Overcoming Resistance to Culture Change: Nursing Home Administrators’ Use of Education, Training and Communication

Abstract

Nursing home culture change is becoming more prevalent and research has demonstrated its benefits for nursing home residents and staff, but little is known about the role of nursing home administrators in culture change implementation. The purpose of this study was to determine what barriers nursing home administrators faced in implementing culture change practices and to identify the strategies used to overcome these. We conducted in-depth individual interviews with 64 administrators identified through a nationally representative survey. Results showed that a key barrier to culture change implementation reported by administrators was staff, resident and family member resistance to change. Most nursing home administrators stressed the importance of using communication, education and training to overcome this resistance. Themes emerging around the concepts of communication and education indicate that these efforts should be ongoing, communication should be reciprocal, and that all stakeholders should be included.

The nursing home culture change movement has been in existence for nearly two decades (Koren, 2010) and has been operationalized through practices that include both physical and organizational changes. Physical changes to nursing facilities aim to make them more homelike, sometimes resulting in facilities that bear little resemblance to traditional nursing homes (Rabig, Thomas, Kane, Cutler, McAlilly, 2006). Such changes include removing nursing stations or creating small self-contained households or neighborhoods including kitchens and communal space. Organizational changes are aimed at altering how care is delivered, such as increasing the autonomy of direct-care workers in ways that allow them to organize their work around the needs and preferences of facility residents (Angelelli, 2006).

While culture change can be described as a social movement it is carried out through these types of specific practices. Nursing home culture change aims to alter the way care is provided in skilled nursing facilities by making these facilities more homelike and less institutional and by providing care that is more resident-centered, which is defined as being focused on the preferences and desires of care recipients (Rahman & Schnelle, 2008). This includes, but is not limited to, allowing residents to choose their own meals and sleeping and waking times. Resident-centered care of this type aims to preserve the autonomy of those receiving care in residential settings and is more in line with modern conceptions of care for the aged (Persson & Wästerfors, 2009).

The number of nursing homes reporting implementation of at least some of these practices has been steadily increasing. A survey conducted in 2007 by the Commonwealth Fund found that 43 percent of nursing homes reported no involvement with culture change (Doty, Koren & Sturla, 2008). Our own nationally representative survey conducted in 2009/10, which utilized several questions from the Commonwealth survey, found only 14 percent of nursing homes reported having not implemented any culture change practices (Miller, et al, 2013).

While several studies have examined resident health outcomes associated with culture change implementation (Hill, Kolanowski, Milone-Nuzzo & Yevchak, 2011), few studies have examined how facilities have gone about implementing culture change. Bowers and Nolet (2011) found that nursing homes implementing the Green House model of culture change in recent years were more successful at empowering direct-care workers than Green Houses created in years past. They concluded that this was due to an insufficient amount of expert guidance available to early implementers, including lack of access to a recently available training curriculum. A study conducted in four nursing homes by Munroe et al (2011), found that formal culture change training provided by professional trainers produced better outcomes than informal “train the trainer” provided by other facility managers.

A few studies have examined the organizational attributes related to successful culture change implementation. King and colleagues found that direct-care workers’ attitudes and knowledge of resident-centered care improved in most of the domains tested after training (King, O’Brien, Edelman & Fazio, 2011). Crandall and colleagues (2007) examined differences in organizational context and its role in culture change among nine facilities in Oregon. Three of the facilities successfully implemented culture change practices and six facilities did not. Results showed that a facility’s existing organizational culture, attention to sustainability, management practices and staff involvement were important to the successful initiatives. Rosemond and colleagues (2012) conducted a similar study involving eight nursing homes in North Carolina. It was determined that organizational readiness for change, high quality management communications, and favorable perceptions of culture change by direct-care workers all contributed to successful culture change initiatives.

While these previous studies have generated important information about culture change implementation, findings have been limited due to the inclusion of only small numbers of non-randomly sampled nursing homes. What has been missing from the research on culture change implementation are studies conducted among a nationally representative sample of nursing homes (Rahman & Schnelle, 2008). To address this gap in the literature, our study followed-up on a large nationally representative study of US nursing homes by identifying nursing homes utilizing culture change practices.

This study sought to identify the strategies and practices nursing home administrators employed in their culture change efforts and to describe nursing home administrators’ perceptions of their reform practices. The role and effect of managers and administrators on organizational performance and organizational change has long been the focus of research (Smith, Carson & Alexander, 1984). Those with leadership roles in organizations are known to influence organizational culture (Schein, 2004) and set the organizational context within which innovative programming must be implemented (Klein & Sorra, 1996). Often the attitudes of and approach taken by an organization’s leader(s) will result in the success or failure of efforts to implement innovative programming, such as nursing home culture change (Brannon, Kemper, Heier-Leitzell & Stott, 2010). This is as true in health care settings as it is in other organizations (Länsisalmi, Kivimäki, Aalto, Ruoranen, 2006).

Methods

Based on the known importance of an organization’s leaders and managers to implementation efforts, we sought to answer two research questions regarding the role of nursing home administrators in culture change initiatives:

1. What barriers do nursing home administrators face in their efforts implementing nursing home culture change practices?

2. What strategies and approaches do nursing home administrators utilize to overcome these barriers?

Sampling

We conducted individual semi-structured telephone interviews with 64 nursing home administrators identified through a nationally representative survey of 2686 nursing homes conducted as part of a larger study (Miller, et al, 2013). Our sampling strategy for the interviews with nursing home administrators was to target nursing homes in states in each of the four major regions of the US, including states with higher rates of adoption of culture change practices as identified in an earlier survey conducted by the Commonwealth Fund (Doty, Koren & Sturla, 2008). Using culture change scores derived from our survey and quality data obtained from the Online Survey Certification and Reporting (OSCAR) system, we ensured that nursing homes varied by including some with lower and some with higher levels of culture change implementation and some with higher and some with lower care quality.

Interviews

We pilot-tested our semi-structured interview guide through telephone interviews with three administrators and our multi-disciplinary research team then revised the interview guide before interviewing the 64 participants. Interviews were modified primarily to remove references to “culture change” early in the interview. This change was instituted to minimize socially desirable responses about culture change practices by administrators. Administrators were emailed or faxed an introductory letter explaining the study and then called two or three days later so that an interview could be scheduled. We utilized a semi-structured interview guide to ensure that the same questions were asked of each nursing home administrator in the same basic order. To begin the interview, administrators were asked about what they had implemented to “improve quality of care or life for your facility’s residents and/or staff, including any changes made to the physical environment.” By asking administrators to tell their stories without prompting them to speak specifically about the subject of culture change, we hoped to increase the likelihood that administrators would discuss what was important to them instead of providing what they perceived to be socially desirable answers (Bernard, 2011; Curry, Shield & Wetle, 2006). In order to avoid biasing the interviews, interviewers were blinded to the culture change scores for each nursing home derived from our survey. In addition to questions about how changes were implemented, who was mainly responsible, and why changes were implemented; administrators were specifically asked about the barriers they faced in implementing changes in their facility and the strategies and practices they utilized to overcome these. Administrators who did not spontaneously mention culture change or any of its related practices (e.g., resident-centered care, increased autonomy for direct-care workers, physical changes to make facilities more home-like, etc) were asked about culture change before the conclusion of the interview. The interviews were 20 to 30 minutes in length, they were audio recorded and transcribed, and the transcripts were checked for accuracy by the interviewer. The 64 interviews were conducted between March and December 2010. Our university’s Institutional Review Board (IRB) deemed this research exempt because our interviews concerned organizations and not individuals. However, verbal consent was obtained from participants before interviews were conducted.

Analysis

We utilized a framework approach to data management and analysis, which allowed for a stepwise iterative process that proceeded in response to the data as they were gathered and in an ongoing fashion (Smith & Firth, 2011). It also allowed for the use of a modified inductive, grounded theory style technique (Strauss and Corbin, 1998). To begin, two members of our team developed preliminary codes and code groups used to label specific segments of text. These a priori codes and code groups were based on our research questions and theoretical framework (Crabtree and Miller 1999, Miles and Huberman 1994). All five members of the research team then read the first five interviews two or three times and applied these preliminary codes. A consensus meeting was held to reconcile the codes applied to the interviews by each team member and to discuss existing codes and code groups. During this meeting we also developed the additional codes the group agreed were needed as well as their definitions. Based on this process, codes and code groups were edited and code definitions were refined. Therefore, while some codes and code groups were generated a priori based on our theoretical expectations others emerged directly from the interview analysis.

We continued this process as each new interview was conducted and transcribed. The team met bi-weekly to reconcile their coding decisions, so that the codes assigned to each interview passage were agreed upon by all members of the team. Revisions and decisions about codes and code groups were made by team consensus and previously coded transcripts were re-coded for consistency when necessary. Because all interviews were coded by all team members and all codes assigned to interview passages were agreed upon by the entire team, we did not conduct tests for inter-rater reliability.

Throughout the process team members discussed and developed themes, or statements describing the relationships between key concepts (Bradley, Curry and Devers, 2007), that emerged across transcripts. These descriptions of the relationships and patterns among and between codes and code groups (Morse & Field, 1995) were identified as themes and an audit trail related to these themes and all analytical decisions was kept. This allowed the team to review the history of coding and theme decisions. The team also searched interview transcripts for competing interpretations to enhance rigor in identifying themes. Coded interviews were loaded into Atlas.ti for data management. The coding of all interviews by all team members and the use of consensus meetings to make final coding decisions allowed for the search for alternative interpretations, provided analytic rigor about the validity of the findings and greatly increased the trustworthiness of the findings (Miles and Huberman 1994, Crabtree and Miller 1999, Curry, Shield and Wetle 2006). (See Appendix A for the final codes and code groups.)

Findings

The themes and sub-themes identified during data analysis are shown in Appendix B. The main themes identified are described in detail elsewhere (Shield at al., 2013). Two sub-themes (5a and 6a) related to the research questions in this paper: 1) resistance to change among nursing home staff, residents and family members is a common barrier reported by administrators, and 2) education, training and communication were especially important to overcoming resistance to change. These concepts rose to the level of sub-themes during data analysis due to the frequency and consistency with which administrators reported this specific type of barrier and reported utilizing education and communication to overcome it. Interestingly, while other reported barriers such as outdated physical plants for example, were reportedly overcome using a variety of different strategies, administrators consistently reported using education, training and communication to overcome resistance to change. This consistent coupling of a specific barrier with a specific strategy used to overcome it, therefore, was identified as important finding to report in terms of guiding practice and future research efforts.

Resistance to Change

As has been reported elsewhere (Shield et al., 2013), nursing home administrators reported several barriers or challenges to culture change implementation in their facilities, including their facility’s resident mix and old or outdated physical plants. However, as detailed here, staff, resident and family member resistance to change was often cited as a particularly difficult obstacle. This included general resistance to change and resistance to specific culture change practices. With regard to staff resistance to change one administrator said:

Typically what you find is the folks that have been here for a longer period of time are very much engrained to the old institutional model. (M7)

Many administrators reported that facility residents were also resistant to change. One administrator explained why she believed this was the case:

We’ve kind of trained them, this is how things work in a nursing home so to un-train them, you know, they’ll say, ‘Oh, everything is fine, we don’t need to change anything. I’m perfectly happy.’… For example, clothing protectors or bibs, we’ve tried to get rid of those, but we’ve trained them to use them. So when we don’t put them out, they ask for them…That’s because of how we’ve trained them…We’re still working on that. (J4)

Administrators also described resistance to change on the part of residents’ family members:

We’ve had some families not be as keen on it because to be quite honest, it’s a little different… that’s been one of the challenges, is to try to get the families onboard with things, and to kind of make them understand our position and why this is the benefit to the resident. I think that’s been the biggest challenge. (M5)

Strategies to Overcome Resistance to Change

The nursing home administrators we interviewed who told us they were implementing culture change in their facilities reported using a variety of strategies to overcome barriers and challenges, such as using small and incremental changes (Shield et al., 2013). However, unique to the barrier of resistance to change, administrators consistently reported that the strategies they used to overcome this were related to education, training and communication. In addition, our analysis found that utilizing education and communication to overcome resistance to change included several different types of communication, education and training.

Education & Training

Education included incorporating culture change concepts into new employee orientation, tailoring education and training provided to the specific needs of the facility, and the use of more traditional in-service training. Administrators discussed the training they and other managers received about culture change and also described how they provided training and education to staff. For example, they reported receiving training through their state, through coalitions of providers interested in culture change, through the existing culture change organizations (e.g. Pioneer Network or Eden Alternative), and through their own corporations:

Some of our other facilities are a little bit further along in the program and they’ve kind of been the guinea pigs where we brought other facilities in to take a look at them, see how they do things. And we’ve tried to model ourselves after them as much as possible. (M5)

Another said:

I’ve been to conferences on culture change and I’m now sending my staff. I’ve got six staff members who have been to Eden Training. (R2)

Nursing home administrators also reported using a variety of different training mechanisms to educate their staff about culture change. This included more traditional in-service training sessions:

We have had two in-services, very lengthy ones, to teach staff about how to find the difference between institutionalized care and person-centered care… Trying to distinguish what’s considered institutional and what’s considered personal. Cause it’s a tough thing. (M12)

As evidenced by the above quotation, administrators reported tailoring the training they provided to staff based on the specific needs of their facility. This administrator continued by describing how a long training that managers had completed was broken into shorter in-service sessions more appropriate for other staff:

We had an 8 hour orientation and in-service. And we brought that back to the facility and began, because it was an 8 hour training, we broke ours down into 20 minute segments so it took a very long time to do. But my thoughts for the staff was, 15 to 20 meetings that are 20 minutes long are better than 8 one hour sessions. Because my opinion was they would remember more….So it took us almost a year to accomplish all the in-servicing. (M12)

Another reported incorporating culture change concepts into new employee orientation:

It’s also upon orientation, we especially for our new CNAs [certified nursing assistants], we hook them up with some CNAs who’ve been here for a while and they’re drilling it in people from the second they walk in the door: ‘This is how we do things here and it is different, it’s about the residents.’ And, so everybody’s driving that message home. It’s really nice. (J11)

Another mentioned tailoring training by organizing it into small group sessions during regular work days:

Well, we have a staff educator here, a nurse, and we would do small group sessions on the units. We would get the CNAs together in small groups or get the LPNs [licensed practical nurses] together in small groups and talk about these issues. (R11)

While the above quotations focus on education and training for nursing home staff, the administrators we spoke to also stressed that education must include everyone involved, including staff, residents, and residents’ families:

…education is the key. It requires a lot of in-servicing and making sure that everybody’s on the same page before you can roll out the program. Same thing with the residents, you want to meet with the residents ahead of time and let them know what’s going to happen and ask them their ideas and inputs and then we even had a family night where we… explained it all to family members so that they weren’t coming in the next day and saying, why… are all these changes going on. I think that’s the key is to get everybody involved and empowered and educated. (R15)

Communication

Key to the quotation above and central to what we learned from nursing home administrators was the idea that, in addition to education and training, a successful culture change initiative must involve good communication. Communication in this context included both formal and informal imparting of and receipt of information. Thus, while education can be thought of as the unidirectional imparting of knowledge, what is also necessary to successful culture change implementation is communication which is bi-directional. As such, administrators reported that communication must include all stakeholders (staff, residents and families) be two-way, and be ongoing. Administrators also reported that communication of this type allows for feedback about the initiative and fosters involvement and buy-in.

As one administrator reported, open and ongoing communication appears to make those involved less resistant to change:

…we try to keep the communication open… once the folks know what changes are coming and they feel like they’re a part of the solution, they tend to be more receptive to making the changes. (R13)

In terms of communication with facility residents, administrators reported a number of ways of involving them and ensuring that the lines of communication were open:

The next thing we’re doing now… [is] to interview all of our residents, just what is their level of satisfaction, what is important to them… we might think we know but in fact, it might be something totally different. We’re just trying to work with them. (M6)

In addition to involving everyone, nursing home administrators reported that communication must be two-way, involving both imparting and receiving of information, and cannot be handled in a top-down fashion. For example, one administrator said:

Well, I think you have to get the buy-in from the staff so I think the very, very first thing is to get them involved, not to just tell them this is what we’re going to do. You need to empower your staff and you need to let them know ahead of time, this is what we’re looking to do. You know, if anybody has any suggestions or ideas or questions or concerns, you really have to get everybody onboard and make sure that they’re aware of what the idea is that you’re going to be doing…So I think that’s the most important thing is to get everybody onboard and not just have it be a management decision…(R15)

A benefit of this type of communication according to the administrators we spoke to was that it allowed for feedback and that positive feedback could often spur on their culture change efforts:

And the nice thing about it is… the positive feedback that we received immediately from the residents and the residents’ families kind of helps spread the faith or spread that message a little bit that, hey, this stuff does work. Because a lot of times, you have people saying, ‘Well, why do we want to change?”’ And for everybody change can be difficult, and so it’s been nice to get that positive feedback, that immediate gratification that ‘Hey, this is a good way to go’…(M7)

Of course, two-way open communication that allows for feedback will also likely generate some negative feedback. We found that administrators we spoke to who were implementing culture change were able to flexibly respond to the feedback they received and alter their approach when necessary:

…just making sure they know their input is important and asking them what they think… If they have suggestions making sure that if we don’t implement them we at least explain why we can’t, or else implement what they think. Because most of the time they know what would make things better. (J4)

They reported that this flexibility helped to foster teamwork and ensure that everyone was focused on the primary goal of improving care for facility residents:

It’s like I tell them all the time, I can’t run this facility by myself. You know, it takes all of us pulling together to work as a team to make sure this facility runs like it needs to run. And there are times that the team gets a little disjointed. You know, and that’s just human nature. We’re all going to have bad times, bad days but you know, just keeping that team pulled together and everybody focused on what’s important and that’s the patient. (J7)

Discussion

The nursing home administrators we interviewed who were implementing culture change in their facilities spoke about the importance of involving all stakeholders in planning and decision making. They reported using education, training and communication to establish buy-in from those resistant to change. They also displayed an ability to be flexible and tailor their communication and, especially, their training activities to their facility’s organizational context and to the needs of their specific staff members, residents, and residents’ family members. They did this, for example, by altering programming in ways that made it more palatable and useful to their particular employees, such as by breaking down an eight hour training into 20 minute sessions, or by incorporating the culture change philosophy into their existing structure, such as during new employee orientation. Our findings confirm the results of several smaller non-random studies that have pointed to the importance of training, education, management practices, high quality communications, and staff involvement to successful nursing home culture change initiatives (Crandall, White, Schuldeis & Talerico, 2007; King, O’Brien, Edelman & Fazio, 2011; Rosemond, Hanson, Ennett, Schenck & Weiner, 2012).

Future Research

Our findings also suggest areas for future research. Management or leadership training for nursing home administrators may be an important first step in culture change efforts (Morgan, Haviland, Woodside & Konrad, 2007). Such training could help administrators to improve communication skills and learn more effective management practices so they could more effectively tailor their culture change education, training and communication efforts to better match the idiosyncrasies of their facilities and enhance staff involvement in implementation. Therefore, future research should determine if management and leadership training better equips nursing home administrators to introduce and lead culture change initiatives that are ultimately more successful.

Seminal research by Rogers (1995) has demonstrated that effective leadership is important to the adoption, implementation, and sustainability of new and innovative practices. Our findings are consistent with this previous research and are also consistent with research on the diffusion of innovation in nursing homes (Bradley et al, 2004). Future research should address whether lack of an effective leader who is skilled in the communication styles and management practices that our interview subjects reported utilizing could prove an insurmountable barrier to culture change initiatives. It is possible that an inability to tailor education, training and communication to a facility’s specific needs could be the cause of an important impediment to the diffusion of culture change and explain resistance to culture change found among nursing home administrators themselves. This resistance has been previously identified as a barrier to culture change in the industry (Miller, Miller, Jung, Sterns, Clark & Mor, 2010). The authors are uncertain about the role that leadership training and management skills development for nursing home administrators plays in implementing successful culture change initiatives. However, based on the delicate balance needed to create culture change it is evident that leadership and management skills would be an important asset worth developing and may be an important first step in a facility’s culture change efforts. Future research should address this.

Limitations

Although we included a large number of subjects by the standards of qualitative research, the 64 nursing home administrators we spoke to are not expected to be representative of nursing home administrators nationally. It is possible that more successful nursing home administrators may have been more willing to speak to us. The fact that we asked nursing home administrators to discuss practices they had implemented to improve quality of care likely resulted in our not hearing more about unsuccessful efforts regarding culture change implementation. Had we asked administrators to also discuss their less successful efforts or to discuss things they had not tried we may have garnered additional information about what did not work. Our study is also limited by the fact that we only spoke to one representative at each nursing home, the administrator and that we only spoke to that person once. We may have received different or additional information had we also interviewed the director of nursing, medical director, members of the direct-care staff, or residents. We may have also received additional information had we interviewed administrators multiple times providing them time in between interviews to think further about our questions.

Conclusions

This study sought to understand the barriers and challenges nursing home administrators faced when implementing culture change in their facilities and the strategies they utilized to overcome these. While administrators reported a wide variety of barriers (Shield et al, 2013), our findings indicate that a key barrier faced is resistance to change on the part of nursing home staff, residents, and residents’ family members. This barrier proved to be unique among barriers in that, while strategies used to address other types of barriers varied widely, administrators consistently reported utilizing education, training and communication to overcome resistance to change. In addition, administrators discussed the ways they tailored education and communication to their facility’s unique needs and also indicated that these efforts should be ongoing, communication should be reciprocal, and that all stakeholders should be included. Future research should empirically test the findings of this study that training, education and communication are effective tools in overcoming one of the key barriers to implementing culture change practices in nursing homes – resistance to change.

Appendix A. Codes and Code Groups

1. Decision factors for quality improvement practices (General, not below; e.g., cost, mission, physical plant)

   1. Market-driven (e.g., marketing, competition)
   2. Responses to nursing home populations (e.g., short-term/rehab, dementia, bariatric)
2. Implementation & management strategies & styles (General, not below; e.g., meetings, satisfaction surveys, QI monitoring)

   1. Process of implementation (e.g., first steps, role of individuals, leadership factors)
   2. Educational resources (e.g., training, conferences, consultants, literature, toolkits)
   3. Financial, regulatory strategies (e.g., grants, policies, waivers)
   4. Communication (e.g., obtain input, share decisions, share progress)
   5. Physical plant
   6. Next steps
3. Barriers & ongoing challenges of implementation or impact (General, not included below)

   1. Individuals (e.g., staff, family, residents, physicians, other)
   2. Regulatory barriers
   3. Costs
   4. Physical plant
   5. Resident mix (e.g., short-stay, rehab, dementia, bariatric)
4. Facilitators of implementation or impact (General, not included below)

   1. Individuals (e.g., staff, family, residents, physicians, other)
   2. Financial, regulatory barriers (e.g., grants, policies, waivers, other)
   3. Corporate/ownership/management group
   4. Physical plant
   5. Resident mix (e.g., short-stay, rehab, dementia)
5. Resident practices (General, not included below; e.g., activities)

   1. Dietary
   2. Personal care (e.g., ADLs, bathing, scheduling)
   3. Resident-centered/directed practices
6. Staff practices (General, not included below; e.g., empowerment strategies)

   1. Changes in job design (e.g., cross-training, responsibilities, supervision, new jobs)
   2. Staff advancement (e.g., remuneration, training)
7. Physical environment changes (not considered culture change; e.g., interior, exterior; carpeting, vans)

   1. “Culture Change” enhancements (e.g., remove nursing stations, private rooms, names)
8. Impacts (pos., neg., expected, unintended, lack of; e.g., physicians, administrators)

   1. Residents/families
   2. Staff (e.g., recruitment, turnover, retention, satisfaction)
   3. Costs
   4. Market (e.g., marketing, competition)
9. Good quotes (General, not included below)

   1. 1^st mention of culture change and/or resident-centered practices in interview
   2. Philosophy
   3. Advice to NHs

Appendix B. Themes and Sub-themes

Number	Theme
1	Reasons for implementing culture change practices vary
2	Nursing home approaches to implementing culture change practices are diverse
3	Nursing homes consider resident mix in deciding to implement practices
4	Administrators note benefits and few implementation costs of implementing culture change practices
5	Implementation of changes is challenging and faces barriers, and strategies for overcoming these are tailored to the challenge encountered
5a.	Resistance to change among nursing home staff, residents and family members is a common barrier reported by administrators.
6	Education and communication efforts are vital ways to institute change
6a.	Education, training and communication are especially important strategies for overcoming resistance to change
7	NHA and other staff leadership is key to implementing changes