Implementing Culture Change in Nursing Homes: An Adaptive Leadership Framework.
OBJECTIVE
To describe key adaptive challenges and leadership behaviors to implement culture change for person-directed care.


METHODS
The study design was a qualitative, observational study of nursing home staff perceptions of the implementation of culture change in each of 3 nursing homes. We conducted 7 focus groups of licensed and unlicensed nursing staff, medical care providers, and administrators. Questions explored perceptions of facilitators and barriers to culture change. Using a template organizing style of analysis with immersion/crystallization, themes of barriers and facilitators were coded for adaptive challenges and leadership.


RESULTS
Six key themes emerged, including relationships, standards and expectations, motivation and vision, workload, respect of personhood, and physical environment. Within each theme, participants identified barriers that were adaptive challenges and facilitators that were examples of adaptive leadership. Commonly identified challenges were how to provide person-directed care in the context of extant rules or policies or how to develop staff motivated to provide person-directed care.


CONCLUSIONS
Implementing culture change requires the recognition of adaptive challenges for which there are no technical solutions, but which require reframing of norms and expectations, and the development of novel and flexible solutions. Managers and administrators seeking to implement person-directed care will need to consider the role of adaptive leadership to address these adaptive challenges.
Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina. Duke University School of Nursing, Durham, North Carolina. kirsten.corazzini@duke.edu.
Kirsten
K
Corazzini
Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina. Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.
Jack
J
Twersky
Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina.
Heidi K
HK
White
Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina.
Gwendolen T
GT
Buhr
Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina.
Eleanor S
ES
McConnell
Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.
Madeline
M
Weiner
Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, North Carolina. Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.
Cathleen S
CS
Colón-Emeric
D003468:Cultural Evolution; D017144:Focus Groups; D006270:Health Facility Administrators / Q000458:organization & administration; D006707:Homes for the Aged / Q000458:organization & administration*; D006801:Humans; D007857:Leadership; D009042:Motivation; D009718:Nurse Administrators / Q000458:organization & administration; D009735:Nursing Homes / Q000458:organization & administration*; D015279:Organizational Culture; D036301:Qualitative Research; D011787:Quality of Health Care; D014481:United States; D016526:Workload
Culture change; Leadership; Nursing homes