Today’s culture change movement is the result of an effort to change the impersonal nature of the nursing home environment and the “institutionalization” of individuals who reside in this setting. This chapter describes signs of “institutionalization” and explains the risks associated with individuals becoming institutionalized. It identifies similarities between institutional life and homelessness and describes core elements of culture change. The chapter reviews positive outcomes associated with culture change and describes the four stages of culture change. The stages of culture change are: the institutional model, the transformational model, the neighborhood model, and the household model. The chapter also describes the actions nurses can take to support culture change. Heightened interest in creating a different style of nursing home life is driving a transformation in this setting. Nurses need to be actively engaged in this process to ensure that change occurs thoughtfully and is based on sound evidence.

The Minimum Data Set (MDS) provides a uniform approach to conducting a comprehensive assessment that is recorded on a standardized tool. This chapter identifies the times when an MDS assessment must be completed. A registered nurse (RN) must conduct or coordinate the assessment with the input of other health team members and the resident. Upon completion, the MDS is electronically transmitted to the quality improvement evaluation system assessment submission and processing system designated by Centers for Medicare and Medicaid Services (CMS). The MDS offers a standardized approach for collecting assessment data. The chapter describes the data that are collected in the MDS assessment tool and explains the Care Areas and their purpose. It also describes the time period for which MDS assessments must be maintained by the nursing home.

This chapter describes the care planning process. Care planning begins with the assessment process in which physical, emotional, and psychosocial needs are identified. The chapter explains the characteristics of well-developed goals and interventions. A goal is developed for each major problem that has been identified, describing the specific outcome the resident will achieve. Specific interventions are developed for each goal. Interventions are the approaches, actions, and procedures that support the resident in meeting the goal. The chapter reviews the regulatory requirements related to care plans. Because care planning is viewed as a crucial component of resident care, specific regulations address the process. The chapter then describes the measures to encourage residents’ participation in the care planning process. The care plan provides a map to care that ensures the resident’s physical, mental, and psychosocial needs are met in a manner that addresses the unique characteristics of that individual.

This chapter describes the four types of surveys that examine resident care, namely: standard survey, abbreviated standard survey, extended survey, and partial extended survey. If deficiencies were found during a survey, the facility develops a plan of correction that specifies the actions that will be taken to correct the deficiencies. A follow-up survey will then be done to determine if the plan of correction was effective. The chapter enables the reader to list severity levels and scope of deficiencies. Surveys are based on the standards stated in the regulations. By being familiar with the regulations, nurses can be proactive in assuring compliance. Surveys are a means of assuring that the care residents receive meets acceptable standards and the facility is a safe environment for residents and employees. The chapter also explains the standards that nursing homes are required to meet as stated in regulations.

Sudden changes in a resident’s status may indicate a life-threatening health problem and need to be addressed promptly. It is essential that the resident’s baseline status be known by staff so that changes can be identified. Pain, nausea, vomiting, dyspnea, bleeding, and other signs and symptoms also need to be noted. Changes in status demand assessment. Unusual findings and symptoms reported by the resident should be explored and thoroughly described, as should recent relevant events, such as a fall or administration of a new medication. This chapter describes the general changes that can indicate emergency conditions and explains the actions to take when an emergency condition occurs. It explores the signs of and nursing responses to possible: acute glaucoma, angina pectoris, congestive heart failure, detached retina, hypothermia, myocardial infarction, pneumonia, pulmonary embolism, and transient ischemic attack.

This chapter describes the differences between management and leadership. The complexities of the nursing department demand both leaders and managers. Leaders also can possess management responsibilities and skills; likewise, managers, as well as people who do not carry management titles, can demonstrate leadership. Critical thinking is an important skill for both leaders and managers. Leaders and managers need to display the behaviors they desire and expect in staff, such as a positive attitude, team spirit, openness to learn, and adherence to high standards. Various styles can be used to lead a department or team to accomplish goals. Some of the common leadership styles include: Autocratic/authoritarian, Laissez faire, Democratic/participative, and Inconsistent. The chapter describes strategies to enhance communication and explains the steps in effective delegation. It discusses the methods that can be used in performance appraisal and explores measures for managing complaints. The chapter also reviews methods to improve time management.

This chapter enables the reader to list factors influencing staffing needs and to determine productive and nonproductive time. Nurses need to be sensitive to the fact that nonnursing professionals who develop the facility’s budget may lack an understanding of the factors that affect staffing and work from the assumption that all facilities of similar bed size can be staffed similarly. Nurses need to educate these individuals about the factors affecting staffing needs in their individual facilities to ensure that adequate staffing is budgeted. The chapter describes the methods for estimating hours per resident day (HPRD) and helps the reader to calculate number of full-time equivalent (FTE) employees needed based on three approaches: census, HPRD, and employees’ productive time. It is valuable to monitor staff satisfaction, resident satisfaction, survey results, incidents and accidents, pressure ulcer development, absenteeism, and turnover as problems noted in these areas could be associated with insufficient staff.

This chapter describes the basic features of person-centered care. A variety of factors contributes to person-centered care, including consistent assignment of staff, effective communication, empowerment of residents, and promotion of a meaningful life for residents. Being cared for by the same staff on a regular basis fosters residents’ ability to receive person-centered care. The ability to choose when and how care will occur and the type of activities that they wish to engage in fosters an active role for residents in their care, respects them as adults, and enhances quality of life. Helping residents achieve the highest possible level of physical, mental, and psychosocial function and well-being are crucial elements of person-centered care. Promoting physical activity not only carries many benefits for physical health, but also enhances residents’ confidence and independence, which influences quality of life.

This chapter describes the stages of grief and explores the challenges faced by a resident’s family members and staff when the resident is dying. Support will need to be provided to dying residents, their loved ones, and staff as part of end-of-life care. Some of the difficulties families and staff face can be reduced when residents have advance directives. Advance directives are legally binding documents that help families and the health care team understand the desires of an individual related to care and treatment if that individual is unable to express those desires. The two major types of advance directives are a living will, and durable power of attorney. The chapter also describes the physical needs of the dying and related nursing care and explores the specific practices related to death and dying of persons of various religions and cultures.