The Six Cs of Culture Change

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Jennifer Carson

Jennifer Carson, PhD, Director, Dementia Engagement, Education, and Research (DEER) Program, School of Public Health, University of Nevada, Reno

The case for culture change – the moral imperative to transform nursing homes – has never been more urgent or clear. Drawing on data available during the SARS-CoV-2 pandemic, “the best evidence for minimizing morbidity and mortality within nursing homes has been shown by homes that have moved the farthest away from the medical model of care” (Power & Carson, 2021, p. 3). Nursing homes that were committed to a person-directed and relationship-centered culture before the pandemic have experienced significantly better outcomes during the pandemic.

As nursing homes continue to emerge from the pandemic, many have committed to building back stronger and better by embarking on a culture change journey. As nursing homes strengthen their crew, raise the sails, and set out for a brighter and more just future, I want to share some reflections as a fellow traveler about the process of culture change – the “how to” for a positive, effective, and sustainable journey. But in lieu of a cookie-cutter recipe, formula, or blueprint for success (of which I am extremely wary), I would like to frame my reflections as important principles – the “Six Cs of Culture Change.” Let’s get started by exploring what culture change is not.

Culture change is not a discrete program that is expertly and uniformly implemented from the top-down, nor is it a quality improvement effort built on the shoulders of some charismatic leader, or even a small and fixed group of enthusiastic champions who manage the whole process. Having made these mistakes earlier in my own career, I can attest that these types of change efforts almost always fail as soon as you remove the person or small group of people at the steering wheel. Such efforts conjure an illusion of culture change, but they seldom produce deep, systemic, sustainable transformations. A number of C-words come to mind when I think of top-down efforts to implement culture change: Co-opting, Convincing, Commanding, Controlling, Coercing, and ultimately Contradicting (the values of culture change). These are definitely not the Six Cs of Culture Change.

Instead, culture change is a highly Collaborative, deeply Communicative, Capacity-building, Community-driven process that produces different outcomes at different times in different places because every nursing home is unique. No two communities are the same, and therefore no two culture change processes are the same, and neither are the outcomes, not if it is truly a Collaborative, Communicative, Capacity-building, Community-driven process. These are four of the Six Cs of Culture Change.

Now within this process, instead of following some static recipe or formula (i.e., implement A + B then measure C for X), community-driven transformations are guided by a set of shared values. For example, some communities use the Pioneer Network’s principles and values as their guiding compass. Some communities use the Canadian culture change values, developed as part of the inaugural 2014 Canadian culture change conference, Walk with Me. Other communities might embrace other values or develop their own to guide their culture change journey. As community members work collaboratively to live their shared values, an infinite number of possible outcomes emerge.

Culture change is and should always be defined as a process, and not as an outcome – a journey, not a destination. It is up to each community to decide how to embody and live out their culture change values, and the inclusive, collaborative, consciousness-raising discussions community members have about ‘what to do’ and ‘how to do it’ serve to build capacity for an effective and sustainable journey.

A lot of people say that long-term care is a broken system. But I think one of the biggest problems with long-term care is that it is treated as a system and that systems-thinking and instrumental rationalities have invaded the living, breathing lifeworld of long-term care like a parasite, essentially systematizing and institutionalizing places where people live – systematizing their communities, systematizing their homes, systematizing their daily existence.

As we consider approaches to fostering true culture change, please know that we do not need a better system. Culture change calls for a turn away from the system and toward people, toward human reason. Culture change processes must honor the experiences, knowledge, creativity, and diversity of community members whose lives are impacted. All people and all groups have a right to speak for themselves, in their own voice, and to have that voice heard, understood, accepted, and prioritized. This includes residents, family and employee care partners.

Culture change calls for a “revitalization of the lifeworld” (Fals Borda, 1988; Habermas, 1987), that is, a returning of inclusive networks of good communication among actual people who share their life experiences as they work together toward a better tomorrow. And through this collaborative action, each nursing home can develop a greater understanding of the situation in which they find themselves, and with a range of possibilities, instead of a single, authoritative directive, address the question, “Where do we go from here?”

Drawing on the wisdom of culture change pioneer, Barry Barkan (2013), the solution to the problems experienced in nursing homes is “real community,” a place where people know each other and have role and identity… where individually and collectively people have a voice and a choice in the small and large decisions that impact their lives, including decisions about culture change. Real community is an achievable reality.

I believe the process of culture change must include efforts to directly and supportively engage, educate, organize, and support residents, family and employee care partners in directing their own change efforts within their own communities; culture change by people, for the people. Here’s a litmus test. How can you tell if culture change process is top-down or truly collaborative? Well, if you find one or two people running around trying to get other people to buy-into their grand vision of an ideal community, then it may be top-down. Culture change is not achieved through buy-in. It’s achieved through Co-ownership (our fifth C).

As context for the sixth C, I want to share a quote from one of my favorite change agents, Brazilian educator and philosopher Paulo Freire (2007), who said: “Any situation in which some [people] prevent others from engaging in the process of inquiry [or change] is one of violence; …to alienate people from their own decision-making is to change them into objects” (p. 85). The people who live and work in nursing homes are not objects. They are citizens of their communities, and active Citizenship (the sixth C) must be protected and promoted within the culture change process itself. Any culture change initiative that fails to engage community members as active citizens and authentic participants in all aspects of the culture change process is simply not a culture change.

While there may be other Cs (and plenty of other letters, too) that support the culture change process, these are the six principles that I have found most useful, inclusive, and generative: Collaborative, Communicative, Capacity-building, Community-driven, Co-ownership, and Citizenship. Look up. Like stars in a night sky, these principles can guide you forward.

For additional information, please visit: for free access to: Jennifer Carson (2015). Working Together to Put Living First: A Culture Change Process in a Long-Term Care and Retirement Living Organization Guided by Critical Participatory Action Research. UWSpace. 

10 comments on “The Six Cs of Culture Change

  1. Jennifer Carson on

    Thank you, all, for sharing your insights, experiences, and encouragement. I hope we can continue the conversation at the Pioneer Network Conference in beautiful Denver, Colorado! Can’t wait!

  2. Michelle Olson on

    Thank you, Jennifer for such a beautifully articulated article. I appreciate thinking more deeply about turning away from a systems approach to a human experience. When we view these communities as homes and residents as individuals, creating a collaborative and inclusive culture becomes inevitable.

    Frank Ostaseski, who is one of my favorite lecturers and a renowned Buddhist teacher, said to me, “See yourself in those you serve. It changes the way care happens.” This has stuck with me as I believe this perspective along with the lessons Covid has given us—will help us transform our views and our care of people living in long-term care homes.

    Thank you again for your leadership and light in this world!

  3. /Sandra Stimson CEO on

    Dr. Carson
    This is an excellent article and I believe people can follow the 6 C’s as you so brilliantly explained and provided the road map to follow. Your article is thought provoking. This is why ICCDP strongly believes in person centered care approach and the certification ICCDP offers, CMDCP Certified Montessori Dementia Care Professional and 7-hour online course. The core focus is infantilization, respect, understanding and recognizing all those seniors can do for themselves. This is not a hard concept to incorporate in the day-to-day care provided and activity and therapeutic programs, either in the long-term care setting or home care environment.

    International Council of Certified Dementia Practitioners
    a division of National Council of Certified Dementia Practitioners

  4. Kristine Theurer on

    Thank you Jennifer for this brilliant article. Culture change is talked about so much, and like you I have learned that it is so critical to empower and include the voices of all of the people within the community. I was a part of a home that embarked on the Edenizing journey for 10 years with much success, only to have the changes completely dismantled when a new CEO took over. It was incredible (and so discouraging) how quickly it all fell apart. Thank you for sharing your thoughts on these very important distinctions of what culture change is and what it isn’t. It brought me hope and reminded me that culture change is a journey.

  5. Jeanne Della Guardia on

    Glad to see that the Coalition I was involved with in Pennsylvania 20 years ago is still growing and evolving! Jeanne Della Guardia RN,BSN,MHA

    • Cathy Lieblich on

      This is Cathy Lieblich and I remember you, Jeanne! Yes, the PA coalition that you helped to grow is still going strong! I hope you’re doing well.

  6. Tim Graves on

    Good morning Dr. Carson!

    Thank you for the insightful article. I feel the Assisted Living Facility realm is also at risk of the “systematizing and institutionalizing” you speak of above.

    I am wondering if you can point me to the resource you quoted at the outset (Power & Carson, 2021). I would be very interested to read more on these findings!

    Thank you so much for your critical work in the field!

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