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Resident Directed Care and Culture Change in Nursing Homes

Christine Mueller, PhD, RN, FAANUniversity of MinnesotaSchool of NursingMathy Mezey, EdD, RN, FAAN, Sarah Greene Burger, RN-C, MPH, FAANEthel Mitty, EdD, RNHartford 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

With support from

Grant to the

University of Minnesota School of Nursing

this project is endorsed by
This project is endorsed by:

Project Steering Committee

View List of Members

about module 3 resident directed care and culture change in nursing homes
About Module 3: Resident Directed Care and Culture Change in Nursing Homes

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


At the end of this module you will be able to:

reasons to choose a culture change nursing home as a clinical placement site
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
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
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 aboutContinuum of Person-Directed Culture

geriatric nursing competencies for resident directed care
Geriatric Nursing Competencies for Resident Directed Care

Click to view the competencies developed by the Pioneer Network

outcomes of culture change
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
Research SupportingCulture 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
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


  • 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
Defininga “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
  • 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
Artifacts of Culture Change 1: CAREPRACTICES 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 dyingresident 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
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
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
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
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
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
nurse leadership and culture change
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
  • Nurses may not have been involved in creating this culture change
potential dilemmas for rns in 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
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

recap key points about resident directed care and culture change
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 SeriesNursing 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