< Culture Change

Intensive Learning Gives Birth to Households

The stir caused by the first glimpse of the new Huntersville Oaks households at a ribbon-cutting ceremony last September (2007) would have been suitable for the long-awaited birth of a first grandchild.

“Family members were weeping… residents were stunned… staff members were jumping out of their skins with anticipation,” says Bev Cowdrick, former Administrator of Huntersville Oaks and current Director of Long-term Care Education and Research for its parent organization, Carolinas HealthCare System.

A local network-news affiliate televised the event at 5:15. By 5:45, some 500 to 700 viewers poured into the new $25 million building to see this “village” of eight connected households, four neighborhoods and “Main Street.” The carpeted rooms with residential-style furniture, abundant natural light and cheerful, soothing colors are a stark contrast to the 80-year-old building they replace, a former tuberculosis hospital with huge nurses’ stations, long terrazzo corridors and institutional clutter and regimentation.

The new environment offers residents a private room (or shared, two-bed suite) with bath, the option to eat and sleep by their own schedules, socialize in homey, intimate surroundings, or sit alone and watch the sun set from the screened-in porch or their bedroom window. It marks a historic milestone in the organization’s culture change journey begun four years earlier.

“It made me cry when a resident told me she hadn’t let herself get excited over the last four years because she didn’t know if she’d live long enough to move into the new building,” says Cowdrick.

After the ceremony, some elders reluctant to leave their future households had to be coaxed back into the old building for two final weeks of institutional living. The waiting list for new residents grew longer that evening, and job seekers were at the door the next day to fill out employment applications.

Not evident at the ceremony were the years of study, preparation and challenges that led to this joyous birth of a new cultural environment, successfully carried to full term, says Cowdrick and Amy Clary, the new Administrator, by making learning part of everyone’s job.

Wizards on the Path to Knowledge

Among the first to make learning part of the job were the Wizards of Change, a select group conceived after a few Huntersville staff members attended the 2004 Pioneer Network annual conference.

The Wizards were 24 CNAs, three from each of the old building’s eight residential units. They took road trips and phoned culture change nursing homes around the country (Meadowlark Hills in Manhattan, KS, and Northern Pines Communities in Big Fork, MN, among others) to talk to CNAs working in those facilities, and then shared what they learned with co-workers.

They trained intensively on person-centered care during an 18-month pilot project sponsored by the state’s Quality Improvement Organization and helped organize their individual nursing units in the old building into “neighborhoods.”

Each neighborhood decided for itself what additional changes to undertake: whether to improve the shower room, break down part of the large dining areas into comfortable living rooms, or “gussy up” the residents’ bedrooms. “They started going around seeing what each unit was doing and getting ideas, and it took off from there,” says Cowdrick.

One neighborhood decided to stop assigning caregivers to specific residents (a practice carried over to all the current households). Instead, they divided into two “households” and two work teams and made each resident the responsibility of all household team members. “No longer do we hear caregivers say ‘That’s not my resident,’” says Cowdrick.

Administrative and support staff were assigned to units as “extended family” members, and were encouraged to spend a few minutes every day in activities with residents in their new neighborhoods. In a building three stories high, just having extra hands to take a resident down the elevator for a walk through the garden was appreciated by everybody, says Cowdrick. Extended family members also joined learning circles and went to neighborhood meetings.

Though the old-building neighborhoods had no kitchens, they began offering buffet dining once a week. Residents chose from a menu the theme for each weekly buffet. The practice helped relieve caregivers’ anxieties about doing food service in the future households.

They collected educational DVDs on culture change from Action Pact, CMS, and the Pioneer Network for viewing by staff and residents. And as with any Household Model organization, they held countless learning circles on every topic. “People were really getting steeped in the possibilities of culture change as we designed the building and thought about how we wanted our community to operate,” Cowdrick adds.

Growing Skills at Household Academy

But a year and a half away from cutting the ribbon on the new building she was concerned learning wasn’t happening quickly enough. “I started wondering, how are we going to build the leadership and self-directed team skills we need in a building with 300 staff members on three shifts?” says Cowdrick.

Care for 65 percent of residents at Huntersville Oaks is paid by Medicaid, and the budget is too tight for additional training or for turning part of the old building into a working model of the future households.

They found the answer in the “Household Academy” (featured in our May 2007 newsletter). An activity room in the old building was turned into a mock-up of a household kitchen and dining room. Here, staff attended classes throughout the week for half-hour lessons on learning circles, daily pleasures, conflict resolution, leadership development and how to run household meetings. They shared their personal stories about what “home” means to them. In one exercise, participants drew 1) a picture of their childhood home and the simple pleasures it offered, 2) a picture of their present home and its simple pleasures, and 3) a picture of the nursing home household they’d want to live in.

To ensure Household Academy didn’t interrupt resident care, each session was attended by only one person from each unit or department. “We would do the same lesson 14 times during the week so all staff could eventually attend,” explains Cowdrick. The best times for the sessions, she found, were after lunch and at shift change. She, the DON, a staff development person and others served as trainers.

Stocked with culture change magazines, DVDs and the like, the room was open 24 hours a day. It was also the testing room for furniture samples. “People would come in to test out the furniture and leave their written comments on sticky notes,” says Cowdrick. Thus, the decision evolved on what style of furniture to purchase for the new building.

A similar process played out across the hall in a room containing a mockup of a bedroom and bath. In still another area, the “architecture room”, a full set of plans for the new building were laid out on a conference table for people to study and leave comments. “People decided the bathroom should be bigger for the roll-in shower, and where to place mirrors and light switches… the residents told us a lot about how to design the bedroom,” she says.

Residents and family members participated on the kitchen design team. And staff, having shared their own stories in Household Academy, interviewed residents to learn their “daily pleasures.”

Residents told staff they wanted wider beds, a surprising but understandable revelation. “I slept on one of the beds myself one night; it was a harrowing experience, says Cowdrick. She passed that information along to a North Carolina furniture manufacturer who is looking into building wider beds and mattresses with features needed for nursing homes.

The process of inclusion in the design process encouraged everyone’s “buy-in” of culture change and built excitement as ribbon-cutting day approached, says Cowdrick.

Nursing Assistants Step Up to Leadership

“What we expect in terms of leadership [from non-formal leaders] is that they do critical thinking, be aware of the environment and take the initiative to address problems as they come up rather than waiting for [formal leaders] to notice.”

- Bev Cowdrick

Leadership and team-building skills were well honed on the Household Academy, but lack of time and resources made it impossible to practice how new systems would function in the actual households still under construction. How would laundry get done, for example?

In the old building, staff sent clothes to the central laundry and that was that. In the new building, there are washers and dryers in each household, so the respective work teams do laundry. About a week after move-in, it occurred to Cowdrick and the new Administrator, Amy Clary that household laundry procedures hadn’t been worked out. “I had some real concerns because I personally didn’t know how it was going to happen,” says Clary.

But the household work teams had already decided. “We worked together (in learning circles) and agreed that all shifts would do laundry as needed, so we don’t even need a schedule,” explains Maggie Newson, CNA.

“So I guess it was me worrying over nothing,” says Clary. “Since we’ve moved, I’ve not had a single conversation about laundry.”

Proof, adds Cowdrick, that the Household Academy was effective and that nursing assistants can be trusted with leadership and decision-making. “The CNAs have really stepped up to the plate,” she says.

During Household Academy, she and other trainers helped staff get in touch with how they are already leaders in their lives outside the nursing home, running their own households, organizing church choirs and the like. “We asked them to talk about how they take leadership of situations in their own lives… we acknowledged them and their experience… we gave them permission to put their leadership hats on at work,” says Cowdrick.

“Leadership training taught us how to work as a team,” adds Cindy Bost, C.N.A. “Now when you can’t get a task done, somebody has your back.”

In the new building, CNAs help determine scheduling, resolve conflicts and share responsibility throughout their household. They take turns monitoring the computerized “care tracker” located in each neighborhood to ensure residents get plenty of attention.

As CNAs take ownership, life becomes less stressful for Household Coordinators like Terri Ivory. “I enjoy letting go of some of that responsibility,” she says.

Soon, CNAs also may have an opportunity to assume formal leadership roles in the households as Caregiver Guides. “Now that we’ve been in the new building for six months, we are rethinking who should be coordinators,” says Clary. “It makes a lot of sense to have CNAs in more of a leadership role.”

Lessons for the Next Household Academy

They’ve learned a lot in those last six months, including how the Household Academy could have been even more effective. If she had it to do over again, Cowdrick would offer more training on household technical skills. Though difficult for “Medicaid” nursing homes with limited resources to set up a training environment, anything you can practice hands-on before moving is beneficial for staff, she says. For example:

Hook up and practice with a household dishwasher prior to moving. Waiting until they were in households before working out technical glitches and dishwashing procedures “tripped us up like crazy,” she says.

Start leadership training earlier. Social workers, activities staff and nurse leaders are used to working alone with residents and may need more time than others to feel comfortable as part of a household team.

Put more emphasis on training Household Coordinators. Action Pact has recently developed an intensive training program for coordinators, she notes.

Today at Huntersville Oaks the excitement of birth has given way to the reality of child rearing. “You carry this child for nine months (or in this case, four years) and think it’s going to be Norman Rockwell beautiful. Then it is born and has colic for six months,” says Clary.

Her point: Just because you move to a household environment does not mean it will be challenge-free. But those challenges are far more manageable when your culture change journey follows the path of learning, she concludes.