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The Power of Words: Creating a Person-Directed Culture
posted 08.30.2016

By Audrey Weiner

Writing on history can be instructive—the facts, the context in which they’re found and the words used to describe events. In 1890, Burdett described The Home for The Aged and Infirm Hebrews (of New York City, now The New Jewish Home) as follows:

“In them (the aged) is (sic) often combined the fractiousness of babes and the helplessness of the sick, while above all they brood o’er remembrance of better days. The future for the majority of them is dark and dreary. They see no possible prospect of any brighter existence than life in the institution until Death claims them.”

“They must bow to the same discipline, eat at the same table, and live the same life as their fellows in poverty and old age who maybe never soared one-tenth as high as they …” (“The Home for The Aged and Infirm Hebrews of New York,” Illustrated American Jewess).

The article continues:

“A striking feature of the sleeping arrangements … airy little rooms, containing two single beds, are substituted for the large wards common to most institutions of the kind. The privacy thus insured is highly valued by most of the inmates.”

“Three days a week are set apart for receiving visitors, and inmates are permitted to visit their friends once a fortnight.”

As Language Evolves, So Must We

At the time, these words held meaning and were appropriate. Today, we cringe at the name of the institution, the use of the term “inmates,” the existence of such rules and regulations and the view that all an older person could do was wait for death. Words matter and the visceral reaction one has to reading this text suggests that Carmen Bowman’s view on the power of language is accurate, from her 2012 presentation to the Colorado Coalition of Elder Rights & Abuse Prevention, “Transforming the Culture of Aging: Self-Directed Living in all Settings.”

More than 165 years after its creation, The New Jewish Home has embraced person-directed care as articulated by the values and principles of the Green House model—involving family, integrating into the community and empowering staff—while creating living environments for elders (from Robert Jenkens’ chapter in Models and Pathways for Person-Centered Elder Care, 2014).

This decision built on our experiences from 10 years earlier as we used an iterative approach to implementing culture change. At that time, using Pioneer Network principles—knowing each person, establishing relationships as the building blocks of transformed culture, putting person before task and recognizing that culture change is a journey (from Rose Marie Fagan’s chapter in Culture Change in Elder Care, 2013) and learning from visits to organizations that had implemented culture change, Jewish Home tried to measure, evaluate and define what steps were essential to creating a person-directed culture in three large, urban and suburban nursing homes in down-state New York (see sources sidebar for a description of the implementation and research, below.

Sources for Research Implementation
 
Burack, O. R., Reinhardt, J. P., and Weiner, A. S., 2012. “Person-Centered Care and Elder Choice: A Look at Implementation and Sustainability,” The Clinical Gerontologist; http://goo.gl/Tnc9mL.
 
Burack, O. R., Weiner, A. S., and Reinhardt, J. P. 2012. “The Impact of Culture Change on
Elders’ Behavioral Symptoms,” Journal of the American Medical Directors Association; http://goo.gl/jU3vYH.
 
Burack, O., et al. 2012. “What Matters Most to Nursing Home Elders: Quality of Life in the
Nursing Home,” Journal of the American Medical Directors Association; http://goo.gl/31M22U.
 
—Audrey Weiner

The conclusions drawn from the data analyzed by our research department were that the positive changes experienced by our elders, staff and their families in the pilot implementation of culture change were not sustained when our model was implemented across our system.

Clarifying Language Specific to the Culture

We had changed workflows, accountabilities and programs in our pilots and tried to place the older adult at the center of this work, but had not changed the culture of our organization. To do that required not just clarity of language, but also clarity of values, principles, training and standards. Our selection of the Green House model reflected our belief that it created a real opportunity to fundamentally change our culture.

The Green House model of care on our Westchester campus faced a specific challenge with language. Through the renovations and creation of three (ultimately seven) small houses operating as Green House homes, the Shahbaz work role (in which, according to Jenkens, each certified nursing assistant works a blended role, providing personal care, cooking, light housekeeping, laundry and activities) was discussed and negotiated with our union, SEIU 1199.

However, the term Shahbaz was not embraced. Rather, the name Adir (pronounced ah-DEER; plural: Adirim, ah-dee-REEM) is used at the Jewish Home. This Hebrew word means noble, majestic, mighty, wonderful or impressive. In Jewish tradition, when a couple arrives at the beginning of their wedding ceremony the leader recites, “Mi adir al hakol?” “Who is greater than all?” Answer: The one who rejoices with the couple and helps them to create a home together. So too, Adirim at The New Jewish Home welcome and help our elders to create a true home.

The title Adir conveys the special work done by care partners who take on this new role, and is an acknowledgement of Jewish Home’s heritage. The selection of this word was made in collaboration with care partners and management and approved by the Green House project. For The New Jewish Home, Adir was a very important word.

In assessing institutional language, Ronch, Bowman and Madjaroff (2011), the Eden Alter-native (2011), Schoeneman (2014) and Bowman (2012) all provide examples of how the words we use define context, how we think and how others perceive our communication.

As The New Jewish Home implemented culture change a second time, through these small houses, training included “The Power of Language.” As an example, in our setting, the Adirim learn how to lead a discussion about older adult care planning. The sidebar, below, gives some examples from training.

A Look at Langauge

Preferred Language to Use Versus Status Quo Language
Elders Residents
Quality of engagement
In how many activities did an individual
participate (quality vs. quantity)
Time spent sharing food and
companionship
Meals at 8 a.m., 12 p.m. and 5 p.m.
Expressed choice with meals;
participated in preparation of breakfast,
lunch and dinner
Good appetite; modified diet;
refused to eat
Meaningful life; family involvement Family complaint
Elder-to-elder relationship Resident refuses to sit next to (him/her)
Living with dementia Demented
Visit Tour

There has been substantial improvement in clinical outcomes and elder, family and Adirim satisfaction with the implementation of these small houses. Such improvements build on this facility’s existing five-star quality rating within the Medicare’s Nursing Home Compare (Burack et al., in preparation).

Words are necessary, but not sufficient to change culture. They remind us of our focus, our direction and our commitment to change. It is our experience that in changing culture, language provides the anchor for all care partners, managers, board members and funders and, in so doing, truly matters.


Audrey S. Weiner, D.S.W., M.P.H., is president and CEO of The New Jewish Home in New York City.

Editor’s Note: This article appears in the September/October 2016 issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store or Join ASA.


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