Culture Change In LTC?

Valerie Salva, BSN, RN · Jan 14, 2008

most facilities are NOT engaging in illegal or unethical activity, other than the short-staffing that is prevalent in our profession. The facilities that are engaged in anything illegal are caught by regulatory agencies and closed down, as they should be.

I have worked in a number of LTCs, hospitals, clinics, etc. I find that there are illegal and unethical practices going on daily as part of their normal routines. If every place that engaged in illegal activities really were shut down, we'd probably have at least 50% fewer facilities of any kind in this country.

Long Term Care Columnist / Guide · Jan 14, 2008

Moved to Staff Review for further discussion.

Editorial Team / Admin · Jan 16, 2008

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Simplepleasures · Jan 17, 2008

Thank you moderators for editing the previous posts, you kept the pertinenance of the discussion intact and removed the parts that distracted from the true message of the statements. I am glad that you saw fit to bring this thread back as it speaks to the heart of a major aspect of LTC nursing.

My opinion is that culture change begins with facility and its owners. Many seasoned nurses are a bit cynical and tend to see through the smoke screen of false promises of culture change by the facility owners. We have been promised such changes before only to realize it was not a true change, only a ruse.Perhaps this is changing, maybe it can only happen in baby steps.

LTC nurses are sometimes overwhelmed with the enormity of their everyday tasks and just don't have the physical and emotional energy to change one more Depend, much less the culture.

One step in the right direction is to unionize, I know , I know , I am guilty of shouting "UNION" in a burning theater so to speak. Well, its not the theater that burning , its the LTCs of this country and the nurses who are getting burnt out with the untenable patient load and the fear of retaliation if reporting or complaining about patient care issues, etc.

I know that we as nurses are often disheartened by what we have to see and face at work, I know it takes a toll on us as human beings and nurses. GOOD unions help nurses get the laws passed that are needed to change nurse/patient ratios, to help pass legislation that gives the nurse legal recourse ,when retaliated against for reporting to a regulating body, or even just discussing issues in house. I do believe when the time is right, meaning when the LTC nurse feels secure in her job and has been empowered, culture change will happen. This is my fervent HOPE.

For those of you fortunate nurses who are lucky enough to be working in a LTC that has TRULY embraced culture change, hoorah, I hope this will sweep the nation and be the TRUE change we need in LTC.

CapeCodMermaid, RN · Jan 18, 2008

Hmmm..interesting you want to stay on the topic and then bring up unions.....

Culture change in LTC is a huge undertaking. I would say 95% of the residents in my building have a better, safer, more activity filled life than they did when they lived at home. Perhaps it is because we, management and line staff alike, actually care about the residents. As a manager I also have to care about the budget. As culture change grows, I hope many of the useless unneeded tasks we were once so concerned about go the way of reusing needles. No long term resident really needs their blood pressure checked 4 times a day. No one in their late 90's is going to benefit from taking 23 medications at 9am. Did these people bathe 2x/day at home? No...more like once a week and they didn't smell and didn't have dried skin. The issue of quality care and culture change AND a good quality of life is too huge an issue for one thread.

PATRIOTS...the next Super Bowl Champions....AGAIN!

Simplepleasures · Jan 18, 2008

Hmmm..interesting you want to stay on the topic and then bring up unions.....
Culture change in LTC is a huge undertaking. I would say 95% of the residents in my building have a better, safer, more activity filled life than they did when they lived at home. Perhaps it is because we, management and line staff alike, actually care about the residents. As a manager I also have to care about the budget. As culture change grows, I hope many of the useless unneeded tasks we were once so concerned about go the way of reusing needles. No long term resident really needs their blood pressure checked 4 times a day. No one in their late 90's is going to benefit from taking 23 medications at 9am. Did these people bathe 2x/day at home? No...more like once a week and they didn't smell and didn't have dried skin. The issue of quality care and culture change AND a good quality of life is too huge an issue for one thread.
PATRIOTS...the next Super Bowl Champions....AGAIN!

Having a union in place would facilitate culture change, the nurse would feel secure in her position, have a say in her wages and benefits and would create a generally happier nurse. Also unions such as the CNA have been active in bringing about nurse/ patient ratios which would also help a TRUE culture change in LTC.

I agree with your position that there are too many redundant procedures and meds that bog down the nurse, but are not some of those required by the state. I bet you know better than me how hard it is to deal with state.

There are many things that need to be in place before culture change can take root around the country, for our seniors and fellow nurses I hope it can happen soon.

ltcconsultant · Jan 24, 2008

IMHO, culture change doesn't happen when a facility fully embraces the Eden Alternative and totally redesigns the place. Culture change happens when administration stops acting like a-holes (from the front line staff's perspective) and the front line staff starts embracing person centered care.

Scrabbler · Jan 24, 2008

Our provincial legislation regarding continuing care facilities states that there must be a certain number of hours between meals (eg, not more than 5 I think...) so that kind of culture change would mean huge shifts in everything. We have adopted the Planetree philosophy and are the first facility in our region to do so. Check it out if you're not familiar

http://www.planetree.org/

Simplepleasures · Jan 24, 2008

http://www.caregivereducation.org/culture/core_principles.htm

the foundations of culture change: underlying principles

culture change is bigger than any one theory or model. cultural transformation is more than just a collection of things to do in a home. instead, the best way to view culture change is as a foundational philosophy that underlies our desire to improve the quality of life for our residents and the staff who provide care for them.

the philosophy of cultural transformation can best be summed up in two statements:

"making our homes places where people want to live, versus places where they go to die."
"making our homes places where people want to go to work, versus places where they have to go to work."

to reemphasize this point, culture change is not merely a set of things we do or policies that we change. instead it is a global way of thinking about the work we do and how we provide care to the people who live in our homes. you have many choices about what specific plan you will follow to change the culture of your community. no matter what model(s) of care you choose, it is the foundational principles that underlie your commitment which are most important.

the institute's 5 core principles of culture change

principles that we believe are vital to your cultural transformation efforts are summarized below. these principles are all important and apply equally well to the residents who live in our communities and the workers who devote their lives to providing care. these principles are interconnected and shape the overall feel and atmosphere of the home.

:up: emphasis on respect -- each member of your community regardless of role in the home (resident, frontline worker, nurse, groundskeeper, etc.) has the right to voice views, ideas, and opinions without fear of ridicule or recrimination. each person's views should be incorporated into discussions before decisions are made.

:up: emphasis on empowerment -- all members of the community, regardless of role in the home, need to feel as though they make a difference. all are recognized as valued, contributing members of the community. each member is entitled to information and resources that foster critical thought. residents and workers have decision-making authority over things that impact them, while at the same time respecting more global organizational and regulatory constraints.

:up: emphasis on choice -- residents and workers in long term care communities should be given a range of options that reflect personal preference. having residents and/or workers buy into management directed policies is not choice. residents have the right to make choices regarding their day-to-day lives without penalty. workers are given the flexibility to make choices regarding the work they are responsible for in the home without penalty. choices should be made with consideration of global organizational and regulatory policies and procedures.

:up: emphasis on relationships -- relationship building should be an ongoing activity within each home. this includes strengthening the bonds among residents, among workers (at all levels), and between residents and workers.

:up: emphasis on community -- a primary goal of culture change is the ability of homes to evolve from a hospital-like environment to a true community. the phrase, "would i do this in my own home?" should never be far from your thoughts. along with medical care, residents' social, emotional, spiritual, cognitive, and cultural needs should receive equal attention. staff should be viewed as complete individuals versus the more traditional view of identifying workers with the tasks they perform.

when embarking on your culture change journey, keep these principles in mind. use these principles as a touchstone for deciding if you are on track. if your ideas to change the culture of your home include respect (for residents and staff), empowerment (for residents and staff), choice, an emphasis on relationships, and a commitment to making your long term care community more homelike, then you have succeeded. most of all, remember that...

culture change begins with you!

(emphasis in red is mine.)

dream'n, BSN, RN · Jan 27, 2008

How lovely it sounds. But if LTC is the same as it was when I was working in it, we need to focus on fixing the basic, most important problems first. Redunant paperwork, high turnover and ratios, and inane policies and laws. Nurses are so busy trying to provide the basics of safe medical care, they don't have time to worry about providing spa treatments, individualized mealtimes, etc. Does management/TPTB think nurses and CNAs have the time to do this? If they really want to implement Culture Change, they need to put their money where their mouth is and provide much, much, more staff. Perhaps if nurses and CNAs weren't run ragged all the time, they would stay and the ratios would decrease, then they would have the time to provide the little special touches that they would love to do. I say to TPTB; Put up or shut up.

:angryfire

The state of LTC is generally awful in this country, and all I see being done is more laws/policies which bring more paperwork and problems, and 'window-dressing.'

ltcconsultant · Jan 27, 2008

Dream'n, I agree with you wholeheartedly. What I see as a major problem is that nursing homes don't even make an attempt to understand the law. They don't realize that the MDS can legally replace at least a half-dozen other assessments (MDS 3.0 appears to replace even more than that). The excessive paperwork is due to ignorance in regards to what is actually required by the state/feds, and a groundless fear of lawsuits. Paper doesn't serve as lawyer repellent, decent staff-family relationships do.

RN 4 Life · Mar 14, 2008

We are implementing some of the changes now.
The way we did the "get up when you want to" thing is we interviewed each resident (the ones who were cognitively impaired, we interviewed family members to see what their routine was like earlier in their life) and asked what time they would like to get up in the morning. Then we made a list of all the times and that is when they were assited with getting up.(in other words, they just couldn't choose a different time each day but they could pick a later time than they were getting up now.)
We are trying open dining for breakfast only right now. From 7am-9am. There are menus on the table and we take their order every day and they can pick from virtually anything on the breakfast menu. The residents seem to really like this.
We just ripped out our old nursing station that was, as someone put it, right in the middle of their living room. We still have a nurses station but it was moved to an office room out of the way.
Haven't tackled the shower issue yet.
We are taking it little steps at a time and it hasn't been to bad.

How are things coming along? How are the patients and their families responding and how is the staff adjusting. I think your facility taking the best approach to implementing culture change.