The Past, Present, and Future of the Culture Change Movement in Long-Term Care

By Scott King

The long-term care (LTC) culture change movement is considered by many to have begun in 1997 with the first meeting of the Nursing Home Pioneers (now known as the Pioneer Network). Since then, the movement had progressed slowly until 2005 when the Centers for Medicare and Medicaid Services (CMS) implemented initiatives to support the movement, giving it federal momentum to gain a foothold in the seniors housing and care industry. Anna Rahman and John Schnelle recently provided a detailed history of this movement, elaborating on their view of its weak empirical base and suggesting an agenda to improve research in the area.

Researches have neglected defining culture change since the coining of the term at the 1997 meeting; instead, they have tended to describe the processes that they feel make up culture change. Culture change can take on various forms and sizes, but in general it refers to a transformation of a community’s values, attitudes, and behaviors in order to allow both staff and residents to flourish in a caring environment aimed at improving residents’ quality of life. Initially, the movement grew slowly despite programs conducted by the American Association of Homes and Services for the Aging (AAHSA) and American Health Care Association (AHCA), as well as associations with other models of LTC such as The Eden Alternative and Wellspring models.

The early years of the culture change movement were characterized by a lack of rigorous evaluation—without a definition and because of a prolonged growth process, it was difficult to determine cause and effect. Finally, in 2002, Robyn Stone and her AAHSA colleagues published a thorough evaluation of the Wellspring model. They found improved quality outcomes, better staff retention rates, and reduced turnover rates. A handful of other studies appeared in a double issue of Social Work in Long-Term Care and were later published as a book in 2004. But, in March of 2005, a report from the National Commission for Quality Long-Term Care criticized the dearth of empirical evaluations of culture change and claimed that state regulations, limited resources, and established practices were all impeding the movement.

Despite that bleak outlook, in June of 2005, the Pioneer Network and Quality Partners of Rhode Island hosted the St. Louis Accord—a meeting that brought together 400 long-term care leaders and representatives that regulatory CMS and State Survey and Certification agencies once considered hindrances of the movement. After that meeting, CMS endorsed culture change by instructing state Quality Improvement Organizations to improve organizational culture. Since then, more funders have supported the movement—especially the Commonwealth Fund—and the CMS has become more involved by establishing goals relating to the creation of a person-centered culture of care.

Despite the growth in funding and advocacy, however, rigorous evaluations of culture change in peer-reviewed journals have continued to be scarce. Rather, books, case studies, and anecdotal reports tend to be presented as proof of its success. At the same time, numerous culture change advocates have distributed toolkits and guidelines that seem to confer “best practice” status on interventions that have not yet been evaluated empirically.

The authors of the study consider the culture change movement full of innovations that have yet to be tested but do not consider it a sign of weakness; they argue that the movement is mature enough now to withstand critical analysis, and call for a research agenda organized around five questions:

• What are the potential outcomes?
• What care processes are related to these outcomes?
• What factors limit staff ability to implement the intervention?
• What are the staffing costs of implementing the intervention?
• Do all residents, including those with cognitive impairments, benefit from the intervention?

Source: Rahman, A. N., & Schnelle, J. F. (2008). The nursing home culture-change movement: Recent past, present, and future directions for research. The Gerontologist, 48, 142-148.

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