Pioneering Change Guide Book of Education Modules to Promote Excellent Alternatives in Kansas Nursing Homes PIONEERING CHANGE Education Modules for Changing the Culture of Care in Nursing Homes as a part of the PEAK Initiative prepared by Lyn Norris-Baker, Ph.D. Gayle Doll, Ph.D. Linda Gray, M. S. Pamela Evans Joan Kahl, L.A.C.H.A. With contributions from other members of PEAK-ED: The PEAK Education Initiative published by Galichia Center on Aging, Kansas State University Kansas Department on Aging PEAK-ED web site: http://www.ksu.edu/peakCopyright (c) 2003 Kansas State University and its licensors. All rights reserved. Notice of nondiscrimination Kansas State University is committed to nondiscrimination on the basis of race, sex, national origin, disability, religion, age, sexual orientation, or other nonmerit reasons, in admissions, educational programs or activities, and employment (including employment of disabled veterans and veterans of theVietnam era), as required by applicable laws and regulations. Responsibility for coordination of compliance efforts and receipt of inquiries, including those concerning Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act, has been delegated to Clyde Howard, Director of Affirmative Action,Kansas State University, 214 Anderson Hall, Manhattan, KS 66506-0124, 785-532-6220. Pioneering Change Culture Change Education Module to Promote Excellent Alternatives in Kansas Nursing Homes How to Use the Modules This educational material has been created for the nursing home administrator who is focusing on changing the culture of his/her organization. As the PEAK-Ed staff have visited sites around the state they have seen varying stages of progress. Some innovators are forging ahead, creating their own road maps, while others remain more cautious, waiting for the outcomes of these change endeavors and for best practice information. This material has been written, recognizing the uniqueness of each organization. We have developed this material to be project-based so that it will potentially provide the motivation and the results that will "jump-start" culture change in your facility. We encourage the administrator or administrative team to go through these materials first. There are some individual activities that should be completed and questions to be answered, either individually or as a small group. The initial review of the materials should take no more than a few of hours. Also included in the module are group activities that can be used to develop concepts and projects with the staff in your organization. We have also developed a power point presentation for each of the modules that can be used in staff training sessions. This power point presentation is available on request from the Galichia Center on Aging, Kansas State University, 785-532-5945 or gerontology@ksu.edu. At the end of each module, except for Measuring Change, you will find a list of potential projects. Some of these projects are more appropriate for beginners in the culture change process while others may be considered review or appropriate for organizations that are more advanced in the change process. Most of them are fairly simple, requiring few resources in terms of money or man hours. Each encourages you to consider assessing the need to change prior to your project and then measurement of the effects of the project on the culture of your organization. It is important that you read the Measuring Change module before you begin any of the projects that have been listed. It is likely that these project ideas will spark ideas of your own. The creative process, when it comes from full staff involvement can be a very exciting thing for your organization. By all means, come up with your own ideas. The PEAK-Ed staff is here to provide technical assistance or to match you with another organization that is doing similar work. The materials in this book may be reproduced for educational/training activities. There is no requirement to obtain special permission for such use. If used for these purposes, the following statement should appear on all pages of such reproductions. Reproduced from Pioneering Change: Culture Change Education Module by Lyn Norris-Baker, Gayle Doll, Linda Gray, Pamela Evans and Joan Kahl, Manhattan, KS: Kansas State University, 2003. This permission statement is limited to the reproduction of materials for educational/training use. Reproduction or distribution of more than 30 copies in one year may be done only with prior written permission. Reproduction on computer disk, CD, or by any other electronic means requires prior written permission. No copies of this material, in full or in part, may be made available for sale. For more information on this publication or to request permission to use/reproduce portions of this material, please contact us at: Galichia Center on Aging Kansas State University 203 Fairchild Hall Manhattan, KS 66506-1102 785-532-5945 gerontology@ksu.edu www.ksu.edu/gerontology Table of Contents Culture Change Education Module Course Objectives 2 Pretest 3 Overview of Culture Change Processes 5 Definitions of Culture Change 6 Examples of change processes 7 Outcomes 9 Culture Change Activities 10 Elements of Change Leadership 12 Essay from Monte Coffman, Windsor Place 14 Resources for Leaders 15 Board Members as Leaders 16 Resources for Boards 16 The Ten Commitments of Leadership 17 Leadership Activities 18 Creating a Vision 19 Mission Statements 21 Mission Statement Activities 22 Developing a Plan 24 Planning Resources 30 Planning Activities 24 Education 26 Education Activities 27 Education Resources 28 Implementation 28 Implementation Resources 29 PIONEER & PEAK Objectives 30 Projects 31 A Word from the PEAK-ED Staff 33 References 34 Appendix 1 36 Post-test 37 Pretest and Post-test Answers 39 Course Objectives: 1. To become familiar with the characteristics of traditional and culture change nursing home models. 2. To understand various processes of organizational change and be able to select a process most appropriate for their own organization's needs. 3. To be exposed to assessment and evaluation techniques and be able to apply appropriate measures for a culture change project. Overview of Culture Change Processes This material is meant to provide background information about the process of culture change in the nursing home profession, provoke discussion about the necessity to change the way care is provided, and promote the ability for nursing home organizations to envision new models appropriate for their needs by providing examples of change. The information is presented in what is intended to be an unbiased structure: explaining methods that have been undertaken and permitting readers to select the approaches that match their own situations. Research reveals that many of the older adult population state that they would choose death over life in a nursing home (Mattimore et al., 1997). This is not a new situation. Nursing home residency has been seen as a last resort for most people for many years, yet there has been little conscious effort to reform this type of long-term care. Until recently, despite occasional allegations of abuse that may unfairly tarnish all nursing homes, facilities have remained at full capacity and have seen no need to make changes. Now alternative long-term care choices are more readily available to older people and a competitive environment has been created. In addition, many innovators of change have called attention to the fact that the way we have provided care for older adults is a reflection of an ageist society. Whatever the reason, pressures are increasing for all nursing homes to address the possibility of changing environments within their homes for both the people who live and the people who work there. Because of these pressures we are seeing all kinds of change within nursing facilities. Some are tiny steps like a change in a dining policy to allow residents to sleep until they awaken later in the morning. Some are giant steps that may entail major building renovations and organizational restructuring. Throughout the educational modules it will be repeated again and again that these steps in and of themselves do not represent culture change. They can be seen as strategies or pieces of the culture change puzzle. Definitions of Culture Change Culture has been described as a multi-level phenomenon that represents the shared symbolically constructed assumptions, values and artifacts of a particular organizational context (Mohan, 1993, p. 17). Within nursing homes this change is generally conceived as a change from the "traditional model", with its emphasis on medical diagnosis and care, to a model that recognizes equally with medical needs, the residents' social and psychological needs. The changed model has been manifested in a number of ways. The following is a partial list of culture change care models: The Eden Alternative. Designed to overcome the 'three plagues' of nursing home residents: loneliness, helplessness, and boredom, the Eden Alternative is intended to create a "holistic environment." Typical notable elements include animals, plants and children but organizational changes are incorporated as well. Bill Thomas, the creator of the model, believes that people need to give care as well as receive it to feel valuable. Eden currently is the only model that provides training and certification. (www.edenalt.com) Person-Centered Care. Residents' are treated with unconditional positive regard and are considered the best judges of whether or not their needs are being met. Lee Fabiano (1999), a pioneer in person centered care, believes that the resident and his/her family should be guaranteed: (a) consistency in caregiver's approach and expectations (b) continuity of past life patterns and preferences, (c) respect for personal values and beliefs, (d) involvement in decision-making, and (e) support in decreasing or eliminating those things that impede quality of life. (www.bethanygrp.org/rosehaven/personcenteredcare) Regenerative Care. This model views aging as another stage of life and respects individual needs. A regenerative nursing home allows residents more control over their lives and includes a management philosophy of: (a) continued personal growth, (b) learning with aging, and (c) community focus. (www.live-oak.net) or (www.culturechangenow.com/stories/liveoak) Resident-Directed Care. Providence Mount St. Vincent in Seattle decided to change their model of care in 1991 and titled it "resident-directed care" to capture the vision they had of a "community directed by the residents." Change included developing and providing more choice and control for the residents. Middle levels of management were eliminated and aging in place was supported. (www.providence.org/Long_Term_Care/Mount_St_Vincent) See the Pioneer Network or Culture Change Now Web sites for additional information. www.culturechangenow.com & www.PioneerNetwork.net. Examples of Change Processes It would seem that there are three different ways that nursing homes attempt to change their culture. Evolution: Evolution is what happens naturally with any nursing home, or any organization, for that matter. As employees leave and new people and new ideas arrive, the culture shifts subtly. Sometimes it may be regulations that force slight changes upon the existing environment. When a staff member who worked in a traditional nursing home was asked what had changed in the last ten years, she stated that the changes were seen in the reduction of the use of restraints and medications. These could be described as evolutionary changes. Revolution: A revolutionary change suggests that many changes are made all at once. These changes may address physical structures, organizational hierarchies, and social environments at the same time. Typically, revolutionary change has occurred within Continuing Care Retirement Communities. It remains unclear whether these facilities are more successful with adopting change because of additional resources that may be available to them or because they are more likely to be innovative. Some of the most successful revolutionary change efforts occur because of a crisis. Frequently there has been a change in management, a buy-out, or some sort of disaster. In this type of an atmosphere everyone recognizes that change is needed. This recognition of a problem is less likely to occur in a facility where the census remains high and surveys are consistently good to excellent. Sometimes leaders can develop a sense of urgency by pointing out potential problems like marketing pressures due to the baby boom generation. Some change leaders have been able to portray current models of care as being opposed to the basic civil rights of older persons. Successful change leaders demonstrate a commitment to the organization and its values. Managed evolution: Managed evolution occurs in the facilities where a careful plan has been set into place with incremental steps to be completed on the way to a culture change. These steps may include strategic planning, leadership development, orientation and continuous education, redesign of organizational structure, renovation or new physical structures, and changes in the social structure of the environment. It is not likely that culture will change by addressing one of these areas alone and there is some evidence that change may fail if the steps to reach a new culture are set up in such a way as to appear to be the "change of the month." Many of the nursing homes are in the midst of managed evolution. While most are committed to full-scale, all-inclusive culture change, many do not have the resources that are necessary to do it all at once. Not only are the financial resources necessary for training and physical renovations but an enormous amount of time and energy on the part of all staff members must be committed to the effort. Commitment appears to be the operational word in the question of "what makes one nursing home better than another." Research shows that higher quality nursing homes that operated at lower than average costs used very different strategies to meet cost and quality goals. What they all shared was a commitment to quality and cost control (Phillips, 2002). "Different processes and structures may generate the same basic result, when a common commitment underlies these processes and structures. But the same processes and structures may generate different results when supported by different leadership commitments or organizational cultures" (Phillips, 2002, p. 155). This means that definitive culture change objectives will be difficult to describe alone because the measure of the leadership commitment to the change process must also be added to the equation. It makes no difference how wonderful the plan for culture change if there is no commitment to it. A second important word in the success of culture change is trust. Nursing home organizations should not attempt to change unless administrators, staff and residents know they can trust each other. Many of the steps taken through managed evolution will be outlined within this module. They include: Leadership Creating a vision Developing a plan Education Implementation and projects Assessment and evaluation of projects A goal for the PEAK-ED project is to help nursing home personnel learn to evaluate their own needs and outcomes so that other organizations can learn from them. Outcomes Culture change outcomes research is limited but promising and reveals the possibility for resident improvements in the following areas: reduction in the use of antidepressants, reduction in decubitus ulcers, decrease in bedfast residents, decrease in use of restraints, reduction in incident reports, and increases in resident activity and interaction levels. Facilities have seen cost savings in reduced food waste and incontinence products, and in less absenteeism and turnover of staff. Anecdotal evidence abounds when nursing homes are asked to report the benefits of changing the culture of care. Staff members state that residents are getting out into the community more frequently, that residents appear to be more engaged or that fewer are observed sleeping in their chairs. Some express a belief that family members visit more frequently within culture change homes. There are always stories of benefits for individual residents. Herb expressed a desire to run a gift shop and a display case was installed from which he sells homemade items. Alice listens to her favorite music every afternoon as she enjoys her favorite ice cream sandwiches which she selects herself from the neighborhood's refrigerator. Doris had worked the night shift before she needed the security of living in the nursing home. Staff recognized her lifetime habits and allow her to stay up at night and sleep during the day if she desires. Several residents experience great pleasure from tending tomato plants in the facility courtyard. Anecdotal evidence is important for providing uplifting stories for staff and families. They make great human interest stories and should be actively spread throughout the facility as well as the broader community. However, it may be necessary to collect data regarding the effect of culture change on the financial picture of the nursing home as well as the way it can affect surveys and staff and resident well-being. A goal for the PEAK-ED project is to help nursing home organizations to learn to measure their own outcomes so that other facilities can learn from them. Culture Change Activities Case Study: ABC Care Home was seen within the community and the regulatory system as a "good" nursing home. The home seldom had deficiencies, staff turnover rates were under 20%, the beds were full, and judging from satisfaction surveys, residents and family members were happy with care. Ms. B, the administrator, had been hearing about culture change at association meetings and she began to talk to her board and staff about making changes in the organization. These suggestions were met with a great deal of resistance. Board members and staff wanted to know why she wanted to fix something that wasn't broken. Discussion: This is a scenario that is being played out in many homes. Change is much more difficult when there is no crisis or "broken pieces" to fix. Answer the following questions: 1. Should ABC Care Home change the way they provide care? ________________________________________________________________________ ____________________________________ ____________________________________ 2. What reasons could be given that would justify these changes? ____________________________________ ____________________________________ ________________________________________________________________________ 3. Can you think of a way to reduce the resistance in these groups? ____________________________________ ____________________________________ ____________________________________ ____________________________________ (These questions could also be discussed in a group setting). Group Activity: Before beginning this activity with staff, administrators must be committed first to educate the staff about possible changes and second to carry out several of the top choices so that staff feel like they have a role in change. This empowerment will reduce resistance to change. The test some individuals use to evaluate nursing homes is to determine if employees would feel comfortable living there. Sometimes, personalization can help staff members examine the work they do from another perspective. Hang three large sheets of paper on the wall in a staff meeting. Ask: "Who would feel comfortable having your mother live in the home?" The first sheet is for the staff who say "yes, they would feel comfortable having their mother in the home." Fill the page with reasons why. These are the strengths that can be built upon. The second and third sheets are for the things that would need to be changed within the nursing home before the other staff members would feel comfortable moving a parent there. The second sheet is for the small changes that could easily be done without a lot of money or policy changes. The third sheet is for the dreaming-big stuff like private rooms, a swimming pool or bringing a pet to the nursing home. The next step is to have the staff help prioritize items on each of the three sheets. Strengths: On the first page have staff arrange the items in numeric order by the things that they believe are the very best about the organization and then brainstorm ways that they can become even better, or perhaps ways that these strengths can be marketed. On the second and third sheets, staff members order the items by their favorite suggestions. Some thought should be given to whether the ideas are reasonable to achieve and what the possible outcomes might be. List here the choices selected by your organization: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ This activity has been expanded for one of the projects at the end of the module. THE GALICHIA CENTER ON AGING KANSAS STATE UNIVERSITY Through teaching, research, outreach, and service, the Galichia Center on Aging at Kansas State University strives to provide a focus on aging issues that orients the talents of the faculty and resources of the University towards identifying and addressing the challenges and opportunities of an aging society. The Center coordinates and develops educational and training programs in aging, conducts gerontological research, and engages in outreach activities to serve older Kansans and those who provide services to them. The Galichia Center on Aging has the responsibility for working with the long-term care profession, advocates, and state government to develop the educational resources for long-term care organizations as part of the Promoting Excellent Alternatives in Kansas (PEAK) initiative. ACKNOWLEDGMENTS This module was supported by the Kansas Department on Aging (KDOA) and the Kansas Department of Social and Rehabilitation Services through a Title XIX contract and through matching funds provided through Kansas State University. Additional matching funds were provided through the Kansas Association of Homes and Services for the Aging, the Kansas Health Care Association, and the personal time volunteered by the following long-term care professionals: Steve Shields, Linda Bump, Monte Coffman, Jim Klausman, Carla Lehman, Sharon McCabe, Dana Rice, Evelyn Walters, and Rodney Whittington, Jr. This module is the second phase of the educational component of the PEAK initiative. It is intended to promote chulture change in Kansas nursing homes through the teaching of concepts of changed care environments and the promotion of the philosophies upon which these concepts are based. The modules for this guide will be released in installments, giving homes the opportunity to work through the materials and implement projects and strategies based on the concepts presented. This work has been made possible by the many nursing homes visited through PEAK site visits that have helped to inform the authors of the many opportunities for change. The authors wish to express their appreciation to all who made this project possible, especially the many individuals who contributed to and reviewed the content of the modules. The names of these advisory group members and faculty consultants are listed on the following page. In addition, the authors would like to thank Pamela Evans and Emi Kiyota of the Galichia Center on Aging, who provided administrative and technical support for the project. Kansas State University Project Staff Lyn Norris-Baker, Ph.D. Principal Investigator Gayle Doll, Ph.D. Project Coordinator Linda Gray, M.S. Research Associate Joan Kahl, L.A.C.H.A. Extension Assistant Pam Evans Administrative Officer Emi Kiyota, M. Arch. Web Master Faculty Consultants Sally Bailey, M.F.A., M.S.W. Speech Communications, Theater, & Dance Nancy Gyurcsik, Ph.D. Kinesiology & Office of Community Health Mary Higgins, Ph.D., RD, LD, CDE. Human Nutrition & Nutrition Specialist, K-State Research and Extension Migette Kaup, M. Arch. Apparel, Textiles, & Interior Design Valentina Remig, Ph.D., RD, FADA. Human Nutrition Rick J. Scheidt, Ph.D. School of Family Studies & Human Services Susanne Siepl-Coates, M. Arch. Architecture Candice Shoemaker, Ph.D. Horticulture, Forestry, & Recreation Resources PEAK Educational Development Advisory Committee Deanne Bacco Kansas Advocates for Better Care Linda Bump Meadowlark Hills Retirement Community Manhattan Monte Coffman Windsor Place, Coffeyville Phyllis Kelly Kansas Adult Care Executives Jim Klausman Midwest Health Services, Topeka Carla Lehman The Cedars, McPherson Patricia Maben Kansas Dept. On Aging Sharon McCabe Kansas Masonic Home, Wichita Linda Mowbray Kansas Health Care Association Joe E. Dobson Regional Office of the State Long-Term Care Ombudsman Dana Rice Minneapolis Good Samaritan Center Loretta Seidl Kansas Association of Homes & Services for the Aging Steve Shields Meadowlark Hills Retirement Community Manhattan Evelyn Walters Cornerstone Village, Pittsburg Rodney Whittington, Jr. Wheatridge Park Care Center, Liberal KDOA Representatives Elaine Schwartz Patsy Samson Dave Halferty Bill McDaniel Sam Alvey