The Nursing Home of the Future: Are You Ready?
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).
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).
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.
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 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.
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.
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 else.
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.
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 firstname.lastname@example.org or email@example.com.
The Restraint Reduction Movement
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.