FEATURE ARTICLE

Culture-Change Training: Nursing Facility Staff Perceptions of Culture Change

Donna J. Munroe, PhD, RN Poonam L. Kaza, MBBS, MPH David Howard, MHA

Identifying effective alternative strategies for training staff and implementing culture change can be useful to nursing facilities striving to provide optimal resident-centered care. This study assessed the perceptions of nearly 400 nursing facility staff experiencing organizational culture change. Formal and informal training methods were used. We used a pre- and post-test to evaluate leadership practices and 6 subscales related to culture change (systemwide culture change, resident choice, organization design, empowering supervision, job design, decision making, and permanent assignments). Staff of formally trained facilities perceived improvements in all subscales; 2 were statistically signicant (resident choice and organization design). Respondents for informally trained facilities identied improvement in decision making, although this was not statistically signicant. Formalized culture-change training produced better outcomes than did the informal strategy. Culture change is a complex process and may continue to evolve over time. A 3-year evaluation period may be insufcient to demonstrate the full extent of these changes. (Geriatr Nurs 2011;32:400-407) he subject of culture change in nursing facilities was the focus of a front page story in a major metropolitan newspaper in July 2010.1 The story promoted culture change, using examples such as letting residents decide when to bathe, eat and sleep; allowing them to organize their own activities; and redesigning nursing units into small households (pp. 1e2). Although an important human interest story with a positive perspective on nursing facilities (which is rare), this view of culture change seems supercial. Nursing facilities are seen as bureaucratic organizations in which decisions are made at

administrative levels and as environments with long uncarpeted hallways, dull interiors, semiprivate rooms, large dining rooms, and minimal spaces for residents to congregate.2,3 Public perception of life in a nursing facility is equated with losing freedom, identity, and individuality and with depending on others to make decisions.4 The history of culture change as chronicled by Rahman and Schnelle5 goes back to the early 1990s, with Dr. William Thomas introduction of Eden Alternative6 creating a Human Habitat to increase interaction among residents by using plants, animals, and children.7 The Wellspring Model, founded in 1994, focuses on clinical nursing care, staff training, interdisciplinary resource teams, and resident outcome data.8 The Pioneer Network, founded in 1994, supports the creation of living environments based on strong, loving relationships and emphasizes resident and staff interaction.9 Discussion about culture change has gained momentum over the past decade. However, the movement has not been widespread.5 The principles of resident-choice,10 decentralization, and greater control given to the front-line staff for care delivery11 are widely known. However, achieving culture change in nursing facilities requires commitment and extensive training of administrative and frontline staff. The implementation of culture change typically involves the use of consultants and extensive staff training, which is time- and resource-consuming and a challenge to sustain.12 Nursing facilities seek strategies for culture change that make good use of limited nancial resources. In addition, nursing facility administrators want to ensure that the strategies used are effective for initiating and sustaining culture change. There is little in the literature that documents the evaluation of culture change in nursing facilities. The time-consuming process of culture change may be one barrier to evaluation. A 1-year study of a nursing facility that adopted the Eden Alternative reported no positive effect

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on resident mortality, functional status, or cognitive status.13 One year may not be a sufcient length of time to observe changes in these outcomes. Another barrier is identifying the appropriate outcomes to evaluate. In the previous study, some might argue that these outcomes (mortality, function, cognition) are less likely to achieve positive change for a population of frail residents. The evaluation of the Wellspring Model found lower rates of staff turnover, performance improvement on federal survey, low cost, and a better quality of life for residents in these facilities.8 However, the evaluation team acknowledged that their preintervention data were drawn from historical documents and interviews, and ongoing changes within the organizations during the study period may have confounded their ndings. Another study identied a decrease in number of deciencies on state inspection.14 The author suggested that this nding represents improved quality of care. However, many argue that meeting minimum state requirements is not true quality. Sterns et al.15 found that implementation of simple culture-change practices (such as personalized resident bedtime and bathing practices) are more likely to be adopted than more complex practices (eliminate nurse stations, develop small neighborhoods). However, this study did not examine resident outcomes from these types of changes. Rahman and Schnelle5 noted that without evidence from research, it is difcult to encourage nursing facility providers to adopt change strategies. The challenges to implementing and sustaining culture change are consistent with theories of diffusion of innovation.16 Acquisition of knowledge about change is one phase. However, diffusion involves the spread and adoption of new ideas, techniques, behaviors, or products throughout an organization.17 Rogers16 noted that there is a 49% to 87% variance in the rate of spread of an innovation within an organization, which is related to perceptions of those affected by the change. Perceptions are driven by key personnel. Berwick18 indicated that the role of leadership in the process is critical. Adoption of change is facilitated when the innovation is perceived to be consistent with the values of the organization and its staff. Jippes et al.19 found that social networks among those affected by the change are inuential in understanding the change process and eventual adoption of the change. Furthermore, Berwick18 observed that the change is often reinvented within the Geriatric Nursing, Volume 32, Number 6

organizationdnot as a form of resistance but as a way to align the change process with existing values of the affected groups. In summary, knowledge, spread (diffusion), and perception are key factors in implementing change. The cost of training and implementation of culture change is signicant, both in terms of the process (e.g., hiring consultants vs. developing and distributing an in-house curriculum) and the resource commitments of personnel for the training. Identifying effective alternative strategies for training staff and implementing culture change can be useful to nursing facilities striving to provide optimal resident-centered care. Given the limited evaluation data as to the success and sustainability of culture-change initiatives, we evaluated a demonstration project that was designed to test a dual-model culture-change processdformal and informal culture-change training. We anticipated that the social networking between formally and informally trained staff would positively affect staff perceptions of culture-change implementation in all facilities. There were 3 research questions: 1. Are there improvements in staff perception of culture-change implementation for facilities (Formal) that participated in formal training for culture change? 2. Are there improvements in staff perception of culture-change implementation for facilities that received informal training (Informal) by the staff members who received formal training? 3. Are there differences in staff perception of culture-change implementation between Formal and Informal facilities?

Methods
Design This was a quasi-experimental study using pretestepost-test design. The interventions were formal culture-change training for Formal facilities by Action Pact, Inc., and informal culture-change training by leadership and staff members of Formal facilities to Informal facilities. Interventions Formal Training. Training for the Formal facilities was conducted by Action Pact, Inc. This 401

training began in May 2006 and continued until October 2007. Intermittent consulting with Action Pact staff occurred until April 2008. Over this 20-month period, 10 sessions of training were conducted to educate facility leadership and key staff members of each of the 2 facilities. According to Action Pact Inc., culture change involves 6 phases: the study circle, the study phase, the design phase, skills assessment and development, team development, implementation, and evaluation.20 The latter 3 (skills assessment and development, team development, and implementation) are the focus of the Action Pact training process. Skills assessment and development involves the creation of an environment that will allow leaders to learn and nurture. During this phase, the skills are learned and applied to their environment. This training is in the form of classroom teaching and small-group activities. Topics addressed in the training are found in Table 1. Team development involves changing the original traditional institutional nursing facility into a more homelike place. This involves changing the facility structure to create households, neighborhoods, or cluster homes. During this phase, various ex-

isting staff members are assigned to these new neighborhoods and work consistently with the residents there. Implementation is the main phase of culture-change training. This phase involves implementation of the changes learned and continued work toward attaining the goal of culture change. In this phase, the change evolves through the development of new job descriptions, assignments, reporting structures, policies, and procedures. This implementation is a collective process involving administrative and key staff, along with resident and families.21 Informal Training. The 2 Informal facilities participated in informal culture-change training. This was conducted and supervised by an administrator of a Formal facility. This training began in early 2007 and continued through the end of 2008. Administrators and the assistant administrators of the 2 Informal facilities also attended a weeklong training by Action Pact. Training materials from Action Pact were used by Formal leadership for orientation and staff training in Informal facilities. In addition, key staff personnel of the Formal facilities interacted with their counterparts in Informal facilities to help facilitate the implementation of specic culture change efforts.

Table 1.
Topics for Leadership and Team Training in Culture Change
Theme The Challenges of Leadership Topic Shared leadership Values of leadership Phases of culture change Factors to create home Three Rs of culture change High-involvement techniques Theories of adult education, change, attitude Storytelling Person-centered care Person-centered care skills Personal leadership skills Team awareness Physical design Organizational reframing High involvement Person-centered care planning process Team awareness Organizational design Workplace opportunities People and process skills development Team development and maintenance

Homelessness to Home

Creating a Learning Climate

The Kitchen Is the Heart of the Home

Renovating into Home

Holistic ViewdNursing, Social Work, Therapies and Activities Reframing the Organization PersonFirst

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Evaluation Sample. A convenience sample of 4 facilities was selected for this demonstration project by the administrative team of a multifacility health care corporation. Formal facilities were selected because the leadership and staff of these facilities expressed interest in the culture-change movement and were in initial stages of exploring the potential for implementing culture-change strategies. Informal facilities were selected because their demographic characteristics were similar to the Formal facilities, and they were geographically close to a Formal facility, which would facilitate the informal training. The facilities averaged 128 beds (range, 73e179) and 165 employees (range, 111e225). All facilities were in suburban locations within 150 miles of the corporate ofces of the organization. Formal facilities averaged 127 beds and 165 employees; Informal facilities averaged 126 beds and 175 employees. One-hundred ninety-nine staff responded to the baseline survey, and 198 responded at follow-up. The majority of respondents were nursing assistants, food service workers, and housekeeping personnel who had worked for the facility more than 1 year but fewer than 10 years. The respondents were predominately female and white and had high school degrees. These characteristics were similar for all facilities at baseline. The characteristics of the follow-up samples for all 3 groups were similar. Total staff turnover in all facilities averaged 10% over the study period. Measures. Primary data were collected using the Leadership Practices and Culture Change Survey,22 which assesses nursing facility staff perceptions of the progress of culture change within their organization. The tool focuses on leadership and 6 subscales related to culture change (systemwide culture change, resident choice, organization design, empowering supervision, job design, and decision making) and was developed for a previous study of culture change and leadership development.23 Grant reported Cronbachs alpha ranging from .80 to .97 for these 6 subscales.23 For the current study, we found similar reliability scores for these subscales. We distributed the survey to all personnel in the Formal and Informal facilities. Questionnaire packets included an informational letter, informed consent document, questionnaire, and a sealable Geriatric Nursing, Volume 32, Number 6

envelope marked condential and addressed to the rst author (DM) and were distributed on payday. The informational letter indicated a central location in the facility where a secure box was labeled to accept the completed questionnaires. The facility then shipped the secure box to the rst author. Some individual questionnaires were also posted by the staff member and mailed separately. Baseline data were collected in 2006; follow-up data were collected in 2008. Protection of Human Subjects. Research procedures and instruments were approved by the institutional review board of a midwestern university and the institutional review board of the health system that sponsors the 4 nursing facilities that were included in the study. Data Analysis. Quantitative analyses included descriptive and inferential statistics. The analysis of variance methodology was used, implemented by a procedure (generalized linear model [GLM]) through the SAS statistical package.24 The GLM procedure was used to construct the comparisons of scores at different time points. The scores are the dependent variables, and the sites are the independent variables.

Results
Results are described according to the research questions. All staff members at Formal facilities were asked to complete the Leadership Practices and Culture Change Survey22 at baseline (February 2006) and follow-up (January 2008). Staff members of Informal facilities completed the baseline survey in September 2006 and the follow-up survey in May 2008. For all facilities, the return rate was 29% at baseline and 30% at follow-up. Research Question 1: Are there improvements in staff perception of culture change for facilities (Formal) that participated in formal training for culture change? Table 2 provides descriptive statistics for all the culture-change subscales from the Leadership Practices and Culture Change Survey22 at baseline and follow-up. Table 3 shows the comparison of baseline and follow-up scores for the culturechange subscales for Formal facilities. Although all subscales showed improvement from baseline to follow-up, only 2 were statistically signicant, Resident Choice (t 5 4.41, p 5 .037) and Organization Design (t 5 6.83, p 5 .009). There was an 403

Table 2.
Culture-Change Subscales for Facility Staff Survey
Formal Variable Baseline Leadership Systemwide Cultural Change Resident Choice Organization Design Empowering Supervision Job Design Decision Making Follow Up Leadership Systemwide Cultural Change Resident Choice Organization Design Empowering Supervision Job Design Decision Making n 106 106 105 104 103 103 104 114 114 114 113 114 114 113 M 3.83 3.94 4.00 3.3 4.0 3.6 3.53 3.94 4.05 4.18 3.6 4.04 3.83 3.54 SD 0.99 0.89 0.66 0.77 0.97 1.07 0.98 0.82 0.74 0.63 0.92 0.83 0.93 0.86 n 93 93 92 93 93 93 93 84 84 84 84 83 83 83 Informal M 4.00 4.09 3.75 3.3 4.09 3.8 3.34 3.93 4.02 3.66 3.29 3.87 3.81 3.46 SD 0.63 0.59 0.66 0.69 0.81 0.94 0.96 0.79 0.73 0.83 0.83 0.95 0.92 0.92 p .177 .600 .009 .887 .568 .117 .174 .920 .069 .000 .018 .191 .860 .56

interesting anecdotal nding at follow-up. For 1 of the Formal facilities, several individuals indicated their position both in traditional terms (e.g., certied nursing assistant, housekeeper) and also wrote in roles associated with the culturechange training (e.g., neighborhood coordinator). Research Question #2: Are there improvements in staff perception culture change for facilities that received informal training (Informal) by the staff members of Formal facilities? Table 2 provides descriptive statistics for all culture-change subscales from the Leadership Practices and Culture Change Survey22 at baseline and follow-up. Table 4 shows the comparison of baseline and follow-up scores for the culture-change subscales for Informal facilities. Only 1 subscale, Decision Making, showed improvement from baseline to follow-up, but this was not statistically signicant. Research Question #3: Are there differences in staff perception of culture change among Formal, Informal, and the comparison facilities? Table 2 compares Formal and Informal facilities on the culture-change subscales. At baseline, 404

Formal facilities scored signicantly higher on Resident Choice (M 5 4.00) than did Informal facilities (M 5 3.75, p 5 .009). At follow-up (Table 2), Formal facilities scored higher that Informal facilities on all the subscales. Formal facilities scored signicantly higher on Resident Choice and Organization Design than did Informal facilities.

Discussion
The results of this multiyear evaluation provide an interesting picture of the evolution of culture change in 4 facilities of a multifacility organization. The culture-change training occurred in 2 modes. Formal facilities received formal training in culture change from a consultant group. Informal facilities received culturechange training from personnel from 1 Formal facility. The expectation was that the critical aspects of culture change could spread from a formally trained facility to other facilities using key personnel, strategies, and interactions, which is consistent with diffusion of innovations13 and social networking.16 We found the results of the Leadership Practices and Culture Change Survey22 to be quite positive for Formal facilities. Although only 2 subscales were statistically signicant, all subscales related Geriatric Nursing, Volume 32, Number 6

Table 3.
Culture-Change Subscales for Formal Facilities at Baseline and Follow-Up
Baseline M Leadership Systemwide Cultural Change Resident Choice Organization Design Empowering Supervision Job Design Decision Making 3.84 3.76 4.00 3.37 4.01 3.60 3.53 Follow-Up M 3.94 3.92 4.18 3.62 4.04 3.83 3.54 df 1 1 1 1 1 1 1 f 0.75 2.71 4.41 6.83 0.05 2.74 0.01 p .39 .1015 .0368 .0096 .8189 .0991 .9328

to culture change showed improvement for these formally trained facilities. If we consider culture change to be a long-term process, the improvement over this 3-year demonstration period is acceptable for the early phases of change. One would expect that these subscales might continue to improve in subsequent years. In addition, the individuals who anecdotally indicated both traditional and culture change roles on their follow-up survey may be evidence of culture change success for 1 of the Formal facilities. These ndings seem to support that formal culture-change training can improve the perceptions of staff about culture change. Formal training that includes knowledge and team development can support the spread of change through social networking.16 This is consistent with the conclusions of Robinson and Rosher,3 who indicated that culture change consultants can also help administration view their roles and relationships with staff and residents differently.

It seems that the strategy to spread culturechange training from Formal to Informal facilities was not as effective as hoped. For Informal facilities, only 1 subscale (Decision Making) showed improvement from baseline to follow-up, and this nding was not statistically signicant. It may be that the process of spread takes much longer to effect change than the formalized culture-change training. Knowledge delivery is an important aspect of diffusion that may have been less effective in informal training.

Limitations
Our evaluation focused on a limited sample of 4 facilities of a multifacility organization. In addition, our ndings may be inuenced by the culture of the organization. The evaluation data focused on staff perceptions about culture change. In the resident-centered environment,

Table 4.
Culture-Change Subscales for Informal Facilities at Baseline and Follow-Up
Baseline M Leadership Systemwide Cultural Change Resident Choice Organization Design Empowering Supervision Job Design Decision Making 4.00 3.81 3.75 3.38 4.09 3.83 3.34 Follow-Up M 3.93 3.74 3.66 3.36 3.87 3.807 3.46 df 1 1 1 1 1 1 1 f 0.39 0.61 0.64 0.03 2.58 0.03 0.78 p .53 .4353 .4256 .8609 .1101 .8531 .3789

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the perceptions from residents and families would be important data to obtain. The perceptions obtained at baseline were from a group of staff members that may have changed by the time follow-up data were collected. The modest turnover rate for these facilities (10%) and the size of our staff sample may offset these concerns.

Conclusion
This evaluation of culture change adds to the limited literature on this topic. This study differs from previous ones in that it was prospective and multiyear. For this demonstration project, formalized culture-change training produced better culture-change outcomes for the participant facilities than did the less formal spread strategy. This may be due to several factors. First, there was no predescribed procedure for conducting the culture-change training in Informal facilities. Key personnel in Formal facilities developed the procedures and methods incrementally while they planned visits to the Informal sites. The experience of the Formal personnel, however, could now produce a more formalized process for conducting the spread in the future. Second, the implementation of the spread of culturechange training was related to the amount of time key personnel (administration, core team members, steering team members) from Formal facilities could devote to this activity. Overall stafng in nursing facilities is streamlined, and it may be inappropriate to expect that key personnel could assume additional duties over a long period of time. Furthermore, if these additional duties are an expectation, they should be documented in job descriptions and evaluated in periodic performance appraisals. Third, it seems that this spread process needs a dedicated person to oversee and conduct the training activities. This role might be a more centralized position, rather than expecting a current facility leader to assume these responsibilities. This culture-change training strategy was implemented in a multifacility organization that has a rich tradition of interfacility communication and sharing of best practices. This organizational structure may have reduced the differences among the 2 sets of facilities. The usual and customary communication venues (meetings, quality improvement initiatives, etc.) may have resulted 406

in the adoption of culture-change practices for all facilities. Further study with independent facilities is necessary to determine whether the spread strategy would have an effect on facilities that do not have the same type of communication venues Finally, the process of culture change is not a rapid one. There may be changes in the leadership and culture change subscales that are yet to occur and were not identied during this 3-year evaluation period.

References
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23. Grant LA. Culture change in a for-prot nursing home chain: an evaluation. The Commonwealth Fund, 2008, February. Available at http://www.commonwealthfund. org/Content/Publications/Fund-Reports/2008/Feb/ Culture-Change-in-a-For-Prot-Nursing-HomeChaineAn-Evaluation.aspx. Cited June 6, 2011. 24. Bowerman BL, OConnell RT. Linear statistical models: an applied approach. 2nd ed. Boston: PWS-Kent; 1990. DONNA J. MUNROE, PhD, RN, is a Professor in the Nursing Program at Northern Illinois University School of Nursing and Health Studies, DeKalb, IL. POONAM L. KAZA, MBBS, MPH, is a Staff Research Associate II, Posttraumatic Stress Disorder Research Program, San Francisco VA Medical Center/Northern California Institute for Research and Education, San Francisco, CA. DAVID HOWARD, MHA, is Vice President of Nursing Home Operations, Advocacy Program Director, Provena Life Connections, Rockford, IL. ACKNOWLEDGMENTS This work was supported by the Retirement Research Foundation (Grant No. 2005-273). 0197-4572/$ - see front matter 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2011.07.001

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