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Barriers and Facilitators to Adopting Nursing Home Culture Change
From RTI International, Waltham, MA, and Brown University School of Public Health, Providence, RI.
Abstract
- Objective: To review the nursing home culture change literature and identify common barriers to and facilitators of nursing home culture change adoption. Nursing home culture change aims to make nursing homes less institutional by providing more resident-centered care, making environments more homelike, and empowering direct care staff.
- Methods: We reviewed the research literature on nursing home culture change, especially as related to implementation and outcomes.
- Results: Adoption of nursing home culture change practices has been steadily increasing in the past decade, but some practices are more likely to be adopted than others. A commonly reported barrier to culture change adoption is staff resistance to change. Studies suggest that this resistance can be overcome by changes to management practices, including good communication, providing training and education, and leadership support.
- Conclusion: The numerous benefits of nursing home culture change are apparent in the literature. Barriers to its adoption may be overcome by making improvements to nursing home management practices.
Nursing home culture change is a philosophy and combination of diverse practices aimed at making nursing homes less institutional and more resident-centered [1]. Nursing homes have been depicted as dehumanizing “total institutions” [2–4] in which the quality of residents’ lives and the quality of care are generally poor, daily life is medically regimented, only residents’ basic physical needs receive attention [5–8], and direct care workers are subject to poor working conditions for the lowest possible pay [9,10]. Since the 1980s, transforming the culture of nursing homes to be more humanizing, resident-centered, empowering, and homelike has been a primary mission of many stakeholder groups, including nursing home residents and care workers and their advocates [11].
Comprehensive culture change requires transformation of the nursing home environment from that of an institution to that of a home, implementation of more resident-centered care practices, empowerment of direct care staff, and flattening of the traditional organizational hierarchy so that residents and direct-care workers are actively involved in planning and implementing changes that empower them [12,13]. Culture change requires both technical changes, which are relatively straightforward efforts to address issues within a system while fundamentally keeping the system intact, and adaptive changes, which are more complex and entail reforming fundamental values that underlie the system and demand changes to the system itself [14,15].
Over time, nursing home culture change has gained widespread mainstream support. In 2009, the federal government issued new interpretive guidelines for use by nursing home inspectors that call for nursing homes to have more homelike environments and to support more resident-centered care [16]. The Centers for Medicare & Medicaid Services also required state quality improvement organizations to work with nursing homes on culture change efforts [1]. Some states effectively incentivize culture change by tying nursing home reimbursement rates and pay-for-performance policies to the implementation of culture change practices [17]. In addition to federal and state regulations, some nursing home corporations encourage or require facility administrators to implement culture change practices [18]. Overall, nursing homes are pushed to implement culture change practices on many fronts. The promise of beneficial outcomes of culture change also motivates implementation of some culture change practices [19].
In this article, we discuss the key elements of culture change, review the research examining the association between culture change and outcomes, identify key barriers to culture change, and offer suggestions from the literature for overcoming resistance to culture change.
Elements of Culture Change
Changing the Physical Environment
Changing the physical environment of nursing homes to be less institutional and more homelike is a core component of culture change [1]. These include both exterior and interior changes. Exterior changes can include adding walkways, patios, and gardens; interior changes include replacing nurses’ stations with desks, creating resident common areas, introducing the use of linens in dining areas, personalizing mailboxes outside of resident rooms, and adding small kitchens on units [20]. Other ideas for making environments more homelike include providing residents with the choice of colors for painting rooms and the choice of corridor/unit names and replacing public announcement systems with staff pagers [20].
Although changes to the physical environment may be considered cost-prohibitive, many of these changes entail minor and inexpensive enhancements that can help make environments more intimate and reminiscent of home than are traditional nursing homes [21,22]. Additionally, some environmental changes, such as adding raised gardens and walkways, can be designed not only to make the environment more homelike but also to help residents to engage in meaningful activities and connect to former roles, such as those of a homemaker, gardener, or farmer [21–23].
Providing Resident-Centered Care
Making care resident-centered entails enhancing resident choice and decision making and focusing the delivery of services on residents’ needs and preferences. According to Banaszak-Holl and colleagues [24], resident-centered approaches often emphasize the importance of shifting institutional norms and values and drawing employees’ attention to the needs of residents. This cultural shift in values and norms may be signaled by the implementation of practices that strengthen residents’ autonomy regarding everyday decisions. For example, as part of a resident-centered approach, residents would be offered choices and encouraged to make their own decisions about things personally affecting them, such as what to wear or when to go to bed, eating schedules, and menus [1,17,25].
Empowering Care Aides
Nursing home staff empowerment, particularly the empowerment of nursing assistants and other “hands-on” care aides—who are the predominant workforce in nursing homes and provide the vast bulk of care [26]—is a core component of culture change [1]. Such staff empowerment generally entails enhanced participation in decision making and increased autonomy. Staff empowerment practices that were examined in a national survey of nursing home directors [17] included:
- Staff work together to cover shifts when someone cannot come to work
- Staff cross-trained to perform tasks outside of their assigned job duties
- Staff involved in planning social events
- Nursing assistants take part in quality improvement teams
- Nursing assistants know when a resident’s care plan has changed
- Nursing assistants who receive extra training or education receive bonuses or raises
- Nursing assistants can choose which the residents for whom they provide care
We found that the staff empowerment practices most commonly implemented by nursing homes included nursing assistants knowing when a resident’s care plan has changed and staff working together to cover shifts when someone can’t come to work, but it was uncommon for nursing homes to permit nursing assistants to choose which residents they care for [17].
Outcomes of Culture Change
Research over the past 2 decades has examined the outcomes of culture change and the challenges involved in its implementation. Culture change is intended to improve the quality of life for nursing home residents, but the impact of culture change interventions is not clear. Shier and colleagues [27] conducted a comprehensive review of the peer-reviewed and gray literature on culture change published between 2005 and 2012 and found that studies varied widely in scope and evidence was inconsistent. They concluded that there is not yet sufficient evidence to provide specific guidance to nursing homes interested in implementing culture change [27]. The reviewed studies (27 peer-reviewed and 9 gray literature) also were noted to include small sample sizes and restricted geographic coverage, which both limit generalizability.
Although the literature had substantial limitations, Shier and colleagues [27] found numerous beneficial outcomes of culture change. Statistically significant improvements in numerous resident outcome measures were found to be associated with the implementation of culture change practices, including measures of resident quality of life/well-being, engagement and activities, functional status, satisfaction, mood (depression), anxiety/behavior/agitation, and pain/comfort. Two quality of care and services outcome measures also showed significant improvement associated with culture change practices, including increased completion of advance care plans and improved quality of workers’ approach to residents. Various staff outcome measures also showed significant improvement associated with culture change, including improvements in staff turnover/retention, satisfaction/well-being/burnout, absenteeism, knowledge, and attitude. Additionally, studies have shown culture change to be associated with improvements in select organizational outcome measures including operations costs, occupancy rates, revenue/profits, and family satisfaction. Four of the 36 studies reported negative outcomes of culture change. These negative outcomes included increased resident fear/anxiety [28], increased resident incontinence, decreased resident engagement in activities, decreased family engagement [29,30], decreased resident well-being [31], and increased physical incidents [32]. Notably, negative outcomes often co-occurred with positive outcomes [27,28].
To address the limitations of previous culture change research, such as small sample sizes and limited geographic coverage, and to explain some of the previous equivocal findings from quality studies when the extent of culture change practice implementation was not considered or measured, we collaborated on a national study to understand whether nursing home introduction of culture change practices is associated with improved quality [33]. We identified 824 U.S. nursing homes that had implemented some culture change practices, and we classified them by level of culture change practice implementation (high versus low). In nursing homes with high levels of culture change practice implementation, the introduction of nursing home culture change was associated with significant improvements in some care processes (eg, decreased prevalence of restraints, tube feeding, and pressure ulcers; increased proportion of residents on bladder training programs) and improvements in some resident outcomes, including slightly fewer hospitalizations. Among nursing homes with lower levels of culture change practice implementation, the introduction of culture change was associated with fewer health-related and quality-of-life survey deficiencies, but also with a significant increase in the number of resident hospitalizations [33]. Conclusive evidence regarding the impact of nursing homes implementing specific culture change practices or a comprehensive array of culture change practices on resident outcomes and quality of life remains needed, but numerous benefits of culture change are apparent in the literature.
Diffusion of Culture Change Practices
As culture change is widely supported and shows promise for beneficial outcomes, culture change practices are increasingly being implemented in nursing homes nationally. In 2007, a Commonwealth Fund survey found 56% of directors of nursing in U.S. nursing homes reported any culture change implementation or leadership commitment to implementation, but only 5% reported that culture change had completely changed the way the nursing home cared for residents in all areas of the nursing home [34]. In contrast, by 2010, 85% of directors of nursing reported at least partial culture change implementation and 13% reported that culture change had completely changed the way the nursing home cared for residents in all areas [14]. In a more recent survey of nursing home administrators, 16% reported that culture change had completely changed the way the nursing home cared for residents in all areas [35].
Barriers to Culture Change Implementation
Although the growth of culture change in the nursing home industry in the past decade has been impressive, implementation of comprehensive culture change has lagged behind. This is because one notable feature of nursing home culture change is that it is a philosophy that consists of many related practices. As noted above, implementing culture change can involve changes to physical environments, resident-centered care practices, and staff empowerment. This means that facilities can choose to implement as many or as few changes as they would like, and research has shown that there has been a lot of variation in which culture change practices are implemented. For example, in previous research we found that facilities interested in attracting highly reimbursed Medicare rehabilitation patients were more likely to implement hotel-style changes to their physical environments than they were to implement resident-centered care practices or forms of staff empowerment [19]. Sterns and colleagues [36] found that facilities were more likely to implement less complex practices (eg, allowing residents to choose when they go to bed) than more complex practices (eg, involving staff and residents in organizational decision making). The authors suggest that differences in commitment of facility leaders to comprehensive culture change may have contributed to these differences.
Attributes of facility leaders and other aspects of organizational context have been shown to contribute to more and less successful culture change implementation. For example, Scalzi and colleagues [37] found that some important barriers to culture change implementation were not involving all staff in culture change activities and a lack of corporate level support for these efforts. Schuldheis [38] examined differences in organizational context and its role in culture change among 9 Oregon facilities; 3 facilities successfully implemented culture change practices and 6 facilities did not. Results showed that a facility’s existing organizational culture, attention to sustainability, management practices, and staff involvement were important to the success of the initiative. Similarly, Rosemond and colleagues [39] conducted a study involving 8 North Carolina nursing homes. They determined that unsuccessful culture change initiatives could be attributed to the organizations’ readiness for change, a lack of high quality management communications, and unfavorable perceptions of culture change by direct-care workers. A study conducted in 4 nursing homes by Munroe et al [40] found that formal culture change training provided by professional trainers produced better outcomes than informal “train the trainer” sessions provided by other facility managers. Bowers and colleagues [41] also found that unsuccessful implementation of the Green House model of culture change was likely related to a lack of training resources for staff. Similarly, after an in-depth ethnographic study of culture change implementation, Lopez [42] found that it was unrealistic to expect direct-care workers to perform their jobs in radically new ways without being provided with ongoing support from management.
Resistance to Change: A Key Barrier
Our own research sought to understand the barriers and challenges nursing home administrators faced when implementing culture change in their facilities and the strategies they used to overcome them. In interviews conducted with 64 administrators who had participated in a previous nationally representative survey about culture change implementation, administrators reported a wide variety of barriers, including old and outdated physical plants, the costs of some changes, and issues with unions [18]. A key barrier that administrators reported facing was resistance to change on the part of nursing facility staff, residents, and residents’ family members [43]. Administrators reported that residents were resistant to change primarily because they had been institutionalized in their thinking. In other words, nursing homes had essentially trained residents to expect things to be done at certain times and in certain ways. Resistance among staff reportedly included resistance to the overall concept of culture change and to specific culture change practices. Often, staff perceived that changes related to culture change implementation involved additional work or effort on their part without additional resources, but this was not the only reason for resistance. Most often staff, especially longer-term staff, simply were resistant to making any changes to their usual routines or duties.
This type of resistance to change among staff is not unique to culture change implementation and has long been a commonly cited barrier in the organizational change literature. For example, in a 1954 Harvard Business Review article, Lawrence [44] stated that resistance to change was “the most baffling and recalcitrant of the problems which business executives face.” Since that time, resistance to change has been extensively studied as have methods for overcoming such resistance.
Recommendations for Overcoming Resistance to Culture Change
In seminal work on employee resistance to change conducted shortly after World War II, Coch and French [45] challenged the concept that resistance to change was the result of flaws or inadequacies on the part of staff, which would make addressing resistance difficult. Instead, they proposed, and proved through experimental methods, that resistance arose primarily from the context within which the changes were taking place. In other words, they found that managers could ameliorate resistance to change through changes to management and leadership practices. In their experiment, resistance to change in a manufacturing plant was overcome when management effectively communicated to staff the reasons for the change and engaged staff in planning for the desired changes. Studies on the barriers and facilitators of culture change implementation in nursing facilities have similarly found that facility leaders can take steps to address, or even avoid, staff resistance to change.
In our own research, we have found that resistance to change is a common barrier faced by facility leaders. We also found that resistance to change was unique among barriers in that, although strategies used to address other types of barriers varied widely, administrators consistently reported using the same strategies to address and overcome resistance to change. These strategies all involved management and leadership activities, including education and training and improved communication. In addition, administrators discussed in detail the ways they tailored education and communication to their facility’s unique needs. They also indicated that these efforts should be ongoing, communication should be two-way, and that all staff should be included [43].
Good Communication
One important tool for avoiding or overcoming resistance to culture change that facility administrators reported was good communication. They reported that open and bidirectional communication fostered feedback about ongoing culture change efforts and encouraged engagement and buy-in from staff. They also suggested that it is important that this type of communication be ongoing. Good communication about culture change, in particular, included providing a strong rationale for the changes and involved getting input from staff before and during implementation [43].
These findings are similar to other studies of culture change which have found that culture change implementation should involve staff at all levels [37] and that facility leaders should follow through on the plans that have been communicated [39]. Interestingly, the importance of good and open communication has also been identified as important to other forms of nursing facility quality improvement [46].
Training and Education
The facility administrators we interviewed also reported providing education and training for staff about culture change in a variety of ways, including as part of regular in-service training and as a component of new employee orientation. The training materials used were often obtained from the leading culture change organizations. However, importantly, administrators reported tailoring these trainings to the specific needs of their employees or unique context of their facility. For example, administrators reported breaking up long training sessions into shorter segments provided over a longer period of time or organizing trainings to be provided to small groups on the units rather than in more didactic conference-style settings [43]. Administrators explained that providing training in this way was more palatable to staff and helped incorporate learning into everyday care.
Other studies of nursing home culture change have also found training and education to be important to implementation. For example, in a study of a labor-management partnership for culture change implementation, Leutz and colleagues [47] found training of staff from all disciplines by culture change experts to be an important element of successful implementation. Training topics included those that were very general, such as gerontology, and very specific, including person-centered care. Staff were paid for their time participating in training, which took place at their facilities to make participation easier. The trainings were also staggered over the course of several months, so that staff had time to use what they had learned between sessions and could discuss their experiences at the later sessions.
Munroe and colleagues [40] conducted a study of culture change training using pre-post test survey methods and found that formal training had more of an effect on staff than informal training. In the study, staff at 2 facilities received formal education from a consulting group while staff at 2 other facilities then received informal training from the staff of one of the formally trained facilities. An important conclusion of the authors was that the formal training did a better job than the informal training of helping facility leaders and managers view their relationships with staff differently. This suggests that facility leaders and managers may have to alter their management styles to create the supportive context within which culture change efforts can succeed [48].
Leadership Support
Good communication and training/education can be thought of as 2 examples of leadership support, and support from facility leaders and managers has been found, in multiple studies, to be critical to successful culture change efforts. For example, in a recent study of nursing facility culture change in the Netherlands, Snoeren and colleagues [49] found that facility managers can facilitate culture change implementation by supporting a variety of staff needs and promoting the facilities’ new desired values. Another study found that facilities with leaders who are supportive and foster staff flexibility, such as allowing staff to be creative in their problem-solving and have decentralized decision-making, were more likely to report having implemented culture change [24].
In a study focused specifically on facility leadership style and its relation to culture change implementation, Corazzini and colleagues [50] found an adaptive leadership style to be important to culture change implementation. Adaptive leadership styles are ones that acknowledge the importance of staff relationships and recognize that complex changes, like those often implemented in culture change efforts, require complex solutions that will likely evolve over time. These authors conclude that culture change implementation necessitates development of new normative values and behaviors and can, therefore, not be accomplished by simply generating new rules and procedures [50].
Of course, not all nursing facility leaders have the management skills needed to perform in these adaptive and flexible ways. Therefore, management training for facility leaders may be an important first step in a facility’s culture change efforts [51]. This type of training may help improve communication skills and allow facility leaders to perform in more adaptive and flexible ways to better meet the needs of their particular facility and staff. Research also suggests that culture change training for facility leaders may help them to form new and better relationships with staff [40], an important element of culture change.
Conclusion
Nursing home culture change aims to improve care quality and resident satisfaction through changes to physical environments, resident care practices, and staff empowerment. These include both relatively simple technical changes and more complex changes. Nursing home managers and leaders have reported a variety of barriers to implementing nursing home culture change. A common barrier cited is staff resistance to change. Many decades of research in the organizational change literature and more recent research on culture change implementation suggest steps that facility managers and leaders can take to avoid or overcome this resistance. These steps include providing management support, especially in the form of good communication and training and education.
Corresponding author: Denise A. Tyler, PhD, RTI International, 307 Waverly Oaks Rd., Waltham, MA 02452, [email protected].
Financial disclosures: None.
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From RTI International, Waltham, MA, and Brown University School of Public Health, Providence, RI.
Abstract
- Objective: To review the nursing home culture change literature and identify common barriers to and facilitators of nursing home culture change adoption. Nursing home culture change aims to make nursing homes less institutional by providing more resident-centered care, making environments more homelike, and empowering direct care staff.
- Methods: We reviewed the research literature on nursing home culture change, especially as related to implementation and outcomes.
- Results: Adoption of nursing home culture change practices has been steadily increasing in the past decade, but some practices are more likely to be adopted than others. A commonly reported barrier to culture change adoption is staff resistance to change. Studies suggest that this resistance can be overcome by changes to management practices, including good communication, providing training and education, and leadership support.
- Conclusion: The numerous benefits of nursing home culture change are apparent in the literature. Barriers to its adoption may be overcome by making improvements to nursing home management practices.
Nursing home culture change is a philosophy and combination of diverse practices aimed at making nursing homes less institutional and more resident-centered [1]. Nursing homes have been depicted as dehumanizing “total institutions” [2–4] in which the quality of residents’ lives and the quality of care are generally poor, daily life is medically regimented, only residents’ basic physical needs receive attention [5–8], and direct care workers are subject to poor working conditions for the lowest possible pay [9,10]. Since the 1980s, transforming the culture of nursing homes to be more humanizing, resident-centered, empowering, and homelike has been a primary mission of many stakeholder groups, including nursing home residents and care workers and their advocates [11].
Comprehensive culture change requires transformation of the nursing home environment from that of an institution to that of a home, implementation of more resident-centered care practices, empowerment of direct care staff, and flattening of the traditional organizational hierarchy so that residents and direct-care workers are actively involved in planning and implementing changes that empower them [12,13]. Culture change requires both technical changes, which are relatively straightforward efforts to address issues within a system while fundamentally keeping the system intact, and adaptive changes, which are more complex and entail reforming fundamental values that underlie the system and demand changes to the system itself [14,15].
Over time, nursing home culture change has gained widespread mainstream support. In 2009, the federal government issued new interpretive guidelines for use by nursing home inspectors that call for nursing homes to have more homelike environments and to support more resident-centered care [16]. The Centers for Medicare & Medicaid Services also required state quality improvement organizations to work with nursing homes on culture change efforts [1]. Some states effectively incentivize culture change by tying nursing home reimbursement rates and pay-for-performance policies to the implementation of culture change practices [17]. In addition to federal and state regulations, some nursing home corporations encourage or require facility administrators to implement culture change practices [18]. Overall, nursing homes are pushed to implement culture change practices on many fronts. The promise of beneficial outcomes of culture change also motivates implementation of some culture change practices [19].
In this article, we discuss the key elements of culture change, review the research examining the association between culture change and outcomes, identify key barriers to culture change, and offer suggestions from the literature for overcoming resistance to culture change.
Elements of Culture Change
Changing the Physical Environment
Changing the physical environment of nursing homes to be less institutional and more homelike is a core component of culture change [1]. These include both exterior and interior changes. Exterior changes can include adding walkways, patios, and gardens; interior changes include replacing nurses’ stations with desks, creating resident common areas, introducing the use of linens in dining areas, personalizing mailboxes outside of resident rooms, and adding small kitchens on units [20]. Other ideas for making environments more homelike include providing residents with the choice of colors for painting rooms and the choice of corridor/unit names and replacing public announcement systems with staff pagers [20].
Although changes to the physical environment may be considered cost-prohibitive, many of these changes entail minor and inexpensive enhancements that can help make environments more intimate and reminiscent of home than are traditional nursing homes [21,22]. Additionally, some environmental changes, such as adding raised gardens and walkways, can be designed not only to make the environment more homelike but also to help residents to engage in meaningful activities and connect to former roles, such as those of a homemaker, gardener, or farmer [21–23].
Providing Resident-Centered Care
Making care resident-centered entails enhancing resident choice and decision making and focusing the delivery of services on residents’ needs and preferences. According to Banaszak-Holl and colleagues [24], resident-centered approaches often emphasize the importance of shifting institutional norms and values and drawing employees’ attention to the needs of residents. This cultural shift in values and norms may be signaled by the implementation of practices that strengthen residents’ autonomy regarding everyday decisions. For example, as part of a resident-centered approach, residents would be offered choices and encouraged to make their own decisions about things personally affecting them, such as what to wear or when to go to bed, eating schedules, and menus [1,17,25].
Empowering Care Aides
Nursing home staff empowerment, particularly the empowerment of nursing assistants and other “hands-on” care aides—who are the predominant workforce in nursing homes and provide the vast bulk of care [26]—is a core component of culture change [1]. Such staff empowerment generally entails enhanced participation in decision making and increased autonomy. Staff empowerment practices that were examined in a national survey of nursing home directors [17] included:
- Staff work together to cover shifts when someone cannot come to work
- Staff cross-trained to perform tasks outside of their assigned job duties
- Staff involved in planning social events
- Nursing assistants take part in quality improvement teams
- Nursing assistants know when a resident’s care plan has changed
- Nursing assistants who receive extra training or education receive bonuses or raises
- Nursing assistants can choose which the residents for whom they provide care
We found that the staff empowerment practices most commonly implemented by nursing homes included nursing assistants knowing when a resident’s care plan has changed and staff working together to cover shifts when someone can’t come to work, but it was uncommon for nursing homes to permit nursing assistants to choose which residents they care for [17].
Outcomes of Culture Change
Research over the past 2 decades has examined the outcomes of culture change and the challenges involved in its implementation. Culture change is intended to improve the quality of life for nursing home residents, but the impact of culture change interventions is not clear. Shier and colleagues [27] conducted a comprehensive review of the peer-reviewed and gray literature on culture change published between 2005 and 2012 and found that studies varied widely in scope and evidence was inconsistent. They concluded that there is not yet sufficient evidence to provide specific guidance to nursing homes interested in implementing culture change [27]. The reviewed studies (27 peer-reviewed and 9 gray literature) also were noted to include small sample sizes and restricted geographic coverage, which both limit generalizability.
Although the literature had substantial limitations, Shier and colleagues [27] found numerous beneficial outcomes of culture change. Statistically significant improvements in numerous resident outcome measures were found to be associated with the implementation of culture change practices, including measures of resident quality of life/well-being, engagement and activities, functional status, satisfaction, mood (depression), anxiety/behavior/agitation, and pain/comfort. Two quality of care and services outcome measures also showed significant improvement associated with culture change practices, including increased completion of advance care plans and improved quality of workers’ approach to residents. Various staff outcome measures also showed significant improvement associated with culture change, including improvements in staff turnover/retention, satisfaction/well-being/burnout, absenteeism, knowledge, and attitude. Additionally, studies have shown culture change to be associated with improvements in select organizational outcome measures including operations costs, occupancy rates, revenue/profits, and family satisfaction. Four of the 36 studies reported negative outcomes of culture change. These negative outcomes included increased resident fear/anxiety [28], increased resident incontinence, decreased resident engagement in activities, decreased family engagement [29,30], decreased resident well-being [31], and increased physical incidents [32]. Notably, negative outcomes often co-occurred with positive outcomes [27,28].
To address the limitations of previous culture change research, such as small sample sizes and limited geographic coverage, and to explain some of the previous equivocal findings from quality studies when the extent of culture change practice implementation was not considered or measured, we collaborated on a national study to understand whether nursing home introduction of culture change practices is associated with improved quality [33]. We identified 824 U.S. nursing homes that had implemented some culture change practices, and we classified them by level of culture change practice implementation (high versus low). In nursing homes with high levels of culture change practice implementation, the introduction of nursing home culture change was associated with significant improvements in some care processes (eg, decreased prevalence of restraints, tube feeding, and pressure ulcers; increased proportion of residents on bladder training programs) and improvements in some resident outcomes, including slightly fewer hospitalizations. Among nursing homes with lower levels of culture change practice implementation, the introduction of culture change was associated with fewer health-related and quality-of-life survey deficiencies, but also with a significant increase in the number of resident hospitalizations [33]. Conclusive evidence regarding the impact of nursing homes implementing specific culture change practices or a comprehensive array of culture change practices on resident outcomes and quality of life remains needed, but numerous benefits of culture change are apparent in the literature.
Diffusion of Culture Change Practices
As culture change is widely supported and shows promise for beneficial outcomes, culture change practices are increasingly being implemented in nursing homes nationally. In 2007, a Commonwealth Fund survey found 56% of directors of nursing in U.S. nursing homes reported any culture change implementation or leadership commitment to implementation, but only 5% reported that culture change had completely changed the way the nursing home cared for residents in all areas of the nursing home [34]. In contrast, by 2010, 85% of directors of nursing reported at least partial culture change implementation and 13% reported that culture change had completely changed the way the nursing home cared for residents in all areas [14]. In a more recent survey of nursing home administrators, 16% reported that culture change had completely changed the way the nursing home cared for residents in all areas [35].
Barriers to Culture Change Implementation
Although the growth of culture change in the nursing home industry in the past decade has been impressive, implementation of comprehensive culture change has lagged behind. This is because one notable feature of nursing home culture change is that it is a philosophy that consists of many related practices. As noted above, implementing culture change can involve changes to physical environments, resident-centered care practices, and staff empowerment. This means that facilities can choose to implement as many or as few changes as they would like, and research has shown that there has been a lot of variation in which culture change practices are implemented. For example, in previous research we found that facilities interested in attracting highly reimbursed Medicare rehabilitation patients were more likely to implement hotel-style changes to their physical environments than they were to implement resident-centered care practices or forms of staff empowerment [19]. Sterns and colleagues [36] found that facilities were more likely to implement less complex practices (eg, allowing residents to choose when they go to bed) than more complex practices (eg, involving staff and residents in organizational decision making). The authors suggest that differences in commitment of facility leaders to comprehensive culture change may have contributed to these differences.
Attributes of facility leaders and other aspects of organizational context have been shown to contribute to more and less successful culture change implementation. For example, Scalzi and colleagues [37] found that some important barriers to culture change implementation were not involving all staff in culture change activities and a lack of corporate level support for these efforts. Schuldheis [38] examined differences in organizational context and its role in culture change among 9 Oregon facilities; 3 facilities successfully implemented culture change practices and 6 facilities did not. Results showed that a facility’s existing organizational culture, attention to sustainability, management practices, and staff involvement were important to the success of the initiative. Similarly, Rosemond and colleagues [39] conducted a study involving 8 North Carolina nursing homes. They determined that unsuccessful culture change initiatives could be attributed to the organizations’ readiness for change, a lack of high quality management communications, and unfavorable perceptions of culture change by direct-care workers. A study conducted in 4 nursing homes by Munroe et al [40] found that formal culture change training provided by professional trainers produced better outcomes than informal “train the trainer” sessions provided by other facility managers. Bowers and colleagues [41] also found that unsuccessful implementation of the Green House model of culture change was likely related to a lack of training resources for staff. Similarly, after an in-depth ethnographic study of culture change implementation, Lopez [42] found that it was unrealistic to expect direct-care workers to perform their jobs in radically new ways without being provided with ongoing support from management.
Resistance to Change: A Key Barrier
Our own research sought to understand the barriers and challenges nursing home administrators faced when implementing culture change in their facilities and the strategies they used to overcome them. In interviews conducted with 64 administrators who had participated in a previous nationally representative survey about culture change implementation, administrators reported a wide variety of barriers, including old and outdated physical plants, the costs of some changes, and issues with unions [18]. A key barrier that administrators reported facing was resistance to change on the part of nursing facility staff, residents, and residents’ family members [43]. Administrators reported that residents were resistant to change primarily because they had been institutionalized in their thinking. In other words, nursing homes had essentially trained residents to expect things to be done at certain times and in certain ways. Resistance among staff reportedly included resistance to the overall concept of culture change and to specific culture change practices. Often, staff perceived that changes related to culture change implementation involved additional work or effort on their part without additional resources, but this was not the only reason for resistance. Most often staff, especially longer-term staff, simply were resistant to making any changes to their usual routines or duties.
This type of resistance to change among staff is not unique to culture change implementation and has long been a commonly cited barrier in the organizational change literature. For example, in a 1954 Harvard Business Review article, Lawrence [44] stated that resistance to change was “the most baffling and recalcitrant of the problems which business executives face.” Since that time, resistance to change has been extensively studied as have methods for overcoming such resistance.
Recommendations for Overcoming Resistance to Culture Change
In seminal work on employee resistance to change conducted shortly after World War II, Coch and French [45] challenged the concept that resistance to change was the result of flaws or inadequacies on the part of staff, which would make addressing resistance difficult. Instead, they proposed, and proved through experimental methods, that resistance arose primarily from the context within which the changes were taking place. In other words, they found that managers could ameliorate resistance to change through changes to management and leadership practices. In their experiment, resistance to change in a manufacturing plant was overcome when management effectively communicated to staff the reasons for the change and engaged staff in planning for the desired changes. Studies on the barriers and facilitators of culture change implementation in nursing facilities have similarly found that facility leaders can take steps to address, or even avoid, staff resistance to change.
In our own research, we have found that resistance to change is a common barrier faced by facility leaders. We also found that resistance to change was unique among barriers in that, although strategies used to address other types of barriers varied widely, administrators consistently reported using the same strategies to address and overcome resistance to change. These strategies all involved management and leadership activities, including education and training and improved communication. In addition, administrators discussed in detail the ways they tailored education and communication to their facility’s unique needs. They also indicated that these efforts should be ongoing, communication should be two-way, and that all staff should be included [43].
Good Communication
One important tool for avoiding or overcoming resistance to culture change that facility administrators reported was good communication. They reported that open and bidirectional communication fostered feedback about ongoing culture change efforts and encouraged engagement and buy-in from staff. They also suggested that it is important that this type of communication be ongoing. Good communication about culture change, in particular, included providing a strong rationale for the changes and involved getting input from staff before and during implementation [43].
These findings are similar to other studies of culture change which have found that culture change implementation should involve staff at all levels [37] and that facility leaders should follow through on the plans that have been communicated [39]. Interestingly, the importance of good and open communication has also been identified as important to other forms of nursing facility quality improvement [46].
Training and Education
The facility administrators we interviewed also reported providing education and training for staff about culture change in a variety of ways, including as part of regular in-service training and as a component of new employee orientation. The training materials used were often obtained from the leading culture change organizations. However, importantly, administrators reported tailoring these trainings to the specific needs of their employees or unique context of their facility. For example, administrators reported breaking up long training sessions into shorter segments provided over a longer period of time or organizing trainings to be provided to small groups on the units rather than in more didactic conference-style settings [43]. Administrators explained that providing training in this way was more palatable to staff and helped incorporate learning into everyday care.
Other studies of nursing home culture change have also found training and education to be important to implementation. For example, in a study of a labor-management partnership for culture change implementation, Leutz and colleagues [47] found training of staff from all disciplines by culture change experts to be an important element of successful implementation. Training topics included those that were very general, such as gerontology, and very specific, including person-centered care. Staff were paid for their time participating in training, which took place at their facilities to make participation easier. The trainings were also staggered over the course of several months, so that staff had time to use what they had learned between sessions and could discuss their experiences at the later sessions.
Munroe and colleagues [40] conducted a study of culture change training using pre-post test survey methods and found that formal training had more of an effect on staff than informal training. In the study, staff at 2 facilities received formal education from a consulting group while staff at 2 other facilities then received informal training from the staff of one of the formally trained facilities. An important conclusion of the authors was that the formal training did a better job than the informal training of helping facility leaders and managers view their relationships with staff differently. This suggests that facility leaders and managers may have to alter their management styles to create the supportive context within which culture change efforts can succeed [48].
Leadership Support
Good communication and training/education can be thought of as 2 examples of leadership support, and support from facility leaders and managers has been found, in multiple studies, to be critical to successful culture change efforts. For example, in a recent study of nursing facility culture change in the Netherlands, Snoeren and colleagues [49] found that facility managers can facilitate culture change implementation by supporting a variety of staff needs and promoting the facilities’ new desired values. Another study found that facilities with leaders who are supportive and foster staff flexibility, such as allowing staff to be creative in their problem-solving and have decentralized decision-making, were more likely to report having implemented culture change [24].
In a study focused specifically on facility leadership style and its relation to culture change implementation, Corazzini and colleagues [50] found an adaptive leadership style to be important to culture change implementation. Adaptive leadership styles are ones that acknowledge the importance of staff relationships and recognize that complex changes, like those often implemented in culture change efforts, require complex solutions that will likely evolve over time. These authors conclude that culture change implementation necessitates development of new normative values and behaviors and can, therefore, not be accomplished by simply generating new rules and procedures [50].
Of course, not all nursing facility leaders have the management skills needed to perform in these adaptive and flexible ways. Therefore, management training for facility leaders may be an important first step in a facility’s culture change efforts [51]. This type of training may help improve communication skills and allow facility leaders to perform in more adaptive and flexible ways to better meet the needs of their particular facility and staff. Research also suggests that culture change training for facility leaders may help them to form new and better relationships with staff [40], an important element of culture change.
Conclusion
Nursing home culture change aims to improve care quality and resident satisfaction through changes to physical environments, resident care practices, and staff empowerment. These include both relatively simple technical changes and more complex changes. Nursing home managers and leaders have reported a variety of barriers to implementing nursing home culture change. A common barrier cited is staff resistance to change. Many decades of research in the organizational change literature and more recent research on culture change implementation suggest steps that facility managers and leaders can take to avoid or overcome this resistance. These steps include providing management support, especially in the form of good communication and training and education.
Corresponding author: Denise A. Tyler, PhD, RTI International, 307 Waverly Oaks Rd., Waltham, MA 02452, [email protected].
Financial disclosures: None.
From RTI International, Waltham, MA, and Brown University School of Public Health, Providence, RI.
Abstract
- Objective: To review the nursing home culture change literature and identify common barriers to and facilitators of nursing home culture change adoption. Nursing home culture change aims to make nursing homes less institutional by providing more resident-centered care, making environments more homelike, and empowering direct care staff.
- Methods: We reviewed the research literature on nursing home culture change, especially as related to implementation and outcomes.
- Results: Adoption of nursing home culture change practices has been steadily increasing in the past decade, but some practices are more likely to be adopted than others. A commonly reported barrier to culture change adoption is staff resistance to change. Studies suggest that this resistance can be overcome by changes to management practices, including good communication, providing training and education, and leadership support.
- Conclusion: The numerous benefits of nursing home culture change are apparent in the literature. Barriers to its adoption may be overcome by making improvements to nursing home management practices.
Nursing home culture change is a philosophy and combination of diverse practices aimed at making nursing homes less institutional and more resident-centered [1]. Nursing homes have been depicted as dehumanizing “total institutions” [2–4] in which the quality of residents’ lives and the quality of care are generally poor, daily life is medically regimented, only residents’ basic physical needs receive attention [5–8], and direct care workers are subject to poor working conditions for the lowest possible pay [9,10]. Since the 1980s, transforming the culture of nursing homes to be more humanizing, resident-centered, empowering, and homelike has been a primary mission of many stakeholder groups, including nursing home residents and care workers and their advocates [11].
Comprehensive culture change requires transformation of the nursing home environment from that of an institution to that of a home, implementation of more resident-centered care practices, empowerment of direct care staff, and flattening of the traditional organizational hierarchy so that residents and direct-care workers are actively involved in planning and implementing changes that empower them [12,13]. Culture change requires both technical changes, which are relatively straightforward efforts to address issues within a system while fundamentally keeping the system intact, and adaptive changes, which are more complex and entail reforming fundamental values that underlie the system and demand changes to the system itself [14,15].
Over time, nursing home culture change has gained widespread mainstream support. In 2009, the federal government issued new interpretive guidelines for use by nursing home inspectors that call for nursing homes to have more homelike environments and to support more resident-centered care [16]. The Centers for Medicare & Medicaid Services also required state quality improvement organizations to work with nursing homes on culture change efforts [1]. Some states effectively incentivize culture change by tying nursing home reimbursement rates and pay-for-performance policies to the implementation of culture change practices [17]. In addition to federal and state regulations, some nursing home corporations encourage or require facility administrators to implement culture change practices [18]. Overall, nursing homes are pushed to implement culture change practices on many fronts. The promise of beneficial outcomes of culture change also motivates implementation of some culture change practices [19].
In this article, we discuss the key elements of culture change, review the research examining the association between culture change and outcomes, identify key barriers to culture change, and offer suggestions from the literature for overcoming resistance to culture change.
Elements of Culture Change
Changing the Physical Environment
Changing the physical environment of nursing homes to be less institutional and more homelike is a core component of culture change [1]. These include both exterior and interior changes. Exterior changes can include adding walkways, patios, and gardens; interior changes include replacing nurses’ stations with desks, creating resident common areas, introducing the use of linens in dining areas, personalizing mailboxes outside of resident rooms, and adding small kitchens on units [20]. Other ideas for making environments more homelike include providing residents with the choice of colors for painting rooms and the choice of corridor/unit names and replacing public announcement systems with staff pagers [20].
Although changes to the physical environment may be considered cost-prohibitive, many of these changes entail minor and inexpensive enhancements that can help make environments more intimate and reminiscent of home than are traditional nursing homes [21,22]. Additionally, some environmental changes, such as adding raised gardens and walkways, can be designed not only to make the environment more homelike but also to help residents to engage in meaningful activities and connect to former roles, such as those of a homemaker, gardener, or farmer [21–23].
Providing Resident-Centered Care
Making care resident-centered entails enhancing resident choice and decision making and focusing the delivery of services on residents’ needs and preferences. According to Banaszak-Holl and colleagues [24], resident-centered approaches often emphasize the importance of shifting institutional norms and values and drawing employees’ attention to the needs of residents. This cultural shift in values and norms may be signaled by the implementation of practices that strengthen residents’ autonomy regarding everyday decisions. For example, as part of a resident-centered approach, residents would be offered choices and encouraged to make their own decisions about things personally affecting them, such as what to wear or when to go to bed, eating schedules, and menus [1,17,25].
Empowering Care Aides
Nursing home staff empowerment, particularly the empowerment of nursing assistants and other “hands-on” care aides—who are the predominant workforce in nursing homes and provide the vast bulk of care [26]—is a core component of culture change [1]. Such staff empowerment generally entails enhanced participation in decision making and increased autonomy. Staff empowerment practices that were examined in a national survey of nursing home directors [17] included:
- Staff work together to cover shifts when someone cannot come to work
- Staff cross-trained to perform tasks outside of their assigned job duties
- Staff involved in planning social events
- Nursing assistants take part in quality improvement teams
- Nursing assistants know when a resident’s care plan has changed
- Nursing assistants who receive extra training or education receive bonuses or raises
- Nursing assistants can choose which the residents for whom they provide care
We found that the staff empowerment practices most commonly implemented by nursing homes included nursing assistants knowing when a resident’s care plan has changed and staff working together to cover shifts when someone can’t come to work, but it was uncommon for nursing homes to permit nursing assistants to choose which residents they care for [17].
Outcomes of Culture Change
Research over the past 2 decades has examined the outcomes of culture change and the challenges involved in its implementation. Culture change is intended to improve the quality of life for nursing home residents, but the impact of culture change interventions is not clear. Shier and colleagues [27] conducted a comprehensive review of the peer-reviewed and gray literature on culture change published between 2005 and 2012 and found that studies varied widely in scope and evidence was inconsistent. They concluded that there is not yet sufficient evidence to provide specific guidance to nursing homes interested in implementing culture change [27]. The reviewed studies (27 peer-reviewed and 9 gray literature) also were noted to include small sample sizes and restricted geographic coverage, which both limit generalizability.
Although the literature had substantial limitations, Shier and colleagues [27] found numerous beneficial outcomes of culture change. Statistically significant improvements in numerous resident outcome measures were found to be associated with the implementation of culture change practices, including measures of resident quality of life/well-being, engagement and activities, functional status, satisfaction, mood (depression), anxiety/behavior/agitation, and pain/comfort. Two quality of care and services outcome measures also showed significant improvement associated with culture change practices, including increased completion of advance care plans and improved quality of workers’ approach to residents. Various staff outcome measures also showed significant improvement associated with culture change, including improvements in staff turnover/retention, satisfaction/well-being/burnout, absenteeism, knowledge, and attitude. Additionally, studies have shown culture change to be associated with improvements in select organizational outcome measures including operations costs, occupancy rates, revenue/profits, and family satisfaction. Four of the 36 studies reported negative outcomes of culture change. These negative outcomes included increased resident fear/anxiety [28], increased resident incontinence, decreased resident engagement in activities, decreased family engagement [29,30], decreased resident well-being [31], and increased physical incidents [32]. Notably, negative outcomes often co-occurred with positive outcomes [27,28].
To address the limitations of previous culture change research, such as small sample sizes and limited geographic coverage, and to explain some of the previous equivocal findings from quality studies when the extent of culture change practice implementation was not considered or measured, we collaborated on a national study to understand whether nursing home introduction of culture change practices is associated with improved quality [33]. We identified 824 U.S. nursing homes that had implemented some culture change practices, and we classified them by level of culture change practice implementation (high versus low). In nursing homes with high levels of culture change practice implementation, the introduction of nursing home culture change was associated with significant improvements in some care processes (eg, decreased prevalence of restraints, tube feeding, and pressure ulcers; increased proportion of residents on bladder training programs) and improvements in some resident outcomes, including slightly fewer hospitalizations. Among nursing homes with lower levels of culture change practice implementation, the introduction of culture change was associated with fewer health-related and quality-of-life survey deficiencies, but also with a significant increase in the number of resident hospitalizations [33]. Conclusive evidence regarding the impact of nursing homes implementing specific culture change practices or a comprehensive array of culture change practices on resident outcomes and quality of life remains needed, but numerous benefits of culture change are apparent in the literature.
Diffusion of Culture Change Practices
As culture change is widely supported and shows promise for beneficial outcomes, culture change practices are increasingly being implemented in nursing homes nationally. In 2007, a Commonwealth Fund survey found 56% of directors of nursing in U.S. nursing homes reported any culture change implementation or leadership commitment to implementation, but only 5% reported that culture change had completely changed the way the nursing home cared for residents in all areas of the nursing home [34]. In contrast, by 2010, 85% of directors of nursing reported at least partial culture change implementation and 13% reported that culture change had completely changed the way the nursing home cared for residents in all areas [14]. In a more recent survey of nursing home administrators, 16% reported that culture change had completely changed the way the nursing home cared for residents in all areas [35].
Barriers to Culture Change Implementation
Although the growth of culture change in the nursing home industry in the past decade has been impressive, implementation of comprehensive culture change has lagged behind. This is because one notable feature of nursing home culture change is that it is a philosophy that consists of many related practices. As noted above, implementing culture change can involve changes to physical environments, resident-centered care practices, and staff empowerment. This means that facilities can choose to implement as many or as few changes as they would like, and research has shown that there has been a lot of variation in which culture change practices are implemented. For example, in previous research we found that facilities interested in attracting highly reimbursed Medicare rehabilitation patients were more likely to implement hotel-style changes to their physical environments than they were to implement resident-centered care practices or forms of staff empowerment [19]. Sterns and colleagues [36] found that facilities were more likely to implement less complex practices (eg, allowing residents to choose when they go to bed) than more complex practices (eg, involving staff and residents in organizational decision making). The authors suggest that differences in commitment of facility leaders to comprehensive culture change may have contributed to these differences.
Attributes of facility leaders and other aspects of organizational context have been shown to contribute to more and less successful culture change implementation. For example, Scalzi and colleagues [37] found that some important barriers to culture change implementation were not involving all staff in culture change activities and a lack of corporate level support for these efforts. Schuldheis [38] examined differences in organizational context and its role in culture change among 9 Oregon facilities; 3 facilities successfully implemented culture change practices and 6 facilities did not. Results showed that a facility’s existing organizational culture, attention to sustainability, management practices, and staff involvement were important to the success of the initiative. Similarly, Rosemond and colleagues [39] conducted a study involving 8 North Carolina nursing homes. They determined that unsuccessful culture change initiatives could be attributed to the organizations’ readiness for change, a lack of high quality management communications, and unfavorable perceptions of culture change by direct-care workers. A study conducted in 4 nursing homes by Munroe et al [40] found that formal culture change training provided by professional trainers produced better outcomes than informal “train the trainer” sessions provided by other facility managers. Bowers and colleagues [41] also found that unsuccessful implementation of the Green House model of culture change was likely related to a lack of training resources for staff. Similarly, after an in-depth ethnographic study of culture change implementation, Lopez [42] found that it was unrealistic to expect direct-care workers to perform their jobs in radically new ways without being provided with ongoing support from management.
Resistance to Change: A Key Barrier
Our own research sought to understand the barriers and challenges nursing home administrators faced when implementing culture change in their facilities and the strategies they used to overcome them. In interviews conducted with 64 administrators who had participated in a previous nationally representative survey about culture change implementation, administrators reported a wide variety of barriers, including old and outdated physical plants, the costs of some changes, and issues with unions [18]. A key barrier that administrators reported facing was resistance to change on the part of nursing facility staff, residents, and residents’ family members [43]. Administrators reported that residents were resistant to change primarily because they had been institutionalized in their thinking. In other words, nursing homes had essentially trained residents to expect things to be done at certain times and in certain ways. Resistance among staff reportedly included resistance to the overall concept of culture change and to specific culture change practices. Often, staff perceived that changes related to culture change implementation involved additional work or effort on their part without additional resources, but this was not the only reason for resistance. Most often staff, especially longer-term staff, simply were resistant to making any changes to their usual routines or duties.
This type of resistance to change among staff is not unique to culture change implementation and has long been a commonly cited barrier in the organizational change literature. For example, in a 1954 Harvard Business Review article, Lawrence [44] stated that resistance to change was “the most baffling and recalcitrant of the problems which business executives face.” Since that time, resistance to change has been extensively studied as have methods for overcoming such resistance.
Recommendations for Overcoming Resistance to Culture Change
In seminal work on employee resistance to change conducted shortly after World War II, Coch and French [45] challenged the concept that resistance to change was the result of flaws or inadequacies on the part of staff, which would make addressing resistance difficult. Instead, they proposed, and proved through experimental methods, that resistance arose primarily from the context within which the changes were taking place. In other words, they found that managers could ameliorate resistance to change through changes to management and leadership practices. In their experiment, resistance to change in a manufacturing plant was overcome when management effectively communicated to staff the reasons for the change and engaged staff in planning for the desired changes. Studies on the barriers and facilitators of culture change implementation in nursing facilities have similarly found that facility leaders can take steps to address, or even avoid, staff resistance to change.
In our own research, we have found that resistance to change is a common barrier faced by facility leaders. We also found that resistance to change was unique among barriers in that, although strategies used to address other types of barriers varied widely, administrators consistently reported using the same strategies to address and overcome resistance to change. These strategies all involved management and leadership activities, including education and training and improved communication. In addition, administrators discussed in detail the ways they tailored education and communication to their facility’s unique needs. They also indicated that these efforts should be ongoing, communication should be two-way, and that all staff should be included [43].
Good Communication
One important tool for avoiding or overcoming resistance to culture change that facility administrators reported was good communication. They reported that open and bidirectional communication fostered feedback about ongoing culture change efforts and encouraged engagement and buy-in from staff. They also suggested that it is important that this type of communication be ongoing. Good communication about culture change, in particular, included providing a strong rationale for the changes and involved getting input from staff before and during implementation [43].
These findings are similar to other studies of culture change which have found that culture change implementation should involve staff at all levels [37] and that facility leaders should follow through on the plans that have been communicated [39]. Interestingly, the importance of good and open communication has also been identified as important to other forms of nursing facility quality improvement [46].
Training and Education
The facility administrators we interviewed also reported providing education and training for staff about culture change in a variety of ways, including as part of regular in-service training and as a component of new employee orientation. The training materials used were often obtained from the leading culture change organizations. However, importantly, administrators reported tailoring these trainings to the specific needs of their employees or unique context of their facility. For example, administrators reported breaking up long training sessions into shorter segments provided over a longer period of time or organizing trainings to be provided to small groups on the units rather than in more didactic conference-style settings [43]. Administrators explained that providing training in this way was more palatable to staff and helped incorporate learning into everyday care.
Other studies of nursing home culture change have also found training and education to be important to implementation. For example, in a study of a labor-management partnership for culture change implementation, Leutz and colleagues [47] found training of staff from all disciplines by culture change experts to be an important element of successful implementation. Training topics included those that were very general, such as gerontology, and very specific, including person-centered care. Staff were paid for their time participating in training, which took place at their facilities to make participation easier. The trainings were also staggered over the course of several months, so that staff had time to use what they had learned between sessions and could discuss their experiences at the later sessions.
Munroe and colleagues [40] conducted a study of culture change training using pre-post test survey methods and found that formal training had more of an effect on staff than informal training. In the study, staff at 2 facilities received formal education from a consulting group while staff at 2 other facilities then received informal training from the staff of one of the formally trained facilities. An important conclusion of the authors was that the formal training did a better job than the informal training of helping facility leaders and managers view their relationships with staff differently. This suggests that facility leaders and managers may have to alter their management styles to create the supportive context within which culture change efforts can succeed [48].
Leadership Support
Good communication and training/education can be thought of as 2 examples of leadership support, and support from facility leaders and managers has been found, in multiple studies, to be critical to successful culture change efforts. For example, in a recent study of nursing facility culture change in the Netherlands, Snoeren and colleagues [49] found that facility managers can facilitate culture change implementation by supporting a variety of staff needs and promoting the facilities’ new desired values. Another study found that facilities with leaders who are supportive and foster staff flexibility, such as allowing staff to be creative in their problem-solving and have decentralized decision-making, were more likely to report having implemented culture change [24].
In a study focused specifically on facility leadership style and its relation to culture change implementation, Corazzini and colleagues [50] found an adaptive leadership style to be important to culture change implementation. Adaptive leadership styles are ones that acknowledge the importance of staff relationships and recognize that complex changes, like those often implemented in culture change efforts, require complex solutions that will likely evolve over time. These authors conclude that culture change implementation necessitates development of new normative values and behaviors and can, therefore, not be accomplished by simply generating new rules and procedures [50].
Of course, not all nursing facility leaders have the management skills needed to perform in these adaptive and flexible ways. Therefore, management training for facility leaders may be an important first step in a facility’s culture change efforts [51]. This type of training may help improve communication skills and allow facility leaders to perform in more adaptive and flexible ways to better meet the needs of their particular facility and staff. Research also suggests that culture change training for facility leaders may help them to form new and better relationships with staff [40], an important element of culture change.
Conclusion
Nursing home culture change aims to improve care quality and resident satisfaction through changes to physical environments, resident care practices, and staff empowerment. These include both relatively simple technical changes and more complex changes. Nursing home managers and leaders have reported a variety of barriers to implementing nursing home culture change. A common barrier cited is staff resistance to change. Many decades of research in the organizational change literature and more recent research on culture change implementation suggest steps that facility managers and leaders can take to avoid or overcome this resistance. These steps include providing management support, especially in the form of good communication and training and education.
Corresponding author: Denise A. Tyler, PhD, RTI International, 307 Waverly Oaks Rd., Waltham, MA 02452, [email protected].
Financial disclosures: None.
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7. Kayser-Jones JS. Old, alone, and neglected: care of the aged in the United States and Scotland. Berkeley, CA: University of California Press; 1990.
8. Vladeck B. Unloving care: the nursing home tragedy. New York: Basic Books; 1980.
9. Diamond T. Social policy and everyday life in nursing homes: a critical ethnography. Soc Sci Med 1986;23:1287–95.
10. Kalleberg A, Reskin BF, Hudson K. Bad jobs in America: standard and nonstandard employment relations and job quality in the United States. Am Sociolog Rev 2000;65:256–78.
11. Rahman AN, Schnelle JF. The nursing home culture-change movement: recent past, present, and future directions for research. Gerontologist 2008;48:142–8.
12. White-Chu EF, Graves WJ, Godfrey SM, et al. Beyond the medical model: the culture change revolution in long-term care. J Am Med Dir Assoc 2009;10:370–8.
13. Misiorski S, Kahn K. Changing the culture of long-term care: Moving beyond programmatic change. J Soc Work Long-Term Care 2006;3:137–46.
14. Anderson RA, Bailey DEJ, Wu B, et al. Adaptive leadership framework for chronic illness: framing a research agenda for transforming care delivery. Adv Nurs Sci 2015;38:83–95.
15. Bailey DE, Docherty S, Adams JA, et al. Studying the clinical encounter with the adaptive leadership framework. J Healthc Leadersh 2012;4:83–91.
16. Centers for Medicare & Medicaid Services Manual System. Revisions to Appendix PP “Guidance to Surveyors of Long Term Care Facilities” Washington, DC: Department of Health and Human Services 2009. Accessed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R48SOMA.pdf.
17. Miller SC, Looze J, Shield R, et al. Culture change practice in US nursing homes: prevalence and variation by state Medicaid reimbursement policies. Gerontologist 2014;54:434–45.
18. Shield R, Looze J, Tyler D, et al. Why and how do nursing homes implement culture change practices? Insights from qualitative interviews in a mixed methods study. J Appl Gerontol 2014;33:737–63.
19. Lepore MJ, Shield RR, Looze J, et al. Medicare and Medicaid reimbursement rates for nursing homes motivate select culture change practices but not comprehensive culture change. J Aging Soc Pol 2015;27:215–31.
20. Shield RR, Tyler D, Lepore M, et al. Would you do that in your home? Making nursing homes home-like in culture change implementation. J Housing Elderly 2014;28:383–98.
21. Cutler L, Kane RA. As great as all outdoors. J Hous Elderly 2006;19:29–48.
22. Jurkowsky ET. Implementing culture change in long-term care: Benchmarks and strategies for management and practice. New York: Springer; 2013.
23. Wang D , Glicksman A. “Being grounded”: Benefits of gardening for older adults in low-income housing. J Hous Elderly 2013;27:89–104.
24. Banaszak-Holl J, Castle NG, Lin M, Spreitzer G. An assessment of cultural values and resident-centered culture change in US nursing facilities. Healthc Manage Rev 2013;38:295.
25. White-Chu EF, Graves WJ, Godfrey SM, et al. Beyond the medical model: the culture change revolution in long-term care. J Am Med Dir Assoc 2009;10:370–8.
26. Stone RI. Developing a quality direct care workforce: searching for solutions. Pub Pol Aging Rep 2017.
27. Shier V, Khodyakov D, Cohen LW, et al. What does the evidence really say about culture change in nursing homes? Gerontologist 2014;54:S6–S16.
28. Fritsch T, Kwak J, Grant S, et al. Impact of TimeSlips, a creative expression intervention program, on nursing home residents with dementia and their caregivers. Gerontologist 2009;49:117–27.
29. Kane RA, Lum TY, Cutler LJ, et al. Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial Green House program. J Am Geriatr Soc 2007;55:832-9.
30. Lum TY, Kane RA, Cutler LJ, Yu TC. Effects of Green House nursing homes on residents’ families. Healthc Financ Rev 2008;30:35–51.
31. Brooker DJ, Woolley RJ, Lee D. Enriching opportunities for people living with dementia in nursing homes: an evaluation of a multi-level activity-based model of care. Aging Ment Health 2007;11:361–70.
32. Detweiler MB, Murphy PF, Myers LC, Kim KY. Does a wander garden influence inappropriate behaviors in dementia residents? Am J Alzheimers Dis Other Dement 2008;23:31–45.
33. Miller SC, Lepore M, Lima JC, et al. Does the introduction of nursing home culture change practices improve quality? J Am Geriatr Soc 2014;62:1675–82.
34. Doty MM, Koren MJ, Sturla EL. Culture change in nursing homes: how far have we come? Findings from the Commonweath Fund 2007 National Survey of Nursing Homes; 2008. Accessed at http://www.commonwealthfund.org/Publications/Fund-Reports/2008/May/Culture-Change-in-Nursing-Homes--How-Far-Have-We-Come--Findings-From-The-Commonwealth-Fund-2007-Nati.aspx.
35. Miller SC, Tyler D, Shield R, et al. Nursing home culture change: study framework and survey instrument design. Presentation at the International Association of Gerontology and Geriatrics meeting, San Francisco, CA; 2017.
36. Sterns S, Miller SC, Allen S. The complexity of implementing culture change practices in nursing homes. J Am Med Dir Assoc 2010;11:511–8.
37. Scalzi CC, Evans LK, Barstow A, Hostvedt K. Barriers and enablers to changing organizational culture in nursing homes. Nurs Admin Q 2006;30:368–72.
38. Schuldheis S. Initiating person-centered care practices in long-term care facilities. J Gerontol Nurs 2007;33:47.
39. Rosemond CA, Hanson LC, Ennett ST, et al. Implementing person-centered care in nursing homes. Healthc Manage Rev 2012;37:257–66.
40. Munroe DJ, Kaza PL, Howard D. Culture-change training: Nursing facility staff perceptions of culture change. Geriatr Nurs 2011;32:400–7.
41. Bowers BJ, Nolet K. Developing the Green House nursing care team: Variations on development and implementation. Gerontologist 2014;54:S53–64.
42. Lopez SH. Culture change management in long-term care: a shop-floor view. Pol Soc 2006;34:55–80.
43. Tyler DA, Lepore M, Shield RR, et al. Overcoming resistance to culture change: nursing home administrators’ use of education, training, and communication. Gerontol Geriatr Educ 2014;35:321–36.
44. Lawrence PR. How to deal with resistance to change. Harvard Bus Rev 1954;May/June:49–57.
45. Coch L, French JRP. Overcoming resistance to change. Hum Relat 1948;1:512–32.
46. Scott-Cawiezell J, Schenkman M, Moore L, et al. Exploring nursing home staff’s perceptions of communication and leadership to facilitate quality improvement. J Nurs Care Qual 2004;19:242–52.
47. Leutz W, Bishop CE, Dodson L. Role for a labor–management partnership in nursing home person-centered care. Gerontologist 2009;50:340–51.
48. Tyler DA, Parker VA. Nursing home culture, teamwork, and culture change. J Res Nurs 2011;16:37–49.
49. Snoeren MM, Janssen BM, Niessen TJ, Abma TA. Nurturing cultural change in care for older people: seeing the cherry tree blossom. Health Care Anal 2016;24:349–73.
50. Corazzini K, Twersky J, White HK, et al. Implementing culture change in nursing homes: an adaptive leadership framework. Gerontologist 2014;55:616–27.
51. Morgan JC, Haviland SB, Woodside MA, Konrad TR. Fostering supportive learning environments in long-term care: the case of WIN A STEP UP. Gerontol Geriatr Educ 2007;28:55–75.
1. Koren MJ. Person-centered care for nursing home residents: The culture-change movement. Health Affairs 2010;29:1–6.
2. Goffman E. Asylums: essays on the social situation of mental patients and other inmates. Garden City, NY: Anchor Books; 1961.
3. Kane RA, Caplan AL. Everyday ethics: resolving dilemmas in nursing home life. New York: Springer; 1990.
4. Mor V, Branco K, Fleishma J, et al. The structure of social engagement among nursing home residents. J Gerontol B Psycholog Sci Soc Sci 1995;50:P1–P8.
5. Foner N. The caregiving dilemma: work in an American nursing home. Berkeley, CA: University of California Press; 1993.
6. Gubrium J. Living and dying at Murray Manor. New York: St. Martins; 1976.
7. Kayser-Jones JS. Old, alone, and neglected: care of the aged in the United States and Scotland. Berkeley, CA: University of California Press; 1990.
8. Vladeck B. Unloving care: the nursing home tragedy. New York: Basic Books; 1980.
9. Diamond T. Social policy and everyday life in nursing homes: a critical ethnography. Soc Sci Med 1986;23:1287–95.
10. Kalleberg A, Reskin BF, Hudson K. Bad jobs in America: standard and nonstandard employment relations and job quality in the United States. Am Sociolog Rev 2000;65:256–78.
11. Rahman AN, Schnelle JF. The nursing home culture-change movement: recent past, present, and future directions for research. Gerontologist 2008;48:142–8.
12. White-Chu EF, Graves WJ, Godfrey SM, et al. Beyond the medical model: the culture change revolution in long-term care. J Am Med Dir Assoc 2009;10:370–8.
13. Misiorski S, Kahn K. Changing the culture of long-term care: Moving beyond programmatic change. J Soc Work Long-Term Care 2006;3:137–46.
14. Anderson RA, Bailey DEJ, Wu B, et al. Adaptive leadership framework for chronic illness: framing a research agenda for transforming care delivery. Adv Nurs Sci 2015;38:83–95.
15. Bailey DE, Docherty S, Adams JA, et al. Studying the clinical encounter with the adaptive leadership framework. J Healthc Leadersh 2012;4:83–91.
16. Centers for Medicare & Medicaid Services Manual System. Revisions to Appendix PP “Guidance to Surveyors of Long Term Care Facilities” Washington, DC: Department of Health and Human Services 2009. Accessed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R48SOMA.pdf.
17. Miller SC, Looze J, Shield R, et al. Culture change practice in US nursing homes: prevalence and variation by state Medicaid reimbursement policies. Gerontologist 2014;54:434–45.
18. Shield R, Looze J, Tyler D, et al. Why and how do nursing homes implement culture change practices? Insights from qualitative interviews in a mixed methods study. J Appl Gerontol 2014;33:737–63.
19. Lepore MJ, Shield RR, Looze J, et al. Medicare and Medicaid reimbursement rates for nursing homes motivate select culture change practices but not comprehensive culture change. J Aging Soc Pol 2015;27:215–31.
20. Shield RR, Tyler D, Lepore M, et al. Would you do that in your home? Making nursing homes home-like in culture change implementation. J Housing Elderly 2014;28:383–98.
21. Cutler L, Kane RA. As great as all outdoors. J Hous Elderly 2006;19:29–48.
22. Jurkowsky ET. Implementing culture change in long-term care: Benchmarks and strategies for management and practice. New York: Springer; 2013.
23. Wang D , Glicksman A. “Being grounded”: Benefits of gardening for older adults in low-income housing. J Hous Elderly 2013;27:89–104.
24. Banaszak-Holl J, Castle NG, Lin M, Spreitzer G. An assessment of cultural values and resident-centered culture change in US nursing facilities. Healthc Manage Rev 2013;38:295.
25. White-Chu EF, Graves WJ, Godfrey SM, et al. Beyond the medical model: the culture change revolution in long-term care. J Am Med Dir Assoc 2009;10:370–8.
26. Stone RI. Developing a quality direct care workforce: searching for solutions. Pub Pol Aging Rep 2017.
27. Shier V, Khodyakov D, Cohen LW, et al. What does the evidence really say about culture change in nursing homes? Gerontologist 2014;54:S6–S16.
28. Fritsch T, Kwak J, Grant S, et al. Impact of TimeSlips, a creative expression intervention program, on nursing home residents with dementia and their caregivers. Gerontologist 2009;49:117–27.
29. Kane RA, Lum TY, Cutler LJ, et al. Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial Green House program. J Am Geriatr Soc 2007;55:832-9.
30. Lum TY, Kane RA, Cutler LJ, Yu TC. Effects of Green House nursing homes on residents’ families. Healthc Financ Rev 2008;30:35–51.
31. Brooker DJ, Woolley RJ, Lee D. Enriching opportunities for people living with dementia in nursing homes: an evaluation of a multi-level activity-based model of care. Aging Ment Health 2007;11:361–70.
32. Detweiler MB, Murphy PF, Myers LC, Kim KY. Does a wander garden influence inappropriate behaviors in dementia residents? Am J Alzheimers Dis Other Dement 2008;23:31–45.
33. Miller SC, Lepore M, Lima JC, et al. Does the introduction of nursing home culture change practices improve quality? J Am Geriatr Soc 2014;62:1675–82.
34. Doty MM, Koren MJ, Sturla EL. Culture change in nursing homes: how far have we come? Findings from the Commonweath Fund 2007 National Survey of Nursing Homes; 2008. Accessed at http://www.commonwealthfund.org/Publications/Fund-Reports/2008/May/Culture-Change-in-Nursing-Homes--How-Far-Have-We-Come--Findings-From-The-Commonwealth-Fund-2007-Nati.aspx.
35. Miller SC, Tyler D, Shield R, et al. Nursing home culture change: study framework and survey instrument design. Presentation at the International Association of Gerontology and Geriatrics meeting, San Francisco, CA; 2017.
36. Sterns S, Miller SC, Allen S. The complexity of implementing culture change practices in nursing homes. J Am Med Dir Assoc 2010;11:511–8.
37. Scalzi CC, Evans LK, Barstow A, Hostvedt K. Barriers and enablers to changing organizational culture in nursing homes. Nurs Admin Q 2006;30:368–72.
38. Schuldheis S. Initiating person-centered care practices in long-term care facilities. J Gerontol Nurs 2007;33:47.
39. Rosemond CA, Hanson LC, Ennett ST, et al. Implementing person-centered care in nursing homes. Healthc Manage Rev 2012;37:257–66.
40. Munroe DJ, Kaza PL, Howard D. Culture-change training: Nursing facility staff perceptions of culture change. Geriatr Nurs 2011;32:400–7.
41. Bowers BJ, Nolet K. Developing the Green House nursing care team: Variations on development and implementation. Gerontologist 2014;54:S53–64.
42. Lopez SH. Culture change management in long-term care: a shop-floor view. Pol Soc 2006;34:55–80.
43. Tyler DA, Lepore M, Shield RR, et al. Overcoming resistance to culture change: nursing home administrators’ use of education, training, and communication. Gerontol Geriatr Educ 2014;35:321–36.
44. Lawrence PR. How to deal with resistance to change. Harvard Bus Rev 1954;May/June:49–57.
45. Coch L, French JRP. Overcoming resistance to change. Hum Relat 1948;1:512–32.
46. Scott-Cawiezell J, Schenkman M, Moore L, et al. Exploring nursing home staff’s perceptions of communication and leadership to facilitate quality improvement. J Nurs Care Qual 2004;19:242–52.
47. Leutz W, Bishop CE, Dodson L. Role for a labor–management partnership in nursing home person-centered care. Gerontologist 2009;50:340–51.
48. Tyler DA, Parker VA. Nursing home culture, teamwork, and culture change. J Res Nurs 2011;16:37–49.
49. Snoeren MM, Janssen BM, Niessen TJ, Abma TA. Nurturing cultural change in care for older people: seeing the cherry tree blossom. Health Care Anal 2016;24:349–73.
50. Corazzini K, Twersky J, White HK, et al. Implementing culture change in nursing homes: an adaptive leadership framework. Gerontologist 2014;55:616–27.
51. Morgan JC, Haviland SB, Woodside MA, Konrad TR. Fostering supportive learning environments in long-term care: the case of WIN A STEP UP. Gerontol Geriatr Educ 2007;28:55–75.