Culture Change in Skilled Nursing

Originally published by the Journal of Housing for the Elderly in 2019

By Lori Gonzalez and Lisa Rill


The culture change movement has pushed for reform for more than two decades to align policy, the long-term care industry, and resident preferences with regard to care. Evidence from research indicates that culture change has the potential to improve quality in nursing homes. There is no one-size-fits-all way to implement culture change; however, there are key elements and associated concepts and models. A common thread is that they run counter to the medical model, typically found in nursing homes, where care is provided in a hospital-like setting according to the schedules and routines of physicians and staff with little resident input. This qualitative study looks for evidence of culture change in a traditional model of care compared to a newer culture change model, by describing the differences in practices associated with the medical model, person-centered care, and person-directed care between the two settings. Our results indicate that there is evidence of person-directed care in one model of culture change—the Green House home—but not in the traditional nursing home. Future studies should examine other culture change models to compare the differences in the utilization of person-directed care. This information will help to clarify the definitions and concepts of culture change, along with developing best practices for future culture change models.


Roughly 25% of all deaths in the United States occur in nursing homes, and by 2020 an estimated 40% of Americans will pass away in a nursing home (Kelly et al., 2010). For many of these residents, the quality of care and quality of life are less than optimal. This has been a common story throughout the history of nursing homes.

Ironically, although the Omnibus Budget Reconciliation Act (OBRA’87) was developed with the intention of supporting quality of life with regard to residents’ rights, its emphasis on quality of care and health outcomes had the unintended consequence of increasing the orientation of nursing homes on medical outcomes rather than on quality-of-life outcomes (Kapp, 2013), thus reinforcing the process of the medical model of care. Improvements in nursing home quality are further impeded by labor force issues, a lack of leadership buy-in, a shortage of funding, and regulation (Engle et al., 2017; Kogan, Wilber, & Mosqueda, 2016; Miller et al., 2010).

The culture change movement has pushed for reform for more than two decades to align policy, the long-term care (LTC) industry, and resident preferences with regard to care. This study, to our knowledge, is the first qualitative study to illustrate evidence of culture change in a traditional nursing home care model compared to a newer model, the Green House home, which utilizes the principles of the culture change movement. We do this by reflecting the differences in practices associated with the medical model, person-centered care, and person-directed care between the two sites. In doing so, our goal is to present preliminary, exploratory, and descriptive findings to encourage future empirical research on the topic in other LTC communities that are implementing the culture change movement.

Culture change

The culture change movement gained significance with respect to consumer advocacy, legal, legislative, and policy after the National Citizens’ Coalition for Nursing Home Reform group shared the results of its 1983 Consumer Survey on Long-Term Care (Koren, 2010). More than 60 national organizations endorsed the findings, which showed that quality of care and quality of life are intrinsically related to each other and are key to elders’ well-being in nursing homes. The Institute of Medicine (2008) used the results of the study to inform nursing home regulations and medical practice. Stakeholders came to a consensus that the ideal facility would be characterized by resident direction, homelike atmosphere, close relationships, staff empowerment, collaborative decision making, and quality improvement processes. The early culture change pioneers, largely drawing on their own experiences as social workers, nurses, and geriatricians, further elaborated these ideas formally as an organization in 1997—the Pioneer Network.

The Pioneer Network defines culture change as

the common name given to the national movement for the transformation of older adult services, based on person-directed values and practices where the voices of elders and those working most closely with them are solicited, respected and honored. Core person-directed values are relationship, choice, dignity, respect, self-determination and purposeful living. (Pioneer Network, 2018)

Comparably, Weiner and Ronch (2003) suggested that it was a way “to balance the power of the medical professions with more consumer empowerment” (p. 95). For this to happen, there needs to be transference of power from the health care professionals to the resident.

Culture change has a distinctive meaning for every organization, depending on where it is in the continuum of change (Deutschman, 2005). While there is no one-size-fits-all way to implement culture change, there are common elements and values found in the movement. Dupuis, McAiney, Fortune, Ploeg, and Witt (2016) identified six principles of culture change held by stakeholders. These principles include a relationship-based approach to care, do no harm, citizenry rights (meaningful choice, self-determination, and respect), diversity and inclusiveness, fairness in eligibility and access, and accountability. They also identified three pillars, including an informed society, enabling and supportive environments, and personal, social, and system connectedness. Other researchers discuss common factors associated with person-centered care, which is found in the culture change movement. A literature review of 132 articles on person-centered care found the customary domains were respect, value, dignity, whole-person care, purposeful living, and choice (Kogan et al., 2016).

Although there are a number of studies that have evaluated the impact of culture change initiatives on nursing home quality, the results to date have been inconsistent because the studies are based on varied outcomes and measures (Grabowski et al., 2014; Rahman & Schnelle, 2008; Shier, Khodyakov, Cohen, Zimmerman, & Saliba, 2014; White-Chu, Graves, Godfrey, Bonner, & Sloane, 2009). However, some evidence from research studies, testimonials, and evaluations have indicated that culture change has the potential to improve quality in the nursing home (for a full review of this literature, see Shier et al., 2014). Additional studies have also shown culture change to be associated with improved psychosocial outcomes and some outcomes related to physical health (Hill, Kolanowski, Milone-Nuzzo, & Yevchak, 2011; White-Chu et al., 2009). Finally, select studies have examined staff with regard to person-centered care (as part of the culture change movement) and outcomes. These findings suggest, organizations with leaders who were fully engaged in person-centered care and who implemented supportive supervisory practices were more likely to report staff job satisfaction and better resident outcomes (Austrom et al., 2016; Caspar, Le, & McGilton 2017; Caspar, O’Rourke, & Gutman 2009; Kogan et al., 2016).

Even though the majority of the culture change literature focuses on the impact of culture change, the aim of this study is not to examine whether or not it has the potential to improve quality or its effect on resident health and staff outcomes, but rather to take a step back to identify what is happening in two different types of nursing home settings with regard to the culture change principles. The culture change movement is currently being implemented through new LTC communities and initiatives, such as the Eden Alternative, The Green House Project, The Wellspring Model, Planetree, and the Pioneer Movement (Brune, 2011; Dupuis et al., 2016). A common thread among them is that they run counter to the medical model, typically found in nursing homes where care is provided in a hospital-like setting. This study focuses specifically on the Green House homes.

The Green House Project

The Green House Project, founded by Dr. Bill Thomas, opened its first Green House home in Tupelo, MS, in 2003 with the intention of transforming the nursing home industry. The vision was to provide homes

where elders and others enjoy excellent quality of life and quality of care; where they, their families, and the staff engage in meaningful relationships built on equality, empowerment, and mutual respect; where people want to live and work; and where all are protected, sustained, and nurtured without regard to the ability to pay. (The Green House Project, 2018)

The research literature on the Green House Project model shows promise for the culture change movement. The model is relatively new; however, studies indicate that in the Green House residents experience better quality of life. In a 2007 study, for example, Kane, Lum, Cutler, Degenholtz, and Yu (2007) compared four Green House homes to two groups: (a) a nursing home that shared the same administration (on-campus), and (b) a smaller nursing home in the same region (off-campus). They found, after controlling for things like residents’ health and functioning, demographics, date of admission, and activities of daily living (ADLs), that residents in the Green House homes were either more satisfied or equally satisfied with their quality of life compared to the other two comparison groups. Additionally, Green House residents, compared to the on-campus nursing home, had greater satisfaction with regard to relationships, food enjoyment, autonomy, individuality, privacy, dignity, and meaningful activity. Researchers have also found that residents and their families liked the Green House homes’ private bedrooms, bathrooms, and home environment, and family members enjoyed visiting the homes (Cutler & Kane, 2009).

Other research has revealed positive outcomes with regard to staff in Green House homes. When looking at time spent on caregiving, Sharkey and colleagues (2011) illustrated that although overall staff time was 18 minutes less in Green House homes than in traditional nursing homes, staff members in the Green House homes spent more time on direct resident care. Bowers, Roberts, Nolet, and Ryther (2016), in their study of 28 Green House homes in six states, found that staff members who had previously worked in a traditional nursing home had greater familiarity and increased interaction with residents, their families, and other care workers in the Green House home. Another study that interviewed certified nursing assistants (CNAs) about their transitions from traditional nursing homes to a Green House home in New York showed that the CNAs felt more empowered, stronger ties to elders, and less guilt and stress about their jobs in the Green House homes (Loe & Moore, 2012). Furthermore, staff in Green House homes had higher staff retention rates, compared to traditional nursing homes (Bowers et al., 2016). Taken together, these studies indicate that Green House homes have positive outcomes with regard to resident and staff satisfaction.

Types of care: Defined

The three types of care examined in this study, which we base our analysis on, can be found in the LTC industry: medical model, person-centered care, and person-directed care. The medical model puts all of the control over the lives of the residents in the hands of the medical professionals (Lines, Lepore, & Wiener, 2015; Weiner & Ronch, 2003). The medical decisions regarding treatments and all aspects of daily life, such as bed and meal times, are controlled by the medical professionals with little conscious consideration of the impact on the residents (Ronch and Weiner, 2013). The residents often accommodate the staff preferences and follow the decisions of the professional (Lines et al., 2015).

Person-centered and person-directed care represent a paradigmatic shift in focus away from the medical model (Lines et al., 2015). With person-centered care, the residents are better informed and have some choice within the existing routines (Ronch & Weiner, 2013). The preferences of the resident are considered when creating the plan of care. The staff begin to organize and incorporate certain aspects of the resident’s preference into their daily routine. But overall, the majority of the power remains with the health care professionals (Ronch & Weiner, 2013).

Person-directed care goes a step further and empowers the individual to direct their care (Lines et al., 2015). Person-directed care gives more control to the resident by enabling self-determination, freedom, choice, and autonomy (Ronch & Weiner, 2013). The difference is the “shift from the person as the object of care (person-centered) to participating as a care partner (person-directed)” (Ronch & Weiner, 2013, p. 21). The residents make the decisions about their daily routines, and the staff members organize their schedule to meet the needs of the residents’ preferences (Lines et al., 2015; Mueller, Burger, Rader, & Carter, 2013). More specifically, Brune (2011) describes person-directed culture as having the following characteristics: Staff members’ relationships with the elders are based upon individualized care needs and personal desires; elders and staff members design schedules together that reflect the elders’ personal desires; staff members have consistent assignments to build relationships; the environment reflects the comforts of home; unstructured activities are available throughout the day; and there is a sense of community and belonging for both the elders and staff members. Overall, a major part of culture change movement is to shift from the medical model to person-directed care, to allow for maximal quality of life for both residents and staff members (Brune, 2011).

Research design and methods

The aim of this research project was to explore culture change in two settings—the traditional nursing home and the Green House home —to differentiate between how prominent the medical model, person-centered care, and person-directed care models were when examined in both sites. A qualitative research design was used in this study. The design was based upon semistandardized interviews with open-ended questions, which allowed participants maximum freedom to express themselves in their own terms and at their own pace (Bernard, 1995). The interviews were conducted to elicit narratives of the overall perceptions and experiences of how traditional nursing homes operate, which were then compared to those experiences in the Green House homes.

The framework chosen for this study was content analysis, which was used to systematically organize the data into a structured format (Tong, Sainsbury, & Craig, 2007). Participants were chosen using purposive sampling, which involved selecting individuals who shared particular characteristics and were likely to provide rich data relevant to the research question (Denzin & Lincoln, 2011; Tong et al., 2007). Participation in the study was completely voluntary and confidential, and participants could opt out during any point. A demographics form was designed to protect the identities of the participants. An informed consent form was provided for their review and signature if they wished to participate. The interviews were recorded and later transcribed for analysis. This study received institutional review board (IRB) approval: number 2018.23051.

Traditional nursing homes: Setting

A typical nursing home in the South, where this study took place, includes the following framework. Upon entering, one can usually expect to encounter a reception desk and a lounge area for residents and their visitors, with couches and chairs arranged around small coffee tables. After passing through the lounge, most homes are then separated into different hallways. The hallways are typically divided into the different payment types or level of care needed. For instance, there are often wings specifically for Medicare and Medicaid residents, private pay residents, and long-term stay residents. Some nursing homes have separate locked units for residents living with dementia or Alzheimer’s disease. These units are designed to keep the residents safe from wandering outside the nursing home.

The rooms may vary from single occupancy to two or four residents per room. Each room contains a single adjustable bed for every resident, a privacy curtain for rooms with two or more residents, a bathroom, a bedside table, a television, and dressers for their clothing. Residents often decorate the rooms with memorabilia from their homes, which can range from simple things such as framed pictures to bigger objects like their favorite chair. These decorations are often an attempt to cover the institutional-type setting and help make the resident feel more at home.

On each hallway there is a nurse’s station. This is where all the nursing supplies are kept and the residents’ charts are filed. There are three different types of nursing personnel: registered nurses (RN), licensed practical nurses (LPN), and certified nursing assistants (CNA). Each type has specific responsibilities on the floor and to the residents. It is the responsibility of the RN to delegate assignments, perform administrative tasks, and document on each resident’s daily progress. The LPNs apply resident treatments and dispense medications. It is the CNAs’ job to provide the direct care to the residents. This involves duties such as assisting with dressing, going to the bathroom, and bathing the residents.

In addition to the nursing staff, there are many other employees found in the nursing home, including the housekeeping/janitorial staff, dietary/kitchen staff, activity staff, therapists, and social services. Each department has its own policy and procedures manual that members are expected to follow. The state evaluates each of the departments in the nursing home to help reinforce the rules and regulations. Overall, the nursing homes in the South consist of highly regulated departments that include the task of caring for the residents in their own specialized way.

Traditional nursing homes: Interviews

The participants included in the study were administrative staff (administrator, former owner, former administrator, consultant, and MDS [Minimum Data Set] coordinator) and nursing staff (LPN and CNA) from multiple nursing homes. Throughout the course of this study, 12 face-to-face interviews were conducted. Nine of the informants were women, and three were men. Five of the interviewers were from the administrative staff and seven were from the nursing staff.

Green House homes: Setting

Green House homes look and feel much more like home than the traditional nursing home. They are designed to resemble the communities in which they reside and are based on available real estate. The 12 Green House homes in the current study are located in a continuing care retirement community and housed in a seven-story building. Each Green House home has between 10 and 12 elders, who are each given their own private bedroom and bathroom. They have a hearth area with fireplace, a dining room where residents and staff eat together, and a kitchen that is open to residents. Each home provides access to green spaces or gardens. Numerous windows allow natural light to flow into the homes, including bay windows in each private bedroom. The ground level has a spa, a fitness and rehabilitation center, and a restaurant.

The Green House model reworks the traditional hierarchy that exists in nursing homes with a self-managed work team. Shahbazim (certified nursing assistants) get an additional 128 hours of training in topics such as food preparation, cardiopulmonary resuscitation (CPR), teamwork building, and coordinated care with the other care team Guides (Green House administrators, nurses, physical therapists, activities director, dieticians, and social workers). In addition to health-related responsibilities, Shahbazim perform other tasks such as grocery shopping, cooking, and cleaning. This type of staff organization gives Shahbazim the ability to interact with residents on a social level and to work directly with the other health care team members to coordinate care (Rabig, Thomas, Kane, Cutler, & McAlilly, 2006; The Green House Project, 2018). The intended result of this type of organization is to empower Shahbazim to provide quality care and to encourage social interaction for a more meaningful life for residents. Sages, or elder volunteers, living within the community provide informal advice to the care team including the Shahbazim.

The Green House Project also accomplishes its goal of creating a home by fostering person-centered and person-directed care. Residents are treated with respect and dignity—they make decisions about when they want to get up, what they want to eat, and when and how they want to engage in social interaction. Medical equipment is stored out of sight and residents help to administer their medications and treatments, reducing the medical model of care.

Green House homes: Interviews

The participants in this study included Guides, Shahbazim, and residents’ family members. Throughout the course of this study, 21 face-to-face interviews were conducted, including nine Guides (dieticians and registered nurses), one marketing director, nine Shahbazim (direct care workers), and two family members. Thirteen of the informants were women, and eight were men.


A codebook was developed using both an a priori and inductive approach (Castleberry & Nolen, 2018; Ryan & Bernard, 2003). The a priori codes came from the professional definitions found in the literature reviews, and the investigators’ prior theoretical understanding and personal experiences of the culture change movement. The inductive approach came from the data as it developed during the coding process. The interviews were analyzed individually by the researchers (Ryan & Bernard, 2003). While reading through the transcripts, possible codes were noted in the margins as they were encountered. The codebook was further developed for each separate code by including the following seven coding methods: A title was chosen; a mnemonic abbreviation created; listed in vivo equivalents; developed a short, precise definition of the code; created a longer, more detailed definition of the code; listed the criteria for including data in the category; and listed the criteria for excluding data from the category (Castleberry, & Nolen, 2018; MacQueen, McLellan, Kay, & Milstein, 1998). After the researchers agreed on code labels and definitions, they selected example quotes within the data that best illustrated each code (DeCuir-Gunby, Marshall, & McCulloch, 2011).

The terms included in the coding of the interviews were created in two steps. First, the interviews were coded, more generally, according to the three types of care defined (medical model, person-centered, and person-directed care). For instance, if a response from a CNA mentioned a routine in which she had to get all the residents up in the morning at the same time to give them their medications with no choice for the resident, it was coded as the medical model. Second, the interviews were coded in more detail with the common variables typically found in nursing home settings (activities, care planning, death/dying, decision-making, education, environment, food, language, medication management, staff, and values). For example, if a staff member stated that the residents could decide when they wake up in the morning and whether or not they wanted to take their medication at that time, it was coded as decision making in person-directed care and medication management in person-directed care. Therefore, there were three possible subcodes for each variable. For example, in the case of decision making, there was decision-making medical model (DMMED), decision-making person-centered (DMPC), and decision-making person-directed (DMPD). For medication management, there was medication management medical model (MEDMED), medication management person-centered (MEDPC), and medication management person-directed (MEDPD). Thus, the first example, of the staff member dictating the residents morning schedule and medication, was further coded as DMMED and MEDMED, and the second example, of the residents being in control of their schedule and medication, was coded as DMPD and MEDPD.

The data were reviewed multiple times by the researchers to make sure all of the important codes were identified. On the first review, the salient codes were marked with highlighters. In the next stage, the researchers looked for the less obvious codes in the unmarked data. Once complete, the codebook with the selected quotes was then transferred and stored in Excel with tables and rows for each entry. The frequency of each code was then determined and listed in a separate table. Some of the selected quotes are provided as examples, throughout this study, to illustrate the type of care that was practiced in the two nursing home settings.


Table 1 shows the differences in how prevalent each type of care (medical model, person-centered care, and person-directed) is when comparing the two settings—traditional nursing homes versus Green House homes. The medical model of care was the most prevalent type of care practiced in the traditional nursing homes (100 times), while person-directed was the most common type of care provided in Green House homes (123 times). There was no evidence of person-directed care in the traditional nursing homes and no evidence of the medical model in the Green House homes. Person-centered care was present in both models, but it was found more frequently in the Green House homes (40 times) than in the traditional nursing homes (26 times). Overall these trends indicate that traditional nursing homes provide care largely based on the medical model of care and somewhat on the person-centered model, whereas the Green House homes provide care primarily using the person-directed model with some person-centered traits.

Table 1. Medical model mentions in traditional vs. Green House homes.

Table 2 illustrates how often the variables (e.g., Activities, Care Planning, Food, and Staff) are expressed in the two settings. The Staff variable came up the most in both the traditional nursing homes (42 times) and the Green House homes (53 times). Although Staff was the most frequently discussed in both homes, it is important to indicate that the variable was talked about in different ways. For instance, in the traditional nursing homes, the staff members regularly complained about patient load, compared to the staff members in the Green House homes, who frequently talked about the freedom they had to help the elders with planning their day. Language was discussed the second most in the traditional nursing homes (21 times), while Decision Making was second in the Green House homes. Death and Food tied for the least mentioned (two times) in the traditional nursing homes, while Death, Medication Management, and Care Planning tied for the least mentioned (one time) in the Green House homes.

Table 2. Variable mentions in traditional vs. Green House homes.

Medical model

Table 3 shows the differences in how prevalent the medical model was when comparing the traditional nursing homes and the Green House homes. Most striking is the lack of medical model type of care used in the Green House homes. In contrast, the medical model was found in every category in the traditional nursing homes, with the most comments for Staff (36 times), followed by Language (18) and Medication Management (14 times).

Table 3. Medical model in traditional vs. Green House homes.

Quotes from the staff in the traditional nursing homes illustrate feelings of work overload:

Well they were overworked too. I can’t say that they didn’t care, but my experience in nursing homes has been that they’re given too much and you’re in a no win situation because regardless of what your position, you’re given too much to handle. So, everything is prioritized, and consequently some small things, like a blister becomes as a decubitus and just because nobody had the time to do the proper care. (NH_LPN)

They tell you, oh, yeah, make sure your residents are taken care of well. But if something’s missing in that paperwork, you’re going to hear about it. You got to make sure everything is right, because when the state walks in there, you cannot have anything wrong. Because they don’t want to get citations. Because guess what, if they get cited, they lose money; and if they lose money, they get rid of you. (NH_CNA)

Oh, yea. They get a lot of work. I mean to get people up in the morning, I mean some of them, I think they’re basically given like 10 to 12 people—each person. Do you know what it’s like to get 10 to 12 people up in the morning and bathe them and all that stuff? And some people that can’t do it themselves, they can’t do anything? Total care. You know, it’s tiring. You’re tired, you’re exhausted, you know, and that’s why some of these people don’t get the care they need. Because these people are overworked, they’re tired, they don’t want to be there, or “I want to go home”—they’re rushing because the time is running out, you know, that’s what happens. (NH_LPN)

Quotes referring to the Language variable focus on the type of pejorative language they use and the task-based procedures they talk about, both of which fall under the medical model:

Yea, and I had about 15 people to get up in the morning, and you know, give them all breakfast. Some were quasi—they could do a few things themselves. Some of them were independent feeders, some of them we had to feed them every last drop of food or they just didn’t eat. You know, sort of the whole gamut on this ward of women. (NH_CNA)

And then the ones that required a lot of care you would start with that, because in two hours you’d have to change the diaper or undergarment diaper—whatever you feel like calling it. (NH_CNA)

I ask the nurse, what is the diagnosis for me to know and what care do I need to give the patient? (NH_CNA)

Quotes from the Medication Management variable demonstrate the medical model procedures for dispensing medication:

And in the nursing home, when the older person rebels, they get more and more psychotropic medication. (NH_LPN)

Plus you have to do two med passes while you’re there. There’s one at midnight and then one to start at 5:00 in the morning to complete when you leave the shift at 7:00 a.m., which never happens. You never leave there at 7:00, I’m sorry, it never happens. (laughing) You know, then you have all the paperwork to deal with. (NH_LPN)

She was taking the pill, putting it in the applesauce and shoving it down their throat. Now I was I like, why is she doing this with this little old lady and I thought the old lady was so sweet. And you know, she was just forcing it. Some of them are really forceful with these people, and you know, it’s not good. (NH_LPN)

Overall, these quotes demonstrate the type of care provided to the residents and the problems associated with the medical model in a traditional nursing home.

Person-centered care model

Table 4 shows how predominant person-centered care was when comparing the traditional nursing homes and the Green House homes. For person-centered care in traditional nursing homes, Education and Staff tied for the most dominant discussion (six times). For Green House homes, Staff (12 times) and Food (10 times) were the most mentioned.

Table 4. Person-centered care in traditional vs. Green House homes.

This quote from the tradition nursing home illustrates the dearth of education and training for the CNAs under the person-centered model:

We get the CNA certificate, then we get the test to be certified. And in that 180 hours you have some classes, some conference about aging, about dealing with old people, about how to treat them. It is not that deep. (NH_CNA)

A Shahbaz in the Green House home describes how one of her trainings helped her to see elders as people, not patients which is in line with person-centered care:

I’ve watched a documentary—because we have so many trainings. And one was to me … it was … it takes you back to what the person was before they came to this. So that documentary helped me grow and see my elders from a different perspective. I don’t see them sick: I see them for who they were. And that’s what makes the difference, you know? You see them for who they were: Some of them were lawyers, doctors, you know? Stuff like that. And they were meaningful people in society. So that documentary helped me to see my çlders as that, you know? (GH _SHAH)

In the following quotes from the staff members in the traditional nursing home, one starts to see some self-direction and talk about spending time with the residents during the medication pass, as opposed to previous talk of them being forceful with the medication:

That’s one thing I will always follow through with. If I’m busy and the resident needs me, I always send a message or I go back to the room and I say, listen I’m in the middle of something right now, what is it that you need? If it’s urgent or, you know, you have to delegate yourself in a way that, what’s more important? If somebody’s having diarrhea and somebody’s chest pain, who are you going to take care of first? (NH_LPN)

And you know, when I do my rounds in the morning and my med pass, I take much longer because I stop and I talk and, you know, and I say “yea, you got your hair done” or your nails, you know, I only chat them with them and stuff. (NH_LPN)

The next quote is illustrative of person-centered care in the Green House homes. The Shahbaz understands her role as being different than the role of a CNA but stops short of a person-directed understanding in the final sentence:

I didn’t know I had that in me because as a CNA, you have an assignment. You’ve got the mop, you get them dressed, and whatever and that’s it. But being a Shahbaz is more. It’s like nurturing, caring, you know? Being their advocate. It’s all about that and it makes it so interesting because as a Shahbaz, you are responsible: We are the person that literally runs the home. (GH_SHAH)

This following quote illustrates the tension between wanting to provide person-directed care with full access to the kitchen and state regulations that enforce a more person-centered approach to food:

Yes, there were challenges along the way: How do you have this open-concept kitchen; where there’s access to food twenty-four hours a day; while maintaining the sanitation regulations, you know, since we are governed by the state regulations, we still have to have everything labeled and dated, and temperatures taken when the food comes out of the oven and served to the elders. (GH_DIET)

In general, these quotes illustrate the difference between how staff members apply person-centered care in the traditional nursing homes compared to the Green House homes.

Person-directed care model

Table 5 shows how extensive person-directed care was when comparing the traditional nursing homes and the Green House homes. Strikingly, there was no evidence of person-directed care in the traditional nursing homes. The most evidence in the Green House homes was for Staff (41 times) and Decision Making (27 times).

Table 5. Person-directed care in traditional vs. Green House homes.

Decision making is a key component of person-directed care. The following two quotes are from family members of residents in the Green House homes reflecting on the ability of their loved ones to direct their lives:

He has a swallowing problem and he has asked not to have his food pureed; if he chokes, that’s the way he wants to go. You can do what you want here. And you have a final say in what you want to do; and what a lovely place to do it. (GH_FAM)

And that’s the one thing that’s very important. And the Green House philosophy is one that allows a person to be older but not to lose their self-respect and lose who they are as a person. They still have decisions that they can make. She’s going to explore those decisions. Sometimes … sometimes … I’m not saying that all her decisions are the best decisions, but those are her decisions. And if God wants to take her home, then God will take her home. But she’s going to go home independently: She’s not going to go home because she’s got a life that she’s miserable; that people are telling her what to do. That will not happen anyway. Okay? (GH_FAM)

The following quote from a Shahbaz shows staff commitment to person-directed care:

Being a caregiver initially you have to get yourself in a setting where it’s a job but the profound importance is making sure that your elders are happy and with that said, we are kind of motivated to push ourselves to make them happy. So, if we’re out of yogurt today and one of the residents needs a yogurt, we’re going to find it. Even if it takes going to the fourth or fifth floor. So, we have this drive to always make it happen for them. Even in kind of difficult situations. That’s the thing about a Shahbaz, is you kind of have to come up with significant ideas that will help the elders in their unique situations. (GH_SHAH)

This next quote from a Shahbaz illustrates internalization of person-directed care and her role in providing that care:

The fact that our elders are back in a home; that they’re comfortable; they’re safe; they’re happy; they have choice; they have their quality of life back; they can do what they want; they can go outside; they can sit on the patio with a cup of coffee; they can sleep until eleven o’clock. Being able to fulfill those … what our elders deserve. That’s why I come to work every day. Because you can’t do that in the institutional model: You can’t poach them eggs at twelve o’clock in the middle of the day. They can’t sleep until ten o’clock because there’ll be no breakfast then if they do. They deserve the best life possible and it’s on us to provide that to them. (GH_SHAH)

These quotes demonstrate how person-directed care is applied in the Green House homes, where elders are fully in charge of their day-to-day lives and care.


This study contributes to the culture change research by providing a qualitative approach to understanding the different ways the two types of nursing home settings practice culture change principles; however, it also has some conceptual and methodological limitations. First, the study only included traditional nursing homes in the South. The nursing homes in this study are typical of nursing homes around the United States in that they all have similar settings and they must follow the same regulations from the government. However, although the nursing homes are required to follow certain federal regulations, the policies and procedures vary from state to state. Thus, in terms of the state laws, employee backgrounds, the residents, and their family members, this is not representative of all nursing homes in the United States. Because the results are not representative of the broader population, generalizations are more risky.

Another limitation is that this study only examined one model of culture change—the Green House model. Future studies should examine other LTC communities that have adopted culture change characteristics, as a way to compare the differences in the utilization of person-directed care. This information will help to clarify the definition of culture change, along with developing best practices for future culture change models.

Discussion and implications

The Pioneer Network recognizes that

In-depth change in systems requires change in governmental policy and regulation; change in the individual’s and society’s attitudes toward aging and elders; change in elders’ attitudes towards themselves and their aging; and change in the attitudes and behavior of caregivers toward those for whom they care. (Pioneer Network, 2018)

The results of this study indicate that everyday life in the Green House homes is in line with what culture change agents have been trying to accomplish for over 20 years with regard to changes in the attitudes and behaviors of the staff members and the elders themselves. It is also indicative of a better working environment for staff. Our analysis revealed that while the medical model was pervasive in the traditional nursing homes, it was completely absent from the Green House homes. This is likely due to the Green House Project’s mission to create environments, staffing, education, meaningful activities, and other factors that are based on person-centered or person-directed care.

Culture change is possible outside of the Green House model, despite some barriers. Several policy interventions, for example, can make culture change attractive, including direct engagement (encouraging state officials to participate), payment incentives, facility replacement, regulatory approaches (including surveyor education about culture change), public recognition programs, workforce enhancements, and research (Miller et al., 2010).

Cost is an important consideration; however, it is unlikely to be a significant barrier to culture change. For example, research suggests that the Green House model reduces Medicare expenditures by decreasing resident hospitalizations and saves Medicaid dollars by maintaining resident health and functioning over time (Sharkey, Hudak, Horn, James, & Howes, 2011). In a comparison of financial data from the Centers for Medicaid and Medicare Services (CMS), Green House operators, and other public sources, Jenkens, Sult, Lessell, Hammer, and Ortigara (2011) demonstrated that private pay is higher in Green House homes (which could offset some of the burden on Medicaid) and that Green House homes had higher occupancy rates (95% compared to 88.5% in 2009).

Federal and state regulations can impede adoption of person-directed care. Residential care communities can get caught up in what is required as opposed to what residents want and need, fearing fines. Care planning and negotiated risk can alleviate some of the legal pressure. Many regulators interpreted choice and rights from OBRA’87 in terms of the medical model. Often surveyors assume that residents’ choices to refuse aspects of care were risky and the wrong choice and would think that it was up to staff members to decide what’s best. CMS does not dictate the particular structure and contents of care plans, just that it be based on a comprehensive resident assessment using the Minimum Data Set. Therefore, there may be room to negotiate risk and resident preferences to better align with person-directed care combined with well-informed decisions to negate liability (Grubman, 2016).

A final impediment to adopting person-directed care is institutional creep or the tendency of the old way of doings things to reenter the institution after attempts have been made to change. Institutional creep in LTC post culture change efforts can occur, for example, if there is high staff turnover and new staff members are brought in from the traditional nursing home model. A guard against this consists of ongoing education, data, and monitoring (Cohen et al., 2016).

In sum, recognizing how culture change principles are implemented in different models is an important step in understanding culture change aspirations and best practices for providing and delivering person-directed care. Regulation, organizational barriers, cost, and other types of barriers can be overcome to provide quality care and quality of life to the residents. As consumers become more aware of culture change and LTC options, they can demand better care.