2005 OPTIMA Award entry: an adventure into Snoezelen therapy; Using the Snoezelen philosophy--and setting--to transform severely disabled residents' lives.

Snoezelen is a combination of two Dutch verbs: snuffelen (to seek out, sniff, or explore) and doezelen (to relax). Its concept was defined in the late 1970s by two Dutch therapists. While working at an institute in Holland, the two therapists learned of the positive responses a colleague elicited from a severely challenged client while exposed to a sensory environment he had assembled. More than 25 years ago the Snoezelen concept was considered radical compared with traditional therapies. Today, after discovering Snoezelen's benefits, we can't imagine life without it.

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Snoezelen is a wonderful environment, filled with sights, sounds, textures, and aromas and used to stimulate, calm, relax, or energize. This controlled environment has been designed within one room of the facility; the experience can be staged to provide a multisensory exposure or single-sensory focus by simple adaptation to one stimulus. The Snoezelen environment is safe, nonthreatening, and proven effective with long-term care residents with diagnoses such as dementia, stroke and traumatic brain injury, chronic pain, behavioral and mood disturbances, and sensory deprivation caused by physical conditions.

Reports on Snoezelen environments document accounts of residents who have stopped self-abusive behavior; of people who have "seen" (become aware of the physical environment), spoken, or smiled for the first time in years; and of those who have showed unusual (for them) peace, happiness, and contentment. The room can be used individually or for small groups for whom a similar outcome is desired. It can be used therapeutically or as a leisure activity. Snoezelen has no formal focus on therapeutic outcome. The focus is instead on assisting users to gain maximum pleasure from the activity.

Implementation of Snoezelen at our facility began with the receipt of a large state grant in May 2004. The program is ongoing and continues to grow and flourish.

The Problem

Long-term care's changing population required that we find new and innovative ways to provide life-enhancing activity for a variety of people with varying needs. The administrator and the facility's interdisciplinary team reviewed our 2003 admission/referral data, which indicated a large number of admission denials because of a behavioral diagnosis. The team wanted to better understand what was involved in starting a behavioral unit and if a true need for one existed.

The administrator traveled to other parts of the state to consult with management staff from mental health facilities and state-run hospitals to determine the exact need for placement of behavioral patients. It turned out that they were having great difficulty getting any facility to accept patients with mental health diagnoses, since many facilities' staffs were not properly trained and had no programs to accommodate these patients' needs.

Next, the administrator and social worker visited local hospital-based behavioral programs to assess the need. They then attended a state mental health meeting that discussed placement for patients with a mental health diagnosis. Even the state mental health agency, they discovered, was looking for facilities for these patients.

While visiting an out-of-state hospital, the administrator discovered a Snoezelen room in the facility's behavioral unit. With great enthusiasm she shared her experience with the interdisciplinary team, who also visited the hospital for a Snoezelen experience. They were sold on the idea. They felt they could not only have a locked behavioral unit but a Snoezelen room, too.

Data were gathered, the business plan was written (very rapidly, actually), the pro forma statements were completed, and the plan was submitted to regional headquarters. Week after week, more meetings were held and more information was submitted. Yet funding for the Snoezelen room was not made available. The corporate decision makers did not fully understand the Snoezelen concept and its potential benefits at first.

Undaunted, the administrator was determined to find a way to include the room in the overall project. She heard of a state grant program that would consider a Snoezelen application, and the facility was awarded an almost $14,000 grant to fund its Snoezelen room.

Planning

The planning stages for the behavioral unit and Snoezelen room actually began the day the interdisciplinary team experienced the hospital's Snoezelen room. The team met many times and involved many other staff members and consultants. We knew we wanted to create an environment where we could ensure patients' safety and dignity--our first priority. We knew that staff members who worked with this new population would need a great deal of education and training to meet patients' special needs. We knew that additional staff would be necessary, too.

Minor construction was the first part of the process, focused on painting and interior design. We talked with various consultants about the right colors to use. These needed to be soothing, with different colors needed for hallways, dining areas, and patient rooms. We also needed to consider lighting and make changes, as needed. We wanted to use wall murals rather than smaller paintings that would have to be bolted to the walls.

The level we planned to use for the unit was separated from the rest of the facility by three sets of stairs and two elevators. It also had direct access to the kitchen and laundry departments. Locked keypads were used for every exit door and each elevator. A wall was constructed to block one elevator and reserve it for the kitchen's private use. We consulted the state life safety office to ensure that we met all codes.

The team decided that another part-time social worker was needed, as well as a music therapist. Because the unit consisted of 35 beds, additional nursing assistants were also needed. The activity department was challenged with developing new activities and specialty programs, including the addition of an art therapy program.

Many issues surrounded training staff for the new unit: Who would be trained? How would they be trained? Who would provide the training? The social worker, who was most instrumental in the Snoezelen room's development, contacted a company that provided us with a Snoezelen expert who recommended the layout for our room, the equipment we needed and its placement, and the training for the staff in the use of the room. The social worker also traveled to New York for a "train the trainer" program.

A dementia expert provided behavioral training to the staff, and we purchased a video training program. Many of the direct-care staffers attended a state-certified training session on dealing with difficult and/or violent patients. All staff members, including nursing, housekeeping, dietary, and ancillary staff, received Snoezelen training and behavioral training. As each would interact at some point with these patients, we wanted them to know how to handle this population.

The unit's goal was to offer residents safety and dignity, as well as special enhancements and activities. The Snoezelen room's goal was to provide a relaxing environment in which patients, relatives, caregivers, and staff were able to develop a therapeutic relationship that did not require an intellectual response. The objectives were for the Snoezelen room to provide an environment that gently stimulated all the sensory modalities to heighten awareness; create a secure environment in which patients, relatives, and staff could explore and relax; promote a therapeutic relationship by sharing experiences of sensory stimulation; and provide a failure-free activity that could be nondirective.

Program measures were gathered through daily documentation of each participant on an Agitated Behavior Scale, along with daily monitoring of blood pressure and pulse rates. The Snoezelen room was used by therapy staff, primarily speech therapy, who documented progress with behaviors, oral-motor stimulation, and nutritional status. The room also was used for reminiscing activities to increase socialization skills. Family members used the room to relax, and we looked for their smiles, recalled memories, and even hugs.

Implementation

Implementing the program was an involved process that began with identifying a space that could be dedicated to a Snoezelen environment. In many facilities this is the first obstacle because extra space always seems to be limited. We designated a resident room on our behavioral unit to be redesigned for this program. It is crucial to grasp the concept and understand the room's desired effects before beginning such a large project. Although we used the main supplier and advocate of Snoezelen to help design our room and provide our equipment, other companies provide a similar service and refer to their spaces as multisensory environments. These companies provide a great resource for information on how to begin, including room design, electrical plans, installation support, and training.

Company representatives are essential in the planning phases of a Snoezelen environment. With their assistance, we chose a room design based on our space and budget. They made recommendations on remote systems and safety requirements. Our representative referred us to a worldwide-known occupational therapist and Snoezelen advocate to provide our training.

Our Snoezelen room's primary features include:

* A solar projector and various-effect "wheels" that display recognizable objects for reminiscence therapy, as well as other abstract wheels used for relaxation or stimulation (depending on the wheel used). We also use accessories to change the images and arousal levels.

* A bubble tube, which is a large, freestanding, acrylic tube in which bubbles flow upward with gently changing colors for visual stimulation.

* A fiberoptic light spray, which consists of 200 small cables of gently changing lights that can be held and manipulated into designs.

The room's other important features include aromatherapy, tactile objects, and music.

We prepared our room by removing unnecessary wall lights and painting the room a soft white. The window was covered with a white curtain that darkened the room. We left the floors tiled. To absorb sound we padded and covered the doors in a white quilted fabric as opposed to just painting them. White shelving was installed in a back corner to provide storage. We traded traditional electrical outlets with a special remote outlet system.

Snoezelen equipment is made in the United Kingdom and shipped to U.S. companies. The company does not always keep a large quantity of the more expensive items, such as the bubble tubes; therefore, it is important to order early and allow for delays. It took between 30 and 60 days to receive our complete order.

All equipment was installed prior to training. We used talented volunteers and staff to install our remote system and assemble the larger equipment. Our bubble tube was placed in the room's most visible corner from the entrance. The largest empty wall was left blank to display projector images, and in the other front corner the fiberoptic light spray was mounted. The projector was mounted on a shelf at a reachable height in the middle of the back wall.

When the room is darkened and the Snoezelen equipment's lights are turned on (displayed against the white background), with wonderful aromas filling the air and music playing softly, the room is instantly transformed into a relaxing and tranquil place that seems to be far removed from the often chaotic halls of a nursing facility.

Final touches were made with the assistance of our trainer, who first introduced Snoezelen to the United States in the 1970s. We added sheer fabric curtains to divide the room, if desired, and to add increased effect to the projector images. We have added more features to the environment, such as small lights in the ceiling above a cloud of sheer fabric, along with a fan and wind chimes for nature sounds.

The trainer was at our facility for two days. After putting finishing touches on the room, along with explanations and demonstrations of various pieces of equipment, the room was ready for staff training. Staff were trained on obtaining residents' sensory profiles or "sensory diets" and, based on this information, how to determine which equipment to use, along with a procedure for entering and exiting a session. Our medical directors and other physicians were invited to attend the trainings.

The trainer helped the social worker identify the residents who would participate in the program first and the goals for those residents. Nurses and physicians offered input on which residents would benefit most from this program. We began with residents who had the most need based on mood and behavioral indicators, such as those who had frequent episodes of agitation leading to falls, residents requiring use of PRN medications because of severe agitation, and a resident who had frequent episodes of yelling that disrupted the unit.

Sessions were typically 30 minutes, and residents began the program on a one-on-one basis with a staff member monitoring the resident's response to the room five days per week. Each resident might have an individual plan for the equipment, aromas, and music used while in the room, and it was recommended to use the same room setup at least one week before making changes unless there was a negative response.

The room was a hit with most residents, especially those in the middle and stressful stages of Alzheimer's dementia. As sessions progressed, many enjoyed entering the room in a group setting to converse and reminisce, with initial prompting from a staff observer, something that residents did not do outside the Snoezelen environment. Some residents were inspired to dance to music familiar to them, and others continued to benefit from one-on-one time spent in the room. After a three-month period, some residents were able to reduce visits to the room to two or three days a week for maintenance therapy, allowing for new residents to be introduced to the program.

One resident who suffered from Alzheimer's dementia and was losing weight because of distractions in the dining room was transitioned to the Snoezelen room for his lunch meal. While in the room he was prompted to self-feed and was able to increase his food intake; during the first month he had a 2.8-lb weight gain. We have had many other successes with individual goals, and we have plans to implement additional studies.

In addition to our Snoezelen environment, we offer Snoezelen "A La Carte." This is a mobile unit with most of the room's features. It holds a smaller bubble tube, a fiberoptic light spray, a projector, music equipment, aromatherapy materials, and a variety of tactile toys. We have integrated this cart into our activity program to provide in-room, one-on-one multisensory stimulation for bed-bound residents or for those who choose not to spend much time out of their rooms. A part-time nursing assistant provides this service to the residents. The cart has a power strip and can be plugged into a room's outlet. The same guidelines are followed from beginning to end, and each resident's "sensory diet" provides a guide for his/her experience. A variety of activity concepts are incorporated, such as fingernail fashions, snack time, small-scale (seated and indoors) volleyball, and country music sessions.

The response from the family members of those visited by the cart has been very positive. Family feedback indicates an improved quality of life for residents who have significant limitations with regard to cognition and mobility.

This program's success would not have been possible without the staff's enthusiasm and dedication. Program enhancements proposed by the administrator received 100% support from all department managers. Staff members from various departments, including housekeeping, laundry, and nursing, as well as department managers, became so excited about the improvements that they offered to scrape and paint walls among other tedious chores.

Evaluation

Snoezelen has been one of our greatest success stories. The major benefit has been to our residents, but in so many ways it has benefited the staff, physicians, and families, as well. Residents' medical conditions have improved; they are smiling and laughing more, as well as appearing more relaxed. Some previously nonverbal residents are speaking. The challenge has been to allow as many residents as possible to benefit

from the room, which we have been able to accomplish through the use of the portable Snoezelen cart. We hope to create another Snoezelen room in the future.

We have completed many case studies of residents who have used the Snoezelen room (see "Case Studies," p. 70). They range from those involving therapy services to those involving reminiscence. Each resident has his/her own version of success, including the woman who was able to dance to ballroom music with her husband again because of the calming atmosphere of the Snoezelen room.

Figures 1-3 illustrate how residents' agitated behavior, blood pressure rates, and pulse rates were affected. The figures profile ten patients during one quarter.

Conclusion

When residents can be free from the pressure to perform, have no limitations (within their space), and are free from control and routine, they are able to react and respond in their own ways. Our hope is that regardless of studies, research, and graphs, we have given our residents a sense of self once again.

For more information, contact Administrator Debbie Spohn at [phone]. For more information on the OPTIMA Award, please visit www.nursinghomesmagazine.com. To send comments to the editors, e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].

Program Staff

Debbie Spohn, Administrator

Angela Rutledge, Social Worker

Peggy McGuire, Social Work Assistant

Kay Steen, Director of Nursing Services

Margaret London, LPN, Charge Nurse

Julie Murray, SLP, Director of Rehab Services

Julie Cooley, Activity Coordinator

Shelly Simmons, Certified Nursing Assistant

Chuck Gould, Outside Consultant (now Maintenance staff)

Gene Roncali, Maintenance staff

Robert Anderson, Marketing/Personnel

BY THE STAFF OF THE BRIAN CENTER HEALTH AND REHABILITATION/BREVARD, BREVARD, NORTH CAROLINA

RELATED ARTICLE: Agitated Behavior Scale

The Agitated Behavior Scale includes 14 items that describe specific behaviors. The scale indicates whether the behavior described in each item was present during the observation period and to what degree.

Evaluation Scale

1 = Absent: The behavior is not present.

2 = Present to a slight degree: The behavior is present but does not prevent the conduct of other appropriate behavior.

3 = Present to a moderate degree: The individual needs to be redirected from an agitated/inappropriate behavior to an appropriate behavior.

4 = Present to an extreme degree: The individual is not able to engage in appropriate behavior because of the interference of agitated/inappropriate behavior.

Before/After

_____/_____ 1. Short attention span, easy distractibility, inability to concentrate

_____/_____ 2. Impulsive, impatient, low tolerance for pain, or frustration

_____/_____ 3. Uncooperative, resistant to care, demanding

_____/_____ 4. Violent and/or threatening violence toward people or property

_____/_____ 5. Explosive and/or unpredictable behavior

_____/_____ 6. Rocking, rubbing, moaning, or other self-stimulating behavior

_____/_____ 7. Pulling at tubes, restraints, etc.

_____/_____ 8. Wandering from treatment areas

_____/_____ 9. Restlessness, pacing, excessive movement

_____/_____ 10. Repetitive behaviors, motor and/or verbal

_____/_____ 11. Rapid, loud, or excessive talking

_____/_____ 12. Sudden changes of mood

_____/_____ 13. Easily initiated or excessive crying and/or laughter

_____/_____ 14. Self-abusiveness, physical and/or verbal

_____/_____ Total score (out of a possible 56)

Scale source: Corrigan JD. Development of a scale for assessment of agitation following traumatic brain injury. Journal of Clinical and Experimental Neuropsychology 1989;11:261-77.

RELATED ARTICLE: Case Studies

Improving Swallowing and Decreasing Agitation

H.F. has a history of dementia with psychosis and post-traumatic encephalopathy (head injury). H.F. was referred upon admission for speech-language treatment because of a swallowing disorder. He had only limited participation in treatment while at the hospital because of combative behaviors and agitation. Recommended treatment for the swallowing delay included thermal stimulation of the swallow with an iced dental mirror. He was unable to tolerate this treatment in a traditional therapy environment because he became agitated.

Treatment was initiated using the Snoezelen room for oral-motor exercise, oral-motor stimulation, and thermal stimulation. The resident became calm with the use of auditory and visual stimuli and would often whistle along with the music, another great oral-motor exercise. He had no episodes of combative or agitated behavior while in the Snoezelen room. Treatment was also provided outside the Snoezelen room with a focus on his overall by-mouth intake. After approximately six weeks of treatment, the resident was discharged from therapy. He had improved swallowing skills with no signs/symptoms of aspiration or episodes of aspiration. He also gained more than 7 lbs. Caregivers reported decreased episodes of agitation/combative behaviors.

Calming a Restless Resident

C.W. had a diagnosis of severe dementia with behavioral disturbance, anxiety, and insomnia. On the day of admission the resident entered the facility very anxious and restless, with periods of repetitive speech patterns alternating with crying and continual physical movements and no recognition of staff. Then she began sessions in the Snoezelen room. During her first session her anxiety and restlessness stopped, and she began singing some words to familiar instrumental music. Her crying decreased, her movements slowed, and she began to make eye contact with staff.

She was seen in the room two times daily for the first month: one by speech therapy before breakfast, with a goal of increasing her meal intake, and the other for leisure and relaxation. Over time we saw increased meal intake and overall less restless and agitated behavior. Her actions became more outward and displayed awareness of objects in the room, and she used coherent verbalizations versus expressing reactions to internal stimuli. At the time of her first quarterly assessment, her episodes of sad affect and tearfulness had decreased, both in frequency and duration, and her nighttime sleep was on a more normal schedule, with no reported episodes of insomnia.

Reducing a Resident's Yelling

B.M. had a history of multiple cerebrovascular accidents, causing dementia, delusions, and depression, with his targeted behavior being constant yelling. The goal was for the resident to decrease yelling by offering an environment where he could have an alternate type of interaction that was relaxing and did not require intellectual response. He was participating in sessions five days per week for 30 minutes each day. He was very hard of hearing. Sessions consisted of his preferred music (with adequate hearing assistance), cloud wheel (most often), lavender scent, bubble tube, and fiberoptic light spray. Most of his attention was on the cloud projection and the music. If he entered the room yelling or groaning, he often stopped as soon as the music started. This resident normally did not initiate conversation, but he did in the Snoezelen room. Repetitive hand movements would cease, and he would display intentional movement of the right foot to the music's beat. Outside the room he yelled less often. Before using the Snoezelen room, his yelling episodes averaged 5.3 times a day. After three months they were reduced to 2.8 per day, with the episodes' duration being much shorter. The resident also verbalized enjoyment of the room.

A gitated Behavior Scale

             Total Score
Patients     Before    After

A.Q.         27        16
E.B.         18        14
B.B.         24        16
R.J.         25        16
R.A.         24        15
E.P.         23        16
O.E.         26        16
L.C.         20        14
B.K.         20        14
K.F.         21        15

Figure 1. Before and after results of the Agitated Behavior Scale (see
sidebar on page 68) show how ten residents improved with Snoezelen
therapy.

Note: Table made from bar graph.

Blood Pressure Rate Data

                              Blood Pressure
                Systolic  Diastolic
Patients        Before    Before     Systolic After  Diastolic After

A.Q.            130       72         126             68
E.B.            123       71         110             68
B.B.            118       65         115             62
R.J.            124       71         120             67
R.A.            137       66         131             62
E.P.            144       72         139             69
O.E.            121       80         117             77
L.C.            128       79         124             74
B.K.            131       82         127             78
K.F.            147       77         139             72

Figure 2. Before and after blood-pressure-rate measurements show how ten
residents relaxed with Snoezelen therapy.

Note: Table made from bar graph.

Pulse Rate Data

          Pulse Rate
Patients  Before  After

A.Q.      79      74
E.B.      68      64
B.B.      79      73
R.J.      80      75
R.A.      93      87
E.P.      77      73
O.E.      92      88
L.C.      78      74
B.K.      81      76
K.F.      79      73

Figure 3. Before and after pulse-rate measurements show how ten
residents relaxed with Snoezelen therapy.

Note: Table made from bar graph.