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Culture change: Its lapses, anomalies—and achievements

May 1, 2007
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Culture change” was not born, nor was it founded. Rather, it emerged out of the experiences of long-term care (LTC) devotees and enthusiasts. Their ideas and ideals, filtered through a common perspective, found a thematic unity under the culture change canopy.

In its barest formulation, “culture change” is a call to nursing facilities to abandon the traditional efficiency model of institutional caregiving and adopt a culture of quality, the practice of “person-centered care,” that affirms the dignity of residents and staff, respects their individuality, maximizes their choice, and empowers them.

The term “culture change” sounds appropriately sophisticated, high-minded, and ambitious. That image and its message quickly radiated throughout the LTC rank and file and attracted followers of many stripes and varied agendas. Soon, LTC added the term to its lexicon.

From the start, no one claimed parentage, no charismatic leader gave the rallying cry, no official canon defined its orthodoxy, no organization claimed jurisdiction over it. It had a compelling vision, but it had no institutional anchor; its varied ideas were summed up in a set of principles, but the door remained open for new arrivals.

This social and theoretical tolerance, predictably, encouraged an undergrowth of incongruities, inconsistencies, and anomalies. Today, culture change is an open, catchall term, sometimes liberally applied to careless definitions, unmarinated concepts, and unfinished agendas. Consider these obvious anomalies:

The Power and Politics of Words

“Culture change” is not a neutral term—it takes a stand. It bids us to do what we accuse state surveyors of making us do; it makes us focus on the process, not on the goal. Notice that many a successful movement is known by a name that proclaims its mission and goal—labels such as “pro-choice,” “civil rights,” and “solidarity” identify their goals clearly. The label “culture change” does not.

“Culture change” is like the reformist preacher's call that asks you to take the righteous path. How do you greet the preacher at your door eager to sell you the culture change message when you have successfully implemented it already? What if you reached that goal via roads less traveled that don't show on the preacher's MapQuest directions? Is Culture Change Route 1 the only assured highway to excellence?

You have to keep reminding yourself: Culture change is the process. A compassionate, caring culture is your goal.

Next, look at the term “resident-centered” care. Do you really mean what the term implies? If a “resident-centered” culture is what you wish to establish, where does the caregiver fit in that setting? In a culture of caring, everyone looks out for each other. The resident is, of course, your primary customer, but the caregiver is always your first customer. In a “person-centered” community, a resident's bill of rights goes hand in hand with the resident's bill of responsibilities, especially toward the caregiver.

The media give lurid coverage to resident abuse, but ignore the much more prevalent abuse of caregivers. Of all assaults that occur in the service sector in a year, 27% occur in nursing homes. In a year, 92% of CNAs are pushed, grabbed, or shoved by a resident, with half of CNAs experiencing this 10 times during that year; 70% are hit or have something hard thrown at them; and 40% are kicked or bitten. Can we expect caregivers to deliver quality of life to residents if there is no quality to their lives? A “person-centered” ambience affirms the dignity of all—residents, staff, managers, and families.

Total Surrender or Part Victory?

You have heard the familiar lament: Institutionalized living depersonalizes residents. All too quickly does a new resident surrender his or her established personal routine, preferences, and choices to the institutional demands of nursing home life. Institutional efficiency feeds on personal individuality and creates institutional conformity.

Examine the issue from two angles. Does institutional conformity cramp the human spirit? A familiar case may provide the context and suggest an answer. Catholic convents and monasteries are quintessential social institutions. Much activity within their walls is collective; life is structured and the organization's identity takes primacy over the individual's. Many are close-knit, caring communities in which collective responsibility ensures an individual's welfare. Through the centuries from within their walls have emerged the finest examples of human achievement, from Catherine of Siena—mystic, teacher, reformer, and diplomat—to the Nobel Laureate Mother Teresa; from Saint Augustine—sinner, saint, and theological giant—to Saint Ignatius and his Jesuits, who shaped the history of Europe. Monastic life has nurtured talent that has enriched every aspect of human endeavor.

If tightly organized life is harmful to residents, you prevent such harm not by tearing down institutional structures—a mission impossible—but by doing two things. First, you redesign the physical and social structure to set up neighborhoods, a task that has been imaginatively explored in several facilities and design-oriented publications. Second, you use institutional logic to create systems that inculcate, monitor, remind, reward, and encourage excellence in caregiving. Much of this terrain lies fallow.