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Research in Culture Change Spotlight - Jewish Home Lifecare of New York

Culture Change in the Nursing Home: The Impact on Elder, Staff, and Family

Principal Investigators: Audrey Weiner, DSW and Sigal Barsade, PhD
Senior Research Associate: Orah Burack, MA

Background

Jewish Home Lifecare (JHL) is New York's oldest and largest not-for-profit long-term care and rehabilitation provider and is internationally recognized as an innovative leader in providing healthcare to elders, as well as an academic center for research and education. With campuses in the Bronx, Manhattan and Westchester and through Community Services, JHL serves more than 10, 000 elders annually via long-term care, short-stay rehabilitation, Alzheimer's/dementia care, respite care, hospice care, home healthcare, adult day care, care management, telehealth programs, senior housing and transportation.  JHL places a strong focus on wellness, healthy aging and caregiver support.  Our mission is to support health, individuality and the dignity of our elders.  By ensuring person-centered care we strive to enable our elders to enjoy a rich and full life, giving them the opportunity to live as independently as possible.

As a natural extension of our mission and values, JHL has been undergoing a culture change transformation at all three of our nursing home campuses for the past six years.  The focus of this culture change initiative has been on our long-term care units, which serve approximately 1400 elders. Since the start of the culture change initiative we have implemented a culture change study to monitor and understand the phenomenon and effects of culture change at JHL.  Specifically, the purpose of this study is to examine (1) the extent to which culture change has been implemented on the units (now referred to as communities) and (2) the impact of the culture change initiative on elder care, satisfaction, and quality of life; family satisfaction; and staff satisfaction.

Study Design

Timeline. The Culture Change study is a three phase longitudinal study which was initiated in September 2003.  Data collection for the third time point was completed in June 2008.  The data collection period for each time point took approximately six months and each time point was separated by about two years. We are currently working on the analyses for all three time points. 

Design. Thirteen long-term-care communities across our campuses (in Manhattan, the Bronx, and Westchester) participated in this study. Seven of the communities were culture change communities and six communities were designated as control communities.  The seven culture change communities were those communities at each of our three campuses that were the first to embark on the culture change initiative[1].  At the start of the study, two control communities were selected at each campus.  These communities were chosen because they best matched the culture change communities along the following key variables:  level of care, staffing practices, number of elders on the community, and the environmental structure.  

During most of the first two data collection periods, the control communities functioned according to our traditional pre-culture change model of care (the typical nursing home organizational structure with standard administrative and departmental hierarchies). However, some control communities began to phase into the culture change process during the end of the Time 2 data collection period.  Currently, all communities throughout our facility (including the original control communities) are culture change communities.  They are however at different stages of the transformation process since they began the process at different time points. 

Subjects

The subjects in this study were elders, staff members, and elders' primary family contacts on the 13 study communities.  Every staff, elder, and family member who was on a study community for at least two months prior to the start of each data collection period was asked to participate.  Subjects who did not participate in an earlier phase of the study could join the study at a later phase. Participation in the study was voluntary and IRB approval was obtained.           

In Time 1, 287 staff members, 199 nursing home elders, and 108 family members participated.  Time 2 included 280 staff members, 233 nursing home elders, and 122 family members participated, and Time 3 included 216 staff members, 218 nursing home elders, and 170 family members.  

Culture Change Initiative

While the culture change process evolved somewhat independently on each of the communities as change was made in response to community members' needs and choices, there were many common innovations put in place that reflected or helped facilitate the core values of JHL and culture change.  These included: 

1. Community Coordinator. The position of community coordinator was created at the start of the culture change transformation.  This is a central and key position in the implementation of culture change at the JHL.  Each community has a community coordinator who has the responsibility of facilitating the change process and organization on the communities.  The community coordinator acts as the community "team leader" interacting closely with all members of the community including staff, elders, and elders' family members. At the JHL a community is first identified as a "culture change community" once it has a community coordinator in place. One coordinator is typically assigned to between two to four communities.

2. Person centered care. Care is taken to interact with and treat each elder as an individual.  To support this value, elder feedback is solicited regarding care, quality of life, and treatment. Elders are given greater choice concerning daily activities such as the time the elder wants to get out of bed or go to sleep, when and how often the elder wants to bathe, and greater food selection for meals and snacks. 

3. Flattening organization from departmental hierarchy to community teams. As opposed to the traditional hierarchical departmental structure that is found in most nursing homes and hospitals, staff members on the communities are organized as community based autonomous work teams.  These teams are responsible for community policies and procedures, within the parameters of overall facility budget and clinical standards -.  All community staff, including nurses, CNAs, physicians, dieticians, environmental service workers, therapeutic recreation workers, and social workers make up the team.

4. Collaborative work environment. All community staff members have the opportunity for increased autonomy, participation in decision-making, and job enrichment. Similarly, staff members are encouraged to share responsibilities and help each other in activities ranging from care planing to answering call bells.

5. Family involvement. A greater focus is placed on integrating family members into the life of the community as well as in care and treatment planning.

Measures 

Elders: Face-to face interviews were conducted with elders to examine their satisfaction and perceived quality of life in the nursing home.  Elder behavioral measures were collected by interviewing each elder's primary day and evening certified nursing assistant.  Medical chart reviews were also conducted.  While only about one third of elders were sufficiently cognitively intact to participate in face-to-face interviews, behavioral measures and chart reviews were collected for all elders.

Families: Families completed surveys either by phone with an interviewer or self-administered the survey at home and returned the survey by mail.  The survey was designed to examine family member's perceptions of the degree to which culture change values (elder-centered care, focus on elder and family participation, and empowerment of staff) are implemented on the communities and the degree of family satisfaction with the nursing home. 

Staff Members: Staff completed self-administered surveys examining staff satisfaction, employee burnout, participation in decision-making, collaborative decision-making on the communities, and perceived implementation of organizational values on the communities. 

System Changes: The community coordinator, unit manager, and nurse on each community completed a questionnaire examining culture change initiatives occurring on the communities. 

General Summary of Results From Time 1 to Time 2 

Initial longitudinal analyses of Time 1 and Time 2 data based on the 185 staff members, 108 nursing home residents, and 40 family members who participated in both time points indicated that (1) Elders showed positive changes in both quality of life and behavioral measures on the culture change communities as compared to elders on the control communities. (2) Families reported increased implementation of culture change values (e.g. staff empowerment, person centered care, family involvement) on the culture change units as compared to the control units, indicating that the culture change intervention is being enacted and growing over time. (3) Elder outcomes were related to staff outcomes in a positive direction.   

Analyses with the Time 3 data will allow us to explore the continuing evolvement of the culture change program at JHL. The results of this study will be used to improve the culture change process and structure at JHL.  Additionally, we hope to develop a model of care that can be replicated in other nursing homes, and contribute to published research about the influence of culture change on the lives of elders, their families/friends and staff.


[1] JHL has 41 long-term care units.  At the start of the culture change initiative six years ago, two to three units at each campus were chosen to be the pilot culture change initiative.  Each year more and more units joined the culture change initiative and currently all long-term care units at JHL function as culture change communities.