Why reiterate the PNM? It is because of a paradigm shift in philosophy in long term care.
As the elderly population grows each year there has been more discussion and creative innovations developed in how to care for them. With the realization of the extent to which mental well being affects physical health, alternative models of long term care have developed. Proponents of these alternatives want to see the elderly people thrive instead of decline. They want to give credence to their years of wisdom to allow them a say in their care. Just because a senior citizen requires more care and must move into a nursing home doesn't mean they must give up all independence and are subject to assembly line impersonal care.
This movement from staff directed care to resident centered or resident directed care is known as culture change. Its history goes back to the 1990s and was likely a result of the National Reform Act of 1987. The Kaiser newsletter interviewed the CEO of Meadowlark Nursing Home in 2005. In the interview he stated that the administration became dissatisfied with their current conditions and set the goal for better clinical outcomes. Staff were encouraged to increase their skill set and allowed to exercise their judgment, working to the maximum of their licenses. They became part of ‘self led' teams. The results were positive, medical outcomes improved and staff turnover was reduced. They were the forerunners of a movement that understood the importance of going beyond maintenance in long term care to thriving and a higher quality of life.
Not much thought was given to how nurses fit into this paradigm shift or what similarities there were between culture change and PNM. A productive question to ask is how can similarities in the PNM and culture change create synergy to advance both concepts?
Do nurses feel resistance to culture change and see it as an imposition rather than a participatory invitation?
If so how can that perception be changed? There has not been a lot of research to document nurse reaction to culture change. It is true that certain aspects of culture change are different from the way nurses were traditionally taught. One example is accountability for clinical care. This in turn may change the traditional scope of practice of nurses in a care team. They may become less direct care more supervisory in nature in charge of care teams of CNAs, for example.
What skills and knowledge do nurses need to become initiators of culture change?
In 2008 the Hartford Institute for Geriatric Nursing put together an Interdisciplinary Expert panel to outline and discuss how nurse involvement would look like in culture change. The title of the paper said it all: Overcoming Barriers Advancing Opportunities.
One of several recommendations was to develop a set of nursing competencies specific to nursing home care. Nurse experts reviewed current competencies in nursing and other disciplines with relation to geriatric care and also considered input from nurses nationally through a survey. From 39 it was narrowed to 10 competencies.
A summary of the list is as follows:
Effective communication skills are modeled taught and used. Examples of effective communication are active listening, productive feedback, resolving conflict, and understanding diversity.
Creation of systems through identification of potential barriers to patient directed care.
Adaptation of routines with outcome of person directed care, and evaluation of these systems.
Application of problem solving skills to medical situations in relation to resident choice and risk, facilitating team members, including resident and family, and participation in creating solutions.
Creating systems to ensure consistency of caregivers for residents, and sees the environment as the residents' home, striving to create a home like atmosphere Staff role model person directed care though leadership abilities to promote patient directed care.
The final competency is seeing oneself as part of a team. All 10 competencies in some way reflect the components of professional nursing values, relationships, patient care delivery systems, and management approach.
These competencies are the beginning of the creation of measurement tools to evaluate culture change. Possible resistance to change can be changed by the following best practices: have a measurable mission statement. Feedback and outcome measurement, interdisciplinary interdepartmental involvement, ongoing education and resources, incentive and recognition program, identification of champion and stakeholders in and out of the nursing home.
To be successful culture change must be built on excellence in nursing and the commonalities between it and a PNM. Past examples from 2 decades ago show how PNM can be the foundation of high quality long term care. Although before the time the phrase culture change was invented, these examples show that aspects of PNM helped create nursing care that was effective meaningful work. In the first example the change was initiated based on nursing's service ideal demonstrated in an emphasis on healing.
Nurses exercised judgment in responsive action based on residents' needs instead of textbook care. Peer relationships, documenting care practices and medical outcomes, and forums to further interdisciplinary collaboration, among other initiatives were instituted over a 15 year period.
As far back as 1971, one nurse said at the end of the initiative:
“Here the nurse is the unifying member of the health team…nursing is the chief therapy experienced by our patients…”.
In the second example nurses wanted to increase clinical function by facilitating clinical decision making of the RNs and creating an environment that encouraged professional development. They created a shared governance model where nurses conducted meetings to learn from each other and make decisions collectively. After 4 years the nursing care was less task-oriented and nurses had acquired professional autonomy and accountability for their clinical care.
The traditional scope of nursing practice will need to be modified only after extensive input from those most involved: nurses. In culture change there will be structural organizational change as well as a change in personal attitudes towards elderly and their care. All this will impact nurses and their practice, research, and education. A successful lasting culture change depends on nurses engaging their knowledge, skills, and values.
PNM is the values nurses hold about professional behavior and responsibility put into action. It can do much to enhance long term care and help achieve organizational goals. Much more can be discussed about this area of nursing especially concerning the way PNM and CMS Artifacts coincide. That will be a discussion for another day.
- Sources:
http://consultgerirn.org/uploads/File/NHModule/Module3_Resident_Directed_Care_CChange.ppt
http://hartfordign.org/uploads/File/issue_culture_change/Culture_Change_Background_Beck.pdf
http://www.pioneernetwork.net/Data/Documents/TenCompetenciesReport0510.pdf
Research on Gerontological Nursing Vol. 1 No. 3, 2008.
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