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Pioneering Culture Change

October 1, 2003
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What is that oft-mentioned Pioneer Network all about? BY SUSAN MISIORSKI, RN, BSN
The Pioneer Network shares its approach to creating culture change in long-term care by Susan Misiorski, RN, BSN Across the nation, a growing number of nursing homes are embracing the philosophy and values of "culture change." They are on an exciting journey to transform traditional medical-model nursing homes into places that genuinely reflect the safety, comfort, and pleasures of "home." Providers engaged in culture change are part of a movement that fosters a renewed sense of hope that nursing homes can become environments where elders, individuals with disabilities, and those who work with them can thrive.

In 1997, a small group of 33 long-term care professionals gathered in Rochester, New York, to discuss nontraditional approaches to long-term care that would support vibrant living environments for nursing home residents. From this meeting, the Pioneer Network was born. Today, it is a growing group of individuals dedicated to the culture change movement and to redefining the way aging is viewed in America. It envisions a culture of aging that is life-affirming, satisfying, humane, and meaningful in whatever setting elders live-home, assisted living, or nursing home. This article is adapted from the Pioneer Network's upcoming handbook: Getting Started: A Pioneering Approach to Long Term Care Culture Change,1 and from a forthcoming publication on resident-centered practices to be distributed through the U.S. Department of Health and Human Services' Office of the Assistant Secretary for Planning and Education.

What Is "Culture Change"?
To transform the culture of traditional long-term care institutions, it is important to first understand what this means. "Culture" is generally defined as an aggregate of customs and common ways of living by a group of individuals, passed down from one generation to the next.

The nursing home "way of living" that was transmitted from prior generations to the present is completely foreign to ways of living in the community today. Somehow, despite good intentions, systems were created that deny residents even the smallest amount of control over their lives. For example, a resident admitted to room 2 in the west wing of ABC Nursing Home will likely inherit the same bath schedule as the person occupying the bed before her. If Mrs. Jones had a whirlpool bath on Monday and Thursday at 10 a.m., then so will Mrs. Smith when she moves into that room. This pattern evolves because assignments are designed to be efficient for the staff, not to meet residents' individual needs. Residents get out of bed, go to the bathroom, eat, attend activities, and go to sleep on a schedule dictated by the facility. These systems negatively undermine quality of life to the point where American society tends to consider nursing home services only as a "last resort."

The culture change movement is working to transform this institutional approach to care delivery into one that is person-directed. The culture envisioned is one of community, where each person's capabilities and individuality are affirmed and developed. The Table identifies some of the core differences between an institution-centered culture and a person-centered culture.

To create a person-centered culture, it is necessary to fundamentally transform an organization's values, structures, and practices. The traditional hierarchical structure of the nursing home, which places power in the hands of the leadership staff, must be flattened so that more control is shifted to residents and those closest to them. Historical practices, such as having CNAs care for an ever-changing group of residents, must be discarded and replaced by practices such as consistent assignment, which allows CNAs to get to know a group of residents and care for them as individuals.

There are a number of long-term care providers throughout the country who have been working passionately to transform the living and working experience in their nursing homes. The early results are encouraging, with positive outcomes being self-reported in staff turnover, resident and family satisfaction, census, and clinical outcomes. Table. A Comparison of Cultures.

Institution-Directed Culture
  • Staff provide standardized "treatments" based upon medical diagnosis.

  • Schedules and routines are designed by the institution and staff, and residents must comply.

  • Work is task-oriented and staff rotates assignments. As long as staff know how to perform a task, they can perform it "on any patient" in the home.

  • Decision making is centralized.

  • There is a hospital environment.

  • Structured activities are available when the activity director is on duty.

  • There is a sense of isolation and loneliness.

Resident-Directed Culture