“It is like stepping into another world”: Exploring the possibilities of using appreciative participatory action research to guide culture change work in community and long-term care

In recent years, researchers and practitioners alike have emphasized the urgent need for a culture change in long-term care (LTC) that emphasizes choice and self-determination, close interdependent relationships, collaborative decision making, and supporting informed and compassionate care partners (cf. Fagan, 2003; Jurkowski, 2013; Pioneer Network, 2013; Thomas, 2003). To date, many approaches to culture change in LTC settings have focused on a person-centered/resident-centered care approach. While a person-centered approach is useful in the way it shifts the focus of care towards an individual’s needs and wants (Jones, 2011), it is still limiting, because it often does not consider the relational aspects of care that involve residents, family, other care partners, and staff, a key consideration when engaging in culture change in different healthcare contexts (cf. Suchman, Sluyter, & Williamson, 2011). As such, a person-centered approach to changing the culture of care in LTC can overlook individuals involved in care, including persons living with dementia/residents, and how they can meaningfully participate and contribute to decision making and positive organizational change (Dupuis, Gillies, et al., 2012; Shura, Siders, & Dannefer, 2011).

Thus, we believe in the urgent need to align care practices with relational theory, a philosophy that emphasizes relational responsibility, mutual empathy, authenticity, sharing power, mutual accommodation, relational competence, and relational ethics (Jordan, Walker, & Hartling, 2004). A relational approach requires collaborative, participatory processes inclusive of all involved in the care process (Dupuis, McAiney, Fortune, Ploeg, & de Witt, 2016; Fagan, 2003; Hill, Kolanowski, Milone-Nuzzo, & Yevchuk, 2011). More specifically, our approach to culture change is rooted in authentic partnerships that “actively incorporates and values diverse perspectives and includes all stakeholder voices directly in decision making. It involves working with others, not for others” (Dupuis, Whyte, et al., 2012, p. 436) and questions who is involved in decision making, how decision-making processes are structured, and how decision-making processes can be more inclusive (Dupuis, Whyte, et al., 2012). Dupuis, Whyte, et al. (2012) explained, there are a number of enabling factors that need to be considered, valued, and put in place when mobilizing authentic partnerships:

[b]eginning with connecting and committing to others from diverse groups, creating a safe space to come together, equally valuing the perspectives of all in the partnership, learning new ways of communicating with others, and conducting regular critical reflection and dialogue. (p. 443)

Given our focus on mobilizing authentic partnerships in our culture change efforts, participatory action research (PAR), as a form of action research, appeared to be a strong choice for facilitating culture change in different healthcare contexts, as PAR is concerned with transforming individuals along with the culture of the groups and organizations to which they belong (McTaggart, 1991). PAR guides a genuine co-learning process through which different ways of knowing are valued and integrated (Boyes-Watson & Pranis, 2012; Minkler, 2004) and the research process is often considered to be as important as the outcome (Pain & Francis, 2003; Ristock & Pennell, 1996). PAR approaches focus on enabling full participation of all those involved in culture change efforts (Shura et al., 2011) and forging partnerships so participants can explore possibilities for transformation together (Frisby, Reid, Millar, & Hoeber, 2005).

Although PAR aligns strongly with culture change values, to date, limited studies have examined how PAR can be used to facilitate culture change in healthcare communities (for exceptions, see Leutz, Bishop, & Dodson, 2009; Shura et al., 2011) and the possibilities for transformation. To address this gap, the purpose of this paper is to explore the possibilities for transformation when appreciative PAR is used by a diverse group of participants interested in working together to change the culture of dementia care in LTC and community care settings. We set the stage for sharing our findings and discussion, by first outlining the way we used PAR appreciatively to guide our culture change process. We then describe the research context, including an explanation of how we collected reflections on the process from participants and our process for analysis and interpretation of the data.

Appreciative PAR

Despite the strong alignment between culture change values and PAR, to our knowledge, the few research studies that have considered how PAR can be used to engage in culture change in care communities have been oriented towards identifying what is not working well in those settings (cf. Leutz et al., 2009; Shura et al., 2011). Indeed, the challenges involved in culture change have been highlighted in the literature (cf. Kitwood, 1997; Zimmerman, Shier, & Saliba, 2014). However, when participants focus solely on identifying problems and challenges in care communities, individuals can feel blamed, defensive, isolated, and powerless (Cooperrider & Whitney, 2000; Lerner, 1986) and these feelings can deflate a culture change process focused on establishing change. Focusing solely on problems can also stifle conversations, diminish a sense of community, silence voices, reaffirm hierarchies, and weaken organizational culture (Ludema, Cooperrider, & Barrett, 2006). Rather, a study by Cottingham et al. (2008) found focusing on competence and capacity, “enhanced the organization’s self-image, bolstered confidence, and created a hopeful and self-fulfilling expectation that positive change was indeed possible” (p. 721). In line with Cottingham et al.’s study, we contend there is a need to consider how PAR can be used to guide culture change in dementia care contexts in a way that does not ignore problems, but identifies and builds on the strengths and possibilities of these care contexts, tackling problems and challenges in a different way.

Previous issues of this journal have illustrated the methodological strengths and challenges of taking an appreciative approach to PAR (cf. Duncan & Ridley-Duff, 2014; Fieldhouse & Onyett, 2012). In particular, appreciative inquiry (AI), as one of many practices of PAR, offers a framework for change inspired by an organization’s best practices. Duncan and Ridley-Duff (2014) described, “AI focuses…on ‘the best of what is,’ or the ‘life-giving properties’ within social systems, operating from the premise that solutions are already within organizations, teams, individuals or communities and will be discovered if the right attention is given” (p. 118). When an appreciative approach to PAR is used to guide culture change in care contexts, it involves working collaboratively, thinking and doing differently, and re-imagining new possibilities (Dupuis et al., 2016). Moreover, previous research has shown an appreciative approach to action research can work well when research involves marginalized populations, given that it can encourage marginalized groups of people to think critically about issues of power and to challenge assumptions (cf. Duncan & Ridley-Duff, 2014).

Yet, AI, as one of many PAR practices, is not without its critiques. Researchers have raised concerns over the simplified and overly positive approach to AI described in much of the AI literature (cf. Bushe, 2012; Duncan & Ridley-Duff, 2014; Rogers & Fraser, 2003), with some researchers advocating to merge critical theory with AI to bridge the paradox between the two approaches and offer AI a more critical edge (Grant & Humphries, 2006). We kept these critiques in mind throughout our process to ensure our use of appreciative PAR did not only focus on revealing and understanding the strengths and possibilities of the process, but also exposed the system-wide challenges associated with engaging in culture change in community care and LTC contexts. We have written about challenges experienced in our culture change process and the strategies that were developed to address these challenges in a previous paper (see Fortune, McKeown, Dupuis, & de Witt, 2015). We chose to focus this paper on the possibilities of a culture change process in LTC and community care guided by appreciative PAR.

The research context and process

The Partnerships in Dementia Care Alliance

The Partnerships in Dementia Care (PiDC) Alliance is a collaborative research network and culture change initiative based in Ontario, Canada. Our work is focused on improving the dementia care experience within LTC and community care settings (Dupuis et al., 2016). The ultimate goal of the PiDC Alliance is to transform dementia care so it aligns more with relational and partnership models of care and living.

The PiDC Alliance, working collaboratively with members of the community, is implementing and evaluating the process of culture change within four diverse care contexts (i.e., three unique LTC homes and one community care setting). Given that our research process is rooted in authentic partnerships, each of the four care communities involved in the project created a Culture Change Coalition (CCC) that included persons living with dementia/residents, family partners in care, staff working in various disciplines and levels of healthcare, and researchers. In some cases, members volunteered to join the CCC, in other cases, members were invited as a way to promote diverse perspectives and a more inclusive process.

Each of the CCCs is responsible for championing and facilitating the culture change process within their specific site, meeting monthly, for two hours each time. This paper focuses on the culture change work of two of these CCCs who began their culture change journey at the same time, during the fall of 2010. One of the CCCs is situated within a dementia-specific LTC home located in Ontario, Canada, and is home to 112 residents. The other CCC is made up of community members and representatives of care organizations involved in dementia care and home support for persons living in a rural Ontario, Canada community. Each of these CCCs is comprised of approximately 15 members.

CCCs prepared themselves for a collaborative and appreciative approach to PAR through an initial phase called Dawn (see Dupuis et al., 2016), where the CCCs were established, and members of the CCCs had the opportunity to get to know one another and build strong, trusting, and authentic relationships. Once these relationships were established, CCC members, as part of their appreciative PAR process, began moving through the 4D phases of AI described by Ludema et al. (2006): Discovery, Dream, Design, and Delivery (for more information about how the CCCs moved through each of these phases, please see Dupuis et al., 2016). Central to both authentic partnerships and PAR, throughout these phases we invited members from the CCCs to critically reflect and provide feedback on the process.

Gathering reflections on the process

One of the ways we facilitated critical reflection and collected feedback was through conversational process interviews with CCC members. All interviews were conducted by telephone, using a semi-structured interview guide. Interview questions focused on understanding CCC members’ experiences participating in the process, including the best part of their experience, challenges associated with their experience more specifically and the culture change process more generally, the impact their CCC involvement had on their personal life and work, and key learnings they gleaned from their involvement in the culture change work in their care settings.

Consistent with our PAR process, critical reflection was important for understanding diverse experiences and perspectives. To ensure CCC members felt comfortable to openly reflect on their experiences, interviews were conducted by research assistants who were not members of either CCC and were not involved in the research process. Research assistants conducted the interviews to also make it possible for the researchers who co-facilitated the culture change process within each CCC to participate in the interviews. All interviews were audio-recorded and later transcribed into verbatim transcripts. Pseudonyms were assigned to each member to protect their confidentiality. A total of 25 interviews were conducted with CCC members at both sites, including 13 from LTC and 12 from community care. Interview participants included 15 staff, 4 family members, 4 researchers, and 2 volunteers.

In addition to the process interviews, data for this paper were collected through two types of critical reflection exercises that were incorporated into monthly CCC meetings throughout each of the phases of the culture change process in both care communities: critical reflection questions and critical reflection through process mapping. Dupuis, Gillies, et al. (2012) outlined a number of questions to encourage critical thinking and discussion as well as to build and maintain authentic partnerships. Inspired by these questions, we built our own critical reflection questions into monthly CCC meetings relating to assumptions, relationships, language, and practices (e.g., What previous assumptions have been challenged since your involvement in the culture change process? How have relationships changed since embarking on your culture change journey? etc.).

CCC monthly meetings also incorporated critical reflection through process mapping exercises. We asked members to reflect on the process and to create a visual representation of their experiences, including roadblocks encountered along the way as well as supports that helped facilitate the process. These maps were continuously re-visited and expanded on at subsequent CCC meetings as members were asked to identify what, if anything, was changing for them or they were doing differently because of the process.

It is important to note, both of the CCCs experienced some difficulty securing ongoing commitment from, and inclusion of, persons with dementia in the process. This challenge was also noted by Wilkinson (2002), who shared that although there is a known value and importance of including persons with dementia in research processes and practices, there remain issues and challenges of doing so safely, effectively, and in ways that are meaningful for persons with dementia. We used the process interviews and critical reflection exercises (both questions and mapping described above) during the CCC meetings to ask CCC members to reflect on the implications of not having active engagement by persons living with dementia and for input into how we might better include persons with dementia in our processes moving forward. From these discussions and reflections, we recognized the need to seek out feedback from persons living with dementia in these care contexts in more inclusive and accessible ways. In particular, one of the researchers involved in the process who was a visual artist worked with a staff member who was a recreation therapist to develop an arts-based approach to achieve this end. We hosted a series of arts-based sessions with persons living with dementia to capture their experiences and stories (in textual and visual form) as well as to get their feedback and reflections about the culture change process taking place in their care communities.

Members from the PiDC Alliance analyzed the data, beginning with the process interview transcripts. Once the reading of the transcripts was completed, we looked across interview transcripts for common themes and compared this data with the data obtained from the critical reflection exercises (questions and mapping) that CCC members engaged in throughout the process as well as data collected from the arts-based sessions with person living with dementia. Specific to this paper, while reading the data we asked ourselves the following questions: (1) What about the process is working well? (2) What do CCC members consider to be the possibilities of engaging in an appreciative PAR approach to culture change in these care contexts? Our analysis process resulted in the creation of three themes representing the possibilities participants shared. We describe these themes in detail next.

Illuminating the possibilities of using appreciative PAR to guide culture change in LTC and community care

Members of the two CCCs identified a number of possibilities for transformation they associated with their culture change processes. These possibilities are described under the themes: embracing an appreciative approach, valuing different experiences and perspectives, and engaging new ways of communicating and relating.

Embracing an appreciative approach

This theme captures the possibilities for transformation members experienced when using appreciative PAR to engage in culture change in both care communities. More specifically, engaging in appreciative PAR was a unique experience for CCC members involved in the project, as members learned to focus less on problems and more on working together to discover what was working well in their care communities. Jasmine, a staff member working in the LTC home, explained that her participation in the CCC enabled her to look at things from a new perspective, given that she works within a system that does not typically encourage working with an appreciative lens: “It is so refreshing…to be working on a project that is going to concentrate on the positive. All of the ministries, all of our legislative requirements; everything is always looking at what you’re not doing.” This perspective was shared by several persons with dementia, living in the LTC home, who participated in an arts-based session. In particular, they noted the importance of feeling like you have succeeded at something.

Several members also noted that an appreciative lens made it easier to examine the culture of care collaboratively and to take steps toward implementing change. As Rebecca, a family member of a resident living in the LTC home, shared, “it’s almost easier to work through the positives because I think if you’re working on negatives often people can’t get beyond – it doesn’t move forward.” These sentiments were shared by Karen, a staff member working in the LTC home, who explained the benefits of starting from an appreciative lens and strengthening commitment: “if you think of everything from a positive spin, it’s much easier to come up with a positive solution… it’s a tangible…process for people to buy into.”

Some members noted how it was one thing to learn about AI, but another to learn how to do AI. Gloria, a family member from the LTC home, described how doing AI, in terms of actually being appreciative, required effort: “It is like stepping into another world…You had to strive to get onboard…We’re talking about things we do do well and that gives everybody sort of an upbeat approach to everything.” Members also stressed the importance of sticking with the process and believing in it. As Karen, a staff member working in the LTC home, noted: “So if you continuously are positive and focus on the strength base…I know it sounds so hokey, but if you really do…you’re going to change the culture of your home.”

Through ongoing and frequent conversations between CCC members and the continual practicing of engaging in appreciative PAR, it became possible for members to learn ways to reframe problems into possibilities. Jasmine, a staff member working in LTC, described how she applied AI in her day-to-day work: “I now find myself thinking about what’s going well or what are we doing well and how can we just expand on that. If we encounter a difficulty I try to think how we can look at this in a positive light.” As a means to embrace problem-focused discussions with others in their care settings, the CCC members worked collaboratively to develop a set of principles and questions they could use when faced with problem-focused encounters, such as: What does that tell us about how things could be better? What can we learn from your experience?

Members also talked about how their involvement using appreciative PAR had a spillover effect to their other work. Lindsey, a researcher, revealed: “It’s something I’ve been wanting to take away and apply to the other work I am doing. And both my research and even in my artwork too, it’s really spilled over in so many ways.” Karen, a staff member working in the LTC home, also noted how the engagement with an appreciative approach to PAR had shaped her professional practice: “It’s actually changed…my leadership style … It hit home with me…there’s always an opportunity…to talk to them appreciatively and ask and seek their input and I think being an advocate of that has taken me a long way.”

Not only did the CCC members share how their experiences engaging in appreciative PAR promoted reflection within their professional practice, they also spoke about changes in their personal lives. Brenda, a family member from the LTC home, shared how her involvement in the culture change process positively impacted her experience caring for her mother. She explained, “it gave me a feeling of control and I was looking for that.” Linda, a researcher, also shared, ‘the appreciative inquiry practice is sort of trickling down to my personal life…this type of study is making me realize things and how I can enhance them [relationships] in my teaching and my research and my own life.”

Valuing different perspectives and experiences

For some CCC members, involvement in the culture change process, guided by appreciative PAR, helped to strengthen relationships between group members and increase knowledge of the different perspectives of other members in the group. More specifically, members of both CCCs talked about how their work in the CCC created relatively rare opportunities to come together face to face in their care contexts. Michelle, a staff member working in community care, considered face-to-face interactions to be crucial for relationship building among various healthcare providers in the community: “It has been nice to work with all the various providers and other groups and it’s been a good connection. I think there’s been growth in relationships.”

Working collaboratively helped members to get to know colleagues, family members, and persons with dementia/residents on a more personal level. Lindsey, a researcher, also noted how relationships were strengthened through membership on the CCC: “It’s very meaningful to be able to work closely with people and to build those relationships that are not just…like a business relationship…to see people both in their roles in long-term care, but also…who they are as people.”

In addition to strengthening relationships, some members also spoke about how appreciative PAR helped to bring members with diverse experiences and perspectives together to work as a team. Jasmine, a staff member working in the LTC home, highlighted the cohesion achieved during meetings: “What I really liked is that we have staff, management, we have family members, some residents, all coming together around the table and talking about common goals.” Georgia, a staff member working in the LTC home, also spoke about how different perspectives can enrich the information being shared, “Everybody in the committee brings valuable information and different perspectives, and expertise, and what they know about dementia.” Similarly, Amy, a staff member working in community care, emphasized the value of people working within various organizations coming together and sharing their insights to enhance awareness and understanding: “The experience has been very enlightening…in the fact that it’s always good to sit at the table with individuals in the community who we are partnering with, to get their perspective on things. There is always something to learn.”

The insights gleaned about the importance of sharing perspectives and learning from each other as part of the work of their CCC, inspired several staff members to introduce a monthly staff forum at the LTC home as a way to give all staff a safe space to dialogue together. Georgia, a staff member working at the LTC home, described: “It is up to staff. There is no agenda, it is open…and… it is really well received, because everybody comes down, not because it is mandatory, but [staff] know if they have questions, they can get answers.”

CCC members also spoke about newly acquired insight into how people living with dementia and care partners lived their daily lives and accessed support. Members from the community care CCC described how the information gathered through the project contributed to them having greater empathy for the families and clients with whom they work. Michelle, a staff member working in community care, explained, “You know, now that you have an idea of what the families and the clients are going through, you have a lot more empathy for them.” Members from both CCCs discussed how their involvement in the project caused them to reflect on and consider more closely support for people living with dementia and their families. Deanna, a staff member working in community care, acknowledged, “I’m getting more of an idea from the family’s perspective. I thought I knew what they were going through, but I never really thought about how we could help them.”

Engaging new ways of communicating and relating

For some members of the CCC, their engagement in appreciative PAR also opened up new possibilities for communicating and engaging on a day-to-day basis with staff, family, and persons with dementia in their respective care settings. CCC members were reminded of the importance of really listening to and talking with persons living with dementia. Several persons with dementia living in the LTC home who participated in an arts-based session also shared the importance of people asking for their opinions and really listening to them. Michelle, a staff member working in the LTC home, reiterated this sentiment, explaining “I guess really it’s…reminding ourselves they are a person and you need to continue to talk to them the same way you would a person without Alzheimer’s disease.”

CCC members also discussed how their involvement in the culture change process in their care communities encouraged them to consider new ways of interacting with persons with dementia. Danielle, a staff member working in the LTC home, explained: “Sometimes I'm so burnt out and I just don't realize my approach…It's so mechanical but I never really realized with just maybe one simple question, or one simple smile - the residents, it would probably make their day.”

Family members also found their involvement in the culture change process helped them to feel more comfortable interacting with residents. Gloria, a family member from the LTC home, shared, “On a personal level, it has really taught me how to communicate…because obviously I could communicate with my husband … but I was so apprehensive about doing the wrong thing as far as communicating with the other residents.”

In addition to residents, Lana, a staff member working in the LTC home noted the importance of taking the time to talk with other staff: “By just taking time to actually talk to people…but especially with staff members I didn’t even know and you learn so many interesting things about them.” Similarly, Michelle, a staff member working in community care, captured how she was enacting change in her professional practices by being “more conscientious and really sitting down and taking time to say how could we make it different? That has become more forefront in my approach.”

The changes in staff members’ professional practices were noticed by family members. Gloria, a family member from the LTC home, explained: “I have noticed more….deliberate greetings between the staff and the management. So, instead of passing each other just in the halls…there is eye contact. There is a nod…there is a smile or a nod, or hello.” Brenda, a family member from the LTC home, noticed more confidence in staff members’ interactions with residents: “It’s more confidence I think is maybe a better word, confidence in their relationships, more human relationships.” Staff members also noted the changes other staff were making in their interactions with others. For example, Lana, a staff member working in the LTC home, explained, “Staff are just taking more time…maybe more touch … when they are walking by a resident, just like stroking someone’s back or touching someone’s arm, cause that really makes a big difference.”

In addition to shaping interactions and communications on a day-to-day basis, members noted how being involved in the process helped reinforce the humanity of persons living with dementia and brought greater awareness in the care communities of the contributions persons with dementia can make to culture change. The importance of valuing and including all voices in the process was noted by Peter, a person with dementia living in the LTC home: “The residents’ need a little bit of space and ability to be their own man, rather than just being pushed around.” Several persons with dementia living in the LTC home who participated in an arts-based session also stressed the importance of feeling included and welcomed. The recognition of the importance of hearing directly from persons with dementia, was also noted by Sara, a researcher, who explained: “People were so blown away by some of his (a person with dementia) contributions…he just would come out with some things, and we’d be like ‘oh ya!’”

How the possibilities inherent in appreciative PAR can impact culture change work in LTC and community care

Culture change involves re-examining the language, values, assumptions, attitudes, practices, approaches, and policies embedded within an organization (Fagan, 2003; Pioneer Network, 2013) and developing specific strategies and actions to create alignment with culture change values. This co-learning process is complex and evolving and relies on incremental steps towards change being taken by many individuals. In line with these ideas of culture change, PAR is meant to involve a process of co-learning and empowerment through the reciprocal transfer of knowledge, skills, capacity, and power (Israel, Schulz, Parker, & Becker, 1998). While the co-learning aspect of PAR is well established, the possibilities and implications for research and practice when appreciative PAR is used to guide culture change in care communities have yet to be fully explored. The findings from this paper illustrate a number of possibilities for transformation that can occur when diverse participants use appreciative PAR to engage in culture change in LTC and community care. Such possibilities for transformation are essential if responsibility for taking action and enacting change more broadly is going to be a shared and sustained process (Aveyard & Davies, 2006).

In particular, the findings highlight how shifts happened when CCC members learned about the theoretical and methodological underpinnings guiding the research and were able to use this knowledge and experience to not only engage in the research process, but in their professional and personal practices. Not surprisingly, the findings suggest using appreciative PAR to engage in culture change can help participants to see and understand the meaningful changes that take shape throughout the culture change process when they are actively engaged in the process from the beginning. As our findings illuminate, utilizing appreciative PAR to guide culture change in these care communities helps to encourage participants to look for, recognize, celebrate, and build on the changes that transpire along the culture change journey. Participants are able to open up space to consider new ways of thinking and to explore possibilities for change more fully within their specific care communities.

Moreover, given that many culture change processes take time and commitment over the long term, being able to build off of the positive changes that happen as the process unfolds is helpful for harnessing the energy required to move the culture change process forward in these care contexts. It also helps keep participants engaged in the process, as they see the tangible impacts of their efforts and know they are making a difference and enacting change. This finding is also reflected in a study by Cottingham et al. (2008) who found small changes that take shape over time, which they refer to as “ripples of change,” can have a significant impact on the experiences stakeholders have in an organization. In contrast, approaches to culture change that are solely rooted in identifying and mitigating problems may overlook meaningful changes that happen along the culture change process and this focus may prevent a culture change process from moving forward (Lerner, 1986). In this paper, we highlighted changes identified and experienced by the members of each of the CCCs, but change also happened more broadly within both care contexts and these changes had an impact for non-CCC members (albeit, at times, in different ways). Rather than attempt to tie these changes into this paper, we have chosen to write about these changes in a follow-up paper to ensure we have ample space to describe them in depth.

In addition, through their engagement in the process, CCC members strengthened relationships and learned more about the diverse experiences and perspectives of all those involved in the care context including people living with dementia, their family care partners, and staff from different disciplines, positions and, in the context of community care, diverse organizations. This finding supports previous research that has shown the collaborative process involved in PAR is associated with outcomes, such as strengthening relationships (Dupuis, Gillies, et al., 2012). Intentionally incorporating relationship building as part of the culture change process has been shown to enhance potential for transformation. For example, research by Aveyard and Davies (2006) has shown when people are working in true collaboration, there is greater potential to create and sustain change. The transformative power of working in collaboration was also noted by Leutz et al. (2009) who argued research on culture change within LTC must be focused on strengthening partnerships to support working together for change. Given that close relationships and collaborative decision making are considered to be two key aspects of culture change (Koren, 2010), building these aspects into the research process sets the foundation for culture change and builds capacity for sustainable culture change initiatives over the long term in care communities.

Finally, although PAR has been shown to place tremendous value on the knowledge produced in collaboration (Cahill, 2007), collaboration is often difficult to achieve in research because many projects are not designed to permit the realization of full-scale participation of participants, particularly for persons with dementia (Wilkinson, 2002). The findings from this paper speak to this challenge, and point to the importance of providing a number of points of access so that all persons can engage in and reflect on the culture change process in different care communities, including persons with dementia (e.g., arts-based sessions, process mapping, critical reflection questions, process interviews, etc.).

Concluding remarks

Prior to engaging in the process, CCC members noted how the culture in their care settings was often focused on what was not working well in their respective care settings, which made it difficult to find ways to make changes. While the findings from this paper shed light on possibilities inherent in a culture change process guided by appreciative PAR, they also reveal a number of outcomes that can be attributed to the process. Some notable changes have started to take place in both care contexts. These changes are most evident in terms of care provision. For example, staff spoke about how engaging in this process led them to recognize the importance of taking more time to spend with residents. They also spoke about developing an enhanced understanding and deeper compassion for the challenges encountered by families on the dementia journey. Some staff highlighted shifts in their leadership style, sharing ways the culture change process helped them to be more participatory and open to seeking input from others when making decisions.

The process described here also resulted in building and deepening relationships in both care communities as different stakeholders came together to learn about the diverse experiences and perspectives of others involved in dementia care in their respective care communities. An outcome associated with this process that gives us a particular reason to be optimistic is that CCC members became more attuned to the contributions that persons with dementia/residents can make to culture change efforts and began to seek out ways to include them in the process.

Shedding light on the possibilities and transformation that occur when using appreciative PAR to guide culture change in these care communities demonstrates the value in paying closer attention to the process to recognize changes occurring along the way. Too often we are overly focused on the outcomes of research and easily overlook key transformations that happen along the way as the process unfolds. Dupuis, Whyte, et al. (2012) described, when we focus “on the process (rather than only on outcomes), great things can happen for both personal and social transformation” (p. 443). Understanding these transformations and using them as building blocks, as we show in this paper, can lead to a deeper understanding of what is needed for relationships, language, activities, and established practices to shift within a given care culture (Kemmis & McTaggart, 1988). In addition, realizing these possibilities can and do occur helps to harness the momentum gained through the process to propel culture change efforts in care communities forward.

It is not an easy shift to look at care contexts through an appreciative lens, given that the culture in many healthcare contexts is focused exclusively on identifying problems. Yet, we believe making the shift to appreciating and valuing what is working well in these contexts, by using appreciative PAR to guide culture change, brings with it much promise for the culture change journey as well as for the care settings in which we live and work. We hope this paper encourages others engaging in culture change in healthcare contexts to consider appreciative PAR to guide their culture change journey.