An exciting movement known as "culture change" is sweeping through nursing homes. It seeks to transform nursing homes into homey environments that focus on what residents want, not what's best for the institution and its staff. They are supposed to let residents decide what they want to do--when they want to get up, when to have meals, what they'd like to eat, and how they spend their days. To this end, staff are empowered (they are supposed to get to know the residents for whom they provide care so they can figure out how best to help them) and cross-trained (all staff members perform all tasks, like a family rather than an institution). A recent study found that fully 85% of directors of nursing in a large sample of nursing homes say that their facilities have incorporated at least some features of culture change, compared to 56% in a study done by the Commonwealth Fund in 2008. But does culture change succeed in improving quality of life?
My father lives in a nursing home that is supposed to fully embody culture change. The facility is beautiful. Almost every resident has a private room. The building is carved up into "households" of only 14-15 residents. Life in the household is organized around a bright "country kitchen," similar to what many people experienced in their own homes. But as a home that is supposed to enhance well-being, it is unequivocally a failure.
My dad is 89 years old and has moderate dementia and Parkinson's. Like most of the people in his household, he needs help with the most basic activities--going to the bathroom, getting dressed, bathing, and walking. He cannot initiate activities. He expresses no interest in the various events that take place in the building such as concerts or discussion groups, so unless a visitor takes him, he does not attend. He used to spend most of his time in his room, looking at the New York Times or watching television; because he sometimes got up without calling for help and often fell, he is now required to spend all day sitting at the dining room table where the staff can keep an eye on him. He has nothing to do other than watch a large screen TV that is on continuously and study the daily "schedule of events" (none of which he attends) that is distributed to each resident.
As a group, the nursing assistants at this nursing home are kind and gentle and provide adequate personal care--though they often neglect to put in my father's hearing aid, forget to shave him, do not take him to the bathroom with sufficient regularity to avoid accidents, and leave him wearing soiled clothes. They do not try to engage him in conversation or come up with suggestions for how he might spend his time.
My father lives in an extremely high end facility that was designed from its inception to implement resident-centered care. Perhaps the facility succeeds with the small minority of residents who have no cognitive impairment. Perhaps the facility succeeds with residents who are mobile. The idea behind culture change is inspiring. But either it doesn't work or its implementation is tremendously flawed. In either case, it's time for high quality research to monitor the outcomes of culture change and to figure out what needs to be done to make the dream a reality.