Fly right! Get on board with culture change

Recently, flying from Denver to Baltimore for the “Creating Home in the Nursing Home” conference, I couldn’t help comparing my experience of airline travel to what residents may experience on admission to a facility. I recognized it’s the lack of options that I hate about flying. I’d like to share my story and its parallels to long-term care.

The airport experience

I bought my online ticket early to ensure getting an aisle seat. I’m left-handed and more comfortable on the aisle, where I won’t punch my seatmate in the ribs. I also have difficulty sitting still for a four-hour flight. And since I don’t get to choose my seatmates, I might want to leave my seat to escape gum chewers, loud snorers, or overcrowding.

I arrive to check in. Although I thought I had taken control and guaranteed an aisle seat by purchasing the ticket early and arriving two hours before departure, the boarding pass shows otherwise. I am over-the-top courteous to the agent, hoping to recover that seat. I feel at his mercy. He explains the rules for seat assignments and what I did wrong. My sense of power is waning and my anxiety is rising. Finally he gets me an aisle seat but states this is

only because I arrived early.

Rising anxiety

I arrive at the gate. The rising anxiety is palpable. The first-class people line up a full 20 minutes before boarding. “Would all those in the various prestige classes please board?” I’m in economy. Seating area one is announced. Panic strikes when I realize I’m in seating area four and will be the last to board, with no room in the overhead bin. Finally, seating area three is announced. Anxious, I stand up; I want to be the first of the fours so I won’t have to check my bag at the airplane door and spend an hour in baggage claim at the end of a four-hour flight. I remain courteous, but the feeling of having no control over what is happening to me and my sparse belongings is high. At my seat, I find there is space for my suitcase. One hurdle cleared.

I wonder who will sit next to me; the middle seat is still unoccupied. Again, no control, no choice. My seatmate arrives and we begin negotiating territory: chair arm, elbow space. No choice. Will I have to deal with body odor, snoring, her sleeping body falling on me? Flights are full these days; there are no options for changing seats-even to take a dreaded middle seat.

The pilot announces he expects “chop,” so the flight attendants and passengers must remain seated for the first 45 minutes of the flight. Curses! I forgot to go to the bathroom before boarding (or is it anxiety?) I cannot even control going to the lavatory. And to make matters worse, the plane is bouncing all over the place. Finally, after an hour, the seatbelt sign goes off and I leap up. Five people are ahead of me when I arrive at the bathroom door. I wait and wait and, of course, to add to the agony, the first-class bathrooms are empty while we in economy must wait in line. Isn’t access to the bathroom a basic civil right? I understand the travelers in first class paid more, but really, why can’t we use the available facilities? I, who never have trouble speaking up, now feel so disempowered that I cannot bring myself to say to a flight attendant, “Could one or two of us use the bathroom up front? We’ve been waiting 20 minutes.” Finally I get to the bathroom and return to my seat.

Needs and wants

Negotiations for space begin again. The man in front of me has put his seat all the way back. The man behind me is 6-ft. tall so I hate to put my seat back, but what to do in order to sit comfortably? I compromise; I put my seat back a little and ask if he is okay with it.

Here comes the drink cart. Again, I struggle to get what I want: a whole can of Diet Pepsi instead of a cup, which is mostly ice. I also ask for water without ice, to take a pill. Oh my gosh, if looks could kill! Without saying a word the attendant slams down the can, a cup of ice, and a cup of water, no ice. Yikes! What is happening to me?

In preparation for the conference, I’ve been reading a pile of articles on culture change, and I realize I’m experiencing the very feelings I’ve been reading about: powerlessness and increasing helplessness over my treatment. I recently heard someone say, “Flying is the ultimate metaphor for human freedom.” This could not be further from the truth.


The American Association of Nurse Assessment Coordinators (AANAC) is a nonprofit professional association representing nurse executives working in the long-term care industry. AANAC is operated by nurses for nurses and is dedicated to providing members with the resources, tools, and support they need in their specialized role of leaders and managers in long-term care. To join or get more information, visit or call (800) 768-1880.

No culture change

I imagine being admitted to a facility that has not implemented culture change to any degree. On my arrival someone hands me a pile of paper and begins to explain all the rules and all the reasons I can’t have choices-privacy rules, reimbursement rules, advanced directives, and so on. I’m overwhelmed.

Eventually, I’m taken to a room not of my choosing and introduced to a roommate also not of my choosing. I worry, “What if she has any habits that annoy me, like gum chewing or loud snoring?” And I will be living with this not for four hours but perhaps for the rest of my life. A window? I’m the newcomer, so no window, just a curtain and a dark corner. Panic strikes deep.

I can’t get to the bathroom without staff help, so I am totally at their mercy. I ring the bell but I’ve arrived in airline hell, only worse, waiting with no clear sense of when I will be able to use the bathroom. No wonder some residents feel they get control by wetting themselves. Let’s face it, that is a form of control, no matter how self-defeating it may be. I now understand what my grandmother once told me as I demanded she be helped to the bathroom: “The staff are busy, I have to wait my turn. You go home tomorrow but I live here, so don’t make trouble for me by making demands.”

What is left?

Time for lunch. I’m taken to the dining room and seated with people I either don’t know or have nothing in common with. Food is put in front of me. This isn’t the food I would typically eat. It’s good, but I wouldn’t eat this. I’m used to my bigger meal at night and only a sandwich at lunch. My tablemates don’t say much but I go ahead and introduce myself.

I have recently lost my husband, my home, most of my belongings, and my ability to physically care for myself. Now I face possibly losing all choice in my life. What is left for me?

One of the culture change articles I’ve been reading states, “We humans create our future by having choices. This is how we imagine a future.” What future could I imagine in the place I just described? If, in fact, “home is where dreams live,” how are we creating choice and dreams for residents? What if, on admission to a nursing facility, I was presented not with a pile of papers but with a nurse who said, “What does your future hold for you? What do you imagine yourself doing while here?”

Final thoughts

I think I may understand the disempowerment that residents feel, if only for the four hours of my flight. We all deserve to define our futures. Don’t put residents through airline hell. Line up to get on board with culture change or we’ll be the ones in seating area four before we know it. Please have your boarding pass ready.

Diane Carter, RN, MSN, CS, is President/CEO of AANAC, with more than 30 years of long-term care nursing leadership. She is also on the Steering Committee for the Advancing Excellence Campaign, and has been a board member of the Colorado Culture Change Coalition. Long-Term Living 2010 September;59(9):49-50

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