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Let’s Open Our Eyes to the Barriers to Culture Change


Eliopoulos C. Let's open our eyes to the barriers to culture change. Annals of Long-Term Care: Clinical Care and Aging. 2013;21(12):44-45.


Charlotte Eliopoulos, RN, MPH, PhD

Dr. Eliopoulos is executive director, American Association for Long Term Care Nursing, Cincinnati, OH.

Growing numbers of nursing homes are embracing culture change, a movement to create a more homelike environment in these settings; empower residents and staff to have a more active role in care; provide a high quality of life and care for residents; and provide a high quality of worklife for employees. Expectations for culture change are rising among long-term care consumers who, understandably, desire services that address needs holistically and offer a meaningful life for residents. These factors have influenced rising expectations for all nursing homes to adopt principles and practices of culture change.

Although many US nursing homes have expressed interest in culture change, the reality is that only a minority of them have actually taken steps to see it come to fruition. Most of the nursing homes that have implemented formal culture change training programs, such as Eden Alternative (, Green House Project (, and the Wellspring Program, have either been supported by grant funding and/or have had resources beyond Medicaid reimbursement income to contract and support educational programs and environmental modifications. Yet, culture change principles and practices are being promoted and accepted as universally applicable, despite limited research and application within nursing homes that are not representative of the majority. Culture change has even caught the attention of regulators who are interested in integrating more of these concepts into their standards.

Believing that financial limitations and resources should not be a barrier to culture change, the Beacon Institute, the educational arm of the Maryland-based nonprofit LifeSpan Network (, obtained grant support to offer Wellspring programming to a group of Baltimore-based nursing homes that were low-performing (ie, rating of 3 stars or less per the Centers for Medicare & Medicaid Services Nursing Home Compare Website) and had limited resources (primarily Medicaid residents). Of the 33 nursing homes that met the criteria for participation in this project, 10 initially agreed to participate. Reasons for declining participation included: inadequate staffing to enable staff to attend classes; views that their own educational programming was sufficient; determination that they could not add any new efforts to their current activities; and skepticism about culture change, such as believing that the movement is just a fad or that a nursing home without resources beyond standard Medicaid reimbursement cannot realistically support culture change efforts.

I served as the project director of this program, which was called PULL (Provide Understanding, Leadership and Learning). I must confess that I was surprised by the reluctance of nursing homes to participate in the grant. Why would any nursing home with low performance levels and limited resources resist free on-site education and consultation? The lessons learned from PULL helped me gain insight into some of the answers to that question.

Challenges to Affecting Change

In the early phases of PULL, we recognized that the original design to implement the Wellspring Program of culture change had to be modified due to a variety of barriers that we observed, including:

•     Nursing staff lacked a sound clinical and managerial foundation upon which culture change could be built. Baccalaureate and higher degrees are underrepresented among nursing home nurses. More than half of the directors of nursing, who represent the highest position in the nursing department, hold an associate degree or diploma in nursing; fewer than one-third hold a Bachelor of Science in Nursing degree. Certification, which is associated with higher levels of professionalism, is only held by one-third of the directors of nursing and is rare among other nurses in the facility.

•     Basic staffing patterns prevented staff from being able to engage in educational programs for more than 15 to 30 minutes. Minimum staffing levels were provided; none of the participating homes assessed staffing needs based on resident acuity, nor did any homes factor in time for staff education needs.

•     There was insufficient support for education. Leadership in the facilities viewed educational activities as “extras” rather than core activities. Staff time spent engaging in educational activities was not considered a necessary investment to sustain and advance staff competencies, but rather, a burden that interfered with resident care activities.

•     The availability of educational technology was limited. None of the participating nursing homes had LCD projectors, DVD players, computers, or Internet access available to staff for educational purposes.

The few nursing homes that responded well to the programming changes and supported education had one characteristic that set them apart: leadership with vision. Despite having the same challenges as their peers, the administrators and directors of nursing in those homes conveyed the message that they valued education through actions, such as approving overtime for class attendance and holding recognition celebrations when their nurses completed certification programs offered through the grant. In these cases, the leadership’s values permeated the organization.

Addressing the Barriers to Culture Change

Few would argue against the goals of culture change; however, we must be realistic about the barriers to change that support transformation. To begin overcoming these barriers, it may be beneficial to promote the following:

•     Routine efforts to evaluate, develop, and sustain staff competencies (especially important in light of the rising complexity and acuity levels of residents);

•     Realistic staffing levels based on resident acuity and the inclusion of staff educational needs to enssure and sustain competencies;

•     Effective strategies to disseminate to nursing home leadership the research demonstrating the benefits, including fiscal benefits, of investing in staff development;

•     Creative strategies that make education easily accessible and interesting to employees; and

•     Methods to instill a culture of learning in every nursing home so that every staff member understands the need for continued learning.

To transform our nursing homes, we need to invest in education to ensure we have a solid foundation of competent staff on which to build. Of course, this idea is much easier said than done. Turning these words into actions can be achieved with ongoing clinical research projects, such as PULL, and by sharing information with one another about the successes and barriers to culture change so that we may fine-tune the implementation process. For more details about the design and outcomes of PULL, read the full article published earlier this year in Geriatric Nursing.

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