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The Basics of Promising Practices

Building Blocks of Culture Change: Tools and Resources









About Culture Change

What is culture and culture change? "A culture is a pattern of shared basic assumptions that have been learned by the members of their group. These assumptions stem from people's experience, as they conduct their business over and over again. Cultural assumptions provide meaning to daily events for people inside a group; they make life predictable and therefore reduce anxiety. They are taught (in both explicit and tacit ways) to new group members as the "correct" way to perceive, think, and feel about aspects of daily life.[1]

As applies to the nursing home, the term culture change has come to mean a journey that many homes are finding necessary; a journey of self-assessment, learning, and finding ways to improve resident quality of life and care by improving resident autonomy and choice in areas of life such as bathing, eating, activities, and any aspect of life over which a resident may have a desire or need.  For purposes of achieving the most success in dining, it is presumed that foundational culture change principles must be addressed before or at the same time that a nursing home is focusing on dining.

[1] Barry Barkan, The Way of the Champion: A Personal Journey (Pioneer Network, 2002)

The Building Blocks of Culture Change: Tools and Resources

The following tools and links have been approved for use in this series by the respective organizations and individuals. These tools are not focused on dining practices per se but are building blocks that can help a nursing home begin its culture change journey and ensure that changes in dining and other practices are made using a process that involves input from residents, staff from each department, including front line workers (nursing assistants, dietary aides, housekeepers, etc.), families and volunteers.


Getting Started Tools

Getting Started: A Pioneering Approach to Culture Change in Long-Term Care Organizations
In 2003, Pioneer Network sought grant funding to support the writing and editing of "Getting Started." Financial support was received from the Retirement Research Foundation (RRF) and The Commonwealth Fund (CMWF). Pioneer Network subcontracted with the Paraprofessional Healthcare Institute (PHI) for the development of this culture change book and training modules. The primary author, Susan Misiorski, describes the collective wisdom of many nursing homes and organizations throughout the culture change journey of transformation toward a person-centered culture.

A Tale of Transformation
A Tale of Transformation: Four Stages Tell the Story, focuses on the work by Leslie A. Grant, PhD of University of Minnesota and LaVrene Norton, MSW of Action Pact, Inc. It is filled with images, learning circles, and stories of culture change that will guide you whether you're at the earliest stage (institutional) or have already transformed your facility and energized your staff in the transformational and neighborhood stages, or completely renovated into the Household Model. The workbook includes exercises, team activities specific to each stage.

"In Pursuit of the Sunbeam: A Practical Guide to Transformation from Institution to Household"
By Steve Shields and LaVrene Norton. The sunbeam," the right to home, has eluded the frail elders of this country for too long. It is time for a change. In Pursuit of the Sunbeam is a guide for individuals and organizations looking to embrace the true home of the resident-directed Household Model. Based on James O. Prochaska's stages of change, the Norton and Shields Change Matrix plots the transformational journey from beginning awareness of the need for change on a personal level through physical and organizational reconstruction into households licensed as skilled nursing facilities.

Path to Mastery
Developed for Eden Alternative registered homes, the Path to Mastery™ includes tools and resources to help organizations in the transformation process succeed, and provides a method to track progress along the way. The Path to Mastery has something for everyone including organizations that are experienced with The Eden Alternative, and those that are just starting out on the culture change journey. Click here to download a crosswalk of Path to Mastery Milestones as they relate to Quality of Life F-Tags.


Organizational Assessment Tools

The Artifacts of Culture Change
In April 2006, CMS completed a contract with Edu-Catering to develop the Artifacts of Culture Change (ACC) measurement tool. Carmen Bowman of Edu-Catering and Karen Schoeneman, now Deputy Director of the CMS Division of Nursing Homes co-developed the ACC. The tool is designed to capture tangible changes that come from a changed culture and includes several dining items under the domain of Care Practices. In 2010 the Pioneer Network developed a data base that automates the completion of the tool. The site will enable a nursing home to fill out the Artifacts tool and receive a report comparing them to others in a national data base.

The Artifacts of Culture Change tool is not intended to replace any available tools, only to add to them an instrument to collect actual policy and building changes that many culture change innovators are making. The change process represents change in heart, mind and attitude. The change process includes vision and leadership, but these elements are not visible. What results from these non-visible elements are concrete changes facilities have made, and are in the process of making, which demonstrate the principles behind them. These concrete changes are the markers and artifacts of the change of mind that occurs in a journey toward home (Bowman, 2006).

A Stage Model of Culture Change in Nursing Homes
Developed by Les Grant and LaVrene Norton is a stage model of culture change in nursing homes. This tool assesses the degree of culture change from an organizational development perspective in the four stages of Stage I - Institutional model, Stage II - Transformational model, Stage III - Neighborhood model and Stage IV - Household model, describing the organizational status of Decision Making, Staff Roles, Physical Environment, Organizational Design and Leadership Practices in each.

The Phases of Culture Change
What follows is a condensed version of the full article available for purchase.

There is no cookie-cutter model for culture change; every nursing home must choose for itself what works best in its own unique environment.  But there is a replicable process of establishing a shared vision and moving forward as an organization to create a home for elders.  The process includes six phases: the study circle, the design team, skills assessment and development, team development, implementation evaluation.

The Eden Warmth Surveys
Below are the Eden Warmth Surveys as well as documents that can assist in the evaluation of the results.

Measure the levels of optimism, trust and generosity within an organization that is going through change. With warm soil, people's heart will be open so they can embrace the change process. It is recommended that homes conduct the Eden Warmth Surveys as they begin their journey and then regularly throughout the journey. Cold soil, no matter where it may be found, can become a barrier as new ideas are implemented. The surveys can be completed on paper forms and/or entered online for aggregated results. Online submission is free to Registered Homes. Contact the Community Builder at This e-mail address is being protected from spambots. You need JavaScript enabled to view it to get your home set up for this service. Reports are then accessed electronically.

The Indicator Survey:
The Institute for Caregiver Education indicates to what degree there is a commitment to culture change in the domains of Environment, Organizational Procedures, Resident Involvement and Staff Empowerment. Other factors are considered, such as consistent staff assignments, level of resident involvement in the day-to-day operations of the home, care planning in the first person, and kitchen accessibility. The scoring is a five point scale.


The Education Tools

The Learning Circle Process

A  resource describing the Learning Circle process from Action Pact, Inc.

PHI Coaching Supervision Training Program - Click here for a description of the training curriculum and a sample module.

PHI training in coaching supervision provides nurses and others who directly support direct-care workers with critical skills/competencies necessary to create a relationship-centered culture. Supervisors learn how to support workers in developing their own critical-thinking and problem-solving skills, which are essential to delivering person-directed services.

PHI Coaching Approach to Communication

This training introduces nonsupervisory staff to the core communication skills needed to strengthen teams, enhance leadership, and improve care giving relationships. The key skills learned in this daylong workshop include active listening, paraphrasing and asking clarifying questions, pulling back from emotional reactions, and giving and receiving feedback.  Exploring, understanding, and integrating these core communication skills provides a strong foundation for delivering quality, person-centered care.

Personal Care Services Curriculum:
Available for free download.

Responding to a need for a better trained and better integrated long-term care workforce, PHI has developed this adult learner-centered, competency-based curriculum for personal care workers. The 77-hour curriculum was designed to meet three major goals: to help participants develop the core competencies needed to provide person-directed personal care in a range of long-term care settings; to introduce potential workers to all the different settings; and to lay the foundation for further training as nurse assistants and/or home health aides.

The CMS Educational Series
Four part satellite broadcast series. Institutionalized to Individualized Care Part I Nov, 2006; Part II May, 2007; Part III May, 2007; Part IV, 2007. 


Regulatory Tools

CMS Survey and Certification Letters 


The Staffing Tools

The Consistent Assignments Tool

The concept of consistent assignments includes the routine use of the same caregivers for the same residents on a routine basis. Proponents of consistent assignments point to the strong relationships that are formed when care givers do not frequently rotate to different resident assignments; rather care giver assignments remain consistent over time, which allows care givers to better identify and meet resident individual needs and preferences. Consistent assignments have shown to improve resident-centered care as well as a help homes improve and maintain workforce stability.

The Advancing Excellence Campaign believes a nursing home is successful when staff for the same residents on at least 80-85 percent of their shifts. This means on at least four of five days, evenings and nights, the resident has the same caregivers.

The Staff Stability Toolkit

This tool kit incorporate experiences and lessons learned in over 400 nursing homes. It is designed to serve as a resource for homes just getting started with efforts to reverse turnover as well as employers who have already started to address recruitment and retention and need further assistance in a specific area. The toolkit includes references to the worksheets below:


The Resident Assessment Tools

SOFTEN the Assessment Process workbook and training DVD

By Christine Krugh and Carmen Bowman published by Action Pact.  This workbook is chock full of Ideas and Homework. The mnemonic device SOFTEN helps reframe the institutional process of "assessment" by Supporting Simple Pleasures, Offering Options, Fostering Friendships, Equalizing Everyone and Normalizing Now. Sold as a kit with a training DVD for all staff of all disciplines.

Changing the Culture of Care Planning: a person-directed approach

By Christine Krugh and Carmen Bowman published by Action Pact at This workbook walks one through individual care planning, I Care Plans, Narrative Care Plans and the regulatory support for them in the federal long term care requirements.  It also includes a sample IN2L "Visual Care Plan."


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