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© 2010 Jones and Bartlett Publishers, LLC

© 2010 Jones and Bartlett Publishers, LLC


Chapter 7

Organization, Environment, and Culture Change

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Introduction - 1

  • Health policy promoted nursing home environments patterned after hospitals
  • Medicare rules viewed nursing homes as a place for post-hospital convalescence
  • Clinical organization followed the hospital-based medical model

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Introduction - 2

1980s and beyond:

  • Emphasis on residential and aesthetic features was triggered mainly by market competition
  • To attract private-pay patients
  • Competition from emerging assisted living facilities

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Introduction - 3

  • New choices and alternatives to traditional nursing homes have molded people’s expectations
  • Many facilities now have contemporary architectural features that offer homelike living environments
  • Yet, clinical needs are addressed while improving both quality of care and quality of life

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Introduction - 4

  • Many nursing homes are adopting person-centered care and other aspects of culture change
  • These aspects will drive nursing homes of the future

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Philosophy of Care in Transition - 1

Traditional treatment philosophy in health care:

  • Parson’s sick-role model
  • Promotes an institutional orientation
  • Patient relinquishes individual control
  • Four outcomes:

Rigid daily routines

Social distance

Depersonalization

Blocking routines

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Philosophy of Care in Transition - 2

Philosophy of person-centered care (also emphasized in the Affordable Care Act):

  • Guided by 3 main principles (see Figure 7-1)

Socioresidential component emphasizes amenities, privacy, and opportunities for individual interests to be balanced with social interaction and engagement

Highly individualized clinical care that incorporates evidence-based practices

Overarching human factors

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Philosophy of Care in Transition - 2

Philosophy of person-centered care (also emphasized in the Affordable Care Act):

  • Guided by 3 main principles (see Figure 7-1)

Socioresidential component emphasizes amenities, privacy, and opportunities for individual interests to be balanced with social interaction and engagement

Highly individualized clinical care that incorporates evidence-based practices

Overarching human factors

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Person-Centered Care

Main characteristics:

  • It creates a holistic environment
  • Control is shared between the patient and caregivers (versus sick role)
  • Patient’s autonomy and decision making are enhanced
  • Equal weight to promoting quality of care and quality of life

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Challenges to a Full Integration - 1

  • Primacy of clinical care
  • Facility’s primary duty
  • The sick role cannot be dispensed with entirely
  • Economic necessity
  • Facilities must function efficiently
  • Provide care to a large number of patients

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Challenges to a Full Integration - 2

  • Patient-related constraints
  • Behavioral issues and conflict
  • Patient’s own condition limits choice and decision making
  • Regulatory burden
  • Paranoia of the regulatory system
  • Industry has been slow to respond to what clients want
  • However, the industry has taken innovative steps

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Challenges to a Full Integration - 3

  • Conflicting rights
  • Perfect integration of clinical, socioresidential, and human factors is almost impossible
  • Balance and compromise become necessary
  • What each resident wants may conflict with what other residents may want
  • Some patients wander into other patients’ rooms
  • Yelling noise and combativeness by some disrupt the quality of life for others

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Nursing Home Organization

Organizational chart: see Figure 7-2

  • Each of the 7 main services is managed by a midlevel department head who report to the administrator
  • The various support services interface with clinical care using a multidisciplinary approach

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Clinical Set-Up

Traditional clinical set-up in the majority of nursing homes

  • Nursing units
  • Nursing station
  • Location
  • Furnishings: nurse call systems, medical records, pharmaceuticals room

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Nursing Units

A self-contained wing or section of a facility

Nursing station, bathing rooms, dining rooms, lounges, linen closets, soiled-utility areas

Odor control: enclosed soiled-utility, ventilation, waste elimination, sanitation. No chemical deodorizers.

Segregating patients based on clinical criteria is not always practical

Separate specialized care units are common for subacute and Alzheimer’s care

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Nursing Station and its Location

  • Hub of clinical care
  • Centrally located to serve a nursing unit
  • Located to provide adequate supervision
  • Often adjacent to the nursing station are bathing rooms, special dining areas, and lounges for smokers

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Nursing Station Furnishings

  • Nurse call systems
  • To summon help when needed
  • Audio-visual and voice capabilities
  • Portable pagers
  • Medical records
  • Separate chart for each patient
  • Automated through information systems
  • Pharmaceuticals room
  • Kept locked to safeguard medications
  • Nursing supplies and first-aid box

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Socioresidential Environment

  • A healing environment
  • promotes adjustment
  • relieves pressures on the clinical component
  • Promotes social compatibilities
  • Two main domains
  • Personal domain
  • Public domain

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Personal Domain

  • Security
  • Safety
  • Wayfinding
  • Autonomy
  • Privacy:
  • Privacy of space, time, and person

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Security

  • Physical safety
  • Psychological peace of mind
  • Freedom from risk, danger, and anxiety
  • Safekeeping of personal property
  • Considerations vary from person to person
  • External security should be evaluated; not all neighborhoods are safe

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Safety

  • Federal, state, and local building codes
  • Life Safety Code
  • Safety practices to prevent falls
  • Elimination or close monitoring of hazards
  • Restricted access to areas such as kitchen and mechanical rooms
  • An individual’s safety concerns should be evaluated and addressed in the plan of care

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Wayfinding

  • Disorientation can result from sameness
  • To minimize disorientation, use:
  • Signage
  • Variations in colors, patterns, furniture styles, pictures, displays, etc.

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Autonomy

  • Self-determination, freedom, independence, liberty of choice and action
  • A patient’s autonomy should not infringe on the rights of others, or expose the person to serious harm
  • Liberty to personalize one’s private space, but without creating hazards
  • Allowing informed choices

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Privacy

Privacy of

  • space
  • time
  • person

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Privacy of Space

  • Shared or private accommodation
  • Double occupancy is the most common
  • Physical space
  • Intimacy:
  • privacy during visits with family, friends, and legal or spiritual counselors
  • sexual intimacy

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Privacy of Time

  • Compromised by clinical and blocking routines
  • Some allowance for preferences is necessary
  • Personal reclusion: some freedom from unwanted intrusion is necessary

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Privacy of Person

  • Dignity, regardless of whether the person can perceive indignities
  • Knocking before entering; closing doors/drawing curtains for patient care
  • Appropriate personal covering
  • Proper grooming
  • Lap robes for females in wheelchairs

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Public Domain

Three critical experiences necessary for relieving isolation and loneliness

  • Compatibility
  • Dining
  • Socializing

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Compatibility

  • Room sharing
  • Dining at the same table
  • Other social activities
  • Bonding with and assisting other residents
  • Bonding with volunteers and staff

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Dining

  • Making it an enjoyable experience
  • Seating arrangements to promote social interaction
  • Clinical and social dining areas should be separated
  • Dining environment
  • Ambulatory and wheelchair patients can sit and dine together

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Socializing

  • Scheduled programs must offer numerous opportunities for socializing
  • Even patients with dementia and other limitations can receive sensory stimulation by just being present
  • Interior and exterior spaces should be used
  • “Main street” concept in modern architectural designs – see Figure 7-3

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Modern Architectural Designs

  • Small private rooms
  • Elimination of long corridors
  • Neighborhood living arrangements
  • High-pitched roofs and fireplaces in lounges
  • Connection of indoor and outdoor spaces
  • Elimination/concealment of nursing stations
  • Household-style kitchens

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Neighborhood (Cluster) Design

  • Household clusters within larger clinical units
  • 12 to 13-bed neighborhoods – Figure 7-4
  • Flexibility in segregating patients
  • Personalized food service
  • High construction costs, but better staff efficiencies are achieved
  • Nurse aide stations are in close proximity to patients; each cluster is self-contained

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Nested Single-Room Design

  • A special design that enables small private rooms to be “nested” to conserve space and construction costs
  • Nested rooms can be part of neighborhood living that provide opportunities for socializing
  • See Figures 7-5 and 7-6

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Aesthetics

  • Necessary for promoting wellbeing
  • Can affect sleep, comfort, mental and emotional health, physical health, and social behaviors

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Lighting - 1

  • Nursing home residents generally suffer from visual impairments
  • Inadequate lighting can lead to depression and falls that can be prevented
  • Glare can lead to agitation, confusion, anger, and falls

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© 2010 Jones and Bartlett Publishers, LLC

Lighting - 2

  • Raise light levels substantially
  • Balance natural and electric lighting
  • Eliminate direct and reflected glare
  • Lighting for seniors should be 25 to 50% higher than normal
  • Even level of lighting reduces glare and decreases shadows
  • Natural sunlight is good for health

© 2010 Jones and Bartlett Publishers, LLC

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Color

  • Pleasing and stimulating colors (soft apricot, peach, salmon, coral, soft yellow-orange, earth tones)
  • Colors and wallcoverings liven up unexciting areas.
  • Colors can be used for wayfinding and to promote safety: high-contrast colors. E.g., color contrasts in bathrooms

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Noise

  • Noise levels in US nursing homes were found to be in the range of 50-70 dBs
  • Recommended levels are below 45 dB during daytime and 35dB at night
  • Noise reduction:
  • Acoustical ceiling and wall products; sound proofing resident rooms
  • Lined drapes, wall-hung quilts, sound absorbing panels, place mats on dining tables, rubber tips under tables and chairs, limiting overhead paging, restricting use of cell phones, closing doors

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Furnishings

  • Carpeting adds warmth and softens sound
  • Carpeting can cushion falls
  • Moisture barriers and antimicrobial coating
  • But, not appropriate for all areas
  • Slip-resistant tile is most widely used
  • Resilient flooring and soft-surface flooring are options
  • Coated upholstered furniture
  • Super fabrics, such as Crypton

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Enriched Environments

Theoretical foundations:

  • Biophilia framework
  • Theory of thriving

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Biophilia

  • Affiliation with nature
  • Can be both indoors and outdoors
  • Plants, animals, water, and soil
  • Positive mood and mental restoration as well as physical benefits

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Theory of Thriving

  • Living life to the full
  • Three entities: the person, human environment, nonhuman environment
  • Engaging, supportive, and harmonious relationships between the 3 entities enhance physical, mental, social, and spiritual well-being
  • Discordance results in failure to thrive

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Principles of Enrichment

  • The 3 elements of person-centered care must be integrated
  • Moderate degree of positive stimulation and distraction. Negative distractions (abstract art, uncontrolled noise, etc.) are stressors
  • An environment for thriving includes opportunities for solitude, introspection, spiritual contemplation, and study, but also active engagement in meaningful relationships

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Culture Change - 1

Definition:

A gradual transformation of the traditional nursing home environments and care processes driven by the sick-role model to the ones that promote person-centered care in enriched environments.

Culture change affects residents, direct care staff, management, and the physical environment

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Culture Change - 2

Culture change is achieved by blending:

Integration of the 3 elements of person-centered care

Creation of an enriched environment

Decentralized management and empowerment of associates. Practice of consistent assignment is recommended.

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The Pioneer Network

  • A formal organization that has evolved into a growing national movement
  • Advocates culture change
  • Provides education and advocacy to influence public policy
  • As a result, state governments and the CMS have endorsed the principles of culture change

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How to Bring About Culture Change

  • There is no single model
  • Numerous possibilities that can vary from facility to facility
  • A good starting point is to change management practices and start implementing one of the 3 key factors
  • Training of staff and management and educating residents and families
  • Changes in physical environment can follow

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Contemporary Models:
Eden Alternative

  • Therapeutic values of pets and humans, opportunities to care for others, and spontaneity
  • To banish loneliness, helplessness, and boredom
  • Based on 10 principles (see Exhibit 7-1)
  • Use of alternative therapies (massage, aromatherapy)

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Contemporary Models:
Green House Project

  • Small group environment: freestanding cottages
  • No nursing stations and medication carts needed
  • Ceiling transfer lifts
  • Natural outdoor activities are emphasized
  • Cross-trained associates give care, cook, and clean
  • Skilled nursing staff located in a separate building do visits (visitor’s role)
  • Clinical practice guidelines are employed

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Environment for Dementia Patients

  • Small groupings and small-scale living
  • Moderate stimulation from the environment
  • Stressors lead to dysfunctional behaviors (unpleasant sounds, intense lighting, bold colors)
  • Protected pathways for wandering
  • Residential kitchens and laundry
  • Nature-related activities
  • Pet therapy

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