necessary to develop tools or strategies to assist in their communication. These tools can bridge the communication gap between care receivers and care providers and encourage family participation. Cranley et al. have recently developed a communication tool specifically designed for interacting with patients with dementia, suggesting that it can be utilized in a structured format known as SBARR (Situation, Background, Assessment, Recommendation, and Read back or Response) during communication [34]. Employing a step-by-step communication approach guided by such tools following a guideline may facilitate meaningful discussions about care and provide support to residents in care facilities as they engage in the decision-making process [34].
The results of this study confirmed that staff working at care facilities with a higher level of person-centered climate reported a higher level of SDM. The score for person-centered climate in this study was slightly higher than the mean score (4.82; SD = 0.55) of the staff at long-term care facilities obtained during the development of the Korean version of the PCQ-S [25]. The components of the person-centered climate include safety and everydayness, whereby the residents at care facilities feel at home and enjoy an encouraging environment for building harmonious relationships with the staff and other residents [25]. Person-centered care is often referred to as a culture-change movement, where transforming the environment, including the overall organizational culture, enables facilities to provide person-centered services [35]. It is noteworthy that the nurse-patient interaction is more strongly influenced by organizational culture than the individual competence of the nurse [36]. Therefore, directors and managers of care facilities should make efforts to foster a person-centered environment for staff to provide better person-centered services, including SDM.
Although the present study reveals important findings, it has several limitations. First, as the study participants were recruited from only 13 long-term care facilities, it might be limited to generalize these results. In the future, large-scale studies should be conducted using a more representative sample of staff from various long-term care facilities. Second, as a cross-sectional study, the cause-and-effect relationship between SDM and the explanatory variables of this study could not be verified. Thus, a prospective longitudinal study should be conducted as a follow-up to examine the causal relationship between these variables.