Understanding the Relationship Between Staff and Job Satisfaction,

Stress, Turnover, and Staff Outcomes in the Person-Centered Care

Nursing Home Arena
Santhiny Rajamohan, PhD, RN1 , Davina Porock, PhD, RN2, & Yu-Ping Chang, PhD, RN, FGSA, FAAN3
1 Associate Professor of Nursing, Roberts Wesleyan College, Rochester, NY, USA
2 Professor of Gerontology Nursing, Sheffield Hallam University, South Yorkshire, UK
3 Associate Dean for Research and Scholarship, Patricia H. and Richard E. Garman Endowed Professor, School of Nursing, The State University of New
York, University at Buffalo, Buffalo, NY, USA

Key words Abstract

Nursing home, person-centered care, staff
satisfaction, staff stress, staff turnover
Correspondence
Dr. Yu-Ping Chang, University at Buffalo,
School of Nursing, 3435 Main Street, Wende
Hall Rm 101C, Buffalo, NY 14214.
E-mail: yc73@buffalo.edu
Accepted: January 20, 2019
doi:10.1111/jnu.12488
Background: The provision of quality care in nursing home (NH) facilities
is an ongoing challenge, and the literature indicates that the quality of
care (QOC) is often suboptimal. While it is highly recommended that NH
facilities adopt a culture of person-centered care (PCC) to ensure quality
care, the outcomes of this shift on staff working in NH settings has not
been well studied. The purpose of this article was to understand the theo-
retical relationship between staff and job satisfaction, stress, turnover, and
staff outcomes in PCC NH settings, by utilizing Cohen-Mansfield’s (1995)
comprehensive occupational stress model.
Methods: An integrative review of the electronic databases of research
published in English between 2000 and 2015 was conducted.
Results: A review of 11 papers suggested that job satisfaction in the
nursing workforce is positively related to consistency in QOC delivery and
increased quality of life among residents in NHs. Management support and
PCC practices positively correlate with improved QOC, staff satisfaction,
and staff retention.
Conclusions: This review showed that PCC intervention and training rep-
resenting the key concept of workplace resources has a positive impact
on NH staff job stress and satisfaction.
Clinical Relevance: Supporting the NH workforce through PCC training
is essential for promoting job satisfaction and reducing job-related stress
as well as turnover, which in turn will improve QOC delivered to the
residents living in NHs.

The World Health Organization (WHO) has reported
that by 2050, the world’s population aged 60 years
and older is expected to total 2 billion (WHO, 2018).
While the life expectancy of the older adult popula-
tion increases, their cognitive and functional ability
continues to deteriorate, requiring a need for additional
services to meet the growing demand. Dementia, includ-
ing Alzheimer’s disease, ranks as the fifth leading cause
of death among adults over 65 years of age in the
United States, and 11 million to 16 million cases are
projected by 2050 (Dilworth-Anderson, Pierre, &
Hilliard, 2012). As a result of these changing
demographics and predictive analytics, the number of
older adults requiring long-term care will increase
(Lann-Wolcott, Medvene, & Williams, 2011).
The number of people living with dementia in particular
contributes to the increasing need for nursing homes
(NHs). Currently within the United States, there are
approximately 17,000 NHs providing care to 1.7 million
older adults and disabled individuals, and this number
is expected to increase to 3 million by 2030 (Castle &
Ferguson, 2010; Rosemond, Hanson, Ennett, Schenck, &
Weiner, 2012). Approximately 51% of older adults living
in NHs are 85 years of age or older, and it is estimated

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© 2018 Sigma Theta Tau International
Staff Outcomes in PCC NH Arena
that approximately 30% of residents have some form of
dementia (Lann-Wolcott et  al., 2011). The combination
of these factors places great demands on NH services,
depleting allocated resources, and thus hindering the abil-
ity of the staff to maintain optimal quality of care (QOC;
Kang, Meng, & Miller, 2011).
Contributing factors affecting QOC concerns in NHs
are the high rates of staff and leadership turnover,
along with reported stress and job dissatisfaction among
the staff (Mittal, Rosen, & Leana, 2009; Rosen, Stiehl,
Mittal, & Leana, 2011). The annual turnover rate of
registered nurses (RNs) is estimated at 46.7 %, and
that of licensed practical nurses (LPNs) or vocational
nurses at 41.8%; the rate among nursing assistants
(NAs) or certified nursing assistants (CNAs) and direct
care workers varies from 45% to more than 100%
(Ejaz, Noelker, Menne, & Bagaka’s, 2008; Lerner,
Johantgen, Trinkoff, Storr, & Han, 2014). Based on
various studies, the average annual turnover rate of
nursing home administrators (NHAs) and directors of
nursing (DONs) has been calculated from 20% to 70%,
and 16% to 49.7%, respectively, causing additional
concerns in supporting this workforce (Castle & Engberg,
2006).
These high turnover rates are due to many issues,
with staff burnout and job dissatisfaction being leading
contributors. Furthermore, NH direct care workers are
not satisfied with their pay, benefits, and compensa-
tion in general (Castle, Degenholtz, & Rosen, 2006).
Inadequate compensation is a major causative factor
for high turnover rate (Farrell, Brady, & Frank, 2014).
Job-related stress and burnout is a critical concern
for direct care workers and nursing staff working in
NH facilities. CNAs are on the front lines of nursing
home settings, providing most of the hands-on care
to the residents who are dependent upon them for
their activities of daily living (Kostiwa & Meeks, 2009).
The rate of CNA turnover has been correlated with
decreased QOC among the residents in NHs (Decker,
Harris-Kojetin, & Bercovitz, 2009). The high rates of
turnover among nurses, direct care workers, DONs,
and NHAs result in inconsistency of care delivery and
QOC concerns. A culture change with an emphasis
on PCC is recommended in an effort to increase job
satisfaction and retention among staff, and to decrease
stress and improve the overall QOC (Sharkey, Hudak,
Horn, James, & Howes, 2011).
PCC was the outcome of a unified partnership in
1987, between the Institute of Medicine (IOM) and
the Nursing Home Reform Act which resulted in the
Omnibus Budget Reconciliation Act mandating that
residents have the right to receive and to maintain
the highest QOC (Zimmerman, Shier, & Saliba, 2014).
2 Journal of Nursing Scholarship, 2019; 0:0, 1–9.
Rajamohan et al.
The IOM’s report on improving QOC in NHs indicates
that “whenever possible, facility staff and management
should honor consumer preferences” (Flesner, 2009,
p. 273). The Center for Medicaid/Medicare Services
(CMS) showed concern about the organizational culture
change by releasing the person-centered culture change
assessment in 2006, titled Artifacts of Change (Dana
& Olson, 2007). As a result of the collaborative efforts
of providers, researchers, regulators, and consumer
advocates, an organization called Pioneer Network began
to lead the culture change from traditional care delivery
to PCC approaches. NH facilities have been making
attempts and using various approaches to move toward
a PCC culture over the past two decades to improve
QOC and satisfaction for both residents and staff (Chang,
Li, & Porock, 2013; Sharkey et  al., 2011).
The purpose of our review was to explore the scope
of evidence available regarding PPC and staff outcomes
in NHs and to develop the theoretical basis for future
intervention, study, and application. This article pro-
poses possible solutions to reduce stress and to increase
job satisfaction among nursing staff in NH settings by
developing and maintaining PCC practices.
Organizational Framework
Cohen-Mansfield’s (1995) comprehensive occupa-
tional stress model explains the impact of stress on
staff by integrating all aspects of staff stress in order
to determine the precursors, responses, and conse-
quences of stress for individuals (Figure S1). Sources
of stress for staff include work demands at institutional,
unit, and resident levels, as well as individual needs,
outside-of-work stressors, work, and individual resources
(e.g., personality, skills, and off-the-job resources) that
might affect the relationship between the individual
and the work environment. Recognizing an ongoing
cyclical relationship between stressors and their effects,
Cohen’s model suggests that job demands and stressors
can be used to predict direct care workers’ attitudes
toward residents and may negatively impact the QOC
received by the residents (Cohen-Mansfield, 1995).
Negative psychological and physiologic responses to
stress related to the work environment may lead to
absenteeism, work dissatisfaction, low morale, and
increased care costs (Cohen-Mansfield, 1995; Ramirez,
Teresi, & Holmes, 2006). Additionally, work stress dif-
fers from personal stress, as employees have the choice
to leave employment, suggesting that staff turnover is
a sensitive indicator of job stress (Cohen-Mansfield,
1995).
Evidence suggests that education that reinforces PCC
positively correlates with job satisfaction and retention
© 2019 Sigma Theta Tau International
Rajamohan et al.
of staff in NH settings (Buron, 2008). The work of
Kitwood (1997) has led to a general consensus with
regard to the dimensions of PCC. PCC is a philosophy
and a holistic approach to care that gives emphasis
to the needs and preferences of residents’ physical,
psychosocial, social, and spiritual needs. Relationships,
being the most important foundation for PCC practices,
are valued and nurtured. Collaborative decision making
(such that autonomy is promoted), QOC, and creating
a homelike supportive environment is key to main-
taining the personhood of NH residents (Flesner, 2009;
Kitwood, 1997; Koren, 2010).
Methods: Search Strategy and Appraisal of
Quality and Evidence
We conducted an integrative review of the literature
to examine use of PCC in NH facilities with a focus
on staff outcome of job satisfaction and turnover using
Cohen-Mansfield’s (1995) comprehensive occupational
stress model as an organizing framework. Choosing
the integrative review approach facilitated the inclusion
of multiple research methodologies and the ability to
incorporate both qualitative and quantitative data
(Whittemore & Knafl, 2005). A comprehensive search
was undertaken of available literature in the Cumulative
Index to Nursing and Allied Health Literature (CINAHL),
EBSCO, PsycINFO, PubMed, Cochrane Review,
ProQuest, and Google Scholar using the following key
words individually and in multiple combinations:
patient-centered care/methods, patient-centered care/
utilization, patient-centered care/organization, patient
centered care/workplace, patient-centred care, person-
centered/centred care, person-centered/centred demen-
tia care, resident-centered/centred care, client-centered/
centred care, individualized care, person-centered care
practices, geriatric nursing, NHs, long-term care, culture
change, Eden Alternative, Green House, Wellspring,
Pioneer Network, staff job satisfaction, dissatisfaction,
job demands, job stress, retentions, turnover, burnout,
occupational stress, Cohen-Mansfield stress model, and
staff outcomes. Figure S2 illustrates the process of
selecting the articles for the review.
The searches were narrowed to include only articles
written in English and published from 2000 to 2015,
which produced 55 journal references after removing
duplications. Additionally, reference lists for all appro-
priate articles were also reviewed, but this did not
identify additional sources or publications specific to
staff outcomes of PCC practices. Review of the abstracts
based on inclusion criteria specific to NH settings and
staff outcomes yielded a total of 11 papers from seven
countries for final review (United States, n = 5; Taiwan,
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© 2019 Sigma Theta Tau International
Staff Outcomes in PCC NH Arena
n = 1; Finland, n = 1; Australia, n = 1; Norway, n
= 1; Netherlands, n = 1; and Ireland, n = 1). The
syntheses of the studies are categorized into two groups:
influence of PCC interventions on staff satisfaction and
turnover (n = 4), and the impact of organizational
PCC adaptation on staff satisfaction and turnover (n
= 7). The quality and level of evidence for each study
were evaluated by the guidelines of Harris et al. (2001;
Figure S3).
Results
A total of 11 articles were included in this review:
two studies at hierarchy evidence level IV, as the
findings were from descriptive correlation design
(Edvardsson, Fetherstonhaugh, McAuliffe, Nay, &
Chenco, 2011; Kuo, Yin, & Li, 2008); three studies
at hierarchy evidence level VI, as the findings were
obtained from a qualitative descriptive design (Coogle,
Head, Parham, & Zeman, 2004; Gilster & Dalessandro,
2010; Skrivervik, Buettner, & Testad, 2012); four stud-
ies at hierarchy evidence level VI, as the findings were
obtained from a quantitative descriptive survey design
(Gilster & Dalessandro, 2007; Lubetkin, Annunziato,
Downes, & Burak, 2005; McCormack et  al., 2010;
Pekkarinen, Sinervo, Perälä, & Elovainio, 2004); one
study at hierarchy evidence level V, as the outcomes
were from an integrative review (van den Pol-Grevelink,
Jukema, & Smits, 2012); and one hierarchy evidence
level VII, which included findings from an expert in
the PCC culture transformation (Zigmond, 2009). The
design, appraisals, and outcomes of those 11 articles
are summarized in Table S1.
Definitions of PCC
Before considering the effect of PCC on staff out-
comes, it was important to determine how the studies
included in this review defined PCC. All the articles
reported a form of intervention that either was
described as person-centered or was designed to impact
person-centered outcomes or client-centered practices;
however, only 4 of the 11 articles provided a state-
ment attempting to define PCC (Coogle et  al., 2004;
Edvardsson et  al., 2011). McCormack et  al. (2010)
referred the reader to an earlier publication but did
not restate the definition, and van den Pol-Grevelink
et  al. (2012) summarized Edvardsson, Winblad, and
Sandman’s (2008) definition. Attributes of PCC were
identified in seven articles that did provide some
insight into the interventions. Table S2 details the
definitions and attributes of PCC in the reviewed
articles.
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Influence of PCC Interventions on Staff Satisfaction
and Turnover
Based on Cohen-Mansfield’s (1995) comprehensive
occupational stress model, the intervening variables
consist of work-related resources at institutional, unit,
and patient levels. Providing PCC training for staff is
an essential resource at both the institutional and unit
level. One hierarchy evidence level IV study and three
level VI studies discussed specific PCC interventions
and the associations with staff satisfaction and turnover.
Coogle et  al. (2004) proposed the implementation of
a PCC program named “Skill Building for Staff” in
NH settings. It was shown to promote QOC delivery
to people with dementia and reduce the stress level
of staff. A total of 802 participants completed both
pre- and post-training surveys, and it was evident that
the participants’ knowledge increased significantly (p
< .001) about PCC. In addition, participants shared
that they had better relationships with people who
had dementia, their families, and coworkers, as well
as greater job satisfaction as a result of participating
in the PCC training (Coogle et  al., 2004).
Empowerment is as an essential component in the
implementation of PCC, and it is fundamental at
both the organizational and unit level (Kuo et  al.,
2008; Lubetkin et  al., 2005). In a longitudinal study,
Lubetkin et  al. (2005) evaluated the overall satisfac-
tion of staff working in three NH facilities, using an
employee satisfaction survey consisting of 48 items
designed to measure several aspects of employee
satisfaction. The satisfaction survey consisted of six
constructs: empowerment, teamwork, supervision,
identification, resources, and resident-centered care.
The survey was administrated in 2002 (n = 5,300)
before the implementation of person-centered culture
change and again 2 years after the implementation
(n = 4,700). The results support that staff (except
for social workers, who represented 2% of the employ-
ees) experienced a significant improvement (p = .00)
in satisfaction associated with teamwork, resident-
centered care, and supervision. Empowerment was
the prominent predictor of the overall job satisfaction
of staff (Lubetkin et  al., 2005). The large sample
size is the strength of this study.
When employees are empowered to make creative
decisions based on residents’ or families’ preferences,
they become committed to satisfying relationships with
residents and colleagues, which ultimately enhances
satisfaction for all parties involved. Similar to the find-
ings of Lubetkin et  al. (2005). Kuo et  al. (2008) also
found that empowered teams of CNAs in NH settings
significantly improved job satisfaction. They utilized a
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Rajamohan et al.
cross-sectional design to study 114 NAs at 28 NH
facilities. As a result, empowerment of the CNAs allowed
for creative decision making, which resulted in increased
job satisfaction. Likewise, using innovative interventions
such as individualized music therapy and promoting
the use of specific music preferred by residents ben-
efited both the residents and staff (Skrivervik et  al.,
2012). In another qualitative study of seven staff,
Skrivervik et  al. (2012) reported that individualized
music in dementia care encouraged older adults’ engage-
ment and decreased the frequency of restless or agitated
behaviors. Improved job satisfaction and perceived
meaningful relationships with older adults were themes
revealed in this qualitative descriptive study. Availability
of individualized music as resources at the unit level
contributed to staffs’ greater job satisfaction.
Influence of Organizational Adaptation of PCC on
Staff Satisfaction and Turnover
Cohen-Mansfield’s (1995) model also suggests that
job demands and stressors can be used to predict
NH direct care workers’ attitudes toward residents,
which negatively affects job performance and the
QOC received by the residents (Cohen-Mansfield,
1995; Pekkarinen et  al., 2004). One hierarchy evi-
dence level IV study and six level VI studies explained
the influence of PCC organizations on staff satisfac-
tion and turnover. Pekkarinen et  al. (2004) inves-
tigated the structural factors of NH settings, the
stressors experienced by nursing employees, and the
residents’ quality of life and needs for assistance.
Cross-sectional survey data were collected from 1,194
employees (53% LPNs, 28% RNs, 14% NAs, and
5% head nurses). Multilevel model analyses revealed
that the employees’ time pressures and the residents’
quality of life were negatively correlated with the
large unit size. This study suggested that small units
provide more supportive environments for employees,
better enabling them to cope with job-related stress,
and ultimately enhancing the quality of life for resi-
dents in NH environments.
The findings from the Pekkarinen et al. (2004) study
are supported by the results from van den Pol-Grevelink
et  al.’s (2012) systematic review of different types of
PCC approaches on various dimensions of job satisfac-
tion in NHs. Five types of PCC (person-centered care,
emotion-oriented care,  Snoezelen, demand-oriented
care, and small-scale care) were found among the
seven chosen articles for final reporting. Results indi-
cate that emotion-oriented care, small-scale care,
and  Snoezelen have positive effects on job satisfaction.
A small scale is a homelike care environment similar
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Rajamohan et al.
to the PCC neighborhood model. Findings show that
PCC positively influenced general job satisfaction and
job stress (Pol-Grevelink et  al., 2012).
A PCC SERVICE model (service, education, respect,
vision, inclusion, communication, and enrichment)
developed by Gilster (2005) provides a guide to inte-
grate PCC into the organizational culture. Gilster and
Dalessandro (2010) reported that after 2 years of
implementing the SERVICE model in an assisted senior
living facility and skilled nursing facility, the staff
turnover rate was lowered by 50%, and there was a
considerable increase in overall staff satisfaction (p <
.0001) in addition to resident and family satisfaction.
Qualitative comments regarding staffs’ job satisfaction
2 years after implementation of the SERVICE model
(in 2009) were very positive and favorable, supporting
the desirable outcomes of PCC implementation specific
to increased job satisfaction. The researchers further
reported improvements in QOC measured by a decrease
in deficiencies found on surveys (Gilster & Dalessandro,
2007). Both of these studies were co-authored by the
developer of the SERVICE model; therefore, bias in
sample selection and data collection could be a concern
for validity.
McCormack et  al. (2010) evaluated the nursing out-
comes of PCC practices in a residential setting for
older adults. Among the 18 facilities, staff data were
collected at three different points during a time of
intentional PCC culture development using an instru-
ment called the Person-Centered Nursing Index. Nurses’
stress levels decreased in nine measures, while their
levels of job satisfaction remained high within all three
study periods. The commitment to the organizational
culture was high, while the intent to leave scored
low, supporting the positive outcome of PCC practices.
The three-period accumulation of data is one of the
strengths of this study, as it allowed for the measure-
ment of stress levels and job satisfaction for nurses
over time, which supports the sustainability of staff.
This study is another example of how a PCC organi-
zational culture contributes to the internal resources
of staff, thus increasing job satisfaction and turnover.
Though the researchers noted that the applicability to
nurses’ practice environment has been established, reli-
ability and validity of the tool were not specified in
this study.
Edvardsson et  al. (2011) examined the relationship
between PCC and job satisfaction in a cross-sectional
convenience sample (n = 297) of staff working in
residential aged care settings. The results of this study
confirmed that PCC was positively associated with job
satisfaction and  extent of personalizing care strongly
associated with higher job satisfaction (r = .57, p <
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Staff Outcomes in PCC NH Arena
.01), satisfaction with work load (r = .50, p < .01),
team spirit (r = .47, p < .01), and professional sup-
port (r = .45, p < .01). Using reliable and validated
tools to measure PCC and job satisfaction is one of
the strengths of this study (Edvardsson et  al., 2011).
As a result of the collaborative efforts of providers,
researchers, regulators, and consumer advocates for
older adults, an organization called Pioneer Network
began to lead the culture change from traditional care
delivery to PCC approaches. As Zigmond (2009) noted,
the Pioneer Network has shared some successful case
studies that have revealed culture change is beneficial
for consumers, families, staff, and all involved. In 1994,
an NH in Seattle designed a new “neighborhood” model
and transformed the traditional NH to become a more
person-centered environment. As a result, employee
satisfaction improved significantly, and the annual
turnover rate fell from 50% to 15% in 2006 and
18% in 2007. Another facility in Kansas also reported
substantial improvement after the adaptation of a PCC
model. Staff turnover rate lowered from 80% to 30%,
and the revenue increased from $3 million to $20
million a year (Zigmond, 2009).
Limitations of the Reviewed Studies
Measuring and evaluating the outcomes of PCC
practices or interventions on staff have not been con-
sistent among the studies. The articles included in this
review were cross-sectional or descriptive. The lack of
a control group suggests methodological weaknesses.
There were no uniformities regarding PCC interven-
tions or programs, and their application and viability
were unclear. Generally, there were very poor descrip-
tions of what the training actually entailed, thus limit-
ing replication. Sustainability of the PCC practices were
not addressed in any of the above studies. Findings
of the Coogle et  al. (2004) study are particularly
important due to the large sample size, but the par-
ticipants’ informal feedback regarding job satisfaction
was subjective and not measurable. The number of
staff who gave feedback was not addressed. The stud-
ies included in this review adopted different PCC
interventions and programs. Therefore, there were no
universal PCC interventions across different NHs as a
system approach to care delivery.
The lack of use of consistent terminology and defi-
nitions of terms along with various forms of PCC
interventions among facilities make conducting a sys-
tematic review a challenge. Various tools have been
utilized to measure PCC and job satisfaction and strain,
which adds to the challenge of inconsistent measure-
ments. Most of the studies mentioned job satisfaction
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Staff Outcomes in PCC NH Arena
as outcomes, but did not address job stress or turnover
specifically (Coogle et  al., 2004; Edvardsson et  al.,
2011; Kuo et  al., 2008). Assumptions could be made
that if the staff is satisfied with their jobs, they will
experience minimal stress and will remain in their
jobs. Increased staff job satisfaction, less reported stress,
and longevity on the job can be the indication for
staff outcome of a successful person-centered culture
transformation (McCormack et  al., 2010). The bias of
the self-reported data is another limitation of most of
the studies in this search. While limited, this review
provides insight into the perceptions of staff working
in NH facilities.
Discussion
Existing evidence supports PCC practices as best
practices for older adults in NHs, but the evaluation
of the impact of PCC practices on staff working in
NHs has not been studied extensively. This review
supports improvement in job satisfaction and reduction
in stress and turnover when the staff are educated
and trained in PCC practices, as well as when they
work in a PCC environment. Unfortunately, the qual-
ity of the existing evidence is not strong from a meth-
odological perspective, and the lack of consistent
definition or attributes contributes to the poor quality.
As Zigmond (2009) stated “… it is hard to establish
a research base when the concept is still being defined”
(p. S1). The definitions and attributes as they were
described in the various papers each describe only
partially the complexity of PCC. We know that PCC
is a complex and multifaceted concept, and exploring
isolated concepts of PCC, such as empowerment and
specific PCC interventions, does not address the system
changes required to sustain PCC practices and evaluate
the perceptions of staffs’ satisfaction longitudinally. It
is suggested that NH staff prefer interactive PCC inter-
ventions and like to provide care that is person cen-
tered (Edvardsson et  al., 2011; Edvardsson, Sandman,
& Borell, 2014). The longitudinal studies found that
in order to maintain a person-centered culture, it is
vital to develop effective and empowered teams with
the support of management or leadership (Edvardsson
et  al., 2014; Lubetkin et  al., 2005; McCormack et  al.,
2010).
Information about facility resources and staff com-
pensation and their association with PCC is limited
in our review. Funding and advocacy for more resources
to create an environment that encourages staff is
essential to reduce turnover and to increase job sat-
isfaction, which ultimately will influence the QOC of
the older adults. When the staff working in NH
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Rajamohan et al.
settings are not adequately compensated and the work-
ing environment lacks support and resources, the ability
to provide the best care for the vulnerable older adults
may be affected negatively.
Cohen-Mansfield (1995) considers personality, skills,
off-the-job resources, individual resources, and the
person-to-job fit as central concepts to his model, which
represents the balance between the needs of the employ-
ees and the work environment. One significant gap
identified by this review is the lack of studies that
address personality, person-to-job fit, skills, and edu-
cational preparation of CNAs in relation to their job
stress and satisfaction. Cohen-Mansfield (1995) explained
that these individual factors have a great impact on
staff compatibility and responses, which ultimately influ-
ence their daily work with residents. If the research
studies had examined such attributes of the nursing
home staff, the relationships between staff and residents
would have been better determined, which would have
fully supported Cohen-Mansfield’s framework, and
added strength to the application of the comprehensive
occupational stress model. This gap in the literature
reveals the need for further research utilizing all the
components of this occupational stress model.
Conclusions
Based on Cohen-Mansfield’s (1995) comprehensive
occupational stress model, this review showed that PCC
intervention and training representing the key concept
of off-the-job resources and individual resources have
a positive impact on NH staff by reducing job-related
stress and promoting job satisfaction. Supporting the
NH workforce through the provision of PCC is essential
for promoting job satisfaction and reducing job-related
stress as well as turnover. PCC is a philosophy that
needs to be understood and adapted by all staff, includ-
ing the administration and management, in order to
successfully impact the culture change warranted in the
NH industry. Failure to do so may result in staff dis-
satisfaction through poor performance, burnout, and
increased turnover rates, resulting in a lack of QOC
and thus affecting the quality of life for the older adult
population, including those with dementia. It is evident
that effective leadership is a critical component in creat-
ing and sustaining a PCC environment in NHs. The
leadership in NH facilities is challenged with transforming
the traditional NH culture to a PCC culture, in addition
to supporting the workforce in their daily practices.
The culture shift toward PCC was first initiated in
the United Kingdom, and then PCC influenced the
European countries, Australia, and North America. PCC
is a promising global innovation, and integrating PCC
© 2019 Sigma Theta Tau International
Rajamohan et al.
philosophy as the mission and vision of the organiza-
tion has proven to be a viable solution that increases
both staff satisfaction and QOC, thus improving the
quality of life for the older adult. The NH industry
must continue to prepare its workforce to care for
the demanding needs for the rapidly growing older
adult population. Furthermore, ensuring that the work-
force is adequately trained and compensated in a nur-
turing and resourceful environment will be the key
to establishing PCC organization.
Future research utilizing rigorous designs needs to
evaluate successful PCC facilities that have adopted
the philosophy and integrated it into their organiza-
tional culture. Evaluating staff based on PCC attributes
and ensuring the attributes coincide with the staff
development process will support them in sustaining
a PCC environment. Formulating a universal defini-
tion for PCC and coming to a consensus with a PCC
model, framework, or national guideline to guide
implementation and evaluation will be critical in future
research to move PCC cultural transformation forward.
Future research is warranted to gain a better under-
standing of the current status of leadership in NHs
and the challenges of adapting to PCC culture.
Clinical Resources
• Alzheimer’s Association. Dementia care practice
recommendations. https​://alz.org/profe​ssion​als/
profe​ssion​al-provi​ders/demen​tia_care_pract​ice_
recom​menda​tions​
• Centers for Medicare & Medicaid Services.
Person-centered care planning and practice
recommendations call. https​ ://www.cms.gov/
Outre​ach-and-Educa​tion/Outre​ach/NPC/Natio​
n a l - P r o v i ​ d e r - C a l l s - a n d - E v e n t s - I t e m s /​
2018-03-20-Demen​tia-Care-Impro​vement.html
• ElderCareLink. Person-centered care in nursing
homes: http://www.elder​carel​ink.com/Nursi​ng-
Homes/​ P erson-Cente ​ r ed-Care-in-Nursi​ n g-
Homes-Enhan​ c ed-by-Consi​s tent-Assig​ n ment.
htm
• National Institute on Aging. Alzheimer’s disease
& related dementias. https​ ://www.nia.nih.gov/
healt​h/alzhe​imers​
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Supporting Information
Additional supporting information may be found in
the online version of this article at the publisher’s
web site:
Figure S1. Occupational Stress Model from “Stress
in Nursing Home Staff: A review and a Theoretical
Model” by Cohen-Mansfield, 1995, The Journal of Applied
Gerontology, 14(4), 444-466.
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Ioannidis, J., & … Moher, D. (2009). The PRISMA
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methods of the US Preventive Services Task Force: a
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Table S1. Study Design, Appraisals, and Outcomes
Table S2: Definitions and Attributes of PCC
9