Pioneering Culture Change

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

  • Staff enters into a caregiving relationship based upon individualized care needs and personal desires.
  • Residents and staff design schedules that reflect their personal needs and desires.
  • Work is relationship-centered, and staff have consistent assignments. Staff bring their personal knowledge of residents into the caregiving process.
  • Decision making is as close to the resident as possible.
  • The environment reflects the comforts of home.
  • Spontaneous activities are available around the clock.
  • There is a sense of community and belonging.

Reprinted with permission from the Pioneer Network, 2003.

The Culture Change Process
Figure 1 describes four critical elements in changing nursing home culture: Getting Ready, Implementation, Evaluation, and Continuing the Journey. The primary focus of this article is the beginning of the journey-Getting Ready.

Getting Ready
The getting-ready phase is a time for learning, self-reflection, adopting new beliefs, organizational assessment, and planning. There is much to be accomplished during this time, all of which is critical to the success of the change process.

Learning involves gathering all of the information you can to support your own growth and the education of those who live and work in your facility. By visiting other places that have person-centered environments and practices, it is possible to envision the many ways in which culture change can be accomplished.

The Teresian House in Albany, New York (Figure 2), exemplifies how an organization can successfully pioneer culture change. The Teresian House staff, under the leadership of Sr. Pauline Brecanier, offers training opportunities and hosts monthly tours to keep the culture change movement active. During a tour of this nursing home of 300 private rooms, people see how traditional nursing stations have been transformed into neighborhoods with household kitchens, dining areas, and family rooms. Meals are eaten family style in dining areas that are open to the kitchens. Consistent assignment allows staff to develop ongoing, consistent caregiving relationships with the residents in these neighborhoods. The direct care staff meet with each individual one on one and incorporate his or her lifelong patterns and personal desires into a personalized care plan. Staff turnover at this unique city home with strong person-centered values is less than 10%.

Self-reflection is needed, particularly by those in leadership positions. Leaders who are championing culture change need to engage in self-reflection to develop their own internal motivation, which requires exploration of their own attitudes, values, and beliefs about aging and eldercare. Some questions to consider:

  • Do you think most residents in your nursing home are thriving? Why or why not?
  • Do you think the staff who work in your nursing home are thriving? Why or why not?
  • What is motivating you to bring culture change to your workplace?
  • Are your organization’s daily practices consistent with Pioneer Network values?
  • Do you agree that long-term care can and should be transformed?
  • Are you willing to do the hard work to bring about this level of change?

Exploring their responses to these questions will help individuals determine their readiness to tackle culture change in their own facilities.

The Pioneer Network strongly recommends that those in positions to lead the change try to answer some of these questions after gaining invaluable firsthand experience. The CEO, administrator, and other key personnel can be admitted to the nursing home as residents for at least 24 hours. During this time, they should receive no special treatment and should genuinely seek to experience life as a nursing home resident. This includes full participation in the same daily routine that all other residents endure. In addition, setting aside time in each department for leaders to work in different staff roles will help them better understand the workers’ challenges.

Figure 1. Once the process of culture change has begun, it should continually evolve. Reprinted with permission from the Pioneer Network, 2003.
Adopting new beliefs is important for a provider considering culture change. It is essential to review and revise facility mission, vision, and values statements. For example, Neville Manor, a not-for-profit nursing home in Cambridge, Massachusetts, revised its mission statement to reflect its culture change initiative. The original mission was:

    To provide quality of life and quality of care to residents who come to us for long-term residential or short-term rehabilitative care. We assist residents to achieve their highest possible level of physical, psychosocial and spiritual potential, always working to protect and enhance their dignity. We seek to continually improve the services we provide.

This mission statement is a fairly common example from a traditional nursing home viewpoint. However, after initiating its culture change, Neville Manor’s new mission statement, with input from residents, staff, families, ombudsmen, and others, became:

    To be a thriving healthcare community in which the individual needs and desires of the residents direct and shape daily life.

This new mission statement makes the shift to person-centeredness evident.

The vision statement answers the questions: Where are we going? What is the goal? Using an inclusive process to shape culture change, vision helps to clarify the difference between the atmosphere existing in the nursing home and the atmosphere everyone is being asked to help create. The team at Fairport Baptist Home in Rochester, New York, for example, designed this vision statement to support its culture change initiative:

    We envision for our residents normalcy and individualized, quality care. We will work in partnership to create the best of “home”: an environment of friendship, spontaneity, creativity, comfort, and pleasure. We envision a place where each of us is known, where each is comfortable being one’s self, where each of us wants to be. And, we envision a thriving and growing community, full of life and vitality, in which all are welcome and all contribute.

This vision statement describes an atmosphere where the residents and staff are known as individuals.

A values statement explains how people in the nursing home want to live and work together, and serves as a yardstick against which practices should be measured. For example, a nursing home that claims person-centered care as a value, but assigns wake-up times according to CNA assignment, is not practicing this value.

The Edgewood Centre in Portsmouth, New Hampshire, drafted a statement that defined five values: Home, Empowerment, Appreciation, Relationship, and Teamwork. Together these values define how community members strive to treat one another: with respect, caring, compassion, and cooperation.

The process of establishing mission, vision, and values to support culture change takes time. An inclusive process is critical. If an advisory committee creates a first draft, it can submit the document to others within its nursing home community for their feedback. Several drafts of each statement will probably be generated before everyone is satisfied and feels a connection with the content. Encouraging widespread feedback is a step that cannot be skipped; without it, the statements will be mere pieces of paper hanging on the wall, having little meaning to those who live and work in the home.

Organizational assessment is next. Having redefined its mission, vision, and values, a home needs to assess its current practices in light of its new beliefs and determine its readiness to embark on a culture change effort. What are the facility’s strengths? Its weaknesses? Knowing the starting point and gathering some baseline information allow the home to evaluate outcomes. There are many sources of information, both quantitative and qualitative-for example, a home can measure turnover rates, track census figures, and count residents with pressure sores or incontinence. Qualitative information will tell the stories that add meaning to the quantitative data. Focus groups are one means of gathering this type of feedback. Keeping a journal and a photo album is another good way to capture stories showing the difference the changes are making to residents, their families, and workers.

Planning is the final task of the getting-ready stage. Creating a plan for how systems, organizational structure, and practices will change to support the organization’s new mission, vision, and values will provide a segue into the implementation phase. Using the assessment process to inform the planning, culture change must be included in the strategic plan. The team designing this plan can prioritize changes with significant input from staff, residents, families, and the board of directors/leadership. The plan serves as a starting point and should be implemented at a realistic pace for the organization. Plans should be reviewed and revised on an ongoing basis. It is inevitable that much learning will take place as changes are made, and plans should grow to reflect this.

Evidence of Success
As yet, few studies have focused on nursing homes that have taken on this type of deep system change, but the anecdotal evidence collected by the Pioneer Network suggests that facilities initiating such deep system change are transforming the quality of life for their residents. Positive results include reduced use of medications, increased time spent socializing, improved nutritional health, less depression, lower resident mortality, stronger family ties, and improved clinical outcomes. In addition, staff retention has dramatically improved, and resident waiting lists for pioneering homes are growing.
Figure 2. Family room, The Teresian House. Training and monthly tours foster an atmosphere of culture change.
This change is also cost-effective. The dollars historically spent on reacting to problems are now spent on real solutions. For example, with less staff turnover, less money is spent on temporary agency staff, overtime, and advertising. Instead, providers are able to put resources into staff training and professional development, which improve both recruitment and retention. For example, The Loomis House in Holyoke, Massachusetts, has been implementing culture change for three years. In this time, Loomis has reduced expenses related to employee turnover by $110,000.

Such positive results won’t happen overnight, of course. The process of cultural transformation takes sustained effort over time, and there will undoubtedly be resistance and setbacks along the way. But with committed leadership and an inclusive process, every nursing facility can become a place that residents and staff enjoy being a part of.

One More Reason for Culture Change
Although most people who work in long-term care are talented and dedicated individuals, the system itself is failing. To be blunt, most nursing homes offer a “product” that no one wants. Many Americans live in fear of needing even the shortest of stays in this institutional environment. Nursing homes suffer from staff turnover rates averaging 71%¦. And it’s not only frontline staff who leave: Traditional nursing home cultures are “burning out” good administrators and directors of nursing, who are also seeking to change career paths. By accepting this reality, we can take our passion for caring and put it into creating a new vision-one of energetic, life-sustaining, and life-affirming long-term care communities. NH

Susan Misiorski, RN, BSN, is an organizational culture change specialist for the Parapro-fessional Healthcare Institute. For more information, phone (718) 402-7766, visit, or visit To comment on this article, please send e-mail to

1. The forthcoming handbook is a tool for providers seeking guidance on how to bring culture change to their own institutions. Funding for the handbook was provided by the Retirement Research Foundation and the Commonwealth Fund.
2. American Health Care Association, 2002 Survey of Nursing Staff Vacancy and Turnover in Nursing Homes, February 12, 2003.

Topics: Advocacy , Articles , Facility management