Introducing Resident Directed
Care and Nursing Home
Culture Change: A Case Study
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 5 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 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 and The American Association of Colleges of Nursing
About Module 5- Introducing Resident-Directed
Care and Nursing Home Culture Change: A
Case Study
Objectives/Purpose:
At the end of this module
you will be able to:

In a culture change nursing home: assist faculty to
structure student clinical experiences

In a traditional nursing home: integrate principals of
culture change and resident-directed care into the
clinical experience

In both types of nursing homes: collaborate with
nursing home staff to create learning experiences that
promote student understanding of resident-directed
care
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Scenario: School of Nursing
Erica Meyers, MSN, BC, RN, is a
gerontological clinical nurse
specialist on the faculty at Astor
University School of Nursing.
A recent revision in the
curriculum includes a clinical
experience for undergraduate
students in a nursing home as
part of a geriatric nursing course.
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Focus of Students’ Clinical Experience
Provide students with
opportunities to apply knowledge
about geriatric care with a
particular focus on the frail older
adult
Acquire an understanding of
culture change and residentdirected care
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Goals for Nursing Home Selection
Erica’s goal is to select 2 nursing
homes engaged in transforming from
an institutional (traditional) model to a
resident-directed care model
In a resident-directed care home:
 Care focuses on resident needs,
wants, habits and preferences
 Students have positive learning
experiences and are encouraged to
consider a career in long-term care
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Goals for Nursing Home Selection
Erica identified all nursing homes
in a 25 mile radius of the
university by going to the CMS
web site Nursing Home Compare,
http://www.medicare.gov/NHCom
pare/
Nursing Home Compare provides
information about nursing home
quality, including the CMS 5 Star
Rating
Click here to view the Nursing Home
Compare Website
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Erica found six nursing homes whose CMS quality ratings varied from 2 to 5
stars. On CMS quality of care and life measures, two homes (Spring Lake and
River Shores) ranked higher than other homes in the state and the U.S.
Note: Nursing Home Compare did not provide information about whether or not these nursing
homes were engaged in culture change.
Spring Lake
River Shores
9
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Identifying Culture Change Nursing Homes
To verify if these two nursing homes had a resident-directed care philosophy, Erica:
1
Identified her state coalition website through the Pioneer
Network State Nursing Home Culture Change Coalition
http://www.pioneernetwork.net/Coalitions/Websites
2
Spoke to her state coalition representative
3
Recorded her findings
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Erica’s Findings
Spring Lake had been engaged in culture change for 6
years and was well known for their quality of care
River Shores had a good reputation for quality of care with
traditional care practices
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Evaluating the Culture Change Nursing Home:
Spring Lake Web Site
•
Spring Lake web site shows that it was designed with
neighborhoods* that have:
• Private room and bath for every resident
• Permanent staff focusing on resident preferences
and abilities and
• Residents pursuing their individual interests
*Neighborhoods consist of : Small units of 8-20 residents
 Consistent staff assignment
 Separate dining and living areas
 Local (i.e., community) decision making
To view a profile of a nursing home, click on the following link:
http://www.innovations.ahrq.gov/content.aspx?id=1906
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Evaluating the Traditional Nursing Home:
River Shores Web Site
River Shores web site shows that it provides:
• Care for persons needing medical supervision by
licensed nurses
•
Help and support for physical and emotional wellbeing
•
A comfortable and supportive environment
 Availability of 24 hour medical personnel
 Private and semi-private rooms
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Arranging to Visit the Culture Change Nursing
Home: Spring Lake
Below is the phone conversation between Erica and Jan Avery, BSN, RN, BC, Spring
Lake Director of Nursing
Erica: Hello, Jan. My name is Erica Meyers and I am on the
nursing faculty at Astor University. I am interested in having our
nursing students learn about geriatric nursing and residentdirected care at Spring Lake. I understand that Spring Lake has
been on the nursing home culture change journey for six years.
Jan: That is correct, Erica. I am pleased that you know about us
and am interested in exploring having nursing students at Spring
Lake
Erica: Can we arrange a time for me to come to Spring Lake?
Jan: Yes, and I’d like you to meet with some of the nursing staff
and residents.
Erica: I could come next week Wednesday at 2 p.m.
Jan: That’s a good time. Every afternoon some residents are
planning the meal menus for the next day and baking the dessert
for the evening meal.
Erica: Great! I look forward to spending time at your residents’
home.
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Arranging to Visit the Traditional Nursing Home:
River Shores
Below is the phone conversation between Erica and Sue Jones,
BSN, RN, BC, River Shores Director of Nursing
Erica: Hello, Jan. My name is Erica Meyers and I am on the
nursing faculty at Astor University. I am interested in discussing
clinical placements for our nursing students at River Shore.
Sue: I would be very interested in exploring having nursing
students at River Shore. We pride ourselves on our excellent
nursing care
Erica: We are committed to exposing students to homes with
excellent care. We also want students to learn about residentdirected care. Does this philosophy happen at River Shore?
Sue: Our leadership team is discussing culture change and
plans to introduce it to staff soon
Erica: Could we arrange a time for me to come to River Shore?
Sue: Yes, and I would like you to meet some of our registered
nurses and learn how they assure quality nursing care for
residents
Erica: I could come next week Thursday at 10am
Sue: That’s a good time. I can give you a short tour and you can
sit in on nurses’ care rounds for residents at high risk for falls
Erica: Great! I look forward to meeting you and your staff and
learning more about River Shore
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Helpful Resources in Preparing to Visit the
Nursing Homes




These resources helped Erica prepare to evaluate the quality of each home and their
involvement in/commitment to resident-directed care
Observable Indicators of Nursing Home quality Instrument (Rantz et al, 2006)*
 http://www.nursinghomehelp.org/OIQaL.pdf
Artifacts of Culture Change
 http://www.pioneernetwork.net/Providers/Artifacts/
 http://culturechangenow.com/pdf/artifacts.pdf
Resources from the Pioneer Network re:
 Consistent Staff Assignments ,
http://www.pioneernetwork.net/Providers/Continuum/CareAssign/
 Dining Practices, http://www.pioneernetwork.net/Providers/Continuum/Dining/
 Bathing Practices, http://www.pioneernetwork.net/Providers/Continuum/Bathing/
 Medication Administration,
http://www.pioneernetwork.net/Providers/Continuum/Medication/
Click here to view content on resident directed care and culture change: Module 3: Resident Directed
Care and Culture Change
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Visit to the Culture Change Nursing Home:
Spring Lake
A resident greeted Erica at the
neighborhood door.
Erica walked through the neighborhoods
observing and talking with staff and
residents.
Erica used the resources to
evaluate the environment,
quality of professional nursing
care, and resident-directed
care practices.
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Visit: Spring Lake
When visiting Spring Lake, these are some of the things Erica saw:
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Evidence of Culture Change: Spring Lake
• Neighborhoods had no visible nurses station
• Medications kept in the residents’ room; no visible medication
carts
• Residents could choose what they wanted to eat and could eat
meals on their own time schedule
• Food was available 24 hrs/day
• Residents’ care plans were called “I-Care Plans,” e.g. care
plans in the resident’s voice and developed together by
resident and staff
For examples of “I” care plans, see the following links:
http://jeny.ipro.org/showthread.php?t=2006
“I” Care plan example- Riverview Care Center
“I” Care plan example- Clark-Lindsey Village
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Student Learning: Spring Lake
• Erica told Jan about the objectives and content of the geriatric
nursing course and resident-directed care
• Jan brought in Lisa Thomas, RN, BSN, BC, coordinator for two of the
neighborhoods available to students. Together, they identified
potential student learning experiences about resident-directed care.
– Students work with Click
nursing
learn
how
towith
bathe residents
to view assistants
article regardingto
bathing
older
adults
dementia
with dementia
– Role of the professional nurse in culture change
Click to view Culture Change
background paper
– Students shadow the nurse coordinator to learn about the role of the
professional nurse and nursing home culture change
– Students attend meetings as staff plan the day according to the
residents’ preferences
– Students participate in an interdisciplinary care meeting with a resident
and their family
– Students develop I-Care Plans for their residents
Click to view sample I-Care
Plan
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Staff Learning: Spring Lake
• Erica discussed the use of evidence-based geriatric nursing
assessment and interventions
• Jan & Lisa indicated a desire to educate themselves and staff about
evidence-based care
• Erica showed them the website www.ConsultGeriRN.org. She
specifically reviewed the:
– The Try This® Assessment Series
– The How to Try This assessment videos
– The AJN Series on How to Try This
– Evidence-based Protocols
• Erica shared two examples of student assignments that students will
have as part of their experience at Spring Lake
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Student Assignment: Resident Assessment Spring Lake
Example 1: A student conducts a
cognitive assessment with a resident
using 2 standardized instruments. In
the clinical conference, the student
will describe:
The purpose of the assessment
instrument
The results of the assessment
The interpretation of the results
How their findings compare with
recent MDS and medical diagnoses
of the resident
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Student Assignment: Observing Resident
Behavior - Spring Lake
Example 2: A student observes
behavioral symptoms of
residents with cognitive
impairments. In the clinical
conference, the student will
describe:
– Observed behavioral
symptoms
– Potential causes of behavioral
symptoms
– Effectiveness of strategies that
nursing staff used to
reduce/minimize symptoms
– Comparison of staff practices
used to bathe residents with
the nursing literature
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Creating a Learning Partnership: Spring Lake
Jan & Lisa were
enthusiastic about creating a
plan for staff professional
development re evidencebased assessment and care.
They proposed:
Students conduct a “journal
club” for staff
Staff review assessments
and protocols on
www.ConsultGeriRN.org
Partnering to develop
evidence-based policies and
procedures for Spring Lake
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Preparing for Student Experiences: Spring Lake
Erica, Jan & Lisa identified how to prepare for student
experiences at Spring Lake
– Resources to assure that students understood
resident-directed care and culture change
– Time for Erica to meet with:
• Staff to explain student rotations
• Residents to determine their willingness to have
students assist them with their care
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Visit to the Traditional Nursing Home:
River Shores
• Erica was greeted by a receptionist at a desk in the foyer area.
• The receptionist paged Sue on the overhead pager. While Erica was
waiting for Sue, she talked to several residents who were sitting in
the foyer in wheelchairs.
• Several minutes later, Sue greeted Erica and they toured the home.
• Erica observed and talked to nursing staff and some residents during
the tour.
• Erica used her resources to evaluate the environment, quality of
professional nursing care, and person-directed care practices.
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Visit: River Shores
When Erica visited River Shores, these are some of the things she saw:
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Evidence of Traditional Care:
River Shores
At River Shores, consistent with a
more traditional nursing home, Erica
observed:
The home arranged in 2 “wings” with
nurses station in center and four hallways off
the nurses station

Residents dressed and sitting in wheel
chairs around nurses station

Two medication carts with nurses
administering meds in the hallway and in
resident’s rooms


A main dining room and posted mealtimes

Staff smiling and laughing with residents
Nursing assistants offering water to
residents

Staff conducting exercises in lounges on
each wing

© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Student Learning: River Shores
Erica told Sue about the objectives and content of the geriatric nursing course and
resident-directed care
Sue brought in Alice Trent, RN, BSN, BC, Asst. Director of Nursing. They had
implemented evidence-based care but were very early in introducing residentdirected care.
Together, they identified potential student learning experiences about
resident-directed care.
Students review how current nursing care practices for bathing,
dining, medication administration, staff assignments will change
when River Shore starts to implement resident-directed care
Students develop a model “I” care plan in a resident’s voice
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Staff Learning: River Shores
Erica discussed early steps to introduce resident-directed care. Sue & Alice were
enthusiastic to educate themselves and staff about resident-directed care.
Together they agreed to implement the following activities:
A Learning Circle with staff and students to
discuss:
 What does “home” mean to you?
 When you come to a nursing home to live,
what will make if a “home” for you?

Click to view guidelines for a Listening and Learning Circle
Students
to develop and share their residentdirected “I” care plans with staff
 Students to start and run a journal club to discuss
the article “Bathing the Older Adult with Dementia,”
Nursing staff to receive a copy of the article in
advance
Lunch served
Click to view article regarding bathing older adults with
dementia
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Preparing for Student Experiences:
River Shores
Erica, Sue & Alice identified how to prepare
for student experiences at River Shore.
Resources will be developed to assure that
students understand resident-directed care
and culture change.
Scheduled a time for Erica to meet with:
• Staff to explain student rotations
• Residents to determine their willingness
to have students assist them with their
care
Learn more about resources for resident-directed care
© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing
Recap: Key Points about Introducing Resident-directed
Care and Nursing Home Culture Change: A Case Study
Staff in a culture change nursing
home can: assist faculty to select and
structure student clinical experiences in
resident-directed care

We present the following
key points to consider:
Staff in a traditional nursing home
can: learn the principals of culture change
and, working with the faculty and students,
integrate resident-directed care into the
students’ clinical experience

In both types of nursing homes:
faculty collaborate with nursing home staff
to create learning experiences that promote
student understanding of resident-directed
care in established culture change nursing
homes and in transitioning nursing homes.

© 2010 The Hartford Institute for Geriatric 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 and The American Association of Colleges of Nursing