RAI/MDS process and nurse competencies in culture change

Diane Carter, RN, MSN, CS

The MDS 3.0 demands that you focus on resident voice and choice. But the MDS, Care Area Assessments (CAAs), and care planning will take you only so far in transforming this federal mandate into real choices in the daily lives of your residents. Without organizational infrastructure and processes in place to support making the MDS 3.0 a living and breathing document at the facility level, resident voice and choice will reside in the chart, thus denying the resident the opportunity to live the life s/he might imagine. For example, the MDS asks, “How important is it to you to choose your bedtime?” If I was asked this question I would assume that my preference would be honored starting the day of my arrival in the community. Simply by asking questions, this tool sets in motion a series of expectations about care. Is your facility staff prepared to meet them?

Several years ago the Hartford Institute for Geriatric Nursing began collaborating with the Coalition of Geriatric Nursing Organizations and Pioneer Network on a grant funded by the Commonwealth Fund. They convened a panel of 31 nursing and other experts to explore opportunities for and barriers to nursing and culture change. The panel worked to answer the question, “What is the role of nurses in achieving and sustaining this change?”

The decision was made by a core group of nurses and clinical nurse leaders involved in cultural transformation to create a list of useful and realistic competencies that are unique to culture change nursing. They built the competencies on an already completed body of work that identified specific clinical competencies for geriatric nursing (see www.aacn.nche.edu/education/gercomp.htm and Position Descriptions and Related Competencies for Long Term Care Nursing Positions, www.ltcnursing.org). The initiative brought together nursing and geriatric experts from across the country and resulted in the document “Nursing Competencies for Nursing Home Culture Change.” The paper offers 10 competencies deemed most relevant and critical for creating and sustaining person-directed care (see below). It allows communities a specific list of guidelines they can follow to ensure proper provision of the voice-and-choice mandate.


Why are these nursing competencies necessary when there are already so many existing competencies in which nurses must be proficient? Adding a new list of skills may seem like overkill, but it is not. Creating these competencies is step one in developing measurements and other tools that can educate and support nurses in this work. This will allow nurses a measurable tool that focuses not only on the physical tasks of nursing, which at times seem to take precedence, but also on enhanced communication skills designed to improve the outcomes of those tasks. It is expected that the creation of new competencies will not undermine existing competencies but boost the quality of care overall, and that the skill sets will build on each other.

With these new competencies, the nurse:

  • Models, teaches, and utilizes effective communication skills such as active listening, giving meaningful feedback, communicating ideas clearly, addressing emotional behaviors, resolving conflict, and understanding the role of diversity in communication.

  • Creates systems and adapts daily routines and “person-directed” care practices to accommodate resident preferences.

  • Views self as part of the team, not always as the leader.

  • Evaluates the degree to which person-directed care practices exist in the care team and identifies and addresses barriers to person-directed care.

  • Views the care setting as the residents’ home and works to create attributes of home.

  • Creates a system to maintain consistency of caregivers for residents.

  • Exhibits leadership characteristics/abilities to promote person-directed care.

  • Role models person-directed care.

  • Problem solves complex medical/psychosocial situations related to resident choice and risk.

  • Facilitates team members-including residents and families-in shared problem-solving, decision-making, and planning.

The release of “Nursing Competencies for Nursing Home Culture Change” is supported by these eight esteemed national nursing organizations, part of the Coalition of Geriatric Nursing Organizations:

  • American Academy of Nursing (AAN), Expert Panel on Aging

  • American Assisted Living Nurses Association (AALNA)

  • American Association for Long Term Care Nursing (AALTCN)

  • American Association of Nurse Assessment Coordination (AANAC)

  • Gerontological Advanced Practice Nurses Association (GAPNA)

  • Hartford Institute for Geriatric Nursing (HIGN)

  • National Association of Directors of Nursing Administration in Long Term Care (NADONA/LTC)

  • National Gerontological Nursing Association (NGNA)

To view and download a complete copy of “Nurse Competencies for Nursing Home Culture Change,” please visit: www.pioneernetwork.net/Providers/ForNurses.


Nursing leadership in long-term care now has a list of useful, measurable competencies that can drive the culture change movement, allowing residents true person-directed care. Giving residents a voice in the type of care they receive will help supply the level of choice that people living independently are accustomed to enjoying. Once a person’s health status has declined to the point that they require long-term care placement, they lose so much; offering residents the opportunity to state their preferences when possible allows them a bit of control when there is so much in life that they cannot control. This begins and ends in the hands of nursing.

AANAC is focused on supporting the use of these competencies and is taking a public stance that following through on the recommendations of this initiative will not only support residents having more control in their lives but will also provide a better quality of life and a higher level of dignity in their lives. As we move forward on the competencies, we are looking for examples that provide either the “how to” for building infrastructure based on these competencies or examples that inspire all of us to move forward in this movement.

Why is this important? I received an example this week from Carol Job, past AANAC board chair and PEAK Award evaluator for the state of Kansas. Let the experience from a facility in Kansas inspire you:

I was visiting with a gentleman who was fairly new to the nursing home and I asked him about being involved in voicing his preferences and what he likes to do. He told me that the facility staff asked him if there was something that he would like to do that was very special to him-kind of like the “Make-A-Wish” program. He told the staff person that he would love to see his sister. His wish came true. One of the staff worked with this gentleman’s wife and contacted the sister. Then the staff person picked up his sister and brought her back to the nursing home. The sister was able to spend a week with her brother. The staff person then took his sister back home. The gentleman was so pleased that he was able to see his sister and spend time with her.

Email me your ideas at dcarter@aanac.org. Help us help each other in finding ways to honor the wishes of residents and give us the strength to push through barriers to culture change, as so much is at stake for the residents of our communities.

This endeavor was supported by the Commonwealth Fund, a national, private foundation based in New York City that supports independent research on healthcare issues and makes grants to improve healthcare practice and policy. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund, its directors, officers, or staff. For more information, visitwww.commonwealthfund.org. LTL

Diane Carter, RN, MSN, CS, is the President, CEO, and founder of AANAC, a non-profit organization dedicated to education, networking, and advocacy for nurses in long-term care. Long-Term Living 2011 February;60(2):41-44

Topics: Articles , MDS/RAI , Medicare/Medicaid , Regulatory Compliance , Risk Management