Creating a healing environment: a Planetree pioneer explains that there's more to this than bricks and mortar.

In the late 1970s, Angelica Thieriot created the Planetree Organization in an attempt to personalize, humanize, and demystify the healthcare environment. Her vision was to design healthcare from the patient's perspective, and not just from that of staff convenience. Her plan addressed not only how each facility should be designed from architectural and patient physical comfort points of view but, more importantly, from an intrinsic point of view. That is, her philosophy required caregivers to rethink their paradigm of "giving" care. The new paradigm Thieriot discussed called for a holistic approach that encouraged healing in all dimensions. More importantly, it called for caregivers to rethink their reasons for choosing their career. (1)

Delano Regional Medical Center's (DRMC, Delano, California) journey with Planetree began in 1989; it was the first long-term care unit to employ Planetree principles. Its skilled nursing unit had regularly provided above-average care, but nothing set it apart from other long-term care facilities. Planetree consultants recognized a longing in DRMC's leadership to be different--to serve residents in a nontraditional manner that really made a difference in quality of life.

The Planetree transformation at DRMC included everything from rethinking the space and architecture of the unit to a reevaluation of the way care was delivered. Indeed, the most important change occurred in the way the caregivers thought about what they do. Their paradigm changed from "delivering" care to becoming a "partner" and a "facilitator" in care. In other words, the staff no longer "gave" a bed bath but rather "facilitated" the resident in the process.

This shift in thinking began with DRMC staff retreats, in which the Planetree philosophy was discussed and "resident-centered care" was defined. "Aha's" for each staff member occurred at these retreats, especially through the use of guided imagery. Staff were taken on a mental journey to a time of being ill and being the ones to receive care, and then to a time of caring for a loved one who was ill. These retreats also taught various specific components of Planetree, including art as therapy, music as therapy, and food as therapy. Teams and committees were developed with responsibility to establish each of the Planetree components at DRMC.

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Environmentally, the long-term care unit got a face-lift. The change included special homelike rooms for visitation, a kitchen where residents and their families could prepare special dishes, and special "garages" for linen carts when they were not in use.

Although skilled nursing facilities have long been ahead of their acute care counterparts in the physical design of their environments, beautifully designed settings can only go so far in creating a healing environment. They meet the extrinsic needs of the residents, families, and employees, but do they meet their intrinsic needs? Psychologist Abraham Maslow believed that human beings are motivated by their needs and, as "lower order" needs are met, the "higher order" needs become more important to them. (2) Using Maslow's Hierarchy of Needs framework, the external environment can only satisfy some of the physical and security needs of resident and families. The caregivers' attitudes and behaviors lend themselves to satisfying their higher order social, esteem, and self-actualization needs. Regarding the latter, "Self-actualization is defined as 'a process of becoming, the process of development which does not end [emphasis added].'" (2) This process continues until death and we, as caregivers, have the rare and wonderful opportunity to assist our residents in that process.

Nine components make up the Planetree environment: a supportive environment, physical involvement of family and friends, physical environment, respect for the individual, access to information, participation, choice, human environment, and autonomous decision making. As is seen with Maslow's needs hierarchy, realization of these components depends upon the staff's attitudes and behaviors. Following the nine components of the Planetree environment are the nine principles that form the basis of patient- or, in this case, resident-centered care. These principles are human interaction, information, healing partnerships, nutrition, spirituality, human touch, complimentary practice, alternative practice, and healing environments. Again, staff have a key role.

These components and principles can only be achieved through a cultural shift in the organization. The answer lies in creating a resident-centered culture, a culture in which the staff are empowered to make decisions in the best interest of residents and families, and which, in the long run, better serve the organization.

To create a culture where these nine components and nine principles are met, leadership must take the first step in deciding that it is the right thing to do, and then realize that it all begins with staff empowerment. According to Flesner and Rantz, "An empowered staff is a successful agent for residents and can act to assist the residents in meeting their life preferences and goals." They point out, "Management practices, including open communication patterns, participation in decision making by staff, and relationship-oriented behaviors, can positively influence four resident outcomes: prevalence of aggression, restraint use, complications from immobility, and fractures." (3)

Empowering staff has many benefits, and the barriers to this are usually systemic, not personal. According to McManus, "While we might want to believe that it's the people that cause our daily challenges or hold back our efforts to make things better, it is the systems we use that affect performance, attitudes, and effort." (4) Leadership must first identify systems that create barriers for staff trying to do their jobs. These barriers can range from bureaucratic policies and procedures to not having enough equipment and linen available.

Planetree begins the culture change process through staff retreats, such as we conducted. The goal is to ensure staff's ownership of the principles. Education about the components is provided and discussions are held concerning why the individuals chose a health career. The thought behind this is that taking stock of one's own reasons for entering the healthcare field may help staff realize "what's in it for them." Recalling when they or a loved one received care, or when they provided care to a loved one, helps them to get in touch with what "caring" is all about. Educating staff about the effects their behaviors have on residents also helps.

According to Stone, the "most important prediction of job satisfaction and nursing assistant turnover is management style allowing worker autonomy." (5) What does worker autonomy look like in a long-term care environment? Autonomy is having control over day-to-day activities through the use of guidelines; it is not allowing staff to run amok and do whatever they want to do. Let the staff make choices on how to deliver care: "If the organization wants employees to be creative and innovative, it must facilitate the appropriate working environment. The organization must treat its employees as their most important resource." (6)

Communication plays a key role in this autonomy. The findings by Scott-Cawiezell et al show that "nursing homes with good communication are expected to have better performance than nursing homes experiencing poorer communication among staff members." (6) Staff must know what their limits are in the decision-making process. What, specifically, are they empowered to do? If a resident asks a nursing assistant for ice cream and the diet allows it, can the nursing assistant call the kitchen or should she instead have to go through the charge nurse? Can nursing assistants sit and read to a resident during their shifts? What are the limits to their autonomy?

Human interaction is the first, and arguably the most important, of Planetree's nine principles of resident-centered care. It encompasses what residents desire (value, respect, sense of control, and the opportunity to participate) and what employees want (appreciation and recognition, communication and participation, and kindness). Frank, open discussions with staff about what residents desire and what that means can trigger an invaluable dialogue. It's important to remember that staff, to a large extent, share the same desires as residents.

Therefore, it is important to acknowledge that each staff member typically has unique and special talents, whether in a performing art (e.g., singing, dancing, playing a musical instrument, storytelling) or a visual art (e.g., painting, knitting, sewing). (A facility crafts fair, if you've ever conducted one, can be very revealing.) The activities program is an excellent way to tap into the talents you discover. In fact, the cornerstone of any long-term care facility is its activities program, which in Planetree often becomes the healing arts program. It is through these programs that the residents' psychosocial, physical, and spiritual needs are met.

An activities committee composed of staff with untapped talents ensures staff ownership and success. Imagine an activities program where different staff members "own" the day for creatively engaging residents. Hurst states, "... organizations that genuinely focus on understanding each person's own natural talents tend to achieve corporate success." (7) In this case, the higher order needs of esteem and self-actualization are met for both residents and staff.

Healing partnerships such as a care partner program can be successful in helping staff feel a greater sense of responsibility for resident outcomes. Care partners (usually family members) assist staff with resident care. Residents without families can benefit by having staff members themselves serve as care partners. Care partner responsibilities go beyond those of the caregiver by ensuring that the resident is seen as a whole person and that more than just basic care needs are met. This can be as simple as sending a birthday card or as complex as taking the resident shopping at the mall. The resulting interaction forms bonds as strong as those with any family.

The importance of spirituality, especially for many elderly residents, cannot be overlooked. Staff can assist in recognizing the need for spiritual assessment and intervention, counseling, and even prayer. Spirituality also includes ritual, whether it be religious ritual or the everyday ritual of waking up and getting ready for the day. As staff recognize that each resident is special and unique, with special and unique needs, they will find ways to support each resident's needs and desires.

Teaching staff about the benefits of human touch brings humanity to the long-term care environment. We all need to be touched and have our hands held. Teaching staff about massage and how to do it properly will therefore bring them closer to residents and help residents fulfill their socialization and self-esteem needs.

A recent study of long-term care organizations found that "The predominant strength, identified by over 130 responses, was that staff within each facility cared for the residents whom they served." (6) At DRMC, our staff care for whom they provide care. They often didn't have an outlet to show it, but we had the opportunity to bring it all together by recognizing the part they played in meeting our residents' needs. In a state licensing survey shortly after our adopting the Planetree principles, the surveyor said, "The care here is so profound as to be touching."

That's the power of staff empowerment, as envisioned by Planetree.

References

1. Planetree. www.planetree.org/welcome.html. 2003.

2. Kiel JM. Reshaping Maslow's hierarchy of needs to reflect today's educational and managerial philosophies. Journal of Instructional Psychology 1999;26:167.

3. Flesner MK, Rantz MJ. Mutual empowerment and respect: Effect on nursing home quality of care. Journal of Nursing Care Quality 2004;19:193-6.

4. McManus K. Quality requires a strong foundation. Industrial Engineer 2003;9:22.

5. Stone RI. The Future of the Long-Term Care Workforce: It's Not "Just the Economy, Stupid." UNC Institute on Aging Distinguished Lecture Series. December 7, 2000.

6. Scott-Cawiezell J, Schenkman M, Moore L, et al. Exploring nursing home staff's perceptions of communication and leadership to facilitate quality improvement. Journal of Nursing Care Quality 2004;19:242-52.

7. Hurst E. Targeted talent management. May 7, 2004. Available at: www.hrmguide.co.uk/opinion/talentmanagement.htm.

BY ALLAN G. KOMAREK, PHD, RN

Allan G. Komarek, PhD, RN, is the Executive Director at Delano Regional Medical Center in Delano, California. For more information, call [phone] or visit www.drmc.com. To comment on this article, send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].