By: Margaret Calkins, PhD
Tomorrows 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,
Its happening againand theres
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 namesresident 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 wont 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 lets 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 liftputting an extra set of fire doors between hallways
to create households, using updated colors and patterns,
adding a few chintz throw pillows and carpetingand assume
this is sufficient guarantee of quality of life.
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
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 showeringand
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 didnt 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
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
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 residents
life pattern of activities. But it goes beyond following the established
routines of each resident. Virtually everyone in a nursing homestaff
as well as residentshas 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 placesall 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 individualsnot 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 its 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 theyre 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
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 didnt work; The residents dont
want to do that; There isnt enough time;
There isnt enough money; or I wont
get everything done that needs to be done. These reflect the
anxiety that change brings. The same things were said about restraint
reduction programsyet see how far weve come in that
While the challenges of restructuring the entire
care setting are much greater than tackling a single issue, there
are also greater opportunities. Theres no one right way to
go about this change process. You can start with a single care practicefor
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
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 1950s
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 receivingthese
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 email@example.com or firstname.lastname@example.org.
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
3. Martin-Cook K, Haynan L, Chafetz P, Weiner M. 2001. Impact of
family visits on agitation in residents with dementia. American
Journal of Alzheimers 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 OKeven a sign of good careto
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 mobileand 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
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 thinkingand 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.
This article appeared in the June 2002 issue of
Nursing Homes/Long-Term Care Management magazine.