The Culture of Care Understanding the "Personality" of Your Long-Term Care Facility

by Olga W Malott, Phd.

The notion of organizational culture gained attention in the 1980's when management scientists began to report that organizational change could not succeed without an appreciation of the culture of that organization. As is often the case, ideas that emanate in one area of research and application, cross over to another. Organizational culture as understood in the business sector was soon applied to health care services, especially when health care services began to restructure and reengineer. Visioning sessions, lead by consultants from the management sector, guided the creation of new mission statements and soon health care services shifted to "customer focused" care.

No longer were the users of the services to be perceived as passive recipients of care, but rather as consumers whose well-being and outcome were a reflection of the quality of the service. Patients became clients. This change challenged existing values, attitudes and behaviours of all the members of the health service organization. Not only were new policies and procedures required to support this shift in focus, but the very core of the organization, its culture, had to be modified.

Long-term care services were not immune to this movement toward consumerism. The term "resident" soon replaced “patient” and residentfocused care is now considered a requirement for quality care. In long-term care as the move toward resident-focused care progresses, the concept of organizational culture is also gaining attention. Long-term care facilities are crafting mission statements that reflect their commitments to excellence in resident care. However, it is one thing to write and post a mission statement and another to have the behaviour and activities in the facility accurately reflect resident-focused care. It should never be forgotten that the mission statement is not just a marketing tool. Rather it is a guide for the members of the organization and should direct their behaviours. To capture the full meaning of a mission statement that places resident-focused care as a primary goal, an understanding of the organizational culture of the facility is key.

The existing attitudes, values, and behaviours of the members of the organization, in the care management and staff of a long term care facility, may not be aligned with a residentfocused care philosophy. Thus, it is insufficient to simply develop and post a new mission and change policies. The very personality of the facility must change and this personality is shown in the behaviours and attitudes of staff and management. In resident-focused care cultures, the resident's needs and outcomes become the benchmarks of success. In the same way that we assess the personality of people we meet through our appraisal of their actions, so too families and residents come to know the "personality" of a facility through its actions as modeled by management and staff. The culture of care that exists in a long term care facility is very quickly apparent to all who enter.

Organizational Culture - Definitions

Several authors have provided definitions of organizational culture which clarify the importance of the concept. Schein (1985) was among the first to define organizational culture as the pattern of shared meanings or rules that a group develops to manage their responsibilities and which work well enough to be taught to others who come into the work group. A set of behaviours that are solutions to everyday problems is the definition provided by Van Maan and Barely (1985). A more simplistic definition is provided by Deal and Kennedy (1982), who state that culture (the informal rules) is the way things are done around the workplace. More recently other researchers have agreed with these early propositions, and have added that organizational culture provides a framework for the performance of appropriate behaviours in the presence of day-to-day problems (Hughes, 1990). Currently there are numerous articles in the nursing literature that point out the importance of understanding organizational culture as health services move toward delivering care which has a customer focus and measurable quality indicators and outcomes.

Organizational Culture

The Rules that Govern Culture: Written and Unwritten

In every long-term care facility the staff manage their day-to-day efforts by two sets of rules. One set represents the formal rules, the written policies and procedures that are often enshrined in binders and placed on shelves. Formal rules define when the workday starts and ends, job responsibilities, the wearing of identification badges, in some cases parking spaces, and so forth. There are few facilities without hefty policy and procedure manuals which detail every aspect of the "business". In Ontario for licensed facilities there is the additional guide, the Program Manual, which outlines the rules of operation according to Ministry of Health and Long-Term Care. To ensure the guidelines are followed a Compliance Officer visits from time to time to assess the degree to which this set of formal rules is followed.

But there are other sets of rules that also operate in each facility. These are the informal rules, the ones that are not written down yet but which every staff member knows implicitly.

It is these rules that best capture the culture of the organization. New employees learn these rules through socialization processes and orientation of new employees. The informal rules can be more powerful than the formal rules in controlling behaviour and maintaining attitudes.

Formal Rules (written)

Informal Rules (unwritten)

Impact of Culture

The culture of an organization serves four main roles. These are illustrated in the diagram below. The identity responds to "Who we are." As a sense making device it provides answers to questions regarding "Why do we do things the way we do." Ensuring that all members of the organization have similar goals is part of the collective commitment. Finally social system stability ensures that behaviours of members comply with the established norms.

In the process of influencing the behaviour of staff of a long-term care facility, culture serves as a socialization mechanism for new staff.

Through this process the work group priorities are set and new staff quickly learn which tasks are most important (e.g. it is more important that all the beds are made by 9 a.m. than spending time talking with a family member who is concerned about their relative's confusion), who has the power on the unit (who can tell who how to do a task), and who works with whom (which staff person can be asked to help). Culture also controls how readily change can be implemented, for the informal rules are more firmly entrenched and can be more difficult to change than any written policies.

Nurse researchers have identified that an understanding of culture is critical if there is a desire to change work group behaviour (Coeling & Wilcox, 1988; Coeling & Simms. 1993; Seago, 1996; Goodridge & Hack, 1996). Culture's impact on behaviour is broad and subtle. Furthermore, culture is powerful, exerting control over all members of the group, since it serves as a definition of how to survive the day-to-day problems faced by the work group. Any innovations, such as new care planning methods or novel programming approaches, will be met with resistance if they are perceived to threaten the existing culture. Knowing and respecting the existing culture of the work group, and demonstrating that innovations will also result in successful outcomes for residents and staff, will reduce the resistance. A clever manager will not simply impose change; rather he or she will ensure that the innovation is incorporated into the existing culture to enhance it and modify it in a positive way.

Informal Rules in Operation

Purpose of Informal Rules

Culture can vary from unit to unit. Coeling and Simms (1993) point out that although standards for patient care plans are the same for all nursing units, unique norms within each unit determine the degree of non-compliance with the plans. Perhaps this is best illustrated in facilities that have specially designed dementia care units. Often staff on these units have received special training in how to respond to residents who are cognitively impaired, and are given greater flexibility scheduling care tasks. An observer who enters such a unit and then returns to another unit in the facility can readily see the different rules that are functioning in each unit. The culture of this unit can therefore vary significantly from that of a unit where the residents are less active, better able to make their needs known and have a higher need for medical support. Even when there is no unique dementia care unit in a facility differences between units exist. Consider the facility where you work. How much time would it take to adapt to working on a different unit? If your assignment were the same as on your former unit would you carry it out in exactly the same manner? What sources of information about how things work on that unit would you seek out? How would you learn what is accepted and what is not? The following are examples of the types of questions a person may need answered to understand the informal rules in a particular unit or facility. The answers to these questions will then facilitate how well the person "fits in".

Can anyone make a suggestion to enhance practice or are there only certain individuals that can do this?

Achieving a Culture of Care

Currently in long-term care, emphasis is placed on operating within a culture of care. A culture of care is one where the needs of the resident come first, staff have the skills and characteristics needed to support residentfocused approaches, innovation is embraced and encouraged, success is rewarded and learning opportunities are sought out. All of these characteristics are supported by visionary leadership. In sum, a facility which wishes to achieve a culture of care must have a visionary leader, empowered staff, and organizational learning.

Visionary leadership is required to achieve a culture of care, for a visionary leader embodies the mission statement, empowers the staff, and supports organizational learning. Research has shown that the administrator has the greatest influence on culture and resident outcomes. How is this possible? The administrator sets the tone, reinforces formal and informal rules and embodies the vision of the organization. Being a visionary leader is more about motivating people than giving them direction. Visionary leaders set an inspiring example that demonstrates to others within the organization that the mission is achievable and worthwhile. The administrator who participates in mealtime, demonstrating respect for the resident and supporting resident choice is one example of a visionary leader who models and motivates staff toward excellence.

Empowering staff within a culture of care means that decision making authority be shifted downward.

In addition, staff are encouraged to take risks, to try new things if these will enhance the quality of care. In an empowering culture there are opportunities for leadership roles for all levels of staff, while at the same time existing sources of power and authority are recognized and motivated to use this power for the benefit of resident care. For example front line staff decide on the most appropriate time for resident baths and who is best suited to assist a particular resident with bathing.

Finally a culture of care also reflects a learning organization where staff see opportunities to try new approaches to care and learn from taking risks. A learning organization is also one that responds quickly to changing circumstances such as new resident needs and requests for non-traditional models of care. An example of this would be implementation of intergenerational programming or the Eden model.

How to Assess the Culture of a Long-Term Care Facility

The most straight forward approach to learning about the culture or personality of a long-term care facility is to observe the behaviours of staff, management and residents. From these observations the answers to questions such as the following provide a view of the culture. What behaviour patterns predominate? How does communication take place? Who has the greatest amount of autonomy? Under which circumstances are residents allowed to decide about how their care needs should be met? In addition the unwritten or informal rules of behaviour become apparent and problem solving methods that have been accepted by the group become known. A creative manager is sensitive to these behaviour patterns and acknowledges the broad, subtle and powerful influence of culture.

Assessing the culture of care is also accomplished with the use of questionnaires and surveys that are completed by staff. One such questionnaire is the Nursing Unit Cultural Assessment Tool (NUCAT-2) developed at the University of Michigan School of Nursing (Coeling & Wilcox, 1988; Coeling & Simms, 1993; Rizzo, Gilman & Mersmann, 1994). This measure consists of 50 statements that describe behaviours and values and cultural norms within a nursing unit. Respondents indicate their preference for the content of the statement by rating it on a scale of 1 to 4 with a higher value meaning a greater preference. At the same time respondents are asked to indicate the degree to which each of the statements reflects the actual behaviours on their unit. The developers of the NUCAT-2 used resident-focused care as the basis for the instrument. And all items have a positive slant.

Sample Items - NUCAT-2

In Summary

Assessing the culture of care is also accomplished with the use of questionnaires and surveys that are completed by staff. One such questionnaire is the Nursing Unit Cultural Assessment Tool (NUCAT-2) developed at the University of Michigan School of Nursing (Coeling & Wilcox, 1988; Coeling & Simms, 1993; Rizzo, Gilman & Mersmann, 1994).

This measure consists of 50 statements that describe behaviours and values and cultural norms within a nursing unit. Respondents indicate their preference for the content of the statement by rating it on a scale of 1 to 4 with a higher value meaning a greater preference. At the same time respondents are asked to indicate the degree to which each of the statements reflects the actual behaviours on their unit. The developers of the NUCAT-2 used resident-focused care as the basis for the instrument. And all items have a positive slant.