Culture Change in Nursing Homes

There is a movement today in nursing homes called "Culture Change". This concept means different things to different people and the movement is not new- although the name is relatively new. Culture change in nursing homes  goes back at least to the early 1970's. In New Hampshire, a long term care visionary by the name of Bill Thoms (Greenbriar) pioneered  such things as the "restraint free" movement and Liz Turcotte (Bedford Nursing Home and Hoodkroft) led the charge for a new Residents Bill of Rights- one that has the following language in it today "The patient shall be treated with consideration, respect, and full recognition of the patient's dignity and individuality..."  Our Residents' Bill of Rights at Sowerby Healthcare included, "... with full recognition of his/her rights under the Constitution of the United States of America and the State of New Hampshire." 


That last point is the foundation of what we mean when we speak of culture change. Without a true understanding of Resident's Rights, there can be no culture change. If a nursing home resident maintains all of his/her rights when entering a nursing home, how can that resident then be restrained? How can we dictate what time a resident must go to bed or get up? How can we restrict visitors or infringe on that resident's rights in any way? Obviously, a nursing home resident also has responsibilities just as anyone does who is living in a communal living environment. A person living in at home in an apartment can not play the stereo or TV loudly at 3:00 in the morning because that infringes on someone else's rights. Similarly, a nursing home resident may not infringe on the rights of other residents. Thus, we have a balancing act. However, it is still a matter of balancing rights versus responsibilities; it is not a "Father/Mother/doctor/nurse" knows best model.


The sad thing to me is the status we see today. It is a very long step backwards in most , but not all, facilities. Bill Thoms argued for fewer or no restraints in the early 1970s; Northwood Nursing Home was restraint free in 1976. In the mid-late 1980's we found that we had slid backwards a little. OBRA 1986 reminded us. Sowerby Healthcare, spurred by Administrator Zofia Long, led the way in the Restraint Free movement. Our Administrators and Directors of Nursing pushed hard to have a new and better vision of resident care, one grounded in  Resident's Rights. Chief among those were Cynthia DuBois and Carolyn Doyle, National Director of Nursing of the Year in 1995, of Northwood Healthcare. Vivienne Wisdom was the Executive Director of the New Hampshire Healthcare Association and was determined to have this philosophy spread throughout the state. She "preached the gospel" both here and nationally and soon New Hampshire was renown as the leader in the advancement of Resident Rights- especially the Restraint Free movement.


Although a key component of Resident Rights/Culture Change, the freedom from restraints is but a part of the philosophy. It is all too easy to mistake a means for the end or a symptom for the cause. If you have a true understanding of Resident's Rights, there is no need for "Culture Change". "Culture Change" is not having a pet in the house or learning circles. Nor is it any one of a dozen or so catch phrases such as "person centered care" or "social model" versus "medical model." I do not mean to disparage any of those concepts; those are concepts and tools that certainly help in achieving true reform but they are only that- tools- not reform itself. If we start from a resident rights perspective- and we follow that with a customer service model- we will reach the goal we seek. 


If you want to gauge a nursing home's commitment to resident rights, look at any of the following non-exclusive list:


1. What is the policy on alcohol?  Is a resident permitted to have a "nightcap" without the necessity of a physician's order? Where and how? At the nursing station from a med cup or from a brandy snifter in her room?


2. Are there restraints used? Even today with the increased acuity we see in nursing homes, restraints should be extremely rare.


3. Are foods that are pureed reconstituted to resemble the house diet or are such meals served in small bowls of unrecognizable mystery food? It is not that hard and presentation is half of the enjoyment of a meal.


4. Do residents (or their proxies) actually participate in care planning or are care plan meetings the time for the facility to tell the resident what the plan is going to be?


5. Are pets allowed?


6. May a resident furnish his/her own room? Use his/her own bed?


7. Are residents (or their proxies) actively involved in planning their daily lives? Menus? Activities?


8. Are there prescribed times for going to bed or for rising in the morning?


9. Are married residents permitted to share a room? What about a bed? What about unmarried couples? Same sex couples?


10. How do staff refer to residents? Mr, Mrs and Miss? Or "Dearie?" Or the "broken hip in room 204"?


This is certainly not an exhaustive list nor should it be presumed that each of those items must be included or the facility fails at "Culture Change." A facility also has certain rights as well as responsibilities.  It is certainly possible for a facility to be alcohol free or smoke free, for example. This can be due to  religious commitments or safety and health reasons pertinent to that facility. It should not be due to the fact that someone in charge at the facility has made a determination that the resident must be protected from himself.


There are some facilities that have remained a beacon of light in New Hampshire. A few years ago, I was on the Travel team for the State in the Quality of Life contest. We only visited eight facilities but of those, I was most impressed with two facilities- Peabody Home, and Hanover Hill were at the top of the list. Havenwood and the New Hampshire Veterans home got high marks for trying. Some other homes did not impress. Please note this was three years ago (or so) and things may very well have changed for better or worse.


If you have an interest in this subject, I would be most happy to discuss this with you. I will also note that there is an organization called the New Hampshire Culture Change Coalition which is promoting the subject. There is a Facebook page at http://www.facebook.com/groups/241871799205678/

Choosing a Nursing Home

Choosing a nursing home for a loved one is about as much fun as a root canal. The process usually starts late in the day, maybe on a Friday, when you get a call from the hospital telling you that your parent/grandparent is going to be discharged over the weekend. "Which nursing home do you want?"  A mad dash to the phone book or Google ensues. How can you tell which ones are good? The newspapers would have you believe that they are all terrible. First stop may be the web site the federal government provides: http://www.medicare.gov
This site purports to provide the information you will need to make a rational choice and even rates nursing homes on a "Five Star" basis- five stars equals good and one star not so much. After a little digging, however, you are probably totally confused. The site doesn't really rate the quality of nursing homes but rather rates the homes on how well they performed on federal and state Medicare inspections (called "Surveys") The results are confusing and the surveys are much too paper oriented, rather than people oriented. For example, nursing homes are required to have written policies for nearly everything. Failing to have  a policy may appear to be equal to actually failing to do something: a lack of a written policy or even the presence of one policy while the practice is to follow something else, will result in a "deficiency" . A lack of a policy that requires the nursing home to conduct criminal background checks on employees will appear to be the same as hiring someone with a history of resident abuse. A policy that certain food surfaces must be cleansed with a particular cleaning product while the actual cleaning is done with something else will result in a food sanitation citation- as will failing to clean the surface at all!! As a result, the medicare site is not of much help to anyone "not in the know." It is, however, a place to start.
So the question remains, "How can you tell if the home is a good one?" first of all, there is absolutely no way better than actually going to the home and seeing for yourself. Your common sense will guide you better than any web site. Is the place clean? Is there an odor? Do the residents look comfortable and relaxed? Realize that an odor may result anytime that a resident has a "problem" but there is a distinct difference between a fresh odor and a stale, nasty odor that has been around a long time.

There is a movement for something called "culture change" in nursing homes. Simply put, this movement strives to put the residents and families in charge of the residents' care. It is often confused with various "progressive" care strategies but really has at its core a full and complete understanding of Residents' Rights. Those rights start with the premise that a person who is admitted to a nursing home gains rights, not loses rights. For your purposes of choosing a home, those homes that truly respect each and every resident's rights (or the person legally exercising those rights) will be the best choice. A simple test question: "My mother likes to have a small glass of brandy in the evening before bedtime. Is that permitted?" If the answer is no or "sure, your mother can come to the nurses' station and we will provide a sip of her brandy in a medicine cup- providing we can get a doctor's order for it" then that facility does not understand the concept of resident rights. If your mother could have a glass of brandy at home without a doctor's order, what happened to her rights once admitted to a nursing home?
While  brandy may not apply to your relative, the example does. Ask the question anyway. If the attitude of the nursing home is that they are in total charge of your relative's life and they will make the decisions, look elsewhere.

When you tour the nursing home, try to go at different times of day. Early in the morning after breakfast and right after supper are tough times for nursing home staff and residents alike. This is the time of the most work and, at least in the evening, the least staff for the amount of work to be done. Are the people- staff and residents- friendly and busy but not stressed? Is there an odor? Noise?

Ask to meet with the Administrator and head nurse (usually called the Director of Nursing). Where are these offices located? If they are inaccessible to the residents, that is a warning sign. If the offices are near the resident's rooms and residents feel comfortable visiting the offices, that is a good sign. Does the Administrator seem to know the residents or is the Administrator simply paying lip service. Do the residents know him/her?

Ask to see the Activities schedule. If there is an activity scheduled while you are there, go to it. Are you welcomed? Is the activity well attended? Age appropriate and appropriate for the level of care or are residents bored and listless?

If you are there at meal time (always a good idea), visit the dining area. The food service should be judged no differently than you would judge a restaurant. Does the food being served match the posted menu? The menu is posted, is it not? Is the meal served on reasonable dining plates, cups, etc or is it served on trays with institutional dishware? If your relative requires a special diet, are special diets prepared and served in the same manner as the "house diet" or is the special diet something left over? What about diets that require pureed foods? There are methods of preparing pureed foods so that the food looks just like the regular meal and is, in fact, the regular meal pureed and reconstituted to look similar.

You probably will not find the perfect place; the perfect place is at home. You can however, choose the better or best facility. Unfortunately, the very best will probably, but not necessarily, be the most expensive and difficult to gain admission.

Do not get too hung up on extraneous matters such as size or whether the home is operated by a not-for-profit. I have seen wonderful small facilities that had the feel of home and that gave great care; I have seen small facilities that were simply lost in time and culture and no concept of modern methods of treating nursing home residents. I have also seen large homes that did a great job and some that did not. Not-for-profit homes usually have good intentions but sometimes their good intentions do not translate into good care. Some for- profit homes, put short term profit before care. The only way to judge is to see for yourself.