Culture change in long-term care is committed to transforming traditional nursing homes from impersonal health care institutions into genuine person-centered homes where residents' choice, dignity, respect, self-determination, and purposeful living are valued, and staff members' voices are solicited and respected (The Pioneer Network, 2018). In the United States, culture change began as a grassroots movement in nursing homes in the 1990s, and it has become a nationwide and global campaign to promote person-centered values and practices across all long-term care areas (Koren, 2010). A number of culture change models have been widely implemented in U.S. nursing homes, including the Eden Alternative, the Green House Project, Wellspring, and the Household Model (Hill, Kolanowski, Milone-Nuzzo, & Yevchak, 2011; Shier, Khodyakov, Cohen, Zimmerman, & Saliba, 2014). Although culture change practices are implemented differently, the commonly acknowledged principles embrace resident-directed care, home-like atmosphere, close relationships, staff empowerment, collaborative decision making, and quality improvement processes (Koren, 2010).
The ultimate goal of culture change is to improve resident quality of life (QOL) (Koren, 2010; Rahman & Schnelle, 2008). QOL is an individual's multidimensional appraisal of important aspects of life (Kane, 2003; Ormel, Lindenberg, Steverink, & Verbrugge, 1999), and is an essential quality measure for nursing home care (Castle & Ferguson, 2010). A body of literature studying the effects of culture change practices on a variety of outcomes has been growing, and some literature reviews have synthesized empirical findings about culture change effects (Hill et al., 2011; Shier et al., 2014). These reviews mainly focused on quality of care measures such as clinical outcomes (e.g., morbidity, mortality, adverse medical events) and organizational outcomes (e.g., hospitalization, medical cost) (Hill et al., 2011; Shier et al., 2014). No synthesis of the literature has specifically focused on QOL as an outcome of culture change practices. One of the challenges in synthesizing the evidence for QOL is the variation in definitions and measures of QOL. Despite this challenge, QOL is an important primary outcome. Unlike quality of care measures, which only have clinical focus and are from staff reports or other administrative records, QOL conceptually corresponds to the principles of culture change as it captures an individual's physical and psychosocial well-being and is directly derived from residents' voices through a survey or an interview (Castle & Ferguson, 2010).
Although culture change has strong face validity in improving QOL intuitively (Koren, 2010), a synthesis of literature is warranted to inform evidence-based policy and practice for promoting culture change practices. The current integrative review aimed to (a) examine how QOL was measured in studies examining the effects of culture change practices; and (b) analyze the current evidence on the effects of culture change practices on QOL for residents in U.S. nursing homes.
Given that both culture change practices and QOL are multidimensional constructs and are not consistently defined, a conceptual framework was developed to specify the operational definitions of the two constructs and to guide the selection and synthesis of studies (Figure 1). The conceptual framework is based on the Nursing Home Integrated Model for Producing and Assessing Cultural Transformation (the Nursing Home Integrated Model) (Hartmann et al., 2013) and the Social Production Function theory (Ormel et al., 1999; Ormel, Lindenberg, Steverink, & Vonkorff, 1997). The Nursing Home Integrated Model categorizes culture change practices into three domains including care practices, workplace practices, and the environment of care (Hartmann et al., 2013). Culture change in care practices involves prioritizing resident preferences and autonomy regarding daily living, privacy, and comfort, providing meaningful activities, and promoting resident engagement and resident-centered clinical care where clinical protocols are individualized and shared decision making is promoted. Culture change in workplace practices involves decentralization of authority and staff empowerment (e.g., granting direct care staff decision-making authority regarding routines and care delivery); consistent staff assignment; interdisciplinary collaboration; and effective, respectful, and nonhierarchical communication among leadership, management, staff, and residents. Culture change in environment involves modifying the physical environment to create a home-like atmosphere, promoting independence and privacy and fostering spontaneity and engagement.
Framework for evaluating the relationship between nursing home culture change and residents' quality of life (QOL).
The Social Production Function theory provides a heuristic framework for understanding QOL (Gerritsen, Steverink, Ooms, & Ribbe, 2004; Steverink, Lindenberg, & Ormel, 1998). Integrating theories from psychology and economics, the Social Production Function theory proposes a multidimensional and hierarchical structure of QOL (Ormel et al., 1999; Ormel et al., 1997). Like people of other ages in general, older adults living in nursing homes maintain QOL through realizing two universal goals— physical well-being and psychosocial well-being, which are achieved by realizing lower-level instrumental goals. Physical well-being is attained by fulfilling two instrumental goals including comfort and stimulation. Comfort refers to the satisfaction of basic physical needs (e.g., food, rest, warmth) and the absence of pain, fatigue, and other health complaints. Stimulation refers to the pleasant range of activation (physically and mentally) and the absence of boredom. Psychosocial well-being is attained by fulfilling three instrumental goals including status, behavioral confirmation, and affection, which refer to whether a person is respected, accepted, and loved by self or others, respectively. Accordingly, QOL can be measured at three levels: overall perception of life, two universal goals (physical and psychosocial well-being), and five instrumental goals (comfort, stimulation, status, behavioral confirmation, and affection).
The Social Production Function theory provides a theoretic basis for the potential effects of culture change practices on QOL. The theory assumes that a person strives to achieve instrumental goals for attaining optimal QOL through optimizing physical and psychosocial resources he/she possesses, and a deficiency of one type of resources will be substituted with other types of resources (Ormel et al., 1999; Ormel et al., 1997). Older adults residing in nursing homes are faced with considerable changes in physical and psychosocial resources, such as the decline in physical and cognitive function, a transition to a new living environment, interruption of previous social network, and changes in daily life routines. Culture change practices that are committed to providing a home-like environment, normalizing resident daily life routines, focusing on resident needs, and nurturing caring relationships will function to mitigate residents' loss of physical and psychosocial resources they used to possess.
The current review included peer-reviewed and gray literature published in English from January 1997 to June 2019. Four databases, including Ovid MEDLINE, CINAHL, PsycInfo, and the Web of Science, were searched using keywords individually and in combination: culture change, resident-centered care, person-centered care, the Eden Alternative, the Green House, the Pioneer Network, Wellspring, the household model, or staff empowerment. The search was limited to nursing homes, skilled nursing facilities, residential facilities, or homes for the aged. Gray literature was searched in the Web of Science Conference Proceedings Citation Index, ProQuest Dissertations & Theses, and the New York Academy of Medicine. In addition, reference lists of selected articles were reviewed to identify additional relevant articles.
Titles and abstracts were screened to select articles that examined the effects of culture change practices on QOL. Culture change practices are operationalized as any domain or subdomain classified by the Nursing Home Integrated Model (Hartmann et al., 2013). QOL is measured by self-reported instruments and at any of the three levels congruent with the Social Production Function theory (Ormel et al., 1997). In addition, further inclusion criteria were: (a) studies conducted in U.S. nursing homes that provide on-site 24-hour skilled nursing care; and (b) quantitative research designs with a concurrent comparison group or self-comparison. Only studies conducted in nursing homes in the United States were selected to eliminate the influence of health system variations across countries. Following the initial screening of the titles and abstracts, full texts of selected articles were reviewed to determine eligibility for final inclusion.
Data Extraction and Synthesis
The first author (Y.D.) extracted the following information from eligible studies: study design, setting, participants, culture change practices, QOL measures, and results. Given the heterogeneity of the studies' theoretical underpinnings, designs, and outcome measures, a narrative analysis was conducted and organized according to the categories of QOL measures.
Assessment of Study Quality
The first author evaluated the quality of each study using the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project (1998). The second author (C.A.M.) reviewed the results in an iterative manner until consensus was reached. The Quality Assessment Tool for Quantitative Studies has well-established validity for randomized and non-randomized studies and is particularly appropriate for evaluating population-based intervention studies or public health programs (Thomas, Ciliska, Dobbins, & Micucci, 2004). The tool assesses domains of selection bias, study design, confounders, blinding, data collection, and withdrawals. Each domain was rated strong, moderate, or weak, and a global rating of the overall quality was determined based on ratings of each domain. Studies having no weak rating, one weak rating/unreported domain, or two or more weak ratings/unreported domains were rated strong, moderate, and weak, respectively, in the global rating.
Of 869 publications identified, 11 studies (six peer-reviewed articles, four dissertations, and one report from the Commonwealth Fund) were eligible to be included for the qualitative synthesis. The flow diagram in Figure 2 illustrates the search process as suggested by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Group (Moher, Liberati, Tetzlaff, & Altman, 2009). As demonstrated in Table 1, the studies used four types of research designs including a quasi-experimental design with comparison groups and repeated outcome measures (n = 6), a single group pre/posttest (n = 2), a longitudinal retrospective cohort design (n = 1), and a cross-sectional design (n = 2). Studies involving repeated outcome measures had different follow-up durations ranging from 6 months to 5 years. The sample sizes ranged from 25 residents in a single nursing home to thousands of residents in a national sample of nursing homes. All studies conducted face-to-face interviews of residents to collect QOL data.
PRISMA flow diagram of literature search (Moher et al., 2009).
Note. QOL = quality of life.
Basic Characteristics of 11 Eligible Studies
Study Quality Appraisal
Table 2 summarizes the quality appraisal of each study. Th e global rating of methodological quality was moderate for five (45.5%) studies and weak for six (54.5%) studies. Moderate and weak ratings were due to selection bias, a non-randomized study design, inadequate control of confounders and/or withdrawals, and a lack of blinding. Three studies were rated weak in the domain of selection bias, given a consent rate <60%. In the domain of study design, seven studies applying a quasi-experimental design with comparison groups or a retrospective cohort design were rated moderate, whereas four studies using a cross-sectional design and a single group pre/posttest design were rated weak. As two groups of confounders were expected to bias the test of culture change effects on QOL, including structural and organizational characteristics of nursing homes and sociodemographic and health-related characteristics of residents (Shippee, Henning-Smith, Kane, & Lewis, 2015; Xu, Kane, & Shamliyan, 2013), studies addressing none, either, or both types of confounders were rated weak (n = 5), moderate (n = 4), and strong (n = 2), respectively, in the domain of confounders. Studies having withdrawals <20% were considered strong in the domain of withdrawals (n = 3). Studies were rated moderate if they had >20% withdrawals yet had conducted sensitivity analysis to eliminate the influence of missing data (n = 2). All quasi-experimental studies (n = 8) were rated weak in the domain of blinding due to a disclosure of group assignment to participants. Nine studies using validated outcome measure instruments were rated strong in the domain of data collection.
Quality Evaluation of 11 Eligible Studies Using the Quality Assessment Tool for Quantitative Studies
The Implementation of Culture Change Practices
Among the quasi-experimental studies, culture change practices were implemented either through adopting an internally developed model (Burack, Reinhardt, & Weiner, 2012; Grant, 2008; Jones, 2010) or a well-defined culture change model, such as the Green House Model (Kane, Lum, Cutler, Degenholtz, & Yu, 2007), the Eden Alternative (Bergman-Evans, 2004; Parsons, 2004; Ruckdeschel & Haitsma, 2001), and the Small House Model (Molony, Evans, Jeon, Rabig, & Straka, 2011). All three observational studies did not involve a specific culture change model and instead measured culture change practices using a dichotomous measure (i.e., culture-change adopters vs non-adopters) (Aguilar, 2011), a staging tool (i.e., no implementation, partial implementation, full implementation) (Poey et al., 2017), and a comprehensive assessment tool (i.e., the Artifacts of Culture Change Instrument) (Murray, 2010).
Table 3 presents culture change domains and subdomains addressed by eight quasi-experimental studies based on the Nursing Home Integrated Model (Hartmann et al., 2013). It was difficult to specify culture change practices for the remaining three observational studies due to lack of information regarding culture change implementation. Six quasi-experimental studies addressed more than one culture change domain, and five studies addressed all three culture change domains (Bergman-Evans, 2004; Burack et al., 2012; Grant, 2008; Kane et al., 2007; Parsons, 2004). Two studies only addressed one domain of culture change. For example, Ruckdeschel and Haitsma (2001) only adopted one principle of the Eden Alternative model that is associated with including pets, plants, and children as the axis of daily life; in Jones' (2010) study, the intervention only involved fulfilling residents' preferences and promoting autonomy.
Domains and Subdomains of Culture Change Practices in Quasi-Experimental Studies (n= 8)
Five studies involving the domain of workplace practices addressed three essential subdomains, including interdisciplinary collaboration; authority decentralization and staff empowerment; and effective, respectful, and nonhierarchical communication; and two studies addressed consistent staff assignment along with the three subdomains (Bergman-Evans, 2004; Burack et al., 2012; Grant, 2008; Kane et al., 2007; Parsons, 2004). Honoring resident preferences and autonomy and providing meaningful activities were addressed most frequently in care practices (seven studies), whereas resident-centered clinical care (e.g., residents/family involved in care planning) was only mentioned in two studies (Burack et al., 2012; Grant, 2008). Although most studies focused on creating a home-like environment (e.g., home-like and personalized decorations), some studies implemented more thorough transformation, such as using a household model to promote independence and privacy, or introducing plants, animals, and child day care to foster spontaneity and engagement.
Measures of QOL
Studies measured QOL differently, and they used more than one QOL measure. Table 4 summarizes QOL measures that correspond to QOL domains defined by the Social Production Function theory. Studies addressing overall perception of life measured satisfaction with life or care and emotional well-being. Regarding two instrumental goals for achieving physical well-being, stimulation was measured with boredom and comfort was measured with physical environment comfort, food enjoyment, and security. Psychosocial well-being comprising status, behavioral confirmation, and affection was measured with diverse indicators. Studies measuring status used indicators such as helplessness, choice/autonomy, dignity/self-esteem, privacy, and individuality/personal identity. Behavioral confirmation was measured with indicators such as functional status, self-rated health, meaningful activities, and spiritual well-being. Affection was measured with social support, loneliness, relationships, and feeling of belonging.
Summary of Quality of Life (QOL) Measures and the Effects of Culture Change (CC) Practices on QOL by Domains/Subdomains of QOL Measures
Multiple instruments were used to measure QOL, and they varied in comprehensiveness and psychometric properties. The most comprehensive QOL instrument was the Quality of Life Scale for Nursing Home Residents developed by Kane (2003), which was used in three studies (Jones, 2010; Kane et al., 2007; Murray, 2010). Two other multi-domain QOL instruments were used—the Quality of Life in Dementia Scale (Ruckdeschel & Haitsma, 2001) and the Dementia Quality of Life Tool (Parsons, 2004). Other instruments were also applied to measure discrete QOL–related constructs, including the Duncan Choice Index (Burack et al., 2012), Geriatric Depression Scale (Molony et al., 2011; Parsons, 2004), Experience of Home Scale (Molony et al., 2011), UCLA Loneliness Scale (Bergman-Evans, 2004; Parsons, 2004; Ruckdeschel & Haitsma, 2001), Norbeck Social Support Questionnaire (Molony et al., 2011), Lubben Social Network Scale (Parsons, 2004), and Pearlin and Schooler's Mastery Scale (Ruckdeschel & Haitsma, 2001). Two studies used a single item to measure boredom or helplessness (Bergman-Evans, 2004; Ruckdeschel & Haitsma, 2001).
Effects of Culture Change Practices on QOL
Table 4 summarizes the study findings regarding the effects of culture change practices on QOL, illustrating the number of studies examining the relationship between culture change practices and each QOL measure for all studies (N = 11) and for those that were rated as moderate quality (n = 5). The number of studies where the relationship between culture change practices and the QOL measure was statistically significant are also shown. Overall, there was a positive trend indicating culture change practices in nursing homes have a positive effect on resident QOL. Non-significant findings were most oft en from studies rated weak in quality or studies with a small sample size (e.g., <30 participants). For the five moderate quality studies, the QOL measures including satisfaction with care and satisfaction with life associated with the domain of overall perception of life (Kane et al., 2007; Poey et al., 2017) and autonomy associated with the domain of psychosocial well-being (Burack et al., 2012; Grant, 2008; Kane et al., 2007) demonstrated the strongest evidence for the effects of culture change practices on QOL.
Guided by the conceptual framework, 11 studies were included in this review. QOL measures varied across studies, ranging from overall measures to domain-specific measures. Th is review categorized QOL measures into overall perception of life and specific instrumental goals for achieving physical and psychosocial well-being. Culture change practices varied in scope and content among reviewed studies. Overall, the effects of culture change practices on all QOL measures had a positive trend. Although inconsistent evidence existed for most QOL measures, relatively consistent evidence was found to support positive effects on satisfaction with care, satisfaction with life, and autonomy.
It was difficult to compare the effects of different culture change models and link the effective components of culture change to certain QOL measures because of variations in culture change implementation. In fact, culture change was initially proposed as a care philosophy rather than a uniform care model (Koren, 2010). Although the current review categorized culture change practices into three major domains and a number of subdomains based on the Nursing Home Integrated Model (Hartmann et al., 2013), a lack of detailed description and fidelity measures of the interventions made it difficult to determine how a given culture change practice was implemented by each study. For instance, Bergman-Evans (2004) and Parsons (2004) only provided general principles of the Eden Alternative model without giving sufficient details regarding how and to what extent each principle was operationalized. In addition, even the same culture change practices may not be implemented in the same way and to the same level. For instance, in the Green House Model, staff empowerment was realized by building a self-managed nursing assistant team with guides for applying decision-making authority in directing care activities (Kane et al., 2007), whereas in Eden Alternative homes, staff empowerment was only approached as an organizational philosophy (Bergman-Evans, 2004; Parsons, 2004).
The amorphous and multifaceted nature of culture change necessitates a comprehensive and domain-specific assessment of culture change practices to ensure the integrity of culture change implementation within or across studies, thereby enabling a deep investigation of its effects on QOL (Campbell et al., 2000; Hawe, Shiell, & Riley, 2004). Only one study (Murray, 2010) measured multiple culture change domains using the Artifacts of Culture Change Instrument (Bowman & Schoeneman, 2006). In fact, a number of domain-specific measures of culture change practices have emerged as examined in a recent literature review (Sturdevant, Mueller, & Buckwalter, 2018). Yet, these tools have been rarely used in intervention studies to evaluate the fidelity of culture change interventions. In addition, repeated measurements are crucial in such studies given culture change is never a one-time and static effort but an evolving and continuous process. However, none of the studies measured culture change implementation repeatedly, which impeded further examining the sustainability of culture change benefits.
Grounding the literature review in the Social Production Function theory facilitated a systematic analysis of diverse QOL measures through categorizing these measures into overall perception of life and specific instrumental goals for achieving physical well-being and psychosocial well-being. Culture change practices were positively associated with some measures of overall perception of life such as satisfaction with care and satisfaction with life. This association reflects the broad-based and comprehensive nature of culture change that seeks to not only transform overt facets of care practices, workplace practices, and the physical environment, but seeks to promote a revolutionary change in organizational climate and care philosophy (Zimmerman, Shier, & Saliba, 2014). Favorable evidence for overall perception of life was particularly observed in studies implementing comprehensive culture change models such as the Green House Model (Kane et al., 2007; Poey et al., 2017). Poey et al. (2017) also indicated that overall satisfaction with care and life were relatively more evident in nursing homes fully implementing culture change.
Culture change practices were also positively related to autonomy, which was generally referred to as free choices for daily routine activities and was one of the indicators measuring the perception of status concerning whether a person is respected by others or self (Ormel et al., 1999; Ormel et al., 1997). According to other psychological theories such as self-determination theory, autonomy—the extent to which a person's acts are self-determined instead of being compelled—is one of the basic psychological needs for human beings (Deci & Ryan, 2012). Empirical studies consistently suggested a positive relationship between autonomy and psychosocial well-being for nursing home residents (Andrew & Meeks, 2018; Chang, 2018; Kloos, Trompetter, Bohlmeijer, & Westerhof, 2019). However, the need for autonomy is prone to be compromised in a nursing home context as a result of functional limitations in residents, rigid work schedules, and a shortage of workforce in a facility (Heid et al., 2016). With the advocacy for person-centered philosophy and the preferences-based model of care, integrating residents' preferences for daily routine activities into care planning and care delivery has become one of the most commonly implemented culture change practices in nursing homes (Miller et al., 2018; Van Haitsma et al., 2019). Although this particular culture change practice is directly related to residents' autonomy, more research is needed to examine whether other culture change practices, such as environment transformation and staff empowerment, may have positive effects on autonomy and other measures of perception of status such as dignity, privacy, and individuality.
The current review observed less favorable evidence to support the effects of culture change practices on other QOL measures that were associated with behavioral confirmation (being accepted by self or others) and affection (being loved by self or others). Satisfying these psychosocial needs to maintain holistic well-being may require a deeper and more sustained change in organizational culture. Although nursing homes tend to start with less laborious and complex culture change practices, such as fulfilling residents' preferences and creating a home-like environment, they may confront challenges to achieve a comprehensive change focusing on a caring and enriched social environment where residents and staff can thrive (Harrison & Frampton, 2017; Sterns, Miller, & Allen, 2010). A comprehensive change calls for organizational and managerial initiatives, such as staff education on person-centered care, and building a coalition of individuals including personnel from different departments as well as residents and family to enhance frontline staff's commitment and knowledge of person-centered care and to promote a broad spectrum of buy-in from all stakeholders (Hartmann et al., 2013). Furthermore, care initiatives such as individualized and meaningful activities and function-focused care are necessary to help residents thrive and continually grow toward their highest potential (Li & Porock, 2014; Morley, Philpot, Gill, & Berg-Weger, 2014; Resnick, Galik, & Boltz, 2013; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011).
Inconsistency of culture change effects on different QOL measures underscored the importance of a comprehensive QOL measure that captures multiple aspects of nursing home life and various psychosocial needs of residents (Jones, 2010; Kane et al., 2007; Murray, 2010; Parsons, 2004; Ruckdeschel & Haitsma, 2001). It is theoretically plausible that culture change practices meet different needs of residents and therefore benefit them in different ways (Steverink et al., 1998). For instance, some residents may gain a sense of purpose from actively taking the responsibility of caring for pets in Eden Alternative homes, whereas others may gain emotional support through developing an interdependent relationship with pets (Bergman-Evans, 2004; Parsons, 2004). Among all reviewed studies, only five studies used a comprehensive QOL measure (Jones, 2010; Kane et al., 2007; Murray, 2010; Parsons, 2004; Ruckdeschel & Haitsma, 2001).
Despite a positive trend regarding the influence of culture change practices, some of the reviewed studies generated non-significant results. Caution is needed when interpreting these non-significant results, as they were likely influenced by insufficient statistical power due to a small sample size. Previous studies indicated that the effect size of facility-level factors, such as culture change practices on QOL, is minimal compared to individual factors, such as physical and cognitive function (Shippee et al., 2015). As such, a large sample is necessary to discern the influence of culture change practices on QOL.
The strength of evidence for the effects of culture change practices on QOL are compromised to some extent by a lack of randomization among the reviewed studies. Potential threats to internal validity may include history threats, maturation/mortality threats, regression threats, and social interaction threats. History threats are common in studies conducted in nursing homes because real-world settings cannot be fully isolated to avoid events outside of the study intervention. In the reviewed studies, changes in organizational structure (Parsons, 2004; Ruckdeschel & Haitsma, 2001) and introductions of other quality improvement projects (Molony et al., 2011) could confound culture change effects. Maturation/mortality threats were another concern because of the natural decline in physical and cognitive function of residents, which may mask the influence of culture change. High attrition was also common because of death or hospitalization. Regression threats primarily arose from self-assignment to study groups (Jones, 2010; Kane et al., 2007), which may introduce some extreme samples and cause the regression to the mean. For example, residents with low satisfaction with current care might opt to move in a culture change home, resulting in a potential to overestimate or underestimate the effects of culture change (Burack et al., 2012; Kane et al., 2007; Molony et al., 2011). Social interaction or intervention contamination are likely to occur in studies conducted in facilities from the same provider given shared administration or geographical proximity between intervention and comparison facilities (Burack et al., 2012; Grant, 2008; Kane et al., 2007; Molony et al., 2011; Parsons, 2004).
Despite a non-randomized research design, an effective control of selection bias and confounders is essential to address the threats to internal validity. Studies rated moderate in quality to some extent addressed the methodological concerns by applying analytic strategies such as propensity score matching (Poey et al., 2017), mixed effects models (Kane et al., 2007; Molony et al., 2011; Poey et al., 2017), and difference in difference analysis (Parsons, 2004). These strategies contributed to building comparable samples of residents in intervention and control groups, despite a lack of randomization.
Strengths and Limitations
A strength of the current review is its grounding in a pre-defined conceptual framework, which guided the categorization of culture change practices and QOL measures. Although such a framework is crucial for analyzing and synthesizing varied sources (Whittemore & Knafl, 2005), only relying on a single theoretical framework may lead to an incomplete literature search and biased data synthesis. Nonetheless, both the Nursing Home Integrated Model (Hartmann et al., 2013) and Social Production Function theory (Ormel et al., 1999; Ormel et al., 1997) hold promise in offering comprehensive definitions of nursing home culture change and QOL and are heuristic in light of potential effects of culture change practices on residents' QOL (Gerritsen et al., 2004). The current review was limited by its inability to distinguish the effect of individual culture change domains, and the dose-response relationship was not tested due to the heterogeneity in culture change implementation. In addition, this review only included studies conducted in the United States, which may exclude potential evidence from other countries.
Implications for Future Research and Practice
Findings from the current review suggest that rigorous methodological designs are essential for future research to test effects of culture change practices on QOL. Given practical difficulties in conducting randomized controlled trials (RCTs) in nursing home settings, a desirable design could be a cluster RCT or longitudinal designs with concurrent comparison and repeated measures of intervention fidelity and outcomes. Researchers should incorporate rigorous analytic strategies to address selection bias and confounders caused by the absence of randomization. Reliable and valid measures of QOL and culture change practices are imperative for future research. Examining dose effects and sustainability of culture change effects on QOL should be highlighted in future research. In addition, qualitative or mixed methods designs may provide deeper insights into how culture change practices benefit QOL.
Culture change practices are promising for improving residents' QOL. Care providers should design culture change practices centering on meeting various psychosocial needs of residents. It is important to bear in mind that changing the care culture in nursing homes is an evolving process and a continuous endeavor. Although addressing basic needs, such as comfort, autonomy, dignity, and privacy, are important first steps, a deeper and more extensive transformation should be pursued to provide a caring social environment in which other psychosocial needs, such as affection, personal growth, and purpose of life, can be met. Nursing home culture change initiatives should consider QOL indicators as a component of program evaluation. Moreover, it is imperative for nursing home reimbursement policy to include QOL measures in the quality measure scheme to motivate nursing homes to deliver person-centered care.
Although nursing home culture change was initially advocated for improving residents' QOL, the empirical evidence supporting its effects on QOL is still underdeveloped. The current review identified a positive trend that culture change practices can influence a resident's QOL. Although inconsistent evidence existed for most QOL measures, relatively consistent evidence was found to support positive effects on satisfaction with care, satisfaction with life, and autonomy. However, the methodological weaknesses may undermine the strength of the evidence, which needs to be addressed in future research. Sound empirical evidence will advance knowledge about culture change and QOL and support care providers and policy makers to make informed decisions toward evidence-based culture change practices.
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Basic Characteristics of 11 Eligible Studies
|Study (Year)||Study Design (Follow-Up Duration)||Setting||Participant Characteristics||Culture Change Model||QOL Measures||Resultsa|
|Bergman-Evans (2004)||Quasi-experimental with a control group (1 year)||Veterans home as an implementing NH and a non-profit NH as a control NH||N= 64 (55.9% female, 91.2% White)
Age range = 51 to 105||Eden Alternative Model|
|Implementing NH had lower boredom (p= 0.01), less helplessness (p= 0.03) compared to control NH at 1-year follow up|
|Parsons (2004)b||Quasi-experimental with a control group (9 months)||Two implementing NHs and one control NH from one provider||N= 60 (73.3% female, 88.3% White)
Mean age = 77.5
Mean LOS = 41.2 months||Eden Alternative Model|
Five domains of QOL (self-esteem, positive affect, negative affect, feelings of belonging, sense of aesthetics)
Overall QOL (a single question)
|Depression and loneliness were significantly lower in implementing NHs compared to control NH at 9-month follow up (p< 0.05)|
|Kane et al. (2007)c||Quasi-experimental with a control group (6, 12, and 18 months)||Four implementing NHs and two control NHs from one provider||N= 120 (80.8% female, 88.3% White)
Mean age = 85.7
Mean LOS = 32.7 months
Mean MDSd cognitive performance = 3.2||Green House Model|
ADL and IADL
11 domains of QOLe
|Green House had better outcomes compared to control NHs overall at all follow up (p< 0.05):|
QOL domains such as privacy, dignity, meaningful activity, relationship, autonomy, food enjoyment, security, spiritual well-being, and individuality.
|Grant (2008)b,c||Quasi-experimental with a control group (6 and 12 months)||Seven implementing NHs,10 matched control NHs from a for-profit chain||N= 950 (not reported)||An internally developed culture change model|
|Implementing NHs had better autonomy compared to control NHs at 6-month (p= 0.056) and 12-month (p< 0.01) follow up|
|Molony et al. (2011)c||Quasi-experimental with control group (1, 3, and 6 months)||One implementing NH and one control NH from one provider||N= 25 (84% female)
Mean age = 84
Mean MMSE score = 22.9||Small-House Model|
|Significant time by implementation interactions for at-homeness and ADL (p< 0.01) (at-homeness and ADL maintained in control NH and improved in implementing NH overall at all follow up)|
|Burack et al. (2012)c||Quasi-experimental with a control group (2 and 5 years)||13 communities across three NHs from one provider (seven for implementation and six matched for control)||N= 63 to 75 (56.5% female, 61% White)
Age range = 63 to 102
Mean LOS = 3 to 120 months
95% of residents had moderate cognitive impairment or less||Internally developed culture change model|
Perceptions of choice over basic everyday activities
|Overall choice increased from baseline to 2-year follow up in implementing NH (p< 0.01), but decreased at 5-year follow up (p< 0.01)|
|Ruckdeschel & Haitsma (2001)||Single group pre/post-test (6 months)||One NH||N= 26 (77% female)
Mean age = 87
Mean MMSE score = 22.8||Eden Alternative Model with only the introduction of animals and pets|
|No significant improvements in any outcome over time (p> 0.05)|
|Jones (2010)b||Single group pre/post-test (3 months)||Two units in a NH||N= 29 (82.8% female)
Age range = 63 to 96
Mean MMSE = >25||In-services person-centered care education for CNAs|
11 domains of QOLe
|Dignity (p= 0.04) and security (p= 0.02) were significantly improved at 3-month follow up|
|Aguilar (2011)b||Observational cross-sectional||24 implementing NHs and 25 control NHs||N= 368 (not reported)||Not-unified culture change models (dichotomous measure—culture change adopters vs non-adopters)|
Satisfaction with life
Satisfaction with clinical care
Satisfaction with social services
Physical environment comfort
|No significant difference in any outcome between implementing NHs and control NHs (p> 0.05)|
|Murray (2010)b||Observational cross-sectional||Two NHs from one provider||N= 13 (76.9% female, 53.8% White)
Age range = 65 to 97
LOS range = 10 to 120 months||Not-unified culture change models (measured with the Artifacts of Culture Change Instrument)|
11 domains of QOLe
Choice and control
|NH with higher culture change score had better privacy and security (p< 0.05)|
|Poey et al. (2017)c||Observational longitudinal retrospective cohort (1 year)||320 NHs in Kansas||N= 5,538 to 6,214 (not reported because the unit of data analysis was at facility)||Not-unified culture change models (measured with a culture change staging tool)|
Satisfaction with life
Satisfaction with clinical care
Satisfaction with social services
|Overall satisfaction, overall QOL, satisfaction with clinical care were higher in NHs that had fully implemented culture change practices (stage 4) compared to non-adopters (p< 0.05); NHs at stage 1–3 had no significant improvement in outcomes|
Quality Evaluation of 11 Eligible Studies Using the Quality Assessment Tool for Quantitative Studiesa
|Study (Year)||Selection Bias||Study Design||Confounders||Blinding||Data Collection Method||Withdrawals and Dropouts||Global Rating|
|Kane et al. (2007)||+||±||+||—||+||±||Moderate|
|Molony et al. (2011)||±||±||±||—||+||+||Moderate|
|Burack et al. (2012)||±||±||±||—||+||NRc||Moderate|
|Ruckdeschel & Haitsma (2001)||+||—||—||—||+||+||Weak|
|Poey et al. (2017)||NRb||±||+||NAd||+||±||Moderate|
Domains and Subdomains of Culture Change Practices in Quasi-Experimental Studies (n= 8)
|Domains of Culture Change Practices||Subdomains of Culture Change Practices||Culture Change Model & Study|
|The Eden Alternative||The Green House||The Small House||Internally Developed Model|
|Bergman-Evans (2004)||Parsons (2004)||Ruckdeschel & Haitsma (2001)||Kane et al. (2007)||Molony et al. (2011)||Grant (2008)||Jones (2010)||Burack et al. (2012)|
|Workplace practices||Interdisciplinary collaboration||X||X||X||X||X|
|Authority decentralization and staff empowerment||X||X||X||X||X|
|Effective, respectful, and nonhierarchical communication||X||X||X||X||X|
|Consistent staff assignment||X||X||X|
|Care practices||Preferences and autonomy||X||X||X||X||X||X||X|
|Resident-centered clinical care (e.g., residents/family involved in care planning)||X||X|
|Environment fostering spontaneity and engagement (e.g., introducing plants, animals, and children)||X||X||X|
|Environment promoting independency and privacy (e.g., small-house, household model)||X||X||X|
|No. of subdomains (n=10)||7||7||1||8||4||9||2||8|
Summary of Quality of Life (QOL) Measures and the Effects of Culture Change (CC) Practices on QOL by Domains/Subdomains of QOL Measures
|QOL Domains Based on Social Production Function Theory||QOL Measures in Reviewed Studies||No. of Studies|
|All Studies (N = 11)||Studies With Moderate Quality (n = 5)|
|Measuring the Outcome||Generating Statistically Significant Findings Supporting the Effects of CC on the Outcome||Measuring the Outcome||Generating Statistically Significant Findings Supporting the Effects of CC on the Outcome|
|Overall perception of life||Satisfaction with care||5||2||2||2|
|Satisfaction with life||5||2||2||2|
| Comfort||Physical environment comfort||4||0||1||0|
|Behavioral confirmationb||Functional competence||4||1||2||1|
|Feeling of belonging||1||0||0||0|