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Inspiring a culture change journey

August 1, 2009
by Betty MacLaughlin Frandsen, RN, NHA, BSHCA, CDONA/LTC
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Culture change is a topic of growing interest in long-term care, but confusion remains for many about its real meaning, especially if individuals have no firsthand knowledge of this initiative. Some believe culture change requires an increased emphasis on cultural diversity or on adopting a more professional business culture. Others think it requires extensive and expensive structural changes that result in a more appealing environment.

While those things can be part of a journey to improvement, culture change is primarily concerned with a renewed focus on the resident as the center of all activity within the long-term care setting. Initiatives do not have to be expensive or exhausting. What matters most is creating an atmosphere that empowers staff to perform their jobs in a way that demonstrates they believe the resident is the center of everything they do. True culture change is a personalized journey in each setting desiring to provide care that is individualized, respectful, and dignified. It is achieved by the collective heart of those who live and work together.

Start small

When embarking on a culture change journey, it is best to start small rather than taking on too much and becoming overwhelmed in the process. Since change is often resisted, draw in direct-care team members from the start and seek input from all levels of employees willing to share in the generation of ideas. At first our efforts might seem like baby steps, but early successes become a strong foundation for future growth. Inviting certified nursing assistants (CNAs) to participate in interdisciplinary care plan meetings in a meaningful way, not merely through their attendance, acknowledges that frontline workers know a great deal about the needs and wishes of residents. Who can speak better of the daily habits, likes and dislikes, and care needs of residents than the CNA? A first culture change step then may be as simple as arranging staffing coverage that allows a CNA as the caregiver of the resident to join the care conference and share what he or she knows and experiences daily with the individual.


Historically, long-term care facilities have placed their focus on tasks that must be performed and systems designed to ensure the work gets done. Culture change is primarily concerned with a renewed focus on the resident as the center of all activity within the long-term care setting. That may work for patients in a hospital, but who among us wants to spend the rest of our lives in a hospital-like setting? Culture change has generated movement away from the hospital-based medical model that dictates a day to shower, a time for meals, a time for activities, restrictive visiting hours, and a time for lights out. Long-term care facilities are re-creating their focus from the inside out, and performing an internal self-assessment is the place to start.

A baseline self-assessment achieved by an honest look at where your facility's focus truly lies provides the information needed to begin or strengthen a culture change journey. Walk through your center and actively look at everything as if you are experiencing it for the first time. Active looking goes beyond a walk-through in which things seen daily are accepted as normal. Active looking requires special effort to examine each thing observed, questioning if it should really be that way. When exiting an elevator, see if the appearance is pleasant and homelike or is it hospital-like with medical equipment and posted memos the first things that catch one's eye? Observe resident-staff interactions. Is there evidence of a caring attitude toward the people who live there, or do you see staff focused on completing tasks, visiting with each other, going on break, or going home? Look carefully at resident rooms, hallways, shower and tub areas, and lounges. Do they please the eye? A committed team can remove clutter and make a big difference. As you practice active looking, do you see a place you would want to live, not just based on eye-appeal, but on the interactions you observe? This initial activity will reveal opportunities for culture change initiatives and education.

‘See the reality’

After you personally complete the active looking exercise, replicate it by having your nurses and your nursing assistants view their work area in the same way. Generate discussion that helps them “see” the reality of the workspace they have helped create. Ask each of them to spend just five minutes on active looking to identify areas needing improvement, and then bring them together to discuss their findings. This activity will help you get their attention so you can begin your culture change journey together. Based on what they identify, start with a small project in an area where the team expects to have success.

Culture change requires a team effort. Nursing administration's role is not to dictate how it must be done, but rather to encourage and facilitate the development of ideas that come from residents, nursing staff, and other departments, and then to ensure that projects remain within the boundaries of regulation and life safety codes. Regulation in reality strives to drive us to deliver person-centered care. Identify the strengths, needs, and talents of staff and residents, and use that knowledge to create warm and caring neighborhoods within the overall community that is your long-term care facility.




Interestingly, the patient does not seem to be a core team member! Gee, how about having a patient advisor or representative on the "team," since they are the ultimate user?!

I enjoyed the article. However, in my opinion, the writer missed the point. In the paragraph about the care plan meetings (a government-centered requirement) she asked, " Who can speak better of the daily habits, likes and dislikes, and care needs of residents than the CNA?" The answer is not the CNA. The correct answer is "the resident."
Thanks for this opportunity to comment.
Dan Moles