Research in Gerontological Nursing

Empirical Research 

Nursing Home Culture Change: What Does It Mean to Nurses?

Jennifer Bellot, PhD, RN, MHSA

Abstract

The purpose of this study was to explore, from the perspectives of licensed nurses, the organizational culture, work environment, and factors influencing culture change in two nursing homes participating in the Wellspring Program. All licensed nurses ⩾0.25 full-time equivalent from two nursing homes were invited to complete the Organizational Culture Inventory and the Work Environment Scale. A subset of respondents was invited to participate in subsequent interviews. Data indicated unresolved conflict, low employee satisfaction, high work demands, and managerial control in the workplace. Qualitatively, three categories emerged: Confusion over culture change, role, and documentation; Conflict over the integration of traditional care with a resident-centered model; and Commitment to providing quality nursing care to the resident. To ensure the successful implementation of culture change, consideration must be given to clarity of communication, anticipation of role conflict, and building on the underlying strength of job commitment.

Abstract

The purpose of this study was to explore, from the perspectives of licensed nurses, the organizational culture, work environment, and factors influencing culture change in two nursing homes participating in the Wellspring Program. All licensed nurses ⩾0.25 full-time equivalent from two nursing homes were invited to complete the Organizational Culture Inventory and the Work Environment Scale. A subset of respondents was invited to participate in subsequent interviews. Data indicated unresolved conflict, low employee satisfaction, high work demands, and managerial control in the workplace. Qualitatively, three categories emerged: Confusion over culture change, role, and documentation; Conflict over the integration of traditional care with a resident-centered model; and Commitment to providing quality nursing care to the resident. To ensure the successful implementation of culture change, consideration must be given to clarity of communication, anticipation of role conflict, and building on the underlying strength of job commitment.

Historically, American nursing homes have provided total institutional living for older adults and those who are disabled, with little consideration for residents’ individualized preferences for care. In the mid-1980s, the institutional paradigm of nursing homes was redefined as a provider of both health and social services. Currently, many nursing home facilities are engaged in culture change, that is, initiatives aimed to completely reorganize nursing home care, addressing staff, resident, environmental, and/or behavioral outcomes.

The Wellspring Program addresses both clinical care and organizational culture change, emphasizing individualized care, collaboration among all workers providing care, improving the skills and knowledge of all workers, accountability for care outcomes and frontline decision making, and the empowerment of hands-on caregivers to make resident-centered decisions regarding care (Wellspring Program, unpublished promotional materials available from http://www.lifespan-network.org/beacon_wellspring.asp). Stone et al. (2002) found that Wellspring facilities had higher immunization rates, fewer bedfast residents, lower restraint use, more preventive skin care, lower psychoactive medication use, less incontinence, and fewer tube feedings than comparison nursing homes. Wellspring facilities also had fewer state survey deficiencies and higher nursing staff retention rates than peer facilities (Kehoe & Van Heesch, 2003).

The Wellspring Program uses eight clinical modules ( http://www.lifespan-network.org/beacon_wellspring_progs.asp). Clinical modules are presented by Wellspring administration to a Care Resource Team (CRT) from each nursing home. The CRT designs and evaluates the implementation of each clinical module and is the Wellspring resource in its respective facility. The module sessions are held at regular intervals and repeated, with slightly different content, every 2 years.

Little research has been published regarding the formal evaluation of culture change initiatives in the nursing home. This study used an adapted version of the Quality Health Outcomes model (Mitchell, Ferketich & Jennings, 1998). This model builds on Donabedian’s (1966) Structure/Process/Outcomes model to create one that is non-linear, dynamic, and explicitly shows the interactions between structure, process, outcome, and client factors. This multifactor influence is reflected in the Wellspring Program’s philosophy of simultaneously altering several aspects of care and care delivery.

Within the context of culture change, the organizational culture—or those patterns of basic assumptions that have been invented, discovered, or developed in learning to cope with the problems of external adaptation and internal integration (Schein, 1987)—is not well understood. As hands-on caregivers and those who plan and craft the care of older adults, nurses are an essential element of culture change. Further, change recipients, or those who implement and experience the organizational changes they did not initiate, are often cast as resistant without further probing (Bartunek, Rousseau, Rudolph, & DePalma, 2006; Kuhn & Corman, 2003; Oreg, 2003). The purpose of this study was to examine licensed nurses’ perceptions of organizational culture and work environment and those factors influencing the implementation of culture change while participating in the Wellspring Program.

Method

Design

This study used surveys and interviews in a sequential, mixed-methods design. Analyses of quantitative and qualitative data were completed at the same time and weighted equally. Quantitative survey data were used to describe licensed nurses’ perceptions of their nursing home’s organizational culture and work environment, while qualitative interview data detailed those aspects of organizational culture and work environment that influenced the adoption of the Wellspring Program and allowed deeper exploration of the perspectives, values, and beliefs of the licensed nurses.

Settings and Sample

Wellspring nursing homes are organized into Alliances that enter the Wellspring Program at the same time, are exposed to the same amount of training and evaluation, and are geographically proximal. The researcher contacted administration from all Wellspring-participating facilities in one Alliance and invited participation. Of nine eligible facilities, this study enrolled a convenience sample of the first two that agreed to participate. At the time of data collection, both facilities had completed the initial implementation and training of all staff regarding the Wellspring Program and had been engaged in the program for 2.5 years. Table 1 displays the characteristics of each participating facility.

Demographic Description of Participating Nursing Homes

Table 1: Demographic Description of Participating Nursing Homes

A licensed nurse (RN or licensed practical nurse [LPN]) was eligible for participation, regardless of primary job description, as long as the primary job involved working in the nursing home for more than 20 hours per pay period (⩾0.25 full-time equivalent). Overall, there were 47 survey respondents, for a total response rate of 57% (Facility 1: 55%, n = 27; Facility 2: 61%, n = 20).

Sixty-six percent of respondents (n = 31) held an RN license, and 34% (n = 16) held an LPN license. Seventy-five percent of respondents (n = 35) reported working full time. Sixty-four percent (n = 30) of respondents listed hands-on resident care as their primary job responsibility, followed by 26% (n = 12) management, 9% (n = 4) administrative, and 2% (n = 1) “other.” A Mann-Whitney U test determined no significant demographic differences between nurse respondents from Facility 1 and Facility 2.

The subset of 13 interviewees represented both sexes and licenses, as well as all shifts, employee statuses, and primary job descriptions. A Mann-Whitney U test determined no significant differences in age, license tenure, or tenure in long-term care between survey respondents and interviewees. A significant difference (p = 0.004) was found in the nurses’ tenure at their respective nursing homes. This was an expected and deliberate finding. Table 2 provides information on the characteristics of the licensed nurse respondents and interviewee subset.

Age and Experience of Non-Interviewees (n = 34) and Interviewees (n = 13)

Table 2: Age and Experience of Non-Interviewees (n = 34) and Interviewees (n = 13)

Data Collection

The researcher systematically visited each floor and shift in both facilities, ensuring all eligible nurses had the opportunity to complete a survey packet. Those nurses with longer tenure working in their respective facility were then sought for interviews to ensure maximum exposure to the Wellspring Program and its implementation. All interviewees had been employed at their nursing home for at least the entirety of the Wellspring Program. Interviews were recorded outside work time in a location that ensured confidentiality. Throughout data collection, the researcher maintained field notes regarding each nursing home and its employees.

Instruments

Organizational culture was measured using the Organizational Culture Inventory® (OCI, Cooke & Lafferty, 1986), a 120-item instrument composed of 12 behavioral subscales. Participant responses range from 1 (not at all) to 5 (to a very great extent). The OCI categorizes organizational cultures into three cultural types (i.e., Constructive, Passive/Defensive, Aggressive/Defensive), each composed of four subscales. In this study, Cronbach’s alpha coefficients for the overall instrument, subscales, and cultural styles ranged from 0.723 to 0.953. Widespread use and psychometric robustness of the OCI make it an attractive option for researchers investigating organizational culture (Ashkanasy, Broadfoot, & Falkus, 2000).

Work environment during culture change was measured using the Work Environment Scale (WES, Moos & Insel, 1974). The WES is a 90-question, true/false instrument with 10 subscales. In this study, Cronbach’s alpha coefficients ranged from 0.744 to 0.846. One study has been found that used the WES in the nursing home setting (Karsh, Booske, & Sainfort, 2005). It has been reported that the WES is valid and reliable across a range of health care settings (Moos, 1994a). Construct, concurrent, and predictive validities of the WES have been established in multiple studies (Moos, 1994a; Staten, Mangalindan, Saylor, & Stuenkel, 2003).

Licensed nurses’ descriptions of the aspects of organizational culture and work environment that influenced the adoption of the Wellspring Program were obtained by interviews. The semi-structured interview guide was developed by the researcher based on theory and research regarding organizational culture and culture change. Questions were designed using a qualitative descriptive framework involving no variable manipulation or hypothesis testing (Sandelowski, 2000).

Data Analyses

All quantitative data were analyzed using SPSS version 15.0.1 using no impution for missing data. As this was an exploratory study, a significance value of p < 0.10 was used. OCI subscale medians were calculated for the entire sample and then were compared to a Human Synergistics® normative sample of 5,685 respondents (Human Synergistics International, 2003). Overall cultural styles were computed by transforming the median raw score for each cultural norm to a percentile score, based on OCI normative sample data. Then, the percentiles of the four cultural norms in each cultural style were averaged. The largest mean represented the prevailing cultural style.

WES subscales were calculated by finding the mean scores of all respondents. Subscales were compared against Moos’ (1994b) normative sample of 4,879 employees working in the health care field.

Qualitative data were analyzed using content analysis, a method most often used to describe a phenomenon when existing literature on that phenomenon is limited (Hsieh & Shannon, 2005). Analysis began during each interview, with the researcher keeping memos to identify initial impressions, to note repetition and issues needing follow up, and to bracket personal opinions. Following each interview, the researcher listened to the audiorecordings multiple times, concurrent with scheduling and conducting additional interviews. The point of data saturation had been attained after 13 interviews, as determined by both ongoing review of the audiorecordings and the conclusions of a qualitative peer review group.

Consistent with content analysis methodology, transcripts were entered into Atlas.ti version 5 software, and a holistic reading of each interview was performed to create a sense of the gestalt and immerse the researcher in the data. First, summary comments were made to note initial thoughts and impressions. Second, interviews were read line by line, and codes were established and defined. Additional categories reflective of more than one key concept or code were created. Codes were grouped by relation to each other, resulting in the formation of three categories. A qualitative peer review group was used to examine the analyses for consistency, objectivity, and confirmability, as well as to monitor the audit trail of analytical process (Guba & Lincoln, 1981).

Quantitative Findings

Organizational Culture

OCI data were not normally distributed. Using the standard OCI scoring procedure, medians were calculated for each subscale, and runs testing determined that only the median of the Conventional subscale was significantly different from the normative median (p = 0.049). A high Conventional score characterizes an organizational culture that emphasizes conformity, avoiding confrontation, and following established policies. Innovation and adaptation to change are difficult in a Conventional organizational culture (Human Synergistics International, 2003). Table 3 shows all OCI subscale results.

Organizational Culture Inventory Subscale Descriptives for All Respondents (N = 47)

Table 3: Organizational Culture Inventory Subscale Descriptives for All Respondents (N = 47)

Overall cultural styles were then determined by transforming and aggregating subscale median scores. Subscale median scores were then transformed to a percentile value provided in the OCI scoring guide (Human Synergistics International, 2003). The four subscale percentiles comprising each overall cultural style were averaged, with the largest mean determining the prevailing cultural style. The mean of percentile scores for cultural norms comprising the Constructive Style (i.e., Achievement, Self-Actualizing, Humanistic-Encouraging, Affiliative) was 49, the mean of percentile scores for cultural norms comprising a Passive/Defensive Style (i.e., Approval, Conventional, Dependent, Avoidance) was 60, and the mean of percentile scores for cultural norms comprising an Aggressive/Defensive Style (i.e., Oppositional, Power, Competitive, Perfectionistic) was 56.5, indicating overall cultural style of Passive/Defensive.

The Passive/Defensive culture is typified by employees interacting with each other but in a manner that does not threaten their individual job security. Members of Passive/Defensive cultures are often pressured to think or behave inconsistently with how they personally think or behave (Human Synergistics International, 2003). This cultural style places a high emphasis on approval from others, especially superiors, and avoids interpersonal conflicts. Rules, procedures, and orders are highly valued. Passive/Defensive cultures are often marked by unresolved conflict, employee turnover, and low employee satisfaction (Human Synergistics International, 2003).

Work Environment

WES data were normally distributed, thus means were calculated for each subscale score. Using a t test, seven subscale means differed significantly from the normative means. Supervisor support, autonomy, and innovation were the only subscales that did not significantly differ from the normative mean. Overall, subscale scores indicated that respondents had a higher-than-average concern for and commitment to their jobs, and that planning, efficiency, and completing tasks were important. Subscale scores also indicated high work demands, time pressure, and a high degree of managerial control using rules and procedures (Moos, 1994b). These results were consistent with the OCI findings of a Passive/Defensive culture with Conventional behaviors. Table 4 details the full WES results.

Work Environment Scale Descriptives for All Respondents and Normative Sample (N = 47)

Table 4: Work Environment Scale Descriptives for All Respondents and Normative Sample (N = 47)

Qualitative Findings

Data were gathered in 13 audiorecorded interviews, ranging in length from 13 to more than 90 minutes. Due to time, cost, and practicality constraints, 10 interviews were completed face to face, and 3 were completed via telephone. The results were organized into three broad categories: Confusion, Conflict, and Commitment, based on coding of interviewee responses.

Confusion

It was immediately apparent that there was much confusion regarding the terms culture change, organizational culture, and Wellspring Program. Initially, only 3 of 13 interviewees understood the terms culture change or organizational culture to be related to the work environment. This is noteworthy, considering that training materials repeatedly identify Wellspring as a “culture change” or “organizational culture change” program (Norton, n.d., p. 1). All interviewees acknowledged that they had heard of Wellspring and/or noted seeing materials about the program around their nursing homes. There was great variety, however, in degree of understanding of the Wellspring Program. One nurse administrator acknowledged this confusion, stating, “That’s been...one of our biggest [challenges]…trying to get the staff to understand exactly what Wellspring is and why we have joined.”

The following are examples of answers given when the researcher asked, “What do the words culture change mean to you in terms of your job?”

  • The people are a wide variety of cultures that you run into, the residents, and you have to acknowledge and respect [them] once you come upon it.
  • Well, when someone says culture to me…like the survey [OCI/WES] wasn’t anything what I thought it was going to be like, to be honest. I thought it was going to be about different ethnicities and that type thing and I didn’t find that on the survey.
  • Culture change, yeah. I mean, well, for instance just over the last few years a lot of nurses and nursing assistants are from Africa or the different islands and things like that, so their culture’s different than mine and they talk different than me so it’s hard for me to understand them and for them to understand me. So, to me culture is different backgrounds, different ethnic origins, that kind of thing.

Several interviewees associated all quality improvement programs with the Wellspring Program. Some interviewees saw the Wellspring Program as a staff education program (how to do things “right,” “better,” or “according to new policy”) or as a means to develop better working relationships among all staff members. Many interviewees thought that the Wellspring Program pertained solely to physical care, without addressing psychosocial care, organizational culture, or leadership. For example:

I mean, other than hearing the word all the time, Wellspring…I would never know that there was any, like, any major thing going on around here or any change other than, hey, we’re gonna do it like this now…instead of doing this, we’re gonna do this, but we’re gonna call it “gentle bathing.” You know?

All interviewees perceived that Wellspring resulted in increased documentation burden, whether or not new documentation was actually part of the program. Many of the interviewees believed increased documentation removed them from their “essential job,” of hands-on resident care. Interviewees seemed to associate paperwork with change over time. One nurse stated:

There’s a lot more forms to fill out; now I don’t know whether that’s specific to Wellspring or specific to this place because this place always has to have a paper trail and a long one. And I don’t know whether that’s just Wellspring but it seems that for every new initiative that comes out there’s a packet of paperwork at least four to five pages thick.

Another nurse stated:

[Less paperwork] would give me more time to really circulate with the residents and see some of their other problems they’re having that sometimes are overlooked because we’re not spending enough individual time with each resident.

In actuality, the Wellspring Program does not require additional documentation (T. Lohuis, personal communication, January 10, 2007). However, many of the interviewees persisted in linking the documentation burden with the Wellspring Program, accounting for negative feelings and beliefs.

Some interviewees, when stating that they were unfamiliar with or did not understand the Wellspring Program, excused their lack of knowledge as an expected artifact of working the evening or night shift, working only on weekends, or working for a supplemental staffing agency. It should be noted that although one interviewee was from a supplemental staffing agency, this nurse had significantly more experience in the participant nursing home than many other respondents. Explaining their lack of understanding of the Wellspring Program, these nurses stated:

  • Ah, yeah, I’ve heard of the Wellspring Program. But, I’m [from an] agency so they don’t tell us. I mean I’m not into the program so I don’t know what it is.
  • I have heard people talk about that but since I’m only here on the weekends I miss a lot that goes on here. I mean I have heard it and I’ve seen flyers about it, but I don’t know a whole lot about it.

On the other hand, some interviewees expressed that there was a breakdown in the consistency of communication to all nursing staff. One RN expressed her frustration and hurt with what she believed was incomplete communication and exclusion of weekends-only staff:

Well, sometimes there is confusion about what the changes are and, again, by working on the weekends, a lot of the upper management is not here, so you can’t go [to] them and ask questions...sometimes you get the feeling when you’re working weekends that you’re kind of forgotten about or whatnot and it’s like you feel like the…I don’t know if you wanna call them the main people, but the people that work Monday through Friday, they’re like, whew, it’s the weekend, let’s just let them flounder the best they can and muddle through and then when Monday comes we’ll pick up the pieces. You know, the weekend crew can just muddle through. What difference does it make? Well, it does make a difference to us.

Conflict

When queried, each interviewee described a typical day at work. Without exception, all interviewees recounted their daily routine in a mechanistic, task-oriented manner. Interviewees also exhibited a clock orientation, outlining their days in terms of what tasks should be done at what times.

A central tenet of the Wellspring Program is the transformation of the nursing home from an institutional, task-oriented setting to a homelike, resident-centered environment. It was not clear how nurses planned to integrate their task-oriented habits into a resident-centered environment or vice versa. One nurse manager further described the conflict between the task orientation of the nurses’ traditional shift work and a resident-centered paradigm:

Yeah, it’s better for the residents but not necessarily better for the nurse because we’re always like task oriented, you know. They [residents] gotta be up, they gotta be in the dining room, they gotta…you know…where are they? I gotta get their meds in [them]…oh, they’re still back in their room,…you know, whereas, it’s better for the residents and if you have the time to chase [them] around or look for [them] then that’s OK. But it would probably be much easier for nurses, you know, if everybody was on the same routine or schedule, but that’s unrealistic; I mean, this is their [residents’] home.

Other interviewees who worked an “off shift” felt excluded because the training and meetings for Wellspring Program activities were held at times that conflicted with their work schedules. For example:

They invite everyone. No one is turned away, they invite everyone…. The last general meeting that we had with [Administrator’s name]…they was [sic] trying to recruit more night participants. And they said the training would be 2 days. Nights does not…night shift does not compute with days. If you want me to actually go somewhere and sit down and listen to someone for 2 days, when 10 o’clock comes my eyes tell me goodnight, you know. That’s it. I will not…I don’t care if I slept the night before, my eyes tell me goodnight. When 6 p.m. comes or when it gets close to 6 p.m. my body starts doing the automatic shutdown again. You know, I need to go to bed because I trained my body…my body has trained me to do this and I can’t see going somewhere and goin’ to sleep, so it would be difficult to go to training. You know, if they had it at night that would be something different. I could definitely go…. I’m so sorry that I cannot participate in it because I would love to give [sic] inservice at night. That would be one of the things that I would be doing if I was involved in Wellspring. I’d go from unit to unit and tell them, okay, this is what I learned this week, okay.

It was apparent that nurses believed that working the off shifts, weekend shifts, or for supplemental staffing agencies was a significant factor that inhibited their participation in implementation of the Wellspring Program.

Commitment

Overall, most interviewees reported positive feelings toward their jobs, their peers, and the residents. Almost all interviewees conveyed strong dedication, some indicating a “personal mission” or “passion” to providing high-quality care. Many interviewees took pride in providing “the best care at all times.” Often, interviewees used phrases like “satisfaction,” “focus on the resident,” and “resident preference.” For many interviewees, it was clear that their jobs were a personal dedication. This nurse’s comments were consistent with creating a resident-focused environment, a core principle of the Wellspring Program:

That’s the great thing about this place, everything is patient oriented, you know. I mean the incontinence program, that’s not for me, that’s for them, and…but, you know, I benefit, too, because I learn their schedules and what’s going on and if anything changes I know there’s a problem. Yeah, I mean, it’s great.

Echoing these sentiments, one manager stated:

The focus is about quality care…the human that I am, I would not want to work in a facility where I wouldn’t trust my family member and I’ve never had that doubt and, you know, my mom was sick and dying 5 years ago and, you know, I was seriously thinking about putting her there. And I don’t think I could work in a place if I don’t think I could put my mother or father there.

Discussion

Confusion

Despite being involved in the Wellspring Program for 2.5 years at the time of data collection, participants still relayed significant levels of confusion. Unlike many well-known culture change programs, the Wellspring Program is not based on tangible changes to the physical plant. This may account for some of the confusion. It is possible, since the Wellspring Program was a work in progress, that nurses were unclear about many aspects until the program was implemented more fully.

Bartunek et al. (2006) noted that there is often a considerable gap in understanding of and motivation for organizational change between change initiators (administration) and change recipients (frontline workers). Similarly, Balogun and Johnson (2004) found that knowledge gaps can be considerable within levels of management. Findings from the current study were consistent with the findings of these studies. In the current study, nurse administrators spoke at length about the details and planning for the Wellspring Program and how it would benefit their nursing home. Managers reported intermediate levels of confusion, often grasping the core elements of the Wellspring Program, but voicing bewilderment about how to communicate changes to staff who provided hands-on care. The most confusion was noted from those nurses who provided hands-on care. This suggests that all nurses—bedside care providers, management, and administration—need to be given adequate time to learn, negotiate, and integrate changes. Minimally, all licensed nurses need to know the reasons for participation and the expectations for resident care to achieve positive, sustainable change.

Conflict

Respondents characterized their organizational culture as dominated by rules and respect for conformity, but the Wellspring Program espouses individualized, resident-directed care. It appeared that the existing organizational culture was often at odds with Wellspring values, indicating that the nurses were struggling to integrate conflicting concepts. Quadagno (1999) defined role conflict as “occur[ing] when the demands of two or more roles held by a person are incompatible, and the demands cannot be simultaneously met” (p. 407). One example of role conflict mentioned by interviewees was the integration of resident preferences with task completion in a timely manner and within an intensely regulated environment.

Nursing work in the nursing home is typically very task oriented, formulaic, and designed to accommodate the demands of the institution, rather than the preferences of the resident. Nurse participants in the current study repeatedly voiced anguish over activities related to increased documentation and tasks that removed them from their “essential job” of hands-on, resident-centered care. Nurses appeared to have little insight into how best to integrate necessary nursing tasks with resident preferences. Further, the conflicts between the contractual and legal requirements of nursing care and the behaviors encouraged by culture change exacerbated the potential for role conflict.

Esposito (1998) found that realigning the work environment to a patient-focused model of care further contributed to task orientation, as nurses struggled to delegate many hands-on tasks to assistive personnel. These findings were reflected by the task-oriented, rules-driven Passive/Defensive culture in the current study. Kleinman (2004) suggested that management and administration should address the potential for and nature of role conflicts that nurses experience. This forethought may be a critical piece to negotiating the integration of institutionalized, task orientation with homelike, resident-centered orientation.

Commitment

Despite some frustrations, nurses showed evidence of dedication and commitment to their jobs, to each other, and to the residents. Scalzi, Evans, Barstow, and Hostvedt (2006) found that a critical mass of “change champions” who share common goals and values was critical to committed organizational culture change. Their study also found that a management style congruent with the underlying culture change values, that is respectful of others, and that values person-centered care and quality of work life enabled successful culture change. While participants in the current study shared frustrations, there was a strong sense that they were committed to creating an environment that was in the best interests of the residents. It is suggested that administration build on the strong, underlying job commitment of nurses when planning culture change.

Limitations

This study had several limitations. Very little is known about the facilities in the Wellspring Alliance that did not participate. The quantitative portion of this study was also based on a convenience sample, limiting generalizability of findings. Moreover, the interviewee sample was purposively selected based on length of employment in each nursing home, potentially neglecting important findings from those with shorter tenure.

Further, little is known about the nature and intensity of Wellspring introduction into each facility more than the composition and training of each facility’s CRT was consistent with Wellspring standards. This presents limited ability to critique the actual implementation process and the ability to contrast it with nurses’ resultant perceptions of culture change.

To increase the pool of potential respondents, licensed nurses from two nursing homes were invited to participate in this study. Ostensibly, it could be argued that each nursing home yielded a different organizational culture, thereby also affecting the perceptions and thoughts of nurse respondents. While it was true that each nursing home had unique issues, the overall identified themes of confusion, conflict, and commitment held strong across facilities.

Conclusion and Implications

There is concern that culture change will become a meaningless buzzword instead of a profound shift in the implementation of long-term care (Angelelli & Higbie, 2005). Research that determines whether culture change is representative of its espoused values is critical to ensure an honest shift away from institutionalized care. Further, the conceptualization and clarification of culture change will help determine a realistic time line for its implementation. It is disingenuous to evaluate large-scale organizational change, such as the Wellspring Program, before changes have been implemented at a sufficient level.

Results from the current study can inform policy and statement of work initiatives by clarifying the role of licensed nurses in creating a person-centered environment across the health care continuum. It is suggested that quality improvement organizations research more thoroughly nurses’ roles in person-centered care by funding demonstration projects of sustainable culture change models that minimize confusion and conflict and reward commitment, thereby enhancing both nurse and resident satisfaction.

This study adds to a slim body of research regarding licensed nurses and culture change and provides insight into why nurses are often viewed as barriers to change. What is perceived by administration as “resistance” may actually be a struggle to make sense of changes or to reconcile conflicts faced when integrating concepts contrary to the existing organizational culture. “Resistance to change” may be best addressed by improved communication and providing necessary resources for licensed nurses to create and integrate an environment that is conducive to the goals of culture change. Additionally, acknowledging and anticipating the potential for role conflict during times of change may be critical to the successful adoption of culture change.

These findings revealed that, despite confusion and conflicts, licensed nurses were committed to their jobs, each other, and the residents. Participants exuded dedication that suggests resistance to change was not their motive, but perhaps a surface manifestation of confusion and conflict. Based on these findings, it is important to secure nurses’ support and participation from the beginning of change implementation. Clear communication of goals and expectations, as well as careful and explicit attention to the implementation process, are imperatives for successful culture change.

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Demographic Description of Participating Nursing Homes

VariableFacility 1Facility 2
Number of beds>150125 to 150
Tenure of administrator<1 year>5 years
Tenure and education of Director of Nursing<2 years, bachelor of science in nursing degree<3 years, master of science in nursing degree
RN/LPN staffing levelsSlightly above state averageSlightly below state average
Supplemental staffingInternal: Flexible poolExternal: Agency
Medicare certifiedYesYes
Medicaid certifiedYes, only after private pay terminatesYes, accounts for high percentage of residents

Age and Experience of Non-Interviewees (n = 34) and Interviewees (n = 13)

Non-IntervieweesInterviewees
VariableRangeMedianInterquartile RangeRangeMedianInterquartile RangepValue
Age (years)29 to 634713.534 to 634714.50.549
Tenure of nursing license (years)1 to 441516.810 to 441913.50.289
Tenure in long-term care (years)1 to 2596.53 to 16108.50.358
Tenure at facility (years)1 to 2557.33 to 1478.00.004*

Organizational Culture Inventory Subscale Descriptives for All Respondents (N = 47)

Culture TypeSubscaleRangeMedianInterquartile RangeNormative MedianpValue
Constructive styleAchievement18 to 50389.0370.889
Self-Actualizing16 to 483210.5340.127
Humanistic17 to 504014.5360.241
Affiliative12 to 504110.8390.575
Passive/Defensive styleApproval13 to 462812.8270.777
Conventional16 to 473113.0280.049*
Dependent18 to 453012.5301.000
Avoidance10 to 492313.0200.172
Aggressive/Defensive styleOppositional12 to 44229.0221.000
Power13 to 492310.8250.516
Competitive10 to 482112.0220.576
Perfectionistic16 to 483211.8290.947

Work Environment Scale Descriptives for All Respondents and Normative Sample (N = 47)

SubscaleRangeMean (SD)Normative Mean (SD)pValue
Involvement3 to 96.4 (2.0)5.4 (2.3)0.001*
Peer Cohesion1 to 95.7 (2.0)5.2 (2.0)0.085*
Supervisor Support0 to 95.4 (2.3)4.8 (2.2)0.116
Autonomy3 to 95.6 (1.7)5.2 (2.0)0.161
Task Orientation3 to 96.8 (1.4)5.7 (2.2)0.000*
Work Pressure0 to 96.5 (2.3)5.7 (2.0)0.019*
Clarity3 to 86.1 (1.5)4.5 (2.0)0.000*
Managerial Control2 to 97.1 (1.8)5.6 (1.9)0.000*
Innovation0 to 94.6 (2.7)3.9 (2.3)0.106
Physical Comfort1 to 95.8 (2.0)3.8 (2.2)0.000*
Authors

Dr. Bellot is Assistant Professor, Thomas Jefferson University, Jefferson School of Nursing, Philadelphia, Pennsylvania.

The author has disclosed no potential conflicts of interest, financial or otherwise. This work was supported with funding from the Frank Morgan Jones Fund and the John A. Hartford Building Academic Geriatric Nursing Capacity program. The author acknowledges the contributions of the Wellspring Program and the administration and staff of Facilities 1 and 2, and thanks Drs. Lois Evans, Neville Strumpf, and Terese Richmond for their invaluable guidance, support, and expertise.

Address correspondence to Jennifer Bellot, PhD, RN, MHSA, Assistant Professor, Thomas Jefferson University, Jefferson School of Nursing, 901 Walnut Street, Suite 813, Philadelphia, PA 19107; e-mail: Jennifer.bellot@jefferson.edu.

Received: April 21, 2011
Accepted: January 27, 2012
Posted Online: September 17, 2012

10.3928/19404921-20120906-02

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