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 Background: The provision of quality care in nursing home (NH) facilities
is an ongoing challenge, and the literature indicates that the quality of
Correspondence care (QOC) is often suboptimal. While it is highly recommended that NH
facilities adopt a culture of person-centered care (PCC) to ensure quality
Dr. Yu-Ping Chang, University at Buffalo, care, the outcomes of this shift on staff working in NH settings has not
School of Nursing, 3435 Main Street, Wende
been well studied. The purpose of this article was to understand the theo-
Hall Rm 101C, Buffalo, NY 14214.
retical relationship between staff and job satisfaction, stress, turnover, and
E-mail: [email protected]
staff outcomes in PCC NH settings, by utilizing Cohen-Mansfield’s (1995)
Accepted: January 20, 2019 comprehensive occupational stress model.
Methods: An integrative review of the electronic databases of research
doi:10.1111/jnu.12488 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 demographics and predictive analytics, the number of
that by 2050, the world’s population aged 60 years older adults requiring long-term care will increase
and older is expected to total 2 billion (WHO, 2018). (Lann-Wolcott, Medvene, & Williams, 2011).
While the life expectancy of the older adult popula- The number of people living with dementia in particular
tion increases, their cognitive and functional ability contributes to the increasing need for nursing homes
continues to deteriorate, requiring a need for additional (NHs). Currently within the United States, there are
services to meet the growing demand. Dementia, includ- approximately 17,000 NHs providing care to 1.7 million
ing Alzheimer’s disease, ranks as the fifth leading cause older adults and disabled individuals, and this number
of death among adults over 65 years of age in the is expected to increase to 3 million by 2030 (Castle &
United States, and 11 million to 16 million cases are Ferguson, 2010; Rosemond, Hanson, Ennett, Schenck, &
projected by 2050 (Dilworth-Anderson, Pierre, & Weiner, 2012). Approximately 51% of older adults living
Hilliard, 2012). As a result of these changing in NHs are 85 years of age or older, and it is estimated

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that approximately 30% of residents have some form of The IOM’s report on improving QOC in NHs indicates
dementia (Lann-Wolcott et  al., 2011). The combination that “whenever possible, facility staff and management
of these factors places great demands on NH services, should honor consumer preferences” (Flesner, 2009,
depleting allocated resources, and thus hindering the abil- p. 273). The Center for Medicaid/Medicare Services
ity of the staff to maintain optimal quality of care (QOC; (CMS) showed concern about the organizational culture
Kang, Meng, & Miller, 2011). change by releasing the person-centered culture change
Contributing factors affecting QOC concerns in NHs assessment in 2006, titled Artifacts of Change (Dana
are the high rates of staff and leadership turnover, & Olson, 2007). As a result of the collaborative efforts
along with reported stress and job dissatisfaction among of providers, researchers, regulators, and consumer
the staff (Mittal, Rosen, & Leana, 2009; Rosen, Stiehl, advocates, an organization called Pioneer Network began
Mittal, & Leana, 2011). The annual turnover rate of to lead the culture change from traditional care delivery
registered nurses (RNs) is estimated at 46.7 %, and to PCC approaches. NH facilities have been making
that of licensed practical nurses (LPNs) or vocational attempts and using various approaches to move toward
nurses at 41.8%; the rate among nursing assistants a PCC culture over the past two decades to improve
(NAs) or certified nursing assistants (CNAs) and direct QOC and satisfaction for both residents and staff (Chang,
care workers varies from 45% to more than 100% Li, & Porock, 2013; Sharkey et  al., 2011).
(Ejaz, Noelker, Menne, & Bagaka’s, 2008; Lerner, The purpose of our review was to explore the scope
Johantgen, Trinkoff, Storr, & Han, 2014). Based on of evidence available regarding PPC and staff outcomes
various studies, the average annual turnover rate of in NHs and to develop the theoretical basis for future
nursing home administrators (NHAs) and directors of intervention, study, and application. This article pro-
nursing (DONs) has been calculated from 20% to 70%, poses possible solutions to reduce stress and to increase
and 16% to 49.7%, respectively, causing additional job satisfaction among nursing staff in NH settings by
concerns in supporting this workforce (Castle & Engberg, developing and maintaining PCC practices.
2006).
These high turnover rates are due to many issues,
Organizational Framework
with staff burnout and job dissatisfaction being leading
contributors. Furthermore, NH direct care workers are Cohen-Mansfield’s (1995) comprehensive occupa-
not satisfied with their pay, benefits, and compensa- tional stress model explains the impact of stress on
tion in general (Castle, Degenholtz, & Rosen, 2006). staff by integrating all aspects of staff stress in order
Inadequate compensation is a major causative factor to determine the precursors, responses, and conse-
for high turnover rate (Farrell, Brady, & Frank, 2014). quences of stress for individuals (Figure S1). Sources
Job-related stress and burnout is a critical concern of stress for staff include work demands at institutional,
for direct care workers and nursing staff working in unit, and resident levels, as well as individual needs,
NH facilities. CNAs are on the front lines of nursing outside-of-work stressors, work, and individual resources
home settings, providing most of the hands-on care (e.g., personality, skills, and off-the-job resources) that
to the residents who are dependent upon them for might affect the relationship between the individual
their activities of daily living (Kostiwa & Meeks, 2009). and the work environment. Recognizing an ongoing
The rate of CNA turnover has been correlated with cyclical relationship between stressors and their effects,
decreased QOC among the residents in NHs (Decker, Cohen’s model suggests that job demands and stressors
Harris-Kojetin, & Bercovitz, 2009). The high rates of can be used to predict direct care workers’ attitudes
turnover among nurses, direct care workers, DONs, toward residents and may negatively impact the QOC
and NHAs result in inconsistency of care delivery and received by the residents (Cohen-Mansfield, 1995).
QOC concerns. A culture change with an emphasis Negative psychological and physiologic responses to
on PCC is recommended in an effort to increase job stress related to the work environment may lead to
satisfaction and retention among staff, and to decrease absenteeism, work dissatisfaction, low morale, and
stress and improve the overall QOC (Sharkey, Hudak, increased care costs (Cohen-Mansfield, 1995; Ramirez,
Horn, James, & Howes, 2011). Teresi, & Holmes, 2006). Additionally, work stress dif-
PCC was the outcome of a unified partnership in fers from personal stress, as employees have the choice
1987, between the Institute of Medicine (IOM) and to leave employment, suggesting that staff turnover is
the Nursing Home Reform Act which resulted in the a sensitive indicator of job stress (Cohen-Mansfield,
Omnibus Budget Reconciliation Act mandating that 1995).
residents have the right to receive and to maintain Evidence suggests that education that reinforces PCC
the highest QOC (Zimmerman, Shier, & Saliba, 2014). positively correlates with job satisfaction and retention

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of staff in NH settings (Buron, 2008). The work of n = 1; Finland, n = 1; Australia, n = 1; Norway, n

Kitwood (1997) has led to a general consensus with = 1; Netherlands, n = 1; and Ireland, n = 1). The
regard to the dimensions of PCC. PCC is a philosophy syntheses of the studies are categorized into two groups:
and a holistic approach to care that gives emphasis influence of PCC interventions on staff satisfaction and
to the needs and preferences of residents’ physical, turnover (n = 4), and the impact of organizational
psychosocial, social, and spiritual needs. Relationships, PCC adaptation on staff satisfaction and turnover (n
being the most important foundation for PCC practices, = 7). The quality and level of evidence for each study
are valued and nurtured. Collaborative decision making were evaluated by the guidelines of Harris et al. (2001;
(such that autonomy is promoted), QOC, and creating Figure S3).
a homelike supportive environment is key to main-
taining the personhood of NH residents (Flesner, 2009;
Results
Kitwood, 1997; Koren, 2010).
A total of 11 articles were included in this review:
two studies at hierarchy evidence level IV, as the
Methods: Search Strategy and Appraisal of
findings were from descriptive correlation design
Quality and Evidence
(Edvardsson, Fetherstonhaugh, McAuliffe, Nay, &
We conducted an integrative review of the literature Chenco, 2011; Kuo, Yin, & Li, 2008); three studies
to examine use of PCC in NH facilities with a focus at hierarchy evidence level VI, as the findings were
on staff outcome of job satisfaction and turnover using obtained from a qualitative descriptive design (Coogle,
Cohen-Mansfield’s (1995) comprehensive occupational Head, Parham, & Zeman, 2004; Gilster & Dalessandro,
stress model as an organizing framework. Choosing 2010; Skrivervik, Buettner, & Testad, 2012); four stud-
the integrative review approach facilitated the inclusion ies at hierarchy evidence level VI, as the findings were
of multiple research methodologies and the ability to obtained from a quantitative descriptive survey design
incorporate both qualitative and quantitative data (Gilster & Dalessandro, 2007; Lubetkin, Annunziato,
(Whittemore & Knafl, 2005). A comprehensive search Downes, & Burak, 2005; McCormack et  al., 2010;
was undertaken of available literature in the Cumulative Pekkarinen, Sinervo, Perälä, & Elovainio, 2004); one
Index to Nursing and Allied Health Literature (CINAHL), study at hierarchy evidence level V, as the outcomes
EBSCO, PsycINFO, PubMed, Cochrane Review, were from an integrative review (van den Pol-Grevelink,
ProQuest, and Google Scholar using the following key Jukema, & Smits, 2012); and one hierarchy evidence
words individually and in multiple combinations: level VII, which included findings from an expert in
patient-centered care/methods, patient-centered care/ the PCC culture transformation (Zigmond, 2009). The
utilization, patient-centered care/organization, patient design, appraisals, and outcomes of those 11 articles
centered care/workplace, patient-centred care, person- are summarized in Table S1.
centered/centred care, person-centered/centred demen-
tia care, resident-centered/centred care, client-centered/
Definitions of PCC
centred care, individualized care, person-centered care
practices, geriatric nursing, NHs, long-term care, culture Before considering the effect of PCC on staff out-
change, Eden Alternative, Green House, Wellspring, comes, it was important to determine how the studies
Pioneer Network, staff job satisfaction, dissatisfaction, included in this review defined PCC. All the articles
job demands, job stress, retentions, turnover, burnout, reported a form of intervention that either was
occupational stress, Cohen-Mansfield stress model, and described as person-centered or was designed to impact
staff outcomes. Figure S2 illustrates the process of person-centered outcomes or client-centered practices;
selecting the articles for the review. however, only 4 of the 11 articles provided a state-
The searches were narrowed to include only articles ment attempting to define PCC (Coogle et  al., 2004;
written in English and published from 2000 to 2015, Edvardsson et  al., 2011). McCormack et  al. (2010)
which produced 55 journal references after removing referred the reader to an earlier publication but did
duplications. Additionally, reference lists for all appro- not restate the definition, and van den Pol-Grevelink
priate articles were also reviewed, but this did not et  al. (2012) summarized Edvardsson, Winblad, and
identify additional sources or publications specific to Sandman’s (2008) definition. Attributes of PCC were
staff outcomes of PCC practices. Review of the abstracts identified in seven articles that did provide some
based on inclusion criteria specific to NH settings and insight into the interventions. Table S2 details the
staff outcomes yielded a total of 11 papers from seven definitions and attributes of PCC in the reviewed
countries for final review (United States, n = 5; Taiwan, articles.

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Influence of PCC Interventions on Staff Satisfaction cross-sectional design to study 114 NAs at 28 NH
and Turnover facilities. As a result, empowerment of the CNAs allowed
for creative decision making, which resulted in increased
Based on Cohen-Mansfield’s (1995) comprehensive job satisfaction. Likewise, using innovative interventions
occupational stress model, the intervening variables such as individualized music therapy and promoting
consist of work-related resources at institutional, unit, the use of specific music preferred by residents ben-
and patient levels. Providing PCC training for staff is efited both the residents and staff (Skrivervik et  al.,
an essential resource at both the institutional and unit 2012). In another qualitative study of seven staff,
level. One hierarchy evidence level IV study and three Skrivervik et  al. (2012) reported that individualized
level VI studies discussed specific PCC interventions music in dementia care encouraged older adults’ engage-
and the associations with staff satisfaction and turnover. ment and decreased the frequency of restless or agitated
Coogle et  al. (2004) proposed the implementation of behaviors. Improved job satisfaction and perceived
a PCC program named “Skill Building for Staff” in meaningful relationships with older adults were themes
NH settings. It was shown to promote QOC delivery revealed in this qualitative descriptive study. Availability
to people with dementia and reduce the stress level of individualized music as resources at the unit level
of staff. A total of 802 participants completed both contributed to staffs’ greater job satisfaction.
pre- and post-training surveys, and it was evident that
the participants’ knowledge increased significantly (p
Influence of Organizational Adaptation of PCC on
< .001) about PCC. In addition, participants shared
Staff Satisfaction and Turnover
that they had better relationships with people who
had dementia, their families, and coworkers, as well Cohen-Mansfield’s (1995) model also suggests that
as greater job satisfaction as a result of participating job demands and stressors can be used to predict
in the PCC training (Coogle et  al., 2004). NH direct care workers’ attitudes toward residents,
Empowerment is as an essential component in the which negatively affects job performance and the
implementation of PCC, and it is fundamental at QOC received by the residents (Cohen-Mansfield,
both the organizational and unit level (Kuo et  al., 1995; Pekkarinen et  al., 2004). One hierarchy evi-
2008; Lubetkin et  al., 2005). In a longitudinal study, dence level IV study and six level VI studies explained
Lubetkin et  al. (2005) evaluated the overall satisfac- the influence of PCC organizations on staff satisfac-
tion of staff working in three NH facilities, using an tion and turnover. Pekkarinen et  al. (2004) inves-
employee satisfaction survey consisting of 48 items tigated the structural factors of NH settings, the
designed to measure several aspects of employee stressors experienced by nursing employees, and the
satisfaction. The satisfaction survey consisted of six residents’ quality of life and needs for assistance.
constructs: empowerment, teamwork, supervision, Cross-sectional survey data were collected from 1,194
identification, resources, and resident-centered care. employees (53% LPNs, 28% RNs, 14% NAs, and
The survey was administrated in 2002 (n = 5,300) 5% head nurses). Multilevel model analyses revealed
before the implementation of person-centered culture that the employees’ time pressures and the residents’
change and again 2 years after the implementation quality of life were negatively correlated with the
(n = 4,700). The results support that staff (except large unit size. This study suggested that small units
for social workers, who represented 2% of the employ- provide more supportive environments for employees,
ees) experienced a significant improvement (p = .00) better enabling them to cope with job-related stress,
in satisfaction associated with teamwork, resident- and ultimately enhancing the quality of life for resi-
centered care, and supervision. Empowerment was dents in NH environments.
the prominent predictor of the overall job satisfaction The findings from the Pekkarinen et al. (2004) study
of staff (Lubetkin et  al., 2005). The large sample are supported by the results from van den Pol-Grevelink
size is the strength of this study. et  al.’s (2012) systematic review of different types of
When employees are empowered to make creative PCC approaches on various dimensions of job satisfac-
decisions based on residents’ or families’ preferences, tion in NHs. Five types of PCC (person-centered care,
they become committed to satisfying relationships with emotion-oriented care,  Snoezelen, demand-oriented
residents and colleagues, which ultimately enhances care, and small-scale care) were found among the
satisfaction for all parties involved. Similar to the find- seven chosen articles for final reporting. Results indi-
ings of Lubetkin et  al. (2005). Kuo et  al. (2008) also cate that emotion-oriented care, small-scale care,
found that empowered teams of CNAs in NH settings and  Snoezelen have positive effects on job satisfaction.
significantly improved job satisfaction. They utilized a A small scale is a homelike care environment similar

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to the PCC neighborhood model. Findings show that .01), satisfaction with work load (r = .50, p < .01),
PCC positively influenced general job satisfaction and team spirit (r = .47, p < .01), and professional sup-
job stress (Pol-Grevelink et  al., 2012). port (r = .45, p < .01). Using reliable and validated
A PCC SERVICE model (service, education, respect, tools to measure PCC and job satisfaction is one of
vision, inclusion, communication, and enrichment) the strengths of this study (Edvardsson et  al., 2011).
developed by Gilster (2005) provides a guide to inte- As a result of the collaborative efforts of providers,
grate PCC into the organizational culture. Gilster and researchers, regulators, and consumer advocates for
Dalessandro (2010) reported that after 2 years of older adults, an organization called Pioneer Network
implementing the SERVICE model in an assisted senior began to lead the culture change from traditional care
living facility and skilled nursing facility, the staff delivery to PCC approaches. As Zigmond (2009) noted,
turnover rate was lowered by 50%, and there was a the Pioneer Network has shared some successful case
considerable increase in overall staff satisfaction (p < studies that have revealed culture change is beneficial
.0001) in addition to resident and family satisfaction. for consumers, families, staff, and all involved. In 1994,
Qualitative comments regarding staffs’ job satisfaction an NH in Seattle designed a new “neighborhood” model
2 years after implementation of the SERVICE model and transformed the traditional NH to become a more
(in 2009) were very positive and favorable, supporting person-centered environment. As a result, employee
the desirable outcomes of PCC implementation specific satisfaction improved significantly, and the annual
to increased job satisfaction. The researchers further turnover rate fell from 50% to 15% in 2006 and
reported improvements in QOC measured by a decrease 18% in 2007. Another facility in Kansas also reported
in deficiencies found on surveys (Gilster & Dalessandro, substantial improvement after the adaptation of a PCC
2007). Both of these studies were co-authored by the model. Staff turnover rate lowered from 80% to 30%,
developer of the SERVICE model; therefore, bias in and the revenue increased from $3 million to $20
sample selection and data collection could be a concern million a year (Zigmond, 2009).
for validity.
McCormack et  al. (2010) evaluated the nursing out-
Limitations of the Reviewed Studies
comes of PCC practices in a residential setting for
older adults. Among the 18 facilities, staff data were Measuring and evaluating the outcomes of PCC
collected at three different points during a time of practices or interventions on staff have not been con-
intentional PCC culture development using an instru- sistent among the studies. The articles included in this
ment called the Person-Centered Nursing Index. Nurses’ review were cross-sectional or descriptive. The lack of
stress levels decreased in nine measures, while their a control group suggests methodological weaknesses.
levels of job satisfaction remained high within all three There were no uniformities regarding PCC interven-
study periods. The commitment to the organizational tions or programs, and their application and viability
culture was high, while the intent to leave scored were unclear. Generally, there were very poor descrip-
low, supporting the positive outcome of PCC practices. tions of what the training actually entailed, thus limit-
The three-period accumulation of data is one of the ing replication. Sustainability of the PCC practices were
strengths of this study, as it allowed for the measure- not addressed in any of the above studies. Findings
ment of stress levels and job satisfaction for nurses of the Coogle et  al. (2004) study are particularly
over time, which supports the sustainability of staff. important due to the large sample size, but the par-
This study is another example of how a PCC organi- ticipants’ informal feedback regarding job satisfaction
zational culture contributes to the internal resources was subjective and not measurable. The number of
of staff, thus increasing job satisfaction and turnover. staff who gave feedback was not addressed. The stud-
Though the researchers noted that the applicability to ies included in this review adopted different PCC
nurses’ practice environment has been established, reli- interventions and programs. Therefore, there were no
ability and validity of the tool were not specified in universal PCC interventions across different NHs as a
this study. system approach to care delivery.
Edvardsson et  al. (2011) examined the relationship The lack of use of consistent terminology and defi-
between PCC and job satisfaction in a cross-sectional nitions of terms along with various forms of PCC
convenience sample (n = 297) of staff working in interventions among facilities make conducting a sys-
residential aged care settings. The results of this study tematic review a challenge. Various tools have been
confirmed that PCC was positively associated with job utilized to measure PCC and job satisfaction and strain,
satisfaction and  extent of personalizing care strongly which adds to the challenge of inconsistent measure-
associated with higher job satisfaction (r = .57, p < ments. Most of the studies mentioned job satisfaction

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as outcomes, but did not address job stress or turnover settings are not adequately compensated and the work-
specifically (Coogle et  al., 2004; Edvardsson et  al., ing environment lacks support and resources, the ability
2011; Kuo et  al., 2008). Assumptions could be made to provide the best care for the vulnerable older adults
that if the staff is satisfied with their jobs, they will may be affected negatively.
experience minimal stress and will remain in their Cohen-Mansfield (1995) considers personality, skills,
jobs. Increased staff job satisfaction, less reported stress, off-the-job resources, individual resources, and the
and longevity on the job can be the indication for person-to-job fit as central concepts to his model, which
staff outcome of a successful person-centered culture represents the balance between the needs of the employ-
transformation (McCormack et  al., 2010). The bias of ees and the work environment. One significant gap
the self-reported data is another limitation of most of identified by this review is the lack of studies that
the studies in this search. While limited, this review address personality, person-to-job fit, skills, and edu-
provides insight into the perceptions of staff working cational preparation of CNAs in relation to their job
in NH facilities. stress and satisfaction. Cohen-Mansfield (1995) explained
that these individual factors have a great impact on
staff compatibility and responses, which ultimately influ-
Discussion
ence their daily work with residents. If the research
Existing evidence supports PCC practices as best studies had examined such attributes of the nursing
practices for older adults in NHs, but the evaluation home staff, the relationships between staff and residents
of the impact of PCC practices on staff working in would have been better determined, which would have
NHs has not been studied extensively. This review fully supported Cohen-Mansfield’s framework, and
supports improvement in job satisfaction and reduction added strength to the application of the comprehensive
in stress and turnover when the staff are educated occupational stress model. This gap in the literature
and trained in PCC practices, as well as when they reveals the need for further research utilizing all the
work in a PCC environment. Unfortunately, the qual- components of this occupational stress model.
ity of the existing evidence is not strong from a meth-
odological perspective, and the lack of consistent
Conclusions
definition or attributes contributes to the poor quality.
As Zigmond (2009) stated “… it is hard to establish Based on Cohen-Mansfield’s (1995) comprehensive
a research base when the concept is still being defined” occupational stress model, this review showed that PCC
(p. S1). The definitions and attributes as they were intervention and training representing the key concept
described in the various papers each describe only of off-the-job resources and individual resources have
partially the complexity of PCC. We know that PCC a positive impact on NH staff by reducing job-related
is a complex and multifaceted concept, and exploring stress and promoting job satisfaction. Supporting the
isolated concepts of PCC, such as empowerment and NH workforce through the provision of PCC is essential
specific PCC interventions, does not address the system for promoting job satisfaction and reducing job-related
changes required to sustain PCC practices and evaluate stress as well as turnover. PCC is a philosophy that
the perceptions of staffs’ satisfaction longitudinally. It needs to be understood and adapted by all staff, includ-
is suggested that NH staff prefer interactive PCC inter- ing the administration and management, in order to
ventions and like to provide care that is person cen- successfully impact the culture change warranted in the
tered (Edvardsson et  al., 2011; Edvardsson, Sandman, NH industry. Failure to do so may result in staff dis-
& Borell, 2014). The longitudinal studies found that satisfaction through poor performance, burnout, and
in order to maintain a person-centered culture, it is increased turnover rates, resulting in a lack of QOC
vital to develop effective and empowered teams with and thus affecting the quality of life for the older adult
the support of management or leadership (Edvardsson population, including those with dementia. It is evident
et  al., 2014; Lubetkin et  al., 2005; McCormack et  al., that effective leadership is a critical component in creat-
2010). ing and sustaining a PCC environment in NHs. The
Information about facility resources and staff com- leadership in NH facilities is challenged with transforming
pensation and their association with PCC is limited the traditional NH culture to a PCC culture, in addition
in our review. Funding and advocacy for more resources to supporting the workforce in their daily practices.
to create an environment that encourages staff is The culture shift toward PCC was first initiated in
essential to reduce turnover and to increase job sat- the United Kingdom, and then PCC influenced the
isfaction, which ultimately will influence the QOC of European countries, Australia, and North America. PCC
the older adults. When the staff working in NH is a promising global innovation, and integrating PCC

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Rajamohan et al. Staff Outcomes in PCC NH Arena

philosophy as the mission and vision of the organiza- Castle, N. G., Degenholtz, H., & Rosen, J. (2006).
tion has proven to be a viable solution that increases Determinants of staff job satisfaction of caregivers
both staff satisfaction and QOC, thus improving the in two nursing homes in Pennsylvania. BMC Health
quality of life for the older adult. The NH industry Services Research, 6, 60–60.
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Supporting Information
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facilities try new approaches in their operations to
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Table S1. Study Design, Appraisals, and Outcomes
Transforming nursing home culture: Evidence for
Table S2: Definitions and Attributes of PCC

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