Using an Adaptive Leadership Framework to Facilitate Implementation of Culture Change in Nursing Homes

Purpose: The global culture change movement in nursing homes aims to transform current, institutionalized models of nursing care to person-directed, home-like care settings;  well over 50% of nursing homes in the U.S. are engaged in some aspect of culture change (Doty, Koren, & Sturla, 2008).  The purpose of this study was to use the adaptive leadership framework to describe, from the perspective of nursing home staff, technical versus adaptive challenges in implementing culture change, and the role of adaptive leadership to facilitate culture change. 

Methods: The overall study design was a qualitative, ‘broad-involvement’ focus group study design (Krueger & Casey, 2009), comprised of administrators, medical care providers, and nursing staff in 3 nursing homes in NC (N=7 focus groups).  Analysis was conducted in accordance with template organizing analysis (Crabtree & Miller 1999) in two steps.  Step 1 identified challenges and facilitators.  Step 2 analyzed challenges and facilitators in relation to adaptive leadership, whereby challenges were coded for ‘technical challenges’ or ‘adaptive challenges’ and facilitators were coded for ‘adaptive leadership’.  Matrices were constructed to compare codes by focus group and position type.

Results: Six themes were identified, including standards and expectations, motivation and vision, workload, respect of personhood, and physical environment.  All themes included examples of both technical and adaptive challenges, as well as adaptive leadership.  A surprising finding was that direct caregivers (e.g., nurse assistants and nurses) provided substantially more examples of the need for adaptive leadership to accomplish culture change, compared to administrators.

Conclusion: The implications of the study are that administrators may ignore adaptive challenges inherent in system change.  To achieve change in care systems, we need to develop strategies for administrators and managers to facilitate adaptive leadership on the frontlines of care.