The Complexity of Implementing Culture Change Practices in Nursing Homes
The culture change (CC) movement aims to transform the traditional nursing home (NH) that is institutional in design with hierarchical management structure into a homelike environment that empowers residents and frontline staff. This study examines differences in adoption of CC practices according to a NH's self-reported extent of CC implementation and its duration of CC adoption. Furthermore, it examines differences in adoption by whether a CC practice is considered less versus more complex, using complexity theory as the theoretical framework for this classification.
Using data from a 2007 Commonwealth-funded study, we analyzed a national sample of 291 US nursing homes that identified as being "for the most part" or "completely" CC facilities for "1 to 3 years" or "3+ years." Also, using a complexity theory framework, we ranked 16 practices commonly associated with CC as low, moderately, or highly complex based on level of agreement needed to actuate the process (number of parties involved) and the certainty of intended outcomes. We then examined the prevalence of CC-associated practices in relation to their complexity and the extent and duration of a NH's CC adoption.
We found practices ranked as less complex were implemented more frequently in NHs with both shorter and longer durations of CC adoption. However, more complex CC practices were more prevalent among NHs reporting "complete" adoption for 3+ years versus 1 to 3 years. This was not observed in NHs reporting having CC "for the most part."
Less complex practices may be more economical and easier to implement. These early successes may result in sufficient momentum so that more complex change can follow. A nursing home that more completely embraces the culture change movement may be more likely to attempt these complex changes.
Available from: Carole A Estabrooks
- "Substantial evidence suggests that residential long term care (LTC) providers’ use of best practices is sub-optimal in Germany [1-7]. Research implementation is complex, challenging and hard to manage [8-10]. Organizational context (i.e., “the environment or setting in which the proposed change is to be implemented”  (p. 150), or–more generally–“the environment or setting in which people receive health care services”  (p. "
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ABSTRACT: To study the association between organizational context and research utilization in German residential long term care (LTC), we translated three Canadian assessment instruments: the Alberta Context Tool (ACT), Estabrooks' Kinds of Research Utilization (RU) items and the Conceptual Research Utilization Scale. Target groups for the tools were health care aides (HCAs), registered nurses (RNs), allied health professionals (AHPs), clinical specialists and care managers. Through a cognitive debriefing process, we assessed response processes validity--an initial stage of validity, necessary before more advanced validity assessment.
We included 39 participants (16 HCAs, 5 RNs, 7 AHPs, 5 specialists and 6 managers) from five residential LTC facilities. We created lists of questionnaire items containing problematic items plus items randomly selected from the pool of remaining items. After participants completed the questionnaires, we conducted individual semi-structured cognitive interviews using verbal probing. We asked participants to reflect on their answers for list items in detail. Participants' answers were compared to concept maps defining the instrument concepts in detail. If at least two participants gave answers not matching concept map definitions, items were revised and re-tested with new target group participants.
Cognitive debriefings started with HCAs. Based on the first round, we modified 4 of 58 ACT items, 1 ACT item stem and all 8 items of the RU tools. All items were understood by participants after another two rounds. We included revised HCA ACT items in the questionnaires for the other provider groups. In the RU tools for the other provider groups, we used different wording than the HCA version, as was done in the original English instruments. Only one cognitive debriefing round was needed with each of the other provider groups.
Cognitive debriefing is essential to detect and respond to problematic instrument items, particularly when translating instruments for heterogeneous, less well educated provider groups such as HCAs. Cognitive debriefing is an important step in research tool development and a vital component of establishing response process validity evidence. Publishing cognitive debriefing results helps researchers to determine potentially critical elements of the translated tools and assists with interpreting scores.
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ABSTRACT: Throughput performance of a multichannel wireless access protocol with non-instantaneous feedback taking into account the effect of bursty packet losses, caused by a correlation in the multipath fading process is analyzed. M equal capacity orthogonal traffic channels are shared by N mobile users (M≤ N) on the mobile-to-base link. Based on the status (busy/idle) of the M receivers transmission attempts are made on the uplink. The BS (base station) broadcast the status in every slot on the downlink (base station-to-mobile link). A first order Markov model is used to describe the correlation in the packet success/failure process on a Raleigh fading channel. Using the above method., analytical expressions for the average throughput per channel are derived for a multichannel wireless access protocol with non-instantaneous feedback. The effects of Doppler bandwidth on the performance of the protocol with and without capture conditions are compared. For fixed values of N the single channel system perform better than the multichannel system, but for a fixed N/M ratio the multichannel system perform better than the single channel system.
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ABSTRACT: A growing number of nursing homes across the country are embarking on culture change transformations that focus on maximizing elder residents' quality of life (QOL). Challenges to culture change implementation include the wide range of possible interventions as well as a lack of research-based evidence to guide these choices. The purpose of this study was to determine those components of nursing home QOL that are associated with elder satisfaction so as to provide direction in the culture change journey.
A cross-sectional study using a survey administered face-to-face.
Three large urban nursing homes within a long term care system in New York State.
Sixty-two elder nursing home residents participated in face-to-face interviews. All elders had resided in their nursing communities for at least 3 months before participation.
The survey included the Quality of Life Scales for Nursing Home Residents, which examines elder QOL in 11 domains: autonomy, dignity, food enjoyment, functional competence, individuality, meaningful activity, physical comfort, privacy, relationships, security, and spiritual well-being. Elder satisfaction with the nursing home and nursing home staff were also examined.
After accounting for cognitive and physical functioning, among the QOL domains, dignity, spiritual well-being, and food enjoyment remained predictors of overall nursing home satisfaction. Additionally, dignity remained a significant predictor of elder satisfaction with staff.
These results provide one possible path in the culture change journey based on empirical findings.
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