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1. Culture Change in Long Term Care: Why Licensed Practical Nurses Should Care
Dr. Linda Rhodes, Director
Hirtzel Institute on Health Education & Aging
lrhodes@mercyhurst.edu
2. What needed to change? High staff turn-over rates
High deficiency rates
Poor public confidence
Higher acuity rates
High staff injury rates
Institutionalization factor
No one’s happy
3. A Vicious Cycle A you recall from the first LS, Eaton identified the following vicious cycles that occurs in facilities.
This can happen fast.A you recall from the first LS, Eaton identified the following vicious cycles that occurs in facilities.
This can happen fast.
4. Vicious Cycle Fall Out Impact Vacant Shifts
C.N.A.’s report what gets neglected:
Range of motion
Hydration
Feeding
Bathing
Impact High Turn Over
Interrupts continuity:
Incontinence
Facility acquired pressures sores
Urinary Tract infections
Falls and fractures
Tacit knowledge disconnect (Lifting safely, social context of care)
5. LHB infectious disease in nursing homes Loneliness
Lack of meaning
I don’t matter
Depression
Helplessness
Catheters
90% giving care
Compliance
Easier for staff to do it
Boredom
“Killing Time”
6. Catalysts for change Sensational press coverage
Investigative Hearings
1987 OBRA Nursing Home Reform Act
OSCAR Data and online surveys
Advocacy organizations: The National Citizens' Coalition for Nursing Home Reform (NCCNHR)
The Pioneer Network Movement
7. Pioneer Network Values: Know each person.
Each person can and does make a difference.
Relationship is the fundamental building block of a transformed culture.
Respond to spirit, as well as mind and body.
8. Pioneer Network Values Risk taking is a normal part of life.
Put person before task.
All people are entitled to self-determination wherever they live.
Community is the antidote to institutionalization.
Do unto others as you would have them do unto you.
9. Pioneer Network Values Promote the growth and development of all.
Shape the environment: physical, organizational, and psycho-social / spiritual.
Practice self-examination, search for new creativity and opportunities for doing better.
Culture change and transformation are not destinations but a journey, always a work in progress.
10. The Pioneer Vision Thing Our vision is a culture of aging that is life-affirming, satisfying, humane and meaningful.
The Pioneer Network supports models where elders live in open, diverse, caring communities.
Everybody changes:
Governmental policy and regulation
Individual's and society's attitudes toward aging and elders
Elders' attitudes towards themselves and their aging
Caregiver’s attitudes and behavior
Our aim is nothing less than transforming the culture of aging in America.
11. LHB Antibiotic Attachment
Bonding to someone -- Family
Comfort
Feeling safe and secure
Inclusion
Make me feel part of group/community
Purpose
Allow me to be involved in life in a significant way
Identity
Know myself and you know me
12. Culture Change Three R’s: Core Concepts Renovating into Home
Reframing the Organization
Renewing the Spirit
It’s about feeling at home
13. Having the FREEDOM to:
Walk around in your underwear?
Get up in the middle of the night & watch old movies or get a midnight snack?
Sleep as late as you want?
Let the dog sleep with you?
Listen to your favorite music?
Watch Oprah?
Take a bubble bath?
Open the fridge and grab a cold one?
Source: Patrice Acosta, Beverly Enterprises
So, what makes you feel at home?
14. Renovating to Home Create excitement
Organize process
Creates households
Requires input
Causes disruption
Requires funds
Alternatives exist
Neighborhood. Neighborhood.
15. Reframing the Organization Moves leadership closer to elders
Flattest organizational structure
Eliminates departmental barriers
Requires self-directed teams
Embraces versatile workers
Builds relationships
Presents risks
Family
16. Renewing the spirit Involves Everyone
Requires Training
Requires Communication
Unites Residents, Staff and family Members
Involves Learning Circles
Renewal of residents and staff
17. Person Directed Care “I” Plans
18. Person Directed Care Planning It is directed by the person it is about.
Written in language everyone understands. (Family & Elder)
Focus on person’s strengths.
Recognize issues of the moment.
Starts with elders – their needs & perspective
It’s about me! (“I”)
Includes a social history
A team approach
19. “I” PlansPerson Centered Care Plans Old Way
Diagnosis:
CVA
Cognitive deficit
AMB: STM loss
Treatment:
R/O Therapy 3 x wk
Facility calendar posted in room
New Way
Problem:
I have a problem with my memory due to a stroke. When I wake up in the morning and after naps I have trouble remembering where I am.
Goal:
I would like to use my calendar to get to activities I enjoy.
The Activity Aide will put a calendar on my bulletin board each week.
When I get ready in the morning, show me my clock and calendar to help me pick out activities I like.
If I appear confused, help me get back on track by showing me my calendar of what I planned on doing.
20. I Plan: Nutrition Example Since my stroke, my appetite just hasn’t been the same. I have been losing weight since July. It helps to have my special adaptive silverware at the table. I eat better when I sit with Marlene so please have our special table set so we can eat together at every meal.
I’ve loved snacks since my hiking days. I enjoy Almond Joy’s, chocolate milkshakes and a burger from McDonalds which my daughter brings in. Offer me a snack between meals and before bed. Also invite me to join the cooking group. Food always tastes better when you make it yourself I always say.
Goal:
I want to keep my current weight and maybe even gain five pounds.
21. I Plan Mobility Example Old Way
Mobility
Treatment: Ambulation 2X/day New Way
Mobility
“I like to walk. My favorite times for walking are after lunch and dinner. On nice days I like walking outside for about 15 minutes.”
Goal: “I want to remain active as long as possible.”
22. Culture Change How you can tell the difference
23. How you can tell the difference: Neighborhoods, communities & households rather than wings or floors.
No mega-nursing station.
Residents instead of patients.
Residents wake up and go to bed when they want.
Nurses know the life stories of each resident.
Residents decorate their rooms with their belongings from home.
24. How you can tell the difference: Dogs and cats roam hallways; hugged and stroked.
Birds, fish and plants adorn halls.
Residents dine in small communal areas. Small is better.
Resident in charge of daily routine.
Person directed care planning.
No bureaucracy – team directed.
Relationships with family, staff and resident top priority.
25. How you can tell the difference: Staff are cross-trained: No rotations
Everyone is accountable to everyone else
Learning Circles
Life Stories
Medical model takes back seat to social model
Less staff turn-over rates, higher morale
Less medicated residents
26. How you can tell the difference: Medical vs. Social Medical Model
Standardized Rx plans based on diagnosis
Schedules & routines designed by staff for efficiency
Residents comply
Decision making centralized
Hospital-like environment
Structured activities
Sense of isolation & loneliness Social Model
Caregiving relationship based on desires of resident
Resident & staff design schedules reflecting personal needs
Decision making is as close to resident as possible
Comforts of home environment
Spontaneous activities
Sense of community & belonging
27. What you can do even without culture change Think of care plans in the context of “I” plans.
Practice team building leadership
Include CNAs in care plans, ask advice, RESPECT them, foster autonomy
Include residents in care planning
Build your communication & conflict resolution skills
28. What you can do even without culture change Create a blame free environment
Be flexible
Advocate for consistent assignments of CNAs with residents (Family)
Lead by example: pitch in on short-staff days
Feedback: How do they know you value them?
Identify Caring Outcomes – not just clinical
Ask to lead study group for culture change
29. Study for Action National Citizens Coalition for Nursing Home Reform www.nccnhr.org
American Associations of Homes & Services for the Aging www.aahsa.org
The Pioneer Network
www.pioneernetwork.net
Culture Change Now
www.culturechange.now.com
American Health Quality Association
www.ahqa.org
30. Study for Action Greenhouse Project
(www.greenhouseproject.com)
Wellspring Project (www.wellspringis.org)
Eden Alternative (www.edenalt.com)
Better Jobs, Better Care (www.bjbc.org)
Institute of Medicine (www.iom.edu)
Hirtzel Institute (www.hirtzelinstitute.org)