Resident Directed Care and Culture Change in Nursing Homes

Resident Directed Care and
Culture Change in Nursing Homes
Module 3 of Nursing Homes as Clinical Placement Sites for Nursing Students Series
1
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  Compare and contrast the benefits of choosing
culture change nursing homes as clinical placement
you will be able to: 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
© 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:
 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
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

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
•When to get up and go
organizing their care:
to bed
•Staff and resident
•When, where and what
together deciding the
to eat
care
•How often and where to
•A care plan that is in
bathe
the resident’s (e.g.
•Keeping a pet “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

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

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
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
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 Culture
choice, dining, bathing, change is
taking medications 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

Defining a “Home Like” Environment
Household model: the generic term
Neighborhood: Green House:
 Small units of 8-20 residents  Built from the bottom up

 Consistent staff assignment  Changes in facility size,
 Separate dining and living areas layout, interior design
 Local (i.e., community) decision  Staffing patterns modified to
making reflect resident needs and
preferences
 Goal is to eliminate large
Eden Alternative: a philosophy of nursing homes and de-
home and practice institutionalize 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
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
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
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
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
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
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.
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
Professional Nurse Practice Model Should
Underpin Culture Change Nursing Homes
Interdisciplinary team Decentralized

shares accountability organization
for care outcomes
Aspects of
Professional Nurse
Practice Model
Site-specific innovations Empowered bedside

designed and staff (i.e., CNAs)
implemented by nurses
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
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
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

Recap: Key Points about Resident-Directed
Care and Culture Change
 Care practices aimed at

Culture change nursing improving resident quality of
homes can serve as care and quality of life
excellent clinical placement
sites by exposing students  Nursing service delivery
models
to innovative:
 Resident and staff decision
making
 Care plans and

interdisciplinary team
planning
 Environmental designs that

replicate a sense of home
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

Resident Directed Care and Culture Change in Nursing Homes

Uploaded by

Copyright:

Available Formats

Resident Directed Care and Culture Change in Nursing Homes

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Resident Directed Care and Culture Change in Nursing Homes

Uploaded by

Copyright:

Available Formats

Resident Directed Care and

Culture Change in Nursing Homes

 Evaluate a nursing home’s adoption of resident-

 Explain the differences between a culture change

 Explain the CMS Artifacts of Culture Change

 Identify the risks to nurses when working in a

Expose students to a respectful

A resident in a traditional nursing home would have:

 Nursing staff who do different “tasks”

 Care dictated by nursing home

 A room and environment that looks

 Little attention to their emotional and

 A sense of isolation and loneliness

Choice as to: The same staff

Learn more about Continuum of Person-Directed Culture

Click to view the competencies developed by the Pioneer Network

Nursing homes implementing culture change report improvements in:

 Quality (pressure ulcers, restraint

 Culture change took hold as

 Creating a research base was

 Culture change was initiated

 The few existing research

Create a “homey” environment

Click to View CMS Survey and Certification Letter, 4/09

Household model: the generic term

Neighborhood: Green House:

 Small units of 8-20 residents  Built from the bottom up

 “Where elders live must be

 Artifacts of Culture Change is a

Click to Learn more about Artifacts in culture

Click to Learn more about the Development of the

• 24 hour dining where residents can order food

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

• Residents have private rooms or privacy is

• Space for community groups to meet with

• Nursing assistants attend and participate in care

• RNs, LPNs, and CNAs consistently work with the

Interdisciplinary team Decentralized

Site-specific innovations Empowered bedside

Culture change requires a coaching and

Nurses have little

Nurses may not have

Potential issues include:

Resident risk/harm from poor

RN accountability when

Loss of a nurse’s station and

This guide provides key questions and “listen for”

How will you get to know my family

Source: Pioneer Network http://pioneernetwork.org/Consumers/Guide

 Care practices aimed at

 Care plans and

 Environmental designs that

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