This week’s blog is looking back at one of the Association for Dementia Studies’ earlier projects, CHOICE (Care Home Organisations Implementing Cultures of Excellence). Funded through the PANICOA (Preventing Abuse and Neglect in Institutional Care of Older Adults) programme by the Department of Health and Comic Relief and working with colleagues from the University of East Anglia, University of Stirling and Cardiff University, the project investigated the relationship between organisational culture in care homes and the quality of care experienced by residents.
Why is this important?
Care homes with similar resources and demands have been seen to provide vastly different experiences of care for their residents, but little is known about why some homes achieve positive care experiences and others do not. Organisational culture is thought to play an important role in shaping the care experience, but it is not understood what organisational culture means in terms of the day-to-day practices in care homes.
What is organisational culture?
Organisational culture is the values, assumptions and norms of behaviour that influence how members behave and interact, so essentially ‘the way we do things here’. These provide working solutions to everyday problem-solving and decision-making. These practices are habitual and passed on from one worker to another, and are normalised in day-to-day work.
What influence does culture have?
“Culture is the all-pervasive substance in which we grow. It is where we have our roots and from where we absorb our nourishment. Whether it is the culture of our workplace, community, organisation or society, we take up and use what is available to us from our cultural soil, good or bad. Crucially, we cannot help but soak it up…. What is in the soil affects how well we can grow, regardless of how much pruning or attention we receive from outside,”
Fulfilling a person’s basic psychological needs depends on having a positive care culture.
What methods were used in the project?
The project used 11 in-depth case studies of care homes, including PIECE-dem observations of care for residents with advanced dementia and complex needs, observations of day-to-day like in the care home, and interviews with staff, residents and visitors. Analysis of the data within and between case studies identified key practices and cultural elements influencing the care experience.
What did the CHOICE project find out?
The CHOICE research project identified seven features of positive care cultures:
We all work together to deliver best care
- Everyone has the same understanding of what person-centred care means in their care home
- This understanding is based on practical, everyday actions and their impact on residents
We all matter to each other – a sense of community
- All residents, staff and visitors have opportunities to be involved in home life
- Residents are known throughout the home and enjoy everyday experiences
- Friendship-like interactions take place with and between residents
Leadership protects frontline care
- Managers protect the daily work of staff from the impact of external factors by absorbing it or translating it into resident-focussed action
- External factors include: regulatory & organisational requirements, family requests and financial pressures
Empowering and supporting frontline staff
- Staff are both willing and able to make decisions and take action for resident well-being
- Management and leadership practices encourage this
We constantly look to make life better
- There is openness to change for the benefit of residents
- When it directly benefits a resident, change happens daily
We help people enjoy places
- The environment is used flexibly and changed daily to meet residents’ needs
- There is constant reflection on the impact of the physical environment on residents, not just in terms of design but how the environment is used
We help people to enjoy life
- We enable meaningful occupation and engagement for residents all of the time
- It is a fundamental part of care work in the home, not an added extra
In summary, all seven elements were present in the care homes, but carried out in different ways. There was also fragmentation of culture in which some, but not all, of the elements were present. Positive care experiences did occur, but were dependent on individual staff and could be undermined by the absence of certain elements of culture. However, poor care experiences were unusual and infrequent, and were often counteracted by other elements of culture.
To find out more about the CHOICE project, please contact Isabelle Latham.
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