Sample

Purposive sampling was used to identify directors of nursing (DONs) in Central Florida nursing homes (N = 270). Nursing home DONs were contacted by mail, e-mail, and telephone about participating in the study. DONs who selected to participate in the study were provided an e-mail with the informed consent form and a secure link to the Artifacts of Culture Change survey. DONs from Florida nursing homes completed the Artifacts of Culture Change survey online between March 2014 and March 2015. The response rate for this study was 30.0% for DONs (n = 81). The Institutional Review Board at the University of Central Florida approved this research.

This study merged 2014 data from the Certification and Survey Provider Enhanced Reports (CASPER) and Artifacts of Culture Change survey data using the names and addresses of nursing homes. CASPER data were used to obtain information on nursing home characteristics, such as staffing, ownership, and chain affiliation. Surveyors evaluate nursing homes’ structural features to ensure that minimum standards are being met.²⁵ This information is routinely collected through the Medicare and Medicaid certification process by state licensure and certification agencies. As a part of the recertification process for nursing homes, the data are updated annually.

Culture change adoption was measured using the Artifacts of Culture Change instrument. The Artifacts of Culture Change instrument was developed in 2001 by the Centers for Medicare and Medicaid Services.²⁶ In addition, an online version of this instrument is supported by the National Pioneer Network, a national organization that advocates for person-directed care, which allows nursing homes to assess their level of culture change adoption and benchmark those changes within their facility and with other facilities. While various measures have been developed to evaluate nursing home culture change, instruments vary in their degrees of validity and provide limited evidence of reliability.²⁶ Although the Artifacts of Culture Change instrument has similar limitations to these instruments, it is a comprehensive measure to assess culture change in nursing homes.