1. Systemically Changing Nursing Home Culture A Project of Human Change funded by the van Ameringen Foundation and the New York State Department of Health Dementia Grants Program Systemically Changing Nursing Home Culture A Project of Human Change funded by the van Ameringen Foundation and the New York State Department of Health Dementia Grants Program

2. Dale Dannefer, Ph.D. and Paul Stein, M.S. In association with Craig Barclay, Ph.D., Madalina Chireac, M.D., Jason Dauenhauer, M.S.W., Janet Gelein, M.S., R.N., Lorraine Gianvecchio, M.S., R.N., Jeffrey Lashbrook, Ph.D., Catalina Novic, M.S., Naomi Schlagman, M.S., and Louise Stein, Ph.D.

3. The problem: Our society suffers from age segregation, and The problems of long-term care are rooted in the social practices that comprise the twin tragedies of age in Twentieth Century America: 1) Age Segregation -- the systematic separation by age of individuals of every age 2) Stigmatization of the Aged -- The systematic and relentless devaluation of elders The problem: Our society suffers from age segregation, and The problems of long-term care are rooted in the social practices that comprise the twin tragedies of age in Twentieth Century America: 1) Age Segregation -- the systematic separation by age of individuals of every age 2) Stigmatization of the Aged -- The systematic and relentless devaluation of elders

4. Tragedy #1: The systematic segregation of individuals by age From “pre-K” to “young adult”; From the school-regulated teenage years to retirement community ghettoes: From the school-regulated teenage years to retirement community ghettoes: Social opportunities and norms in modern societies are heavily regulated by age

5. Tragedy #2: The Systematic and Relentless Devaluation of Elders Elders are assumed to be socially uninteresting and to have little left to offer or contribute to others Elders are assumed to be socially uninteresting and to have little left to offer or contribute to others Society has tolerated and sanctioned the segregation of dependent elders into nursing homes Society has tolerated and sanctioned the segregation of dependent elders into nursing homes excluded from the normal and familiar rhythms of life excluded from the normal and familiar rhythms of life subject to Thomas’s “three plagues” (boredom, helplessness and loneliness) subject to Thomas’s “three plagues” (boredom, helplessness and loneliness)

6. Plague #1: Boredom Meaningful activities few and far between Meaningful activities few and far between Much time spent idle, or in passive activities Much time spent idle, or in passive activities Daily life suffers from monotony and lack of variety Daily life suffers from monotony and lack of variety Few meaningful alternatives in how to spend Few meaningful alternatives in how to spend one’s time one’s time Few opportunities to take an active, constructive Few opportunities to take an active, constructive role in activities role in activities

7. Plague #2: Helplessness Elders are not expected to contribute to one’s own or other’s well-being Elders are not expected to contribute to one’s own or other’s well-being Not consulted or even informed concerning important life choices Not consulted or even informed concerning important life choices Not credited with having knowledge useful to others Not credited with having knowledge useful to others

8. Plague #3: Loneliness Most personal contact focused on physical condition and needs Most personal contact focused on physical condition and needs With limited mobility and regulated routines and activities, elders have limited opportunities for building or sustaining meaningful relationships With limited mobility and regulated routines and activities, elders have limited opportunities for building or sustaining meaningful relationships Few connections with the outside community Few connections with the outside community An unappealing environment for family and friends to visit. An unappealing environment for family and friends to visit.

9. The Sources: Institutional Culture, Institutional Constraints Medicalization of Aging Medicalization of Aging Assumes inevitable organismic decline requiring treatment Assumes inevitable organismic decline requiring treatment Subordinates quality of life to professionalized treatment/service delivery Subordinates quality of life to professionalized treatment/service delivery Depersonalizes care, assaulting elders’ sense of self and identity Depersonalizes care, assaulting elders’ sense of self and identity The paradox for residents: trying to make one’s “home” in a “hospital” culture. The paradox for residents: trying to make one’s “home” in a “hospital” culture. The contradiction for staff (including leadership): trying to provide genuine human care when only clinically indicated care is evaluated and rewarded. The contradiction for staff (including leadership): trying to provide genuine human care when only clinically indicated care is evaluated and rewarded.

10. CULTURE CHANGE... from a Medical Model - from a Medical Model - Hospital Regime Hospital Regime Emphasizes “decline” and “disengagement” as Emphasizes “decline” and “disengagement” as inevitable characteristics of elders inevitable characteristics of elders Emphasis on Treatment Emphasis on Treatment Requires elders adjusting to facility’s routine Requires elders adjusting to facility’s routine to a Resident-Centered Model – to a Resident-Centered Model – “Normalcy” Regime “Normalcy” Regime Emphasizes special strengths and growth Emphasizes special strengths and growth potentials of elders potentials of elders Emphasis on Meaningful Living, Emphasis on Meaningful Living, of which medical treatment is part of which medical treatment is part Requires adjustment of facility to elders’ routine Requires adjustment of facility to elders’ routine

11. Definition of an “Elder” An Elder is a person who is still growing, still a learner, still with potential and whose life continues to have within it promise for and connection to the future. An Elder is a person who is still growing, still a learner, still with potential and whose life continues to have within it promise for and connection to the future. An Elder is still in pursuit of happiness, joy and pleasure, and her or his birthright to these things remains in tact. An Elder is still in pursuit of happiness, joy and pleasure, and her or his birthright to these things remains in tact. Moreover, an Elder is a person who deserves respect and honor and whose work it is to synthesize wisdom from long life experience and formulate this into a legacy for future generations. Moreover, an Elder is a person who deserves respect and honor and whose work it is to synthesize wisdom from long life experience and formulate this into a legacy for future generations. Barry Barkan, Live Oak Project

12. Features of the Resident-Centered Model, for Residents Increased control in setting everyday life routines Increased control in setting everyday life routines Increased opportunities for social participation Increased opportunities for social participation Increased range of options for meaningful contributions to others Increased range of options for meaningful contributions to others New options for participation in normal activities New options for participation in normal activities Cooking Cooking Personal laundry Personal laundry Participation in Other Household Tasks Participation in Other Household Tasks Children integrated into everyday life of facility Children integrated into everyday life of facility Plants and pets integrated into everyday life Plants and pets integrated into everyday life Aging in Place – deconstructing the “resident career” Aging in Place – deconstructing the “resident career”

13. Features of the Resident-Centered Model, for Staff Greater decision-making discretion for frontline staff Greater decision-making discretion for frontline staff Emphasis on personal caring as well as professional Emphasis on personal caring as well as professional practice practice Permanent work assignments -- nurturing personal Permanent work assignments -- nurturing personal relationships while increasing efficiency relationships while increasing efficiency Cross–training for greater flexibility on the neighborhoods Cross–training for greater flexibility on the neighborhoods Enhanced appreciation of value of elders, and awareness of the cultural assaults on the aged Enhanced appreciation of value of elders, and awareness of the cultural assaults on the aged

14. Project Settings Fairport Baptist Homes Fairport Baptist Homes Jewish Home of Rochester Jewish Home of Rochester

15. Fairport Baptist Homes Sectarian Sectarian Not-for-profit Not-for-profit Founded 1904 Founded 1904 196 Beds 196 Beds Suburban location Suburban location Longstanding reputation for excellence Longstanding reputation for excellence Staff drawn largely from rural areas Staff drawn largely from rural areas

16. Jewish Home of Rochester Sectarian Sectarian Not-for-profit Not-for-profit Founded 1920 Founded 1920 362 beds 362 beds Suburban location Suburban location Longstanding reputation for excellence Longstanding reputation for excellence and innovation and innovation National leader in restraint-free care National leader in restraint-free care Staff drawn from diverse areas, including Staff drawn from diverse areas, including central city central city

17. EACH FACILITY DEVELOPED ITS OWN INDEPENDENT PLAN FOR CULTURE CHANGE…

18. Fairport Baptist Homes: FROM HALLWAYS TO HOUSEHOLDS Articulating Vision, Values and Principles Articulating Vision, Values and Principles Architectural restructuring to create a homelike Architectural restructuring to create a homelike environment environment Flexibility of mealtimes Flexibility of mealtimes Increased opportunities for activity Increased opportunities for activity Regular contact with children Regular contact with children Aging in Place Aging in Place Additional pets, including staff members’ Additional pets, including staff members’ personal pets accompanying staff to work personal pets accompanying staff to work Community meetings Community meetings Redefining jobs – developing broader skills through cross- Redefining jobs – developing broader skills through cross- training training Staff Training and Team-building Staff Training and Team-building

19. Architectural Restructuring to Create a Homelike Environment “From Hallways to Households” --- Units of up to 60 residents transformed to households of 10, neighborhoods of 20 “From Hallways to Households” --- Units of up to 60 residents transformed to households of 10, neighborhoods of 20 Long hallways replaced by “households” -- circular living areas encircled by rooms for about 10 residents Long hallways replaced by “households” -- circular living areas encircled by rooms for about 10 residents Long hallways replaced by open Living area encircling elders’ rooms

20. Homelikeness and Mealtime Household model Institutional model Meals served on tray Meals served on tray Assigned seating for all residents Assigned seating for all residents Common time for all meals including breakfast Common time for all meals including breakfast No resident choice of when to get up in the morning, whatever her sleep preferences! No resident choice of when to get up in the morning, whatever her sleep preferences! All meals served family styleAll meals served family style Breakfast: Breakfast: -Prepared individually for each elder in -Prepared individually for each elder in household kitchen household kitchen -Elders decide when to arise in the morning -Elders decide when to arise in the morning -Elders control breakfast menu and timing -Elders control breakfast menu and timing -Morning kitchen smells add homelikeness -Morning kitchen smells add homelikeness -Elders may use kitchen for cooking, fixing -Elders may use kitchen for cooking, fixing snacks, personal food storage, etc. snacks, personal food storage, etc. -Kitchen also used for cookie baking and -Kitchen also used for cookie baking and other resident activities other resident activities Before renovation, elders were rushed into dining rooms serving up to 60, to eat meals served on trays In household model, food is served family style to household groups of about 10, staff may eat themselves at the same time they assist elders

21. Replacing traditional nurses’ station with workspace integral to household workspace integral to household Before renovation, a nurses’ station insulated staff from residents In the households, staff work space is integrated into household space

22. Childcare Center adjoining Nursing Home Children regularly visit households Children regularly visit households Household kitchens used for intergenerational projects

23. Community Meetings -- Regular Neighborhood-based events for elders

24. Community and Personal Connections Objectified in Neighborhood Displays which Residents Help to Create

25. Aging in Place Enables elders to remain in familiar and comfortable surroundings as long as they choose Enables elders to remain in familiar and comfortable surroundings as long as they choose Eliminates the discouraging resident career of decline and “downward mobility” Eliminates the discouraging resident career of decline and “downward mobility” Requires integration of diverse levels of care needs on each unit (except for at-risk wandering) Requires integration of diverse levels of care needs on each unit (except for at-risk wandering)

26. Jewish Home of Rochester: Relationship-Centered Care Articulating Vision, Values and Principles Articulating Vision, Values and Principles Community-building – Community-building – Among JHR families – Partnering with families Among JHR families – Partnering with families Staff Training and Team-Building Staff Training and Team-Building Community Meetings Community Meetings Regular contact with children Regular contact with children Zack, the Therapy Dog Zack, the Therapy Dog Active Resident Involvement in Home Active Resident Involvement in Home Resident participation in staff hiring Resident participation in staff hiring Resident-Created and Resident-Led Culture Change Group Resident-Created and Resident-Led Culture Change Group Cooking via the Portable Cooking Cart Cooking via the Portable Cooking Cart Buffet Breakfast Buffet Breakfast Staff Training and Team-Building Staff Training and Team-Building

27. Breakfast on Trays replaced by fresh Buffet Breakfast Breakfast trucked from central kitchen eliminated Breakfast buffet card provides for fresh-cooked breakfast on each unit Wonderful morning smells of cooking can again be enjoyed by residents Elders convey preferences directly to cooking staff Preliminary studies have indicated improved food intake and reduced waste

28. Zack, the Therapy Dog Zack joined JHR as a “permanent resident” in late 1999 Specially training for interacting with elders Cared for by staff members of the “Friends of Zack Committee”!

29. “Cooking Cart” invites active participation Mobile “Cooking Cart” takes the joys of cooking to the units Residents actively participate in cooking projects Many recreational staff now based on units, increasing accessibility and contact with elders

30. Other Culture Change Initiatives Expanded use of “permanent assignments”, nurturing personal connections between elders and staff Expanded use of “permanent assignments”, nurturing personal connections between elders and staff Partnering with Families Partnering with Families Team-building and leadership training for front-line staff Team-building and leadership training for front-line staff Relocation of Resident Services (Therapeutic Rec, Social Work) to Units Relocation of Resident Services (Therapeutic Rec, Social Work) to Units Regular visits by school classes Regular visits by school classes Liberalization of policies on diets and food Liberalization of policies on diets and food

31. Common Challenges To make major changes in practices and in staff values “without missing a beat” in the delivery of services and provision of care To make major changes in practices and in staff values “without missing a beat” in the delivery of services and provision of care To manage change-related costs effectively To manage change-related costs effectively Deal with Resistance to Change from Deal with Resistance to Change from Widespread fears of “new” and “unknown” among staff Widespread fears of “new” and “unknown” among staff Concern that attention to quality of life issues would compromise nursing and medical care Concern that attention to quality of life issues would compromise nursing and medical care Regulatory requirements that reinforce “status quo” practices Regulatory requirements that reinforce “status quo” practices Culture change innovations in both facilities caused deficiencies Culture change innovations in both facilities caused deficiencies in State Survey process High levels of specialization, standardization and regimentation in High levels of specialization, standardization and regimentation in “SOP” difficult to change “SOP” difficult to change

32. Responding to Challenges Use of Pioneer experts for training in new values, new practices, including Use of Pioneer experts for training in new values, new practices, including Valuing and respecting elders Valuing and respecting elders Resident-centered care Resident-centered care Community meetings Community meetings Resident-centered bathing Resident-centered bathing Organizational consultants for staff training in team- building and leadership Organizational consultants for staff training in team- building and leadership Clarifying lines of authority and Clarifying lines of authority and Clarifying expanded arenas of discretionary decision-making for front-line staff Clarifying expanded arenas of discretionary decision-making for front-line staff Enabling increased communication among staff and between staff and supervisors Enabling increased communication among staff and between staff and supervisors

33. Evaluation Did the effort to implement culture change lead to a changed culture? Did the effort to implement culture change lead to a changed culture? To the extent that change occurred, what were its consequences for elders and staff members? To the extent that change occurred, what were its consequences for elders and staff members?

34. Defining and Assessing Culture Culture is the totality of a social world, which includes Culture is the totality of a social world, which includes norms and values norms and values language and other symbolic systems language and other symbolic systems interaction patterns and styles interaction patterns and styles nature of personal relationships nature of personal relationships physical context, including artifacts and architecture physical context, including artifacts and architecture organization of temporal routines organization of temporal routines relationship with nature relationship with nature

35. Measuring culture - a multi-dimensional task Contextual Dimensions Contextual Dimensions Physical surroundings Physical surroundings Presence of plants and animals Presence of plants and animals Opportunities for contact with others Opportunities for contact with others Elder Activity – how do elders spend their time? Elder Activity – how do elders spend their time? Staff Activity – how do staff spend their time? Staff Activity – how do staff spend their time? Formal systems – structure of authority, Formal systems – structure of authority, division of labor, job definitions, officially defined terms division of labor, job definitions, officially defined terms Informal systems – relationships and meaning systems shared Informal systems – relationships and meaning systems shared by elders and/or staff in everyday life by elders and/or staff in everyday life

36. Activity Mapping Procedure Direct observation of activity -- avoiding selective memory, social desirability and other problems of self-reported data Direct observation of activity -- avoiding selective memory, social desirability and other problems of self-reported data Systematic, structured procedure permits quantification of observed activities Systematic, structured procedure permits quantification of observed activities Systematic sampling of activities of elders and staff throughout the day provides representative picture on each day of observation Systematic sampling of activities of elders and staff throughout the day provides representative picture on each day of observation Repeated sampling over duration of study period permits construction of three-year trend Repeated sampling over duration of study period permits construction of three-year trend

37. Figure 1. Elder Activity Trends 1998-2001, Jewish Home of Rochester Note: Vertical axis indicates the percentage of total activity comprised by each discrete activity

38. Figure 2. Elder Activity Trends 1997-2001, Fairport Baptist Homes Note: Vertical axis indicates the percentage of total activity comprised by each discrete activity

39. Activity Map Findings At beginning of project, elders spent most of the time when in public view asleep or withdrawn At beginning of project, elders spent most of the time when in public view asleep or withdrawn More than 14,000 acts of elders observed over course of project More than 14,000 acts of elders observed over course of project In both facilities, the proportion of time elders were asleep was reduced, and while engagement in social activity increased In both facilities, the proportion of time elders were asleep was reduced, and while engagement in social activity increased These changes were substantial and statistically significant in both facilities, and were especially dramatic at FBH These changes were substantial and statistically significant in both facilities, and were especially dramatic at FBH

40. Elder Outcomes Quality of Life Indicators Quality of Life Indicators Rebuilding elders’ sense of self Rebuilding elders’ sense of self Developing cherished relationships Developing cherished relationships Sense of community evident in residents’ joint initiation of new projects Sense of community evident in residents’ joint initiation of new projects Medication Use Medication Use On some units, use of psychotropic medications was reduced On some units, use of psychotropic medications was reduced Health Indicators Health Indicators Incidents (falls, accidents, pressure wounds) Incidents (falls, accidents, pressure wounds) Infections Infections Mortality Mortality

41. Rebuilding a Sense of Self: Entering nursing home entails an “assault on self” IDENTITY COHERENCE – a psychological index of self-integrity Narrative technique, measuring degree of “self-integration” encompassing past, present and anticipated events into a meaningful account of identity (Barclay, 1993) Narrative technique, measuring degree of “self-integration” encompassing past, present and anticipated events into a meaningful account of identity (Barclay, 1993) Pre-change (T1) self narrative stories of were generally temporally disassociated : Pre-change (T1) self narrative stories of were generally temporally disassociated : past divorced from present past divorced from present future indescribable. future indescribable. Important relationships situated outside of nursing home setting Important relationships situated outside of nursing home setting Affective focus disconnected from immediate events and experiences. Affective focus disconnected from immediate events and experiences. Some mid-change narratives (especially in new household at FBH) evidenced contrast to T1: Some mid-change narratives (especially in new household at FBH) evidenced contrast to T1: self-stories assimilating nursing home life into the composition of self self-stories assimilating nursing home life into the composition of self care relationships entering emotional meaning care relationships entering emotional meaning household histories integrating with biographical narratives. household histories integrating with biographical narratives. ‘

42. Other Indications of Quality of Life Cherished relationships -- many examples of residents developing increased attachment to others, and to place Cherished relationships -- many examples of residents developing increased attachment to others, and to place Sense of Community evident in new projects initiated by elders, sometimes challenging staff or management in surprising and welcome ways Sense of Community evident in new projects initiated by elders, sometimes challenging staff or management in surprising and welcome ways At JHR, residents organized to create a discussion group regarding culture change and a consultation resource for administration. At JHR, residents organized to create a discussion group regarding culture change and a consultation resource for administration. At FBH, residents mobilize to preserve memories of household members At FBH, residents mobilize to preserve memories of household members Regular use of cooking opportunities Regular use of cooking opportunities Other new opportunities for participating in homemaking and other everyday tasks Other new opportunities for participating in homemaking and other everyday tasks

43. Falls and Injuries 1997-2001, JHR *Per 1000 bed days **Average per month

44. Infections 1997-2001, JHR *Per 1000 bed days **Annual rate (based on 362 residents)

45. Falls and Injuries 1997-2001, FBH Annual rate per resident

46. Infections and Mortality 1997-2001, FBH Annual rate per resident

47. Interpreting Incident, Infection and Mortality Data No clear trend of change in infections No clear trend of change in infections Mortality trends downward overall, despite some fluctuation. Mortality trends downward overall, despite some fluctuation. Is culture change making life more worth living? Is culture change making life more worth living? Substantial reductions in both facilities, in Substantial reductions in both facilities, in Falls Falls Injuries Injuries Fractures Fractures Higher levels of resident activity have not increased incident risk Higher levels of resident activity have not increased incident risk

48. Staff Outcomes Attitudes and Experiences Attitudes and Experiences Activity Patterns Activity Patterns Staff Turnover Staff Turnover

49. Staff Activities, Attitudes, Experiences No clear trends of change observed in staff activities was observed, except staff increased time spent in paperwork (based on Activity Mapping) No clear trends of change observed in staff activities was observed, except staff increased time spent in paperwork (based on Activity Mapping) Staff indicated an increased awareness of “resident- centeredness” Staff indicated an increased awareness of “resident- centeredness” Numerous examples of staff bringing their own dogs/other pets regularly to work and bringing their children to visit elders Numerous examples of staff bringing their own dogs/other pets regularly to work and bringing their children to visit elders A Paradox? At FBH, working in new environment produced simultaneously A Paradox? At FBH, working in new environment produced simultaneously Increased stress and feelings of burnout Increased stress and feelings of burnout Increased expression of commitment and engagement Increased expression of commitment and engagement

50. Staff Turnover Shortages of both nurses and certified aides is a growing national crisis Shortages of both nurses and certified aides is a growing national crisis High staff turnover reflects the shortage, is frustrating for elders, and costly for institutions High staff turnover reflects the shortage, is frustrating for elders, and costly for institutions Can culture change encourage staff retention through providing a more feasible and meaningful job description and better work conditions? Can culture change encourage staff retention through providing a more feasible and meaningful job description and better work conditions?

51. Staff Turnover At JHR, 1997-2001 CNA (Certified Nursing Assistant) Turnover declined by a a third -- from 33% in 1997 to 22% in early 2001 Nurse Turnover is relatively stable, with no clear trend of change Turnover for 2001 is projected here, based only on data for the first quarter These trends square with other evidence indicating that culture change encourages positive changes in attitudes and work commitment among CNAs Turnover (%)

52. Staff Turnover At FBH, 1996-2001 CRA (Certified Resident Assistant) Turnover has, with one exception, decreased each year -- from 36% in 1996 to 14% in early 2001. The exception to the general trend was the year 2000, when turnover spiked upward to 39% Nurse Turnover has edged upward, but was down slightly in 2001 2001 data projected from first quarter For CRAs, trends converge other evidence indicating that culture change encourages positive changes in attitudes and work commitment Turnover (%)

53. Observations on Staff Turnover Overall, both facilities appear to have “bucked” a national trend toward increasing and high levels of turnover for frontline care staff (CNAs/CRAs). (The exception was a sharp increase at FBH only, in the year 2000) Overall, both facilities appear to have “bucked” a national trend toward increasing and high levels of turnover for frontline care staff (CNAs/CRAs). (The exception was a sharp increase at FBH only, in the year 2000) In both facilities, nursing turnover shows greater year-to-year stability than CNA turnover, although there was In both facilities, nursing turnover shows greater year-to-year stability than CNA turnover, although there was a slight trend of decrease at JHR, reversed in 2001 a slight trend of decrease at JHR, reversed in 2001 a slight trend of increase at FBH, reversed in 2001 a slight trend of increase at FBH, reversed in 2001 Given the growing national nursing and CNA shortage, these overall trends are remarkable. Both the stability in nurse turnover, and the overall picture of reduction in aide turnover, support the hypothesis that the culture change efforts have helped to retain staff Given the growing national nursing and CNA shortage, these overall trends are remarkable. Both the stability in nurse turnover, and the overall picture of reduction in aide turnover, support the hypothesis that the culture change efforts have helped to retain staff

54. What Have We Learned? Part I: Possibilities of change Broad-based culture change in LTC is urgently needed Broad-based culture change in LTC is urgently needed For the quality of life of elders For the quality of life of elders For the quality of work of staff For the quality of work of staff Culture Change efforts encounter multiple sources of resistance Culture Change efforts encounter multiple sources of resistance Creating and sustaining meaningful change requires Creating and sustaining meaningful change requires Addressing not only values and good intentions but also Addressing not only values and good intentions but also Organizational processes and structures, and Organizational processes and structures, and Staff development and training Staff development and training Attention to the former without dedicated leadership in dealing with the latter is unlikely to succeed Attention to the former without dedicated leadership in dealing with the latter is unlikely to succeed Changing physical architecture (replacing hallways with more home-like areas) facilitates but is not essential for culture change Changing physical architecture (replacing hallways with more home-like areas) facilitates but is not essential for culture change

55. What Have We Learned? Part I: Possibilities of Change (continued) Culture Change runs counter to State and Federal regulations based on logic of Culture Change runs counter to State and Federal regulations based on logic of punitiveness – negative sanctions rather than affirmation punitiveness – negative sanctions rather than affirmation medicalization – focused on medical treatment of illness medicalization – focused on medical treatment of illness rather than nurturing of wellness rather than nurturing of wellness

56. What Have We Learned? Part II: Consequences of Change Effort Even under difficult circumstances, culture change efforts demonstrated positive results for Even under difficult circumstances, culture change efforts demonstrated positive results for Culture Culture Elders Elders Staff Staff

57. What Have We Learned? ( Part II,continued): Co nsequences of Change Effort -- for Culture Increased options for elder participation in daily life Increased options for elder participation in daily life Increased levels of elder activity Increased levels of elder activity “Aging in place” permits development of enduring “Aging in place” permits development of enduring relationships relationships Increased local “sense of belonging” on units Increased local “sense of belonging” on units Increased awareness of “resident-centeredness” as a Increased awareness of “resident-centeredness” as a norm norm “New culture” architecture is helpful, but not essential “New culture” architecture is helpful, but not essential for meaningful, enduring change for meaningful, enduring change

58. What Have We Learned? ( Part II, continued): Consequences of Change Effort -- for Elders Increased options for controlling scheduling of Increased options for controlling scheduling of activities activities Aging in place Aging in place removes dread of forced relocation removes dread of forced relocation nourishes “sense of place” – attachment to space nourishes “sense of place” – attachment to space nourishes relationships with others nourishes relationships with others Mixing residents with different functional Mixing residents with different functional abilities provides opportunities for elders to abilities provides opportunities for elders to be helpful to others be helpful to others Reduction in Falls, fractures and other incidents Reduction in Falls, fractures and other incidents despite increased activity levels despite increased activity levels

59. What Have We Learned? ( Part II, continued): Consequences of Change Effort -- for Staff Many are Secure in their own knowledge of resident needs Secure in their own knowledge of resident needs Welcome opportunity for expanded decision- making authority vis-à-vis residents Welcome opportunity for expanded decision- making authority vis-à-vis residents Welcome the greater personal connectedness afforded by Welcome the greater personal connectedness afforded by Permanent assignment Permanent assignment Aging in place Aging in place

60. What Have We Learned? Part III: Looking back and ahead Despite the difficulties, the strong view in both facilities Despite the difficulties, the strong view in both facilities that quality of life and quality of work have been that quality of life and quality of work have been improved improved “Going back” to traditional operations is unthinkable “Going back” to traditional operations is unthinkable Culture change is never a “completed” project Culture change is never a “completed” project Culture change is an ongoing process of critical Culture change is an ongoing process of critical self-reflection and struggle for change self-reflection and struggle for change

61. Sources Barkan, Barry. 2003. The Live Oak Regenerative Community: Sanctioning a Culture of Hope and Meaning. In A.S. Weiner & J. L. Ronch (Eds.), Culture Change in Long Term Care. New York: Haworth Press. Barrack, Ann Louise, Joanne Rader, Beverly Hoeffer, & Philip D. Sloane (Eds.). 2002. Bathing Without a Battle: Personal Care of Individuals With Dementia. New York: Springer. Boyd, Charlene. 1994. Residents first: A long-term care facility introduces a social model that puts residents in control. Health Progress (September). Dannefer, Dale & Paul Stein. 2001. From the Top to the Bottom, from the Bottom to the Top: Systemically Changin the Culture of Nursing Homes. Final Report to the Van Ameringen Foundation. Fagan, Rosemarie. 2003. The Pioneer Network: Changing the culture of aging in America. In A.S. Weiner & J. L. Ronch (Eds.), Culture Change in Long Term Care. New York: Haworth Press. Thomas, William. 1996. Life Worth Living. Acton, MA: Vanderwyk & Burnham.