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What Does Culture Change Look Like?

The physical environment that is created as a result of culture change is an important part of creating home. However, it is important to understand that the values of culture change—choice, dignity, respect, and relationship—are of primary importance. A facility that focuses only on changing the environment without changing the underlying culture, including the attitudes and roles of leadership and staff, gains little. A resident's daily quality of life and ability to make choices will not be likely to improve through environmental changes only. Using bathing as an example, a beautiful spa-like room is of little benefit if the residents are still bathed on a rigid schedule or against their will. 

To understand what culture change "looks like" it is helpful to look at a few specific examples of long-term care communities that have been on a journey of culture change transformation. However, it is important to recognize that each community might approach culture change differently. Below are some examples of culture change transformations. For additional information about these examples, or to see more examples, click here.

An Example of Culture Change

"The Mount" (Providence Mount St. Vincent), Seattle, WA
The Mount is a continuing care retirement community with assisted living, skilled nursing, sub-acute medical rehabilitation, adult day services, and an intergenerational child care center. The Mount begun their culture change journey in 1991. There were changes throughout the entire community, but we will mostly focus on the changes in the nursing home.

Summary of Changes at The Mount

Four floors of skilled nursing units with approximately 56 beds per unit.Nine 20 to 23 person skilled neighborhoods.
A small centrally-located dining and activity space. Design of spaces physically separated residents and staff.Staff and resident workspaces are no longer segregated. All spaces in community are designed to promote residence independence.
Lack of autonomy for residents in dining, bathing, activities and daily schedules. Staff were task driven and organized work around delivery of care and
staff preferences.
Activities are meaningful. Residents maintain personal schedules based on preferences. Resident choice is documented in the care plan.
Staff-resident interaction not a priority.
Consistent assignment of residents with care assistants. Staff are cross-trained and able to help residents with multiple requests.
Language supported a culture of dependence (e.g. "patient," "ward," "floor" and "unit"); Residents identified by medical conditions or level of care.Work is organized around maintaining resident's autonomy and preferences with inclusive language supporting residents to be "known" as individuals instead of medical conditions.
Centralized departments (departments are "silos" with significant hierarchy).A relatively flat organizational structure with the resident at the top of the organizational chart is prioritized. Employees feel empowered to help control quality, waste, and problem-solve throughout the community.

The photos below show elements of the physical environment at The Mount, prior to culture change, that took away a sense of home for residents and staff. The following institutional examples are evident in the pictures:
  • Institutional sterile environment (modeled after a hospital environment)
  • Long halls and hard surfaces
  • Floor, wall and ceiling materials designed for durability and ease of maintenance (but without aesthetics or warmth)
  • Tight spaces clogged and crowded with people and equipment
  • A small centrally located dining and activity space

Before Culture Change Started at The Mount

After Culture Change Started at the Mount

After culture change started, several common themes, shown in these "after" pictures, created a sense of home and relationship for residents and staff.  They included residents living in small neighborhoods rather than long institutional halls, rooms that were more personalized, small kitchens in the neighborhoods that stocked residents' favorite snacks and drinks, smaller dining room tables so people could talk to each other during meals, and smaller "care stations" in which staff were not segregated from residents.

"I like the fact that they allow you so much independence. That this isn't a facility. This is home. The people here are so friendly. There are so many little touches. They just think of everything."

Resident of Nursing Neighborhood
The Mount has seen many positive effects from their culture change transformation. They include:
  • High resident satisfaction
  • High staff satisfaction
  • The Mount maintains close to a 100% occupancy rate (the average occupancy rate is about 87%).
  • There have been improvements in clinical care outcomes (for example, fewer residents with catheters, less residents with weight loss, fewer pressure ulcers).
  • The turnover rates decreased from 50% to 15-18%.
  • Improving turnover rate and retaining staff amounted to nearly 2 million dollars in savings from 2000-2008. 

Other Examples of What Culture Change "Looks Like"

Cornerstone Residence, Kelliher, MN

Jewish Home, Rochester, NY


These pictures show residents enjoying life, and the relationships they have with each other and their caregivers. These pictures were shared by Teresian House in Albany, NY. Residents being supported to live their lives in meaningful ways is the most important part of culture change.

Take a Virtual Tour!
Click here to take a virtual tour that highlights ten key areas of a nursing home with ideas about how each of these areas can be transformed to "create home."
Note: Some of these pictures may appear grainy or blurry. This is due to their low resolution. They have not been altered but are in the original format we received from long-term care communities. As "candid" photos that were taken by the communities themselves, they genuinely represent culture change transformations.

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