1 resident directed care and culture change in nursing homes christine mueller, phd, rn, faan...

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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


This project is endorsed by:

Project Steering CommitteeView List of Members


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:


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 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


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


Geriatric Nursing Competencies for Geriatric Nursing Competencies for Resident Directed CareResident Directed Care

Click to view the competencies developed by the Pioneer Network


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:


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


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.”


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


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


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


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


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


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.


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


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


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


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:


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


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


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

1 resident directed care and culture change in nursing homes christine mueller, phd, rn, faan...

Documents

nursing research

nursing reasons

nursing assistants

nursing acknowledgments

nursing services

nursing resident care

culture change nursing

nyu college of nursing