AGING IN OREGON

1. AGING IN OREGON Understanding Long Term Care Services for the Older Adult Module 4 –Culture Change & The Emerging Role of the Nurse in LTC

2. Long Term Care Culture Change • What is Culture Change? • The common name given to the national movement for the transformation of older adult services, based on person-directed values and practices where the voices of elders and those working with them are considered and respected. Core person-directed values are choice, dignity, respect, self-determination and purposeful living. • What does Culture Change Transformation Support? • The creation of both long and short-term living environments as well as community-based settings where both older adults and their caregivers are able to express choice and practice self-determination in meaningful ways at every level of daily life. • What does Culture Change Transformation Require? • Changes in organization practices, physical environments, relationships at all levels and workforce models – leading to better outcomes for consumers and direct care workers without inflicting detrimental costs on providers. To learn more about Culture Change go to the Pioneer Network website.

4. Person-Directed Care • A philosophy of Person Directed Care (PD) strives to implement and support the choices that the person being assisted makes and to keep all decision-making as close to them as possible. • It recognizes that some individuals lack the physical or cognitive abilities to tell us with words what their wishes are, but that within their past choices and present behaviors lies the key to what will most honor their current wishes. • In these cases, those who work with them on a daily basis (the family or other direct caregivers) need to have the ability to adapt routines to fit their expressed and implied wishes. PDC recognizes the inherent value of each individual and is focused on supporting their strengths and abilities, capacity for social contribution, unique values, preferences and living habits, and promoting autonomy and choice (White, D. et. al. 2008).

5. Applying Person-Directed Care to the Care Planning Process • Click on this link to open a document from the Department of Human Services in Wisconsin that provides a good overview of how to apply person-directed care to the care planning process for an older adult with dementia (it will open in a separate window). • Pay particular attention to: • The Five Basic Needs of People with Dementia • The Well-Being Profile • Descriptive Language and Old & New Language

6. Culture Change in Oregon: Making Oregon Vital for Elders (M.O.V.E.) • M.O.V.E. is the local culture change organization representing key stakeholders in LTC. The group offers approximately 4 seminars/workshops on a variety of culture change topics each year. • Building on principles of the Pioneer Network, Oregonians from a variety of organizations and experiences founded M.O.V.E., a coalition in which ideas and actions come together to create culture change for the benefit of elders and those who support them. http://orculturechange.org/

7. Culture Change in Oregon: Making Oregon Vital for Elders (M.O.V.E.) • Vision: We share the vision that Oregonians will live and work in communities that embrace aging; where individual contributions are valued, unique talents celebrated and personal life experiences honored. • Building on principles of the Pioneer Network, a national grassroots organization committed to changing the culture of aging in America, Oregonians from a variety of organizations developed a statewide coalition in which ideas and actions come together to support culture change. • Mission: To create and sustain personalized, enriching communities where older adults and those who support them can thrive. • We are dedicated to culture change by enhancing the way care and services are delivered to older adults throughout Oregon. Our goal is for all people to live in communities where each person’s capabilities and individuality are affirmed and developed regardless of setting. http://orculturechange.org/

8. Culture Change in Oregon • In many ways, the LTC culture change began, particularly in Oregon, with the development of community-based care settings such as assisted living and adult foster care. The need to address issues such as privacy, respect, choice, and promoting independence are written into the Oregon laws governing these services.

9. Culture Change in Oregon • Many pioneers, including nurses such as Joanne Rader from Oregon (who has contributed to major nursing practice changes such as individualized dementia care, restraint reduction and bathing without a battle) and Anna Ortigara (who created the training program “LEAP” – Learn, Empower, Achieve, Produce), have spent their careers focusing on changing nursing home practices. • These efforts, as well as those of countless administrators, regulators, and providers have culminated in a national movement.

10. Issue Paper: Nurses Involvement in Nursing Home Culture Change: Overcoming Barriers, Advancing OpportunitiesFrom the Hartford Institute for Geriatric Nursing, New York University College of NursingCoalition for Geriatric Nursing Organizations (CGNO), The Pioneer Network, Spring, 2009 Recommendations: • Develop and distribute a Statement of Goals for Practicing Nurses in Culture Change Nursing Homes. • Develop competencies for nurses practicing in culture change nursing homes. • Conduct a comprehensive review of culture change content in pre-licensure (associate degree and bachelor of nursing) nursing programs. • Disseminate existing tools/resources on culture change and nursing’s role in culture change to academic nursing programs, including strategies for incorporating this content into the curriculum. • Create new tools/resources based on the competencies for nurses in nursing homes • Identify research priorities for examining the role of nurses in nursing home culture change. http://hartfordign.org/policy/position_papers_briefs/

11. Nurse Competencies for Nursing Home* Culture Change • Models, teaches and utilizes effective communication skills such as active listening, giving meaningful feedback, communicating ideas clearly, addressing emotional behaviors, resolving conflict and understanding the role of diversity in communication. • Creates systems and adapts daily routines and “person-directed” care practices to accommodate resident preferences • Views self as part of team, not always as the leader. • Evaluates the degree to which person-directed care practices exist in the care team and identify and addresses barriers to person directed care. • Views the care setting as the residents’ home and works to create attributes of home. • Creates a system to maintain consistency of caregivers for residents.

12. Nurse Competencies for Nursing Home* Culture Change (cont.) • Exhibits leadership characteristics/ abilities to promote person-directed care. • Role models person-directed care. • Problem solves complex medical/psychosocial situations related to resident choice and risk. • Facilitates team members including residents and families, in shared problem-solving, decision-making, and planning. *Note: although developed specifically for nursing homes, these competencies are relevant to nurses in other LTC settings such as ALF, RCF, AFC, Home care. Developed through a collaboration of Pioneer Network and Hartford Institute for Geriatric Nursing, 2010, www.pioneernetwork.net

13. Culture Change in Oregon • Nurses in long term care (LTC) need to be knowledgeable about the key tenants of this movement. • The role of nursing in these settings, particularly in community-based care settings, is evolving. • Long term care nurses will have a unique opportunity to work in an interdisciplinary partnership to shape LTC services to meet the future needs of residents and their families, and staff.

14. The Important and Emerging Role of the Nurse in Long Term Care • Nurses have had a presence in long term care for some time, particularly in the nursing facility. • As the population ages and nursing’s focus shifts toward care of the older adult, nurses have an opportunity to significantly influence care in the long term care setting. • The nurse’s role in long term community care is also emerging, especially in the assisted living and residential care environments.

15. Nursing Expertise in Assisted Living and Residential Care • Oregon was the first state to provide housing/care in assisted living facilities (ALF), often as a substitute for nursing home placement. • There is no “ceiling” on the level of care that can be provided in ALF in Oregon. Older adults living in ALFs have chronic conditions such as dementia, diabetes, and cardiovascular concerns that require complex clinical management and demand expert nursing oversight, observation, and intervention (Singer, McDaniel, & Hornby, 2002; McDaniel, 2003).

16. Nursing Expertise in Assisted Living and Residential Care (cont.) • Recent changes in Oregon ALF and RCF regulations require an increased level of nursing services and a nurse who is able to respond to complex resident care needs, including frequent change of condition assessments; medication, wound, and pain management, nursing delegation; end-of-life care; and directing unlicensed staff. • The knowledge and effectiveness of the nurse can make the difference for an older adult to age successfully in place.

17. Nursing Competencies • Four competency domains for nursing practice in the assisted living/residential care setting have been identified. • Care of Older Adults (care/clinical management) • Systems (policies, procedures, quality improvement, regulatory compliance) • People (interpersonal communication/supervision with staff, residents, families, and outside agencies) • Time Management (organization, planning, prioritization) McDaniel, 2009

18. In their own words… Click on the links below to hear nurses who are working in long term care share their thoughts about the rewards and challenges of this role. Please note: Allowing the YouTube clips to fully load in your browser window may result in better video quality. • Polly Youngren, RN, MN talks about providing the best possible care for patients. • Hannah Perry, BSN, RN talks about the high potential to make a difference in long term care. • Beth Jackson, RN talks about seeing the positive impact of caring for patients • Brad Finley, RN talks about what gets him to work in the morning. • Joan Morris, RN talks about the best parts of her job.

19. In their own words… Click on the links below to hear nurses who are working in long term care share their advice for nursing students: Please note: Allowing the YouTube clips to fully load in your browser window may result in better video quality. • Polly Youngren, RN, MN advises students to ask a long term care nurse about the work that they do. • Beth Jackson, RN talks about being fulfilled by seeing her impact on patients. • Brad Finley, RN talks about misperceptions of long term care nursing. • Joan Morris, RN talks about autonomy and decision making as a long term care nurse. • Leslie Joy Boyer, RN talks about the many qualities important for a long term care nurse to possess.

20. Resources • Check out these great resources to enhance your learning and support your nursing practice with older adults. • Hartford Center for Geriatric Nursing • ConsultGeriRN.org • Oregon State Board of Nursing, Division 47, RN Delegation of Nursing Tasks to Unlicensed Persons • Nursing Delegation Self-Directed Course