What Does the Evidence Really Say About Culture Change in Nursing Homes?

Shier, Victoria; Khodyakov, Dmitry; Cohen, Lauren W.; Zimmerman, Sheryl; Saliba, Debra

doi:10.1093/geront/gnt147

Cited by 107 publications

(104 citation statements)

References 31 publications

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“…29,30 Despite providing care to many at EOL, NHs largely focus on rehabilitation and restoring function. 31 Facilitating conversations about EOL contradicts this focus.…”

Section: Discussionmentioning

confidence: 99%

Conversations about End of Life: Perspectives of Nursing Home Residents, Family, and Staff

Towsley

Hirschman

Madden

2015

Journal of Palliative Medicine

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Background: Care in nursing homes (NHs) often overlooks individual values and preferences. Residents' voices are critical to discussions about preferences, yet there remains limited research on conversations about the end of life (EOL) from the perspective of older adults who reside in NHs. Objective: The aim of this study was to describe the communication, content and process, related to EOL conversations among residents, family, and staff. Methods: We used semistructured interviews in this qualitative, descriptive study to describe conversations about EOL preferences. We examined participants' conversation, when it occurred, and what was discussed. We queried about barriers to and facilitators in discussing EOL care in the NH setting. We interviewed residents (n = 16), family (n = 12), and interdisciplinary staff (n = 10) from four NHs. Results: The overarching theme-missed conversations-describes EOL-related communication. Residents, families, and staff rarely talked about EOL care preferences, nor did they pass along information about preferences or initiate conversations about EOL care with each other. Three categories explained missed conversations: inquiry (''No one asked''); assumptions (presence of an advance directive [AD], ''They know me''); and conveying (lack of conveying information or wishes). Existing barriers and lacking facilitators resulted in missed opportunities to hold conversations about EOL preferences. Conclusions: Not all residents wanted to have conversations, but many wanted to be asked about their preferences. Missed conversations may adversely affect the quality of EOL care. Conversations with residents can be initiated by asking residents who they would like involved in the conversation and drawing upon the experience of others.

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“…29,30 Despite providing care to many at EOL, NHs largely focus on rehabilitation and restoring function. 31 Facilitating conversations about EOL contradicts this focus.…”

Section: Discussionmentioning

confidence: 99%

Conversations about End of Life: Perspectives of Nursing Home Residents, Family, and Staff

Towsley

Hirschman

Madden

2015

Journal of Palliative Medicine

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“…Previous work described the association between quality of care and staffing patterns, 41e44 and quality of care and designation as a successful "culture change" site, 45,46 as well as the importance of nursing homes as an end-of-life setting. 4,38,43,47 However, no reports have focused explicitly on associations between organizational context and symptom burden or trajectories of symptom burden in the last year of life.…”

Section: Practice and Policy Implicationsmentioning

confidence: 99%

Dying in a Nursing Home: Treatable Symptom Burden and its Link to Modifiable Features of Work Context

Estabrooks

Hoben

Poss

et al. 2015

Journal of the American Medical Directors Association

101

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Symptom burden increases as the end of life approaches but differs between high- and low-context facilities and between residents with and without dementia. Trajectories of treatable, burdensome symptoms at the end of life in nursing homes should be a priority focus for quality improvement. Modifiable features of organizational context that are linked to symptom burden offer new potential strategies and interventions for quality improvement.

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“…Some studies have identified adverse outcomes of culture change, such as a heightened fall risk among residents, 18, 19 but it does not appear that culture change practices lead to significant negative outcomes. 3 …”

Section: Introductionmentioning

confidence: 99%

Does the Introduction of Nursing Home Culture Change Practices Improve Quality?

Miller¹,

Lepore

Lima³

et al. 2014

J American Geriatrics Society

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Objectives To understand whether nursing home (NH) introduction of culture change practices is associated with improved quality Design NH-level panel study using multivariate fixed-effects statistical modeling to estimate the effect of culture change introduction on quality outcomes Setting and Participants 824 U.S. NHs with culture change practice involvement beginning between 2005 and 2010 Measurements A culture change practice score (derived from a 2009/10 national NH survey) was used to stratify analyses by NHs with high practice implementation (scores in the top quartile; n=217) versus other NHs (n=607). NH-level outcomes included 1) prevalence of seven care practices and three resident outcomes; 2) a NH’s health-related and quality-of-life weighted survey deficiencies; and, 3) the average number of hospitalizations per resident year. Results For NHs with high practice implementation, introduction of culture change was associated with a significant decrease in the prevalence of restraints, tube feeding and pressure ulcers; an increase in the proportion of residents on bladder training programs; and, a small decrease in the average number of hospitalizations per resident year (coefficient −0.04, standard error (SE) 0.022; p=0.06). For NHs having lower practice implementation (practice scores in lower-three quartiles), introduction was associated with fewer health-related (coefficient −5.26; SE 3.05; p=0.09) and quality-of-life (coefficient −0.10; SE 0.049; p=0.04) survey deficiencies. However, these NHs also had small statistically significant increases in the prevalence of residents with urinary tract infections and in the average hospitalizations per resident year (coefficient 0.03; SE 0.014; p=0.02). Conclusion The introduction of NH culture change appears to result in significant improvements in some care processes and outcomes in NHs having high practice implementation. For other NHs, culture change introduction results in fewer survey deficiencies.

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What Does the Evidence Really Say About Culture Change in Nursing Homes?

Cited by 107 publications

References 31 publications

Conversations about End of Life: Perspectives of Nursing Home Residents, Family, and Staff

Conversations about End of Life: Perspectives of Nursing Home Residents, Family, and Staff

Dying in a Nursing Home: Treatable Symptom Burden and its Link to Modifiable Features of Work Context

Does the Introduction of Nursing Home Culture Change Practices Improve Quality?

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