Myths and Misconceptions About Culture Change

Culture change is the new "buzz" word surrounding nursing home professionals. It seems everyone is talking about it – Quality Improvement Organizations, CMS, Ombudsman and trade associations. Unfortunately, if you ask ten people what nursing home culture change means, you are likely to receive ten different interpretations. As a result, there are many myths and misconceptions regarding culture change in LTC. Here we debunk some of those myths.

Myth: The goal is to move from the medical model to social model

This myth may be foundational to why the spread of culture change innovations have been so slow. Such a message turns off physicians, nurses, pharmacists and other clinical practioners. SNFs are licensed to provide quality medical care. Thus, such a message confuses professionals.

Reality: The goal is to move from institutionalized care to individualized care. At its essence, individualized care is foundational to good clinical care. The literature clearly supports the link between psychological well-being and physical ailments. Therefore, the person-directed care model is more holistic in nature. The goal is quality of life and quality care.

Myth: Culture change is all about improving residents’ quality of life

Certainly, the focus is on individualizing care for each resident. But culture change is an approach that positively affects everyone associated with the organization. In addition, the innovations are not one-dimensional they are multi-dimensional. Nursing homes are fragile, complex eco-systems. Thus achieving any positive outcome such as enhanced resident quality of life requires success in multiple areas of the organization.

Reality: Culture change improves resident’s and caregivers quality of work life. Care that de-humanizes the elder also de-humanizes the caregiver. The innovative changes associated with implementing person-directed care strike at the root cause of staff instability in LTC. The new leadership paradigm focuses on enhancing staff satisfaction through recognition, education and empowerment.

Myth: Culture change costs a lot of money (i.e. building renovation).

Reality: Such a myth stems form the misguided notion that culture change only involves environmental, physical changes. The fact is that implementing individualized care requires changes in many different domains: care practices, workplace practices, leadership and the physical environment.

You do not have to renovate a building to achieve culture change. Some environmental enhancements can be achieved with a very small investment. A good starting point of the culture change journey is in the domain of workplace practices and changes associated with the way staff are treated each day.

Myth: One specific model of culture change fits all

The culture change models such as Eden, LEAP or HATCh are all excellent and share more similarities than differences. Yet, the key to successful implementation of any model remains imbedded in the complex process of organizational change.

Reality: No prescription fits every facility. If you have seen one nursing home you have seen one nursing home. Each facility is unique. Leaders should study the different models but refuse to get bogged down trying to select the perfect model. A better approach is for a facility is to start anywhere but just be sure to start. In addition, many facilities on the journey of culture change are using the principles of a few of the models and some of their own innovations.

Myth: The Administrator/Executive Director must "get it" before you start

Reality: All it takes are a few committed leaders within an organization to get the implementation of person-directed care started. Some administrators may need some time before experiencing a paradigm shift.

Reality: The leader does not need an epiphany before beginning. Change can be difficult for everyone including the Administrator.. Again, just begin - after Administrator sees results they will come on board. Therefore, be sure to measure every change. Collect baseline data, implement changes and measure again. Create confidence from the data not just inspirational words.

Myth: It takes five years before you bear the fruits of culture change

This is a surefire way to stagnate leaders. There may be serious flaws in the process of implementing person-directed care if it takes five years before leaders see the positive results. The solution is measurement. Collecting data from the start facilitates a clear view of the impact of culture change.

Reality: Positive results can be achieved in months. Culture change is a journey that does not lend itself to specific timeframes. However, it does not take 5 years before you see results. Some changes can result in dramatic improvements within months. For example, many facilities that have switched from rotating staff assignment to consistent assignment have seen a decline in falls, pressure ulcers, staff absenteeism and staff turnover.

Myth: Department of Health surveyors do not support these changes.

All across the country, surveyors are proving to be receptive to educational programs that show how these innovative, individualized care practices and system changes result in clinical improvements and enhanced quality of life for the residents. The key is to bring regulators into your culture change story. The best approach is to keep them informed of your changes so that they are not surprised when they walk into the facility.

Reality: The true intent of the OBRA regulations is person-directed Care. F279 Calls for a holistic, individualized approach to - “…attain or maintain highest practicable physical, mental and psychosocial well-being of each resident.” Some surveyors have become institutionalized just as some providers have. It is not the Dept. of Health surveyors who are holding back culture change. Rather, it is own paradigms.

References:

Eaton S. "Beyond Unloving Care Linking Human Resource Management and Patient Care Quality in Nursing Homes."

International Journal of Human Resource Management 3 (June 11, 2000): 591-616.

Patchner MA. "Permanent assignment: A better recipe for the staffing of aides." Successful nurse aide management in nursing homes Phoenix, AZ; Oryx Press, 1989: 66-75.

Wunderlich, G. (2000). Improving the Quality of Long-Term Care. The Institute of Medicine.