Culture change starts from the heart

How does a facility achieve genuine culture change? Is it through the implementation of “person-centered care” or other innovative approaches such as the Eden Alternative? Indeed, these approaches do provide excellent models and road maps leading to culture change through such innovative ideas such as natural-timed waking and retiring, flexible medication orders/passes, liberalized diets, alternatives to showers and baths, and spontaneous activities 24-hours a day. But fundamental culture change cannot take place solely by providing these options in an environment that is not filled with warmth and compassion, unwavering dedication, genuine relationships, and a deep respect for residents.

What we in the long-term care industry must not overlook is that true culture change comes from the heart, specifically the heart of our employees.

What do residents really want?

Residents’ primary needs (or rights) include a safe environment, high-quality care, and good nutrition. However, as providers we may have become so obsessed with resident rights and needs that we have overlooked what they really want. Relationships may be more important to residents than anything else, including the environment and their ability to make choices for themselves.

Nothing takes the place of good, old-fashioned, tender, loving care. And by the way, caring from the heart is not an “intervention” that is written in the resident’s plan of care and discussed at quarterly review meetings. It is a way of life in the facility. It is absolutely necessary for culture change.

What does caring from the heart really mean?

Many direct care staff in long-term care today indicate that they choose to stay with their employer not because of their income or benefits, accumulated vacation time, or esthetics of the building, but rather for the relationships they develop with their residents, and because they feel good that they can make a difference in residents’ lives. These employees don’t feel that working in nursing homes is a job. Rather, it’s a calling. They are providing care to people who need them at the most vulnerable time in their lives.

Many employees indicate that they develop such deep relationships with their residents that they pick up nuances in their behavior and emotional state that others might overlook. For instance, if the resident isn’t eating a favorite food, that loving caregiver will know immediately that something might be wrong. Caring from the heart means developing a strong, genuine relationship with residents, just as we would with our own family and friends.

Caring from the heart also means that giving loving, personal attention is more important to many residents than the issue that worries so many administrative staff in long-term care: privacy. Indeed, we must continue to honor personal choice, dignity, and privacy. But it makes more intuitive sense that inclusion is better than seclusion, connectedness is better than withdrawal, and the opportunity to chat with someone is far better than being alone in bed for sometimes up to 16 hours per day.

Person-centered care is all about residents being in control of their lives, making decisions about their care, and expressing their wants and desires to a caring staff who will honor these things. Therefore, one of the most important things that staff can do to begin culture change is ask residents what they want. It seems to make sense that institutionalized people crave social interaction and human relationships much more than they are concerned with privacy or their care needs.

Connecting hearts and creating culture

It has been said many times that “no man is an island,” and this is certainly true in long-term care. “Creating culture change through loving care” should be first and foremost on employees’ job descriptions in nursing homes. Caring from the heart can be infectious and spread from one caregiver to another, from one resident to another, and from families to the community at large. Caring with compassion, dedication, dignity, and respect lays the foundation for real and lasting culture change. True culture change begins in the heart and creates a ripple throughout the entire facility. It expands to others, creating strong bonds of friendship and loving relationships in its path.

Hearts should be connected at every level—from management to direct care staff, from person to person, and department to department. Culture change, regardless of the method implemented, cannot occur without a deep sense of care and love from the leadership in the facility. Many transformative nursing homes have an administrative team who feel in their hearts that person-centered care or some other approach to culture change is desperately needed throughout the industry and not only endorse this kind of care, but provide living examples of how care should and can be provided in their facilities. It is important to stress that leadership can endorse caring from the heart in a number of ways. First, nurse aides, housekeepers, universal workers, or anyone else employed in the facility should feel comfortable sitting down with residents and sharing a conversation, a cup of coffee, or just holding hands while watching the resident’s favorite television program. In the more traditional and institutionalized facility, employees who are sitting around are “not doing their work.” Caring from the heart means allowing employees to care from their hearts in the manner they see most meaningful at the time.

Second, administrative staff should empower caregivers to make decisions on their own regarding what they think is best for their residents. After all, it probably is the direct caregiver who knows the residents best and is aware of their schedules, likes and dislikes, needs and desires, and personal preferences. Handing this kind of power to direct caregivers is the purest form of empowerment.

Third, all staff must become involved in the lives of the residents they serve. It isn’t up to the direct caregivers alone to fulfill the resident’s wishes. Caring from the heart to create true culture change is a team effort. Everyone on that team is vital in fulfilling our promise to provide the best care and the highest quality of life to residents in our facilities.

Most nursing homes have a mission statement and a vision. Perhaps with the tides of culture change churning throughout the country, management and floor staff can come together to rewrite their mission statement and vision to include the following statement: “We promise to provide a culture of care where caring starts from the heart.”

James Collins, PhD, is a gerontologist based in Poland, Ohio. For further information, phone (330) 707-1691 or e-mail To send your comments to the author and editors, e-mail

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