The (not so) undercover resident.

Your facility runs like a well-oiled machine. The surroundings are tasteful and pleasant. Residents' days are creatively scheduled so caregivers can complete their tasks expediently. Everyone is happy with this arrangement, right? Maybe not. Is it possible that there is too much tasking and not enough asking? Susan Black, administrator of Exempla Colorado Lutheran Home--a CCRC with 31 assisted living and 64 independent living apartments and a 120-bed nursing home, located in Arvada, Colorado--decided to experience resident life firsthand to find out.

The idea for living a day in the life of a resident came from a road trip to visit facilities that have completed or are undergoing culture change, explains Black. One of the stops was at Meadowlark Hills in Manhattan, Kansas. "When Meadowlark Hills' CEO Steve Shields decided to remodel the facility, he required the architect to spend time in the facility and experience resident life from the inside," recalls Black. When she returned to Colorado, she decided using this approach in her own facility could be very enlightening. "I wanted to see our organization through a resident's eyes. Only management staff and social workers were aware that I intended to admit myself to the nursing home--as a resident--for an entire shift rotation: day, evening, and night," says Black.

Because Exempla Colorado Lutheran Home generally runs at 100% census, the plan was predicated on bed availability. That bed vacancy occurred on March 23, 2004, so Black quickly and quietly put her plan in motion.

On the evening of March 22, social workers informed staff that a new resident, 72-year-old Ernestine Wood (really Black), would be admitted in the morning. "Expecting and preparing for Ernestine Wood, the staff stared in disbelief when I arrived and asked if I was kidding. I told them I [as Ernestine] was really there to stay," laughs Black. She then was admitted with a fictional diagnosis of a broken left ankle, hearing impairment (simulated with earplugs), and an actual case of left hip bursitis.

In an effort to avoid staff discomfort at having to ask their administrator questions that might be too intrusive, an adapted admissions assessment was performed. Ernestine's vital signs were checked, and the edema in her leg was measured. She was weighed, underwent Mini-Mental and restorative statuses, and her meds were checked. "I also met with the activity therapist, dietitian, and other members of services that would be involved in my care," she notes.

According to Black, Exempla Colorado Lutheran Home has a five-year business plan in place for the implementation of culture change. As a result of her admission, one of the first changes made was in assessing a resident's need for restorative dining. "I was told that I had to sit at the restorative dining table with a restorative aide for the noon meal. I tried to explain that this wasn't necessary. I didn't have a swallowing problem and I could feed myself. It was a silly rule," states Black. But poor, compliant Ernestine followed the rules, hated the experience, and went back to her room and cried. "I found the whole situation very depressing, and it opened my eyes to the frustrations of mentally alert residents placed in that position," she recalls. With the earplugs, she could not engage in conversation during the meal, which increased her sense of isolation and helplessness. Watching these residents struggling to feed themselves or being fed pureed food killed her appetite. She came to realize that a negative dining experience like this invites weight loss, malnutrition, and depression. "We changed this procedure the very next day," Black says happily. Restorative dining is now the province of those residents who truly need the extra care and supervision.

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Exempla Colorado Lutheran Home has now instituted open dining for breakfast and lunch. Residents come to meals when they are ready. "We've found that they are more alert and eat better. We don't see as much weight loss as before, and we have discovered that residents will linger after a meal to socialize," states Black. She also observes that now residents feel more in control of their lives because they have choices.

Black reflects, "I think people in healthcare try to do the right thing. As a resident, though, I discovered that the staff made many of my decisions for me: when to wake up, when to eat, when to check my vitals, etc." The biggest frustration for Black was her loss of privacy. "Not necessarily privacy in the bathroom, but rather the opportunity for solitude." She confides that if she went outside to be alone with her thoughts, someone would come out to see if she was okay. If she was in an activity, someone else would stop by to check on her. "I, as an administrator, realize that staff does this because of the paperwork and assessments they have to complete, but as Ernestine, I found this attention smothering," she says.

Black suggests that however well intentioned, caregivers run the risk of promoting resident dependence by doing things for them that could be done independently or with just a little assistance. "I found that people always asked me if I wanted a ride to the dining room. I told them no because I wanted to see what it was like to navigate the corridors. If a resident in her eighties is physically capable of pushing her wheelchair, we need to encourage her to do that to maintain her independence," she says. Black further explains that a more dependent population requires more staff. "I don't fault the staff for using wheelchairs to transport residents. It is quicker and easier, and that's the way they were taught, but we have to remember that we're dealing with folks who still need to make choices in their lives. We often forget to ask the simple questions: What would you like to eat? When would you like to bathe?"

In the same way that staff recognized Black despite her Ernestine persona, so did the residents. After explaining why she was there, the residents accepted her as one of their own. "At night when there was fewer staff and less activity, it got a bit too quiet and boring," says Black. To combat the quietude and loneliness, she gathered some independent residents together to play Scrabble until 9 p.m. "We had a lot of fun playing the game and talking about their experiences," remembers Black.

Before Black's experiment new residents were immediately shown to their rooms, and they learned to navigate the facility and its services on their own. "I was never shown around. I'm not sure if that was because I know where everything is, but that is not the way to greet people entering a strange environment," she says. Now a welcoming committee composed of frontline workers meets every new resident and tells him or her about the services and amenities available. It doesn't always happen on the day of admission, but gradually to ease the new resident into facility life.

As seen from Black's experience, walking (or rolling) a mile in residents' shoes can be an eye-opening experience for an administrator. Watching staff work gives the administrator a glimpse at their strengths and weaknesses in caregiving. It also offers a perspective on the environment in which residents must live every day--not just for 24 hours.

BY SANDRA HOBAN, MANAGING EDITOR

Susan Black is administrator of Exempla Colorado Lutheran Home in Arvada, Colorado. For further information, phone [phone]. To comment on this article, please send e-mail to [e-mail].