1. Resident Directed Care and Culture Change in Nursing Homes
Christine Mueller, PhD, RN, FAAN University of Minnesota School of Nursing Mathy Mezey, EdD, RN, FAAN, Sarah Greene Burger, RN-C, MPH, FAAN Ethel Mitty, EdD, RN Hartford Institute for Geriatric Nursing, New York University College of Nursing
Module 3 of Nursing Homes as Clinical Placement Sites for Nursing Students Series

2. This is a joint project of University of Minnesota School of Nursing
Acknowledgments
This is a joint project of
With support from
Grant to the
University of Minnesota School of Nursing 2

3. This project is endorsed by:
Project Steering Committee
View List of Members

4. At the end of this module you will be able to:
About Module 3: Resident Directed Care and Culture Change in Nursing Homes
Objectives/Purpose:
At the end of this module you will be able to:
Describe the concepts of resident-directed care and culture change in nursing homes
Compare and contrast the benefits of choosing culture change nursing homes as clinical placement sites
Evaluate a nursing home’s adoption of resident-directed care and culture change
Explain the differences between a culture change nursing home and a traditional nursing home
Explain the CMS Artifacts of Culture Change
Identify the risks to nurses when working in a culture change nursing home 4

5. Reasons to Choose a Culture Change Nursing Home as a Clinical Placement Site
Expose students to a respectful
model of care that:
Creates a home-like environment
Offers a resident choices about the timing and manner of their care
Empowers RNs, LPNs, and nursing assistants to structure care in a flexible/responsive way
Improves a resident’s sense of identity and purpose

6. Resident Care in a Traditional Nursing Home
A resident in a traditional nursing home would have:
Wake up, meals and baths on a rigid/fixed schedule
Nursing staff who do different “tasks” e.g. temps; meds; toileting
Care dictated by nursing home protocols and procedures
A room and environment that looks like a “mini hospital,” e.g. no small sitting rooms, few plants, pets restricted, limited availability of snacks.
Little attention to their emotional and quality of life needs, e.g. what makes them happy, engaged
A sense of isolation and loneliness

7. Resident Care in a Culture Change Nursing Home
A resident in a culture change nursing home would have:
A home-like environment (pets; plants; food available 24/7)
Choice as to:
When to get up and go to bed
When, where and what to eat
How often and where to bathe
Keeping a pet
The same staff providing and organizing their care:
Staff and resident together deciding the care
A care plan that is in the resident’s (e.g. “I”) voice
Families welcome and participating in care
Click to View Information about Nursing Home Comparisons at the Pioneer Network
Learn more about Continuum of Person-Directed Culture

8. Geriatric Nursing Competencies for Resident Directed Care
Click to view the competencies developed by the Pioneer Network

9. Outcomes of Culture Change
Nursing homes implementing culture change report improvements in:
Quality (pressure ulcers, restraint use, catheter use)
State survey outcomes
Staff turnover and less use of agency staff
Per bed net income
Operating margin
Occupancy

10. Research Supporting Culture Change is Limited
Culture change took hold as “the right thing to do” without research evidence
Creating a research base was seen as slowing down the adoption of culture change
Culture change was initiated by practitioners and consumers
The few existing research studies on culture change have variable designs and small sample sizes

11. The Path to Resident Directed Care and Culture Change
Nursing homes vary as to how they incorporate the principles and practices of culture change. Nursing homes differ in the extent to which they:
Create a “homey” environment
Implement practices of resident choice for food choice, dining, bathing, taking medications
Culture change is
described as
a journey.
Reconfigure nursing services and create staff
empowerment
To learn what nursing homes are participating in the culture change journey, contact the state’s culture change coalition or Google: “culture change coalition.”
Click to View CMS Survey and Certification Letter, 4/09

12. Defining a “Home Like” Environment
Household model: the generic term
Neighborhood:
Small units of 8-20 residents
Consistent staff assignment
Separate dining and living areas
Local (i.e., community) decision making
Green House:
Built from the bottom up
Changes in facility size, layout, interior design
Staffing patterns modified to reflect resident needs and preferences
Goal is to eliminate large nursing homes and de-institutionalize LTC 
Eden Alternative: a philosophy of home and practice
“Where elders live must be habitats for human beings, not sterile institutions.”
Goal: eliminate the “3 plagues of loneliness, helplessness, boredom.”
Eden concepts are integrated into different living models

13. Artifacts of Culture Change
Artifacts of Culture Change is a CMS tool to evaluate a nursing home’s progress from institutional to resident-directed care
The tool has five key domains of culture change:
1. Care Practices
2. Environment
3. Family and Community
4. Leadership
5. Workplace practices
Click to Learn more about Artifacts in culture change at the Pioneer Network
Click to Learn more about the Development of the Artifacts of Culture Change Tool

14. Artifacts of Culture Change 1: CARE PRACTICES Artifacts
24 hour dining where residents can order food from the kitchen 24 hours/day
Snacks, drinks available at all times
Waking and bedtimes and bathing preferences and times are chosen by the resident
Care plans are in the “voice” of the resident, called “I” Care plans
Residents can have their pet live with them
Someone is with a dying resident at all times
Hartford Institute for Geriatric Nursing, College of Nursing, New York University Nursing Homes as Clinical Training Sites

15. Example of a Care Plan in the “Voice” of the Resident
For examples of “I” care plans, see the following links:
“I” Centered Care Plans Message Board
“I” Care plan example- Riverview Care Center
“I” Care plan example- Clark-Lindsey Village

16. Artifacts of Culture Change 2: Examples of ENVIRONMENT Artifacts
Residents have private rooms or privacy is enhanced in shared rooms
Nurse’s stations are not visible
Medications are kept in the resident’s room
Overhead paging system is used only in cases of emergency
Personal laundry is done in the area where the resident lives
Bathroom mirrors are wheelchair accessible

17. Artifacts of Culture Change 3: Examples of FAMILY and COMMUNITY Artifacts
Space for community groups to meet with residents welcome to attend
Café/restaurant available for families, residents and visitors
Dining area available for families to have meals with their family member
Kitchen/kitchenette area where cooking and baking can be done

18. Artifacts of Culture Change 4: Examples of LEADERSHIP Artifacts
Nursing assistants attend and participate in care plan conferences
Learning circles (or equivalent) are used in resident and staff meetings
Residents and families serve on nursing home quality assessment/assurance committees
Community (household/neighborhood) meetings are held regularly with staff, residents, and families.

19. Artifacts of Culture Change 5: Examples of WORKPLACE PRACTICE Artifacts
RNs, LPNs, and CNAs consistently work with the same residents
CNAs self-schedule
Staff not required to wear a uniform or “scrubs”
Nursing home pays for outside conferences and workshops for CNAs
Career ladder, job development opportunities
Day care on site

20. Professional Nurse Practice Model Should Underpin Culture Change Nursing Homes
References:
1. Lyons et al Everyday excellence: A framework for Professional Nursing Practice in Long-Term Care. Research in Gerontological Nursing 1(3),
Beck C Professional Nursing Practice Models and Culture Change. Presented at the CGNO-Pioneer Expert Panel Meeting, NYC. Oct 27-28, 2008.

21. Nurse Leadership and Culture Change
Culture change requires a coaching and transformational nurse leadership style
Nurses have little knowledge of or experience in culture change
Nurses may be unfamiliar with this style of leadership
References:
Burger et al “ISSUE PAPER: Nurses Involvement in Nursing Home Culture Change. Overcoming Barriers, Advancing Opportunities.
Rader J “Nursing Education and Culture Change.” Presented at the CGNO-Pioneer Expert Panel Meeting, NYC. Oct 27-28, 2008.
Nurses may not have been involved in creating this culture change

22. Potential Dilemmas for RNs in Culture Change
Potential issues include:
Resident risk/harm from poor decision making
RN accountability when unlicensed staff inappropriately honor resident requests
Loss of a nurse’s station and medication carts when transforming to a home environment

23. The Pioneer Network Consumer’s Guide to Finding a Nursing Home on the Culture Change Journey
This guide provides key questions and “listen for” answers, including:
How will you get to know my family member?
What is your policy regarding food choices and alternatives?
How do you build a sense of community?
Source: Pioneer Network

24. Recap: Key Points about Resident-Directed Care and Culture Change
Care practices aimed at improving resident quality of care and quality of life
Nursing service delivery models
Resident and staff decision making
Care plans and interdisciplinary team planning
Environmental designs that replicate a sense of home
Culture change nursing homes can serve as excellent clinical placement sites by exposing students to innovative:

25. Please Proceed to the following modules of the Series Nursing Homes as Clinical Placement Sites for Nursing Students
Overview of the Project
Module 1: An overview of nursing homes generally
Module 2: An overview of nursing in nursing homes
Module 3: Content on resident directed care and culture change
Module 4: Selecting and structuring clinical placements in nursing homes
Module 5: A case study to help faculty introduce resident directed care and culture change
Module 6: Strategies to help nursing homes position themselves as clinical placement