In an unusual partnership, a University of Pennsylvania team, led by two School of Nursing investigators, collaborated with for-profit nursing home industry giant Beverly Enterprises to evaluate Beverly’s early efforts to change the culture at three of its nursing facilities and compare them to three traditional Beverly homes, matched for size, location and leadership.

The Penn research team was led by Lois K. Evans, DNSc, FAAN, RN, ViolaMacInnes/ Independence Professor in Nursing and Division Chair for Family and Community Health, and Cynthia Scalzi, PhD, FAAN, RN, Associate Professor in Nursing, the Wharton School, and Director of the Administration and Leadership Graduate Programs. The two other research team members were Alan Barstow, PhD, an organizational anthropologist in the School of Arts and Sciences; and nursing graduate student Katie Hostvedt. Beverly, one of the largest U.S. providers of nursing-home care, operates 452 skilled nursing facilities and 29 assisted living centers in 26 states and the District of Columbia. Beverly began piloting culture change about a year before the study began. Beverly funded the study.

Introduction

While it is somewhat unusual to partner with a for-profit entity, Drs. Evans and Scalzi viewed the joint effort as a unique opportunity to pilot their research design and instruments and also positively affect nursing-home care. A few nursing homes across the country have begun changing their culture to empower residents and staff, to enable older adults to have choices about their care, and to live in more home-like environments. Culture change focuses on relationships, people and personal preferences more than on completion of tasks. Many different models of change exist, mostly in independent homes.

Drs. Evans and Scalzi found not only significant differences between Beverly’s three culture-change facilities and the three operating under a traditional approach, but also saw opportunities for further improvement in the culture change model. The team recommended changes before the company expanded its Resident Centered Elder Care program to additional facilities. Beverly began implementing the Penn researchers’ recommendations almost immediately.

“Normally, it takes 10 to 15 years for research to be put into practice,” said Dr. Evans.“We did this study in seven months, and they immediately began implementing some of our findings.”

The professors brought different expertise to the project. Twenty years ago, Dr. Evans’ pioneering research reduced the use of physical restraints in nursing homes, changed nurses’ perception of the practice, altered public policy and brought international attention to the physical and psychological harm for patients. Once advanced practice nurses worked with staff to identify and implement alternatives to restraints, previously restrained residents began to talk and behave more normally.

“It became clear we could improve quality of care by removing restraints, but quality of life still had a long way to go,” Dr. Evans said.“Once we began to see what nursing homes really looked like when residents were unrestrained, other needs came to the forefront.”

Long a proponent of the importance of values in shaping organizational behavior, Dr. Scalzi’s interest in culture change in nursing homes developed after observing the care of a family member admitted to a nursing home. Although her aunt lived in a highly-rated facility, Dr. Scalzi became convinced a better way of caring for elders must exist.

Evaluating the Culture Change Model

The Penn research team began its investigation of Beverly’s culturechange program by walking through the facilities with clipboards and standardized instruments, noting quality indicators on the floors, in dietary, therapy, the bathrooms and common areas. They then compared observations and reached a consensus rating for each area. Next, they gave two instruments to all levels of staff and rewarded each employee who completed the survey with a $10 honorarium. They received 271 completed questionnaires.
The researchers followed up in two-person teams to conduct interviews with staff and family members,
spending about nine hours at each facility. Staff members seemed quite elder care receptive to participating, with 132 agreeing to interviews. Twenty-one family members also participated. The short time period between receiving the grant and the promised date delivery date precluded obtaining institutional review board approval to talk with residents. “We used a lot of the qualitative interview data to substantiate our findings from the instruments,” Dr. Scalzi explained.“We were meeting our research goals and at the same time we were meeting everly’s objectives.”

In all three of Beverly’s culture change facilities, Penn researchers found good communication between employees and residents and a calm, homelike environment. In addition, residents enjoyed greater physical comfort and privacy, had more choice, and their relationships with friends and family were respected and preserved. In one of the homes, however, more remarkable progress was noted. There, residents were involved in volunteer jobs and activities they found satisfying. For example, residents were provided assistance when they left the facility to tend to personal affairs or to visit a hospitalized roommate. Some families had moved residents from a traditional to a culture-change facility because of the more consistent staffing with the same caregivers and a sense of community. One daughter called her mother’s two months at the culture-change facility the best during her five years in a nursing home.

The Penn research team found that staff members appreciated the team environment in culture-change facilities. They were significantly more likely than associates at the traditional homes to
recommend their facility to families and elder care to peers as a good place to work. The management teams were learning how to let go and to empower staff to make decisions and problem solve.

But the Penn researchers also found opportunities for improvement. Culture change takes time. To effectively alter the environment for nursing home residents, all staff must be included in the training process. During the initial rollout at Beverly, education focused at the leadership level. Nurses, therapists, and aides did not receive the same level of training in culture-change practices.

The study also showed that nurses spend much of their time on tasks – medication administration, treatments, wound care – that only they are licensed to provide. They often do not have the time for sitting and talking with a resident, one of the more enjoyable aspects of working in long-term care. Nurses also provide a crucial link between executives and caregivers. “Nurses carry out a vital role in the care of residents and are the more educated of the staff, yet were not being utilized to their potential,” Dr. Scalzi said.

“While not all findings were positive, we tried to provide an objective assessment of what was working well and what was not,” Dr. Scalzi said.“The Beverly executive team was very receptive to the actions suggested, and many have since been implemented.” Dr. Evans does not want to wait another 20 years for the next major improvement in longterm care to become reality. The Penn nurses will continue researching culture change and quantifying its effect on outcomes.

1. Weiner, A. and Ronch, J. (Eds.) (2003) Culture Change in Long-Term Care. Hawthorne Social Work Practice Press, New York, Co-published simultaneously as Journal of Social Work in Long-Term Care, Volume 2, Nos. 1/2 and 3/4 2003.

2. Noelker, L. and Harel, Z. (Eds.) (2001) Linking Quality of Long-Term Care and Quality of Life. Springer Publishing Company, Canada