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Nursing Home Culture Change

Long seen as places one would avoid living in if one had a choice, in the past decade nursing homes (NHs) have increasingly adopted more resident-centered care paradigms, under a rubric generally termed "culture change." Culture change means that residents' needs and preferences are of central importance in designing the structure of care, and that facility designs, routines, management, and care should be shaped by these needs and preferences. In reality, culture change spans a wide spectrum of potential modifications, including minor or major modifications to the physical environment (from decorating hallways and baking bread to removing nursing stations and remodeling residents' rooms), changes in staff roles (consistent assignment of staff to the same residents and increased autonomy of frontline staff), and changes in management styles (incorporating input from residents and staff into management decision-making). These changes should also include resident participation, for example allowing resident choice in a variety of areas and structuring life around resident needs and wishes.

Evidence Base

The implicit goal of culture change resonates strongly with many stakeholders, but on a day-to-day basis, culture change necessitates a fine balance between the multiple needs and wishes of residents and potential impacts on safety and quality of care. The financial implications of these changes are also a consideration. To date, relatively little research has been undertaken on culture change.¹ Some preliminary studies have shown elements of culture change to correlate favorably with resident, staff, and family outcomes, but not in all instances. For example, it has been shown that some promising changes'such as providing a more home-like environment and promoting freedom of movement for residents-may also have safety implications (e.g., possibility of increased falls).² In addition, while consistent assignment of staff (having the same individual work with the same residents for at least 80 percent of her/his shifts) is one hallmark of culture change, some evidence about the benefits of consistent assignment has been equivocal.³

The redistribution of staff and redefinition of staff jobs that culture change entails are the source of potential tensions too. Much of the current literature indicates that the majority of nursing homes are already understaffed, and specific methods of improving resident outcomes often take more time from staff (e.g., toilet training, walking improvement programs, and turning schedules to avoid pressure ulcers). Given these competing demands, it is unclear exactly how these changes will impact resident outcomes. Finally, with regard to cost, in a study of culture change in a for profit nursing home chain, the primary factor that prevented timely implementation of the more comprehensive elements of culture change at participating sites was expense. ⁴

Since 2004, the VA Office of Geriatrics and Extended Care has spearheaded the movement to change NH care, focusing on four key elements:

1. transforming the current NH culture to a resident-centered approach;
2. empowering frontline team members to help address issues related to the delivery of customized, high quality care;
3. changing the environment to foster a homelike experience; and
4. linking transformation of the NH culture to quality indicators.

In 2008, the Deputy Under Secretary for Health for Operations and Management announced a name change that transformed "Nursing Home Care Units" into "Community Living Centers" (CLCs) to reflect this initiative. Also as of 2008, culture change has become a performance improvement measure. Twice yearly, all CLCs must complete a self-assessment using the Artifacts of Culture Change Tool first developed by the Centers for Medicare and Medicaid Services. However, despite this emphasis from top VA management, much remains unknown.

Research Challenges

While the changes being implemented are designed to affect residents and staff positively, they also have many as yet unknown implications. As noted, very little research exists on the impact of various aspects of culture change on resident and staff outcomes such as quality of care, safety, and satisfaction. Care must be taken, as we move forward, to capture impressions accurately (e.g., in the case of cognitively impaired residents) as well as in sufficient depth (e.g., including qualitative observations of resident-staff interactions). Both short- and long-term financial implications have to be investigated and weighed alongside the quantitative and qualitative impacts. It is imperative that as VA moves forward with culture change, clinicians, researchers, and leadership all work together in a collaborative partnership to continue to define and improve the safety and quality of care for Veterans living in CLCs.

References

1. Rahman AN, Schnelle JF. The Nursing Home Culture- Change Movement: Recent Past, Present, and Future Directions for Research. Gerontologist. August 2009;48(2):142-8.
2. Coleman MT, et al. The Eden Alternative: Findings After 1 Year of Implementation. J Gerontol A Biol Sci Med Sci. Jul 2002;57(7):M422-7.
3. Burgio LD, et al. Quality of Care in the Nursing Home: Effects of Staff Assignment and Work Shift. Gerontologist. Jun 2004;44(3):368-77.
4. Grant LA. Culture Change in a For-profit Nursing Home Chain: An Evaluation. New York: Commonwealth Fund; 2008.