1 introducing resident directed care and nursing home culture change: a case study christine...

1

Introducing Resident Directed Care and Nursing Home

Culture Change: A Case StudyChristine Mueller, PhD, RN, FAAN

University of MinnesotaSchool of Nursing

Mathy Mezey, EdD, RN, FAAN, Sarah Greene Burger, RN-C, MPH, FAAN

Ethel Mitty, EdD, RN Hartford Institute for Geriatric Nursing New York University College of Nursing

Module 5 of Nursing Homes as Clinical Placement Sites for Nursing Students Series

© 2010 The Hartford Institute for Geriatric Nursing and The American Association of Colleges of Nursing

Acknowledgments

This is a joint project of

With support from

Grant to the University of Minnesota School of Nursing


This project is endorsed by:

Project Steering CommitteeView List of Members


About Module 5- Introducing Resident-Directed Care and Nursing Home Culture Change: A Case Study

In a culture change nursing home: assist faculty to structure student clinical experiences

In a traditional nursing home: integrate principals of culture change and resident-directed care into the clinical experience

In both types of nursing homes: collaborate with nursing home staff to create learning experiences that promote student understanding of resident-directed care

Objectives/Purpose:

At the end of this module you will be able to:


Scenario: School of Nursing

Erica Meyers, MSN, BC, RN, is a gerontological clinical nurse specialist on the faculty at Astor University School of Nursing. A recent revision in the curriculum includes a clinical experience for undergraduate students in a nursing home as part of a geriatric nursing course.


Focus of Students’ Clinical Experience

Provide students with opportunities to apply knowledge about geriatric care with a particular focus on the frail older adult

Acquire an understanding of culture change and resident-directed care


Goals for Nursing Home Selection

Erica’s goal is to select 2 nursing homes engaged in transforming from an institutional (traditional) model to a resident-directed care model

In a resident-directed care home:

Care focuses on resident needs, wants, habits and preferences

Students have positive learning experiences and are encouraged to consider a career in long-term care


Goals for Nursing Home Selection

Erica identified all nursing homes in a 25 mile radius of the university by going to the CMS web site Nursing Home Compare, http://www.medicare.gov/NHCompare/

Nursing Home Compare provides information about nursing home quality, including the CMS 5 Star Rating

Click here to view the Nursing Home Compare Website

9


Erica found six nursing homes whose CMS quality ratings varied from 2 to 5 stars. On CMS quality of care and life measures, two homes (Spring Lake and River Shores) ranked higher than other homes in the state and the U.S.

Note: Nursing Home Compare did not provide information about whether or not these nursing

homes were engaged in culture change.

Spring Lake River Shores


Identifying Culture Change Nursing Homes

1

2

3

Identified her state coalition website through the Pioneer Network State Nursing Home Culture Change Coalition http://www.pioneernetwork.net/Coalitions/Websites

Spoke to her state coalition representative

Recorded her findings

To verify if these two nursing homes had a resident-directed care philosophy, Erica:


Erica’s Findings

Spring Lake had been engaged in culture change for 6 years and was well known for their quality of care

River Shores had a good reputation for quality of care with traditional care practices


Evaluating the Culture Change Nursing Home: Spring Lake Web Site

• Spring Lake web site shows that it was designed with neighborhoods* that have:

• Private room and bath for every resident

• Permanent staff focusing on resident preferences and abilities and

• Residents pursuing their individual interests

*Neighborhoods consist of *Neighborhoods consist of : : Small units of 8-20 residents Consistent staff assignment Separate dining and living areas Local (i.e., community) decision making

http://www.innovations.ahrq.gov/content.aspx?id=1906

To view a profile of a nursing home, click on the following link:


Evaluating the Traditional Nursing Home: River Shores Web Site

River Shores web site shows that it provides:

• Care for persons needing medical supervision by licensed nurses

• Help and support for physical and emotional well-being

• A comfortable and supportive environment Availability of 24 hour medical personnel Private and semi-private rooms


Arranging to Visit the Culture Change Nursing Home: Spring Lake

Erica: Hello, Jan. My name is Erica Meyers and I am on the nursing faculty at Astor University. I am interested in having our nursing students learn about geriatric nursing and resident-directed care at Spring Lake. I understand that Spring Lake has been on the nursing home culture change journey for six years.Jan: That is correct, Erica. I am pleased that you know about us and am interested in exploring having nursing students at Spring Lake Erica: Can we arrange a time for me to come to Spring Lake? Jan: Yes, and I’d like you to meet with some of the nursing staff and residents. Erica: I could come next week Wednesday at 2 p.m. Jan: That’s a good time. Every afternoon some residents are planning the meal menus for the next day and baking the dessert for the evening meal.Erica: Great! I look forward to spending time at your residents’ home.

Below is the phone conversation between Erica and Jan Avery, BSN, RN, BC, Spring Lake Director of Nursing


Arranging to Visit the Traditional Nursing Home: River Shores

Erica: Hello, Jan. My name is Erica Meyers and I am on the nursing faculty at Astor University. I am interested in discussing clinical placements for our nursing students at River Shore. Sue: I would be very interested in exploring having nursing students at River Shore. We pride ourselves on our excellent nursing care Erica: We are committed to exposing students to homes with excellent care. We also want students to learn about resident-directed care. Does this philosophy happen at River Shore?Sue: Our leadership team is discussing culture change and plans to introduce it to staff soon Erica: Could we arrange a time for me to come to River Shore? Sue: Yes, and I would like you to meet some of our registered nurses and learn how they assure quality nursing care for residentsErica: I could come next week Thursday at 10am Sue: That’s a good time. I can give you a short tour and you can sit in on nurses’ care rounds for residents at high risk for fallsErica: Great! I look forward to meeting you and your staff and learning more about River Shore

Below is the phone conversation between Erica and Sue Jones, BSN, RN, BC, River Shores Director of Nursing


Helpful Resources in Preparing to Visit the Nursing Homes

These resources helped Erica prepare to evaluate the quality of each home and their involvement in/commitment to resident-directed care

Observable Indicators of Nursing Home quality Instrument (Rantz et al, 2006)* http://www.nursinghomehelp.org/OIQaL.pdf

Artifacts of Culture Change http://www.pioneernetwork.net/Providers/Artifacts/ http://culturechangenow.com/pdf/artifacts.pdf

Resources from the Pioneer Network re: Consistent Staff Assignments ,

http://www.pioneernetwork.net/Providers/Continuum/CareAssign/ Dining Practices, http://www.pioneernetwork.net/Providers/Continuum/Dining/ Bathing Practices, http://www.pioneernetwork.net/Providers/Continuum/Bathing/ Medication Administration,

http://www.pioneernetwork.net/Providers/Continuum/Medication/

Click here to view content on resident directed care and culture change: Module 3: Resident DirectedCare and Culture Change


Visit to the Culture Change Nursing Home: Spring Lake

A resident greeted Erica at the neighborhood door. Erica walked through the neighborhoods observing and talking with staff and residents.

Erica used the resources to evaluate the environment, quality of professional nursing care, and resident-directed care practices.


Visit: Spring Lake

When visiting Spring Lake, these are some of the things Erica saw:


Evidence of Culture Change: Spring Lake

• Neighborhoods had no visible nurses station• Medications kept in the residents’ room; no visible medication carts• Residents could choose what they wanted to eat and could eat

meals on their own time schedule• Food was available 24 hrs/day• Residents’ care plans were called “I-Care Plans,” e.g. care plans in

the resident’s voice and developed together by resident and staff

“I” Care plan example- Clark-Lindsey Village

“I” Care plan example- Riverview Care Center

http://jeny.ipro.org/showthread.php?t=2006

For examples of “I” care plans, see the following links:


Student Learning: Spring Lake

• Erica told Jan about the objectives and content of the geriatric nursing course and resident-directed care

• Jan brought in Lisa Thomas, RN, BSN, BC, coordinator for two of the neighborhoods available to students. Together, they identified potential student learning experiences about resident-directed care.– Students work with nursing assistants to learn how to bathe residents

with dementia – Role of the professional nurse in culture change Click to view Culture Change

background paper

– Students shadow the nurse coordinator to learn about the role of the professional nurse and nursing home culture change

– Students attend meetings as staff plan the day according to the residents’ preferences

– Students participate in an interdisciplinary care meeting with a resident and their family

– Students develop I-Care Plans for their residents Click to view sample I-Care Plan

Click to view article regarding bathing older adults with dementia


Staff Learning: Spring Lake

• Erica discussed the use of evidence-based geriatric nursing assessment and interventions

• Jan & Lisa indicated a desire to educate themselves and staff about evidence-based care

• Erica showed them the website www.ConsultGeriRN.org. She specifically reviewed the:– The Try This® Assessment Series– The How to Try This assessment videos– The AJN Series on How to Try This– Evidence-based Protocols

• Erica shared two examples of student assignments that students will have as part of their experience at Spring Lake


Student Assignment: Resident Assessment - Spring Lake

Example 1: A student conducts a cognitive assessment with a resident using 2 standardized instruments. In the clinical conference, the student will describe:

The purpose of the assessment instrumentThe results of the assessmentThe interpretation of the resultsHow their findings compare with recent MDS and medical diagnoses of the resident


Student Assignment: Observing Resident Behavior - Spring Lake

Example 2: A student observes behavioral symptoms of residents with cognitive impairments. In the clinical conference, the student will

describe: – Observed behavioral

symptoms

– Potential causes of behavioral symptoms

– Effectiveness of strategies that nursing staff used to reduce/minimize symptoms

– Comparison of staff practices used to bathe residents with the nursing literature


Creating a Learning Partnership: Spring Lake

Jan & Lisa were enthusiastic about creating a plan for staff professional development re evidence-based assessment and care.

They proposed:Students conduct a “journal club” for staffStaff review assessments and protocols on www.ConsultGeriRN.org Partnering to develop evidence-based policies and procedures for Spring Lake


Preparing for Student Experiences: Spring Lake

Erica, Jan & Lisa identified how to prepare for student experiences at Spring Lake – Resources to assure that students understood

resident-directed care and culture change– Time for Erica to meet with:

• Staff to explain student rotations• Residents to determine their willingness to have

students assist them with their care


Visit to the Traditional Nursing Home: River Shores

• Erica was greeted by a receptionist at a desk in the foyer area.

• The receptionist paged Sue on the overhead pager. While Erica was waiting for Sue, she talked to several residents who were sitting in the foyer in wheelchairs.

• Several minutes later, Sue greeted Erica and they toured the home.

• Erica observed and talked to nursing staff and some residents during the tour.

• Erica used her resources to evaluate the environment, quality of professional nursing care, and person-directed care practices.


Visit: River Shores

When Erica visited River Shores, these are some of the things she saw:


Evidence of Traditional Care: River Shores

At River Shores, consistent with a more traditional nursing home, Erica observed:

The home arranged in 2 “wings” with nurses station in center and four hallways off the nurses station

Residents dressed and sitting in wheel chairs around nurses station

Two medication carts with nurses administering meds in the hallway and in resident’s rooms

A main dining room and posted mealtimes

Staff smiling and laughing with residents

Nursing assistants offering water to residents

Staff conducting exercises in lounges on each wing


Student Learning: River Shores

Erica told Sue about the objectives and content of the geriatric nursing course and resident-directed careSue brought in Alice Trent, RN, BSN, BC, Asst. Director of Nursing. They had implemented evidence-based care but were very early in introducing resident-directed care.

Together, they identified potential student learning experiences about resident-directed care.

Students review how current nursing care practices for bathing, dining, medication administration, staff assignments will change when River Shore starts to implement resident-directed care

Students develop a model “I” care plan in a resident’s voice


Staff Learning: River Shores

A Learning Circle with staff and students to discuss:

What does “home” mean to you? When you come to a nursing home to live, what will make if a “home” for you?

Click to view guidelines for a Listening and Learning Circle

Students to develop and share their resident-directed “I” care plans with staff Students to start and run a journal club to discuss the article “Bathing the Older Adult with Dementia,”

Nursing staff to receive a copy of the article in advanceLunch served

Erica discussed early steps to introduce resident-directed care. Sue & Alice were enthusiastic to educate themselves and staff about resident-directed care.

Together they agreed to implement the following activities:

Click to view article regarding bathing older adults with dementia


Preparing for Student Experiences: River Shores

Scheduled a time for Erica to meet with:• Staff to explain student rotations• Residents to determine their willingness

to have students assist them with their care

Erica, Sue & Alice identified how to preparefor student experiences at River Shore. Resources will be developed to assure thatstudents understand resident-directed careand culture change.

Learn more about resources for resident-directed care


Recap: Key Points about Introducing Resident-directed

Care and Nursing Home Culture Change: A Case Study

Staff in a culture change nursing home can: assist faculty to select and structure student clinical experiences in resident-directed care

Staff in a traditional nursing home can: learn the principals of culture change and, working with the faculty and students, integrate resident-directed care into the students’ clinical experience

In both types of nursing homes: faculty collaborate with nursing home staff to create learning experiences that promote student understanding of resident-directed care in established culture change nursing homes and in transitioning nursing homes.

We present the following key points to consider:


Please Proceed to the following modules of the SeriesNursing Homes as Clinical Placement Sites

for Nursing Students

Overview of the Project

Module 1: An overview of nursing homes generally

Module 2: An overview of nursing in nursing homes

Module 3: Content on resident directed care and culture change

Module 4: Selecting and structuring clinical placements in nursing homes

Module 5: A case study to help faculty introduce resident directed care and culture change

Module 6: Strategies to help nursing homes position themselves as clinical placement

1 introducing resident directed care and nursing home culture change: a case study christine...

Documents

nursing goals

nursing scenario

nursing acknowledgments

traditional nursing

nursing home quality

nursing home staff

geriatric nursing course

nursing home culture