Implications for nursing practice

• ▪ Structured approaches that enable nursing staff to consider the culture of care they work within are likely to support reflection, critical discussion and improved quality of care.

• ▪ The physical and psychosocial care environment, characteristics of the nursing work and nursing staff, influence the well-being of people with dementia.

Implications for research

• ▪ Understanding how organisational culture can influence the quality of care is an important topic for nursing research.

• ▪ How the culture of care affects residents' quality of life and health outcomes needs further research.

• ▪ Intervention studies in care homes need to consider how to assess organisational context and culture and how different cultural contexts influence outcomes.

Context

As the population ages and more people require long-term care, how the culture of a nursing home influences care is an important question. The values and beliefs of practitioners have been repeatedly identified as, and linked to, how person-centred care for people with dementia is defined, understood and provided.1,–,3 This study uses the Competing Values Framework of Organisational Culture to investigate the relationship between organisational culture and quality of care in dementia units and nursing homes in The Netherlands.

Findings

A total of 248 participants (average response rate of 63% per unit) completed the questionnaire. There was wide variation in the number of nurses employed across the 11 units. The majority of nurses believed the quality of care provided was ‘good to very good’. The tasks most frequently identified as the nurses' main focus were delivering personal individual care, creating a nice and friendly atmosphere and providing residents with emotional support.

Perceived and observed quality of care were positively correlated, and the authors argue that the findings suggest nursing staff base their judgement of quality of care on what they perceive to be their task priorities. Where a unit was characterised as having a clan culture (as opposed to, eg, a market culture), this was positively correlated with perceived and observed quality of care.

Commentary

Studies in care homes consistently identify that how people with dementia are cared for reflect the priorities and values of the organisation.4 ,5 However, there is little work that has tried to establish a link between culture and the quality and outcomes of care. The authors are to be congratulated for taking a systematic approach and linking this work with a wider theoretical literature on organisational culture. It is interesting, however, that the authors in this study did not reference care-home-based work on the culture of care, for example, the nursing home culture change movement or the work that has been done on quality of life (as opposed to quality of care) for people living in long-term care.6 ,7 Nor is there reference to care-home-based studies that have focused on what older people consider to be important in their care and how person-centred care is defined and achieved in long-term care settings.8

The questionnaire on organisational culture was adapted for this study and offered participants rather stark choices in how they could describe their place of work. It is likely that a questionnaire that allowed more nuanced responses about quality and approaches to care delivery would have provided richer insights and still been able to highlight elements of hierarchy and market values as well as clan culture within the care home organisation.

The study relies heavily on practitioner perception and is a snapshot of care provision. It is unclear why the observation included employees as observers. The absence of the residents' experience or evidence from routinely collected data is a weakness of the study. Overall, although the study drew on a validated framework of assessment, the significance of its findings should be interpreted with caution. The study findings need to be linked to particular resident-specific outcomes.