Culture Change in Nursing Homes

The terms "long-term care" and "nursing home" typically bring to mind visions of unwelcoming, regimented institutions. But a growing movement, known within the industry as culture change, is looking to change that perception by radically transforming how residents are treated and served. Proponents of culture change believe long-term care residents can and should drive their own lives, and recommend replacing institutional units with households of small groups of residents and staff. Recently we spoke with Stephen Shields—one of the pioneers of the movement and the president and CEO of the Meadowlark Hills retirement community in Manhattan, Kansas—about the journey from institution to home.

"Culture change" is a now a buzzword in long-term care circles, but it was not so prevalent when Meadowlark Hills transformed its facilities in 2001. What kind of blueprint did you follow?

Stephen Shields: We actually started our work in 1997, so we really didn't have the benefit of a blueprint. First, we familiarized ourselves with change theory to understand the framework for deep, fundamental change. One of the driving forces is to become dissatisfied with the status quo. We realized that the way we served elders in long-term care in institutional environments is fundamentally flawed and morally wrong.Then, we started to identify resources—the Pioneer Network, Eden Alternative, Action Pact.We were also in dialogue with the residents every step of way.

In addition to changing nursing homes' physical facility, culture change requires altering the way staff work. What staffing and work environment changes have you made?

Shields: Part of the sickness of long-term care is not just what we do to residents, but also what we do to staff. It's an assembly-line, industrial-age approach that is ultimately dehumanizing.We recognized that we needed to create self-led teams of people who are closest to the residents and create a household community where the residents and teams build a life together. That's where all the beauty starts to emerge.

What kind of impact have you seen?

Shields: Staff turnover has dropped over 50 percent, while resident staff satisfaction has increased significantly. And clinical outcomes are fundamentally much stronger. Most people fear that a social model will surely be at the cost of medical effectiveness. It's just not true, and our clinical outcomes show that. But the big outcomes for me are the spontaneity of life that would have never been possible before. With staff, we've seen another kind of awakening. People were working day-to-day routines assigned in three-minute increments, with no ability to use judgment. We started pouring skills into these teams and they really began to flower.

In 2004, Kansas Governor Kathleen Sibelius visited Meadowlark Hills. What was her reaction?

Shields: It was visible that she was deeply moved. She went to one of the houses and rang the doorbell like any other home in America. And they answered the door and she came into their living room and gave them respect, like you do when you walk into anyone's home. [Governor Sibelius] wants to see if there's potential for this model to normalize in our state and everywhere.

How can the Meadowlark model work financially?

Shields: There's a belief that treating people like people must be more expensive. It's not. Our operating costs today are no higher than they were before. In fact, our staffing level—especially in certain disciplines—is lower than before. Our hours per resident day are lower.We use small groups of staff, with all the disciplines represented.They learn each other's skills to their licensure limits.

You've been traveling around the country speaking with nursing home administrators about making the change to resident-centered care. What do you tell them?

Shields: We've been telling these organizations that the secret to change is not a to-do list of redesigning medcarts or kitchens.The role of a leader is to create a framework for change. And you do it together, not in a vacuum.You create an organizational structure through self-led teams, and give them power. That's where change emerges from. People aren't quite ready to hear it, but that's critical.

March 2005