Showing papers on "Culture change published in 2010"

Person-Centered Care For Nursing Home Residents: The Culture-Change Movement

Abstract: The “culture change” movement represents a fundamental shift in thinking about nursing homes. Facilities are viewed not as health care institutions, but as person-centered homes offering long-term care services. Culture-change principles and practices have been shaped by shared concerns among consumers, policy makers, and providers regarding the value and quality of care offered in traditional nursing homes. They have shown promise in improving quality of life as well as quality of care, while alleviating such problems as high staff turnover. Policy makers can encourage culture change and capitalize on its transformational power through regulation, reimbursement, public reporting, and other mechanisms.

Mapping the Cultural Landscape in Engineering Education

Abstract: Background Calls for culture change as key to systemic reform in engineering education implicitly assume the existence of common elements of a distinctive culture. The landscape for engineering education studies that invoke the concept of culture is complex and multi-faceted, yet still ill-defined and incomplete. Purpose (Hypothesis) The aim of this study is to develop a conceptual framework of cultural dimensions that has the potential to guide the understanding of culture in the context of engineering education to demonstrate “where we are” and “how to get where we want to go.” Design/Method Ethnographic methods within an overarching interpretivist research paradigm were used to investigate the culture of engineering education as manifested in one institution. Adapting Schein's cultural framework, the data were collected and analyzed to distil from observable behaviors and practices the essence of the culture in the form of tacitly known cultural norms, shared assumptions, and understandings that underpinned the lived experience of staff and students. Results The findings are discussed within six cultural dimensions which emerged from the data as: An Engineering Way of Thinking, An Engineering Way of Doing, Being an Engineer, Acceptance of Difference, Relationships, and Relationship to the Environment. Conclusions The detailed findings from this study, combined with evidence from other studies, support the view that the proposed six dimensions have the potential to be transferred to other institutions as a practical tool for evaluating and positioning the culture of engineering education.

Leadership and Organizational Culture Transformation in Professional Sport

Abstract: Organizational culture has long been recognized as a critical component that can facilitate high performance in business (Balthazard, Cooke, & Potter, 2006). The purpose of this qualitative study was to examine the phenomena of organizational culture change in professional sport (NBA, MLB, and NFL). Six owners or general managers who had successfully brought their organizations through organizational culture change, as evidenced by their team’s performance, agreed to an in-person interview. Five primary themes emerged (Symptoms of a Dysfunctional Culture, My Way, Walk the Talk, Embedding New Culture, and Our Way) which together formed an initial model for organizational culture change in professional sport: the Culture Change Cycle. Each theme is discussed in depth, and differences across sport and role are explained.

Sustainability factors for e-learning initiatives

Abstract: This paper examines the challenges that ‘grass roots’ e-learning initiatives face in trying to become sustainable. A cross-institutional study focused on local, rather than centrally driven, initiatives. A number of successful e-learning innovations were identified that had been driven by capable teachers seeking solutions to real educational problems. However, most of these remain in a high-risk category for institutions and offer poor rewards to their creators. While they may attract grant funding, these initiatives are typically not well supported in other important ways. Semi-structured interviews were conducted with 30 staff in various academic and support roles from the tertiary sector in New Zealand, who were nationally recognised as e-learning leaders. Analysis of their responses revealed both institutional and cultural barriers to long-term sustainability. The following influences on sustainability were identified and discussed: supportive organisational structures, a vision shared by all and staff accountability. The paper proposes that not all initiatives are sustainable and offer practical strategies for achieving diffusion and continuity through collective action. The paper concludes that there is a need for cross-functional collaboration to accommodate different and sometimes conflicting perspectives. This is just one aspect of the culture change that research shows is needed for e-learning to transform, rather than sit uncomfortably alongside, institutional practice. Keywords: e-learning sustainability; e-learning strategy; integration; dissemination DOI: 10.1080/09687769.2010.492848

Nursing Home Organizational Change: The “Culture Change” Movement as Viewed by Long-Term Care Specialists

Abstract: A decade-long grassroots movement aims to deinstitutionalize nursing home (NH) environments and individualize care. Coined "NH Culture Change" the movement is often described by its resident-centered/directed care focus. While empirical data of "culture change's" costs and benefits are limited, it is broadly viewed as beneficial and widely promoted. Still, debate abounds regarding barriers to its adoption. We used data from a Web-based survey of 1,147 long-term care specialists (including NH and other providers, consumers/advocates, state and federal government officials, university/academic, researchers/consultants, and others) to better understand factors associated with perceived barriers. Long-term care specialists view the number-one barrier to adoption differently depending on their employment, familiarity with culture change, and their underlying policy views. To promote adoption, research and broad-based educational efforts are needed to influence views and perceptions. Fundamental changes in the regulatory process together with targeted regulatory changes and payment incentives may also be needed.

Long-Term Care in the United States: Policy Themes and Promising Practices

Abstract: This analysis provides an overview of the major policy themes and promising practices emerging in recent years as policymakers and researchers struggle to design a long-term care system that meets the needs of an aging population. Themes that have dominated the long-term care policy debates include: recruiting and retaining a qualified long-term care workforce; devising financing mechanisms for those requiring long-term care; and moving away from an institutional-based long-term care system towards more home- and community-based services. Three promising practices that have emerged in the past few decades include: the culture change movement; service integration that combines medical and social care; and various forms of community residential care that bring together housing and services in a more home-like environment. It concludes with long-term care recommendations for policymakers.

Model for assessing organizational culture in intercollegiate athletic departments.

Abstract: Beyer and Hannah (2000) have suggested that a major barrier to the reform of intercollegiate athletics is its cultural significance in higher education. Even leaders within the National Collegiate Athletic Association have acknowledged the need for culture change in intercollegiate athletics (Brand, 2001; Dempsey, 2000). Yet major culture change has not occurred and few studies have examined culture within intercollegiate athletic departments (Ridpath, 2008). This gap may be due, in part, to the lack of a framework with which to analyze athletic departments as organizational cultures. Schein’s (2004) model of organizational culture is the most frequently cited perspective in the literature, but it applies primarily to corporate cultures (Hatch, 2000). Several frameworks have been developed to assess college and university cultures, but intercollegiate athletics occupies a unique space between sport and education (Beyer & Hannah, 2000). Therefore, the purpose of this paper is to offer a model for assessing the cultures of intercollegiate athletic departments. The four elements of the model— institutional culture, external environment, internal environment, and leadership/power—are presented and followed by an explanation of their interaction. The paper concludes with a case study demonstrating the use of the model to define one athletic department’s culture.

Culture Change as Identity Regulation: The Micro-Politics of Producing Spatial Planners in England

Abstract: Attempts to reform planning systems often draw into question the attitudes and commitments of the planners charged with realising change. Since 2001 the English planning system has been subject to a complex series of reforms designed to modernise its workings. Central to this have been calls for a culture change, focusing on professional planners in the public sector. The discourse of culture change is rooted in the managerialist thinking that has been central to long-term processes of state restructuring. Du Gay describes this as a project designed to change the identities of public servants. This article therefore explores the messy ways in which reform has sought to re-regulate the identities of English planners, and the response from planners themselves as they have begun to negotiate these changes to their identities and practices. It is argued that attentiveness to the lived experience of change can help to inform a more critical and nuanced account of the normative promises of planning reform.

Creating Healthy Organizations: How Vibrant Workplaces Inspire Employees to Achieve Sustainable Success

Abstract: Figures Acknowledgement Introduction * The Healthy Organization Ideal *Looking at Your Organization through a Healthy Lens *Helping Change Agents *Leveraging Where You Are Today *Learning from your Peers * Chapter Overview 1 The Healthy Organization * Integrating Well-Being and Performance * Healthy Organizations in Action * A Healthy Organization Model * Vibrant Workplaces * Inspired Employees *Beyond Engagement * The Capabilities of an Inspired Workplace * Learning * Collaboration * Culture and Leadership *Culture and Leadership in Action * Better Workplaces * Sustainable Success *Stronger People-Performance Links * Healthier Employees and Communities * Making Well-Being a Priority 2 Beyond Workplace Health Promotion * The Wellness Paradox * Health Workplace Pay-Offs and Potential *Wellness Returns on Investment * Healthy Lifestyle Programs * Addressing Chronic Health Conditions * Targeting High-Risk Employees * An Organizational View of Health and Wellness *Limitations of Workplace Health Promotions * Comparing Health Promotions and Organizational Perspectives * Leveraging Workplace Health Promotion * Organizational Solutions for Wellness *Rethinking Absenteeism * Present but not Productive * Healthy Psychosocial Work Environments * Talking about Health and Performance 3 How Vibrant Workplaces Inspire Employees How Employees Experience Healthy Organizations Envisioning Vibrant Workplaces Envisioning an Inspired Workforce How Vibrant Workplaces Inspire Employees Focusing on Work Experiences Defining Good Jobs Healthy Workplaces through Employees' Eyes Why Some Workplaces Are Healthier than Others Why Employees' Perceptions Matter Closing the Inspiration Gap The Dynamics of a Healthy Organization 4 Positive Cultures * What Is Culture? * Culture as Competitive Advantage * Unhealthy and Healthy Cultures *Unhealthy Cultures * Healthy Cultures * Culture Change *Culture Can Be Revitalized and Can Evolved * The Culture-Strengthening Process * Strengthening Values *The Importance of Values * New Values * Renewed Values * From Values to Behaviours * Revitalizing Your Organization's Culture 5 Inclusive Leadership * Leading the Way to Healthier Organizations *Leading at the Micro Level * Who Are the Leaders? * Widely Distributing Leadership Responsibility * Quality of Inclusive Leaders * Leading with People Skills *Gaps in People Skills * Follow-Through on People Commitments * Setting the Tone * Focusing on Leadership Behaviours *Living the Guiding Principles * Leadership to Build Supportive Workplaces * Leading Change 6 Healthy Change * Getting on a Healthy Change Trajectory *Focusing on the Journey * The Role of Culture and Leadership * Five Principles for Healthy Change *Understanding Change Readiness * Aligning Structure with Culture * Linking People Initiatives to the Business Strategy * Widen the Circle of Involvement * Make Time for Learning and Innovation * Change as Renewal 7 Sustainable Success * What Makes Success Sustainable? *Social and Environmental Dimensions * Human Resources Dimensions * Ingredients of Sustainable Success * Renewing Relationships with Society *Corporate Social Responsibility Evolves * The Changing Face of Social Responsibility * Good Corporate Citizen, Outstanding Employer * Making Sustainability Strategic * Vibrant Workplaces Support Social Responsibility * Renewing Workforce Capabilities *Workforce Diversity Strategies * Inspiring Three Generations of Workers * Long-Range Workforce Planning * Making Progress 8 Measuring Progress * Using Evidence for Action *Practical Challenges of Using Evidence * Thinking Ahead * The Value of Qualitative Consultations * Measurement Tools *Measures * Tools * Design Options * Return on Investment * Using Surveys for Healthy Change *Survey Guidelines * Finding a Clear Direction from Survey Data * Using Survey Results for Leadership Development * Integrated Performance Reporting *Examples of Effective Performance Reporting * Triangulating Your Existing Data * Guidelines for Measuring Improvements * Healthy Organization Measures Are Good Public Policy 9 Designing a Healthy Organization Strategy Notes Index

Dementia Beyond Drugs: Changing the Culture of Care

Abstract: If you could provide a life more affirming and meaningful than current care practices provide, would you do it? Of course, you would! But how? Now the resource you need to make this possible is within our grasp. Dementia Beyond Drugs will enable you to change the way you provide care. Learn what it takes to effect real culture change within residential care settings while reducing the administration of psychotropic drugs in the symptomatic treatment of dementia. This timely new resource, by a board-certified internist, geriatrician, nursing home practitioner, and Eden Alternative (tm) Educator, has what you need. Dr. G. Allen Power brings robust medical experience and a unique perspective to the idea of culture change. His eye-opening book challenges all care providers working with individuals with dementia to undertake a true operational change. Yes, you can move away from an institutional model - viewing individuals as patients defined by their dementia and using prescribed medications to control their "troublesome" behaviors - to an experiential model of care that treats individuals with dementia as the human beings they are, giving them the personal attention, respect, and dignity they deserve. Take advantage of the many benefits to this fundamental change in the provision of care, including a decrease in the need for mood-altering drugs. You will learn how to embrace more humanistic, enlightened practices that address the most common challenges in caring for people who live with dementia.; Overcome communication challenges; Minimize anxiety and depression; Root out the causes of wandering; Gain insights into paranoia and delusions Full of visionary and practical calls-to-action, Dementia Beyond Drugs: Changing the Culture of Care is an essential read for anyone involved in the care of an individual with dementia, including nursing staff, social workers, occupational therapists, medical directors, and administrators in all elder care settings. Family members of individuals with dementia and students breaking into the dementia care field will also benefit from the advice offered. Pick up your copy of Dementia Beyond Drugs and help to pioneer true culture change in your care environment today. Your reward will be improved care environments and enhanced, relationship-based interactions.

Culture Change Refined and Revitalized: The Road Show and Guides for Pragmatic Action

Abstract: Despite a declining interest in the relationship between leadership, culture, and performance in the scholarly literature, culture change is alive and well among leaders in the public sector as a means to improve performance. This essay reviews the trajectory of culture studies and proposes a modest model of organizational culture that sets aside many of the conceptual and methodological arguments about culture, focusing instead on what leaders actually do to change culture. The model is examined in the context of organizational culture change efforts in the city of Alexandria, Virginia. Several practical and theoretical insights are offered from this pragmatic and leadership-focused approach to culture.

'Lean' is a 'Lean' is a Cultural Issue Cultural Issue

Abstract: Philip Atkinson addresses the key issues that relate to culture change and ‘Lean manufacturing.’ He discusses the inability of most organisations to create the culture that will sustain Lean and any other programme of organisational improvement. Failing to plan for change equates to planning to fail. Currently, too much attention is focused on the technical aspects of Lean, rather than the ability to create a self-sustaining Lean culture, where change is seen as the norm and where resistance to change is never an option.

Sport in Transition: Emerging Trends on Culture Change in the Anthropology of Sport

Abstract: Historically, within anthropology, sport has been perceived as an inconsequential form of entertainment spectacle, seemingly at variance with, and secondary to, broader political and social discourses. An analysis of these four works, however, provides an opportunity to explore shifting representations surrounding issues of culture change and identity production within the anthropology of sport, with an emphasis on three inter-related themes: theories and methodologies for representing the intersections between culture change and sport; historical shifts in modes of representation and writing within anthropological sports studies, and representations of identities within sport.

Turning Good Policies into Good Practice: Why is it so difficult?

Abstract: Many engineering employers have introduced policies to improve the retention and progression of women engineers. However, a recent EU project reveals that the uptake and the impact of such policies is generally limited and often uneven; having a good set of policies on paper does not necessarily translate into good practice on the ground. We explore the reasons why highlighting first of all organisational failings in the effective implementation of such policies and in employers’ commitment to gender change; and second, attitudinal barriers of awareness and attitudes to gender politics. This analysis adds weight to arguments that engineering organisations need to undergo major ‘culture change’ if good gender equality and diversity policies are to be turned into good practice.

The Language of Change: Finding Words to Define Culture Change in Long-Term Care

Abstract: Many senior living organizations are working to transform their institutional character into home and community. This undertaking amounts to a virtual cultural shift, known in the industry as culture change. Culture change is receiving growing popularity in the senior living industry; however the majority of organizations have yet to begin tackling this transformation. One of the contributions to this hesitancy may be that no universal explicit definition of culture change is accepted within the industry. This article, based on an extensive literature review, examines the current definitions within the culture change literature and proposes a new definition that may be helpful in understanding and undertaking this challenging holistic transformation.

Reinventing Management Practices in Long-Term Care: How Cultural Evolution Can Affect Workforce Recruitment and Retention

Abstract: Training, team-building, mentoring, and skill development all contribute to positive change. Nursing assistants, home health aides, and other direct-care workers provide almost all long-term care, and play a central role in the quality of life of those who, due to chronic disease or disability, need help with personal care. Direct-care workers are paid low wages, have limited advancement opportunity, and often lack respect (Stone and Harahan, 2010). The resulting high turnover, inadequate training, and shortages lead to problems accessing services, high costs, and poor quality of care (Institute of Medicine, 2008). Despite their importance, however, recruitment and retention of these directcare workers is a challenge for almost all long-termcare providers (Stone and Wiener, 2001). It is difficult to recruit direct-care workers because of the emotionally and physically challenging nature of the work, plus there's a lack of training, few chances for advancement, workplace stress and burnout, poor supervision, lack of respect, and chronic understaffing issues. A number of workforce initiatives have sought to improve recruitment and retention (Harris-Kojetin et al., 2004). The initiatives intended to improve staff management are one component of what has become a movement to change the culture in the nursing home sector. The movement promotes structural and, in some cases, regulatory changes to advance resident-centered care, the inclusion of direct-care staff in decision making, and more homelike environments in the care facilities. Long-Term-Care Management Practices as Cultural Artifacts Proponents of culture change in nursing facilities identify a number of unproductive practices held over from the medical model of nursing home care (Misiorski, 2003; Koren, 2010). Some artifacts of such cultures are architectural (e.g., hospitallike facilities) or otherwise linked to the physical environment. Others are tied to excessive hierarchy, such as job designs that constrain both clinical skill- and relationshipbuilding by discouraging consistent assignments and teamwork. Changing these practices is at the heart of the culture-change movement. Edgar Schein, one of the most influential writers on the nature of culture and organizational change, identified three layers of culture: artifacts, values, and assumptions (Schein, 1985). Artifacts are symbols, such as uniforms, or practices managers display or enforce-and can consciously change. Artifacts may be thought of as the tools of culture maintenance and culture change. Examples of management practices that are cultural artifacts include policies affecting which levels of staff have access to what information, or what physical barriers limit residents' independence. When visible changes are made in an organization, they in turn can lead to changes in perceived value among employees. If these altered values persist over time, they become incorporated into the fundamental taken-for-granted assumptions that provide a foundation for changes in attitudes and behaviors. Changing Management Practices to Change Culture Some changes in management practices challenge existing organizational values and assumptions. Radical change (such as a corporate takeover) may include destruction of the organization's artifacts, values, and assumptions. In nursing facilities, the Green House® model most clearly represents radical change. There is very little about this model of care that looks or feels like a nursing home. Prior research on this and other deliberative, multifaceted culture-change programs in nursing homes have offered some support for improved outcomes for both residents and providers (Coleman et al., 2002; Stone et al., 2002; Misorski, 2003; Kane et al., 2007; Elliot, 2010). As evidenced in the recent Commonwealth Fund National Survey of Nursing Homes, however, few nursing facilities are undertaking radical change even with the culturechange movement taking hold (Doty, Koren, and Sturla, 2008). …

Central Policies, Local Discretion: A Review of Employee Access to Work-life Balance Arrangements in a Public Sector Agency

Abstract: Work-life balance is one of the leading contemporary issues in the Australian employment environment, driven by both employee demands and employer desire to attract employees in a tight labour market. This article is about the important issue of employee experiences of work-life balance, and uses a public sector case study to consider progress and identify issues yet to be resolved. The research considers the extent of the work-life balance policy framework in the case study agency, employees' awareness of their work-life balance options, and employee perceptions about access to flexible working arrangements. The research finds that the agency has a solid policy framework and reasonably high levels of awareness. But it identifies a gap between employees' awareness and their perceptions of access, and uncovers many local-level barriers to access to flexible working arrangements. The article concludes that, to ensure employees have access to work-life balance, the agency should shift its focus to implementation of the policy framework through activities such as education and culture change activities.

Embedding consumer culture in health and social care education – a university office's perspective

Abstract: Health and social care services are changing – and this change is radical. Service user and carer involvement has been a key aspect of health and social care policy for a number of years. In terms of the National Health Service (NHS), this has been significantly strengthened by the report ‘High Quality Care for All’. The NHS will no longer be a monolith dictating what services it offers. It is beginning to take seriously the views of its consumers: the patients, service users and carers. The NHS is starting to put the patient experience at the centre of everything it does, and its regulators are asking for evidence of public and patient involvement. This process may yet prove to be one of the NHS’ greatest challenges as it transforms to prioritize the consumer viewpoint. Social care, though further down the line in relation to involvement, is now responding to the relatively new personalization agenda. This paper will consider what the university sector can do to embed the consumer and service culture within the education of health and social care professionals. It looks at the challenges of involvement and required culture change, highlighting the key points to address in the early and middle stages of involvement from a university office’s perspective. It includes examples of consumer involvement in teaching, assessment and the selection of students and how their input is starting to make a difference. Finally, the paper outlines what is needed in a development office to establish and support effective service user and carer involvement on health and social care courses in higher education. The article concludes by acknowledging that there is much more work that needs to be done in this field to embed the work of a development office, but that early steps have been promising.

Changing Management Cultures in the English National Health Service

Abstract: The language of cultural change is increasingly employed in relation to organizational reforms aimed at improving the efficiency and responsiveness of health systems in many countries. In the wake of high-profile reports documenting gross medical errors in the United States, policy thinking is embracing the notion of culture change as a key element of health system redesign (Institute of Medicine, 1999; Davies et al., 2000) and there is evidence to suggest that many other OECD countries are focusing on cultural renewal and change as a potential lever for health care improvement (Smith, 2002).

Breaking out of strategy vectors: reintroducing culture

Abstract: There is considerable evidence that long periods of success in organisations can lead to ossification of strategy and strategic inertia. Burgelman (2002) shows how co-evolutionary lock-in occurs through the creation of a strategy vector. He demonstrates that the internal selection environment can become configured to create sources of inertia that dampen the autonomous strategy process, driving out unrelated exploration and creating a dominance of the induced, top-down strategy process. While this study shows how lock-in occurs, it does not address how a company breaks out of co-evolutionary lock-in. This is the focus of this paper. We argue that to understand how an organisation breaks out of a strategy vector a more complete conceptualisation of the structural context, and in particular the under specified cultural mechanisms, is required. It also requires an understanding of the linkages between the structural context and the new core capabilities required for breakout. Thus we first expand on what is known about strategy vectors and review research from the strategy process tradition that explores the linkages between strategy, culture and strategic change, to build a more comprehensive picture of the structural context. Our model demonstrates the extent of interconnectedness between the ‘hard’ (e.g., control systems and organisation structure) and ‘soft’ (e.g. beliefs, symbols and stories) components, and that development of new required capabilities is dependent on a holistic shift in all these aspects of the structural context, including, therefore, change in the organisation's culture. We then illustrate the link between lock-in, capability development and culture change through the case of the famous Formula One team, Ferrari. We finish with a discussion of the implications of our findings for strategic change.

Culture and Policy in Early Childhood Development

Abstract: Introduction Policies are cultural products. They are generated using concepts shared by members of a cultural group and implemented through culturally-based institutions. Their effects play out in the natural laboratory of everyday life in a particular cultural place. The relationship between culture and policy in early childhood development is therefore intimate, complex and multi-faceted. Understanding the ways in which culture and policy reflect and influence each other should be part of the theoretical toolkit of educators, health care providers and policy makers; but in fact, culture and policy are rarely considered in the same context. Examining the cultural context of policy is of particular importance in the current era of rapid culture change and globalization.

Strategies for Culture Change

Abstract: The subtitle of this book, Where Technology and Caring Meet, reflects the next stage of challenges for nursing and other health professions in the midst of a rapidly growing need for health information technology (HIT) innovation and implementation. Significantly different cultural perspectives on the meaning of caring and technology for many health care professionals contribute to challenges related to implementation, acceptance, and meaningful use of technology and informatics in the provision of care to patients and consumers. Why should we have a discussion about culture and cultural change as a major part of this 4th edition? In 2006, a group of nursing leaders organized an invitational meeting of nursing leaders across the profession to create a vision and shape strategies to implement technology and informatics within the nursing profession. This initiative was called Technology Informatics Guiding Education Reform (TIGER). In the preparation for the invitational symposium, TIGER leadership identified seven pillars which would frame the discussion of strategies for change: management and leadership, education, communication and collaboration, informatics design, information technology (IT), policy, and culture. Consensus was reached regarding themes and initial action steps for all the pillars except one, the pillar of Culture. As defined at the TIGER summit, culture is “a respectful open system that leverages technology and informatics across multiple disciplines in an environment where all stakeholders trust each other to work together towards the goal of high quality and safety.”1 The summit recommended the following actions as strategies to impact culture: Institute a national marketing campaign to promote the value of technology in a multidisciplinary way that supports an accepting culture. Include HIT in every strategic plan, mission, and vision statement; use of HIT is embraced by executives, deans, all point-of-care clinicians, and students with goal of high quality care and safety. Establish multidisciplinary teams that embrace a shared vision and operate cohesively to push for broad technology integration within/across entire organizations. Develop mutual respect between/among clinicians who may bring different skills and knowledge, e.g., create/develop process in which experienced nurses can mentor new nurses, and also, the new nurses who are more technologically aware can mentor veteran nurses.