Dr. Jones is Adjunct Faculty, University of North Florida, Jacksonville, and Risk Manager, Palatka Health Care Center, Palatka, Florida.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
The author thanks Quality Partners of Rhode Island for the use of the HATCh model. For more information, contact Gail Patry, RN, CPEHR, Senior Director, Quality Programs, Quality Partners of Rhode Island, 235 Promenade Street, Suite 500, Box 18, Providence, RI 02908; e-mail: email@example.com.
Address correspondence to Carol S. Jones, DNP, RN, 320 Cedar Creek Road, Palatka, FL 32177; e-mail: firstname.lastname@example.org.
Culture change in long-term care (LTC) is occurring in many facilities throughout the United States. Culture change transforms the way older adults are cared for by changing the attitudes they and their caregivers have toward aging, as well as through changes in government policy (Fagan, 2003). Fagan (2003) asserted the need for such a transformation: “In nursing homes, assisted living facilities and adult day care programs, we supply our elders with the necessities of survival, but they are too often deprived of the necessities of living” (p. 127). LTC facilities provide excellent quality of care, but often quality of life is overlooked. Culture change aims to create vibrant communities where the frontline staff are empowered and where residents flourish and experience an enhanced quality of life (Rahman & Schnelle, 2008; Robinson & Gallagher, 2008). Culture change involves honoring the older adults’ wishes on a daily basis and authorizing frontline staff to help residents make decisions about their lives, thus improving their quality of life.
Person-centered care, at the heart of various culture change models, has several essential elements: “personhood, knowing the person, maximizing choice and autonomy, comfort, nurturing relationships, and a supportive physical and organizational environment” (Crandall, White, Schuldheis, & Talerico, 2007, p. 47). When person-centered care is adopted, the staff members’ knowledge of the residents rises to a new level. Staff discover what activities the residents desire from the time they awaken to the time they go to sleep. Staff also learn what the residents want to eat, how and when they prefer to bathe, what activities they enjoy, and overall what they want to do each day. The relationship further develops when the frontline staff ascertain residents’ past accomplishments, career, hobbies, friends, and families. Staff also uncover residents’ current wishes and desires, as well as what they may still want to accomplish. The HATCh (Holistic Approach to Transformational Change) model developed by the Quality Partners™ of Rhode Island (2006) is a roadmap for helping facilities make the transformational change from a medical model to person-centered care.
Culture change is not a one-time event. It is a journey that continues through time and evolves: There is no generic blueprint for culture change. Each nursing home makes decisions to modify policies and procedures, manage staff, consider environmental changes to become more homelike, and determine how to care for residents living in the facility (Norton & McMahon, 2008). The success of culture change depends on each facility embracing person-centered care. This includes a change in the entire culture of the facility. Staff members learn about their residents in different ways. They perceive and interact with them as more than dependent, sick people. The staff learn about their residents and the entirety of each person’s life experience to create a rich, three-dimensional picture of each resident as an individual.
Culture change is approached in different ways by different facilities. The key to culture change is providing residents with more choices throughout the day; for example, more choices in dining are offered, such as creating “fine dining” for all in the dining room. The residents choose what they want to do and how they want to do it and, in so choosing, increase the quality of their lives.
Part of culture change involves the “flattening of the hierarchy,” which shifts decision making from the authorities to all parties involved, particularly the residents and frontline staff (Ragsdale & McDougall, 2008). Instead of the administrator and management staff making all of the decisions, the residents and the certified nursing assistants (CNAs) are also involved in the decision making that affects their facility. No matter which culture change model is chosen, altering the decision-making process is essential to transforming the facility. Five different models of culture change have been successful: the Regenerative Community, the Eden Alternative®, the Wellspring Model, the Neighborhood Model, and the Pioneer Network.
The Regenerative Community
The Live Oak Regenerative Community was initiated by Dr. Barry Barkan in 1977 (Barkan, 2003). The entire culture is built around the idea of community, with the older adult at its center. In this community, Barkan posits that regeneration is understood as a lifelong journey and process that can be enhanced by listening to people’s needs and acting on those needs. This community is based on Erikson’s developmental stages theory, which states that aging is another stage of life and every individual continues developing as he or she ages (Mitty, 2005). The community downplays illness, building instead on resident strengths, despite deteriorating health (Holzer, 2007).
The Eden Alternative
The Eden Alternative was started by Dr. William Thomas, who believed that older adults can thrive in an environment that prevents the three “plagues” of nursing homes: loneliness, helplessness, and boredom (Thomas & Johansson, 2003). Thomas identified two fundamental ideas critical to transforming LTC: (a) decisions need to be made by the older adults or by the caregivers closest to them, and (b) staff members will treat the older adults the same way management staff treats them. If the management is concerned and care about their staff and their staff members’ lives, the staff in turn will treat their residents with care and concern. Thomas also believed that children, plants, and animals help older adults thrive by restoring relationships and spontaneity to daily life (Fagan, 2003; Rantz & Flesner, 2004; Thomas & Johansson, 2003). In a study by Drew and Brooke (1999), the number of anxiolytic and antidepressant medications decreased by 33%, pressure ulcer development decreased by 60%, and staff absenteeism decreased by 44% in facilities that adopted the Eden Alternative. In addition, Rosher and Robinson (2005) found significant improvement in family satisfaction with the implementation of the Eden Alternative.
The Wellspring Model
The Wellspring Model is a confederation of not-for-profit, freestanding nursing homes in eastern Wisconsin that joined together to create a better living place for residents and a better work environment for employees (Kehoe & Van Heesch, 2003). Advanced practice nurses are employed as consultants to translate research-based evidence to the practice of the clinical staff to transform and improve the daily care of residents. The fundamental aspects regarding quality of care are developed by top management, but the decision making is best done by the frontline staff closest to the residents (Holzer, 2007; Kehoe & Van Heesch, 2003; Robinson & Gallagher, 2008). A study of this system revealed improved quality outcomes, decreased staff turnover, and improved staff retention (Rahman & Schnelle, 2008).
The Neighborhood Model
The Neighborhood Model transforms large communal spaces into living areas for 8 to 20 residents, with each resident cared for by consistent staff who are cross-trained to perform a variety of jobs. Each neighborhood creates a homelike environment within each living space with its own kitchen, laundry room, living room, and dining room. Resident decision making is at the center of the model (Robinson & Gallagher, 2008). In a study by Ragsdale and McDougall (2008), two conventional nursing homes were converted into Green Houses® and were compared with traditional nursing homes. The study demonstrated how small houses increased the quality of care, which was measured by quality indicators, resident and staff satisfaction, and decreased staff turnover.
The Pioneer Network
The Pioneer Network is an organization of culture change advocates. They believe that to have meaningful lives, older adults need to have “dignity, choice and self-determination” (Fagan, 2003, p. 126). Principles of the Pioneer Network include returning decision making to the residents, empowering the caregiver at the bedside, creating a homelike environment, and continuing the resident’s daily routines (Mitty, 2005). The goal is for residents to live in dignity and comfort while maintaining control of their lives (Krasnausky, 2004). In a study by Elliott (n.d.), a decreased incidence of decline in activities of daily living, weight loss, and pressure ulcers was found. As with the other models, there was an improvement in employee satisfaction in addition to decreased staff turnover.
The current culture in LTC is a medical model. In the 1960s, Medicare and Medicaid bills were passed, and from that time forward, LTC facilities were designed like hospitals. Management of LTC residents included prescribed routines revolving around disease and physical care until death. In 1987, the Omnibus Budget Reconciliation Act was passed by the U.S. Congress. This act required LTC facilities to promote the maintenance or enhancement of quality care for each of its residents. This was accomplished by having a written care plan that assessed the resident’s care needs and was implemented to attain the resident’s highest level of well-being (Robinson & Gallagher, 2008).
In 1986, the Institute of Medicine issued a report entitled Improving the Quality of Care in Nursing Homes. This report succeeded in improving care, but the result was an institutional, medical model (Flesner, 2009). A medical model views patients by their sickness or disability, which has formed the institutional view of them in a LTC facility (Barkan, 2003). The medical model emphasizes quality of care over quality of life. The time for medications, treatments, and activities are structured around a traditional schedule of three 8-hour shifts. When to sleep, eat, and bathe is dictated by a schedule, rather than by personal preference (Krasnausky, 2004). This kind of facility focuses on an efficient operation, not the needs and wants of its residents. The aim is to treat the residents’ weaknesses rather than develop their strengths (Holzer, 2007).
Classic attributes of a medical model include staff providing care based on a medical diagnosis and schedules and treatment designed by the institution staff—all without regard to resident choice. Work is task oriented, and staff rotate assignments frequently. The environment is hospital like, decision making is centralized, and activities are available when the activity staff are working. Loneliness and isolation are often seen in the residents (Misiorski, 2003).
Throughout the literature regarding each of these models is the concept of person-centered care, which is very different from the medical model (Table). At the heart of this care is the relationship between the older adult and the caregiving staff. The resident is honored as an individual and not lost in the daily tasks of his or her care. The focus of the care is on the older adults’ quality of life (Crandall et al., 2007). Attributes of this kind of culture include a focus on staff members’ investment into relationships with the residents based on each resident’s individual needs. The resident’s schedule is designed by the older adult and the caregiver. Consistent staff, combined with the staff member’s personal knowledge of the resident, is brought into the relationship. Decision making lies with the residents and/or the frontline staff who care for them. The environment is homelike; spontaneous activities are available around the clock; and there is a sense of belonging (Misiorski, 2003; Robinson & Gallagher, 2008). Person-centered care is part of the facility’s mission, and the systems are in place to support and sustain this change through policy and procedures, job descriptions, and education. There is involvement and commitment at all levels of the facility (Crandall et al., 2007). Person-centered care also involves the resident’s family, friends, and social network (Talerico, O’Brien, & Swafford, 2003).
Table: Person-Centered Care Contrasted with a Medical Model
Relationships are the cornerstone of person-centered care. The person is put before the task. Self-determination is a right, and risk taking is a part of life, even in a LTC facility. More than just physical care, the older adult’s spirit and mind are nurtured in an environment that promotes growth and development throughout the life span (Flesner, 2009). Williams (2003) expressed the idea that caregiving is the basis of relationships in the following way:
Caregiving is not one person doing a favor for another or giving to another who is simply a recipient. Rather, it is a relationship in which there is a give and take and a bond that is made, person to person. Moreover, it is a living and growing bond which both participants shape and nourish.
Caregiving is an interactive, growing relationship that develops between the resident and the staff member. All staff members are involved in this caring relationship, but it is usually the CNA who is closest to the resident and develops the closest relationship with him or her.
Beyond the relationship between residents and frontline staff is the relationship between frontline staff and management staff. CNAs need to know they are appreciated, understood, and cared about. They need to feel they are recognized as unique individuals with families, hopes, and dreams and are appreciated for their contributions to the workplace (Williams, 2003).
Person-centered care is a change in how frontline staff view and interact with the residents. Instead of seeing residents as ill, dependent people, staff begin to see them with new eyes. What did this person do for a career? What are their hobbies? What do they still want to accomplish in life? What are their interests? Who is this person, and what does he or she have to share? In exchange, the older adult shares some of the CNA’s life. Both the resident and the CNA are enriched by their relationship.
A model is necessary to make a transformational change in how care is provided for older adults. The Quality Partners of Rhode Island (2006) have developed a change model that assists LTC facilities to move from an institutional culture (medical model) to a person-centered care culture: the Holistic Approach to Transformational Change (HATCh; Figure). At the center of the model is a heart that represents the resident, who is the center of care. Three intertwined circles surround the heart. These three domains are critical in transforming the life and care of the residents. The first circle, or domain, is Workplace Practices, which includes activities, procedures, work designs, systems, and individuals. This domain is critical because it is linked to good care, good jobs, and staff stability. The Environment is the next domain, where the facility is truly transformed into a homelike environment. The third domain is Care Practices, which include medical care, clinical care and systems, quality improvement, activities, rituals, celebrations, waking and dining, and the dying experience. These three domains are nested within another circle, Leadership, which represents leadership at all levels of the facility. Empowerment of CNAs occurs within this domain. A fifth domain, Family and Community, encircles Leadership. This is essential to encourage relationships with families and the community. The final circle is Government and Regulations, which offers a partnership between regulatory/government agencies and the LTC facility to aid and complete the transformation (Quality Partners of Rhode Island, 2006).
Figure. Holistic Approach to Transformational Change (HATCh). Copyright ©2006 Quality Partners™ of Rhode Island. The HATCh Model Was Developed by Quality Partners of Rhode Island Under the 8th SoW QIOSC Contract and Therefore Is in the Public Domain.
The Quality Partners of Rhode Island (2006) have created modules for each of the domains to train facility staff in culture change and help them achieve transformation from a medical model to a person-centered care model. In Workplace Practices, the modules address staff retention. In Care Practices, the modules deal with natural awakenings, the dining experience, and honoring the dying process. An example of using the HATCh model is a group exercise entitled “Home vs. Homelessness.” In this exercise, staff participants are divided into pairs and are asked to discuss the word home and what it means to them. The paired teams are then asked to share their ideas with the larger group. The findings of Carboni (1990), who studied the characteristics of home, are related back to what the participants found in their small groups. Carboni’s research showed that the characteristics of homelessness matched the characteristics of people living in LTC. The group is asked to examine the list of homelessness characteristics in the context of people living in a nursing home. The larger group is divided into small groups of four and asked to make two lists: one about how their facility supports people feeling at home and another about how it supports feeling homeless. This discussion is followed by viewing the video Look at Me (Veteran’s Administration Medical Center, Northport, New York, n.d.), which depicts an older man reflecting on a life well lived. Closing points can be made about how older adults are inadvertently made to feel homeless in LTC facilities (Quality Partners of Rhode Island, 2006). This powerful inservice program is just one of multiple modules that support the culture change in all of the domains.
If true culture change is to occur, it is at the level of the CNA and the resident. Many CNAs know how their resident wants care done and cater to their wishes. Magical things happen when the CNAs work to learn about the residents’ lives and what they have accomplished, as well as what they enjoy and what they still want to do with their lives. Person-centered care unleashes unimagined creativity and enriches the lives of both the CNAs and the residents. The facility atmosphere shifts from a “nice place to work” to an energized, exciting, living, and vibrant community.
It does not matter which culture change model a LTC facility chooses to embrace. Every model offers increased choice and decreased institutionalization of the residents. At the heart of each model is person-centered care. True transformation will not occur unless the culture of the facility is changed from an institutional, medical model to a person-centered care model. Culture change is about relationships between the residents and the caregiving staff closest to them. When the frontline nursing staff change their way of providing care and begin to build deeper and more significant relationships with the residents, true culture change can occur.
- Barkan, B. (2003). The Live Oak Regenerative Community: Championing a culture of hope and meaning. Journal of Social Work in Long-Term Care, 2, 197–221. doi:10.1300/J181v02n01_14 [CrossRef]
- Carboni, J.T. (1990). Homelessness among the institutionalized elderly. Journal of Gerontological Nursing, 16(7), 32–37.
- Crandall, L.G., White, D.L., Schuldheis, S. & Talerico, K.A. (2007). Initiating person-centered care practices in long-term care facilities. Journal of Gerontological Nursing, 33(11), 47–56.
- Drew, J.C. & Brooke, V. (1999). Changing a legacy: The Eden alternative nursing home. Annals of Long Term Care, 7(3), 115–121.
- Elliott, A.E. (n.d.). Providence Mount St. Vincent—A case for sustainability. Retrieved from the Pioneer Network website: http://www.pioneernetwork.net/Providers/CaseStudies/Providence/
- Fagan, R.M. (2003). Pioneer network: Changing the culture of aging in America. Journal of Social Work in Long-Term Care, 2, 125–140. doi:10.1300/J181v02n01_09 [CrossRef]
- Flesner, M.K. (2009). Person-centered care and organizational culture in long-term care. Journal of Nursing Care Quality, 24, 273–276. doi:10.1097/NCQ.0b013e3181b3e669 [CrossRef]
- Holzer, C. (2007). Culture change in long-term care. Medicine and Health, Rhode Island, 90, 205–207.
- Institute of Medicine. (1986). Improving the quality of care in nursing homes. Retrieved from the National Academies Press website: http://www.nap.edu/openbook.php?record_id=646
- Kehoe, M.A. & Van Heesch, B. (2003). Culture change in long term care: The wellspring model. Journal of Social Work in Long-Term Care, 2, 159–173. doi:10.1300/J181v02n01_11 [CrossRef]
- Krasnausky, P. (2004). Being who we say we are. “Culture change” helps two long-term care centers align practice with their sponsors’ values. Health Progress, 85(3), 50–54.
- Misiorski, S. (2003). Pioneering culture change: The Pioneer Network shares its approach to creating culture change in long-term care. Nursing Homes, 52(10), 24–30.
- Mitty, E.L. (2005). Culture change in nursing homes: An ethical perspective. Annals of Long-Term Care, 13(3), 47–51.
- Norton, G. & McMahon, E. (2008). The cultural revolution part three: Strategic investments in person-centered care. Provider, 34, 53–56.
- Omnibus Budget Reconciliation Act of 1987, Pub. L. No. 100-203, §2, 101 Stat. 1330 (1987).
- Quality Partners of Rhode Island. (2006). HATCh model—Individualized care. Retrieved from http://www.qualitypartnersri.org
- Ragsdale, V. & McDougall, G. (2008). The changing face of long-term care: Looking at the past decade. Issues in Mental Health Nursing, 29, 992–1001. doi:10.1080/01612840802274818 [CrossRef]
- Rahman, A.N. & Schnelle, J.F. (2008). The nursing home culture-change movement: Recent past, present, and future directions for research. The Gerontologist, 48, 142–148. doi:10.1093/geront/48.2.142 [CrossRef]
- Rantz, M.J. & Flesner, M.K. (2004). Person centered care: A model for nursing homes. Washington, DC: American Nurses Association.
- Robinson, G.E. & Gallagher, A. (2008). Culture change impacts quality of life for nursing home residents. Topics in Clinical Nutrition, 23, 120–130.
- Rosher, R.B. & Robinson, S. (2005). Impact of the Eden alternative on family satisfaction. Journal of the American Medical Directors Association, 6, 189–193. doi:10.1016/j.jamda.2005.03.005 [CrossRef]
- Talerico, K.A., O’Brien, J.A. & Swafford, K.L. (2003). Person-centered care: An important approach for 21st century health care. Journal of Psychosocial Nursing and Mental Health Services, 41(11), 12–16.
- Thomas, W.H. & Johansson, C. (2003). Elderhood in Eden. Topics in Geriatric Rehabilitation, 19, 282–290.
- Veteran’s Administration Medical Center, Northport, New York. (n.d.). Look at me [video]. Retrieved from the QualityNet website: http://www.qualitynet.org/dcs/ContentServer?cid=1163010385272&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools
- Williams, C.C. (2003). Relationship: The heart of life and long-term care. Chicago: Pioneer Network.
Person-Centered Care Contrasted with a Medical Model
||Medical Model (Institutional Care)
|The residents’ schedules are designed by the older adult and the caregiver.
||Staff provide care based on a medical diagnosis.
|Consistent staff, with the staff’s personal knowledge of the older adult brought into the relationship.
||Staff rotate assignments frequently.
|Decision making is with the residents and/or the frontline staff who care for them.
||Decision making is centralized.
|The environment is homelike and spontaneous.
||The environment is hospital like.
|Activities are available around the clock.
||Activities are available when the activity staff are working.
|Staff are invested in a relationship with the resident based on the resident’s individual needs.
||Work is task oriented.
|There is a sense of belonging.
||Loneliness and isolation are often seen in the residents.
|Person-centered care is part of the facility’s mission, including policy and procedures, job descriptions, and education.
||Schedules and treatment are designed by the institution staff, without regard to resident choice.
|There is involvement and commitment at all levels of the facility.
|The resident’s family, friends, and social network are also involved.