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Resident Directed Care and Resident Directed Care and Culture Change in Nursing Homes Culture Change in Nursing Homes
Christine Mueller, PhD, RN, FAANUniversity 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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Acknowledgments
This is a joint project of
With support from
Grant to the University of Minnesota School of Nursing
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
This project is endorsed by:
Project Steering CommitteeView List of Members
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
Objectives/Purpose:
At the end of this module you will be able to:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Resident Care in a Traditional Nursing HomeResident Care in a Traditional Nursing Home
A resident in a traditional nursing home would have: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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Resident Care in a Culture Change Nursing Home
A resident in a culture change nursing home would have:A resident in a culture change nursing home would have:
A home-like environment (pets; plants; food available 24/7)
Families welcome and participating in care
Click to View Information about Nursing Home Comparisons at the Pioneer Network
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
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
Learn more about Continuum of Person-Directed Culture
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Geriatric Nursing Competencies for Geriatric Nursing Competencies for Resident Directed CareResident Directed Care
Click to view the competencies developed by the Pioneer Network
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Outcomes of Culture ChangeOutcomes of Culture Change
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
Nursing homes implementing culture change report improvements in:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Research SupportingResearch SupportingCulture Change is LimitedCulture 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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
The Path to Resident Directed Care and The Path to Resident Directed Care and Culture ChangeCulture 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:
Reconfigure nursing services and create staff
empowerment
Create a “homey” environment
Implement practices of resident choice for food choice, dining, bathing,
taking medications
Click to View CMS Survey and Certification Letter, 4/09
Culture Culture change is change is
described as described as a journey.a journey.
To learn what nursing homes are participating in the culture change journey, contact the state’s culture change coalition or Google: “culture change coalition.”
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
DefiningDefining a “Home Like” Environmenta “Home Like” Environment
Household model:Household model: the generic term the generic term
Neighborhood::
Small units of 8-20 residents Consistent staff assignment Separate dining and living areas Local (i.e., community) decision making
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
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Artifacts of Culture ChangeArtifacts of Culture Change
Artifacts of Culture Change is a Artifacts of Culture Change is a CMS tool to evaluate a nursing CMS tool to evaluate a nursing home’s progress from institutional home’s progress from institutional to resident-directed care to resident-directed care
The tool has five key domains of The tool has five key domains of culture change:culture change:- 1. Care Practices 1. Care Practices - 2. Environment2. Environment- 3. Family and Community3. Family and Community- 4. Leadership4. Leadership- 5. Workplace practices5. Workplace practices
Click to Learn more about the Development of the Artifacts of Culture Change Tool
Click to Learn more about Artifacts in culture change at the Pioneer Network
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of NursingHartford Institute for Geriatric Nursing, College of Nursing, New York University Nursing Homes as Clinical Training Sites
Artifacts of Culture Change 1: Artifacts of Culture Change 1: CARECARE PRACTICES ArtifactsPRACTICES Artifacts
• 24 hour dining where residents can order food 24 hour dining where residents can order food from the kitchen 24 hours/dayfrom the kitchen 24 hours/day
• Snacks, drinks available at all timesSnacks, drinks available at all times• Waking and bedtimes and bathing preferences Waking and bedtimes and bathing preferences
and times are chosen by the residentand times are chosen by the resident• Care plans are in the “voice” of the resident, Care plans are in the “voice” of the resident,
called “I” Care planscalled “I” Care plans• Residents can have their pet live with themResidents can have their pet live with them• Someone is with a dyingSomeone is with a dying resident at all timesresident at all times
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Example of a Care Plan in the “Voice” of the Example of a Care Plan in the “Voice” of the ResidentResident
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Artifacts of Culture Change 2: Examples of ENVIRONMENT Artifacts
• Residents have private rooms or privacy is Residents have private rooms or privacy is enhanced in shared roomsenhanced in shared rooms
• Nurse’s stations are not visibleNurse’s stations are not visible• Medications are kept in the resident’s roomMedications are kept in the resident’s room• Overhead paging system is used only in cases of Overhead paging system is used only in cases of
emergencyemergency• Personal laundry is done in the area where the Personal laundry is done in the area where the
resident livesresident lives• Bathroom mirrors are wheelchair accessibleBathroom mirrors are wheelchair accessible
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Artifacts of Culture Change 3: Artifacts of Culture Change 3: Examples of FAMILY and COMMUNITY ArtifactsExamples of FAMILY and COMMUNITY Artifacts
• Space for community groups to meet with Space for community groups to meet with residents welcome to attendresidents welcome to attend
• Café/restaurant available for families, residents Café/restaurant available for families, residents and visitorsand visitors
• Dining area available for families to have meals Dining area available for families to have meals with their family memberwith their family member
• Kitchen/kitchenette area where cooking and Kitchen/kitchenette area where cooking and baking can be donebaking can be done
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Artifacts of Culture Change 4: Artifacts of Culture Change 4: Examples of LEADERSHIP ArtifactsExamples of LEADERSHIP Artifacts
• Nursing assistants attend and participate in care Nursing assistants attend and participate in care plan conferencesplan conferences
• Learning circles (or equivalent) are used in Learning circles (or equivalent) are used in resident and staff meetingsresident and staff meetings
• Residents and families serve on nursing home Residents and families serve on nursing home quality assessment/assurance committeesquality assessment/assurance committees
• Community (household/neighborhood) meetings Community (household/neighborhood) meetings are held regularly with staff, residents, and are held regularly with staff, residents, and families.families.
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Artifacts of Culture Change 5: Artifacts of Culture Change 5: Examples of WORKPLACE PRACTICE ArtifactsExamples 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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Professional Nurse PracticeProfessional Nurse Practice Model Should Model Should UnderpinUnderpin Culture Change Nursing Homes Culture Change Nursing Homes
Interdisciplinary team shares accountability
for care outcomes
Site-specific innovations designed and
implemented by nurses
Empowered bedside staff (i.e., CNAs)
Decentralized organization
Aspects of Aspects of Professional Nurse Professional Nurse
Practice ModelPractice Model
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Nurse Leadership and Culture ChangeNurse 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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Potential Dilemmas for RNs in Culture ChangePotential Dilemmas for RNs in Culture Change
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
Potential issues include:
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
The Pioneer Network Consumer’s Guide to Finding a Nursing The Pioneer Network Consumer’s Guide to Finding a Nursing Home on the Culture Change JourneyHome 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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
Recap: Key Points about Resident-Directed Recap: Key Points about Resident-Directed Care and Culture ChangeCare and Culture Change
Culture change nursing homes can serve as excellent clinical placement sites by exposing students to innovative:
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
© 2010 The Hartford Institute for Geriatric Nursing, NYU College of Nursing and The American Association of Colleges of Nursing
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