Nurturing Cultural Change in Care for Older People

Health Care Anal DOI 10.1007/s10728-014-0280-9 ORIGINAL ARTICLE Nurturing Cultural Change in Care for Older People: Seeing the Cherry Tree Blossom Miranda M. W. C. Snoeren • Bienke M. Janssen Theo J. H. Niessen • Tineke A. Abma •  Springer Science+Business Media New York 2014 Abstract There is a need for person-centred approaches and empowerment of staff within the residential care for older people; a movement called ‘culture change’. There is however no single path for achieving culture change. With the aim of increasing understandings about cultural change processes and the promotion of cultural values and norms associated with person-centred practices, this article presents an action research project set on a unit in the Netherlands providing care for older people with dementia. The project is presented as a case study. This study examines what has contributed to the improvement of participation of older people with dementia in daily occupational and leisure activities according to practitioners. Data was collected by participant observation, interviews and focus groups. The results show that simultaneous to the improvement of the older people’s involvement in daily activities a cultural transformation took place and that the care became more person-centred. Spontaneous interactions and responses rather than planned interventions, analysis and reflection contributed to this. Furthermore, it proved to be beneficial that the process of change and the facilitation of that process reflected the same values as those underlying the cultural change. It is concluded that changes arise from dynamic, interactive and non-linear processes which are complex in nature and difficult to predict and to control. Nevertheless, managers and facilitators can facilitate such change by generating movement through the introduction of small focused projects that meet the stakeholders’ needs, by creating conditions for interaction and sense making, and by promoting the new desired cultural values. M. M. W. C. Snoeren (&)
B. M. Janssen
T. J. H. Niessen School of Nursing, Fontys University of Applied Sciences, Box 347, 5600 AH Eindhoven, The Netherlands e-mail: m.snoeren@fontys.nl T. A. Abma VU University Medical Center, Medical Humanities, Amsterdam, The Netherlands 123 Health Care Anal Keywords Action research
Complexity theory
Culture change
Person-centred care
Sense making Introduction Since the end of the 1990s there has been a perceptible shift in models of long-term care for older people. There is movement from a traditional and medically oriented approach to one in which more emphasis is placed on the autonomy, choice and self-determination of the individual older person [5] and empowerment of staff [49], aiming at increasing the quality of life of both. In the United States this is known as culture change [10, 21, 49]—a concept for which there appears to be no single accepted operational definition in literature, although there is consensus that it is a systematic and long-term transformation process towards a holistic therapeutic community based on person-centred care and dignified workplace practices [10]. Person-centred care offers a philosophical basis for gerontological care that demands respectful and meaningful relationships between professionals and older individuals in need of support or care [10, 21, 25, 34, 43, 67]. The older person is valued and recognised as an individual and care is directed towards his or her wellbeing and quality of life. Knowledge of the person, consciousness of the other’s convictions, values and experience, building mutual trust and understanding and maximising choice and autonomy are important. Furthermore, it is essential to create a supportive physical and organisational environment in which community and place-making are crucial components [10]. This means working together to create a meaningful and appreciative environment in which people, organisation, programs, etcetera are seen as a coherent system. Everyone working or living in the organisation is regarded as an informed and integral team-member or partner and valued for their input, talent, and potential. Ideally, there is power-sharing between the older person and staff, leading to joint decision-making [34] and residents are urged to help create community life [10]. Culture change appears to be difficult to bring about in care for older people due to the traditional and hierarchical character of organisations [10], a standpoint confirmed by Koren [26]. She indicates that deep culture change is rare and that the adoption of culture change and person-centred practices remains inadequate, although the awareness of the culture change movement has grown in recent years. The main challenges to fundamental change seem to be staff motivation and vision, relationships between staff, residents and family, team work, and empowerment of staff [9, 13, 53, 64]. Such challenges could be met by developing new shared cultural values, deep beliefs and patterns of unconscious basic assumptions [8, 13, 37, 52, 64]. According to Schein [52], these emerge when a group learns to adapt to the environment (external adaptation) and develops internal methods and procedures (internal integration), whereby the most successful solutions or elements are retained and passed on to new members of the organisation. Little is known, however, about how to achieve such fundamental cultural changes as much research in the culture change industry has 123 Health Care Anal focused on superficial attributes and observable issues, for example concerning bathing and dining or consistent assignment of staff [64]. This article aims to contribute to an increased understanding of the development of cultural values and norms associated with person-centred practices by examining an action-research project, aimed at the improvement of daily activity for older people with dementia. The desire to improve the level and type of resident activity arose from problems experienced by staff members, who had the tendency to think and do for instead of with residents. During the project opinions about what constitute meaningful daily activities changed gradually together with what staff members regarded as good care. Values altered and unplanned changes in workplace culture also took place, contributing to the development of culture change. This action-research project is therefore seen as ‘good practice’ and, due to the educational potential as a case-study [58], is examined and described in this article. First some philosophical perspectives of organisational change and transformational processes are outlined. Then the context is sketched and explanation given of the action-research project and its examination at meta-level. By considering the factors contributing to the improvement of daily activities and the wider effects of this improvement in relation to the perspectives on change, philosophical insights about cultural change processes are offered and the lessons learned are shared. Transformational Change Processes Although there are ample perspectives on change, there is no consensus about the nature of organisational change processes or how to transform cultural values. For example, van de Ven and Poole [65] identify four ‘motors’ of change that Kezar [24] completes with two typologies. Graetz and Smith [16] on the other hand define ten change philosophies. Notwithstanding these differing perspectives, one is able to make a division into two general and contrasting beliefs about change processes [18, 24]. A first belief is that change is a planned and manageable process that follows some sequential steps, for example as is suggested by Lewin [30] who claims that change occurs through the phases of ‘unfreezing’, ‘moving’ and ‘refreezing’, or Kotter [27] who explains that change processes start with creating urgency, convincing others that change is necessary leading to the formation of a coalition, and creating and communicating a vision. This technical orientation to change is top–down and linear or cyclic [18, 63] and seems to be dominant and most widely accepted [20, 29, 68]. A second, opposite view of change concerns a continuous and emergent process of adaptation to changing circumstances, which cannot be fully predicted, managed or controlled. Change is a bottom–up, complex and ongoing learning process based on particularity instead of universality [18, 20, 69]. This adaptive view is considered to be better suited to the reality and complexity of practices, and seems to be more successful [20]. Nevertheless, most change processes described in literature, especially within health care, are top–down, and linear or cyclic following a pre-descriptive plan [29]. This tendency seems to be also recognisable in the culture change literature. 123 Health Care Anal Within the culture change literature it is clarified that there is no single path to person-centred care. Each organisation has to find its own, which is not a fixed or linear plan [54, 61], but ‘a journey that continues through time and evolves’ [21]. It is a process that can vary in scope and size and can take various forms [49]. However, several authors have described stages or phases of the transformational process of culture change suggesting some kind of linearity and manageability. For example, Grant and Norton [17] explain that facilities developing culture change move through four successive stages, while Shields and Norton [54] describe the change process using Prochaska’s stages of change [48]. They suggest that in every stage some tasks have to be fulfilled before moving to the next stage. Such phase models give the impression of a mechanical reality and change being predictable. Furthermore, culture change publications appear often to be addressed to executives and change agents, emphasising a top–down approach. Underlying philosophical assumptions and principles of the cultural change process are seldom explained explicitly in the culture change literature. The focus is mainly on enabling conditions, such as staff participation, joint decision-making, training of staff, a willingness and capacity to change, facilitative leadership, and appropriate procedures and policies [6, 14, 51, 53] and the development of supporting tools, like training modules [21], the Artifacts of Culture Change Tool [7], and Culture Change Living Toolkit (PiDC), among others, in which these knowable conditions can be managed. Only recently some authors have contributed to the discussion on implementing culture change on a philosophical level by approaching the transformational process from complexity theory [13, 59]. In-depth research into underlying micro processes of cultural change and transformation of normative values could inform the promotion of necessary conditions and the development of detailed guidelines, which according to Rahman and Schnelle [49] are needed. The action research project examined in this article aims to contribute to this field of interest. Research Approach and Design Setting and Participants The action-research project took place in a nursing home in the Netherlands, in a unit in which a shifting population of 22 older people with psycho-geriatric problems temporarily reside for observation, recuperation or as crisis admittance. The unit is housed in a new building with two home-like living-rooms and a private bedroom for each resident, and had been in existence several months when the project started. Working in the unit are a nurse manager and 20 licensed practical nurses, registered nurses and healthcare assistants, together with a varying group of circa 18 students from various care training programs doing their clinical placement in the unit. In addition there are four ward assistants who help with household tasks and serving meals. The unit also has a part-time activities coordinator, often aided by a 123 Health Care Anal voluntary worker. This nursing team works with other members of the multidisciplinary team such as a gerontologist, psychologist and physiotherapist. Hoping to encourage staff to not act solely on tradition and instruction, the management aimed to combine care, education, innovation and research on the unit with the object of increasing the quality of care and developing a challenging workplace [55]. This process was supported by two facilitators, one of whom is employed by the care organisation, was present in the unit part-time and had an intensive collaboration with the nursing team. She worked with a more experienced facilitator, the first author of this article, who was seconded to the project 2 days each week as consultant and researcher to support the process [19, 50]. Inspired by principles of Practice Development [32, 39], both facilitators have the intention to involve all stakeholders in this process, whereby personal qualities, creativity and professional knowledge are acknowledged. They value equality, participation and mutuality, which they strove to give substance by creating social conditions (such as openness, safety and mutual trust) and encouraging democratic processes, joint decision-making and the bottom–up initiation of improvements. Instead of ‘doing for’, practitioners were invited to and supported in giving form to the process. They were regarded as collaborating partners and co-researchers, with the facilitators supporting them in investigating their own practices [19, 50]. The Action-Research Project In order to improve the quality of care in the unit an action-research project was set up—an emergent and cyclical process that links action and reflection, and theory and practice, and by which learning and change take place and knowledge is developed [50]. Using a responsive approach whereby practices were evaluated in dialogue and from various stakeholder perspectives [1, 3], nursing team members (meaning, as in the rest of the article, both staff and students) reached a consensus on the first area to be improved by means of an action-cycle: they wanted to ‘do more with residents’ and offer residents more (group) activities. An action-research group, formed on a voluntary basis and consisting of the coresearchers (an activities coordinator, nurse, healthcare assistant, ward assistant and volunteer) and both facilitators, initiated the project, monitored its progress and evaluated its results with others involved. Residents and/or family members were not part of this group. The residents’ limited and fluctuating cognitive capacities make full participation and decision-making challenging, an ethical issue which is also raised by Munthe et al. [40]. Furthermore, co-researchers indicated that they themselves were not yet ready for this. Participating in a research group was in itself new and challenging for them. As they were not used to cooperating with residents and family as equal partners, the co-researchers expressed fears that residents and family would not understand the group discussions and felt that resident and family participation would hinder them in speaking openly in the group about their experiences delivering care on the unit. Although not entirely in line with their values, the facilitators’ understood this position and accepted it as a starting point, hoping that team members would gain new insights about resident and family participation during the process, as well as develop the confidence to engage in more co-operative practices. 123 Health Care Anal 4. Evaluation and reflection Through observations and focus group interviews [22] data was collected from all stakeholder groups. Reflection on results took place in a meeting with the nursing team and medical and allied health professionals. 3. Action and observation As a kick-off the action plan was presented in a team meeting using drama [35] and dialogue.Research group members operated as change agents to achieve the actions planned.Based on first experiences the action plan was fine -tuned. 1. Reconnaissance Observations on ward, informal chats with family and storytelling [2] were used to analyse the problem. Goals of the action cycle were set and member checked in dialogue with the team and medical and allied health professionals. 2. Planning Actions were identified using ideas generated in a team-meeting and with a number of brainstorming techniques. Actions were concentrated on different aspects (see table 1). Fig. 1 The action research project To plan and guide the project the research group met once every 2–4 weeks for an hour and a half. In addition, the research group organised a number of meetings with members of the nursing, medical and allied health teams to involve them and to exchange ideas. The action cycle lasted a full year and was set up according to Kemmis and McTaggart’s [23] four-phase framework. The process began with (1) the reconnaissance phase in which the issue was analysed, followed by (2) planning, resulting in an action plan, (3) action and observation and (4) reflection (Fig. 1). In the reconnaissance phase it became evident that many practitioners did not know how to involve residents in activities and that the activities coordinator offered groups of residents activities on a fixed weekly basis. Family members had no active role in undertaking activities with the residents. When no activities were on offer residents drowsed and appeared bored. The research group aimed, therefore, to offer more group activities, to involve family where possible and for this to be the responsibility of the whole nursing team. The nurse manager and the gerontologist added that activities should suit the needs and interests of the individual resident and contribute to meeting admission aims, such as the improvement of the resident’s independence. This was not in team members’ minds as yet and not their focus. However after 1 year, according to diverse stakeholder groups residents were more involved with activities suited to their needs and preferences, which influenced their well-being positively. See Table 1 for a summary of the action and evaluation plan. Meta-study The action-research project was also studied on a meta-level as a case study in order to acquire more insight into how such processes unfold over time and contribute to 123 Health Care Anal changes. A case-study explores a complex phenomenon within its context, to understand the particular case and learn from it [58]. Complementary data to that gathered by the co-researchers was therefore collected by the first author (see Table 2), using a number of methods [57]. Based on her participant observations the first author kept a diary with observational notes and reflections on her own role. The 17 research group meetings and those with other practitioners involved were also audio-recorded and detailed minutes were taken to enable a reconstruction of the case. To gain insight into what contributed to changes in the unit, after 6 months the first author held semi-structured interviews with the five co-researchers. Topics touched on motivation to participate in the research group, the influence of the process, and the interim (learning) benefits. After a year, three group interviews (with respectively three co-researchers, two students and three staff members) and an individual interview with a ward assistant were held. The dialogue in these interviews concerned what participants thought about daily activities (1) before the project, (2) after the end of first action cycle and (3) what had contributed to changing their perspective on daily activities. The interviews, lasting an hour, were audio-recorded and fully transcribed. Data was thematically analysed in collaboration and using ATLAS.ti 6.2. The research question was: ‘‘What, according to the nursing team, had contributed to the improvement in participation in daily activities and what were the results?’’ The data was read in order to become familiar with it; then the same three interviews were independently open coded by the first three authors. Next, consensus was reached about the code words used by discussing agreements and differences and clarifying meaning. The list of code words was then tested on an earlier coded interview and two sets of minutes, also independently coded, resulting in some supplementary codes. The rest of the data to be coded was divided between the first two authors. The code list was used as an aid without being directive and still allowing fully open coding. Subsequently, the code words were categorised and thematised by the first three authors in dialogue. Due to constantly moving between focus on parts of the whole and testing interpretations against the greater whole [41, 44] patterns between themes became visible. By integrating themes and bringing them in relation to each other by using a metaphor, further meaning was given to the data. These results were discussed with the whole research team. Because the fourth author was not so closely involved in the analysis process her critical eye was helpful in refining the results. Quality Procedures and Ethics The research made use of triangulation of data and methods, and a number of researchers were involved in the process of analysis, which encouraged the exploration of the phenomenon from varying perspectives [58]. In addition prolonged engagement and persistent observation contribute to the credibility of the results [31]. Data was also continuously member-checked by asking for participant feedback on reports and summaries of interviews. 123 123 Table 1 Summary of action plan Aims Members of the nursing, medical and allied health teams feel responsible for purposefully involving residents in activities and (household) tasks. These practitioners know their residents’ interests so that activities can be suited to them. The daily activities in which the resident is involved contribute to the aims of admission. Residents appear more alert and their personal expressions and actions give an impression of increased wellbeing. Family members are acquainted with activities in which the resident is involved and, if possible, take an active part in these Actions Generating ideas for (group) activities: A file is available for nursing team members and family members with suggestions for activities that can be undertaken with residents. Nursing team members share with each other which activities were and were not successful and report this in the care dossier. Suiting activities to the interests and needs of the resident: At the resident’s admission a form is distributed and completed by family members in order to collect data on the background and interests of the resident. This information is included in the care dossier. ‘Daily activities’ is a fixed item on the agenda in the multidisciplinary meeting so that agreements are made about how each discipline will give form to the residents’ activities in relation to the aims of admission of the resident. Practitioners note agreements and particulars in the area of welfare and daily activity in the resident’s care dossier. Increasing family involvement: During the admission procedure the primary nurse discusses the expectations and possibilities that exist for daily activities and issues an explicit invitation to family members to join in with these. The unit’s monthly newsletter intended for practitioners, residents and family will include the month’s agenda of group activities and a review of activities that were undertaken the previous month. Increasing co-operation, consultation and support: During the afternoon meeting with the nursing team (daily 13.00–13.30) the way in which residents can be involved in activities is discussed. Aim: learning from each other and sharing practical and resident-oriented knowledge. Health Care Anal Undertaking activities and involving residents in household tasks is a fixed agenda item at the morning meeting with nursing team members (daily 10.15–10.30). Aim: organising who does what. Members of the research group and other motivators bring activities to the attention of colleagues at times both planned and unplanned. At the same time they act as role models in offering activities. Each month the research group posts a pithy saying concerning activities as a reminder for other practitioners. Involving residents in activities is a fixed part of the orientation program for students and new staff members and during supervisory meetings with students. Evaluation Interim evaluation on the basis of experience in the research group meetings and team-meetings. After 1 year evaluation of the whole project using a responsive evaluation approach [1, 3]: Observation of residents’ actions and expressions in various situations: with no activities, during visits, during small-scale activities (\4 residents) and large-scale activities ([4 residents). Focus group meeting with family members (n = 6) about involvement, expectations and satisfaction with daily activities. Focus group meetings with medical and allied health professionals (n = 7) about residents’ behaviour and the degree to which daily activities targeted at the admission aims are implemented. Focus group meetings with nursing team members (n = 7) about residents’ behaviour, the degree to which daily activities targeted at the admission aims are implemented, and relations with residents and family. Data-analysis through critical creative hermeneutic analysis [66] —a cyclical and collective analysis process based on creativity and dialogue. Meeting with nursing team and medical and allied health staff members for dialogue on the results and reflection and response. Health Care Anal Table 1 continued 123 123 Table 2 Summary of collected data Time period Data Collector Aim/focus of data March 2009–July 2010 Diary with notes based on participative observations Researcher May 2009–July 2010 Audio-recordings and minutes from research group meetings (n = 17) Researcher Monitoring process, construction of case, identifying project outcomes and aspects that fuelled the improvement process June, September and November 2009 Audio-recordings and minutes from team-meetings (n = 3) with members of the nursing, medical and allied health teams Researcher November/ December 2009 Transcriptions of individual interviews with co-researchers (n = 5) Researcher April 2010 Audio-recordings and reports of two focus groups with medical and allied health professionals (n = 7) Co-researchers with support from facilitators Audio-recording and report of focus group with family members (n = 6) Co-researchers with support from facilitators Audio-recordings and reports of two focus groups with nursing team members (n = 7) Co-researchers with support from facilitators Four reports of residents observations Students with support from facilitators Audio-record and report of critical creative data-analysis Co-researcher and facilitators June 2010 Audio-record and report of reflective meeting with participants Researcher Evaluation of the project July 2010 Transcription of focus group with co-researchers (n = 3) Researcher Transcription of focus group with students (n = 2) Researcher Identifying project outcomes and aspects that fuelled the improvement process Transcription of focus group with nursing staff (n = 3) Researcher Transcription of individual interview with ward assistant Researcher May 2010 Identifying project outcomes and aspects that fuelled the improvement process Health Care Anal Health Care Anal This research falls outside the provisions of the Dutch law on medical research with people [36]. Ethical approval from a Medical Ethics Review Committee is therefore not possible. The organisation and researchers involved are expected to ensure that the research is conducted in an ethically responsible way. Ethical challenges in the participatory research concern the achievement of partnership with research participants, mutual respect, inclusion, equality and learning from each other [4]. For practitioners these challenges were met by the manner of facilitation, the involvement as co-researcher and through shared decision-making. However, the practitioners’ partnership limited the participation of residents and their family to informants in the data collection. Although there was respect for every individual and one’s wishes and needs, this created unintended inequality. Practitioners and family members (as research participant and as the resident’s representative) were given prior information about the aim and methods of the research and took part voluntarily. Previous permission was requested for the recording of meetings and interviews and transcriptions were made anonymous. Results The results demonstrate that aspects that fuelled the improvement process were also seen as outcomes of the project, while the outcomes mentioned by the nursing team led to changes in cultural values and norms, and in their turn contributed to the improvement process. There appears to have been positive mutual influence and growth, and this seemed to be a messy process [11] that gradually developed in interaction with the context. To demonstrate this messiness and mutuality we present the metaphor of ‘the cherry tree’ in which the growth and development of the tree is the symbol for the improvement of the daily activities in the unit. It should be noted that any description of the research results gives only a temporary and relatively simplistic image of the reality; such a description does not do full justice to the actual dynamic and messiness that occurred during the project. The Germination Process A cherry tree comes from a cherry-stone seed, but only in the presence of suitable fertile ground and favourable growing conditions (Fig. 2). In our case the cherry-stone ‘daily activities’, found fertile soil when there was consensus on greater involvement of residents in activities, an area that the participants (meaning all those involved in the study, not just the research group) themselves found important to improve. The desire or intrinsic motivation to ‘mean a bit more’ to residents encouraged the cherry-stone casing to break open. In addition, favourable external factors ensured the seed’s germination, such as a changing context. An example of this is a reduction of the hours that the activities coordinator was available in the unit. This led to participants experiencing a degree of urgency around allocating tasks differently or even reviewing one’s own function. Contributing most to the experienced fertility seem to have been the feeling that ‘we all want the same’, or having a common purpose, and noting the enthusiasm of others, giving a feeling of solidarity. 123 Health Care Anal Fig. 2 The germination process On your own you can think that it is important to do something with someone [a resident] but it doesn’t really go any further. But now I see others think it important too. I get new ideas about how others look at it. I find that stimulating (licensed practical nurse 1, group interview). These favourable growing conditions suppressed less fertile factors, such as an uncritical attitude, a tendency to accept the status quo and not taking the initiative to change. The seed took root and fragile roots sought an anchor in the earth. In the project this anchor was the facilitators who structured the process. They suggested the formation of a research group, organised meetings of its members and offered the phases in an action-research project as a possible method. The facilitators also promoted the necessary social conditions, such as safety, equality and respect for others, in which the members of the research group dared to be themselves so they could grow and develop. The research group developed into a root in terms of promoting meaningful daily activities. With the team and research group, in any case the research group, we’ve begun to give a lead to get the whole team on board to achieve this. We take it up and lay it out for the others so that we can all get to work on it. If we hadn’t done that, it wouldn’t have happened (co-researcher 1, group interview). The still fragile roots absorb water rich in nutrients necessary for the growth of the cherry tree. In our case-study co-researchers fed on the facilitation which helped them to grow as a group and to shape and structure the process. This ensured that the subject received and retained attention, among other things, by involving everyone and by organising and encouraging regular meetings and dialogue among participants. During these contacts and interactions participants spontaneously told each other stories and shared experiences related to the involvement of residents in daily activities, which contributed to growth in these early stages. The seed gives 123 Health Care Anal forth a shoot with a few tender leaves, in our case a growing awareness and increased understanding among participating individuals of the importance of daily activities and what one can do about it. For example, the realisation that activities do not always have to be large-scale to have an effect. Now I realise I should do something with the people [residents]. For example I see there isn’t any music; we set about making it cheerful and, in the evenings too, I try to make things cosy. Those are the things I’m conscious of, and for me that is a change in myself (licensed practical nurse 1, group interview). Germination stimulates the growth of new roots. More and more participants, including the nurse manager, demonstrated the value of involving residents in activities and the subject was discussed more often in the unit. The number of roots was increasing through which the seedling could absorb more nutrients from the earth, thereby encouraging growth. From Seedling to Tree A seedling is fragile: it can be trampled and is vulnerable to extreme changes in weather (Fig. 3). It is helpful to optimise conditions, for example by fertilising the earth. For this reason, the facilitators kept working on social conditions and continued to organise meetings with the research group and the team. A continually changing context also encouraged growth. For example, the ever-changing population of residents stimulated the participants to adapt their actions to suit the needs of new residents, and the input and questions of family members and the changing group of students kept staff members ‘on their toes’ and limited routine actions. It used to be working on automatic pilot. Not now, you can’t do that anymore. It changes too much. That is what is so good about change; it keeps you alert in the unit. You can’t just go on with routine. It is different every time (coresearcher 1, group interview). In increasing measure a seedling can provide its own energy by photosynthesis, thereby stimulating growth both above and below ground, transforming into a tree. The tree becomes stronger, less dependent on external influences and more resistant to disease. This increasing independence and mutual growth above and below ground is also to be found in our case-study. Due to the fertile circumstances (favourable external factors), participants were more occupied with the subject, both consciously and unconsciously. Participants learned from each other by being in the situation, seeing how colleagues involved residents and by sharing experiences. They did things on a trial-and-error basis and saw the first results or growth: residents reacted positively when involved in activities. This encouraged the participants to involve them still more. But seeing the examples and watching… Just doing it, daily activities, you learn to do it too [involving residents in activities]. I think it’s good this way. 123 Health Care Anal Fig. 3 From seedling to tree Then you start to think more about it […] You try something; in the beginning it’s difficult to do that – you see the reactions and you learn more (student 1, group interview). Through this shared and unplanned learning process the roots of the tree (the participants) became stronger. There is personal growth. Team members said that they gained in self-confidence, dared to trust their own judgment and to stand up for themselves. In addition, the co-researchers could talk more easily in a group. The result was that participants, especially co-researchers, took more initiative and another position or role in the unit; they guided others more often, supported others, led by example, made suggestions, delegated and gave feedback. I think I’ve become more sure of myself and I can express that a bit, so I can delegate more (co-researcher 2, group interview). Not only did the roots strengthen, but a whole network of roots came into being with primary, secondary and tertiary roots and root-hairs: Participants developed a consciousness of being part of a whole. They saw their task or function less sharply defined and ‘doing something with residents’ became encompassed in their view of their job. 123 Health Care Anal It said in my job description: serving food and drink, filling in lists. Nothing about activities. For me it was a case of ‘doing what I do well’. Now I think about what more I can do (ward assistant, individual interview). In this way daily activities grew into a common goal for which everyone, not just the activity coordinator, was responsible. This shared responsibility increased feelings of safety, belonging, support and common cause. It’s a common goal.[…] Thinking together, doing together, a unity. Particularly during meetings, getting a discussion going, sharing with the team in a light-hearted way. Then getting feedback on it to take it further, that’s the process […] That we come to the conclusion that we are very close, because we do something together (co-researcher 3, individual interview). The tree becomes stronger and better able to draw nourishment from the earth, more and thicker branches develop and buds appear. Translated to our project, individuals developed a broader concept of activities. ‘Meaningful activity’ was no longer solely regarded as larger activities for groups of residents, but also as involving the individual resident in everyday (care) activities. Exploring and adapting to the resident’s interests and needs became more important. I never asked about it [about the new resident’s interests, hobbies and what they used to enjoy doing]. Now I always ask and follow it up during the admission interview […]. I consider this to be part of my job, it has become normal (licensed practical nurse 1, group interview). This changed view contributed to making true contact between practitioners and residents and building a closer relationship with the resident. The image held by team members of older people altered generally: it became more holistic. For example, participants said that they could better understand and respond to a resident’s actions and personal expressions when they knew more of a resident’s background. Participants began to see residents’ potential rather than focussing on limitations, and became more aware of their own actions influencing the expressions and responses of residents. I have the idea that I see things more as a whole, sometimes a bit of the past of the resident. Perhaps I get a better picture that way…. […] Yes, less a patient. You learn to know them differently. There’s another side to them, but it isn’t so obvious […]. You see them in another light, more as a person you could say (primary nurse, group interview). And so the tree grows. Participants undertook more activities with residents, more frequently considering consciously and deliberately how a contribution could be made to the welfare of the resident. My client I suppose, who was allocated to me, is pretty negative and I know that when she’s involved in an activity she cheers up and it has a positive influence on her mood. I’ve set up an intervention for her so that every afternoon she is offered some activity […] Now for me, it’s part of the care I offer, it is part of my system (student 2, group interview). 123 Health Care Anal Participants saw and experienced the results of their changed practices. Teamwork improved, residents’ personal expressions appeared to reflect a greater sense of well-being and contacts with and between residents increased and were more harmonious. With some clients there is actually deeper contact, therefore more of a trusting relationship. That was partly there already but it has increased. […] So then you get something in return (co-researcher 3, individual interview). This enthused and energised participants. A self-sustaining mechanism came into being, expressed in the project by continuous dialogue, giving and receiving feedback and a growing professionalism based on new values and norms. It was no longer the norm to focus on ‘getting the day’s work done’ or on the number of residents washed, but instead on the satisfaction of the resident. Furthermore, increasing value was placed on relationships with residents, their families and with colleagues. Participants evaluated their actions in relation to these changed norms and values and continued searching for ways to develop and improve such interactions. The changed norms and values appeared to have become internalised which contributed to the sustainability of the changes. With some clients I don’t know how I can motivate them. But due to the meetings I know that I’ll not give up easily on getting clients to do something. At first I thought pretty quickly ‘okay, they don’t want to’. And now it’s ‘wait a bit, try something else.’ We try this and that. And then it works (coresearcher 2, individual interview). The Cherry Harvest When the tree is sufficiently grown and sturdy it will blossom and produce cherries (Fig. 4). This is the ultimate aim and result of the tree. The results of this project were improved collaboration, a broader view of daily activities, and a more personcentred approach to care, anchored in the appropriate cultural values and norms. The workplace culture seems to be more effective. Relationships are improved and practitioners now find it easier to work together, to ask each other for help and to give each other positive feedback. Individuals also feel valued and have a sense of belonging so that they have the feeling of safety and space in which to raise points and to guide others in offering meaningful activities to residents. Not only is there more collaboration but participants go out of their way to help each other. This can have far-reaching consequences. You get a motivated team and that is expressed in so many ways. If somebody is sick it used to be an ordeal to find someone to fill in and now it’s ‘I’ll come’. Everybody is there for everybody else. Absence due to illness is low. It comes out in so many ways (co-researcher 2, group interview). It appears that a broad and deeply rooted shared vision about daily activities came into being. Activities and care seem no longer to be viewed as separate things, but to increasingly form an integrated whole. Daily activities are valued, whereby it 123 Health Care Anal Fig. 4 The cherry harvest is accepted that time and attention is given to individual residents, even if other tasks are set aside. The client is here temporarily. Assessing care needs and giving care when needed is an important [part of our] role. During an activity I find that you can see a lot about what the client can do themselves and where they need help. […] We also look to see which stage of dementia they are in. So you can really discover a lot [during activities]. You can assess physical, but also cognitive and psychosocial functioning (co-researcher 3, individual interview). Care seems to be more person-centred, starting from the needs and abilities of the individual. Yes something has changed, because it is really person-centred. The planned activities really suit the clients and they are carried out as well; going for a walk, playing cards, household chores. But that [household work and recreational activities] is focused on what is suitable for the client (licensed practical nurse 2, group interview). 123 Health Care Anal Based on residents’ personal expressions and actions participants believe that such changes have positively contributed to resident welfare. Also, relations between residents and team members and between residents themselves seem to be improved, which, among other things, benefits the ambience in the unit’s living room. If nothing had been done then people become easily distracted or irritated, or just sit and drowse. [Now,] if I start to do a jigsaw with one lady then the others come and help or start chatting about what they can see in the puzzle. It just has a positive influence. Distraction, so they can have something else to pay attention to. If you go and do something with people, even just one, it has an effect on the whole group (student 2, group interview). While recognising that care can be further improved, for example by involving family as equal partners in the care for their relative, participants are satisfied with the quality of these ‘cherries’ (activities and care). Individually and as a group participants express feelings of satisfaction, enthusiasm, and motivation, which promote growth and make enduring attention for culture change and person-centred care more probable. Conditions are right for the ‘tree’ to continue to produce a good crop of ‘cherries’. Cherries can be consumed in many ways such as jam, liqueur and tarts, but new trees can also grow from the stones that fall to the ground. This dissemination is true of the project as well. Participants now see other aspects of care that should be improved and this awareness seems to arise from an increased concern for the wellbeing of the residents. Projects focused on improving the ambience at mealtimes and increasing family participation have been started. In addition it is possible that there will be spin-offs in other units and organisations when participants move to another workplace. Now that I’ve seen what you can achieve, it is something I’ll take up and possibly during a clinical placement in a hospital I’ll introduce activities in some way or another (student 2, group interview). Discussion The action-research project has led not only to more daily activities for residents but also to a development in the direction of culture change, characterised by more person-centred care [21, 34], a more effective workplace culture [33] and increased empowerment of the practitioners. Although the ideal of power-sharing between the older person and staff has not yet been achieved, these developments make the participation of residents and/or family as equal partners in future processes more likely. Reflecting on the question of what had contributed to the improvement of daily activities and the development of cultural values associated with person-centred care, this research largely confirms that of earlier research [6, 9, 13, 14, 51]. The promotion of dialogue, participation and influence of the staff during every phase of 123 Health Care Anal the project, joint decision-making and continuous appreciative and adaptive facilitation all contributed to transformational change. Additionally, the case study provides insights into how cultural change processes may unfold. The transformation in the direction of culture change was not the intention of team members. They only wanted to ‘do more with the residents’. Although it is generally assumed that there must be a degree of openness or readiness in regard to change, before any such transformation can take place, in this study the values that lie at the basis of person-centred care grew gradually and were not in place when the trajectory started. This contrasts with the ‘common sense’ or ‘traditional’ literature that states that there needs to be a philosophical mission to initiate person-centred care and to become a culture change organisation [14, 21, 27, 33, 51, 59]. When these conditions are not met, this view holds that the transformation process should start with explicit development of a shared vision around these topics. As already mentioned, such a mission was not present beforehand, neither were the values at the basis of culture change and person-centred care explicitly discussed. Nevertheless the seed germinated and person-centred values grew in interaction and without much direct steering or planning: through dialogue, through doing and experiencing, through seeing examples and the positive responses of the older people themselves. The facilitation and relatively concrete action-research project provided the occasion for culture change actions and increased awareness of other aspects in the care situation that were not person-centred, such as the lack of democratic partnerships with the residents’ families. It has put the transformational process in motion and kept it running. Yet, participants scarcely mentioned the previously planned and consciously initiated interventions of the action plan as factors that promoted the improvement process, instead bringing up aspects that related to involvement, collaboration and the culture of the unit. Although phases, like that of Lewin’s [30] or Prochaska and DiClemente [48] are discernible and may be helpful, they are less neatly identifiable in our case. Despite the initial more linear and planned action research project, the change process was messy and happenstance rather than neatly ordered. Once the process got under way, changes, great and small, ‘just happened.’ This accords with an emergent and complexity view of change rather than a planned and top–down approach, while dialogical constructions or structures like the action research project put such emerging processes in motion. From a complexity approach an organisation is regarded as a holistic and complex adaptive system, consisting of a number of loosely coupled parts or individuals [15, 28, 38, 45, 47]. Through dynamic networks of interaction come continuous and unpredictable changes or mutations, which in turn have spontaneous and unforeseen effects on individuals and the system. In this way a self-organising emergent mechanism comes into being, which, without guidance from outside, gives rise to non-linear changes. Small incidents, actions and interactions (aimed at improvement of activities) can scale up to greater effects (the development in the direction of culture change) occasioning changes in the system as a whole [60]. Individuals deal with such complex situations by sense making while enacting alternative behaviour or as a social and retrospective process of giving meaning to situations and experiences by verbally expressing these and sharing them with 123 Health Care Anal others [56, 62, 70]. These interactive and responsive processes of sense making contribute to the individual and collective development of identity. It creates shifts in definitions of one’s own role and those of others and enhances collective action and enactments of new behaviour making progress and change possible [70]. For example: the team members in the case did not know how to involve residents in activities and gave this (collective) meaning by sharing experiences, by trying things out and seeing how others approached something. It is this shared and spontaneous learning process that influenced the actions of individuals and caused (gradually) shifts in individual and collective values and norms. It brought change to all layers of the culture—at the level of artefacts and espoused values as well as the deep-rooted and underlying assumptions [52]. Cultural change, it seems, is not always particularly susceptible to conscious action and does not necessarily come about by the implementation of a concrete plan. The system itself, and therefore the mutually linked and interacting individuals, are the culture, which can evolve through chaos and momentum. More detailed guidelines for implementing culture change, advocated by Rahman and Schnelle [49] would then appear to be difficult to formulate. Furthermore, the strategies and phased changed models suggested in the culture change literature could be helpful when flexible and loosely used, but taken at face value appear to conflict with values underlying the culture change movement as they seem prescriptive and to promote a top–down and planned approach. Limitations This study has its strengths, such as the use of triangulation and prolonged engagement, but also its limitations. For example, during interviews the questions were chiefly concerned with what had contributed to the improvement process, so that it is possible that factors that hindered the process received too little attention. In addition, the team had not been in place very long before the start of the project so that routines, values and norms were less fixed. Because of this it is probable that it was easier to bring about momentum or that there was already a degree of imbalance. Another limitation is that the study does not reflect the perspective of residents or their family. Practitioners assume that the care and activities undertaken with residents are more person-centred, but these interpretations are mainly based on observations of the residents’ responses. There is also little known about whether and how the project increased the autonomy and empowerment of the residents, which is an important aspect of culture change. However, while residents and their family were not involved in an equal and collaborative venture, the project could have led to an increased willingness among practitioners to involve them as equal partners in future projects. It even may have brought a sense of urgency to examine how this could be achieved working together with residents who have limited and fluctuating cognitive capacities. 123 Health Care Anal Thick description makes it possible to give readers a vicarious experience and to test the naturalistic generalisation of the findings by seeing how these fit with their own practice [57]. Implications The case demonstrates that it makes sense to approach processes of change from a complexity angle. A complexity approach modifies the value of a detailed and realistic plan of change, which Berkhout et al. [6] thought important for transformation towards a culture change facility, and offers an explanation for the co-evolution of the daily activities and the context through which this process of change took place. This indicates that development towards a culture change facility should begin somewhere, and on a small scale as is also suggested by Shield et al. [53], instead of waiting for more ideal conditions for change or a certain organisational readiness, which according to Manley et al. [33] is a favourable factor in the realisation of an effective workplace culture. By inspiring stakeholders to participate and by beginning with a theme that is concrete and meaningful to them, and which they feel is urgent [27] momentum can emerge more quickly and easily than if starting from purposeful development of a person-centred mission and vision, for instance by means of intensive training or education in culture change as advocated by Robinson and Rosher [51]. Through this momentum and imbalance patterns and structures will emerge and changes in the system will occur [28]. Consequently the case teaches us that culture change comes into being from the system itself through a continuous and emergent process of dynamic adaption and action, and therefore learning. This process cannot be completely managed or prescribed. However, as part of the system managers and facilitators influence these processes by definition, but may also do this more consciously by intervening and interacting with others. It is important that managers and facilitators practice what they preach and model the desired values as is also argued by Tyler and Parker [64]. Adaptive leadership [13] and a style of facilitation that is based on the principles of Practice Development [32, 39] and is distinguished by an appreciative approach and attitude [12] support this. Furthermore, inclusion of all stakeholders, the acknowledgement of various insights and the realisation of possibilities for collective interpretation [15] are important. The facilitation of such changes should therefore be aimed chiefly at the enhancement of conditions and possibilities that promote this, such as the development of a meaningful and valued place for all involved [10], the creation of space for multiple voices, the encouragement of interaction, and the support of the process of sense making [62, 70]. This could advance reflexive processes in routine practices. By encouraging collaborative decision-making and flexibility throughout the process adaptive and general plans may arise in response to the changing context, which could give some direction to the process. A participatory action-research project can help in this [15, 45], as long as the accent lies on rapid improvement cycles of attempting and evaluating interventions that arise from earlier actions 123 Health Care Anal rather than a thought-out analysis and planning phase [70]. By making use of the often surprising possibilities that arise during the process, also known as improvising and occasioning, the participatory and emergent character of learning is supported and purposeful interactions and actions can be combined with those that arise spontaneously [15]. In addition it is unrealistic to expect great results immediately, rather it is necessary to be able to challenge and support stakeholders to participate and to keep the process going, whereby it is essential as facilitator to be mindful of the possibilities that emerge from the process [15, 55]. A final suggestion following from this research concerns the explicit embedding of existing strategies and guidelines within a philosophical perspective. By approaching these explicitly from a complexitivist perspective, the flexible and noncommittal use of strategies and guidelines appropriate within the particular context will be emphasised. Furthermore, the use of another language that is more supportive to the complexitivist perspective will be helpful to gather a common sense perspective to culture change. Regular cultural change theories give the impression of being prescriptive and are informed and supported by Western languages using nouns as building blocks for change. These perpetuate linear thinking [42]. ‘‘A shift in vocabulary from change to changing directs attention to actions of substituting one thing for another, of making one thing into another thing, or of attracting one thing to become other than it was.‘‘ [69]. A preference for nouns (‘change’) denote a final stage while a descriptive approach and verbs (‘changing’) draw our attention more to the process. Terms like occasioning, caring and dialoguing seem to provide a space in which both structure and eye for emerging deviations are possible. Conclusions The detailed description of the case provide insights into how cultural norms associated with person-centred practices unfold. As such it contributes to a more philosophical dialogue concerning the implementation of culture change and the generation of some general guiding principles for facilitating cultural change processes. This research illustrates that the improvement of care and cultural change are dynamic, interactive and non-linear processes that evolve together. These processes are characterised by complexity and are difficult to predict or control. Managers and facilitators can support the process of change and the development towards a culture change facility by creating momentum by means of small, focused projects that are suited to stakeholders, by creating conditions for sense making and collaborative decision-making, practicing the desired values and by occasioning and improvising. Action research can support this. Acknowledgments We would like to thank George Vink for visualising the case in some nice drawings and Donna Frost for her feedback and willingness to check and correct the English language. References 1. Abma, T. (2005). Responsive evaluation: Its meaning and special contribution to health promotion. Evaluation and Program Planning, 28, 279–289. 123 Health Care Anal 2. Abma, T. A., & Widdershoven, G. A. M. (2005). Sharing stories: Narrative and dialogue in responsive nursing evaluation. Evaluation and the Health Professions, 28(1), 90–109. 3. Abma, T., Molewijk, B., & Widdershoven, G. M. (2009). Good care in ongoing dialogue. Improving the quality of care through moral deliberation and responsive evaluation. Health Care Analysis, 17(3), 217–235. 4. Banks, S., Armstrong, A., Carter, K., Graham, H., Hayward, P., Henry, A., et al. (2013). Everyday ethics in community-based participatory research. Contemporary Social Science: Journal of the Academy of Social Sciences, 8(3), 263–277. 5. Baur, V. E. (2012). Participation & Partnership. Developing the influence of older people in residential care homes. Ph.D. Thesis, Vrije Universiteit Amsterdam. 6. Berkhout, A. J. M., Boumans, N. P. G., Mur, I., & Nijhuis, F. J. N. (2009). Conditions for successfully implementing resident-oriented care in nursing homes. Scandinavian Journal of Caring Sciences, 23(2), 298–308. 7. Bowman, C. S. & Schoeneman, K. (2006). Development of the artifacts of culture change tool: Centers for medicare & medicaid services and edu-catering. http://www.artifactsofculturechange. org/Data/Documents/artifacts.pdf. 8. Cameron, K. S., & Quinn, R. E. (2011). Diagnosing and changing organizational culture: Based on the competing values framework. San Francisco: Wiley. 9. Caspar, S., Cooke, H. A., O’Rourke, N., & MacDonald, S. W. (2013). Influence of individual and contextual characteristics on the provision of individualized care in long-term care facilities. Gerontologist, 53(5), 790–800. 10. Chapin, M. K. (2010). The language of change: Finding words to define culture change in long-term care. Journal of Aging, Humanities, and the Arts, 4(3), 185–199. 11. Cook, T. (1998). The importance of mess in action research. Educational Action Research, 6(1), 93–109. 12. Cooperrider, D. L., Barrett, F., & Srivastva, S. (1995). Social construction and appreciative inquiry: A journey in organizational theory. In D. M. Hosking, H. P. Dachler, & K. J. Gergen (Eds.), Management and organization: Relational alternatives to individualism (pp. 157–200). Aldershot: Avebury Press. 13. Corazzini, K., Twersky, J., White, H. K., Buhr, G. T., McConnell, E. S., Weiner, M. & ColónEmeric, C. S. (2014). Implementing culture change in nursing homes: An adaptive leadership framework. The Gerontologist, 1–13. 14. Crandall, L. G., White, D. L., Schuldheis, S., & Talerico, K. A. (2007). Initiating person-centered care practices in long-term care facilities. Journal of Gerontological Nursing, 33(11), 47–56. 15. Davis, B., & Sumara, D. J. (2005). Complexity science and educational action research: Towards a pragmatics of transformation. Educational Action Research, 13(3), 453–464. 16. Graetz, F., & Smith, A. C. T. (2010). Managing organizational change: A philosophies of change approach. Journal of Change Management, 10(2), 135–154. 17. Grant, L. A. & Norton, L. (2003). A stage model of culture change in nursing facilities. In culture change II: Theory and practice, vision and reality. The 56th annual scientific meeting of the Gerontological Society of America, San Diego, CA. 18. Hallencreutz, J., & Turner, D.-M. (2011). Exploring organizational change best practice: are there any clear-cut models and definitions? International Journal of Quality and Service Sciences, 3(1), 60–68. 19. Heron, J., & Reason, P. (1997). A participatory inquiry paradigm. Qualitative Inquiry, 3(3), 274–294. 20. Higgs, M., & Rowland, D. (2005). All changes great and small: Exploring approaches to change and its leadership. Journal of Change Management, 5(2), 121–151. 21. Jones, C. S. (2011). Person-centred care: The heart of culture change. Journal of Gerontological Nursing, 37(6), 18–25. 22. Kamberelis, G., & Dimitriadis, G. (2005). Focus groups: Strategic articulations of pedagogy, politics, and inquiry. In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage handbook of qualitative research (pp. 887–908). Thousand Oaks, California: Sage. 23. Kemmis, S., & McTaggart, R. (1988). The action research planner. Victoria, Australia: Deakin University. 24. Kezar, A. J. (Ed.). (2001). Understanding and facilitating organizational change in the 21st century: Recent research and conceptualizations. ASHE-ERIC Higher Education Report. San Francisco, CA: Jossey-Bass. 123 Health Care Anal 25. Kitwood, T. (1997). Dementia reconsidered: The person comes first. Maidenhead: Open University Press. 26. Koren, M. J. (2010). Person-centered care for nursing home residents: The culture-change movement. Health Affairs, 29(2), 312–317. 27. Kotter, J. P. (1996). Leading change. Boston: Harvard Business School Press. 28. Laidlaw, L. (2004). On the importance of little details: Complexity, emergence and pedagogy. Educational Insights, 9(1), 1–13. 29. Lee, S.-Y. D., Weiner, B. J., Harrison, M. I., & Belden, C. M. (2013). Organizational transformation: A systematic review of empirical research in health care and other industries. Medical Care Research and Review, 70(2), 115–142. 30. Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social changes. Human Relations, 1(1), 5–41. 31. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage. 32. Manley, K., McCormack, B., & Wilson, V. (Eds.). (2008). International practice development in nursing and healthcare. Oxford: Blackwell. 33. Manley, K., Sanders, K., Cardiff, S., & Webster, J. (2011). Effective workplace culture: The attributes, enabling factors and consequences of a new concept. International Practice Development Journal, 1(2), 1–29. 34. McCormack, B., & McCance, T. (2010). Person-centred nursing: Theory and practice. Chichester: Wiley. 35. Mienczakowski, J. (1995). The theatre of ethnography: The reconstruction of ethnography into theare with emancipatory Potential. Qualitative Inquiry, 1(3), 360–375. 36. Ministerie van Volksgezondheid. (2006). The medical research involving human subjects act (WMO). The Hague: Ministry of Public Health. 37. Moles, D. (2006). Bringing culture change into better focus: What are the real ingredients of culture change in nursing facilities? http://www.thefreelibrary.com/Bringing culture change into better focus: what are the real…-a0156644298. 38. Morgan, G. (1997). Images of organization. Thousand Oaks, CA: SAGE. 39. Munten, G., Legius, M., Niessen, T., Snoeren, M., Jukema, J. & Harps-Timmermans, A. (2012). Practice Development. Naar duurzame verandering van zorg- en onderwijspraktijken. [Practice Development. To sustainable change in healthcare and education practices]. Den Haag: Boom uitgevers. 40. Munthe, C., Sandman, L., & Cutas, D. (2012). Person centred care and shared decision making: Implications for ethics, public health and research. Health Care Analysis, 20(3), 231–249. 41. Niessen, T. (2007). Emerging epistemologies. Making sense of teaching practice. Ph.D. Thesis, Maastricht University. 42. Niessen, T., Abma, T., Widdershoven, G., van der Vleuten, C., & Akkerman, S. (2008). Contemporary epistemological research in education: Reconciliation and reconceptualization of the field. Theory & Psychology, 18(1), 27–45. 43. Nolan, M. R., Davies, S., Brown, J., Keady, J., & Nolan, J. (2004). Beyond ‘person-centred’ care: A new vision for gerontological nursing. Journal of Clinical Nursing, 13, 45–53. 44. Paterson, M., & Higgs, J. (2005). Using hermeneutics as a qualitative research approach in professional practice. The Qualitative Report, 10(2), 339–357. 45. Phelps, R., & Hase, S. (2002). Complexity and action research: Exploring the theoretical and methodological connections. Educational Action Research, 10(3), 507–524. 46. PiDC. Culture Change Living Toolkit. https://uwaterloo.ca/partnerships-in-dementia-care/culturechange-living-toolkit. 47. Pina e Cunha, M., & Vieira da Cunha, J. (2006). Towards a complexity theory of strategy. Management Decision, 44(7), 839–850. 48. Prochaska, J. O., & DiClemente, C. C. (1994). The transtheoretical approach: Crossing traditional boundaries of therapy. Melbourne, FL: Krieger Publishing Company. 49. Rahman, A. N., & Schnelle, J. F. (2008). The nursing home culture-change movement: Recent past, present, and future directions for research. The Gerontologist, 48(2), 142–148. 50. Reason, P., & Bradbury, H. (2001). Introduction: Inquiry and participation in search of a world worthy of human aspiration. In P. Reason & H. Bradbury (Eds.), Handbook of action research: Participative inquiry and practice (pp. 1–14). London: Sage. 51. Robinson, S. B., & Rosher, R. B. (2006). Tangling with the barriers to culture change: Creating a resident-centered nursing home environment. Journal of Gerontological Nursing, 32(10), 19–27. 123 Health Care Anal 52. Schein, E. (2004). Organizational culture and leadership. San Francisco, CA: Jossey-Bass. 53. Shield, R. R., Looze, J., Tyler, D., Lepore, M., & Miller, S. C. (2013). Why and how do nursing homes implement culture change practices? Insights from qualitative interviews in a mixed methods study. Journal of Applied Gerontology. 54. Shields, S., & Norton, L. (2006). In the persuit of the sunbeam: A practical guide to transformation from institution to household. Milwaukee: Action Pact Press. 55. Snoeren, M. M., Niessen, T. J., & Abma, T. A. (2012). Engagement enacted: Essentials of initiating an action research project. Action Research, 10(2), 189–204. 56. Snoeren, M. M., Niessen, T. J., & Abma, T. A. (2013). Beyond dichotomies: Towards a more encompassing view of learning. Management Learning, 1–19. 57. Stake, R. E. (2003). Case studies. In N. K. Denzin & Y. S. Lincoln (Eds.), Strategies of qualitative inquiry (pp. 134–164). Thousand Oaks: Sage. 58. Stake, R. E. (2005). Qualitative case studies. In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage handbook of qualitative research (pp. 443–466). Thousand Oaks, CA: Sage. 59. Sterns, S., Miller, S. C., & Allen, S. (2010). The complexity of implementing culture change practices in nursing homes. Journal of the American Medical Directors Association, 11(7), 511–518. 60. Sumara, D. J., & Davis, B. (1997). Enactivist theory and community learning: toward a complexified understanding of action research. Educational Action Research, 5(3), 403–422. 61. The Pioneer Network. (2004). Getting started: A pioneering approach to culture change in long term care organizations. Rochester, NY: The Pioneer Network. 62. Thurlow, A., & Helms Mills, J. (2009). Change, talk and sensemaking. Journal of Organizational Change Management, 22(5), 459–479. 63. Todnem By, R. (2005). Organisational change management: A critical review. Journal of Change Management, 5(4), 369–380. 64. Tyler, D. A., & Parker, V. A. (2011). Nursing home culture, teamwork, and culture change. Journal of Research in Nursing, 16(1), 37–49. 65. van de Ven, A. H., & Poole, M. S. (1995). Explaining development and change in organizations. The Academy of Management Review, 20, 510–540. 66. van Lieshout, F., & Cardiff, S. (2011). Dancing outside the ballroom: Innovative ways of analysing data with practitioners as co-researchers. In J. Higgs, A. Titchen, D. Horsfall & D. Bridges (Eds.), Creative spaces for qualitative researching: Living research (pp. 223–234). Rotterdam: Sense Publishers. 67. van Zadelhoff, E., Verbeek, H., Widdershoven, G., van Rossum, E., & Abma, T. (2011). Good care in group home living for people with dementia. Experiences of residents, family and nursing staff. Journal of Clinical Nursing, 20(17–18), 2490–2500. 68. Walsh, K. D., Crisp, J., & Moss, C. (2011). Psychodynamic perspectives on organizational change and their relevance to Transformational Practice Development. International Journal of Nursing Practice, 17(2), 205–212. 69. Weick, K. E., & Quinn, R. E. (1999). Organizational change and development. Annual Review of Psychology, 50(1), 361–386. 70. Weick, K. E., Sutcliffe, K. M., & Obstfeld, D. (2005). Organizing and the process of sensemaking. Organization Science, 16(4), 409–421. 123