The nursing home of the future: are you ready? (Feature Article).
Tomorrow's resident care will take more than "quality-of-life" lip service lip service
Verbal expression of agreement or allegiance, unsupported by real conviction or action; hypocritical respect:
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 will begin to gain momentum. Eventually, if it is successful, it will cause a sea change in thinking, so that we will wonder how we ever accepted the old ways of thinking and doing. A classic example is restraint reduction (see "The Restraint-Reduction Movement," p. 47).
It's happening again--and there's nothing we can do to stop it. It will radically affect how nursing homes, and to some extent assisted living as·sist·ed living
A living arrangement in which people with special needs, especially older people with disabilities, reside in a facility that provides help with everyday tasks such as bathing, dressing, and taking medication. facilities, operate. It goes by many names--resident- centered care, culture change, Eden Alternative, reengineering (to borrow a business term) or resident-directed care. While each of these labels might have a slightly different definition (and these definitions can 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 frail 1
adj. frail·er, frail·est
1. Physically weak; delicate: an invalid's frail body.
2. and impaired individuals. In the future, the focus won't 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).
"Quality of life" is a thorny thorn·y
adj. thorn·i·er, thorn·i·est
1. Full of or covered with thorns.
3. Painfully controversial; vexatious: a thorny situation; thorny issues. concept because it is so hard to define. But let's assume for the moment that quality of life relates to choice and control, positive and meaningful interactions, and quality medical care. Regulations and the survey process have already started moving in this direction (for once leading the pack instead of being behind the curve), so many facilities that receive good surveys think they are already doing this. In reality, however, they are barely scratching the surface. They are paying lip service to the concepts, changing their marketing language, describing former "units" now as "households" or "neighborhoods" without having made any structural or operational changes. Or they give the physical environment a face-lift--putting an extra set of fire doors between hallways to create "households," using updated colors and patterns, adding a few chintz chintz (chĭnts) [probably Hindustani,=variegated], originally a painted or stained calico from India. Esteemed for its bright colors and designs, it was used in Europe for bedcovers and draperies. throw pillows and carpeting-- and assume this is a sufficient guarantee of quality of life.
What is? Different individuals might identify various goals, but the following list is generally accepted as being part of this movement:
1. Respecting the individualized in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. needs and desires of each person (yes, even people with dementia dementia (dĭmĕn`shə) [Lat.,=being out of the mind], progressive deterioration of intellectual faculties resulting in apathy, confusion, and stupor. In the 17th cent. !). 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.
Traditionally, all meals in nursing homes have been offered at set times, and all residents have been expected to eat their meals at those times. Now, however, many facilities are beginning to recognize that they can allow residents more flexibility in when they wake up. If offered a late night snack, a continental breakfast for the early and late risers, and a hot meal at a specified time, residents can choose whether to get up for the hot meal or sleep in and eat a Danish or cereal cereal
Any grass yielding starchy seeds suitable for food. The most commonly cultivated cereals are wheat, rice, rye, oats, barley, corn, and sorghum. As human food, cereals are usually marketed in raw grain form or as ingredients of food products. . Initially, staff were worried that this would mean extra work for them. In reality, staff at most facilities find it easier not to have to get everyone up for breakfast at a specified time.
In terms of bathing, in most facilities every resident is bathed/showered a set number of times per week (once or twice). If the resident is lucky, it is his/her preference that determines whether it is a bath or a shower, and possibly even determines what time the bath/shower is given. But how many facilities bother to ask the residents' preferences related to frequency of bathing or showering--and follow through with those preferences? I can hear staff saying, "But if you gave all residents complete choice, some would say they never want to have another bath or shower!" That might be true. You might need to set some limits, such as getting cleaned (notice I didn't say having a bath or shower) at least once every other week. But by negotiating with the residents, showing that you are trying to individualize in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. the care to their needs, you are likely to find them responding positively and accepting when compromises are necessary.
Embedded Inserted into. See embedded system. 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 might 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 effect 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 "semiprivate sem·i·pri·vate
Shared with usually one to three other hospital patients: a semiprivate room.
Adj. 1. ," 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 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. There is some overlap between this goal and the previous one, particularly as it relates to the resident's life pattern of activities. But it goes beyond following the established routines of each resident. Virtually everyone in a nursing home--staff as well as residents--has done things he or she is proud of. This might be work-related, a volunteer activity, family event or crafts and hobbies It may never be fully completed or, depending on its its nature, it may be that it can never be completed. However, new and revised entries in the list are always welcome. This is a list of hobbies. . Singing in the church choir, running a scout troop, traveling to interesting places--all these are worthy of celebrating in some way. 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 a myriad of other ways. The important point is to spend 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 work life in the facility, staff lead active lives that are full of interesting events and skills. Encouraging staff and residents to start a barber A barber (from the Latin barba, "beard") is someone whose occupation is to cut any type of hair, give shaves, and trim beards. In previous times, barbers also performed surgery and dentistry. shop quartet or to do joint activities with local school children opens the door for both groups to see the others as full and exciting individuals--not just "the resident" or just "the nurse."
3. Supporting opportunities for continued growth. This new philosophy takes a lifelong perspective of development, and does not assume that age and/or physical frailty frailty Vox populi A state of delicacy or weakness which, which encompasses age-related fragility, in particular osteoporosis. See FICSIT, Osteoporosis. means that an individual is no longer capable of or desires new learning. Whether it's learning how to use a computer to send e-mail to family and grandchildren GRANDCHILDREN, domestic relations. The children of one's children. Sometimes these may claim bequests given in a will to children, though in general they can make no such claim. 6 Co. 16. , 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 grasping
a similar equine neurosis to windsucking; the horse grasps a fixed object with its teeth, but does not swallow air. some new skills, even people who are quite cognitively impaired can appreciate new opportunities when they are presented in ways that are nonthreatening and not performance driven.
There are many excellent examples of residents in midstage 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 elementary school: see 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 raking
of an elephant—see back raking. the leaves. A few facilities create opportunities for residents to talk about their past professions or other experiences, either to the rest of the residents or to outside groups.
Residents can serve as reading tutors, or call latchkey kids Latchkey kid or Latchkey child refers to a child who returns from school to an empty home because his or her parents are away at work, or a child who is often left at home with little or no parental supervision. when they're home alone, or even make and sell items (and either donate the proceeds to a charity or keep them). Many residents are capable of volunteering for nonprofit organizations Nonprofit Organization
An association that is given tax-free status. Donations to a non-profit organization are often tax deductible as well.
Examples of non-profit organizations are charities, hospitals and schools. 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. (For more on resident volunteerism vol·un·teer·ism
Use of or reliance on volunteers, especially to perform social or educational work in communities.
volunteerism , see "Not-for-Profit Report," page 29.)
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 agitation /ag·i·ta·tion/ (aj?i-ta´shun) excessive, purposeless cognitive and motor activity or restlessness, usually associated with a state of tension or anxiety. Called also psychomotor a. . (1-3) 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.
Inviting families to a variety of joint activities with other residents and families; offering family members opportunities to run volunteer activities; and creating a variety of spaces in which to visit, where there are things to do, see, touch, smell and watch, are but a few of the ideas that help support relationships.
Having residents start a pen-pal program with a school class can be the beginning of new friendships. If there are residents who can no longerwrite, see if others will serve as scribes Scribes is a text editor for GNOME that is simple, slim and sleek, and features no tabs, auto-completion and much more.
Scribes is Free Software licensed under the terms of the GNU GPL. and write for them.
6. Fostering fun. How many times have you walked through the halls of a nursing home and heard laughter? Many readers are familiar with the principles of the Eden Alternative, which is but one example of a new way of structuring nursing homes. One of the foundations of the Eden philosophy is that the spontaneity spon·ta·ne·i·ty
n. pl. spon·ta·ne·i·ties
1. The quality or condition of being spontaneous.
2. Spontaneous behavior, impulse, or movement.
Noun 1. 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., search for "laughter" at www.WebMD.com for more information). Facilities that are restructuring restructuring - The transformation from one representation form to another at the same relative abstraction level, while preserving the subject system's external behaviour (functionality and semantics). their care settings sometimes incorporate "laugh props" to give both residents and staff more occasions to laugh.
The suggestions above might seem Pollyannaish. I can hear staff saying: "Our residents are too far gone"; "We tried that before, and it didn't work"; "The residents don't want to do that"; "There isn't enough time"; "There isn't enough money"; or "I won't get everything done that needs to be done." These comments reflect the anxiety that change brings. The same things were said about restraint-reduction programs, yet see how far we've come "How Far We've Come" is the lead single from Matchbox Twenty's retrospective collection, Exile on Mainstream, which was released on October 2, 2007. The music video premiered on VH1's Top 20 Countdown on September 1, 2007. in that arena.
While the challenges of restructuring the entire care setting are much greater than tackling a single issue, there are also greater opportunities. There's no one right way to go about this change process. You can start with a single care practice--for 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 might be able to give more insight into the preferences of cognitively impaired individuals than anyone else.
Then look at your bathing room(s). What do they say to the residents about what this experience is going to be like? If these rooms feature cold, antiseptic antiseptic, agent that kills or inhibits the growth of microorganisms on the external surfaces of the body. Antiseptics should generally be distinguished from drugs such as antibiotics that destroy microorganisms internally, and from disinfectants, which destroy white walls with institutional equipment visible, a positive experience is not in the offing coming; arriving in the foreseeable future.
visible but not nearby.
See also: Offing Offing . What occupies most of the field of vision of a person in the tub? Is it the chrome (jargon) chrome - (From automotive slang via wargaming) Showy features added to attract users but contributing little or nothing to the power of a system.
"The 3D icons in Motif are just chrome, but they certainly are *pretty* chrome!" control panel for the tub? Or is it some artwork, or a nicely decorated dec·o·rate
tr.v. dec·o·rat·ed, dec·o·rat·ing, dec·o·rates
1. To furnish, provide, or adorn with something ornamental; embellish.
2. accessory accessory, in criminal law, a person who, though not present at the commission of a crime, becomes a participator in the crime either before or after the fact of commission. shelf, with scented soaps and plush towels? What would make the room more attractive for you to take a bath there?
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 underdefined term, "empowering" the nursing assistants to be major players on the care team is critical to the fundamental shift this movement requires. 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 l950s' hospital-based model, just as hospitals have reinvented themselves over the past decade. Focusing on the positive aspects of personhood per·son·hood
The state or condition of being a person, especially having those qualities that confer distinct individuality: "finding her own personhood as a campus activist" and recognizing residual strengths Residual strength is the load or force (usually mechanical) that a damaged object or material can still carry without failing. and abilities to engage in meaningful relationships that have purpose; giving as well as receiving--these are the foundations of future nursing home care.
Are you prepared?
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 email@example.com or by visiting www.ideasconsultinginc.com and www.ideasinstitute.org.
(1.) Hendy HM. Effects of pet and/or people visits on nursing home residents. Int J Aging Hum hum (hum) a low, steady, prolonged sound.
venous hum a continuous blowing, singing, or humming murmur heard on auscultation over the right jugular vein in the sitting or erect position; it is Dev 1987;25(4):279-91.
(2.) Martin-Cook K, Hynan L, Chafetz PK, Weiner MF. Impact of family visits on agitation in residents with dementia. Am J Alzheimers Dis Other Demen 2001;16(3):163-66.
(3.) Noelker LS, Poulshock SW. Intimacy This article or section may contain original research or unverified claims.
Please help Wikipedia by adding references. See the for details.
This article has been tagged since September 2007. Factors affecting its development among members of a home for the aged. Int J Aging Hum Dev 1984;19(3):177-190.
(4.) Johnson D. Restraint-free care: A look back. Nursing Homes/Long Term Care Management 1995;44(7):26-30.
RELATED ARTICLE: The Restraint-Reduction Movement
We used to think it was okay--even a sign of good care--to tie people to their wheelchairs. After all, if we let them walk they might elope e·lope
intr.v. e·loped, e·lop·ing, e·lopes
1. To run away with a lover, especially with the intention of getting married.
2. To run away; abscond. and get lost, hurt or even die before we could find them. Or they might fall. And because they would try to get out of their chairs, we often put these chairs, with the brakes on, across from the nursing station so staff could easily monitor them. We kept the restraints on, long after these residents were no longer independently mobile--and after they had stopped trying to get out of their chairs. This practice was widespread throughout the industry and condoned by the regulators. Indeed, in 1989, restraint usage was the accepted practice for more than 50% of all nursing home residents. (4)
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 cod·i·fy
tr.v. cod·i·fied, cod·i·fy·ing, cod·i·fies
1. To reduce to a code: codify laws.
2. To arrange or systematize. 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 thinking, and there are still some caregivers who feel that restraints reflect good care practices. But most of us in the long-term care long-term care (LTC),
n the provision of medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders. field now firmly believe in the underlying principles of this "new" approach that once seemed so radical.
Margaret P. Calkins, PhD