Transforming Cultures of Care: A Case Study in Organizational Change

Article excerpt

The authors report on a small organizational case study highlighting the dimensions of trauma-informed care, the processes of organizational change, and the growth of caregiver expertise. The article is framed by the notion of caregiving cultures, which refers to the beliefs, languages, and practices of caregivers and caregiving organizations.

What is becoming increasingly well understood is the impact of childhood loss and trauma on the development and behavior of children and youth (Perry, 2008a, van der Kolk, 2005). What is not so well understood is how we can transform caregivers, and caregiving organizations, so that they can provide trauma-informed care to the children and youth who need it. This article (a) introduces the notion of a caregiving culture, (b) describes a "pre-transformation" caregiving culture, (c) describes some transformational experiences in a small caregiving organization, (d) presents some data documenting organizational change, (e) describes a "post-transformation" caregiving culture, and (f ) concludes with some observations about the structure of change.

Caregiving Cultures

A culture can be defined as the set of shared attitudes, values, goals, and practices that characterize an institution, organization, or group (Fetterman, 2010). Every organization serving children, youth, and families has its own caregiving culture, consisting of cognitions and behaviors that characterize that organization's caregiving. Two of us, Purvis and Cross, have been working with caregiving organizations for almost a decade in an effort to help them change their caregiving cultures. The emphasis of our work has been training in trauma-informed care, but we have become increasingly engaged with the complexity of organizational change.

Our third author, Daren Jones, has been supervisor of a group home that provides transitional services for children and youth who can no longer live with their families. The goal is to prevent placement in residential in-patient facilities and to facilitate placement in foster or adoptive homes. When successful, the program reduces costs and increases permanency. The caregiving culture of the program has been transformed over the past two or three years, largely because of strong leadership and exposure of key staff to the principles and practices of trauma-informed care (see Bath, 2008). This article documents these changes to provide some insight into the mechanisms of change. Daren has been a key actor (informant) in this ethnography (see Fetterman, 2010). Our fourth author, Gary Buff, is currently Chief Operating Officer at ACH Child and Family Services.

The Previous Culture

This Behavioral Care Program (BCP) serves up to ten children, ages 4-12, with a caregiving staff of nine youth care workers, a case manager, and a group home supervisor. The average age of children in the program is 9.6 years, with half coming from families of origin and half coming from Child Protective Services. The program is part of a larger social service organization that provides a range of services for children, youth, and families. Children attend public schools and receive some therapeutic services (e.g., counseling, occupational therapy). Daren Jones has been with the program since 2006.

Between 2006 and 2009, the caregiving environment could be characterized as chaotic; staff were in survival mode, just trying to make it from one crisis to the next. Medications were common, as were temporary (1-2 week) hospital placements for difficult-to-manage clients. Key practices included a level system based on points and isolation - a 24-hour time-out - delivered as a consequence for misbehavior. Physical constraints were common (see Figure 2), and the overall mindset was one of containment, not healing. Despite everyone's good intentions, it was a stressful environment for staff and children both (see Fisher & Stoolmiller, 2008).

Transformative Experiences

Transformation of the program began in 2009 when Daren and his supervisor decided to abandon the level system, which in their view was ineffective. …