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RAI/MDS process and nurse competencies in culture change

February 1, 2011
by Diane Carter, RN, MSN, CS
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New guidelines promote enhanced leadership, communication
Diane Carter, RN, MSN, CS
Diane Carter, RN, MSN, CS

The MDS 3.0 demands that you focus on resident voice and choice. But the MDS, Care Area Assessments (CAAs), and care planning will take you only so far in transforming this federal mandate into real choices in the daily lives of your residents. Without organizational infrastructure and processes in place to support making the MDS 3.0 a living and breathing document at the facility level, resident voice and choice will reside in the chart, thus denying the resident the opportunity to live the life s/he might imagine. For example, the MDS asks, “How important is it to you to choose your bedtime?” If I was asked this question I would assume that my preference would be honored starting the day of my arrival in the community. Simply by asking questions, this tool sets in motion a series of expectations about care. Is your facility staff prepared to meet them?

Several years ago the Hartford Institute for Geriatric Nursing began collaborating with the Coalition of Geriatric Nursing Organizations and Pioneer Network on a grant funded by the Commonwealth Fund. They convened a panel of 31 nursing and other experts to explore opportunities for and barriers to nursing and culture change. The panel worked to answer the question, “What is the role of nurses in achieving and sustaining this change?”

The decision was made by a core group of nurses and clinical nurse leaders involved in cultural transformation to create a list of useful and realistic competencies that are unique to culture change nursing. They built the competencies on an already completed body of work that identified specific clinical competencies for geriatric nursing (see www.aacn.nche.edu/education/gercomp.htm and Position Descriptions and Related Competencies for Long Term Care Nursing Positions, www.ltcnursing.org). The initiative brought together nursing and geriatric experts from across the country and resulted in the document “Nursing Competencies for Nursing Home Culture Change.” The paper offers 10 competencies deemed most relevant and critical for creating and sustaining person-directed care (see below). It allows communities a specific list of guidelines they can follow to ensure proper provision of the voice-and-choice mandate.


Why are these nursing competencies necessary when there are already so many existing competencies in which nurses must be proficient? Adding a new list of skills may seem like overkill, but it is not. Creating these competencies is step one in developing measurements and other tools that can educate and support nurses in this work. This will allow nurses a measurable tool that focuses not only on the physical tasks of nursing, which at times seem to take precedence, but also on enhanced communication skills designed to improve the outcomes of those tasks. It is expected that the creation of new competencies will not undermine existing competencies but boost the quality of care overall, and that the skill sets will build on each other.

With these new competencies, the nurse:

  • Models, teaches, and utilizes effective communication skills such as active listening, giving meaningful feedback, communicating ideas clearly, addressing emotional behaviors, resolving conflict, and understanding the role of diversity in communication.

  • Creates systems and adapts daily routines and “person-directed” care practices to accommodate resident preferences.

  • Views self as part of the team, not always as the leader.

  • Evaluates the degree to which person-directed care practices exist in the care team and identifies and addresses barriers to person-directed care.

  • Views the care setting as the residents' home and works to create attributes of home.

  • Creates a system to maintain consistency of caregivers for residents.

  • Exhibits leadership characteristics/abilities to promote person-directed care.

  • Role models person-directed care.

  • Problem solves complex medical/psychosocial situations related to resident choice and risk.

  • Facilitates team members-including residents and families-in shared problem-solving, decision-making, and planning.

The release of “Nursing Competencies for Nursing Home Culture Change” is supported by these eight esteemed national nursing organizations, part of the Coalition of Geriatric Nursing Organizations:

  • American Academy of Nursing (AAN), Expert Panel on Aging

  • American Assisted Living Nurses Association (AALNA)

  • American Association for Long Term Care Nursing (AALTCN)

  • American Association of Nurse Assessment Coordination (AANAC)

  • Gerontological Advanced Practice Nurses Association (GAPNA)

  • Hartford Institute for Geriatric Nursing (HIGN)

  • National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC)

  • National Gerontological Nursing Association (NGNA)

To view and download a complete copy of “Nurse Competencies for Nursing Home Culture Change,” please visit: www.pioneernetwork.net/Providers/ForNurses.