There is a new buzzword that's quickly becoming
popular, similar to when “PPS” emerged in the 90's. This buzz is
“culture change,” a new movement in the long-term care industry to
revolutionize the way care is delivered to those residents who choose
to live in nursing homes.
What is culture change?
Although the culture change trend has reached
relatively few facilities, it embraces various facets and goes by
different names – regenerative communities, the Eden Alternative,
Wellspring model, resident-directed care, resident-centered care, and
more. Whatever it's called, it is the movement from the traditional
institutional setting to a more “homelike” atmosphere.
A nursing home should, first and foremost, be a
home. It is often the last home of a resident's life. The average
nursing home is based upon a “medical” model, taken from hospitals,
where professional staff members provide “treatment” for “dependent”
residents; life revolves around the facility's routine and
administrative needs.
Staff usually make daily, routine lifestyle
decisions for residents (e.g., when to get up in the morning, when and
what to eat), activities are structured, staff float impersonally from
resident to resident, and there's a general sense that the facility
“belongs” to the staff. Residents are known by their diagnoses and
weaknesses, not their strengths.
Many nursing homes are working to create a new
“culture” within the nursing home, centered around the
resident-as-whole-person, including all of one's frailties and
disabilities. In their new nursing home communities, the culture change
movement works to establish a culture of home where residents have
control over their daily lives. Direct caregivers are empowered to
facilitate that control and help to provide for residents' needs –
social and personal, as well as medical. The values – for both
residents and staff – are individual identity, self-respect, growth and
development, satisfaction, pleasure, creativity, opportunity, trust,
comfort, mutual support, and homey-ness.
How does culture change occur?
Start by asking, “Is that what we really want for ourselves?”
Planning is important and must occur at weekly
meetings over a period of months. A communication plan is crucial to
ensure key messages are sent to all members of the community:
residents, staff, families, union officials, volunteers, physicians,
the beautician, and any community persons or providers who interacted
with the nursing home. The key message needs to be resident focused,
resident focused, and resident focused.
Creating communities within the home – which consist
of smaller groups of residents and staff that are the primary
caregivers assigned to those residents – is a key starting step.
Renaming “A Wing” to “Morning Meadow Way” can
establish more of a neighborhood feel. Creating a neighborhood
committee can help residents better understand the others that live
within the community. Both of these examples are keys to creating the
sense of independence and ownership for residents.
Program models such as “gentle awakenings” are used
to allow the residents to choose what time they would like to get out
of bed in the morning, achieve their daily grooming goals, and eat
breakfast.
How does this affect the dining experience?
Often residents enter into the nursing home setting
and are bombarded with schedules for medications, therapy, bathing and
grooming, activities, etc. Quite often, eating on a routine,
three-meal-a-day schedule was not their traditional habit. This may be
a beneficial environment, conducive to enhanced nutrition and providing
a well-balanced diet, but it is on the “nursing home's terms.”
In culture change, the dining experience can be one
of the biggest positive effects on a resident. Creating more of an
open-time schedule for dining and offering more choices is key to
creating a more resident-centered environment. But how is this done
without increasing the costs of staff and food?
The answer is not a simple one. Offering variety can
mean having to overproduce food in order to meet the changing choices
of residents. First, having an updated preference list is important to
prepare as close to what you forecast the resident will request.
Second, have a variety of items that can be offered, such as cold
plates, sandwiches, and single-serve items that can be restored if not
used at that mealtime. Third, have the main menu item be the most
preferred item that most residents will choose; a well-planned menu is
key.
When coordinated appropriately, staffing can be
maintained at a pre-change level. Shifting duties and tasks, and
staggering meal service times can often satisfy a more open dining
situation. The cook's position is the most commonly affected position,
requiring them to stop their lunch production, for example, and cook a
late-riser egg and toast at 10:30 a.m. The staffing patterns and rigid
schedules of the past can become more of an “at your service” situation.
Department heads and auxiliary staff in the facility
become part of the “at your service” team. An “all hands on deck”
approach aids in promoting the best dining experience as staff can cut
up a residents' meat, offer a clothing protector, or serve another cup
of coffee.
Creating the environment
Many changes that occur can be done with little or no financial investment:
• Serve beverages before the main meal arrives.
• Take items off the traditional tray that is set before a resident; “bus” tables after the meal.
• Offer the soup or salad as an appetizer as the residents are waiting for the meals to be served.
• Move the steam table to the main dining area to
offer the aroma; also, if possible (safety concerns!), allow residents
to view their selections.
• Upgrade to china and glassware to create more of a restaurant-like atmosphere.
• Lastly, train staff to understand the importance of
mealtimes as a resident-centered event; soft music playing, appropriate
conversation, and the maximum assistance and service needed is
conducive to the best nutritional intake possible.
Creating change is never easy, because culture
change is a transformation of the whole nursing home atmosphere – the
physical environment, staff routines, authority structure, and resident
care – into an atmosphere that is life-affirming, satisfying, humane,
and meaningful. Culture change has been shown to transform demoralized,
dispirited staff into productive teams and dispirited, isolated elders
into active members of engaged communities.
For more informationn on culture change and the dining experience,
contact Maggie Kangas, RD, at maggiek@summitservices.com. Kangas is the
vice president of Dining Services for Summit Services Group Inc. Based
in Newton Lower Falls, MA, Summit Services Group is a provider of
quality and cost-effective housekeeping, laundry, maintenance, and
dining services specifically for the long-term health care industry.
