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The Nursing Home of the Future: Are
You Ready?
Tomorrow’s resident care will
take more than “quality of life” lip service
The largest movements usually start on
a very small scale. A few people see a better way of doing
something, or begin to question the basic assumptions we
all take for granted. They begin to experiment, to try new
approaches, and then take their message to others. A few
more will hear the call, and join the movement, and it begins
to gain momentum. Eventually, if it is successful, it will
cause a sea-change in thinking, so that we now wonder how
we ever accepted the old ways of thinking and doing. A classic
example: restraint reduction (see “The Restraint Reduction
Movement,” p.00).
It’s happening again—and there’s
nothing we can do to stop it. It will radically affect how
nursing homes, and to some extent assisted living facilities,
operate. It goes by many names—resident centered care,
culture change, Eden alternative, re-engineering (to borrow
a business term), or resident-directed care. While each
of these labels may have a slightly different definition
(and these definitions may vary from person to person),
the movement reflects a fundamentally different way of structuring
care settings.
Traditionally, nursing homes have been
organized around the efficient provision of physical care
to frail and impaired individuals. In the future, the focus
won’t be on the provision of care services (which is
an “input” to the system), but on the quality
of life of the residents (which is the ultimate “output”
or outcome goal).
“Quality of life” is a thorny concept because
it is so hard to define. But let’s assume for the moment
that quality of life relates to choice and control, positive
and meaningful interactions, and quality medical care. Regulations
and the survey process have already started moving in this
direction (for once leading the pack instead of being behind
the curve), and so many facilities that receive good surveys
think they are already doing this. In reality, however,
they are barely scratching the surface. They are paying
lip service to the concepts, changing their marketing language,
describing former “units” now as “households”
or “neighborhoods”, but without having made any
structural or operational changes. Or they give the physical
environment a face lift—putting an extra set of fire
doors between hallways to create “households,”
using updated colors and patterns, adding a few chintz throw
pillows and carpeting—and assume this is sufficient
guarantee of quality of life.
It isn’t.
What is? Different individuals might identify various goals,
but the following list is generally accepted as being part
of this movement:
1) Respecting the individualized needs
and desires of each person (yes, even people with dementia!)
While residents have had individualized
care plans for many years, systems of care are often set
up to maximize efficiency, not to address the unique needs
and desires of each resident. Take, for example, residents’
rising times and bathing schedules.
Traditionally, all meals in nursing homes have been offered
at set times, and all residents have been expected to eat
their meals at those times. Now, however, many facilities
are beginning to recognize that they can allow residents
more flexibility in when they wake up. If offered a late
night snack, a continental breakfast for the early and late
risers, and a hot meal at a specified time, residents can
choose whether to get up for the hot meal, or sleep in and
eat a Danish or cereal. Initially, staff were worried that
this would mean extra work for them. In reality, staff at
most facilities find it easier not to have to get everyone
up for breakfast at a specified time.
In terms of bathing, in most facilities every resident is
bathed/showered a set number of times per week (once or
twice). If the resident is lucky, it is his/her preference
that determines whether it is a bath or a shower, and possibly
even determines what time the bath/shower is given. But
how many facilities bother to ask the residents’ preference
related to frequency of bathing or showering—and follow
through with those preferences? I can hear staff saying:
“But if you gave all residents complete choice, some
would say they never want to have another bath or shower!”
That may be true. You may need to set some limits, such
as getting cleaned (notice I didn’t say have a bath
or shower) at least once every other week. But by negotiating
with the residents, showing you are trying to individualize
the care to their needs, you are likely to find them responding
positively and accepting when compromises are necessary.
Embedded in this goal is the concept that
people, including frail and impaired residents of nursing
homes, have the right to control decisions that are made
about their lives. While this may seem self-evident, it
is often glossed over and not respected in fundamental ways.
The number of rules residents are expected to follow without
being given much of a choice is substantial. Sometimes it
will be difficult or costly to affect changes to give residents
the level of autonomy they deserve. At other times, it might
be less a matter of money than of working with staff to
change the way they do things.
When all bedrooms are shared (I prefer
not to use the term “semi-private,” as I find
nothing even partially private about sharing a room with
someone separated by only a piece of fabric), residents
have little opportunity to control their space or ever have
privacy. This is one reason why so many new construction
projects have virtually all private rooms. It gives people
the choice as to whether to be alone in their rooms or with
others in the shared areas.
2) Honoring the life patterns and accomplishments
of every person within the setting
This is some overlap between this goal
and the previous one, particularly as it relates to the
resident’s life pattern of activities. But it goes
beyond following the established routines of each resident.
Virtually everyone in a nursing home—staff as well
as residents—has done things he or she is proud of.
This might be work-related, or a volunteer activity, or
family event, or crafts and hobbies. Singing in the church
choir, running a scout troop, traveling to interesting places—all
these are worthy of celebrating in one way or another. These
talents and events can be the centerpiece of activities
programs, featured in “resident of the month”
profiles, written up in the facility newsletter, or highlighted
in myriad other ways. The important point is to spend the
time learning about what each person is proud of and finding
ways to incorporate these into the life of the facility.
This philosophy should incorporate staff
accomplishments as well. Beyond their working life in the
facility, staff lead active lives that are full of interesting
events and skills. Encouraging staff and residents to start
a barber shop quartet or do joint activities with local
school children opens the door for both groups to see the
others as full and exciting individuals—not just “the
resident” or just “the nurse.”
3) Supporting opportunities for continued
growth
This new philosophy takes a life-long
perspective of development, and does not assume that age
and/or physical frailty means that an individual is no longer
capable of or desires new learning. Whether it’s learning
how to use a computer to send e-mail to family and grandchildren,
or developing a new hobby, or reading, or listening to literature
and poetry on tape, all these provide opportunities for
individuals to continue to grow and develop. Obviously,
these learning activities need to be tailored to the strengths
and abilities of the residents. Although those with more
significant dementia might have a harder time grasping some
new skills, even people who are quite cognitively impaired
can appreciate new opportunities when they are presented
in ways that are non-threatening and non-performance driven.
There are many excellent examples of
residents in mid-stage dementia participating in writing
poetry or making seasonal books to celebrate the coming
of spring, for example. Or, consider opportunities for joint
collaboration on projects with local elementary school children.
4) Enabling continued productive contributions
to their community
In addition to celebrating their past
and sometimes current accomplishments, people of all ages
often express a desire to contribute to their community
in meaningful ways. Facilities that are committed to this
principle find ways for each person to contribute. Some
facilities have the more cognitively intact or mildly confused
residents run programs and activities for the residents
who are less cognitively intact. Others have found “chores”
that residents like to do as activities, such as sweeping
the floor after a meal or raking the leaves. A few facilities
create opportunities for residents to talk about their past
profession or other experiences, either to the rest of the
residents or to outside groups.
Residents can serve as reading tutors,
or call latchkey kids when they’re home alone, or even
make and sell items (and either donate the proceeds to a
charity to keep them). Many residents are capable of volunteering
for non-profit organizations that need help in many ways.
It just takes the willingness to look for the right opportunities
and setting the stage to enable the residents to continue
to contribute.
5) Encouraging meaningful connections
with family and the community
A number of research projects have demonstrated
the positive impact on residents of visits by family and
friends, including increased smiling and alertness and decreased
agitation.2-4 Yet helping families feel comfortable visiting,
so they will visit longer and more often, is challenging.
Facilities that recognize the value of meaningful connections
find ways to support visits where the families do more than
sit in the residents’ bedrooms.
Inviting families to a variety of joint activities with
other residents and families; offering family members opportunities
to run volunteer activities; and creating a variety of spaces
in which to visit, where there are things to do, see, touch,
smell, and watch, are but a few of the ideas that help support
relationships.
Having residents start a pen-pal program with a school class
can be the beginning of new friendships. If there are residents
who can no longer write, see if others will serve as scribes
and write for them.
6)Fostering fun
How many times have you walked through
the halls of a nursing home and heard laughter?
Many readers will be familiar with the
principles of the Eden Alternative, which is but one example
of this new way of structuring nursing homes. One of the
foundations of the Eden philosophy is that the spontaneity
of pets and children enlivens and enriches a setting in
a very natural, unprogrammed way. A number of studies have
demonstrated the positive, measurable clinical health benefits
of laughter, particularly for people with heart disease
(e.g., see “Laughter” at www.WebMD for more information).
Facilities that are restructuring their care settings sometimes
incorporate “laugh-props” to give both residents
and staff more occasions to laugh.
The suggestions above may seem Pollyannaish. I can hear
staff saying: “Our residents are too far gone;”
“We tried that before, and it didn’t work;”
“The residents don’t want to do that;” “There
isn’t enough time;” “There isn’t enough
money;” or “I won’t get everything done that
needs to be done.” These reflect the anxiety that change
brings. The same things were said about restraint reduction
programs—yet see how far we’ve come in that arena.
While the challenges of restructuring
the entire care setting are much greater than tackling a
single issue, there are also greater opportunities. There’s
no one right way to go about this change process. You can
start with a single care practice—for example, think
about ways to restructure your bathing care practices. Determine,
for each resident, how often getting clean is medically
or socially necessary. This helps you set some parameters.
Then go to each resident, or the family if appropriate,
and ask about his or her preferences. Would the resident
prefer a bath, a shower or a sponge/washcloth bath? What
time and how often would he or she prefer it?
Involve the direct care staff in this
process. Get their input early. They may be able to give
more insight into the preferences of cognitively impaired
individuals than anyone else.
Then look at your bathing room(s). What do they say to the
residents about what this experience is going to be like?
If these rooms feature cold, antiseptic white walls with
institutional equipment visible, a positive experience is
not in the offing. What occupies most of the field of vision
of a person in the tub? It is the chrome control panel for
the tub? Or is it some artwork, or a nicely decorated accessory
shelf, with scented soaps and plush towels? What would make
the room more attractive for you to take a bath in?
Which gets to the final point. Restructuring
includes significant rethinking of staffing roles and relationships.
Most facilities that embrace this concept are moving away
from department-based staff to a team approach, where the
direct care staff have a significantly more central role
in directing that care. They are the ones who see and talk
with the residents every day, and who are in the best position
to know their preferences. Consistent assignments of staff
are a first step in this new direction.
But it goes much deeper than that. Although
it is an overused and under-defined term, “empowering”
the nursing assistants to be major players on the care team
is critical to the fundamental shift this movement is all
about. This means that the supervisory nursing staff needs
to learn to let go of some of its “control” over
the setting. Staff education needs to be different as well:
to focus on the psychological and emotional needs of residents,
including their many strengths, not just their failings
and weaknesses.
Regardless of whether you call it culture
change, or restructuring, or re-engineering, or resident-directed
care, or resident-centered care, this movement is all about
changing the way nursing homes operate. We need to move
out of the 1950’s hospital-based model, just as hospitals
have reinvented themselves over the past decade. Focusing
on the positive aspects of personhood and recognizing residual
strengths and abilities to engage in meaningful relationships
that have purpose; giving as well as receiving–these
are the foundations of future nursing home care.
Are you prepared?
Margaret P. Calkins, PhD, is President
of I.D.E.A.S. Inc, and Chair of the Board of the IDEAS Institute.
Both organizations are dedicated to creating successful
care settings for frail and impaired individuals. She can
be reached at mcalkins@ideasinstitute.org
or macalkins@ideasconsultinginc.com.
References
1. Johnson D. Restraint free care: A look back. Nursing
Homes/Long-term Care Management 1995;44(9):26-30.
2. Hendy H. 1987. Effects of pet and/or people visits on
nursing home residents. International Journal of Aging and
Human Development 1987;25(4):279-291.
3. Martin-Cook K, Haynan L, Chafetz P, Weiner M. 2001. Impact
of family visits on agitation in residents with dementia.
American Journal of Alzheimer’s Disease and Other Dementias
2001;16(3):163-166
4. Noelker L, Poulshock S. 1984. Intimacy: Factors affecting
its development among members of a home for the aged. International
Journal of Aging and Human Development 1984;19:177-190.
The Restraint Reduction Movement
We used to think it was OK—even a sign of good care—to
tie people to their wheelchairs. After all, if we let them
walk they might elope and get lost, hurt or even die before
we could find them. Or they might fall. And because they
would try to get out of their chairs, we often put these
chairs, with the brakes on, across from the nursing station
so staff could easily monitor them. We kept the restraints
on, long after these residents were no longer independently
mobile—and after they had stopped trying to get out
of their chairs. This practice was widespread throughout
the industry and condoned by the regulators. Indeed, in
1989, restraint usage was the accepted practice for over
50% of all nursing home residents.1
Eventually, a few nurses began to question
this practice. Even more, they began to develop alternative
ways of caring for individuals that gave them their freedom.
It was not an easy road to travel. For every success there
were “failures.” But, convinced of the legitimacy
and value of what they were doing, they persevered. They
documented their progress, spoke at conferences and wrote
articles for both academic and trade journals. Soon, other
nurses heard the message: “Let my people (the residents)
go!”. And more facilities began to test the waters
and revise care plans and practices for at least some of
their residents. As the movement gained momentum, it caught
the attention of regulators, and the shift was eventually
codified in the nursing home reform act now called OBRA
’87.
A few facilities had to be dragged, kicking
and screaming (metaphorically speaking), into this “new
age” of thinking—and there are still some caregivers
who feel restraints reflect good care practices. But most
of us in the long-term care field now firmly believe in
the underlying principles of this “new” approach
that once seemed so radical.
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