Michelle M. Doty, Mary Jane Koren, Elizabeth Sturla
The Nursing Home Reform Act, passed in 1987, established quality standards for nursing homes nationwide, emphasized the importance of quality of life, and preserved residents' rights. However, despite enactment of this law, serious concerns remain about the quality of care provided to residents in the nation's 16,000 nursing homes. To improve the quality of care and the quality of life for nursing home residents, a growing movement, known as "culture change," is working to deinstitutionalize long-term care and radically transform the nursing home environment.
In the culture change model, which has gained momentum over the past decade, seniors enjoy much of the privacy and choice they would experience if they were still living in their own homes. Residents' needs and preferences come first; facilities operations' are shaped by this awareness. To this end, nursing home residents are given greater control over their daily lives—for instance, in terms of meal times or bed times, and frontline workers—the nursing aides responsible for day-to-day care—are given greater autonomy to care for residents. In addition, the physical and organizational structure of facilities is made less institutional. Large, hospital-like units with long, wide corridors are transformed into smaller facilities where small groups of residents are cared for by a consistent team.
The Commonwealth Fund 2007 National Survey of Nursing Homes
In the past decade, there has been growing awareness of culture change among professionals and providers in the field, but the extent to which nursing homes across the country have adopted a resident-centered culture is still unknown. In 2007, The Commonwealth Fund conducted a nationally representative survey of nursing homes to learn more about the penetration of the culture change movement at the national level and measure the extent to which nursing homes are adopting culture change principles and practicing resident-centered care. A representative sample of 1,435 nursing homes was surveyed between February and June 2007.
The questionnaire was administered to directors of nursing who were asked about three domains of culture change: resident care, staff culture and working environment, and physical environment. Specifically, the survey examines whether nursing homes have adopted practices that make care more resident-directed, that engender a work environment that fosters staff autonomy and decentralized decision-making, and that alter the physical environment to make their facilities look and function like a home, rather than a hospital.
Although survey results are mixed regarding the degree to which nursing homes report they have adopted resident-centered practices, findings indicate a hopeful picture about the potential for deep, systemic change within the industry. Four or five years ago, few nursing homes were familiar with the term "culture change." Today it is recognized by and familiar to almost all providers. If the first step to change is awareness of a problem and the availability of an alternative, then the field of nursing home care is indeed poised for transformation.
Furthermore, the survey shows that in facilities that incorporate some aspects of culture change, the more culture change initiatives that are under way, the greater the benefits in terms of staff retention, higher occupancy rates, better competitive position, and improved operational costs. As the awareness of these and other competitive and operational advantages becomes more widely known, it is likely that many more nursing homes will begin to shift toward making the changes in human resource management, the physical environment, and care delivery that are the hallmarks of resident-centered care.
Using self-reported data from directors of nursing, we categorized nursing homes that participated in the survey as culture change adopters, culture change strivers, or traditional nursing homes (Figure ES-1).
In general, nursing homes have been most successful at increasing residents' involvement in decision-making, and there is some evidence that management is accommodating collaborative and decentralized decision-making to empower direct-care workers. However, very little organizational redesign has penetrated the field and very few homes have changed their physical environment to support culture change.
Culture change adopters are more likely than traditional facilities to implement resident-centered care approaches. The survey finds that there is wide variation among nursing homes in terms of the choices and autonomy given to residents and in providing environments that are resident-centered (Figure ES-2). About 30 to 40 percent of all nursing homes report they are currently implementing some principle of culture change that fosters resident-directed care, including allowing residents to determine their own daily schedules, practicing resident-centered bathing techniques, or by actively involving residents in nursing home decisions.
Culture change adopters have initiated a range of staff empowerment initiatives. Overall, a minority of nursing homes have undergone organizational changes, such as supporting a team approach for workers or cross-training staff, which makes the organization less hierarchical and empowers direct care nursing home staff. But, direct care workers are more likely to have leadership opportunities and be authorized to make decisions about delivering resident care in nursing facilities that self-identify as culture change adopters.
Very few homes are altering their physical environments. Very few nursing homes have renovated their traditional nursing units into "neighborhoods"—smaller functional areas that can include common community and dining areas—or "households," which are small home settings with a full kitchen, dining room and living areas for 25 or fewer residents and their dedicated staff. Even culture change adopters have difficulty altering their physical environments to make facilities more home-like.
The more culture change principles are embraced, the greater the increase in staff retention and occupancy rates and the greater the decrease in operational costs. As nursing homes become more engaged in culture change and adopt more of its associated practices, staff retention, market competitiveness, occupancy rates, and operational costs also improve (Figure ES-3).
Committed leadership can be a driver of culture change. Nursing homes that are considered strivers—that is, they are not yet culture change adopters, but have leaders who are committed to culture change and resident-directed care—are similar to the culture change adopters in their ability to provide resident-directed care. They also demonstrate that they are moving toward being the type of facility that empowers workers, provides direct-care workers with leadership opportunities, encourages decentralized decision-making, and allows staff to make decisions about resident care. Indeed, culture change strivers reported significantly more positive responses on all measures related to improving staff working environments, compared with traditional nursing homes. These findings reiterate the importance of a committed leadership for encouraging culture change.
The Commonwealth Fund 2007 National Survey of Nursing Homes finds that while many nursing homes are aware of the "culture change" movement, progress has been slow in transforming long-term care facilities from institutions to homes. But with the examples and best practices gleaned from the culture change movement, nursing homes can begin to make the necessary changes to improve the quality of life for their residents and staff.