Finding a balance between honoring residents' choices and providing good clinical care, however, can be difficult for some staff. "Nurses have the most trouble embracing culture change in an organization," says Kantor. Unlike their coworkers, nurses have medical training and can be held legally liable for harm to residents, says Diane Carter, president and CEO of the American Association of Nurse Assessment Coordinators, a long-term-care nursing education nonprofit based in Denver. So relinquishing some control over what nurses see as medical care can be tough to swallow. When a person with diabetes wants sweets, for example, a nurse will inform her and her family members of the risks, "but sometimes it's 'I'm 92 and I'm eating ice cream,' " says Carter. Going along, she explains, can "feel like a double bind to the nurse," whose training taught her otherwise.
An "Aha!" moment revealed to Carter why she should embrace the change. The rigid schedule for giving residents antibiotics starting at 9 a.m., even waking them up if necessary, was "so ingrained in my nursing soul," she says, that when a doctor ordered the first daily pill to be given whenever the person woke up, she practically had heart palpitations. Then came the sudden insight: "I don't plan my day around taking a pill."
One way these homes make the transition easier for caregivers is to do for them what they are doing for residents: give them a voice, and be willing to bend traditional roles. Involving nurses as well as nursing assistants and "homemakers" (a blend of chef and housekeeper) in determining the cause of a medical problem and how to fix or prevent it—a resident who has fallen or has incontinence-related skin infections, say—empowers staff. And nursing homes with a culture-change bent will also nudge employees to step out of their traditional roles: "They'll put on a hairnet and help serve meals," says Lindsey of the nurses and nursing assistants at Garden Spot Village.
Encouraging input and removing some of the traditional hierarchy tend to lead to higher job satisfaction. And that translates into fewer employees calling at the last minute to say they won't be in, requiring overtime work by a colleague or hiring an agency temp to pick up the shift. It also reduces staff turnover, a notorious headache for nursing homes that leads to revolving caregivers for your loved one. Nationally, the average turnover rate for nurses working in long-term settings such as nursing homes is as high as 33 percent. Evergreen's 2009 rate: 9.5 percent. Of his mother's consistent staff for seven years, Dick Harron says, "That shows it's a good place to work. With changeover, you know it's either lack of pay or poor working conditions."
David Farrell, a leader in the culture-change movement and long-term-care administrator for SnF Management, a California-based healthcare group, suggests asking administrators if they measure staff satisfaction, how often, and what they do with the results, as you'll want to get a sense that they act on their findings. Another tipoff that employees are valued: "Progressive nursing homes feed their staff," says Farrell, by providing free or low-cost meals or other meaningful perks, like free flu shots or vitamins, to workers in a relatively low-paying industry.
Culture-change proponents agree that it is vital to keep care from taking a back seat to a resident-centered approach and less rigid schedules. The trick, says Wayne of Case Western Reserve, is diligent monitoring and flexibility. If your aunt has slept late for the past 10 years, she should be allowed to do so in a nursing home, says Wayne. But her caregivers need to keep a keen eye out for weight loss if she's skipping breakfast and for pressure ulcers, which can develop into painful skin wounds in sedentary elders. If either becomes a problem, says Wayne, then waking her is appropriate.
Families may let their diligence slip at a facility that treats their elderly relatives with respect, but standards of health and safety are still paramount. The federal Centers for Medicare and Medicaid Services rates nursing homes on health inspection results, nurse staffing, and quality of care. (The ratings are used to create the U.S. News America's Best Nursing Homes rankings.) Overall, nursing homes committed to culture change, like those that participate in the Pioneer Network, fare better than others do on average, particularly in overall ratings and nurse staffing (a reflection of the average time nursing staff spend with each resident), according to an analysis done by the group.
Corrected on 01/14/10: An earlier version of this article mischaracterized the waiting list status at Evergreen Retirement Community in Oshkosh, Wis. The nursing home facility does not have a waiting list.