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That’s What Nursing Is All About

By Peggy Bargmann

Action Pact trainer Peggy Bargmann, RN shares her experience, along with those of three other RNs, of nursing in a culture change environment.

When kids want to be a nurse when they grow up, they want to be someone who cares for people and makes them feel better. They imagine making their patients more comfortable and having concern for them. They don’t imagine making schedules, managing staff, doing paperwork and being pulled in so many directions at once they barely get a chance to look at their patients’ faces.

One of the most extraordinary things about culture change is the impact it has on the role of nursing in a nursing home. After all, these facilities, by definition are homes where nursing care is offered. However, in an institutional or traditional model facility, nurses have very little time for “home” because of the responsibilities for clinical care and many other managerial duties. They supervise other nurses and CNAs (Certified Nursing Assistants) as well as, to a degree, housekeeping and dietary staff, making sure everybody is doing things in accordance with the facility’s policies for clinical care. Much of a nurse’s time is spent documenting the care provided and filling out reimbursement paperwork for Medicare, Medicaid and private insurance companies. Nurses set the tone, make decisions and are ultimately responsible for fulfilling the prescribed medical care. In addition, their responsibilities include assessment of and reporting of all changes in condition that a resident experiences.

All the administrative duties leave little time for actual face-to-face interaction with residents. When they do have time with residents, nurses in traditional nursing homes feel bound by policies and procedures that seemingly mandate the way in which care is given. Things are often done the way they are done simply because that is the way they have always been done. For example, routines and schedules are very sacred in traditional facilities. Breakfast may be served at 7:30 am. To get everybody to the dining room in time, some residents must be awakened at 5 am. They are then taken to the dining room where they sit, sometimes sleeping, until breakfast is served. “The nursing process is so mechanical but it doesn’t have to be. The role of the nurse is to help people do what they want to do,” said Roger Beins, Clinical Services Mentor at Meadowlark Hills Retirement Community in Manhattan, KS.

Unfortunately, the individual needs and concerns of residents fall down the list of priorities for nurses in a traditional facility. Not because that is how they want it, but because of the way their role and responsibilities are structured and because their performance expectations are so designed. In a culture change facility all staff members are crossed-trained in several areas of nursing home life and all take on leadership responsibilities and are involved in making decisions. Everyone’s focus is on the residents’ quality of life and building relationships with them.

The best way to start to break down barriers between residents and the nursing staff is to literally break down barriers. Most nursing homes have a centrally located nurses station with high counters, some even with glass barriers above the counters. Nurses spend much of their time at the nursing station and residents are brought in wheel chairs to be parked around the station. The idea is that residents can be “close to the action” and nurses can keep an eye on them while they are working. The physical layout clearly says “the action: is in the clinical focus not in a focus on the residents. In a culture change home the nurses’ station is traded in for a smaller residential type desk that blends in with the homey surroundings. At Perham Memorial Hospital and Home in Perham, MN, the nurses’ station is a “den” within the household where medical records are stored and phone calls can be made in seclusion to protect patient privacy. It is expected that nurses will be in the household and not spending too much time in the den. There is also a desk in the living room with locked cabinets and a residential computer for documentation.

Employees who in the traditional model were, for example, housekeepers are cross-trained in dietary, activities and CNA duties in the culture change model. Nurses also take on other household responsibilities. “A nurse is cross trained in all areas (dietary, housekeeping, activities) and works along side other household staff to do ‘whatever needs to be done’,” said Marilyn Oelfke, Sr. Director of Long-term Care Services at Perham. In general, nurses spend 80 percent of their time doing traditional nursing tasks and the other 20 percent helping out in other areas. Nurses in long-term care do need to be skilled in assessment and decision-making but also must be able to lead the staff in providing ordinary loving companionship to residents in a day-to-day setting.

It sounds like a lot more work for all, but when you have staff permanently assigned to a household (typically 15 to 20 residents) instead of different residents every day, responsibilities are spread out. For example, in a traditional model, a resident’s morning may start by being woken before 7 am by one person, given meds by another, and given food by yet another. In a culture change home, one person can do all these things and residents wake when they want. Instead of seeing the resident briefly when medications are administered, a nurse has time to say good morning to the resident, ask how he is feeling, offer his medication and maybe talk about the medication and share a bit of conversation during the course of it all. The nurse does the same for a few other residents, while other staff members tend to the needs of still other residents in the household, keeping in mind, of course, the licensure requirements associated with certain tasks like giving medication. Not only is this a nice human exchange for both the nurse and the resident, but the quality of clinical care is made better as the nurse has a chance to get to know the resident and is better in tune to day to day changes in his mood, appearance and health.

Culture change also flattens the managerial structure within a facility so that the leadership role, that used to rest solely on the nurse, is shared by all staff. The team of versatile workers establishes procedures, makes decisions and deals with performance issues. “Nurses work collaboratively with CNAs, homemakers and other caregivers rather than directing their efforts. They spend time heightening the awareness of those direct care staff and increasing the competency of the organization in the process,” said Beins. The nurse is then relieved of carrying this load by herself and has more time to care for the residents. Educating nurses to claim this role is an important feature of culture change in a learning organization.

The main goal of culture change is to improve the quality of life for nursing home residents. This means they make decisions about how their life in the nursing home will be – when they will wake up, what they will eat and when, what activities they will do (or not) how they will be taken care of. “The challenge,” said Beins, “is to balance a person’s autonomy with what we or their physician feel is in their ‘best interests.’ The concept that has to remain in the forefront of our actions is that it is in the person’s best interests to maintain control over their own life. Our challenge is to facilitate quality care to the degree that the person wants it. If the choice is between balanced blood sugar and a love of chocolate peanut butter pie, how can we facilitate a compromise? And in the end, if the individual does not want to compromise, we have to respect that, and of course, document, document, document.”

In fact, by catering to the residents’ social needs as well as their clinical needs, their medical status can improve. “People aren’t as sick as we thought they were. We’re able to decrease medications. Incontinence has gone down. Behavioral [problems] have gone down. Depression rates have gone down. UTI (urinary track infections) have gone down. Weight loss is down. Fall rates are down. Pressure sore rates are down. There are more people caring for people,” said Deborah Heath, Clinical Mentor at Lenawee Medical Care Facility in Adrian, MI.

The nurses learn to find ways to ask, “What does the resident want” and then figure out a way to work the clinical care into that vision. Through person-centered care a strong emphasis is put on the relationship between the resident and the caregiver. In this way, nurses really get to know the residents. Their likes and dislikes and of course, their daily pleasures and idea of “home.” Residents are seen as real, whole people to whom the nurses give care not just one of many people who need to be bathed or given medication in a short amount of time. The residents see the staff as real, whole people also. So, the residents are happier, but the nurses are as well. “They’re clocking out and going home and they have a smile on their face and they’ve done a good job,” said Heath.

In traditional nursing homes, each source in this story would be considered Director of Nurses. The culture change in their facility has broadened their positions requiring more appropriate titles. They are all registered nurses.

Roger Beins, RN, Clinical Services Mentor at Meadowlark Hills Retirement Community in Manhattan ,KS, “We encourage staff to develop relationships with the elders they serve rather than warn them not to get too attached. Everything we do is about the relationship between the resident, their family and us as caregivers. The concept that has to remain in the forefront of our actions is that it is in the person’s best interest to maintain control over their own life.”

Marilyn Oelfke, RN, Senior Director of Long-term Care Services at Perham Memorial Hospital and Home, Perham, MN, “We have said from the very beginning that if we enhance quality of life for our residents and lose the high quality of care that we are known for, we will have gained nothing for our residents. The nurses are key to maintaining the quality of care. They need to be able to question previous standards of practice objectively when issues of residents quality of life come up.”

Deborah Heath, RN, Clinical Mentor at Lenawee Care Facility, Adrian, MI, “Having been on their culture change journey for over a year the nursing team would never go back to the old way.”

© 2005 Action Pact, Inc.

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Additional resources

"Creating a High Retention Culture," an essay about creating a positive and productive work environment for long-term care employees (PDF)

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