What Does the Evidence Really Say About Culture Change in Nursing Homes?

Purpose of the Study: Although nursing home culture change efforts are becoming more widespread, there have been few efforts to systematically compile the evidence related to the efficacy of culture change. This study uses an analytic framework to evaluate the existing evidence for the impact of culture change on nursing home quality. We focus on the nature and scope of culture change interventions, measurement of culture change and adherence to interventions, measurement of culture change outcomes, and the relationship between culture change and its outcomes. Design and Methods: We conducted a comprehensive review of peer-reviewed and gray literature published between 2005 and 2012 to identify intervention evaluations that addressed at least one culture change domain. Of 4,982 identified publications, 625 underwent full review; 27 peer-reviewed and 9 gray literature studies met inclusion criteria. Results: Studies varied widely in scope and outcomes. Most addressed more than one culture change domain; resident direction, home environment, and close relationships were most common. Few studies measured culture change implementation, but most used validated tools to measure outcomes. Although few studies reported negative outcomes, there was little consistent evidence of positive effects. Implications: Nursing home culture change remains an evolving field. Although culture change has clear face validity, the current evidence does not give providers sufficient information for selecting interventions based on the expectation of improving outcomes. Rigorous research on implementation and outcomes of culture change is needed to determine the specific impact of culture change on quality and to provide guidance to providers and policy makers.