“It’s a Lot!” The Universal Worker Model and Dementia Care in Assisted Living

Introduction

The culture change movement in long-term care settings emerged in the late 1990s aspiring to provide a more home-like environment, encourage personalized care, support staff and resident well-being through empowerment and collaborative decision-making, and promote closer relationships among staff, residents, and family members (1,2). In his groundbreaking 1994 book, The Eden Alternative: Nature, Hope and Nursing Homes, Thomas defined three afflictions endemic to nursing homes: boredom, loneliness, and helplessness (3). He described a medical model where care was equated with medication, and proposed changing the institutional environment of nursing homes by moderating its medical aspects, incorporating indoor foliage plants, and offering opportunities for interactions with children and animals. In 1997, Weinstein discussed the implementation of the Eden Alternative and the positive outcomes in resident health (4). Over time, the focus on personalized care and quality of life in long-term care settings became known as culture change. The Green House Project emerged as a culture change model with “structural, procedural, and philosophical components” (5, p. 354). The Green House Project established housing units of approximately 15 residents with consistent care staff who not only helped residents with bathing and personal care, but also cooked, did laundry, and cleaned the household. In this universal worker (UW) model, the direct care worker (DCW) was expected to facilitate person-centered care and promote greater resident autonomy in care decisions (1,2,5).

Person-centered care refers to individualized care “seeing the person and not the medical condition” and “tailoring care around the person” (6, p.55). The UW model enables the direct care provider to learn the characteristics and preferences of each resident under their care and encourages collaborative decision making, thus reinforcing person-centered care. Bowers and colleagues noted that under the UW model, DCWs were more familiar with residents’ “preferences, idiosyncrasies, daily routines, and functional ability than had been the case when they worked as certified nursing assistants in traditional nursing homes” (7, p. 384). They further revealed that connections between staff and residents “not only facilitated person-centered care but also led to early identification of resident changes in condition” (7, p. 393). In the UW model, the DCW provided important information on the functional status of the resident “because [the physician was] talking to the person that’s actually doing the work” (7, p. 386). Another study found that, under the UW model of task assignment, some care staff expressed a strong sense of teamwork while others felt that time constraints forced them to choose between providing personal care and cleaning tasks (8).

Consistent assignment under the UW model anticipates that the relationships between DCWs and residents will be reinforced (9). However, Cohen and colleagues claimed that “the evidence to support consistent assignment and universal workers is less strong in terms of outcomes” and suggested that over time “some homes had found it advantageous to modify the model by using specialized workers (e.g., ‘schedulers’ and cooks) to perform certain tasks” (10, p. 372). The incidence of increased physical frailty and advanced cognitive impairment of residents creates challenges to the implementation of culture change (1,2) and the heightened care needs of persons with dementia are exacerbated by inadequate staff training and the presumption that these residents are incapable of contributing to the decision-making process (11,12,13).

There have been few studies of culture change in long-term care settings that assess its implementation, especially over time and particularly concerning the care of residents with dementia (14). In a study of 11 nursing homes that adopted culture change, Stone (15), as cited in Bowers, Nolet, and Jacobson (16, p. 401), revealed that “sustainability of the model was ‘extremely challenging’ and a return to former practice patterns was common.” In addition, culture change research has yet to fully capture the perspectives of frontline workers (direct care, housekeepers, maintenance, and dietary staff) in these environments who provide the majority of care. The longitudinal study on which this paper is based helps to fill that gap by comparing data collected from one assisted living (AL) across three NIA-supported research grants to understand how culture change was introduced, monitored, and reinterpreted over time, and to examine how culture change was adapted to care for the increasing numbers of AL residents living with dementia. Drawing on the perspective of staff, this paper focuses on the Universal Worker model of staff assignment in one AL following the implementation of culture change over a period of ten years and explores how the original model was adapted over time.

The Site

Evergreen Place, a 60-bed, 3-story AL, opened in the early 2000s adjoining an existing nursing home/rehabilitation facility. The site is located in the Mid-Atlantic region and operates under the umbrella of a large non-profit organization. The data used in this paper were gathered at Evergreen Place during three distinct NIA-funded ethnographic studies: Study 1, 2007-2010; Study 2, 2012-2013; and Study 3, 2017-2019. Both the residents and staff at Evergreen changed over time. During the first study, our findings show most residents were ambulatory, with mild cognitive impairment. Ten years later many residents were confined to wheelchairs and some showed severe cognitive decline. Duties of DCWs changed when the UW model of task assignment was introduced at Evergreen in 2010; our findings show this adversely affected staff turnover.

Culture change was first introduced at the nursing home adjacent to Evergreen in the early 2000s, and ethnographers observed its nearly complete implementation during Study 1 a decade later. The director of the nursing home was an ardent supporter of culture change, and despite the organizational disruption it entailed (removing nurses’ stations, empowering staff, and enhancing resident autonomy), she was committed to creating a less medicalized residential environment. When the new executive director introduced culture change to Evergreen AL in 2010 the transition was not without challenges.

Methods

Data Collection

Ethnographic data collection involves intensive participant observation characterized by the experiential engagement of the fieldworker (ethnographer) in the setting. During the three studies noted above, ethnographers kept contemporaneous field notes of their observations and interactions with Evergreen staff, residents, and family members as they helped with activities, served meals, attended staff and resident council meetings, and visited with residents. After several months of participant observation, the ethnographers conducted semi-structured interviews with residents who were cognitively able to consent, staff members, administrators, and relatives or friends of the residents. Audio recordings of these ethnographic interviews were transcribed and, along with detailed field notes of ethnographers’ observations and informal conversations, were entered into a text base for analysis using the qualitative software program Atlas.ti.

Data for this paper included a small subset from Study 1 (2007-2010), which examined social relationships in a dozen multi-level residential senior communities. This subset was comprised of transcribed interviews with the director of the adjacent nursing home where culture change was being implemented and with twelve Evergreen staff members (including direct care, activities, and housekeeping) before culture change. Field notes from a meeting in 2010 when culture change was introduced to the families of Evergreen residents were also entered into the data base. Study 2 (2012-2013) looked at resident autonomy in three assisted living settings. The data base for this paper contained 50 field notes and nine staff interviews from Evergreen in Study 2. Primary data for this paper were derived from Study 3 (2017-2019), which specifically looked at the implementation of culture change at Evergreen. Our analysis consisted of 94 field notes dating from late 2017 to mid-2019, and 25 staff interviews – with 16 direct care staff, six administrators, the delegating nurse, one receptionist, and one dietary staff person. In all three studies, structured questions guided the interviews (e.g., “Do you feel that you spend enough time with residents?”) while ethnographers’ unscripted prompts encouraged elaboration and a more thorough understanding of the respondents’ experiences. The interview guide for staff from Study 3 is included in Appendix A.

Analysis

Qualitative analysis began in the early months of Study 3. During research team meetings, the ethnographers who had worked on the prior studies called attention to changes they observed at Evergreen over time. Research was reflexive as questions raised at team meetings instructed ongoing fieldwork. Broad themes emerged from these discussions and guided initial analysis. During the last year of fieldwork, a thematic code list was developed with 40 distinct codes grouped into four categories: (1) Actors, (2) Actions, (3) Aspects of assisted living, and (4) Evaluating culture change. Appendix B provides a detailed list of operationalized codes from Study 3.

Using the analytic software program, Atlas.ti, the research team sorted the textual data from the studies into these codes and drew comparisons among the three time frames. Because only the last study specifically looked at culture change, data analysis of Studies 1 and 2 necessarily involved sifting relevant material into the thematic codes. During ongoing research team meetings, we noted associations related to staff knowledge of and modifications to culture change. For this paper, we sorted our findings into four themes: (1) introduction and implementation of culture change, including staff perception of the UW model of task assignment; (2) how increasing levels of dementia impacted DCWs’ work; (3) modifications over time to task assignment such as housekeeping, activities, and meals; and (4) benefits of culture change, such as strong personal relationships between DCWs and residents. To protect confidentiality, pseudonyms have been used throughout the paper.

Findings

Introduction and Implementation of the Universal Worker Model

Two ethnographers attended the meeting in 2010 held specifically to introduce culture change to the families of Evergreen residents. Anticipating opposition, the director joked that she had “ordered chocolate” to mitigate resistance. Both ethnographers felt that the AL director had been pushed into this new philosophy of care. It was the application of the UW model that drew the most resistance from Evergreen staff and families and, as our findings show, modifications to the UW model were made over time.

In the Green House model of culture change, direct care staff are led by a “guide” who supervises and supports them rather than by a director of nursing or another clinical administrator (9,10,17). At the introductory meeting with family members, the director outlined organizational modifications at Evergreen. Three “neighborhoods” would be established (one on each floor) and direct care staff would be assigned to residents in one neighborhood under the direction of a household coordinator, analogous to the guide in the Green House model. It was explained that consistent assignment of DCWs would foster person-centered care. The director presented the changes to the families as a purposeful intention to create a more home-like environment. The “team members” (DCWs) would be transitioned to a UW model, now responsible for assisting with activities and housekeeping in addition to providing personal care. “We’ll all pitch in … Evergreen Place will be focused on a home environment,” explained the director. Field notes indicated initial resistance:

A family member at the meeting was not willing to accept [the director’s] response and pushed a bit further. “Who is ultimately responsible, then, for housekeeping? This is really a very BIG change.” When it became absolutely clear that there were no longer any housekeepers or activities staff (they were all “let go”) there was quite a bit of stirring taking place in the audience. “How are the aides going to do all this?” a family member called out. [The director] emphasized the desired outcome of more person-centered care. “We are all helping each other. We have more people watching your loved ones.” … Another family member called out, “Why eliminate the activities staff? [The director] responded, “We are working to a universal model.” She assured everyone that the most popular activities – cash bingo and outside trips – would continue….

A woman whose parents had been at Evergreen for five years told the director, “I think what you are asking these ladies [DCWs] to do is unreasonable.”

We observed the implementation of culture change and the UW model of task assignment at Evergreen in 2012-2013 during Study 2. In 2012, a household coordinator shared her thoughts on the transition:

We did the culture change two years ago … We eliminated the activities department, the housekeeping, and assigned floors for the CNAs – I think before they just kind of roamed where a shift was needed… They also serve in the dining room. What they basically did is they assigned the floor so that they could really get to know the person.

During her interview in 2013, a medical clerk who had been a DCW when culture change was introduced offered her perspective on the UW model:

It was really hard because … when you’re working with elders, light housekeeping is one [thing]… If you’re giving a shower, of course you’re going to mop up the floor … But when you’re the sole person that’s doing everything, meaning you’re going to do the housekeeping part of the job, and patient care, and you have to administer medication, you’ve got to watch your wanderers, and you assist in the dining room – assisting in the dining room is always something we have to do – but on top of assisting in the dining room and your regular routine, you have housekeeping and activities. So, you know, you’re adding more responsibility. So, it was a very hard transition.

There was an almost complete turnover of direct care staff in the five years from our first ethnographic visits for Study 1 in 2007 to the beginning of Study 2 in 2012. New staff had been hired and trained, learning the UW model from the onset of employment. The director explained the ongoing effort, “Culture change didn’t just happen – it’s continuous.” Staff turnover continued to be a problem. In 2018, during an interview for Study 3, a household coordinator who had worked at Evergreen for 11 years said:

When I just came here, we had an activity director; we had housekeeping; we had all that stuff. They were cut out. And I think basically it’s for, I think it’s a money thing. It is. So then she cut [housekeeping and activities staff] out and then, you know, oh you’re getting a dollar more. … It was like ten dollars maybe coming in [starting hourly wage for DCWs], Now I think even now coming in it’s only thirteen dollars. That’s why I said it’s a money thing. That’s why we don’t keep staff. … Since I been here we’ve been through a lot of staff.

She attributed the staff turnover to termination of DCWs for medication errors or tardiness, and to DCWs leaving for higher salaries elsewhere: “People just want more money.”

Dementia care from the perspective of DCWs

There was an increase in the number of residents with dementia over the ten years we observed Evergreen. Residents had physically and mentally declined over time and more individuals with dementia were being admitted. In 2008, a DCW who had been at Evergreen since it opened said, “We have gotten more dementia residents … over the years that I have been here … and it’s a lot of work.” In 2018, the office manager who handled admissions stated, “Just in the last two years I’ve seen a huge change, where [new residents have] really been a lot older needing much more help. When I first started here in 2011, they were more independent and just needed a little assistance. … I mean there were a few people that had dementia when I started and now more than half have dementia and it’s more severe.”

Throughout the three studies, staff members noted the challenges of caring for people with varying levels of cognitive impairment and emphasized the change over time. A DCW described how the work-load inherent in caring for residents with higher needs increased.

The difference between 2012 and now [2018], like now we have a lot of residents with dementia. We have to do a lot of toileting, keep reminding them of certain things. It’s just a lot…you got Miss Josephine coming up to us asking us a billion questions…. So it’s a lot versus, you know, the ones that used to come. They used to fold their own clothes. They didn’t want you to come and clean their room or they didn’t need help with showers. So it definitely is a decline.

Residents with higher levels of dementia required proportionately more attention from DCWs, thus lessening the time available for other residents. In 2008, before culture change was introduced, certain DCWs were designated “floaters” assigned to provide care for residents with higher levels of dementia. In Study 3, a DCW shared her belief that some residents were not appropriate for AL:

Some of them need more, way more care. Like some of them I feel don’t even belong here. Some of them belong in locked facilities because they’re wandering and it’s too much to try to control, like keep an eye on them and then still tend to the other residents and give them all the attention that they need, and give out your meds, and follow through with your assignment sheets. So again that’s still a lot on us, but we are required to do that.

Another DCW corroborated in 2018, “I think the people that we’re caring for are not assisted living; I think they’re more of a nursing home.”

Residents with higher levels of dementia posed problems to DCWs who were administering medications. A nurse during the first study noted, “There was a medicine aide, and she did all the medicine and then the others [DCWs] took care of the residents.” Several DCWs from the second study called our attention to the distractions, “You’re responsible for medication and you have a resident on the side yelling, ‘What do I do?’ or ‘I’ve got to go to the bathroom.’ That can cause a medication error. … You get burnt out! It’s a lot of work.” During her interview in 2018, a DCW responded to the question, “Do you think [the UW model] is a good thing?” “No. It’s a lot. It’s a lot. It’s overwhelming at times.”

As residents aged, many experienced cognitive decline over time and behavioral symptoms increasingly strained the UW model. Speaking of a resident who had moved to Evergreen in early 2013, a DCW shared her frustration in her 2018 interview:

We’ve been telling them [management] that he’s been going down, like he’s doing a lot more than what he used to do. He’s peeing in the trashcans. He’s peeing in the corners, and then they complain “Oh, the floor is stained.” At 9 o’clock in the morning when management comes in, “Oh, the floor smells funny.”

Despite DCWs informing management of their decline, residents with high levels of cognitive impairment remained at Evergreen rather than transitioning to a dementia care facility. A DCW offered this rationale in 2018, “I think it’s just based on money. They’re not going to let that person go because … that’s one less person giving them money every month.”

Modifications to the Universal Worker Model

A family member at the initial introduction to culture change in 2010 posed a question to the director, “How are the aides going to do all this?” Evergreen’s administrators gradually acknowledged the time constraints on DCWs. In Study 3, we observed adjustments to the UW model alleviating responsibilities from DCWs in three areas: serving meals, managing activities, and housekeeping. In 2012, a DCW reported that giving out medications often made her late to the dining room and this became an issue with the dining room staff. The first modification to the UW model we observed when we returned to Evergreen in 2017 was that the DCWs were no longer assisting in the dining room as they had been in the earlier studies. Dedicated dietary staff served meals, allowing DCWs time to assist late risers in the mornings and complete some of their varied tasks during mealtimes.

During staff interviews in Studies 2 and 3, DCWs and management told us that activities and housekeeping were areas where the UW model strained the DCWs. Data from our interviews over time underscore the views of DCWs toward the conflicts inherent in the UW model. Asked about the UW model in 2018, a DCW told us:

I would really, really like them to … get an activity person. [The household coordinator] just puts on [the schedule] what’s supposed to be done that day, but we the staff, we the employees got to do it. She just puts like Bingo today, or whatever, but we got to do it.

In 2013, the woman who worked at the front desk compared activities before and during culture change, “They had the activities director [before culture change] and I know she had two people under her. We knew that activities were going on. I know the DCWs are bogged down with so much work because they’re doing three peoples’ jobs.”

The director who introduced culture change to Evergreen retired in mid-2018. During her exit interview she was asked about bringing back an activities coordinator. She responded, “If I were to make a change I might go back in that direction.” A year later the new Evergreen director shared that an activities coordinator would start soon and that prospects for housekeeping had been interviewed.

Concerns about housekeeping and general cleanliness were consistent throughout the ten years we observed at Evergreen. During the 2010 introduction of culture change, a family member loudly voiced her concern about eliminating the housekeeping staff. Two years later a household coordinator told us that each DCW was expected to do five loads of laundry during the night shift and four loads during the day shift. In addition to the routine housekeeping for the residents, DCWs were expected to clean the common areas, including the public restrooms used by visitors. DCWs objected to these added duties and ethnographers observed that the public areas were often soiled.

A DCW highlighted the problem in her 2018 interview:

When [the director] came she changed the whole thing. She’s like we don’t need [housekeeping staff] because we have enough time to do it. … I want to tell you their rooms are not being cleaned like the way they’re supposed to…. We don’t have time.

Asked if she had seen changes in the UW model, the same DCW responded:

Nope. We still do it all. I heard talk of changes because a lot of people were saying like it’s, it’s too much. It’s a lot. And then we get into more trouble, like more write-ups and things because we have so many different roles and we have so many people to take care of at one time it gets overwhelming.

Benefits of the Universal Worker Model

During Study 2, the director explained the benefit of consistent assignment of DCWs as it related to dementia care. “We were seeing residents living longer and having more complicated diagnoses … They behaved in ways that they didn’t behave before. … We wanted the [DCWs] to be more aware and more knowledgeable of their residents and the residents with them.”

In 2013, a household coordinator noted the benefit of consistent assignment to the residents, “Instead of floating all over the building, [DCWs] are consistent with the same people, so [residents] know that Jane is coming in 3 to 11, Mary is coming in at 4 o’clock. … The culture change was good for that.” The UW model seemed to promote person-centered care. In another interview from 2013, a DCW described her strategy to accommodate a resident who wanted to stay in her room but whose family wanted her to participate in activities:

She doesn’t like using the public bathroom, so when I toilet her… like every two hours, maybe two times in the morning, I’ll let her sit in there [her room] for about a half hour to have her quiet time and then I’ll let her go sit [in her room] for another half hour after lunch just to have her quiet time to herself and then bring her back out.

We observed strong social bonds between residents and DCWs throughout the three studies. In 2018, a DCW echoed a feeling that others shared, “You know they’re going to go [die] because this is their home until the end – but when you grow a bond with them, and they live for so long at times, and when they go it’s like, dag!” A household coordinator, who had worked at Evergreen since it opened, told us in 2013:

I’ve seen a lot of seniors come and go and you know, each one of them made an impact on my life. A lot of these people, we’re the only family they really have. Like they see us EVERY day…you know, my heart is in my job, like I don’t come here because I make money.

Not all DCWs felt the workload was overwhelming, but there was little time for the personal interactions that the UW model was supposed to inculcate. In response to our question in 2018, “Do you ever feel like you don’t have enough time?” one DCW responded:

Yeah, it’s enough time for it because we have 10-hour shifts so it’s, it’s enough time to do what you need to do … just not enough time when you want to sit and talk. Because I do want to, I do want to, because I like to hear what the residents have to say because… they just like to talk.

Discussion

Our findings suggest that as the cognitive impairment of Evergreen residents increased, the UW model became strained. As DCWs struggled to complete their varied duties, time constraints inhibited the close relationships between them and their residents that culture change was meant to facilitate. The director who introduced culture change to Evergreen often compared DCWs to home care providers:

So the universal worker model is that you’re working in someone’s home. You’re cleaning their bathroom, you’re giving them a shower, you’re toileting them … You’re also interacting with them in the common area, doing some things with them. You’re doing their laundry. … We don’t have a housekeeper, we have someone who comes into your room and knows … that you want your slippers under your bed rather than in your closet or vice versa, so that that person working in your place gets to know you. Our staff doesn’t float all over the building, they work with the same people and that became really important as we saw the change in cognition of so many of our residents. It was much better to have the same people working with the same residents for continuity and the elders feeling like they knew who the people were. They weren’t having strangers look after them.

The significant difference between in-home care and UW task assignment in a large AL is that home care workers are taking care of one person at a time, not 15 to 20 as was the case for DCWs at Evergreen.

Distractions to DCWs by residents with higher levels of dementia engendered medication errors – which was a cause for dismissal. DCWs reported these distractions and ethnographers observed staff discharges because of mistakes in administering medications. The residents who required constant individual attention also diminished opportunities for social interactions between DCWs and other less demanding residents.

We must acknowledge that many ALs struggle to maintain their census levels – the need to “keep the beds full” is a financial reality. As new residents were admitted to Evergreen, there was an implied promise that this would be their “last move.” The staff made every effort to keep residents until they died, and many people did pass on in their rooms, often attended by a DCW. But this ideal was not always possible, and when a long-time resident’s cognitive decline was severe and disruptive, they were transitioned to a more secure facility. This was the case with the resident who “peed in the trash can” and constantly wandered into other residents’ rooms.

The benefits of culture change were also apparent. Among the long-term staff, some for 15 years or more, many reported close relationships and described residents as “family.” Residents were well cared for and, to a degree, collaborated with DCWs in their daily routines. The application of the UW model of task assignment did not impede care, although housekeeping and activities were attended to sporadically.

Modifications to the UW model relieved stress on DCWs and allowed more person-centered care. The director who served at the end of our time at Evergreen described his view:

If a process wasn’t successful, like the universal worker, … if they are giving meds, but also cleaning, if we keep seeing issues with cleaning, … OK, let’s hire a housekeeper rather than keep pushing this, this person with a clinical background to keep cleaning… There are some aspects that did not work. … You have to adapt.

Limitations

We did not consider residents’ views of culture change in this analysis. Exploring relational care dyads, especially between residents and DCWs, using longitudinal data and focusing on the implementation of culture change principles would enhance our understanding of person-centered care.

Conclusion

Consistent assignment of DCWs to specific residents supports the objectives of culture change. Familiarity between residents and their care givers encourages stronger relationships and promotes person-centered care, especially in the care of residents with severe cognitive decline. In an institutional setting, UW model of task assignment creates time constraints as DCWs struggle to balance personal care of residents with housekeeping and other duties. The UW model was designed to work in small, home-like environments as in the Green House project. When applied in a large institutional setting housing residents with severe cognitive impairment, the UW model diminishes the well-being of the direct care staff and the residents, and leads to high staff turnover. Modifying the UW model, by using dedicated cleaning staff and other support workers, may better preserve the intent and sustainability of the culture change movement in long-term care.

Highlights.

• Direct Care Workers report time constraints; impede person-centered care under Universal Worker model

• Modifications to the Universal Worker model support Culture Change in institutional long-term care settings

• Person-centered Care of persons with dementia is challenged in large institutional assisted living settings

Appendix A. Culture Change Interview Guide: Staff

Work History

1. What kind of work do you do here? What does Evergreen expect from you?

2. How long have you been here?

3. Have you worked with older people in other settings: AL, NH, in-home care, ADS?

4. What brought you to Evergreen assisted living?

5. What were your expectations of Evergreen before you came here? Had you heard about this place? What did you hear?

6. Have you had special training in dementia care? What did it consist of – CD, online, in-person, etc. Is it ongoing?

7. What is your favorite part of your work? Least favorite? Why?

Residents’ Health

1. How is the health of the residents – in general?

2. How independent are most of the residents? Does Evergreen encourage independence? How?

3. How independent are residents with Alzheimer’s? Is independence encouraged for this group as well? How?

4. Do residents with AD affect residents with little to no cognitive impairment? How?

5. What about staff? How are they affected?

Staff Member’s Relationship to Residents

1. Do you help the same residents most of the time or do you rotate? (Hall/Floor)

2. How are residents assigned?

3. What happens if one floor becomes more challenging than other floors?

4. For how many people here do you have responsibility?

5. Are you satisfied with the work plan?

6. What would you like to see changed in the way staff works with residents?

7. Do you feel that you spend enough time with residents?

8. Do you feel that you and each resident work as a team?

9. Do residents make their own decisions? Which ones?

10. Do they have input on scheduling showers? Choice of clothes? Bed time?

11. Does Evergreen feel like home to the residents? Have you heard residents refer to Evergreen as “home?”

12. Do you think residents feel they have power or control over their lives? How?

13. Do you have favorite residents? Why are they your favorites?

14. Are there some residents you don’t care for? Why is that?

15. What do you wish you could do for residents that you can’t?

16. What do they like you to do for them?

17. Do you feel adequately trained for this work? If not, what training is needed?

Culture Change

1. Have you observed any changes going on in Evergreen since you started working here? What changes have you observed?

2. Has anyone spoken to you about “culture change?” Have you heard that term?

3. What about “person-centered care?” Have you heard that term?

4. If yes, please tell me what they mean to you. (If no, talk about it generally and consider the response.)

5. Do you think that “culture change” is going on in Evergreen? Why?

6. How has culture change affected you and your job?

7. Has culture change affected your relationship with residents? Staff? Families?

8. Do you think the health of the residents has improved since they began culture change here? How so? Probe: Physical, Psychological, Emotional.

9. Do you feel that culture change makes life better for residents? What about staff?

10. What is good about culture change?

11. What is not so good?

12. Is person-centered care possible to achieve in an AL? Why or why not?

13. Does it work for all residents? Which ones? Residents with AD?

14. Is there sufficient staff at Evergreen for the person-centered or culture change model to work?

15. In your former employment, had you encountered culture change or person-centered care? Probe.

16. How has your workday changed since culture change was introduced?

17. Do you feel that you and the resident are on the same team?

18. Should culture change/person-centered care be modified? How?

19. What changes would you like to see introduced into Evergreen?

20. What would you like to see remain the same?

21. Do you have enough time to get your work done? What tasks are postponed if time is limited?

22. Do staff members help each other out? When? How?

23. Are the “old ways” of caring for residents better or worse? Explore.

24. Would you rather work in an AL that doesn’t have culture change? Why?

25. Is Evergreen supportive of its staff. How?

26. How could they be more supportive?

27. Do you feel empowered to do your job well?

28. What are your final thoughts on culture change/person-centered care?

Appendix B. Culture Change Code Structure

Category	Code	Definition
Actors	Family	Relatives of residents, chosen family, fictive kin
	Friends	People from outside Evergreen - not other residents
	Paid Caregivers	Private pay care workers
	Residents	Present, past, or pending admission
	Staff-Administration	Director, Office Coordinator, Household Coordinators, Receptionist, other office workers
	Staff-Dietary	Dining room and kitchen staff
	Staff-Direct Care	Frontline staff, med techs
	Staff-Maintenance/Housekeeping	Staff specifically assigned to building maintenance or housekeeping, including PRN housekeepers
	Staff-Nursing	All nursing staff, including adjacent NH
	Volunteers/ Contractors	Paid contractors & musical performers, unpaid volunteers; groups of children visiting
Actions	Activities-Group	Planned or unplanned activities involving three or more residents, including Bingo, games, and events like ice cream socials; NOT groups of residents watching TV or waiting outside the dining room
	Activities-Individual or Self-Directed	Self-directed activities - watching TV, reading, puzzles, solitaire, needlework - in a resident’s room or in public spaces
	Body Care	Toileting, Depends, incontinence, bathing, hair, nails; getting residents ready
	Communication/ Language	Sharing information or opinions, forms, body language, symbols (uniforms)
	Decision-Making/Collaboration	Decisions by any Actor; staff-resident and/or family group decisions; Resident Council; managerial decision making, collaborative (or not)
	End of Life	Talk of death or dying; include hospice
	Housekeeping	Cleaning residents’ rooms or common areas; laundry; does NOT include cleaning up meals in the dining room (code that Dietary)
	Medical Care	Include medications, doctor visits, nursing, podiatry
	Moving in or out/ Returning	Talk of new residents; residents returning from rehab; movement to NH or elsewhere (another AL); change of rooms within the building
	Power/Control	Staff empowerment and resident autonomy (or not); authoritarian rules and behavior; power from the top down; the structure of an institution; a defined set of staff roles
Aspects of AL	Dementia	Reference to confusion; cognitive decline; Alzheimer’s or other dementias
	Dietary/Dining/Food	References to food; residents eating; dining service
	Finance/SES/Class	Money talk; insurance; resident census
	Flexibility/Schedules	Schedules (who does what) and calendars; situations where activities deviate from the published calendar; flexibility in attitude or willingness to change
	Health-Mental	Psychological issues; depression
	Health-Physical	Illness or weakness in the body; brain injury
	Home	“It’s their home”
	Nursing Home or Rehab	Including references to adjacent NH and other NH/rehab facilities
	Physical environment/Maintenance	Building maintenance; rug cleaning; when changes to the physical environment occur, co-code with Change Over Time
	Regulations	References to government oversight at any level
	Religion/Spirituality	Reference to any religion or talk of spirituality; meaning in life
	Social Support/Friendship	Situations or actions that show or encourage connections among staff and/or residents; friendship among residents
	Staff Well Being/ Support/Training	Situations or actions that contribute to staff well-being; training - online, shadowing, or other training provided by the setting; teamwork (or not)
Evaluating Culture Change	Barriers to CC	Resistance to CC by any Actor; situations that work against the principles of CC; challenges of CC model
	Benefits of CC	Situations that highlight good outcomes attributable to CC
	Change over time	How things are different (or the same) from how they were before CC; trying different ideas within the CC model; modifications to CC
	Introduction (2007-2009)	References to Culture Change during Study 1
	Implementation (2012-2014)	References to Culture Change during Study 2
	Meaning of CC	Descriptions of and language relating to CC model/philosophy; references to Person-Centered Care; attitudes toward or about CC by any Actor.