Culture change in nursing homes

Culture change in nursing homes means amending the way we think of the experience. Everything from language awareness to appreciation of dignity in choice. This week on the podcast, we welcome Carmen Bowmen to discuss why a culture change is important to the quality of life for all involved.

Schenk: Hey out there, welcome back to the podcast. My name is Rob. I will be your host for this episode. We’re going to be talking all about culture change in nursing homes – what culture means and how that impacts the lives of residents of nursing homes across the country.

Before we get into culture change in nursing homes, a simple ask, that is please, if you are enjoying the content of these episodes, like and subscribe wherever you get your podcasts from. Then check out our YouTube channel, The Nursing Home Abuse Podcast YouTube channel – like and subscribe there. If you’d like us to talk about a specific topic, let us know. Shoot us an email, leave a comment, let us know somehow, smoke signals, doesn’t matter. We will attempt to get to every single one of your suggestions. In fact, many of our upcoming episodes come to us from listener suggestions.

So with that out of the way, let’s talk about what the topic of the show is, and that is culture change in nursing homes. But we’re not doing that alone, we have a guest this week. Her name is Carmen Bowman. Carmen Bowman is a consultant, trainer, author and owner of EduCatering, catering education for compliance and culture change, turning her former role of regulator into educator.

Carmen was a Colorado state surveyor, an inspector and policy analyst with the federal government Division of Nursing Homes of CMS, where she taught the national basic surveyor course. She’s been a part of many national culture change projects with CMS, The Pioneer Network, National Culture Change Organization. She has a master’s degree in healthcare systems, a bachelor’s in social work and German – sprechen sie Deutsch, Carmen? She cofounded the Colorado Culture Change Coalition and has authored eight culture change books plus host a monthly web culture change talk show, “Conversations with Carmen.” Her passion to share the inexpensive, common-sense better practices of culture change with anyone who will listen and hopefully many of you will be listening as we have Carmen on the show. Carmen, welcome to the show.

Bowman: Thank you. Thanks for having me, Rob.

Schenk: Now we talked a little bit at the top about your background as a surveyor. We didn’t talk about what exactly culture change is. So from a broad standpoint, Carmen, what do you mean when you say, “Culture change in nursing homes?”

What does culture change in nursing homes mean?

Bowman: Yeah, thank you. Sometimes, I’ll just be honest, people – it’s natural, we get confused with the word “culture.” And oddly enough, some people think ethnic culture right away – they get a little stuck on that, so I’m glad you asked because let’s just get that out of the way. Obviously we can’t change someone’s ethnic culture, so if your brain went there, it really means institutional culture. And so in a way, we should have put that in the title, because it can be confusing. But I think everybody knows what we’re talking about when we say institutional culture. Doesn’t take long for people to say, “Oh my goodness, yes.”

That means you kind of lose who you are. It’s not your schedule anymore. It’s the institutional schedule. You are told when to do what. You are not given a lot of choice. So guess what? Culture change means changing institutional culture to actually create home. By the way, we don’t home-like even though you will hear that terminology. Who wants home-like? I don’t want home-like. I want home. I want true home. And it’s a big ticket, everybody, because if it’s your home, guess what? You’re making the decisions. And many of you listening go, “Whoa, my mom and dad, they are not making the decisions.” I know. But that’s why we have a movement and we have leaders in the movement who can show us how they do it.

So for instance, there’s a home in Denver that involves residents and team members – I don’t use the word “staff,” it’s kind of institutionalist. I love the word “team member” – and so the people who work there and the people who live there are all involved in making decisions, true decisions about the place, such as what juice to buy. They’re sampling, “How much does this one cost? How much does this one cost?” We have homes in Illinois where residents are actually involved in hiring the people who are going to take care of them. There’s a resident hiring committee, and you have to pass that committee in order to work there. And so I just need people to hear across the country these things are actually happening.

You are not woken up on the institutional schedule. Instead we recognize how important sleep is. Why would we wake you up? Your body should decide when you wake up. How many of us love getting to sleep until our body has had enough? Isn’t that amazing? And I’ll say a few more things, Rob, and then you react, but it’s your body that decides when to wake. We have open dining so you can dine when you want to, when you’re hungry. That might be early, that might be late, that might not be any breakfast at all.

We have also more like – we have changed environments – maybe some of you have heard. We’re building nursing homes to look like a house, believe it or not. They’re called green houses or small houses. We also have a model called the household model, and so you live in a house and you have a private home. And there’s the dining room and there’s the kitchen you can actually go in. Why? Because it’s your home and it’s your kitchen. So just a smattering right there.

Schenk: Thank you for that. And if I understand correctly, it’s culture – institutional culture change is, if I understand it correctly, not necessarily the changes that the resident has to go through from being independent or living on their own and then going to long-term care. It’s the approach that long-term care takes to the resident…

Bowman: Yes.

Schenk: …In order to make the resident feel at home. Maybe that’s not the right word. As you said, it’s not home-like. That is the home.

Bowman: Right.

Schenk: So institutional culture change is making the facility, the institution of long-term care a home. Did I understand it correctly?

Bowman: Yes, yes, yes. And it can be in any type of building. You don’t have to redesign the building. You can create true home in an old institutional building.

Schenk: I understand. And by way of example, you mentioned that from an institutional standpoint, facilities generally will hire staff based on whatever training they have based on the interviews with the administrator or human resources or whatever the case may be, leaving the residents out of it. However, applying culture change to the institution, making it more of a home, you mentioned that there’s at least one facility that allows the residents to kind of do the interview. So that’s an example of culture change. I think I understand that because at first I was confused, like okay, is culture change the resident comes into this place and it’s no longer home? No, it’s the approach the long-term care facility takes to the resident to make it home.

Okay, so that was – the residents interviewing the potential team member, referring to the team as “team” versus “staff” – what are some other examples from an institution, from a facility-wide standpoint of culture change? Like how can that be approached from an institutional level?

How can culture change be applied institutionally? 

Bowman: Sure. Oh, there’s so much, Rob, that we can talk about. One reaction I’m having to your question is, not to correct you, but another example is to stop calling it “facility.” Here’s what’s helped me and I want to help everyone listening. If you think of a home, would you ever call it a facility? Isn’t that something? We all live in homes. We call it a home. Now sadly, many of these places do look like an institution. I have people kind of joke back and say, “Carmen, it is a facility,” you know? But here’s the point – in real life, real people don’t live in facilities. It’s not a word we use. And this has also helped me.

So what is a facility? It’s like where the buses are parked or it’s even a school, everybody. Why? Because nobody lives there. It’s a facility, it truly is. So even though we’re used to saying it, Rob, you’re used to saying it, even though it’s in the regulations, guess what? We don’t have to use it. And to be honest, the more you use more normal language, the more you will create a culture change because every time you say an institutional word, you promote the institution. Every time you take a breath and you choose to say a better, less non-institutional word, you create a better home. Isn’t that cool? So you can trade out “facility” for the word “home” and the word “community.”

We love the word “community” in this movement because I think it’s a good word. If you think about it, even one small nursing home unto itself is a community. It’s a fair word. Now sometimes you might talk about the community at large, the town you live in, but you can use that lingo. And then it gets even better, instead of “units,” we traded out for the word “neighborhood.” If you think about it, neighborhood fits community fits the language of home. And we even have homes in Colorado where the people who live there, we could talk about not calling them residents, the people who live there chose to be called and call themselves neighbors. So neighbors live in neighborhoods live in communities live in homes.

And now, guess what? This is so, I’m sorry, disgusting to me, when someone goes into a nursing home, they’re often referred to as the “new admit.” Think about that. If you traded out for neighbor, now you’re the new neighbor. Whoo! Isn’t that good?

Schenk: That’s fantastic. And I’m never above reproach with regard to the words I used. I mean I’ve learned so much in the five, six, seven years we’ve been doing this. I completely understand – everything from cognitive impairment to these types of things that you might not say anymore. So I appreciate that. That makes a lot of sense.

Bowman: Of course.

Schenk: In fact, I recorded an episode – we record a lot of episodes at once and they go out in the future, and one of the episodes coming up is about the concept of accidents under the federal regulations, and as a member of the plaintiff’s bar, we discourage the use of the word “accident,” because most people attribute that – most people when they use the word “accident,” they’re saying no one is at fault. So the term accident, that’s why it needs the moniker “avoidable” or “unavoidable” in the federal regulations to get around it. I typically don’t like saying “accident” for that reason, so we need to educate people that the same thing.

Bowman: Thank you. You’re right.

Schenk: So if I understand correctly then, one of the ways that a nursing home, that a community, that a neighborhood may implement culture change is the use of words.

Bowman: That’s right.

Schenk: That’s an institutional thing that the team members can put in place and change their documentation. So the face sheet may read, instead of facility, it would read, “This is whatever, Glen Oaks Neighborhood,” not unit, but this particular Neighborhood Alpha, or not even Alpha – may be too clinical – Neighborhood Tall Tree. I don’t know.

Bowman: Well guess what? I always use this one, Rob – Aspen Neighborhood. I’m from Colorado. We tend to glum onto words from our area.

Schenk: Sure.

Bowman: So you’re right. Tall Tree, Elm, Elm Neighborhood, whatever.

Schenk: There you go. That makes sense. And can you tell me, Carmen, in your experience, in your anecdotal research into this, what are the benefits of these types of changes, this type of approach to long-term care. What effect does this language have on the resident? How is that good or bad for them?

How does culture change and compliance intersect?

Bowman: Well keep in mind, we’re starting with language here, everybody, and language, I do like to point out, is powerful and it costs no money. Isn’t that cool? We can all change our language, and then just watch what it does to the culture. However, that’s just words. Now take it to the next step. If we call it a home, ideally we treat it as their home, like we said. Here’s a sad example. A lot of designers fly in from out of state and they decide how to upgrade the décor and then they fly home. That is not home to the people who live there, see? The people who live there would be deciding what décor they want.

So it’s one thing to change language, and that’s very, very good, but it’s also an important step to make a true home, not just semantics. And as you keep doing this, changing institutional culture so it’s more of a home and less of an institution, the outcomes like you’re asking for are so good. Let’s say I live in a nursing home and I start to say, “You’re not going to believe this place. First of all, they don’t wake me up. They honor sleep. I’m so rested. Finally.” Guess what happens when people are well rested? Their health is better. There’s less depression, less anxiousness. For heaven’s sake, we call ourselves healthcare – it’s kind of a lie because we wake people up on the institutional schedule. We wake them up all night long – we can talk about that – to check and change. We treat people very generically and institutionally. We’re supposed to treat people individually.

And then, “Oh my gosh, you’re not going to believe this place. You can eat when you want. I don’t have to be in the dining room at a certain time. That’s why they can honor my sleep.” By the way, we don’t say, “Let me sleep.” We don’t say, “Allow.” Not to pick on you, Rob, it came out of your mouth a little bit ago. It’s very common, and here’s some good news, everybody – I don’t allow you to do things. You don’t allow me to do things. Adults don’t allow. And so we support the people who live there to make those decisions or we support sleep, and then we honor choice by giving these open dining times. You can dine – the dining room’s open from this hour to this hour, or better yet, we have 24-hour dining. We have homes that have realized, “Well I have a kitchen, I have staff that make food, you give residents what they want when they want it.” Isn’t that cool? That is what we could have, everyone.

So now you have very satisfied, healthy people living there. And then, Rob, it gets even better. Most people want to work in that kind of environment. So you have higher retention. You have better longevity. You have people who are satisfied, not calling the health department with those complaints or the ombudsmen. When ombudsmen are asked, “Where should Mom live?” – “Well, you should check out this home.” Think – all the outcomes are positive. You’re going to save money when you honor people’s natural routines and you don’t make them do stuff. You are going to save money with less turnover. You are going to make money because the nursing home makes money when people want to live there and they’re full, and you’re going to have better regulatory compliance. So it’s all there.

Schenk: So if I understand correctly, there are several benefits to addressing culture change in nursing homes, at least one of them being that your team will be more likely to respect the dignity of the residents, and when the dignity of a person that lives that is respected, they’re more likely to have positive health outcomes.

Bowman: That’s fair.

Schenk: I completely agree with that. I was investigating a case a few months ago where there was no culture change. This was a facility with a capital “F.” And they were cited for immediate jeopardy on several things, but one of the things that was not immediate jeopardy, they were cited for the use of language, which is rare in what I’ve seen, but it reflects the type of training people in this place were receiving, the staff with the capital “S,” not a team. And it was a matter of, in front of the surveyor, one registered nurse who was training I believe a CNA, a couple of CNAs, in front of the residents, in front of the people that lived there, this was their home, said, “Well these are the feeders. These are the ones that maybe can do it on their own,” referring to people as “feeders” or “non-feeders” in front of them, to their faces. And they were cited for that. And to me that reflects not only the care that’s provided by them but what does that do to the dignity of the person that’s standing there and has to hear that they are referred to, reduced to being a “feeder?”

So I completely understand where you’re coming from. Obviously there are many things that make culture change, but language being, as you mentioned, free, but so important to the dignity of these people, which in effect has an effect on the positive outcomes of people.

What is your – obviously, I mean I don’t know in your experience how widespread this concept is, like I don’t know if – the places that I deal with in Georgia aren’t embracing this. What is your understanding of how far we’ve come with these concepts?

Bowman: Yeah, well I have bad news there. Sadly our 20-plus year movement has not taken ahold as you can see. Here’s some evidence that it’s probably going backwards. We used to have 43 state culture change coalitions. I actually am a co-founder of the Colorado Culture Change Coalition. They have various names. We used to have 43. Right now, the last count I heard was 30. So it could be that’s some evidence. So the bad news is maybe it’s taken a step back. It hasn’t grown like it could have. And what we also see there is the administrators that were dedicated to it, they retired, or the companies, the small companies that were doing it, they got taken over by the big companies, right? And so guess what happens when those things happen, right?

But the good news is we have 20 years of evidence that this is better, and thank you, Rob. Perhaps moments like these on podcasts like these where who knows who’s listening and jump on the bandwagon. I’ve got good news for Georgia. There is a Georgia Culture Change Coalition that is trying desperately to make waves and make this happen in that state. You could hook up with them. I could connect you and anyone listening from that state. Be aware of that.

To a general listener, I get excited because we’re Americans. Isn’t there a way to figure out how any of us can help make this happen? So for instance, you’re looking for a nursing home. You ask some of these questions – “Hey, do you wake people up in the morning?” Just see what they say. The institutional nursing home is going to say, “Oh, of course we do,” because it’s like the thing to do, and you’re like, “Oh, I don’t think that’s going to work for my mom.” Maybe ask the next one. Now sadly, maybe they all say, “We wake up Mom.” That’s the hard part. But the more we ask the right questions, “Oh, that’s not going to work for my mom,” “Oh, what do you mean?” “Well she needs her sleep. We don’t want her woken up. She doesn’t want woken up.” And then see what they say. Maybe they say, “Well we can make that work.” That’s what you want, right? At least, “Maybe we can make that work.” But then the culture change answer would be, “Oh my goodness, no. We don’t wake anyone up. Why would we do that?” It’s fun to hear that answer. You know that’s a good place, for instance.

Schenk: Right. So we’ve dealt in the past, we’ve had episodes regarding personal representatives, generally family members that have some type of authorization to act on behalf of their loved ones that are in nursing homes because maybe they aren’t able to do so themselves. So that’s something I heard you say that’s very important, that you ask questions, culture change questions.

Bowman: There you go.

Schenk: That being, “If my mother decides to come here and live here, will you wake her up in the morning?” It’s a threshold question, right?

Bowman: Yes, yes.

Schenk: What are some other things that family members can do to figure out the level of culture in that particular nursing home?

What should families do to demand culture change? 

Bowman: That’s right. So don’t worry, everybody, if you don’t have a list. Just kind of think what would you really want for yourself or your mom, and then turn it into a question. So we want choice – “Do you offer a menu at meals?” See what they say. “Do you have ways for people who live there to make decisions, okay, both about their life, how they run their daily life to decisions about the budget?” like I was saying. So just turn what you hope for into the question, and it’s kind of the opposite of what we typically see in the institution. So I don’t want anybody to panic. Just challenge yourself to get at some good questions.

Another thing I’ve heard people do is you like, with our pandemic, you can’t really do this now, but let’s say you talk to the people who live there already, right? “Are you given decision making power in any way? Do you really get to decide when to take your bath or shower? Do you really get to decide when to go eat?” Just try to get some true information.

Schenk: That makes sense and I would say that education on the family members’ part on what culture change is is equally important because you say, “Ask questions,” but I would say that a lot of my clients, that’s not intuitive. I think my clients, they want a hospital setting because that’s what’s going to keep Mom safe, right, as a home. So I think that’s interesting. Are there any resources on your website that a family member can go to to learn about culture change?

Bowman: Absolutely.

Schenk: And that concept – I know it seems easy as we talk about it, but that might not have dawned on somebody, like, “You know what? I’m going to put my Mama’s dignity first versus her clinical condition when searching for a nursing home.”

Bowman: Good. Well I happen to have some articles on my website where I wrote to the general public for a small newspaper where I used to live, so I’m happy to say I do actually have some resources there. And then just do some Internet searching on culture change in your state – is there a coalition? The Georgia coalition actually has a number of very short videos that they’ve made recently, and it’s meant for all of us, the general public as well as people working in nursing homes. So go check those out.

Schenk: And we’ll have those in the show notes. We’ll have both Carmen’s website and the Georgia Culture Change Coalition website in the show notes.

Bowman: And two more resources – the largest groups representing culture change, one is called The Pioneer Network, so that’s pioneernetwork.net, and the other one is called The Eden Alternative, edenalt.org. And there’s another one, I mentioned the green houses, the small homes, that’s the Green House Project. Oh, and I mentioned households, and the leading group there is Action Pact, actionpact.com.

Schenk: And what was that first one? Pioneer?

Bowman: Pioneer Network.

Schenk: Pioneer Network. Okay, like…

Bowman: Like they’re pioneers in this movement. Yep, that’s right.

Schenk: Well Carmen, we really appreciate it. This is a lot to unpack and a lot to think about, so we appreciate you coming on and sharing your experience with us regarding culture change in nursing homes, and I think we have a lot of good information for our audience, a lot of actionable items for our audience today, so we really appreciate you coming on.

Bowman: You bet. Thanks for having me.

Schenk: Thank you. I learned so much about culture change in nursing homes hosting this podcast. I am never above being corrected on my use of language. Language is absolutely powerful and we should be careful when using particular words, and so I’m so happy that Carmen was able to educate me on my use of these words and how they relate to culture change in nursing homes. So many things I learn – I’m humbled every other week as this podcast comes out.