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A Program for Culture Change

The following is an abstract of Home Again: Here to Stay (A Model for Culture Change in Long-Term Care), developed by Isabella Geriatric Center and written by Harriet Rzetelny, CSW and Constance H. Gemson, CSW. The book contains full details of the steps that are summarized below. Abstract prepared by C. Gourgey Ph.D..

Nursing homes have imported a model of care used in acute-care settings. This model emphasizes hierarchy, routine, and efficient but depersonalized care. The result has been demoralization not only of residents and families but of staff members as well.

This model needs to be changed in favor of one that values input from staff members on all levels, as well as residents and family members. Strictly hierarchical relationships tend to become adversarial. Line staff members feel disenfranchised, and take out their frustration on the residents. (The upper levels are not immune either, since low scores on surveys make them look bad.)

Culture change therefore entails shifting control and involvement from the few to the many. I have had occasion to observe life at Isabella Geriatric Center in New York City. Isabella has made significant progress in improving relations between staff and residents, thus demonstrating that it is possible. It has done so using the following six-step program. Hopefully other nursing homes can learn from this model, each one adapting it to its own particular needs and culture.

Step 1: Preparing the Way

There must be a dedicated group within management that is committed to change. They can begin by making trips to facilities that have successfully implemented culture change, to learn from their experience and discover new ideas. The willingness to undertake a critical self-assessment and ask hard questions is also important.

Step 2: Creating the Guiding Coalition and Grounding Vision

Identify natural leaders within the staff and recruit them in forming a Culture Change Committee. Members of this committee should represent all levels of staff, as well as the different ethnicities present in the home. Management must play an active role. The task of the Culture Change Committee is to allow staff, residents, and family members to determine what changes they wish to make, and to help them find ways to realize those changes. Invite people to share their ideas without criticism. Develop a vision statement.

Step 3: Broadening the Scope of Change

With the Guiding Coalition now in place, conduct community meetings on all units and all shifts. Use these meetings to introduce the Culture Change Committee to educate those present about culture change. Identify common concerns. Get people’s ideas about what is needed. Establish a two-way process -listening is as important as teaching.

Step 4: Making the Vision Concrete

Find concrete changes you can make immediately. This keeps the momentum going and makes the commitment to culture change visible. Use the feedback from community meetings to get ideas for specific changes. These might include a pamphlet introducing the care team, or suggestions for activities that residents and visitors can do together.

Step 5: Empowering the Least Powerful

For culture change to work, the least powerful - residents and line staff - must believe they have a stake in the process. Continue regular involvement between management and those lower down. Bring in outside consultants with experience in culture change. Have them conduct seminars and community meetings. Train Unit Coordinators to monitor culture change on their units

Step 6: Integrating New Changes into the Culture

The Guiding Coalition must stay involved with tackling new challenges. Senior management must continue to support these efforts. Hire a part-time Culture Change Consultant to work with the Culture Change Committee, train staff, and facilitate support groups and community-building groups. Set up ongoing support groups for CNAs.


Systemic change is needed within an institution, with the cooperation and encouragement of senior management, if reforms are to be more than cosmetic. As the authors are the first to point out, every nursing home is different and each must establish culture change in its own way and consistent with its own needs and history. However, if it is possible to abstract one single guiding principle to make this process work, it is this: Establish an ongoing dialogue between management and all levels of staff, residents, and family members. This way all people involved feel they have an interest in the project, all feel recognized, and the mistrust and ill will that characterize so many nursing homes today can finally be overcome.