Behavioral choices and enabling conditions for implementing independence-supportive care among nursing assistants in residential aged care facilities in Hunan Province, China: a qualitative study

Abstract

To explore factors influencing nursing assistants’ implementation of independence-supportive care in nursing homes. A descriptive qualitative study was conducted using purposive sampling. From November 2025 to February 2026, 12 nursing assistants from five nursing homes in Hunan Province, China, participated in semi-structured interviews. The interview data were analyzed using a practical, codebook-oriented thematic analysis approach and subsequently interpreted using the Capability, Opportunity, Motivation–Behavior model. Five themes were identified: (1) knowledge and skills related to independence-supportive care remained unstandardized; (2) residents’ functional status, willingness, and expectations of care affected their participation; (3) poor integration between assessment and care planning prevented retained abilities from becoming daily care goals; (4) limited staffing, time, and assistive devices led nursing assistants to take over residents’ tasks; and (5) safety risks and accountability pressures promoted risk-averse care. Although nursing assistants used some independence-supportive practices in daily work, these practices were largely based on personal experience and lacked standardized criteria for assessing task-specific abilities and determining appropriate levels of assistance. Nursing assistants’ implementation of independence-supportive care is shaped by the interaction of capability, opportunity, and motivation. Residential aged care facilities may consider providing activity-specific training, incorporating retained abilities and graded assistance into care plans, strengthening interdisciplinary collaboration, improving staffing and access to assistive devices, and establishing clear risk-management and shared-accountability mechanisms. Residents and families should also be informed that independence-supportive care is intended to maintain functional abilities rather than reduce the amount or quality of care. The effectiveness of these proposed strategies requires evaluation in future implementation studies.