Comprehensive Culture Change Can Transform Nursing Homes

By Anne Montgomery

Later in life, if you become functionally disabled or frail and it’s no longer easy to live at home, you may want to move to a place that honors your independence and meets your needs for supportive daily care. For most of us, the first choice would not be a nursing home. But comprehensive culture change—which has the potential to reboot traditional nursing home institutional life—could change that thinking.

The majority of nursing homes still operate as medical institutions. That means service delivery is organized in a top-down model, which enforces rigid schedules governing when residents bath, eat, sleep and participate in activities. And often, residents are assumed to be dependent and incapable. Unsurprisingly, this model has proved problematic when it comes to resident satisfaction and quality of life (QOL).

An institutional model ignores what one culture change training organization, The Eden Alternative, refers to as the “three plagues”: loneliness, helplessness and boredom, which are caused in part by the rigidity and sameness of residents’ daily routines, and a lack of understanding of residents’ individual preferences.

Training Designed to Change Culture

Comprehensive culture change training is designed to help homes gradually transform their operations. Trainers (sometimes called guides) build detailed team action plans with staff to help them understand how they can progress toward person-centered care. Trainers identify and provide resources (e.g., workbooks, webinars and other content) that help staff identify targeted, sustainable outcomes to be achieved over time, offer ongoing mentoring and encourage sharing of best practices with other staff.

Initial training typically is conducted in person and spans several days. Later education includes “train-the-trainer” staff-led education of peers and leadership training, and online learning collaboratives that focus on key topics such as dementia care and optimizing medication use.

There also are other excellent culture change training programs, such as Action PACT and the Green House Project, which work in different ways to train or retrain staff and place elders at the heart of a nursing home’s daily rhythms. Almost any home (except those in serious financial and-or regulatory stress) can decide to undertake culture change training and an implementation process that empowers staff to shift practices and protocols in myriad ways.

For example, a home can end overhead paging (except during emergencies); provide easy, safe access to a garden or patio space with unlocked doors, or make team members available to accompany and assist when residents want to go outside; create private, comfortable spaces for family and friends to interact and spend time with residents; and enable residents who want to participate in community events to do so when possible.

Culture change also is about empowering certified nurse aides to implement changes that improve QOL for residents. For residents living with cognitive impairment, staff can be trained to interpret personal expressions (sometimes called “behaviors”) as manifestations of unmet need, and to respond by first offering non-pharmacological therapies and modalities, such as music therapy and stress reduction techniques. Dietary staff can work to make it possible for residents to dine at flexible times, and to have access to snacks and beverages of their choice. Administrators and senior staff can take steps to ensure that residents, staff and family members have opportunities to grieve when a resident dies.

Measuring Culture Change Effects

In one comprehensive culture change quality improvement project in Michigan (for which Altarum is the lead and Eden is the training partner), the six participating homes differ markedly in size and ownership: two are large and publicly owned; two are privately owned and for-profit; and two are nonprofit and part of a larger hospital system. The number of residents ranges from 31 to 217. The changes upon which these homes decide to focus and implement vary.

To track what happens in each home over time as culture change training takes hold, Altarum is examining changes in key clinical quality measures, including the use of antipsychotics, depression incidence, as well as changes in hospitalizations and emergency department outpatient visits. Altarum is assessing QOL via focus groups and interviews with staff and residents; monitoring economic impact through reported changes in implementation costs, such as physical plant and supply costs; and monitoring staffing levels, staff turnover and occupancy rates.

To identify practices and protocols that homes use to implement culture change, Altarum has designed a literature-based tool called the “Systems Change Tracking Tool,” with questions arrayed in six domains (care practices, workplace practices, environment, family-community, leadership and stakeholders). A multidisciplinary group of staff gather each quarter to reach consensus on whether shifts in certain practices are happening (e.g., dining flexibility), or not, and the context for these changes. Over a three-year period, Altarum expects that each home will implement culture change somewhat differently.

But certain commonalities are surfacing. One is residents’ desire for warm, delicious food—an important factor in QOL. In a home pursuing culture change, staff could use questions such as the following to prompt discussions about possible modifications:

  • Is residents’ input solicited about food service? Are there items they would like to add (or omit) from standard menus? How many daily choices are there?
  • How is the food served? Are residents required to eat in common spaces? What if they prefer to eat somewhere else?
  • Are friends and family members welcome to join residents for meals and snacks?

In one Michigan home, staff, based on residents’ input, have started making soup and pancakes for one or two meals per week. Residents report they enjoy the homey aromas, and no capital investment was needed to do make this change.

Working with elders to identify changes they care about is an excellent way to improve a nursing home, build out a person-centered care model and achieve lasting culture change.

Anne Montgomery, M.S., is co-director, Program to Improve Eldercare, at Altarum, in Washington, D.C. She is a member of ASA’s Aging Today Editorial Advisory Committee.

Editor’s Note: This article appears in the May/June, 2020, issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.