(co 2) this type of facility is more homelike and less institutional than in the past
Abstract In this paper, the authors aim to (a) explore attitudes toward and preferences for living in the newly emerging place type of assisted living facilities in comparison to nursing homes, and (b) assess the possible impact of familiarity on those attitudes and preference. Ninety-eight respondents (with a mean age of 62) were surveyed. Respondents were found to be more favorable toward assisted living facilities than nursing homes. A three-factor model was proposed in which attitudes mediated between familiarity and preferences. Increased familiarity seemed to predict enhanced favorable attitudes in the case of assisted living facilities, as opposed to unfavorable attitudes in the case of nursing homes. However, positive attitudes seemed to predict preferences for living in either place type. Results are discussed with regards to the literature on the mere exposure effect and long-term care for older adults. Show
Journal Information Since its foundation in 1974, Social Indicators Research has become regarded as the leading journal for the publication of the results of research dealing with problems related to the measurement of all aspects of the quality of life. These studies – empirical, philosophical and methodological – take in the whole spectrum of society, including the individual, public and private organizations, and municipal, country, regional, national and international systems. Topics covered include health, population, shelter, transportation, the natural environment, social customs and morality, mental health, law enforcement, politics, education, religion, the media and the arts, science and technology, economics, poverty, and welfare. Publisher Information Springer is one of the leading international scientific publishing companies, publishing over 1,200 journals and more than 3,000 new books annually, covering a wide range of subjects including biomedicine and the life sciences, clinical medicine, physics, engineering, mathematics, computer sciences, and economics. Rights & Usage This item is part of a JSTOR Collection. J Hous Elderly. 2014 Oct-Dec; 28(4): 383–398. Qualitative interviews with nursing home administrators reveal innovative and cost-conscious ways to physically modify facilities that help institute culture change practices. Telephone interviews were conducted following a national survey of nursing home nursing directors and administrators. In this cross-sectional snapshot of administrator
experiences, motivations for making facilities more home-like and less institutional and creative responses to challenges are described. State and corporate support and regulator encouragement are noted that help their reform efforts. Administrators note that small steps to create a more home-like environment can result in a positive impact that minimizes disruption to existing care processes. They describe how they respond to challenges, such as the physical plant and high costs, and note how
comparative shopping, cost-conscious physical improvements, and continuous involvement of staff and residents contribute to successful efforts. Their examples illustrate novel ways to humanize long-term care facilities that other nursing homes can emulate. KEYWORDS: nursing home environments, culture change, education, leadership, public policy CreatingTABLE 1 a meaningful sense of identity is a life-long human task often rooted in how individuals fit with their environment (Lawton & Nahemow, 1973; Rowles,
2008). When living in a nursing home is necessary because of impaired function and illness, this fit can be fundamentally challenging; although these institutions aim to deliver care efficiently, individual preference and regard for hominess are often afterthoughts, if ever considered. The culture change movement confronts assumptions governing this reigning nursing home paradigm. Prime
among these efforts are changes to the physical environment that soften the institutional nature of long-term care to incorporate personal choice and comfort and improve quality of life (Kane et al., 2005). Culture change facilities are designed as homes that foster relationships, staff empowerment, resident direction of care, measurement-based processes of care, and collaborative
decision making (Koren, 2010). The Centers for Medicare and Medicaid Services has supported the adoption of culture change practices (Doty et al., 2008), and early reports indicate positive resident and staff satisfaction and lower staff turnover rates (Bishop, Squillace, Meagher, Anderson, & Wiener,
2009; Loe & Moore, 2011; Lum, Kane, Cutler, & Yu, 2008; Tellis-Nayak, 2007). Adding to this momentum, the Veterans Health Administration (VA) has undertaken the ambitious job
of transforming their nursing homes into Community Living Centers to implement culture change (Lemke, 2012)TABLE
1TABLE 2. Sample Questions to Nursing Home (NH) Administrator from Qualitative Interview Guide
TABLE 2Examples of Administrator Ideas to Enhance Home-like Environment in Nursing Homes
To understand how culture change principles and practices are specifically carried out in long-term care facilities, we first designed and fielded a nationally representative survey with nursing home administrators and directors of nurses in the United States to determine the prevalence of culture change practices and features. Of 4,149 nursing homes sent surveys, contact was achieved with 3,695. Cooperation rates (i.e., proportion of responses when contact with a nursing home administrator or director of nurses was achieved) were 62.6% for nursing home administrators (n = 2,215) and 61.6% for director of nurses (n = 2,164). We then conducted individual follow-up semi-structured telephone interviews with a subset of 64 nursing home administrators. The interviews were designed to determine the administrators’ motivations for instituting change, understand which practices they chose to implement in their facilities, identify their challenges and strategies, and illustrate dynamics of decision and implementation processes (Miller et al., 2013; Shield, Looze, Tyler, Lepore & Miller, 2013). Mixed methods research helps examine how culture change principles are enacted in practice (Rahman & Schnelle, 2008). Although changes to the physical environment are often seen as cost prohibitive, this article provides examples that minor and inexpensive enhancements to the exterior and interior plant have substantial potential to create living spaces that are more intimate, cozy, and reminiscent of home (Cutler & Kane, 2006; Jurkowsky, 2013). When implemented to support resident capacities and help connect them to past roles and routines, small changes such as those described here can boost morale and well-being and can help shift the focus to the resident's experience instead of the resident's condition (Davis, Byers, Nay, & Koch, 2009). This article shows how administrators institute environmental changes in their facilities to achieve a homier environment and demonstrates how administrators respond to challenges to make these changes. The article provides a cross-sectional snapshot of nursing home administrators’ experiences. Grounded in everyday realities of management, decision making, policy, and finances, nursing home administrators speak from the trenches of their experiences and provide insight into the implications and consequences of their and others’ actions. Their insights may help others seeking to implement physical change and other reform practices in long-term care institutions. METHODSThe interview guide was informed by the culture change literature and revised after pilot testing. Interviews were audiotaped and transcribed and then reviewed by interviewers to ensure the accuracy of the transcription. The initial open-ended question asking administrators to relate what they had done to “improve the quality of care or life for their facility's residents and/or staff, as well as any changes they had made to the physical environment” eliminated any mention of culture change to minimize socially desirable answers about culture change. Questions were asked about the physical facility, and administrators spoke about the environment and physical changes spontaneously during the interviews. The institutional review board of Brown University found the research exempt from review because we collected no personal information from respondents. The coding structure we used to analyze the transcripts reflected topics from our interview guide and content elicited in interviews (Crabtree & Miller, 1999; Smith & Firth, 2011). Our 5-member multidisciplinary analysis team read and coded all transcripts and met in twice-monthly team meetings to revise the coding scheme, reconcile individual coding decisions, and search for competing interpretations in identifying themes (Curry, Shield, & Wetle, 2006). Revisions to the coding scheme were decided by group consensus and were followed by recoding all transcripts. An audit trail of team decisions concerning codes and themes was maintained throughout the analysis process. The qualitative software program Atlas.ti was used to help organize the interview data. This article focuses primarily on the results related to physical changes to the facilities. RESULTSAdministrators discussed various motivations for changing the physical environment and instituting other reforms and noted their strategic responses to obstacles. Administrators from most of the nursing homes spoke about the need to update older buildings and make them more appealing in a variety of ways. Creating more home-like environments was driven by a desire to stay current with the industry, optimize the older individual's quality of life, and maintain profitability by capturing the Medicare skilled and private pay markets (Lepore et al., n.d.). Input from resident surveys and resident councils provided feedback and ideas. Motivation to Change the Look and Feel of the FacilityIn addition to creating a “cleaner, fresher look” from a more “dingy and grungy” aspect, as one administrator put it, external changes to the facility's exterior were made:
An administrator proudly described external changes to a facility built in 1967:
Another added the following touches to the facility so residents have access to “ … patios and gazebos. In fact, they have their own, they have their own orange tree that they can pick oranges. They have a barbecue grill for barbecuing.” One administrator reported the “resident gardening program” where residents plant “their own vegetables and flowers,” whereas another commented that in response to the numerous residents who used to be farmers, “We have a gardening program where we have these little garden boxes that are on stilts so residents can, you know, be in a wheelchair and sit and work in the dirt if that's what their thing is.” Administrators linked the notion of gardening to enhancing the feeling of home:
One administrator described the heightened resident and staff morale stemming from minor exterior changes:
Another administrator of a rural facility created “a sidewalk that completely loops us, you know, if the residents want to use [it] … [and] some deer feeders set up … there's a herd of about 38 deer.” Some focused on changes within the facility to enhance the feeling of home. As this administrator noted:
Incorporating resident choice in designing the dining room might entail decorative but not extensive changes. This administrator described the first steps:
Another stated the benefits of this dining change to enhance a home-like feeling: “[The nursing home] also includes small kitchens so that the ladies can still stay connected to home, baking cookies and things like that.” Some administrators welcomed having the “clean slate” of planning a new building as an impetus to design the facility in more person-centered ways. One described plans:
Taking Small Steps as a Strategy for Physical Plant ChallengesAdministrators discussed difficulties posed by their physical facilities, and they described innovative responses. Some older buildings presented considerable barriers: “It was built very, very, very well, including block cement in all the rooms everywhere, so that made it a little more costly.” One common mechanism was to tackle small and inexpensive projects gradually. One said, “We started out slow … some homes started out fast … some of them failed.” This administrator added:
This administrator noted a simple enhancement to make the facility more appealing: “Our sub-acute unit, we've also just tried to make it cozier. We have coffee out there available for them.” Another administrator detailed small changes that reflected individual preferences for the residents’ rooms:
Small changes were manageable:
Somewhat more ambitious changes to the interior were also mentioned: To improve the facility's appeal, one administrator said they “ … re-wallpapered the facility and put new carpet in … People are happy with the changes.” Privatizing RoomsMotivated to attract the higher Medicare reimbursement of short-stay residents coming to the facility for rehabilitation following hospitalization, administrators also noted an intent to turn double rooms into private rooms and to provide what they thought these customers wanted:
Another noted inexpensive improvements in the new private rooms:
Other Physical Changes for Greater HominessAdministrators paired talk about physical renovation with principles of person-centered care and home. Some physical aspects of culture change are instituted to eliminate classic features of hospitals and nursing homes, such as nurses’ stations, which also frees up space. One administrator described benefits in not having nurses’ stations:
Another said:
Another thrust of environmental culture change reform in nursing homes is the elimination of intrusive sounds of overhead paging systems and alarms. Administrators described their cost-conscious searches for solutions. One used pagers to decrease noise:
Another administrator bragged, “For eight department heads, it costs me $100.00 bucks a quarter … much cheaper than cell phones … there are less expensive ways to make things better, more homelike.” Communication and Leadership Strategies to Overcome ResistanceAdministrators noted some resident and staff recalcitrance to physical change and new culture change practices and explained their strategies to encourage acceptance. Because physical changes often accompanied other culture change practices, such as dining and bathing schedules, that impacted staff routines, they cited communication and leadership as helpful. In response to resident concerns, one said:
Resident input was sought as a way to ease resident anxieties and create acceptance. One said residents “were part of the discussion” for physical and other changes. Another said, “You know, we involve them … saying what the décor [should be] and … so there's a lot of participation.” Administrators said some staff members “feel that, no, I've been at this for this many years, and I’m not going to change.” In response, some administrators hired new staff members “who don't know it any other way … this is how we do things here.” Constant communication was cited along with leadership (Tyler, Lepore, Shield, Looze, & Miller, 2013). An administrator said, “We gently try to educate them and get them involved.” One credited “a big piece of [success] is that strong nursing team.” Others noted the help of team managers and including “all the necessary players at the table” to institute physical and other culture change practices successfully. Supportive Boards and State and Surveyor Policy ReformCorporate support was sometimes pivotal in financing physical improvements and culture change practices. One administrator related:
Another administrator said: “Our company, in general, has been really preaching and practicing resident centered care,” whereas another noted, “ … [the company told us], ‘Yes, go ahead, hire more workers or do what you have to do to fix the issue.’” An administrator noted corporate support that enabled the addition of a point-of-service meal delivery system in the facility to promote hominess:
State and federal policies were also instrumental in fostering change. Administrators remarked how collaboration with state regulators made the implementation of environmental and person-centered changes easier. One said, “ … we work with the Department of Health … and 9 times out of 10, they’re going to give you a waiver.” Another said when “ … survey[or]s … tell us … you shouldn't have done this … we try to tell them … we’re listening to our residents … making this as home-like as possible.” An administrator summed up: “ … think outside the box because a lot of these things are doable … You’ll be like, ‘Man, this did work, let's do something else,’ and then you begin to get excited.” Pay for Performance ReimbursementAmong our interview sample were 6 administrators from Colorado and Oklahoma, states that instituted Medicaid pay for performance reimbursement with culture change performance measures. (Colorado stopped its pay for performance culture change reimbursement after interviews were concluded.) Nursing home reimbursement is partially affected by how the facility performs on targeted quality and performance measures, including having a more home-like environment (Buika & Skira, 2012; Werner, Konetzka, & Liang, 2010). Although administrators did not explicitly discuss pay for performance programs, their interviews suggest how these incentives may influence the adoption of culture change practices including environmental improvements. In describing policy influence on culture change implementation and environmental improvements, an administrator was cautiously optimistic about “what the new survey process will do … the old survey … hindered this progress. Unless you were … willing to take enormous risks, you just really wouldn't go out on the limb and do certain things.” Another said, “I think surveyors are very much for all the changes that the industry is making and trying to just be more of a resident-centered industry … They’re trying to help us in implementing this culture change.” An administrator said that state regulators “like to see that you’re making it worthwhile for each individual resident, kind of personaliz[ing] it.” One noted that Oklahoma “ … has been really encouraging all the facilities to try it … [now] surveyors are looking at … actual psychosocial needs [not] the policies verbatim … residents are loving it … We’re putting in a fountain machine, a pop machine in the dining room. And they call themselves the Homeowner's Association now … With our state jumping on board, it's been a lot easier.” Finally, another praised the state's support for culture change and physical improvements:
Administrators also described when they were unable to implement desired changes, usually because of prohibitive costs. For example, this administrator reported small physical changes to the facility, then noted constraints limiting improvements:
DISCUSSIONThis article describes innovative initiatives nursing homes are making to become more home-like, and it details responses to challenges in culture change practice implementation. These accounts are striking in how often they describe modest physical changes to nursing homes that are relatively easy to put into practice and together indicate a trend toward adoption of improvements that foster a home-like atmosphere. The administrators’ stories illustrate various motivations for enacting culture change practices and reveal how they exploit resources and exercise leadership to meet barriers. They describe taking small and manageable steps and suggest how corporate support and state and surveyor policy reforms aid culture change efforts. Physical changes to create a more home-like aspect helps advance the principles of the culture change movement; however, efforts to promulgate resident and employee empowerment should also be adopted whenever possible to further the overarching goals of the culture change philosophy (Koren, 2010). While illuminating a variety of administrator views, our qualitatively robust number of interviews cannot represent all nursing homes in the United States. We also did not interview administrators in VA facilities. Furthermore, administrators proud of their practices may have self-selected to speak with us. Administrators reported improvements they had been able to incorporate and indicated constraints under which they operate that limit implementation of environmental and other improvements. In future research, administrators’ perspectives should be complemented by interviews with varied nursing home staff, residents, and family members to more fully understand how reforms are perceived and experienced by them (Scalzi, Evans, Barstow, & Hostvedt, 2006). Ways to cultivate enriched social relationships within these more home-like settings and activities, such as gardening, should be encouraged for their role in helping residents maintain a sense of comfort, self-worth, and connection (Street, Burge, Quadagno, & Barrett, 2007; Wang & Glicksman, 2013). Settings with varying degrees of culture change implementation should be compared to help understand how staff and resident empowerment and other social attributes contribute to the formation and maintenance of relationships. Site visits to nursing homes that have renovated their facilities and implemented reform practices would help show how these changes are implemented and experienced on the ground. Although our data are limited on the practical effects of pay for performance on culture change implementation, they contain suggestions that nursing homes in states with pay for performance Medicaid reimbursements systems may have higher likelihoods of adopting culture change–aligned environmental improvements (Briesacher, Field, Baril, & Gurwitz, 2009; Grabowski, Elliot, Leitzell, Cohen, & Zimmerman, 2014; Miller, Cohen, Lima, & Mor, 2014). Administrator and policy maker perspectives on pay for performance programs with and without culture change incentives and other policies and regulations that support the implementation of culture change practices will help reveal the evolving dynamic of reimbursement and regulatory mechanisms. It is hoped that the positive indications described in this article encourage further regulatory reform to foster continued environmental and other culture change practices that enhance the quality of life in long-term care. CONCLUSIONThe need for older adults to fit their physical environment and exert personal choice is fundamental to a sense of individual mastery and well-being (Golant, 2012; Lawton & Nahemow, 1973). Nursing homes are increasingly attempting to implement physical improvements and person-centered reforms in their facilities that enhance personal control, comfort, and a sense of home. By adopting principles of culture change, nursing home environments can support older adults to achieve a greater sense of mastery, choice, and satisfaction. Physical enhancements to nursing homes help support residents’ capabilities and can provide meaningful reminders and connections to the comfort of domestic life. Culture change practices that improve the physical facility to make it more appealing and home-like can also skillfully connect residents to their identities and prior roles. Examples such as adding raised gardens and walkways included in this article show that small changes that are relatively easy to do can be designed to help connect residents to meaningful former roles, such as homemaker, gardener or farmer (Cutler & Kane, 2006; Jurkowsky, 2013; Wang & Glicksman, 2013). This article demonstrates administrator resiliency in attempting to improve the caliber of their facilities using culture change practices. In recounting how physical improvements to institutional facilities and person-centered reform practices can be implemented, administrator accounts provide practical examples of their ingenuity and leadership in transcending difficulties and suggest how enlightened policy reform may work to aid these reforms. These examples can motivate further efforts to humanize long-term care environments and improve the quality of life for our most vulnerable citizens. FUNDINGThis research made possible by a grant from the Retirement Research Foundation (2008-086) and from the Shaping Long Term Care in America Project funded by the National Institute on Aging (1P01AG027296). During this study Dr. Lepore was funded through the Agency for Healthcare Research and Quality (AHRQ) National Research Services Awards (NRSA) Post doctoral fellowship training grant (5T32HS000011-24). REFERENCES
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