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.
Resident Rights/Culture Change
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.
Recommended Facilities for Culture Change
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/
Posted by Dwight Sowerby , Sowerby Law Office, PLLC
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