Abstract

Objective: As modern concepts of care for the aged stress the importance of independence and autonomy for those receiving care, resident-centered care practices, usually termed “culture change,” are becoming increasingly prevalent in US nursing homes. Because little is known about how nursing homes institute these practices, our study aimed to address how nursing homes implement principles of culture change.

Background: Culture change is a multifaceted philosophy with the central goal of de-institutionalizing nursing home care and making care more resident-centered. The term “resident-centered care” implies that the facility has become more focused on the preferences of individual residents, including improving resident choice and autonomy. In addition to resident-centered care, culture change initiatives can involve changes that give facility physical plants a more home-like appearance and organizational changes aimed at empowering direct-care staff.

Methods: Using survey data we collected from 2,686 nursing homes and administrative data from annual nursing home inspections, we randomly selected 64 nursing home administrators in four strata based on high or low scores for culture change implementation and high or low care quality scores. Interviews were semi-structured, lasted 20–30 minutes, and were recorded and transcribed. Interviews were analyzed using a coding scheme developed by the research team using the first five interviews. Each interview was coded by all members of the team and final coding decisions were made by the entire team during analysis meetings. Related codes were grouped into themes and sub-themes agreed upon by the team.

Results: Those nursing home administrators who reported implementing culture change practices noted varying strategies employed and approaches taken. Most stressed the importance of communication with and education of all stakeholders, including nursing home staff at all levels, nursing home residents, and residents’ family members. Subthemes which emerged around the concepts of communication and education indicated that these efforts should be on going, communication should be reciprocal, and all stakeholders should be active participants in the culture change process. These administrators also displayed an ability to be flexible and gear their education and communication strategies to their facility’s organizational context and to the needs of their specific staff members, residents, and families. Successful administrators were also able to accept input and feedback, while the administrators we spoke to in non-culture change facilities were often unwilling or unable to do this.

Conclusions: We found that leadership is a key to successful culture change implementation and that facility leaders must be able to use communication and education to generate buy-in among stakeholders. Therefore, leadership training may be an important first step in culture change efforts, to help less effective leaders learn better communication skills, how to be more flexible and how to accept and respond to feedback. Additional research is also needed to determine whether it is the more effective leaders who are already implementing culture change and to determine how best to encourage and support less effective managers in their efforts to implement culture change. This is an area where future policy initiatives, such as pay-for-performance, may be important.

Slides