Culture Change in Nursing Homes: Considerations and Questions for Social Workers

Culture change—the shift from institutional models of care toward consumer-directed, socially oriented models—is a growing movement in long-term care communities across the United States and beyond. Culture change, also known as person-centered care, presents new opportunities and challenges for social workers, especially those working in nursing homes. Although many social workers have written about culture change and, indeed, have been involved in implementing culture change in nursing homes, little has been written about the social work role in culture change. Moreover, although some social workers embrace culture change because of the congruence between social work values and culture change’s focus on self-determination and quality of life, others are concerned that culture change may diminish their professional roles.

Is the setting in which you work implementing culture change? If so, what model is being used?

How has your role as a social worker been affected by culture change? Are you taking on new leadership roles? Have you taken on non–social work responsibilities or turned over social work functions to non–social work staff? Do you have any ethical or legal concerns about changes in your role?

How do you think the social work profession can position itself as a leader in culture change while preserving the integrity of the professional social work role in nursing homes?


Read NASW’s Aging Specialty Practice Section article, De-Institutionalizing an Institutional System (2003), to learn more about culture change.

Learn about NASW’s contribution to an interdisciplinary issue paper addressing the role of nursing in culture change.


  1. Missouri has had title protection for awhile, but nursing homes in our state are not required to hire social workers (BSW, MSW) in their facility. NONE of the nursing homes in my area have a BSW or MSW in place. None. However, the residents and families call them “social workers” and think of them as social workers. I don’t believe the medical home model will enhance our degree at all. In fact, as part of the medical home model at our local hospital, they’ve hired un-degreed persons to do in home assessments of our seniors. It’s disappointing to hear so much discussion on the value of social workers as the medical home model grows, but the realization is to the contrary. The positions are being filled in my area with non-degreed persons.

  2. lynne oliver lcsw

    I have resigned after 31/2 years in a nursing home. When I was hired, culture change was the agenda and i was hopeful. unfortunately, i have learned that the nursing system is strong and as a social worker i have lost all hope. A new assistant adm came on board (formerly a salesman) a year ago and social work is now social services. ( i have been a social worker for several years and I have a BSW assistant who does the generalist tasks of social services.)I will continue to be involved with the local culture change coalition but not as a social worker here. It is disheartening to see the agency retreat to the medical model.

  3. I feel that in order to help culture change really happen, as social workers we need to get more involved with families. Family systems can be uncomfortable ground for anyone to engage, but connecting to families and the patients personal history can have a trully profound and positive affect on quality of life care and family dynamics.

  4. Ann M. Allen, LICSW

    I beleive we have further to go with cultural change. As an intensive case manager with high utilizers of an emergency department I have many patients who are not plannign to stop using alcohol or other substances and have no access to the level of care they need to sustain thier life. I do not belive we would discriminate against any other group as much as we do people suffering from addiction.

  5. Jillian Inserra, LCSW

    I am a social worker at the Hines VA Hospital Community Living Center. The VA has been involved in cultural change in our nursing homes for several years now. In fact, the name-Community Living Center, is a product of cultural change. The models my center and the VA have been utilizing are a resident-centered approach, the HATCH (Holistic Approach to Transformational Change) model, and TCAB (Transforming Care at the Bedside). I think the social worker is vital in culture change. Culture change is not just about changing the physical environment, but about how we treat our residents. Many of the principles being suggested, like respect, self-determination, privacy are already values and actions social worker uphold in the nursing home environment. I have taken a leadership role in culture change by educating staff about how to converse with residents. I have been involved in several programs to get staff and residents excited about living at our CLC.

  6. In the State of North Carolina, “Title Protection for Social Workers” has been passed, meaning that in order to use the title “Social Worker” you have to have a Degree in Social Work from an Accredited CSWE School. Thus, apparently nursing homes will have to employ actual “social workers”. Thus, social workers will truly be defined and be able to voice their stance on various issues as “the Culture of the Nursing Homes, etc”

  7. Melissa Bosserman, LCSW

    As a Hospice Social Worker, I provide services to patients in nursing homes in rural Missouri where the struggle continues to place qualified social workers. In all four NH I round in, the position of social worker is filled by individuals without social work degrees. They are titled “social services” since the term social worker can not legally be used in the state without a degree. Therefore, the job becomes one of “intake specialist” rather than Social Worker, focusing primarily on financial concerns. It seems a needed first step would include advocating for professionals who are capable, as Ms. Bah points out, of leading the way in valued efforts such as client self determination and preservation. Imagine, being awoke at 7:00 am in the last days of life to meet state regulations that allocate all individuals must be fed on a schedule. Truly, this change, if embraced by the SW profession can only strengthen our purpose as this model defines a misunderstood language among many healthcare professionals.

  8. As a social worker working as a long term care Ombudsman, I think that my key role has been to educate my colleagues in long term care settings on how they can be effective stewards in the culture change movement. As a former health care unit social worker, I know that education and information to residents, staff and families is a tool of empowerment. As change agents, social workers are in an unique position to advocate for culture change principles. As stewards of the culture change process, we as social workers can ensure that the psychosocial assessments are living tools utilized to individualize resident’s needs. And we play a key role in advocating for consistent staffing assignments, something that culture change strongly supports. Through a systems approach we can advocate for staff on all levels to contribute to the process. After all, it is a strengths based perspective!

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