Long term care facilities are designed to be safe places that foster a culture of caring. However, due to a change in management, the realignment of priorities of the facility, or even plain neglect of the changing culture in long term care, your facility may deteriorate over time.
The conversation around culture in long term care is often dismissed because it requires significant resources and can be a lengthy and taxing process. Moreover, a lot of long term care facilities do not recognize the importance of establishing and improving long term care culture. “I think culture is really nebulous,” said Annette Greely, President and CEO of Jones-Harrison Residence. “As someone who has seen both organizational and individual culture, I can say that the key is to create your own. It requires a lot of manpower, but it pays off in the end.” She discussed improving culture in long term care in her recent interview with Peter Murphy Lewis on the LTC Heroes podcast.
In this article, we explore the significance of improving culture in long term care, provide ideas for practices to help this endeavor, and suggest how you can include more voices in the decision-making process at your facility to ensure greater satisfaction among residents and the staff.
What Is Cultural Change In Long Term Care?
The word “culture” is often used by large corporations to refer to policies and standard practices. In this context, cultural improvement and change refer to implementing a standard set of practices, policies, and organizational changes within an entity to make it a better place to work at and live in. Such change will ensure sustainability and longevity for your long term care facility as well as better quality of life for your residents.
Cultural change in long term care is a systemic and incremental process that includes initiating zero tolerance on negative behaviors, changing policies to encourage positivity, fostering collaboration with residents, engaging in discussions about what is best for them, and providing appropriate training for staff. To accomplish these, changes must be made from top to bottom.
The primary focus of cultural change is on continuous improvement. This requires that managers do not settle for maintaining the status quo and, instead, strive for excellence. Cultural change also focuses on maintaining an evolving corporate strategy that never settles for stagnation and finds better ways of improving daily operations and making relevant managerial decisions.
Ultimately, cultural change in long term care is aimed at improving the quality of life of your residents by changing your facility from an institution into a vibrant community that survives on a culture of accountability and empathy. Focusing on the interests of residents in long term care facilities means putting their physical and psychological well-being at the forefront of decisions. Changing cultural norms also incorporates new approaches to staff training and increases awareness of how residents should be treated with dignity and respect.
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Why Is Culture Change In Long Term Care Facilities Important?
Improving culture will have a direct impact on the quality of life of your residents. This in turn can help with branding, compliance, and predicting quality outcomes. Such change will also ensure the sustenance and longevity of your facility along with higher profit margins in the short term.
According to a study by the Commonwealth Fund, 78% of homes that have implemented seven or more culture-change initiatives reported that the changes have improved their competitive advantage in their market, while only 54% of nursing homes that have implemented three or fewer initiatives have achieved such results.
Cultural change can also help reduce the staffing problem in long term care. Nursing homes invested in the culture change process report significant improvement in staff retention and reduced turnover, going from annual turnover rates ranging from 65% to 100% prior to culture change to a turnover rate of 30% after culture change.
Factors That Contribute to Culture Change In Long Term Care Facilities
Cultural change can be intentional or unavoidable. The latter occurs when there is a change in management. The former, meanwhile, means that leadership actively wants to change the culture at a facility to achieve a certain outcome, like resident independence or improvement in the quality of care provided.
As for the desired cultural change, facilities determine that only after they realize something needs to change. This can be an aha moment for your staff, a complaint from a resident or their family, or just something that your facility has wanted to implement for a long time. Change in culture following a merger or an acquisition presents added challenges to a facility. But if you have adequate standard operating procedures (SOPs) in place to develop and maintain a great culture, you can get newcomers to follow your process relatively easily. In short, you can make the best of any such situation by surrounding yourself with great people, documenting and implementing processes, and taking a resident-centric approach to care.
Practical Ways to Improve Culture In Long Term Care
Changing culture in long term care goes beyond putting on a friendly face for your residents every single day. Being “nice” is not measurable, and implementing a thorough culture policy cannot be restricted to that. Further, culture change is a gradual process. From starting to align your employees on the same core values to getting them to take a resident-focused approach to care, the process can be long and tiresome.
Meaningful Social Engagement
One of the primary reasons elders tend to look at long term care facilities as institutions is that they often stop pursuing their hobbies and interests once they become residents. And it can be challenging for long term care providers to acclimatize residents with their surroundings and help them develop connections within the facility.
As a result, seniors often develop a sense of loneliness and helplessness, even inside a thriving community. As part of a long term care team, it is your job to not only introduce them to other members of the community but also ensure that they are actively connected to them. Developing meaningful relationships with both their fellow residents and your staff will elevate the standard of life of your residents.
Developing meaningful relationships with fellow residents
It is often easier for people to bond with other people their age who understand what they are going through. To avoid feelings of loneliness and isolation, it is important that your residents are friendly with each other and look out for one another. This sentiment can help transform your facility into a community.
Your facility can achieve meaningful relationships between fellow residents through:
- Reminiscence therapy – Reminiscence therapy is used for older adults with dementia or severe memory loss. This is often also called “life review therapy” because it helps people revisit lost memories from their lives. It can be a rather beautiful and nostalgic way to increase social connection among your residents and help them connect with each other on a deeper, more empathetic level. You can choose to bring up old photographs, play a few retro songs, or ask about incidents that you are already aware happened in their lives.
- Support groups – You can introduce a support group for residents dealing with depression, anxiety, or any other form of mental illness. You can also do this for those dealing with grief over losing a family member, spouse, or even a pet. Another option is to experiment with a spirituality and aging group that provides an outlet for discussing spiritual ideas and the complexities of aging.
Developing meaningful relationships with staff
The closer you are to your residents, the easier it will be for you to monitor them and ensure their safety and well-being. Not only will stronger bonds make the process of caring for them easier, but they will also build trust. A small gesture – like taking the time to learn about their childhood pet – can rid your resident of the anxiety of being cared for by a stranger.
Your facility can achieve meaningful relationships with residents through:
- Creative expression – Working in long term care makes you observant enough to learn the natural tendencies of your residents. If you notice that they enjoy singing, gardening or even checkers, find a way to connect with them through this. Find a common interest and keep them engaged. The end goal here is for them to find a way to pursue their hobby and chat about it with you. A study by the Journal of the American Medical Directors Association demonstrates that depression and anxiety have an inverse connection with residents being able to creatively express themselves.
- Quarterly campaigns – You can choose to host “get to know me” days with your residents every three months. This allows for new staff members and residents to be formally introduced. Another benefit of this is that it provides residents the opportunity to look at new faces and interact with a larger crowd. Normally, they will only speak to the nurses that tend to them and fail to learn the names and faces of the other nurses in the facility. Quarterly campaigns will, thus, help expand their social network within the facility.
- Activity calendars – For you to develop a culture where your residents develop and maintain fulfilling and meaningful relationships, you will have to plan the activities dedicated to improving socialization for the year in advance. You can make that happen through an activity calendar. It is only through consistency that these activities can be turned into a culture of social connection.
Organizational Practices That Affect Cultural Change In Long Term Care
Organizational practices in your long term care facility can be defined as “the core actions that run your facility.” These can be articulated in the form of written SOPs that are followed as per the norm. They can also be the natural instincts of your leaders that are transmitted orally. An example of the former is the method by which your facility prepares and serves food, while an example of the latter is the fragrance of the air freshener you decide to use.
The decisions made about these practices are made either in accordance with maximum adherence to compliance or convenience. When organizational practices are centered around your profits instead of the purpose of providing quality health care, your residents suffer. However, to establish a balance between the two, your facility needs to make organizational decisions based on improving the quality of care that will ultimately widen your profit margins. That is why it is crucial to focus on longevity.
Making a change in organizational practices is usually a long journey, but with the right team and processes in place, you can get there faster than most. Here are some tactics to use at your facility:
- Empowering your staff – The best way to empower your staff is to provide sufficient and consistent training. Encourage a team approach for staff and practice cross-training in your facility. This will directly empower RNs and care workers and potentially even challenge hierarchical structures. While, according to the Commonwealth Fund, fifty-three percent of skilled nursing facilities (SNFs) provide staff with leadership training opportunities, only 15% of facilities indicated that they currently enable direct care workers to create self-managed work teams. Further, only 14% of SNFs currently cross-train staff to play several functional roles – like housekeeping, nursing, food service, and activities – to serve a variety of resident needs.
- Changing dining arrangements – Currently, most long term care facilities adhere to predetermined resident seating arrangements and bring out meals at a certain time to prevent temperature loss. In this scenario, residents do not even have a choice about who they sit with because decisions are made with staff efficiency in mind. To change this, your facility can introduce a buffet-style dining experience in which food is put in warmers so as to maintain the temperature. Snacks can be provided on request and the entire dining experience can be catered to help the residents recognize and follow their bodily autonomy instead of sticking to predetermined timings. Nearly half of culture change adopters report they have changed how meals are served. By contrast, only 22% of traditional homes report they are making such changes.
- Physical alterations to the facility – You might want to consider updating the interior of your facility so that it represents the culture you hope to promote. If your facility promises a home-type feeling but is structured like an institution, then your culture and interiors do not align. It would be best to eliminate large working stations and opt for smaller operational units. This will make it easier for your residents to have access to privacy, navigate the facility better, and add a familiar feeling to the facility.
- Update bathing stations and spas – In some facilities, residents have to pass by a number of places before they reach their bathing station. Often, they are covered in a towel or a bathrobe. This can cause great discomfort. To make bathing a more relaxing time, the bathing stations should be closer to the residents’ rooms. Moreover, the residents should be fully clothed while passing by so as to avoid shame and fear. You can make bathing an enjoyable time by taking a training session on it. You can also offer private baths to residents.
- Bedtime schedules – These are generally determined by the work shifts of the nurses in your facility. Sometimes, bedtimes are very close to mealtimes, which can cause irregular digestion patterns as well as irregular sleep patterns. It is best to let the residents adhere to the sleep schedule they had at home unless one’s sleep patterns are erratic or he or she needs assistance going to bed. Shift timings for frontline workers can be arranged according to the residents’ schedules.
It is best to document changes in organizational practices as you implement them so that a culture of accountability and person-centered care is firmly established. This does not just apply to organizational decisions related to structural and procedural changes. Rather, it applies to managerial decisions and the leaders you select for your facility as well. Residents should be involved in conversations about both kinds of decision making.
Oftentimes, managerial decisions in long term care are based upon the figures that leaders produced instead of how much they improved the quality of life of residents. From the point of view of financials, that is necessary for the purpose of ensuring sustenance. However, leaders with no experience or interest in long term care create a lot of problems for their staff. Bad managerial decisions that are based on financial benefits and not aimed at bettering the quality of care provided affect every single team member as well as your residents.
Long term care providers that hope to change the culture of their facilities are listening to both caretakers and residents. The aforementioned study by the Commonwealth Fund has found that 59% of culture change adopters include direct care workers and residents on the senior management team, compared with only 24% of traditional nursing homes. The same study found that seven of ten culture change adopters report that residents are involved in decisions about their facility, while only 27% of traditional nursing homes involve residents in such decisions.
Culture change requires the entire staff to buy in. Annette Greely mentioned on her appearance on the LTC Heroes podcast that a common mistake is to only look to management for answers. “We don’t talk to everybody,” she said. Greely, though, has made an effort to hear the voices of all those involved. “When I’ve had to implement cultural change, I talked to my management, but I really prefer to talk to the cook, the housekeeper, and the maintenance. And they need to know your reasons why.”
This egalitarian approach ensures that every single person on your leadership team exists there because they represent a particular group. As a result, you will find it easier to face the various challenges that arise in long term care. Over a long period of time, this will positively affect your outcomes and profit margins.
A major component of building and maintaining a culture is staying in compliance with state and federal regulations. EHRs make that easier and more efficient. Plus, they allow you and your staff to spend less time on documenting and accounting and more time with your residents. That translates to better care, listening to your residents more, and a healthy culture.
Allowing Residents to Gain Competence and Become Self Sufficient
Residents in long term care facilities are not generally to become independent, nor do they often have the proper resources and tools to learn new skills. This takes a toll on them, especially those on the dementia spectrum, as they become more isolated and less stimulated by those around them. This is sometimes because allowing autonomy can increase the risk of accidents and mishaps, especially if the resident has comorbidities.
However, autonomy under supervision is necessary, even if it goes against one’s instincts. One young long term care administrator, Joe Mason, learned this early in his career. In his appearance on the LTC Heroes podcast, the 28-year-old administrator of Prairie Manor Care Center recalled that, as a student, he subscribed to a formulaic approach to care, playing everything by the book. Then, a teacher told him that, “A resident has the right to fall.” That resonated with him and has helped shape his career. “I’ll never forget it. It was so hard to swallow,” he admitted. Eventually, though, he came to realize that such freedom was key to helping residents regain a sense of self-dependence.
And this wisdom is backed by statistical evidence. The Commonwealth Fund study found that 58% of homes that focused on a cultural shift allowed residents to determine their own schedules, compared with just 22% of traditional nursing homes. This means that your staff assumes the role of supervisor instead of caretaker unless the resident is incapable of taking care of himself/herself.
There are multiple daily activities that you can allow and encourage your residents to do in order to achieve self-sufficiency, such as:
- Making their own beds in the morning – It may seem silly to think that such a small task could contribute to one’s journey to competence, but research has found that making your own bed first thing in the morning can help you feel more productive throughout the day. This is rooted in the psychological effect that results from doing something right at the start of each morning, which then has the power to lead to more productive actions.
- Doing and folding their laundry – As long as your residents are under supervision, it is a perfectly viable option to let them do their laundry. However, you might want to segregate the detergent into user-friendly packs, or just use tide pods for ease of use. It is best to think through the safety issues related to any activity before allowing your residents to partake in it.
- Participating in decision making – If a decision regarding hosting events or seminars has to be made, consult your residents. Take consensus and then host events. Seniors greatly appreciate you asking for their opinions, which are often ignored because they are so dependent on others. This practice will stimulate thought and also help them feel in charge.
Facilitating the independence of your residents will both improve their quality of life and reduce the workload of your staff. For instance, one study found that long term care facilities that updated their culture according to the needs of their residents and implemented a co-dependent culture no longer needed to give crushed medications to residents during mealtime. This after crushed medications were previously given during 100% of observed meals.
Of course, culture is always contextual, and you cannot copy-paste a template from the internet. So it is important to take the time to identify what culture changes are needed at your particular facility in order to improve the lives of your residents. Your decisions must be based upon what you think can most likely be instituted. Some residents and employees may resist change if they cannot see the benefits or if it does not fit their values. You must be prepared to explain your thinking and introduce change in accordance with a timeline that works for the largest number of people involved.
This article is a starting point and guide to cultural change in long term care. But to successfully implement this change and get results, you will have to sit down and have a conversation with your leadership team about your vision for the future of your facility. Real change is the result of consistently implementing decisions that positively affect the quality of care your residents receive. Decisions, though, cannot be made by management alone. Instead, they should include the voices of staff and residents in order to help build meaningful relationships among all at your facility. This approach keeps your residents’ best interests in mind and ultimately allows them to become self-sufficient. Cultural changes, when made in accordance with the guidance above, have the potential to improve quality outcomes and ensure longevity at your facility.