"Would You Do That in Your Home?" Making Nursing Homes Home-like in Culture Change Implementation.

Qualitative interviews with nursing home administrators reveal innovative and cost-conscious ways to physically modify facilities that help institute culture change practices. Telephone interviews were conducted following a national survey of nursing home nursing directors and administrators. In this cross-sectional snapshot of administrator experiences, motivations for making facilities more home-like and less institutional and creative responses to challenges are described. State and corporate support and regulator encouragement are noted that help their reform efforts. Administrators note that small steps to create a more home-like environment can result in a positive impact that minimizes disruption to existing care processes. They describe how they respond to challenges, such as the physical plant and high costs, and note how comparative shopping, cost-conscious physical improvements, and continuous involvement of staff and residents contribute to successful efforts. Their examples illustrate novel ways to humanize long-term care facilities that other nursing homes can emulate.

INTRODUCTION

Creating a meaningful sense of identity is a life-long human task often rooted in how individuals fit with their environment (Lawton & Nahemow, 1973; Rowles, 2008). When living in a nursing home is necessary because of impaired function and illness, this fit can be fundamentally challenging; although these institutions aim to deliver care efficiently, individual preference and regard for hominess are often afterthoughts, if ever considered. The culture change movement confronts assumptions governing this reigning nursing home paradigm. Prime among these efforts are changes to the physical environment that soften the institutional nature of long-term care to incorporate personal choice and comfort and improve quality of life (Kane et al., 2005). Culture change facilities are designed as homes that foster relationships, staff empowerment, resident direction of care, measurement-based processes of care, and collaborative decision making (Koren, 2010). The Centers for Medicare and Medicaid Services has supported the adoption of culture change practices (Doty et al., 2008), and early reports indicate positive resident and staff satisfaction and lower staff turnover rates (Bishop, Squillace, Meagher, Anderson, & Wiener, 2009; Loe & Moore, 2011; Lum, Kane, Cutler, & Yu, 2008; Tellis-Nayak, 2007). Adding to this momentum, the Veterans Health Administration (VA) has undertaken the ambitious job of transforming their nursing homes into Community Living Centers to implement culture change (Lemke, 2012).

TABLE 1

Sample Questions to Nursing Home (NH) Administrator from Qualitative Interview Guide

I’m particularly interested in hearing about any important practices your facility has implemented to improve quality of care or life for your facility's residents and or staff, including any changes made to the physical environment of your facility. Please describe any practices or changes you have implemented to improve quality of care or life and tell me what it's been like.

How were the changes implemented?

Why were changes implemented?

Who was mainly responsible?

Who helped? (workshop, consultants, other)

Were there changes in staff jobs, including supervisory roles?

How did long-employed certified nursing assistants (CNAs) respond? What about new CNAs?

Is CNA supervision different since the changes?

What about changes for staff empowerment?

What has happened to make for more resident-centered care?

What helped facilitate the changes and what barriers did you encounter? If not addressed, include:

Any training needed; resistance from staff, board, chain, or physicians; costs; the physical structure you have; any special care units; regulations

Has it been worth it?

What advice would you give to a NH wanting to implement culture change practices (perhaps something you didn't know before you started)?

TABLE 2

Examples of Administrator Ideas to Enhance Home-like Environment in Nursing Homes

Exterior changes

Minor landscaping

“Cleaned-up look:” tree trimming, bushes, rocks for accent

Butterfly garden

Walkways, patios, gardens

Interior changes

Paint, wallpaper, carpet

Oak chair rails

Replace nurses’ station with desk; use found space for resident common area

Add coffee machine, soda machine to sitting areas

Wood-grained vinyl flooring

New lighting fixtures

Artwork on walls

Sitting areas with cozy chairs, sofas

Table linens in dining room

Personal mailboxes outside resident rooms

Small kitchens on units; pleasing smells from food preparation

Staff and residents

Resident choice of paint colors

Resident choice of corridor/unit names; personalized bathrooms

Dining staff wear restaurant clothing

Replace public announcement system with staff pagers

To understand how culture change principles and practices are specifically carried out in long-term care facilities, we first designed and fielded a nationally representative survey with nursing home administrators and directors of nurses in the United States to determine the prevalence of culture change practices and features. Of 4,149 nursing homes sent surveys, contact was achieved with 3,695. Cooperation rates (i.e., proportion of responses when contact with a nursing home administrator or director of nurses was achieved) were 62.6% for nursing home administrators (n = 2,215) and 61.6% for director of nurses (n = 2,164). We then conducted individual follow-up semi-structured telephone interviews with a subset of 64 nursing home administrators. The interviews were designed to determine the administrators’ motivations for instituting change, understand which practices they chose to implement in their facilities, identify their challenges and strategies, and illustrate dynamics of decision and implementation processes (Miller et al., 2013; Shield, Looze, Tyler, Lepore & Miller, 2013). Mixed methods research helps examine how culture change principles are enacted in practice (Rahman & Schnelle, 2008).

Although changes to the physical environment are often seen as cost prohibitive, this article provides examples that minor and inexpensive enhancements to the exterior and interior plant have substantial potential to create living spaces that are more intimate, cozy, and reminiscent of home (Cutler & Kane, 2006; Jurkowsky, 2013). When implemented to support resident capacities and help connect them to past roles and routines, small changes such as those described here can boost morale and well-being and can help shift the focus to the resident's experience instead of the resident's condition (Davis, Byers, Nay, & Koch, 2009). This article shows how administrators institute environmental changes in their facilities to achieve a homier environment and demonstrates how administrators respond to challenges to make these changes. The article provides a cross-sectional snapshot of nursing home administrators’ experiences. Grounded in everyday realities of management, decision making, policy, and finances, nursing home administrators speak from the trenches of their experiences and provide insight into the implications and consequences of their and others’ actions. Their insights may help others seeking to implement physical change and other reform practices in long-term care institutions.

METHODS

The interview guide was informed by the culture change literature and revised after pilot testing. Interviews were audiotaped and transcribed and then reviewed by interviewers to ensure the accuracy of the transcription. The initial open-ended question asking administrators to relate what they had done to “improve the quality of care or life for their facility's residents and/or staff, as well as any changes they had made to the physical environment” eliminated any mention of culture change to minimize socially desirable answers about culture change. Questions were asked about the physical facility, and administrators spoke about the environment and physical changes spontaneously during the interviews. The institutional review board of Brown University found the research exempt from review because we collected no personal information from respondents.

The coding structure we used to analyze the transcripts reflected topics from our interview guide and content elicited in interviews (Crabtree & Miller, 1999; Smith & Firth, 2011). Our 5-member multidisciplinary analysis team read and coded all transcripts and met in twice-monthly team meetings to revise the coding scheme, reconcile individual coding decisions, and search for competing interpretations in identifying themes (Curry, Shield, & Wetle, 2006). Revisions to the coding scheme were decided by group consensus and were followed by recoding all transcripts. An audit trail of team decisions concerning codes and themes was maintained throughout the analysis process. The qualitative software program Atlas.ti was used to help organize the interview data. This article focuses primarily on the results related to physical changes to the facilities.

RESULTS

Administrators discussed various motivations for changing the physical environment and instituting other reforms and noted their strategic responses to obstacles. Administrators from most of the nursing homes spoke about the need to update older buildings and make them more appealing in a variety of ways. Creating more home-like environments was driven by a desire to stay current with the industry, optimize the older individual's quality of life, and maintain profitability by capturing the Medicare skilled and private pay markets (Lepore et al., n.d.). Input from resident surveys and resident councils provided feedback and ideas.

Motivation to Change the Look and Feel of the Facility

In addition to creating a “cleaner, fresher look” from a more “dingy and grungy” aspect, as one administrator put it, external changes to the facility's exterior were made:

… a butterfly garden… [is in] a courtyard that's been screened in … so that it has plants and butterflies and walkways and stuff like that. And those things, they have just sort have evolved over thought and time, as we move on. Somebody will say, “Oh, it would be nice if we did this, or we had that, or this would be nice too … ” that kind of thing.

An administrator proudly described external changes to a facility built in 1967:

I would use the word homey … [The building is] actually in very good shape. We've done some landscaping since I got here. Put some rocks and some bushes out around the facility, taking some trees out, trimmed up the trees, just to make the outside appearance, you know, cleaner.

Another added the following touches to the facility so residents have access to “ … patios and gazebos. In fact, they have their own, they have their own orange tree that they can pick oranges. They have a barbecue grill for barbecuing.” One administrator reported the “resident gardening program” where residents plant “their own vegetables and flowers,” whereas another commented that in response to the numerous residents who used to be farmers, “We have a gardening program where we have these little garden boxes that are on stilts so residents can, you know, be in a wheelchair and sit and work in the dirt if that's what their thing is.”

Administrators linked the notion of gardening to enhancing the feeling of home:

We show everybody it's a home. You come in, you’re going to see plants, you’re going to see kids running around here, you’re going to see animals, you’re going to see a garden, you know. It's just like the ones in my home.

One administrator described the heightened resident and staff morale stemming from minor exterior changes:

… gardens in the front and the middle and the patio areas, as well as the front of the building, adding flowers and much more of a pleasing environment for them, greatly enhanced the aesthetics to the building basically over the last 4 years. What this in turn has done has not only improved the employee morale of the facility. When I first got here, the employees really didn't care how much they trashed the building … now that we've done a lot of this, the staff is taking a lot more pride in cleaning up after themselves and making sure that their areas are clean … and organized and clutter-free. The residents are much happier because of it … It's also helped them to have a more homelike atmosphere … So those are the physical plant activities that we've done and we've seen great improvements in both in resident morale and staff morale.

Another administrator of a rural facility created “a sidewalk that completely loops us, you know, if the residents want to use [it] … [and] some deer feeders set up … there's a herd of about 38 deer.”

Some focused on changes within the facility to enhance the feeling of home. As this administrator noted:

[The building] was built back in the time when they didn't think about having care centered around the resident and now … we’re looking at trying to make it more like home …  People do want their own space. They want to have a place to go and just relax and sort of get in their own routine as what they would have at home …  [We] try to make little sitting areas and it really does improve the looks of the room and the residents are so happy because they get to have their input in what we put in their room. If we paint it, we let them choose the color.

Incorporating resident choice in designing the dining room might entail decorative but not extensive changes. This administrator described the first steps:

Putting on linens on the tables, nice centerpieces, we’re repainting and painting in there to make it softer. We’re going to add new light fixtures. We have those long florescent bulbs and we’re going to put in more like what you have in your dining room at home type of lighting there. Put some new paintings up ‘cause we have some older paintings and … the cooks will be wearing like a chef's outfit. The dietary aides will be wearing nice, pretty much black aprons, kind of like what you’d see if you went to a fine dining type restaurant.

Another stated the benefits of this dining change to enhance a home-like feeling: “[The nursing home] also includes small kitchens so that the ladies can still stay connected to home, baking cookies and things like that.”

Some administrators welcomed having the “clean slate” of planning a new building as an impetus to design the facility in more person-centered ways. One described plans:

… the outside would look like a home [with] 8 halls coming off of this center of what we call city square and each one of those would look like a house and each one would have a … different style of house … they’re going to look just like a home would look in your neighborhood.

Taking Small Steps as a Strategy for Physical Plant Challenges

Administrators discussed difficulties posed by their physical facilities, and they described innovative responses. Some older buildings presented considerable barriers: “It was built very, very, very well, including block cement in all the rooms everywhere, so that made it a little more costly.” One common mechanism was to tackle small and inexpensive projects gradually. One said, “We started out slow … some homes started out fast … some of them failed.” This administrator added:

Well, [the changes] cost money but we didn't just hire a contractor and do it all, nor are we done yet either, ‘cause we've been doing some rooms at a time … putting in new vinyl floor coverings wood grained … it looks like an oak floor … but it's not …  We had to watch the dollars so we shopped. We found furniture to outfit 8 rooms as brand new furniture. [It] just was 15 years old and never been out of the box.

This administrator noted a simple enhancement to make the facility more appealing: “Our sub-acute unit, we've also just tried to make it cozier. We have coffee out there available for them.” Another administrator detailed small changes that reflected individual preferences for the residents’ rooms:

Well, several years ago we had the residents vote … on what they wanted their neighborhoods to be named …  They happened to pick flowers. So we had done Flower Lane, Rosebud Court, Lilac Lane, and Magnolia Way. And we have mailboxes outside each bedroom with the flowers by where they’re living. We have life histories outside each bedroom for the long stay customers. We also personalize their bathrooms, the bedrooms as best as we can. Their lounges definitely reflect the neighborhood.

Small changes were manageable:

It was actually a little bit easier for us for these renovations ‘cause it was more cosmetic, so we didn't have to get any permits or we didn't have to get anything out of the ordinary … say we wanted new wallpaper, [or] wanted new floors, the only thing we basically had to do was send a letter out to the families notifying them 30 days in advance, this is what we’re going to be doing …  I think the residents are happier because they’re in a newer environment …  Whatever would make their lives more fulfilling, we try to implement that.

Somewhat more ambitious changes to the interior were also mentioned: To improve the facility's appeal, one administrator said they “ … re-wallpapered the facility and put new carpet in …  People are happy with the changes.”

Privatizing Rooms

Motivated to attract the higher Medicare reimbursement of short-stay residents coming to the facility for rehabilitation following hospitalization, administrators also noted an intent to turn double rooms into private rooms and to provide what they thought these customers wanted:

[Some] come in, get a lot of rehab and they go home. So they like that private room, that private room with the private TV and private baths. We are moving in that direction every time we downsize.

Another noted inexpensive improvements in the new private rooms:

… These private rooms are very non-institutional looking … putting in oak chair rail and wallpapering … and new pedestal sinks replacing old sinks …  We had a very poor lighting arrangement in those rooms when they built back in the 70's, so the lighting's been improved.

Other Physical Changes for Greater Hominess

Administrators paired talk about physical renovation with principles of person-centered care and home. Some physical aspects of culture change are instituted to eliminate classic features of hospitals and nursing homes, such as nurses’ stations, which also frees up space. One administrator described benefits in not having nurses’ stations:

We don't really have a nurses’ station. We have more like a desk sitting out in an alcove and bookshelves where they house the medical records. Most recently … we removed the nurses’ station because the nurses’ station was occupying the majority of the unit so the residents had really no space to go to. We took out the nurses’ station and made it into like a living room for our residents.

Another said:

We just recently removed the nurses’ stations. Put all those papers and all those file folders, and all those binders, and put them inside of the room. You know, taking down signs … things that you wouldn't put up in your home. And trying to ask the staff … “Would you do that in your home? Would you have that in your home?”

Another thrust of environmental culture change reform in nursing homes is the elimination of intrusive sounds of overhead paging systems and alarms. Administrators described their cost-conscious searches for solutions. One used pagers to decrease noise:

We got rid of loud noisy bed alarms, wheelchair alarms, and replaced them with staff having beepers or pagers …  there really hasn't been any hurdles except for … staff getting used to the pagers versus the alarms they hear. Our pagers will tell you what room it is coming from, so then you can go down and hopefully prevent a fall or … see what the issue is. So it's going over well.

Another administrator bragged, “For eight department heads, it costs me $100.00 bucks a quarter … much cheaper than cell phones … there are less expensive ways to make things better, more homelike.”

Communication and Leadership Strategies to Overcome Resistance

Administrators noted some resident and staff recalcitrance to physical change and new culture change practices and explained their strategies to encourage acceptance. Because physical changes often accompanied other culture change practices, such as dining and bathing schedules, that impacted staff routines, they cited communication and leadership as helpful. In response to resident concerns, one said:

I think my residents have a harder time changing … I had residents literally in tears because they didn't like the new tables. They couldn't transition from a rectangular table … to a square one.

Resident input was sought as a way to ease resident anxieties and create acceptance. One said residents “were part of the discussion” for physical and other changes. Another said, “You know, we involve them … saying what the décor [should be] and … so there's a lot of participation.”

Administrators said some staff members “feel that, no, I've been at this for this many years, and I’m not going to change.” In response, some administrators hired new staff members “who don't know it any other way … this is how we do things here.” Constant communication was cited along with leadership (Tyler, Lepore, Shield, Looze, & Miller, 2013). An administrator said, “We gently try to educate them and get them involved.” One credited “a big piece of [success] is that strong nursing team.” Others noted the help of team managers and including “all the necessary players at the table” to institute physical and other culture change practices successfully.

Supportive Boards and State and Surveyor Policy Reform

Corporate support was sometimes pivotal in financing physical improvements and culture change practices. One administrator related:

We are able to enlist the help of our office … [and] of some of our vendors and whatnot and the community gives help from time to time. Like the local churches … they realize that we’re on board, that we’re here for the right reason …  It's kind of a win-win situation.

Another administrator said: “Our company, in general, has been really preaching and practicing resident centered care,” whereas another noted, “ …  [the company told us], ‘Yes, go ahead, hire more workers or do what you have to do to fix the issue.’”

An administrator noted corporate support that enabled the addition of a point-of-service meal delivery system in the facility to promote hominess:

We purchased 2 additional steam tables. And so now, rather than having the food being served on trays, it's going to be served right outside the dining room or right outside the resident's door … if they’re in the dining room, which most are … someone will come right to the table, you know, “Which choice today?” and then go get it right off the hot table and bring it …  We just had put in new outlets, they’re special outlets to keep the steam tables hot and they’re all constructed and they’re ready to roll. So yeah, right now, it's just a matter of the training, which corporate has come down to help with and they’ll be back this Friday …  And they want to know what's going on with [this program] and they help us with, they’re very supportive with any ideas that we have. And you know, they want to see it be successful. So really, anything we need.

State and federal policies were also instrumental in fostering change. Administrators remarked how collaboration with state regulators made the implementation of environmental and person-centered changes easier. One said, “ … we work with the Department of Health … and 9 times out of 10, they’re going to give you a waiver.” Another said when “ … survey[or]s … tell us  … you shouldn't have done this … we try to tell them … we’re listening to our residents … making this as home-like as possible.” An administrator summed up: “ … think outside the box because a lot of these things are doable …  You’ll be like, ‘Man, this did work, let's do something else,’ and then you begin to get excited.”

Pay for Performance Reimbursement

Among our interview sample were 6 administrators from Colorado and Oklahoma, states that instituted Medicaid pay for performance reimbursement with culture change performance measures. (Colorado stopped its pay for performance culture change reimbursement after interviews were concluded.) Nursing home reimbursement is partially affected by how the facility performs on targeted quality and performance measures, including having a more home-like environment (Buika & Skira, 2012; Werner, Konetzka, & Liang, 2010). Although administrators did not explicitly discuss pay for performance programs, their interviews suggest how these incentives may influence the adoption of culture change practices including environmental improvements.

In describing policy influence on culture change implementation and environmental improvements, an administrator was cautiously optimistic about “what the new survey process will do …  the old survey … hindered this progress. Unless you were … willing to take enormous risks, you just really wouldn't go out on the limb and do certain things.” Another said, “I think surveyors are very much for all the changes that the industry is making and trying to just be more of a resident-centered industry …  They’re trying to help us in implementing this culture change.” An administrator said that state regulators “like to see that you’re making it worthwhile for each individual resident, kind of personaliz[ing] it.” One noted that Oklahoma “ … has been really encouraging all the facilities to try it … [now] surveyors are looking at … actual psychosocial needs [not] the policies verbatim … residents are loving it …  We’re putting in a fountain machine, a pop machine in the dining room. And they call themselves the Homeowner's Association now …  With our state jumping on board, it's been a lot easier.” Finally, another praised the state's support for culture change and physical improvements:

The state is welcoming this with open arms and they are so excited for what we are doing. They have not said anything but “bravo” … certainly, [surveyors] have to go within code and with what the federal and state guidelines are, but then they’re also being lenient due to the fact that we are an older building and a lot of the state regs that we fall under, we are grandfathered in … they knew we were trying and we were doing everything we could to make this a better place for our residents which is our ultimate goal.

Administrators also described when they were unable to implement desired changes, usually because of prohibitive costs. For example, this administrator reported small physical changes to the facility, then noted constraints limiting improvements:

We do try to change the paint and wallpaper and the rugs, I would say, you know, every 5 years to try to keep the place, you know, almost to camouflage the age of the building, sort of that, but, no, the rooms and the size, the number of patients and we’re about strained to our limit for office space …  The care has definitely improved … [but] the costs skyrocketed … the payroll, you know, for a 40-bed home, my payroll's about $28,000 a week. It's … very expensive, and I’m a very small, but I’m a low-cost home because I’m older …  Yes, you know, every regulation, we’re talking about costs, right? Every regulation is passed as the cost, and the legislature thinks that more regulations equals better care and it really adds to the cost, and I don't really see that ending at all …  And you know, employees are expensive here.

DISCUSSION

This article describes innovative initiatives nursing homes are making to become more home-like, and it details responses to challenges in culture change practice implementation. These accounts are striking in how often they describe modest physical changes to nursing homes that are relatively easy to put into practice and together indicate a trend toward adoption of improvements that foster a home-like atmosphere. The administrators’ stories illustrate various motivations for enacting culture change practices and reveal how they exploit resources and exercise leadership to meet barriers. They describe taking small and manageable steps and suggest how corporate support and state and surveyor policy reforms aid culture change efforts. Physical changes to create a more home-like aspect helps advance the principles of the culture change movement; however, efforts to promulgate resident and employee empowerment should also be adopted whenever possible to further the overarching goals of the culture change philosophy (Koren, 2010).

While illuminating a variety of administrator views, our qualitatively robust number of interviews cannot represent all nursing homes in the United States. We also did not interview administrators in VA facilities. Furthermore, administrators proud of their practices may have self-selected to speak with us. Administrators reported improvements they had been able to incorporate and indicated constraints under which they operate that limit implementation of environmental and other improvements. In future research, administrators’ perspectives should be complemented by interviews with varied nursing home staff, residents, and family members to more fully understand how reforms are perceived and experienced by them (Scalzi, Evans, Barstow, & Hostvedt, 2006). Ways to cultivate enriched social relationships within these more home-like settings and activities, such as gardening, should be encouraged for their role in helping residents maintain a sense of comfort, self-worth, and connection (Street, Burge, Quadagno, & Barrett, 2007; Wang & Glicksman, 2013). Settings with varying degrees of culture change implementation should be compared to help understand how staff and resident empowerment and other social attributes contribute to the formation and maintenance of relationships. Site visits to nursing homes that have renovated their facilities and implemented reform practices would help show how these changes are implemented and experienced on the ground. Although our data are limited on the practical effects of pay for performance on culture change implementation, they contain suggestions that nursing homes in states with pay for performance Medicaid reimbursements systems may have higher likelihoods of adopting culture change–aligned environmental improvements (Briesacher, Field, Baril, & Gurwitz, 2009; Grabowski, Elliot, Leitzell, Cohen, & Zimmerman, 2014; Miller, Cohen, Lima, & Mor, 2014). Administrator and policy maker perspectives on pay for performance programs with and without culture change incentives and other policies and regulations that support the implementation of culture change practices will help reveal the evolving dynamic of reimbursement and regulatory mechanisms. It is hoped that the positive indications described in this article encourage further regulatory reform to foster continued environmental and other culture change practices that enhance the quality of life in long-term care.

CONCLUSION

The need for older adults to fit their physical environment and exert personal choice is fundamental to a sense of individual mastery and well-being (Golant, 2012; Lawton & Nahemow, 1973). Nursing homes are increasingly attempting to implement physical improvements and person-centered reforms in their facilities that enhance personal control, comfort, and a sense of home. By adopting principles of culture change, nursing home environments can support older adults to achieve a greater sense of mastery, choice, and satisfaction. Physical enhancements to nursing homes help support residents’ capabilities and can provide meaningful reminders and connections to the comfort of domestic life. Culture change practices that improve the physical facility to make it more appealing and home-like can also skillfully connect residents to their identities and prior roles. Examples such as adding raised gardens and walkways included in this article show that small changes that are relatively easy to do can be designed to help connect residents to meaningful former roles, such as homemaker, gardener or farmer (Cutler & Kane, 2006; Jurkowsky, 2013; Wang & Glicksman, 2013).

This article demonstrates administrator resiliency in attempting to improve the caliber of their facilities using culture change practices. In recounting how physical improvements to institutional facilities and person-centered reform practices can be implemented, administrator accounts provide practical examples of their ingenuity and leadership in transcending difficulties and suggest how enlightened policy reform may work to aid these reforms. These examples can motivate further efforts to humanize long-term care environments and improve the quality of life for our most vulnerable citizens.

FUNDING

This research made possible by a grant from the Retirement Research Foundation (2008-086) and from the Shaping Long Term Care in America Project funded by the National Institute on Aging (1P01AG027296). During this study Dr. Lepore was funded through the Agency for Healthcare Research and Quality (AHRQ) National Research Services Awards (NRSA) Post doctoral fellowship training grant (5T32HS000011-24).