Resident Directed Care and Culture Change in Nursing Homes Christine Mueller, PhD, RN, FAAN University of Minnesota School of Nursing Mathy Mezey, EdD, RN, FAAN, Sarah Greene Burger, RN-C, MPH, FAAN Ethel Mitty, EdD, RN Hartford Institute for Geriatric Nursing, New York University College of Nursing Module 3 of Nursing Homes as Clinical Placement Sites for Nursing Students Series

This is a joint project of University of Minnesota School of Nursing Acknowledgments This is a joint project of With support from Grant to the University of Minnesota School of Nursing 2

This project is endorsed by: Project Steering Committee View List of Members

At the end of this module you will be able to: About Module 3: Resident Directed Care and Culture Change in Nursing Homes Objectives/Purpose: At the end of this module you will be able to: Describe the concepts of resident-directed care and culture change in nursing homes Compare and contrast the benefits of choosing culture change nursing homes as clinical placement sites Evaluate a nursing home’s adoption of resident-directed care and culture change Explain the differences between a culture change nursing home and a traditional nursing home Explain the CMS Artifacts of Culture Change Identify the risks to nurses when working in a culture change nursing home 4

Reasons to Choose a Culture Change Nursing Home as a Clinical Placement Site Expose students to a respectful model of care that: Creates a home-like environment Offers a resident choices about the timing and manner of their care Empowers RNs, LPNs, and nursing assistants to structure care in a flexible/responsive way Improves a resident’s sense of identity and purpose

Resident Care in a Traditional Nursing Home A resident in a traditional nursing home would have: Wake up, meals and baths on a rigid/fixed schedule Nursing staff who do different “tasks” e.g. temps; meds; toileting Care dictated by nursing home protocols and procedures A room and environment that looks like a “mini hospital,” e.g. no small sitting rooms, few plants, pets restricted, limited availability of snacks. Little attention to their emotional and quality of life needs, e.g. what makes them happy, engaged A sense of isolation and loneliness

Resident Care in a Culture Change Nursing Home A resident in a culture change nursing home would have: A home-like environment (pets; plants; food available 24/7) Choice as to: When to get up and go to bed When, where and what to eat How often and where to bathe Keeping a pet The same staff providing and organizing their care: Staff and resident together deciding the care A care plan that is in the resident’s (e.g. “I”) voice Families welcome and participating in care Click to View Information about Nursing Home Comparisons at the Pioneer Network Learn more about Continuum of Person-Directed Culture

Geriatric Nursing Competencies for Resident Directed Care Click to view the competencies developed by the Pioneer Network

Outcomes of Culture Change Nursing homes implementing culture change report improvements in: Quality (pressure ulcers, restraint use, catheter use) State survey outcomes Staff turnover and less use of agency staff Per bed net income Operating margin Occupancy

Research Supporting Culture Change is Limited Culture change took hold as “the right thing to do” without research evidence Creating a research base was seen as slowing down the adoption of culture change Culture change was initiated by practitioners and consumers The few existing research studies on culture change have variable designs and small sample sizes

The Path to Resident Directed Care and Culture Change Nursing homes vary as to how they incorporate the principles and practices of culture change. Nursing homes differ in the extent to which they: Create a “homey” environment Implement practices of resident choice for food choice, dining, bathing, taking medications Culture change is described as a journey. Reconfigure nursing services and create staff empowerment To learn what nursing homes are participating in the culture change journey, contact the state’s culture change coalition or Google: “culture change coalition.” Click to View CMS Survey and Certification Letter, 4/09

Defining a “Home Like” Environment Household model: the generic term Neighborhood: Small units of 8-20 residents Consistent staff assignment Separate dining and living areas Local (i.e., community) decision making Green House: Built from the bottom up Changes in facility size, layout, interior design Staffing patterns modified to reflect resident needs and preferences Goal is to eliminate large nursing homes and de-institutionalize LTC  Eden Alternative: a philosophy of home and practice “Where elders live must be habitats for human beings, not sterile institutions.” Goal: eliminate the “3 plagues of loneliness, helplessness, boredom.” Eden concepts are integrated into different living models

Artifacts of Culture Change Artifacts of Culture Change is a CMS tool to evaluate a nursing home’s progress from institutional to resident-directed care The tool has five key domains of culture change: 1. Care Practices 2. Environment 3. Family and Community 4. Leadership 5. Workplace practices Click to Learn more about Artifacts in culture change at the Pioneer Network Click to Learn more about the Development of the Artifacts of Culture Change Tool

Artifacts of Culture Change 1: CARE PRACTICES Artifacts 24 hour dining where residents can order food from the kitchen 24 hours/day Snacks, drinks available at all times Waking and bedtimes and bathing preferences and times are chosen by the resident Care plans are in the “voice” of the resident, called “I” Care plans Residents can have their pet live with them Someone is with a dying resident at all times Hartford Institute for Geriatric Nursing, College of Nursing, New York University Nursing Homes as Clinical Training Sites

Example of a Care Plan in the “Voice” of the Resident For examples of “I” care plans, see the following links: “I” Centered Care Plans Message Board “I” Care plan example- Riverview Care Center “I” Care plan example- Clark-Lindsey Village

Artifacts of Culture Change 2: Examples of ENVIRONMENT Artifacts Residents have private rooms or privacy is enhanced in shared rooms Nurse’s stations are not visible Medications are kept in the resident’s room Overhead paging system is used only in cases of emergency Personal laundry is done in the area where the resident lives Bathroom mirrors are wheelchair accessible

Artifacts of Culture Change 3: Examples of FAMILY and COMMUNITY Artifacts Space for community groups to meet with residents welcome to attend Café/restaurant available for families, residents and visitors Dining area available for families to have meals with their family member Kitchen/kitchenette area where cooking and baking can be done

Artifacts of Culture Change 4: Examples of LEADERSHIP Artifacts Nursing assistants attend and participate in care plan conferences Learning circles (or equivalent) are used in resident and staff meetings Residents and families serve on nursing home quality assessment/assurance committees Community (household/neighborhood) meetings are held regularly with staff, residents, and families.

Artifacts of Culture Change 5: Examples of WORKPLACE PRACTICE Artifacts RNs, LPNs, and CNAs consistently work with the same residents CNAs self-schedule Staff not required to wear a uniform or “scrubs” Nursing home pays for outside conferences and workshops for CNAs Career ladder, job development opportunities Day care on site

Professional Nurse Practice Model Should Underpin Culture Change Nursing Homes References: 1. Lyons et al. 2008. Everyday excellence: A framework for Professional Nursing Practice in Long-Term Care. Research in Gerontological Nursing 1(3), 217-228. Beck C. 2008. Professional Nursing Practice Models and Culture Change. Presented at the CGNO-Pioneer Expert Panel Meeting, NYC. Oct 27-28, 2008.

Nurse Leadership and Culture Change Culture change requires a coaching and transformational nurse leadership style Nurses have little knowledge of or experience in culture change Nurses may be unfamiliar with this style of leadership References: Burger et al. 2009. “ISSUE PAPER: Nurses Involvement in Nursing Home Culture Change. Overcoming Barriers, Advancing Opportunities. Rader J. 2008. “Nursing Education and Culture Change.” Presented at the CGNO-Pioneer Expert Panel Meeting, NYC. Oct 27-28, 2008. http://hartfordign.org/policy/position_papers_briefs/ Nurses may not have been involved in creating this culture change

Potential Dilemmas for RNs in Culture Change Potential issues include: Resident risk/harm from poor decision making RN accountability when unlicensed staff inappropriately honor resident requests Loss of a nurse’s station and medication carts when transforming to a home environment

The Pioneer Network Consumer’s Guide to Finding a Nursing Home on the Culture Change Journey This guide provides key questions and “listen for” answers, including: How will you get to know my family member? What is your policy regarding food choices and alternatives? How do you build a sense of community? Source: Pioneer Network http://pioneernetwork.org/Consumers/Guide

Recap: Key Points about Resident-Directed Care and Culture Change Care practices aimed at improving resident quality of care and quality of life Nursing service delivery models Resident and staff decision making Care plans and interdisciplinary team planning Environmental designs that replicate a sense of home Culture change nursing homes can serve as excellent clinical placement sites by exposing students to innovative:

Please Proceed to the following modules of the Series Nursing Homes as Clinical Placement Sites for Nursing Students Overview of the Project Module 1: An overview of nursing homes generally Module 2: An overview of nursing in nursing homes Module 3: Content on resident directed care and culture change Module 4: Selecting and structuring clinical placements in nursing homes Module 5: A case study to help faculty introduce resident directed care and culture change Module 6: Strategies to help nursing homes position themselves as clinical placement