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
1
Acknowledgments
This is a joint project of
With support from
Grant to the
University of Minnesota
School of Nursing
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
This project is endorsed by:
Project Steering Committee
View List of Members
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
About Module 3: Resident Directed Care
and Culture Change in Nursing Homes
Objectives/Purpose:

Describe the concepts of resident-directed care and
culture change in nursing homes
At the end of this module
you will be able to:

Compare and contrast the benefits of choosing
culture change nursing homes as clinical placement
sites

Evaluate a nursing home’s adoption of residentdirected 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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Reasons to Choose a Culture Change
Nursing Home as a Clinical Placement Site
Expose students to a respectful
model of care that:
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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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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:
The same staff
providing and
organizing their care:
•When to get up and go
to bed
•Staff and resident
together deciding the
care
•When, where and what
to eat
•How often and where to
bathe
•A care plan that is in
the resident’s (e.g.
“I”) voice
•Keeping a pet
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Geriatric Nursing Competencies for
Resident Directed Care
Click to view the competencies developed by the Pioneer Network
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Outcomes of Culture Change
Nursing homes implementing culture change report improvements in:
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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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
Eden Alternative: a philosophy of
home and practice
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 deinstitutionalize LTC
 “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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Professional Nurse Practice Model Should
Underpin Culture Change Nursing Homes
Interdisciplinary team
shares accountability
for care outcomes
Decentralized
organization
Aspects of
Professional Nurse
Practice Model
Site-specific innovations
designed and
implemented by nurses
Empowered bedside
staff (i.e., CNAs)
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
Nurses may not have
been involved in creating
this culture change
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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 http://pioneernetwork.org/Consumers/Guide
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Recap: Key Points about Resident-Directed
Care and Culture Change
Culture change nursing
homes can serve as
excellent clinical placement
sites by exposing students
to innovative:

Care practices aimed at
improving resident quality of
care and quality of life

Nursing service delivery
models
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Resident and staff decision
making

Care plans and
interdisciplinary team
planning

Environmental designs that
replicate a sense of home
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing