Is Unconscious Bias Impeding Your Culture Change Efforts?

CHPS | August 21, 2016 | by

An incredible level of self-awareness among administrators, and a concerted effort to overcome conscious and unconscious biases among staff, families, and residents, have helped Leonardville Nursing Home in Kansas thoroughly adopt person-centered care and employee empowerment.

Nursing home operators often over-report the extent of their culture change adoption. Researchers have found several reasons for this curious phenomenon.

Some operators don't fully understand everything that culture change entails. For example, earlier national surveys appeared to show that culture change was widely and thoroughly adopted by many homes, but a recent national survey found that only 15% of homes reported that culture change had “completely changed how we care for our residents.” The recent survey contained language that explicitly described culture change practices.

Other homes may over-report their culture change implementation because their unconscious biases about “institutionalization” prevent them from seeing areas of weakness in their programs.

Leonardville Nursing Home, a LeadingAge member in Leonardville, KS, might have succumbed to the dangers of over-reporting. But an incredible level of self-awareness among administrators, and a concerted effort to overcome conscious and unconscious biases among staff, families, and residents, have helped the home thoroughly adopt person-centered care and employee empowerment.

“Before learning about culture change, we thought we had been implementing person-centered care all along,” says Administrator Sandi Hageman.
 

A 4-Year Transition to Person-Centered Care

Leonardville’s transition to person-centered care began in 2012 when the home joined PEAK 2.0, a state-administered Medicaid pay-for-performance program that offers guidance and incentives to encourage nursing homes to adopt person-centered care and employee empowerment.

Two consultants helped Leonardville assess its level of person-centered care; provided recommendations on architectural, operational, and other modifications; and helped board members, residents, staff, and community members determine what they wanted Leonardville Nursing Home to become.

This process spurred Leonardville to transform its traditional hallways into three neighborhoods that each house 15-25 elders in a mixture of private and semi-private rooms. The neighborhoods features family-style dining areas, private visiting areas, two unlocked outdoor gardens, and a playground.

Despite these physical modifications, however, something crucial was missing. Leonardville still did not feel like home to the elders living there.

What stood in the way? Hageman and other staff members point to a number of institutional assumptions that were still prevalent in the nursing home. Basically, daily practices reflected what staff members thought elders wanted, not what elders actually wanted.

“We gradually realized that our model of person-centered care needed tweaking in all areas,” says Director of Nursing Jennifer Colp.

Those “tweaks” involved nothing less than incorporating resident input into every aspect of nursing home life.

“Now, nothing happens without elder input,” says Hageman. “We just do not make decisions without them. They go furniture shopping with us. They help us pick out paint for renovated areas.”

Staff members help one another other stay on track, adds Colp.

“We hold one another accountable for ensuring that all aspects of nursing home life are elder-directed,” she says.

Elders and their families also needed help to transcend their own institutional assumptions, says Hageman. So Leonardville takes deliberate steps to help families of prospective residents understand that their loved ones have the right to make decisions -- even poor decisions like eating a cookie despite being diabetic.

Elders are also educated about their rights so they will be more likely to make choices about major aspects of daily life, and less likely to adopt the “learned helplessness” that is endemic among nursing home residents.

Empowerment is a Risky Business

Make no mistake. This kind of elder empowerment brings with it enormous risk for the nursing home.

“We are allowing elders to decide whether to take their medication and whether to walk despite being at risk for falls,” says Hageman.

Empowering staff, especially certified nursing assistants (CNA), is also fraught with risks. But Hageman believes that flattening the staff hierarchy is one of the most important aspects of delivering person-centered care because it allows for the development of family-like relationships among residents and staff.

“At their own homes, most of our CNAs are ‘CEOs,’ running the household and caring for family members,” she says. “So we assume that they are capable of organizing and running the Leonardville neighborhoods where they work, and we allow them to do that.”

Benefits Outweigh Risks

A few statistics suggest that the benefits of empowerment may far outweigh the risks.

  • Employee turnover at Leonardville, which soared to 120% just a few years ago, was down to 37% last year. 
  • The home’s occupancy rate is currently at 95%, up from around 85% just 2 years ago. 
  • Most admissions (90%) come through word-of-mouth as families spread the word about the nursing home. 
  • Most important, residents and staff love life at the transformed home. 

Feeling Good to Walk in the Door

When I visited Leonardville recently, I had to agree wholeheartedly with the family member who told me, “It feels good when you walk in the door.”

It did indeed.

The first thing I saw was a group of elders and family members enjoying the nursing home’s new coffee house. Everyone was either talking with visible joy or engrossed in reading the newspaper while enjoying coffee. And I saw no elders anywhere in the home parked in wheelchairs doing nothing.

Leonardville Nursing Home doesn’t have a corner on this type of transformation, of course. Other nursing homes can make the kind of changes that I saw on full display in Kansas. Hageman and Colp offer this advice to others:

  • Implement consistent assignment first. Transformation cannot happen without strong relationships among staff and residents.
  • Clearly communicate the rules of elder-centered living during the employee hiring and orientation process. Each potential hire should know that if an elder wants scrambled eggs at 2 a.m., he or she will have to prepare it. 
  • Offer ongoing education. That will help neutralize the ageist assumptions and institutional mindsets that you will continually encounter among staff, families, and residents. 
  • Put your money where your mouth is. The nursing home currently stocks twice as much food as it did prior to 2012 so it can accommodate resident dining and snacking preferences. 


Leonardville Nursing Home has succeeded in eliminating practices that were convenient for staff, but not what elders wanted. It wasn’t easy. But along the way, the home has learned an important lesson: culture change doesn’t depend on a fancy building.

Radically transformed, person-centered practices -- accompanied by modest renovations -- is what created a home that makes Leonardville’s elders and their families feel good inside the nursing home’s doors.