Culture change in long-term care facilities entails a change in philosophy and approach, moving away from an excessive emphasis on safety, uniformity, and medical concerns. Instead, the focus shifts towards resident-directed, consumer-driven health promotion, and the enhancement of quality of life. Central to this transformation is the recognition of the significance of relationships between residents and direct care staff. This overview highlights and explores essential components of culture change, such as workforce redesign, resident-centered care, leadership, processes of implementation and evaluation and our own story

  • Roshan J Mundapallil, Sowmya Lakshmi

The term “Culture change” refers to a widespread movement aimed at transforming services for older adults on a national scale and it actually evolved in US. This transformation is grounded in person-directed values and practices, prioritising the voices of elders and those caring for them with consideration and respect. The key person-directed values encompass choice, dignity, respect, self-determination, and purposeful living.

Culture change strives to establish a sense of home for elders, shaping care around the individual receiving it. In long-term care, this shift emphasises meaningful relationships and service, ensuring that caregivers truly understand those under their care. The goal is to enable individuals to lead meaningful lives and feel “at home” wherever they reside. A crucial aspect of fostering this sense of belonging involves crafting living spaces that are more private, comfortable, and personalised.

Typically, residents in long-term care facilities are not encouraged to achieve independence, and they frequently lack the necessary resources and tools for acquiring new skills. This lack of support takes a toll, particularly on individuals within the dementia spectrum, leading to increased isolation and reduced stimulation from their surroundings. This limitation often arises from the reluctance to grant autonomy, as it may heighten the risk of accidents and mishaps, especially for residents with co-morbidities.

Nevertheless, supervised autonomy is crucial, even when it contradicts one’s instincts. Swethashree, the long-term care administrator at advantAGE Seniors, experienced this lesson in her career. Reflecting on her early days as a junior administrator, the 28-year-old initially adhered strictly to a formulaic care approach, following protocols diligently. However, a senior colleague shared a profound insight with her: “A resident has the right to fall.” Though initially perplexed by the statement, this perspective resonated with her and profoundly influenced her career. She realised it wasn’t about endorsing falls but understanding that allowing residents some autonomy was vital for restoring their sense of self-dependence.

The prospect of enhancing quality in nursing homes is what piqued our interest in culture change. Implementing culture change lacks a universal approach, yet it involves essential elements, associated concepts, and models. A consistent theme is their deviation from the medical model prevalent in care settings, characterised by a hospital-like environment where care follows physicians’ and staff’s schedules and routines, often with minimal resident input.

In the past, care homes were often dreaded, viewed as undesirable places where living permanently seemed unthinkable, and death was preferred. This perception stemmed from a history of abuse and mistreatment within their confines, often portrayed as destitute, dingy, and unhygienic. However, in recent years, the landscape has changed. Today, amidst the era of baby boomers, we witness the emergence of sophisticated care facilities, assisted living, and modern retirement homes. We’ll share our personal narrative.

Twenty two years ago, when started advantAGE Care Home in Bangalore, a pioneering effort those days, we incorporated the concept of culture change.

The physical layout resembled a house, with each unit designed as an apartment featuring three bedrooms and a combined dining and living area. It deviates from the conventional hotel or hospital arrangement with rooms in a row. Instead, each unit operates as a family, where residents gather in the dining area during meal times and also enjoy the living room for activities like watching TV.

To realise the benefits of culture change, we endeavoured to transition from task-oriented care to fostering person-centered care. First thing we did, we transformed the physical environment to evoke a homely atmosphere rather than an institutional one. Consequently, our skilled nursing and assisted living facility has crafted a beautiful and home-like space, providing a comforting environment where many individuals have found a sense of home.

Many individuals hold a lifelong attachment to specific belongings, often due to emotional significance. Simhaji, for instance, desired a life-sized Sai Baba portrait positioned opposite his bed. He insisted on using his old study table and the vintage table lamp, emphasising their sentimental value. Even the cutlery held emotional importance for him. Similarly, Mary aunty wished to have her 50-plus-year-old sewing machine fixed in her room, and RajaGopal sought to include his small dining table in his space. We make sincere efforts to accommodate these requests, recognising the deep emotional connections individuals have with their belongings.

Transforming the physical setting of care communities is crucial to establishing a genuine home environment. Many elderly individuals who are now frail were once avid gardeners during their healthier years, cherishing those moments. Pradeep Simha, an example of such an individual, engaged in gardening as a pastime. Despite being wheelchair-bound in his later years, he maintained a love for plants and gardening, offering guidance on their upkeep. He actively participated in activities like repotting and acquiring new plant varieties. To enhance the enjoyment of our residents, we incorporated features like fish ponds, aquariums, love birds, and sparrows.

Gowree, Tiger, Murthy, Thankamma, Elvee, Gucci – all once stray dogs, now form part of our adopted family. They receive regular meals and, in return, offer solace to weary souls, playing the role of therapy dogs. The calm companionship of these therapy dogs fosters a connection that significantly impacts the well-being of residents, alleviating intense emotions like aggression and distress. For those feeling lonely and isolated, the presence of these dogs brings comfort. Simple acts like petting or allowing the dogs to sniff fingers can diminish feelings of depression and anxiety. Some residents, former dog owners or passionate animal lovers, engage in conversations about the dog’s breed and personality, indicating mental stimulation and the formation of an emotional connection.

While having faith in person-centered care is crucial, consistently translating that belief into action poses a distinct challenge. In essence, it’s not merely about altering the physical environment but also about transforming the systems and processes of care. Effectively operationalising and implementing culture change demands significant effort, as it involves reshaping the entire workflow. Sustaining such fundamental changes necessitates steadfast leadership, a quality often deficient in environments marked by high turnover, such as health and long-term care settings.

Brown University gerontology researchers affirm that a nursing home’s substantial investment in “culture change” leads to enhancements in the quality of care. They advocate for the implementation of person-centered care, emphasising that involving residents in goal setting can markedly influence outcomes. Ultimately, this approach has the potential to decrease the occurrence of avoidable re-hospitalisations, thereby alleviating both the associated costs and burdens.

Culture change involves a reconsideration of nursing home operations and structure, aiming to create a more residential lifestyle for residents. This approach emphasises providing residents with increased choice in schedules and activities, as well as incorporating more input from front-line staff into care management. For instance, residents gain the ability to decide when to have meals, including what they prefer to eat. While catering to individual preferences may not always be feasible, offering a variety of dishes allows residents the freedom to choose. Recognising everyone’s unique likes and dislikes, there’s a departure from a monotonous routine menu.

Establishing meaningful relationships with residents is pivotal. The closer your connection, the more effectively you can monitor their well-being and ensure their safety. Building strong bonds not only facilitates the caregiving process but also fosters trust. Simple gestures, such as taking the time to learn about their childhood pet, can alleviate the anxiety of being cared for by a stranger and contribute to a more reassuring environment for residents.

Elders often perceive long-term care facilities as institutions because, as residents, they tend to neglect their hobbies. We’ve fostered a proactive approach by enhancing our facility with features that encourage residents to pursue their interests. This way, as a long term care provider we acclimatised our residents with their surroundings and help them develop connections within the facility.

Seniors often experience feelings of loneliness and helplessness, even within a vibrant community. As a member of a long-term care team, your responsibility is not only to introduce them to fellow community members but also to actively foster and maintain those connections. Cultivating meaningful relationships with both peers and staff can significantly enhance the quality of life for residents. For instance, Kamala Mamee occasionally craves “Ela Sappadu” (Veg Meals on Plantain Leaf) and, with the help of staff, shares this dining experience at Woodlands hotel with her friend Vatsala aunty, another resident. This friendship and bonding evolve within the care facility. Here is the summary.

Physical Transformation Initially, we transform the building to evoke a homely ambiance. Eliminating institutional elements, we infuse warmth into the walls, adorn them with art, install modern flooring, and eliminate the clinical aura by removing the nurses’ station. The dining rooms are designed to foster a social atmosphere, allowing residents to bring in furniture from home to craft a personalized space. Lush gardens and inviting patios are curated to provide outdoor gathering spaces.

Organisational Change Subsequently, the organization must redefine its approach to resident care and staff treatment, referred to as “care partners.” Decision-making is entrusted to the residents or those closest to them because of their intimate familiarity with each individual. They comprehend the unique daily rhythms of residents’ lives. Residents retain the freedom to choose when to retire, rise, eat, and actively participate in crafting their own meaningful activity calendars. Inclusive of residents, families, and care partners, participation in training, activities, and committee involvement is encouraged. The leadership is devoted to fostering a home environment that restores autonomy, privacy, dignity, and respect for our residents.

Personal change Our caring staff undergoes consistent training aimed at reshaping their perspective on the elderly and refining our approach to mutual care. Training encompasses cultural change, addressing ageism, enhancing interpersonal skills, and specialized memory care techniques. By transitioning from a nursing home to a care community, we lay the groundwork for the future of caregiving for the aging and disabled population.