Joan Devine, RN-C
Culture change. It is something that is talked about a lot in long term and post-acute care (LT/PAC) these days, and it is central to the vision of Pioneer Network: “A culture of aging that is life-affirming, satisfying, humane, and meaningful.”

What exactly are LT/PAC centers trying to achieve through culture change? At its heart, it is hearing and respecting the elder’s voice and honoring individual choice. Both are central themes supported by the implementation of person-centered practices. Sometimes, however, even the best ideas can go amiss if they are not handled the right way.

Honoring Choice

Some staff have interpreted person-centered care and taken the value of the elder’s choice as an “anything goes” mindset, believing that they “need to let the elders do whatever they want,” no matter the potential consequences. This approach to person-centered care is what has caused some people to see those engaged in culture change and promoting person-centered care as “free spirits” who go about each day with an ideal and no plan beyond “just make life better by doing whatever people want.”

It’s not that easy. Life is not a free-for-all, and neither is the culture of aging that Pioneer Network advocates. In a civilized world, everyone is governed by rules and regulations. That is no different for the world of elders. No one always gets everything exactly as they would like it in their lives and homes, and that does not change with age.

An example of this in a nursing center might be an elder who perhaps practiced nudism in their own home. Being able to continue that practice anywhere in a place shared with others would not be appropriate, but there can be designated locations or times that could be identified to support the resident’s desire and still respect others’ values and preferences.

There is consensus and compromise every day as people defer to the greater good and respect standards that are in place to protect them and those around them. Those in paid or unpaid positions caring for elders strive to honor their preferences in a thoughtful, ethical manner and to maintain high standards.
Take for instance the elder who is at risk for falling yet wants to be independent and not wait for help. The team would work with him/her to define the specific desires and goals that drive the elder’s preference to walk independently and, together, determine approaches that blend safety with preferences.

Need for Appropriate Framework

The founders of Pioneer Network understood that the future they envisioned of person-centered care for elders would require a lot of work, and they knew that this vision would not be realized by passion alone.
Dynamic and passionate individuals can, and often do, initiate and achieve incredible changes in organizations. They may drive the building of beautiful new household environments and implementation of many person-centered practices.

However, without systems and processes to support the changes they put in place, these practices can be gone in the blink of an eye if that passionate person leaves the organization. The passion that ignited this change, if not supported by a process, can be quickly extinguished.

An administrator may believe that elders have the right to take risks, but that belief needs to be backed up with processes and systems. The processes would be focused elder assessment and care planning with the elder. Systems would include dedicated staff assignments; inclusion of all staff in the assessment and care planning process; and acquiring tools, equipment, and resources to support the residents’ preferences. Both processes and systems help guide the care team in defining, analyzing, and developing plans to mitigate risk and support preference.

Person-centered Care Versus Culture Change

A care center can implement a lot of person-centered practices without changing its culture, and while this is a good thing, it will not ultimately get the center to its vision of culture change.

Person-centered practices are the basis of what individuals do to change the culture of an organization and the culture of aging. This includes changing the thinking and the behavior of people. While those who implement person-centered practices are very passionate, it takes more than just passion.

Culture change is the why and the how. One needs to understand the “why “and have clear direction about the “how” in order to redesign the center’s processes and reinvent its relationships. The center needs to grow leadership and the shared values that make all decisions based on the why and the how, not just the what.

To demonstrate the difference between person-centered care practices (the “what”) and culture change (the “how” and “why”), consider the following.

In the institutional model, elders are woken up each morning based on a “get-up” list, while in a person-centered care practice, elders are supported to get up based on natural awakening and individual choice.

In this case, staff are helped to see the importance in their own lives of adequate sleep and the choice of rising time, which can then be transferred to an understanding of the same for the elder. In the institutional model, staff used the get-up list in the name of efficiency, and because the director of nursing (DON) told them to. The understanding and appreciation of “why” were missing. It’s “what” they were told to do.

If, in the person-centered practice, the DON holds a singular vision for a changed practice, the staff may also do it “because the DON told us to.” If she/he was the only one who had the passion that drove this practice, and who understood the value and the positive outcomes for the elders, and staff are accountable only for doing “what” they were directed to do, then the community may have achieved a person-centered practice, but this is not culture change.

Making Culture Change Happen

Only when the reason the staff support an elder’s choice is based on their universal understanding of how choice is the individual’s right, and the staff truly respect the choice and ability of all elders to control their own lives, is it undertaking culture change. In this case, staff carry out the practice because they understand and believe in the “why” and have a process to support the “how.” Only when the center has redesigned the systems and processes to support the practice of natural awakening will the “practice” sustain a change in the culture.

Systems must include consistent and vision-based staff development, an organizational structure that supports staff in knowing and honoring individual preferences, processes for communication (including how to practice critical thinking and decision making that will allow staff to accomplish the daily tasks that must be done without compromising choice), and respecting each elder’s choice while balancing risk.

Embrace Change

So the next time a passionate staff member who has just read an article or seen a video about the possibilities that exist through person-centered practices is fired up to make changes, embrace their passion. Then help them to develop systems and processes to ensure that staff are truly embarking on a culture change journey, creating sustainable and long-lasting changes in the quality of life for elders and the quality of work life for staff.
Resources Available
Pioneer Network has many free resources on to help organizations build the foundation for culture change. These include:
■ Engaging Staff in Individualizing Care: An Implementation Handbook, which was developed based on the lessons learned from Pioneer Network’s National Learning Collaborative;
■ A Process for Care Planning for Resident Choice, sponsored by the Hulda B. & Maurice L. Rothschild Foundation, a tool to support long term care communities in honoring residents’ choices that influence quality of care and quality of life, while mitigating potential risks associated with those choices; and
■ The New Dining Practice Standards, which were the outcome of a symposium hosted by Pioneer Network and the Centers for Medicare & Medicaid Services. Participants included providers and experts from all aspects of senior services, resulting in nationally agreed-upon food and dining standards of practice that support individualized care and self-directed living versus traditional diagnosis-focused treatment for people living in skilled nursing care centers.
Joan Devine, RN, is director of education at Pioneer Network. She can be reached at