Encouraging independence in assisted living: research has unveiled several helpful techniques.

Assisted living offers seniors the promise of a living situation that helps them maintain independence in and control over their lives, while also providing the care and support they require as they get older. However, living up to that promise is often a challenge for assisted living management and staff. It can also be a challenge for the seniors themselves, who sometimes are not aware of their options and rights, or may feel that they must accept an unnecessarily restrictive living environment.

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A three-year study of assisted living in New York State, conducted by the Long Term Care Community Coalition (LTCCC) and the Coalition of Institutionalized Aged and Disabled (CIAD), found a significant gap between what residents want and the level of independence they were given. Such a gap is understandable, since assisted living providers have the dual obligation of providing a good lifestyle while helping people to live safely. Assisted living managers and staff may have concerns about how residents' chosen activities may affect their safety--for instance, what if a resident with poor eyesight wants to walk unassisted? Or how about the resident with poor health who smokes?

Other challenges arise: Family members may feel that they are entitled to make lifestyle decisions for their relatives. Also, regulatory and liability concerns may appear to restrict options for resident choice. And staff may be concerned that managing different lifestyle choices for each resident will make their jobs more difficult or time-consuming.

In response to the study findings about the disparity between residents' desires and reality, we worked with the assisted living industry to review the obstacles to closing this gap.

Importance of Maintaining Independence and Control

The first step we identified is for managers and staff to recognize that maintaining resident independence can significantly affect both resident well-being and the financial health of the facility. When people lose autonomy, they experience low self-esteem and feelings of hopelessness, depression, and helplessness. From the business perspective, this can mean a community with higher care needs and a less desirable living environment. Thus, puttinga little more effort into helping residents maintain independence can benefit everyone.

Next, we suggest conducting a thorough review of the choices that residents have and don't have. Compare them with the choices managers and staff have made in their own lives to help staff understand the importance of personal choice. Can residents decide when to wake up and when to go to bed? Can they have a pet? Can they choose when to eat and with whom, or to go somewhere whenever they want to?

Determine what stands between resident choice of this type and institutional control. Routines and rules may exist only because they make operations easier for staff. Staff accustomed to this regimen may not know how to encourage resident decision making. Corporate rules, such as those requiring uniform furnishings or weekly menus, may further limit autonomy.

Addressing Rules and Restrictions

Once unnecessary restrictions have been identified, address them by forming a committee of residents and staff, including direct care employees, to analyze their impact. For each rule, ask: Why do we have this rule? Does it limit resident choice? Why? Can the rule be eliminated or modified? The committee can then make recommendations for modifications when appropriate. For example, to accommodate residents who wish to eat at different times, while it may not be possible to keep a dining room open all day, it may be possible to extend mealtime hours or offer lighter food at other times.

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Examine your facility's physical layout with the committee, and consider changes that might enhance independence. For example, handrails and better lighting outside the residence may encourage walks around the grounds. Chairs placed in the hallway may make it possible for residents to rest as they walk a long corridor, thus encouraging ambulation and delaying wheelchair use.

Staff Training

It is imperative that staff members understand that they can approach managers with suggestions or problems related to resident independence. Staff can also be trained to work with residents to learn their preferences and thus develop individualized routines and schedules. One facility we reviewed created a training videotape that role-played a "resident" being dressed and saying "I don't want to wear that shirt. I want the blue one," a request that the staff ignored, to the resident's growing frustration. This training tape increased staff awareness of the need to listen and respond to residents more carefully and to respect resident choices to the extent possible.

Taking Appropriate Risks

Having independence and control carries with it the right to take risks. Assisted living understands philosophically the importance of balancing safety with quality of life. Concerns about risks are, of course, understandable: One might be afraid that a resident will get hurt, or believe that a resident is unable to consider some risks prudently. But again, think of the risks you take. Do you ever eat too much? Smoke? Sunbathe? Now imagine how you feel when someone tells you that you shouldn't do these sorts of things.

Begin by making a list of things residents want to do that you consider unsafe: perhaps shopping alone, smoking, or being outside in poor weather. Then, analyze the potential risks of the activity. Develop a process, and document it, for evaluating the risks that residents want to take; you can also document residents' willingness to accept these risks. It is important to consider whether the apparent danger is real or simply an excuse for avoiding staff inconvenience. You may realize that some things we assume to be unsafe actually carry little risk of harm, and may only require some assistance and oversight to make them safer.

Again, staff training is essential to permitting appropriate risk taking. Involving residents in the training may help staff understand that the need to feel in control does not diminish with age. Incorporate discussion about risk taking at individual service plan meetings, and document all actions taken.

The Role of Families

As indicated earlier, many family members may feel that they should make decisions for their relatives. The fact that family members are often involved in choosing a facility or paying for care may make management and staff inclined to let them make these decisions. It is crucial to help families understand that competent residents must be allowed to make their own choices to the extent possible, even if families don't always agree with those choices.

We recommend developing a process for educating families along these lines, rather than attempting to resolve these conflicts on a case-by-case basis. As part of this education, explain the process you have developed for evaluating risk and for reducing the potential for negative consequences. Set up a series of meetings for families and friends to discuss the importance of resident choice and control, and invite social workers and psychologists, as well as the resident council, to give presentations on the importance of control to residents' psychological and physical health.

The Promise of Assisted Living

The promise of assisted living includes maximizing a resident's choice, independence, and the ability to remain in the facility as dependence grows. While it may be challenging to fulfill this promise, it is important to consistently work toward this goal. It will not only make life better for the residents, it can also help make the facility more attractive to consumers and better for staff. Being open to change, focusing on a process for encouraging choice and independence among the residents, and providing staff members with training that emphasizes respect for resident decision making can help provide the template for successful residence in an assisted living facility.

Geoff Lieberman is Executive Director of the Coalition of Institutionalized Aged and Disabled, and Cynthia Rudder, PhD, is Executive Director of the Long Term Care Community Coalition. For further information, phone [phone] or visit www.Itccc.org. To send your comments to the authors and editors, e-mail [e-mail].

RELATED ARTICLE: Informational Guides Available

Two guides for assisted living managers and direct care staff offer ideas and advice on common situations that can dramatically affect residents' perceptions of their living situation.

The Guide For Assisted Living Managers helps managers make their management vision a reality by providing practical tips and case studies that help staff meet residents' needs and overcome typical obstacles.

The Guide For Assisted Living Direct Care Staff is a unique resource that recognizes that staff members know the residents the best and can implement changes to create the most satisfying environment for residents. This simply written guide presents case studies from other caregivers and provides easy-to-locate tips on a range of topics.

The guides are based on research performed by LTCCC and CIAD, were reviewed by a professional advisory board, and were pilot-tested in diverse communities across the nation.

Both can be downloaded for free at www.assisted-living411.org.

BY GEOFF LIEBERMAN AND CYNTHIA RUDDER, PHD