Read Also: PHI’s Nursing Home Culture Change Services

With the new CMS Interpretive guidelines for Quality of Life and the Environment, nursing home leaders are tuning into a movement that began taking root more than a decade ago. Known today as the “culture change” movement, it has become the leading edge of efforts to turn institutional nursing homes into real homes, where residents have the intellectual, emotional and spiritual sustenance they need to thrive.

Culture change is relevant to all long-term settings, but it is in nursing homes that we are seeing some of the most profound changes. The pervasive culture in nursing homes is “institution centered.” The norms that govern daily activity are influenced by the hospital/industrial model of care, placing the locus of control with the facility leadership. The “patients” are perceived of as sick and unable to care for themselves; daily activities are organized around the efficiency of facility operations, not the physical, social, and spiritual needs of the residents. Essentially, the model for delivering acute care services in a hospital has been imported to a setting where people live. As we all know, this model isn’t working. Most Americans consider moving to a nursing home a death sentence.

Institutional practices in nursing homes are everywhere—but staff often don’t see them because “it has always been this way.” Examples include:

• Residents must eat at times set by the facility
• Meals are served on hospital trays
• Residents have little access to the outdoors or activities outside the institution.
• Residents must take showers and baths when scheduled and according to facility policy.
• Staff decide when residents should rise and when they go to bed.

Culture change is about changing this institution-centered culture to one that is sometimes called “person-centered” or “person-directed.” At PHI we see the new model of caregiving as a “relationship-centered” culture. It is a culture where the relationship between residents and the caregiving team is valued, and residents, with the direct-care workers closest to them, make decisions about their daily activities. In relationship-centered facilities, the environment looks like a home, there are familiar objects, and all staff support the growth and development of each individual who resides there. To make this kind of dramatic change, often nursing homes restructure their organization to include smaller neighborhoods or households.

Examples of a person-directed, relationship-centered culture include:

• Residents have consistent caregivers (staff don’t rotate floors/units).
• Caregivers are empowered to listen and take their cues from residents—thus, residents get out of bed when they are ready; bathe when they feel the desire; sleep when they are tired. Food is accessible at all times.
• Meals are served family style in a kitchen or dining room.
• Activities occur spontaneously, as well as at planned times.
• Residents live in neighborhoods or households staffed with empowered teams of caregivers and other supporting personnel. Decisions once made by facility managers are made in the household.

The new CMS interpretive guidelines are intended to move nursing homes in this new direction, because it is imperative that nursing homes support the rights of all individuals to live fulfilling and meaningful lives.

PHI works with nursing homes to envision and build new models of care that support both residents and staff. We know that the desire to change does not make the change easy. Most importantly, to transform your nursing home you will need effective leadership, staff involvement, and new skills to deliver services in an entirely new way.

For assistance in getting started—or for support to move your culture change process to the next stage–explore PHI Training and Organization Development Services or contact our Training and Organizational Team.

See also: “These Nursing Homes Care About Their Elderly Charges,” by Sarah Baldauf, U.S. News & World Report, January 14, 2010.