Assignments

Chapter 7

Organization, Environment, and Culture Change

What You Will Learn

•  Delivery of care in long-term care facilities has been making a transition from the medical model used in hospitals to contemporary building designs, philosophies of care, and practices that spotlight person-centered care.

•  Person-centered care must integrate three major components: socio-residential, clinical, and overarching human factors.

•  Nursing homes encounter several challenges to a full integration of the three main components. The challenges include need for clinical care, economic necessity, patient-related constraints, regulations, and conflicting rights. Yet, compromises must be achieved.

•  A nursing home is organized by departments, but a multidisciplinary approach that works across the various departments is essential.

•  The clinical organization of a nursing home includes nursing units and adequately staffed and well-equipped nursing stations.

•  The socioresidential environment should emphasize both personal and public domains. These domains emphasize security of person and property, safety against potential hazards, wayfinding, autonomy and self-determination, personal privacy, compatible relationships, the dining experience, and opportunities for socializing.

•  Modern architectural designs, such as neighborhood design and nested single rooms, emphasize many of the socioresidential factors.

•  Aesthetics are an important element of homelike environments that also promote a sense of well-being. Lighting, colors, noise reduction, and furnishings require special considerations in creating therapeutic environments for nursing home residents.

•  Enriched environments incorporate the theories of biophilia and thriving. These environments must provide a moderate degree of positive stimulation and also opportunities for silent contemplation and inner reflection.

•  Culture change is a growing movement that will characterize future nursing homes. Culture change requires person-centered care, enriched environments, and staff empowerment based on adoption of new mindsets for managing people.

•  The Eden Alternative and the Green House Project are two contemporary models of culture change.

•  Environments for dementia patients are based on the modern concepts of creating enriched environments.

Introduction

The internal environment and organization of nursing homes traditionally evolved as both a direct and indirect result of health policy, which promoted an environment patterned after hospitals. As hospital building codes were adapted for nursing homes during the 1960s, hospital-like long corridors, shared occupancy, and cafeteria-style dining rooms became the norm in nursing home construction. Licensing and certification rules further reinforced the hospital design because the nursing home was viewed as a place where convalescent treatment would continue following discharge from hospitals, as laid out in Medicare rules. Clinical organization in nursing homes also followed the hospital-based medical model, with central nursing stations, buzzers, and call signals; noisy shower and bathing areas; lack of privacy; scheduled routines; and hallways cluttered with medication carts, soiled linen hampers, food carts, housekeeping carts, and similar items.

During the 1980s and beyond, construction of new nursing facilities and renovation of existing ones began emphasizing residential and aesthetic features. These changes were triggered mainly by market competition, which created the need to attract new patients to keep the beds filled and also cater to the private-pay clientele. Competition also came from the emergence of modern assisted living facilities.

It took some time for nursing home professionals and regulators to fully grasp the fact that, unlike hospitals, a nursing facility is both a clinical and a social establishment. Unlike hospitals, patients stay in nursing homes for extended periods of time. For some, the stay is permanent and, in a sense, the nursing home becomes their home. Hence, new choices and alternatives to traditional nursing home care have molded people’s expectations about long-term care (LTC), and have influenced a gradual transformation from traditional hospital-inspired facilities to contemporary architectural features that have homelike living environments. Yet, at the same time, patients’ clinical needs are addressed while improving both quality of care and quality of life.

Many nursing homes across the United States, and indeed, in many developed nations, are adopting a culture change. As a result, tomorrow’s nursing homes will be much different than what they are today as person-centered care and other aspects of culture change become the centerpieces in long-term care delivery.

Philosophy of Care in Transition

Traditional methods of treating patients in health care institutions have been driven by the  sick-role model  explained by Parsons (1972). The patient is expected to relinquish individual control to medical personnel and comply with their directives. The sick role promotes an institutional orientation to patient care, which is manifested in four ways: (1) rigid daily routines; (2) social distance between staff members and the patient; (3) care practices that lend to depersonalization, such as loss of privacy; and (4) “blocking routines” that require patients to do certain things at prearranged times, mainly for the convenience of staff (Kruzich & Berg, 1985).

Although patients are admitted to skilled nursing facilities primarily to receive therapeutic interventions, increasing emphasis is being placed on care delivery according to the philosophy of  person-centered care , which integrates physical layout and design with empowerment of the residents and their families. It requires a focus away from what is best for the organization to what is best for the patient. It requires a commitment to treating each patient as an individual, not as products in an assembly line. Even the Affordable Care Act puts emphasis on creating environments of person-centered care (Grabowski et al., 2014).

The contemporary philosophy of person-centered care (also called resident-centered care or client-centered care) in modern nursing facilities is guided by three main factors ( Figure 7–1 ):

•  The socioresidential component creates the physical environment in which the resident receives room-and-board services and considers the nursing facility as his or her home. Various amenities, such as personal and social spaces, aesthetic décor, and various conveniences such as a barber/beauty salon, are incorporated into facility designs. Privacy, opportunities to pursue individual interests, and leisure are balanced by social interaction and engagement. Meals not only meet the nutritional and therapeutic needs but are also palatable and attractively served.

•  The elements of clinical care (listed in Figure 7–1) are highly individualized. Care is delivered in accordance with prevailing standards that incorporate evidence-based practices.

•  The overarching human factors—autonomy, independence, dignity, and self-esteem—blend into every aspect of the patient’s life and the delivery of services. Such integration is not achieved without ongoing staff training.

When human factors are integrated into the other two components, it creates an environment in which a person’s physical, mental, social, and spiritual needs are met. In sharp contrast to the sick-role model, person-centered care is characterized by shared control between the patient and the facility personnel. It promotes individual autonomy and decision making, even when a resident’s decision-making capacity is limited. It gives equal weight to promoting quality of care and quality of life.

Challenges to a Full Integration

Integration of the three components will continue to be a challenge for nursing home professionals. Just as it is with improving the quality of care, the goal of achieving person-centered care is never fully realized, but it becomes an endless pursuit. This is because five main challenges present an ongoing struggle: primacy of clinical care, economic necessity, patient-related constraints, regulatory burden, and conflicting rights. Successful juggling through these challenging aspects is what sets apart an effectively managed facility from the mediocre ones.

Figure 7–1  Main Components of Person-Centered Care

Primacy of Clinical Care

The fundamental purpose of a nursing home is defeated if it does not provide clinical care in accordance with up-to-date standards, best practices, and use of appropriate technology, while also complying with regulatory requirements. The sick-role model can be compromised but cannot be entirely dispensed with. For example, giving medications and other treatments in a patient population of any size requires certain routines based on medical directives. Medical examinations result in some loss of personal control by the patient. Necessary staff assistance with daily living activities does create some dependency and loss of autonomy.

Economic Necessity

Nursing facilities exist because of economic necessity. If it were feasible, almost every nursing home patient would choose to be cared for in a private residence by a private-duty nurse. The reality, however, is that unless an individual is very wealthy, neither the individual patient nor the society can afford to incur the expense that private-duty care would entail. Expensive as it is, delivery of care in a nursing facility is highly cost effective compared with private-duty nursing. A nursing home must, by necessity, provide services to a relatively large number of patients 24/7. Hence, the fact remains that nursing facilities must function as efficient organizations.

Patient-Related Constraints

Nursing homes face constraints related to patient characteristics. Examples include behavioral problems, such as frequent combativeness or screaming episodes that can disrupt the environment. By its very nature, any group living arrangement creates an environment in which small-scale conflicts of everyday life are likely to occur. First, respecting autonomy can be “vexatious because the conditions that bring elders into long-term care—confusion, dementia, wandering, and a host of chronic conditions associated with being old—are such that the very capacity for choice and rational decision making is seriously compromised, if not absent” (Agich, 1995, p. 113). Yet, a conscious effort must be made to return to the elder patient some of the responsibilities for his or her own health care in a caring and respectful way.

Regulatory Burden

The nursing home industry particularly views the regulatory process to be onerous, adversarial, and punitive. As a result, the culture of nursing home administration has suffered from paranoia of the regulatory system. Inadequate financing under Medicaid, the largest payer for nursing home care, is also seen as a major constraint to procure needed resources. Historically, the nursing home industry’s response has been largely reactive, mainly to protect itself against possible regulatory sanction (Collopy, 1995, p. 149). However, the industry has been evolving by gradually abandoning its highly risk-averse stance and adopting innovative approaches to create organizations that are most desired by its clients. The culture change, discussed later in this chapter, is an effort in this direction initiated by the industry’s leadership, not by any regulatory requirements. Yet, adoption of person-centered care and culture change are not pervasive, and regulatory oversight is here to stay.

Conflicting Rights

A perfect integration of clinical, socioresidential, and human factors is almost impossible. In person-centered caregiving, balance and compromise are often necessary. The nursing facility can help with the process of adjustment. Familiarity and closeness in the caregiver–patient relationship that is built on the foundation of respect for the patient can also help patients maintain their sense of identity despite the ravages of impairment (Agich, 1995). In a nursing facility, each resident’s desires, interests, and rights can directly affect the interests and legitimate expectations of other residents (Arras, 1995). For example, patients who wander into others’ rooms, rummage through others’ belongings, dip their hands into other diners’ plates, make yelling noises, or display combativeness disrupt the quality of life of other residents. To deal with such conflicts in an institutional setting, the facility must try to achieve an appropriate balance among the needs and rights of different groups. In a social environment, no one patient’s interests are legitimately outweighed by the competing interests of other patients. Hence, appropriate interventions and compromises often become necessary.

Nursing Home Organization

An organizational chart showing the main service departments in a typical skilled nursing facility is illustrated in  Figure 7–2 . In midsized facilities, each of these services is managed by a midlevel department head who reports directly to the administrator.

Figure 7–2  Organizational Chart of a Typical Skilled Nursing Facility

The various support services are adjuncts to the central nursing care process and interface with clinical care using a multidisciplinary approach that works across the various departments. Building a multidisciplinary team requires the administrator’s involvement, and the administrator must develop an organizational culture of interdepartmental communication and cooperation to address patient needs in a holistic system of care.

In an integrated multidisciplinary approach to patient care, professionals who provide medical, nursing, social services, recreational activities, and dietary services share their observations, discuss clinical goals, and develop interventions in which a variety of services interface. Professionals in each discipline are aware of what others are doing to address the multifaceted needs of each patient. Using an individualized plan of care for each patient, the overarching goal is to address all aspects of a patient’s needs without duplicating or disregarding any needs.

Clinical Set-Up

The vast majority of nursing homes use a traditional clinical set-up. Many newer facilities that are being built use innovative design concepts to tone down the clinical organization.

Nursing Units

A nursing unit or wing is a section of a facility that consists of a certain number of patient rooms served by a nursing station. Depending on its size, a facility may have clinically distinct nursing units, each providing a somewhat distinct level of care, such as rehabilitation, dementia care, or specialized care. Distinct nursing units can also be designated according to the type of certification. To achieve staff efficiency, most clinical units are self-contained, having their own bathing rooms, linen closets, dining or feeding rooms, and lounges for patients and visitors. An enclosed area or a hallway nook for depositing soiled linens is located in the unit, with marked containers to ease sorting and to separate lightly soiled and heavily soiled linens. When utility closets are easily accessible to staff, hallways are kept free of clutter, and odors are kept to a minimum. An enclosed soiled utility area, rather than a nook in the hallway, is ideal because it can be equipped with a rinse tub to eliminate heavy wastes. Modern ventilation and waste-elimination systems are designed to keep odors to a minimum. Also, staff members should be trained in sanitation and odor control methods. Chemical deodorizers should not be used to mask odors.

When a facility has more than one nursing unit, it can segregate patients on the basis of clinical criteria. However, neatly categorizing patients in terms of their needs for care is not always practical. Comorbidities often present a challenge to LTC clinicians about where a patient with given health conditions can be best accommodated. Yet, facilities must give due consideration to each patient’s clinical needs as well as quality of life. Distinctly separate specialized care units are often provided for subacute care or Alzheimer’s care. Such specialized units allow the facility to match staff skills to special patient needs. Rehabilitation aides (paraprofessionals who follow up on rehabilitation therapies), for instance, are most appropriately stationed in the skilled nursing facility unit where most of the Medicare patients are located. A separate nursing unit, however, is not generally feasible for every type of specialization. Several clinically complex services such as ventilator care, head trauma care, care for spinal injuries, and treatment for pressure ulcers and wounds can be located on one unit that is served by the same nursing station.

Nursing Station

The hub of clinical care is an appropriately located, adequately staffed, and well-furnished nursing station. This station can be regarded as a service center from where all nursing care is delivered to a certain number of patients, generally on an entire nursing unit.

Location of Nursing Stations

A nursing station should be centrally located to enable the nursing staff to observe and supervise a certain number of patient rooms and to respond effectively to patient needs. As a general rule, a separate nursing station serves each clinical unit or wing in a facility.

Adjacent to the nursing station are rooms for bathing and showering, special dining areas to accommodate patients who need assistance with eating, and patient lounges, including any lounges designated for smokers. Of course, not all patient dining rooms and lounges need to be in the vicinity of a nursing station—only those where supervision from staff is necessary.

Nursing Station Furnishings

The layout and furnishing of a nursing station should enhance staff effectiveness. The station itself is an enclosed area, with a counter behind which nurses and other staff members perform administrative tasks. To protect the confidentiality of patient-related information, no one but authorized staff members should have access to the area behind the counter. Among other things, a nursing station’s furnishings must include three important components: a nurse call system, medical records, and a pharmaceuticals room.

Nurse Call Systems    A call system connects devices at all patient bedsides and in toilets to the nursing station and to pocket pagers carried by individual caregivers assigned to those patients. It should also connect the station to the bathing and shower rooms, dining areas, and lounges located on a given nursing unit. The system enables the patients themselves and staff members working with patients to summon help when needed. The most commonly used systems have audiovisual as well as voice capabilities. A patient uses a sensory device—such as a call button—that sets off the audiovisual signal at the nursing station. A voice or “talk-back” feature allows the staff member attending to a patient to communicate with staff members located at the station; this device saves time that otherwise will be spent walking back and forth from the nursing station. Modern wireless communication devices such as portable pagers have eliminated the need for buzzing sounds at nursing stations and frequent overhead paging, which make the environment noisy and stressful.

Medical Records    Located at the nursing station, there must be a separate medical chart for every patient on the unit. Medical records are increasingly being automated by implementing electronic health records. Automation can greatly facilitate the tasks of keeping records up to date and retrieving them quickly. Privacy practices must comply with HIPAA standards.

Pharmaceuticals Room    The pharmaceuticals room, or medication room, as it is commonly called, should be quickly accessible from the nursing station. This room is locked to safeguard all medications. The pharmaceuticals room is also used to store nursing treatment supplies and a first-aid box.

Socioresidential Environment

A nursing facility is a community in which the social and residential elements are closely intertwined. The environment itself should promote the healing of the body, mind, and spirit. A healing environment relieves the clinical infrastructure of pressures that might otherwise be imposed on it from social conflict or individual ill-adjustment. As mentioned earlier, segregating patients with severe dementia and those with behavioral problems reduces stresses in an environment that can otherwise be disruptive from commotion and confusion. The facility’s set-up should also make it easier for patients to explore their compatibilities with others and engage in social interactions in accordance with personal preferences. The socioresidential environment should emphasize both personal and public domains.

Personal Domain

At a personal level, the main concerns people have are security, safety, wayfinding, autonomy, and privacy. To adequately cope with change, individuals need opportunities for introspection, a sense of personal space, and support from professionals.

Security

Security is a basic human need. It entails physical safety and psychological peace of mind. It includes a variety of conditions that contribute to freedom from risk, danger, anxiety, or doubt (Schwarz, 1996). A nursing facility is responsible for its residents’ personal security and the safekeeping of their belongings and private funds if the latter are deposited in a resident’s trust account that the facility manages. Security considerations often vary from one patient to another. A patient may have a tendency to wander out unnoticed and compromise his or her safety. But if this same person can wander out into a protective environment, such as a fenced-in walkway surrounded with plants and flowers, it can have a therapeutic effect. Another may insist on wearing expensive jewelry that someone could remove or that could get lost. Another may hallucinate and imagine that someone is assaulting her.

Not all nursing homes are located in safe neighborhoods, particularly in large cities. The administrator must evaluate both external and internal security concerns, which include protecting residents and their property from intruders. To the extent that patients feel safe and secure, they can choose to spend time indoors and outdoors.

Safety

Building design is primarily governed by federal, state, and local codes and regulations. Among these, the Life Safety Code® provides the most comprehensive set of rules. However, creation of a safe environment goes beyond compliance with the Life Safety Code®. In 2009, an environment that was not free of accident hazards was the most cited deficiency nationally (Harrington et al., 2010). Hence, several considerations are important in creating a safe environment:

•  The elderly are particularly vulnerable to falls. Great caution and vigilance needs to be exercised around wet floors, power cords, and throw rugs.

•  Potential hazards should be eliminated or closely monitored. Access to products such as drugs, lotions, and ointments on medication and treatment carts should be adequately supervised. Patients could also gain access to other unattended toxic substances, such as cleaning chemicals left unattended on housekeeping carts, or sharp objects, such as certain maintenance tools.

•  Access to areas such as the kitchen, mechanical rooms, and laundry are generally prohibited. However, with some supervision, cooking/baking or laundry activities can provide stimulating and meaningful engagement for some patients, including those with mild to moderate dementia. For this purpose, small household-style kitchens can be included in the facility’s design.

•  All major safety concerns should be incorporated into the patient’s plan of care. The patient may require therapeutic intervention from trained staff. For example, a person’s medications may need to be reviewed or behavior modification may be necessary.

Wayfinding

Wayfinding  refers to features that can help people find their way through a large institution with relative ease. Residents in nursing homes are often susceptible to disorientation because of a decline of various senses. Sameness and repetition—similar layouts, regular pattern of doors, and similar furniture throughout a facility—are the common sources of disorientation (Drew, 1992). Orientation involves much more than use of signs. In addition to clear and readable signage, wayfinding can be facilitated by using a variety of means such as employing different color schemes; change of patterns in different sections of the facility; color-coded handrails; varying furniture styles; varying layout and arrangement; and use of pictures, tapestry, hanging quilts, and window displays. On the other hand, doors leading to utility rooms and areas not meant for residents should be painted to blend with the adjacent walls.

Autonomy

Autonomy  can be defined as “a cluster of notions including self-determination, freedom, independence, and liberty of choice and action. In its most general terms, autonomy signifies control of decision making by the individual. It refers to human agency free of outside intervention and interference” (Collopy, 1988). Because health care by its very nature creates dependency, caregivers must make deliberate efforts to maximize the preservation of patient autonomy. On the other hand, a patient’s autonomy cannot be taken to an extent that it infringes on the rights of others or exposes the patient to serious harm.

Autonomy for patients also requires that they be allowed to personalize their rooms with familiar things, including such personal items as radios, small television sets, family pictures, mementos, artifacts, plants, music, personal furniture, and bed accessories. Emotions and memories from past experiences and events often stimulate conversation and social interaction. Although space is almost always limited, a display shelf in each room can help people personalize their space by displaying memorabilia and other items. On the other hand, certain personal belongings may pose safety concerns. For instance, too many electrical gadgets may overload the circuits and create a fire hazard. Long extension cords and floor rugs pose a tripping hazard.

Autonomy also means that a patient must be able to make informed choices. Although the nursing facility must encourage informed choice, it also has the responsibility to do what is in the patient’s best interest. Occasionally, conflicts may arise between a patient’s autonomy and the facility’s duty toward the patient. Such conflicts should be resolved by taking into consideration legal requirements, regulatory constraints, and ethics.

Privacy

Almost all individuals require some privacy in terms of space, time, and person.

Privacy of Space    In a health care facility, privacy of space is first determined by the type of accommodation: private or shared. Many facilities maintain a small number of private rooms for single accommodation. As a general rule, however, occupying a private room is considered a luxury for which someone has to pay more. Unless a medically determined need exists for private accommodation, public as well as private insurers do not cover it. So, in most instances, a patient must spend out-of-pocket funds if a private room is desired. Hence, for most patients, shared accommodation is the norm, which in most facilities constitutes double occupancy (rather than triple or quadruple accommodation). In these circumstances, privacy rests on how much physical space each individual has, including closet and storage space. Privacy also entails the need for intimacy (Westin, 1967).  Intimacy  refers to a person’s privacy during visits with family, friends, and legal or spiritual counselors. Residents can also express their sexuality in a private environment. Because privacy is generally compromised in a multiple-occupancy setting, the facility should provide secluded areas that may be used for intimate dining experiences with family and friends, for private visits, or for sexual intimacy.

Privacy of Time    Privacy of time is often compromised by clinical routines that are established for the sake of staff efficiency or convenience. However, such routines tend to make patients’ lives regimented. In many nursing homes, wake-up and morning hygiene chores must be completed before breakfast. Because assigning staff members to every resident at the same time is not possible, certain residents must wake up before others, and there may be little provision for patients to sleep late. Meal hours are also generally fixed. Bathing and shower routines are scheduled ahead of time. Yet, within the parameters of such scheduled routines, patients’ individual preferences should be accommodated whenever possible. Privacy of time also includes the need for personal reclusion, that is, have time for oneself and be free from unwanted intrusion, to be alone for quiet reflection. For this purpose, quiet and secluded spaces such as small libraries and chapels are highly desirable.

Privacy of Person    Privacy of person can be equated with dignity. A basic rule for facilities to follow is to treat every person with dignity, regardless of whether he or she can perceive indignities (Kane, 2001). Knocking at the door before entering a patient’s room, closing the door for a patient while that patient is using the toilet, drawing privacy curtains during treatment, providing appropriate personal covering for a trip to the common bathing and shower area, providing proper grooming during a trip to the therapy room or dining room, and giving lap robes to female residents in wheelchairs are examples of how personal privacy is respected to preserve individual dignity.

Public Domain

Loneliness and isolation are common concerns among the elderly. Unless a person chooses to remain alone, opportunities must be provided for wholesome social interaction. The range of opportunities depends on how well a nursing facility functions as a social community. The three most important experiences from this perspective are compatibility, the dining experience, and socializing.

Compatibility

Social interactions in the public domain are primarily driven by compatibility because compatible relationships are something people naturally seek. The issue of compatibility first arises when a new patient is admitted to the facility and has to share a room with another resident who is a complete stranger. Gender compatibility has been a long-established practice. Room sharing by two individuals of the opposite sex is permitted only in the case of legitimate couples. Apart from such obvious types of compatibility, the main consideration in assigning a room to two people is how well the two individuals are likely to get along and engage in a meaningful social exchange. Compatibility is also an important consideration in other situations requiring social groupings, such as dining at the same table or participating in social and recreational events.

Relationship building and bonding can be facilitated in several ways. Some nursing home residents assist other residents with simple tasks, such as escorting a friend to the dining room or assisting someone in a wheelchair. People who have disabilities of their own can find meaning in being helpful to others; it builds their own self-esteem. Nursing home residents can also develop appropriate relationships with volunteers and staff members.

Dining

Meal time should be an enjoyable experience. Seating arrangements should be such that they create opportunities for those who can socially interact. Of course, a patient’s clinical condition will determine to what extent interaction is possible. For patients who require feeding assistance or who may have other special needs, dining may become a clinical event, but staff interaction can still help make it a social event. To the extent possible, clinical dining areas for those who cannot eat on their own should be separated from social dining areas so that those who are able to dine in a social setting can enjoy the dining experience without interruption or distraction.

The dining environment should be relaxed. Comfortable chairs, tablecloths, placemats, cloth napkins, table centerpieces, and soft music contribute to a relaxed and enjoyable experience. A facility should also have some special tables to accommodate wheelchairs, but ambulatory and wheelchair patients can sit and dine together.

Socializing

The facility must schedule programs that offer numerous daily opportunities for residents to socialize according to their personal interests. Social events also enable patients with dementia and other limitations to receive sensory stimulation by just being present. Events should be held in both interior and exterior spaces.

Interior spaces include lounges, dining areas, craft and game rooms, and chapels. Some modern facilities also have spaces such as mini malls, ice cream parlors, and barber and beauty shops where residents can enjoy some of the social activities they once pursued. One example of modern architectural designs for senior care environments includes the concept of “main street,” in which a common area opens into large interior volume spaces that have façades with exterior building appearances (see  Figure 7–3 ). In some designs, a chapel can have the look of a church, a meeting space can appear as a town hall, and food service operations can look like a sidewalk café. Such features can give residents the feeling of going out to dinner, church, or other event (M. Milligan, personal communication, March 19, 2014).

Exterior spaces include courtyards, patios, balconies, terraces, vegetable and flower patches, gazebos, and spaces around bird feeders and fountains. The building’s design should permit all residents easy access to the exterior. The outdoor spaces should have appropriate seating arrangements so that the residents can spend time relaxing, socializing, and simply enjoying the surroundings.

Figure 7–3  Illustration of the “Main Street” Concept. Towne Center Community Campus, Avon, Ohio

Reproduced with permission from JMM Architects, Inc., Columbus, Ohio. Courtesy of Mike Milligan.

Modern Architectural Designs

The average size of a nursing facility increased by 44% from 75 beds in 1973 to 108 beds in 2006 (National Center for Health Statistics, 2007). Although the larger size creates operational efficiencies, it detracts from a residential environment. In response, some architects have created innovative facility designs that strike a balance between the clinical and socioresidential factors. Increasingly, in new constructions, private rather than shared rooms are in vogue to give patients more personal space. In addition, current architectural designs no longer feature the traditional long corridors that are lined with rooms on both sides, which often get cluttered with all kinds of barrels and carts and create an institutional look and feel. High-pitched roofs, creation of neighborhoods rather than hallways, use of natural light, installation of fireplaces in lounges, and the connection of indoor to outdoor spaces can make a building seem more like a home than an institution. In some cases, the medical character of the facility can be deemphasized by even eliminating the traditional nursing station. In large institutions, some smaller self-contained units can be created, each with its own household-style (family) kitchen and a common room that can serve as a multipurpose room for dining, activities, and socializing.

Neighborhood Design

Also referred to as a cluster design, it places decentralized self-contained neighborhoods, or “household clusters,” within the larger clinical units, creating relatively small residential groupings. Each neighborhood may have its own living and dining spaces, and may also include a “family kitchen.” Cluster designs practically eliminate the traditional long corridors, and offer better flexibility in segregating residents than traditional layouts do. For instance, patients requiring heavy care could be accommodated in the same cluster. Small groupings of residents are also desirable in short-term rehabilitation units and dementia units. Neighborhoods allow food service to be more personalized with small serving kitchens adjacent to dining spaces. Food can be served on plates rather than trays, and allows caregivers to accommodate individual requests quickly and easily (M. Milligan, personal communication, March 19, 2014).

Figure 7–4  illustrates adjoining 12 to 13 bed neighborhoods. High construction costs for clusters present a major challenge to facilities, although better functional efficiencies are often gained. By decentralizing staff and services and giving associates quick access to utilities, a cluster layout can make associates more productive and the delivery of care can be improved. In some arrangements, small nursing assistant (nurse aide) stations—generally no more than a desk and chair—enable the staff to be in close proximity to residents, allowing for prompt attention to their needs. The self-contained clusters also have their own bathing rooms, linen closets, and soiled utility closets. Associates can function more efficiently because this arrangement shortens walking distances and saves time. Services are brought to each cluster instead of transporting residents to the nursing station, dining room, or therapy room. A group of permanent caregivers assigned to each cluster can also provide opportunities for interaction and bonding between caregivers and residents.

Figure 7–4  Adjoining Neighborhoods in a Cluster Arrangement. Vrable Healthcare Center, Dublin, Ohio

Reproduced with permission from JMM Architects, Inc., Columbus, Ohio. Courtesy of Mike Milligan.

Nested Single-Room Design

To counter the high construction costs of private rooms, the architectural firm of Engelbrecht & Griffin (now named EGA, PC) pioneered the design of nested single rooms. Cost is conserved by efficient use of space. Although nested rooms are much smaller than regular rooms, they are self-contained bedrooms with their own private half-bathrooms that have a toilet and a sink ( Figure 7–5 ). Nested single rooms offer privacy, and when they are placed in a cluster setting, they can also provide opportunities for socializing through “neighborhood living” arrangements ( Figure 7–6 ). Easy access to common lounge areas in the vicinity of the rooms encourages residents to get out of their rooms to meet and converse with familiar neighbors and provides a comfortable setting for visiting with family and friends.

Figure 7–5  Overhead One-Point Interior Perspective of Nested Rooms

Reproduced with permission from EGA, P.C. “Designs for Living.”

Aesthetics

Aesthetics are necessary to promote a sense of well-being. Light and color, for example, influence patients’ sleep, wakefulness, emotions, and health. Use of lighting, color, and furnishings create an environment that is both aesthetically appealing and comfortable. Institutions are often noisy places where conscious efforts must be made to reduce noise levels. The physical environment can also affect social behavior and certain clinical outcomes.

Lighting

Vision impairment increases with age. Compared with community-dwelling elders, nursing home residents suffer from far greater visual impairment (West et al., 2003). Inadequate lighting can promote depressive symptoms, and can cause falls that can otherwise be prevented. Glare can lead to agitation, confusion, anger, and falls. Lighting issues in LTC facilities should be addressed by (1) raising light levels substantially, (2) balancing natural light and electric light to achieve even light levels, and (3) eliminating direct as well as reflected glare (Brawley & Noell-Waggoner, n.d.). As a rule of thumb, lighting for seniors should be 25 to 50% higher than normal. Consistency in lighting is also important. An even level of lighting from wall to wall, from floor to ceiling, and from corridor to public and private rooms reduces glare and decreases shadows (Moller, 2008).

Figure 7–6  Partial Floor Plan of Cluster Scheme

Reproduced with permission from EGA, P.C. “Designs for Living.”

Natural sunlight has positive effects on overall health. Facility design should incorporate as much natural lighting as possible while also incorporating artificial light. Chandeliers, wall sconces, recessed lighting, table lamps, floor lamps, and other light fixtures can be incorporated to improve lighting, reduce glare, and enhance the homelike feel. Patios and porches enable residents to enjoy fresh air as well as direct sunlight. Windows, skylights, atriums, and greenhouse windows can be used to bring some of the natural daylight indoors. Low windows in patient rooms, lounges, and corridors allow residents to see the exterior grounds from their beds and wheelchairs. Window treatments should be used to regulate sunlight and minimize glare. Horizontal miniblinds are generally preferable to vertical blinds, but light-filtering pleated shades are considered even better. Valances can enhance the overall décor.

In resident rooms, night-lights are essential. Along with clear pathways to the toilet, night-lights can facilitate safe trips to the bathroom and help prevent falls (Brawley, 1997).

Color

Colors used in health care settings have changed dramatically in recent years. Traditional colors such as white, bold yellow, beige, and green are no longer considered appropriate. More pleasing and stimulating colors, applied in judicious combination, have now become popular. Such colors include soft apricot, peach, salmon, coral, soft yellow-orange, light cinnamon, and a variety of earth-colored tones. Patterns and colors in wall coverings and decorative borders can liven up some otherwise unexciting areas. Bedrooms, bathrooms, dining rooms, living rooms, and alcoves are all appropriate places where wall coverings can enhance residential quality. Coated wall coverings can be used in areas such as hallways, where soiling is a serious problem. Handrails are necessary in hallways and other areas, but a natural wood finish can help maintain the residential look.

Colors can be used to promote wayfinding and safety. Aging reduces a person’s ability to distinguish colors, such as blue, which may appear grey (Moller, 2008). To compensate for this reduced visual function, high-contrast colors should be used. For example, the color of grab bars in the toilet should contrast sharply with the color of the wall, to ensure maximum visibility. Countertop colors should stand out strongly from those of floors. For many nursing home residents, being able to use the toilet may depend on being able to locate it. In a totally white bathroom, some patients will find it difficult to distinguish the toilet from the floor or the adjacent wall. Colored toilet seats create visible contrasts against the surroundings and can facilitate locating the toilet. Conversely, a colored wall can provide visual contrast against a white toilet.

Noise

Unpleasant noise jars, disrupts, and upsets because it lacks meaning and sense (Picker, 2003). Noise reduction may appear to be a matter of common sense, but when caregivers are busy with heavy workloads and numerous demands on their time, common sense may not become so common. Hence, nursing homes need to engage in a conscious noise-reduction program. Bharathan and colleagues (2007) found that noise levels in U.S. nursing homes were in the range of 55–70 decibels (dBs). The Environmental Protection Agency recommends noise levels below 45 dB during daytime and 35 dB at night (Bharathan et al., 2007). Benbow (2013) has suggested a number of measures to reduce noise. Noise mitigating design features can include acoustical ceiling and wall products that reduce echoes, sound proofing resident rooms, and ventilation and heating systems with sound reduction. Other techniques include use of lined drapes, wall hung quilts or sound-absorbing panels, place mats on dining tables, and rubber tips under table and chair legs. Use of alarm and overhead paging systems should be confined to emergencies. Fire drills can be conducted silently, without the use of alarms. Visitors can be asked not to use cell phones inside the facility. Staff can be trained to use lower speaking voices. Closing of doors is one of the most effective methods to reduce noise.

Furnishings

Carpeting adds warmth and softens sounds. It also provides cushioning against falls and can prevent serious fractures of the hip or wrist. Today’s high-performance carpets, which are resistant to stains and odors, are also cost effective. New carpets are treated with a vinyl moisture barrier and an antimicrobial coating (Yarme & Yarme, 2001). Proper installation and regular maintenance can make carpeting last for several years. Of course, carpeting is not appropriate for all areas in the building. Slip-resistant tile is by far the most widely used flooring material. Resilient flooring with low sheen can be used in certain high-use areas without creating an institutional appearance. For example, these hard-surface floorings also come in beautiful wood-grain patterns that add a homelike touch. Also available are new soft-surface floorings that are made of easy-to-maintain sheet vinyl material with a dense, soft, carpet-like surface and a cushioned backing. These materials have been tested to ensure that they reduce injuries from falls (Yarme & Yarme, 2001). Highly polished and buffed surfaces are not recommended for the elderly because they produce glare, appear wet or slick, and can be a source of anxiety and confusion.

A variety of furniture is available that is specifically designed for LTC facilities. Lounge chairs, sofas, and rocking chairs can add charm and variety as well as comfort. Use of upholstered furniture has actually become quite common. Some manufacturers are producing foam cushions that are soft enough to be comfortable and yet firm enough for residents to rise easily from chairs and sofas (Child, 1999). Brawley (1997) commented on several enhancements in high-tech finishing of upholstery fabrics. These include soil- and stain-resistant finishes, lamination with vinyl, fluid barriers, and antimicrobial finishes. For nursing home use, these fabrics must also be flame retardant. “Super fabrics,” such as Crypton, have built-in stain and moisture resistance and have been tested for fire and microbial resistance. These new fabrics have replaced vinyl coverings for chairs and sofas, and a range of colors, textures, and patterns are now available to enhance the residential environment in nursing facilities.

Enriched Environments

The environment is viewed as a “silent partner” in caregiving because it contributes to the healing process (Noell, 1995).  Enriched environments  (or enhanced environments) are physically and psychologically supportive environments that promote positive feelings, harmony, and thriving. They also reduce boredom and stress.

Theoretical Foundations

Creation of enriched environments finds support in two complementary theories: biophilia framework and theory of thriving.

Biophilia Framework

E.O. Wilson, a biologist, coined the term  biophilia  for the human propensity to affiliate with other life forms. In short, it describes the human tendency to pay attention to, affiliate with, and respond positively to nature (Wilson, 1984). People not only have an inborn biophiliac tendency to relate to animals and to natural settings, but people’s relationship with nature is essential to their thriving. Plants, animals, water, and soil are the most common elements of the natural environment (Wohlwill, 1983). Based on an integrative review of the literature, Jones and Haight (2002) reported consistent findings that interactions with the natural environment, which can be experienced both indoors and outdoors, produce beneficial effects in human beings, such as positive mood and mental as well as physical restoration. For instance, a study of hospitalized patients recovering from an appendectomy showed that patients with plants in their rooms had a significantly lower need for pain medication, had lower blood pressure and heart rates, and had less anxiety and fatigue than their counterparts in the control group with no plants in their rooms (Park & Mattson, 2008).

Theory of Thriving

Thriving  means living life to the full. It is also a growth process that occurs as a result of humans interacting in a symbiotic relationship with their environments to enhance their physical, mental, social, and spiritual well-being. According to Haight et al. (2002), the integrative model of thriving includes three elements: (1) the person; (2) the human environment comprising family, friends, caregivers, and others; and (3) the nonhuman environment comprising the physical and ecological surroundings of the person. Thriving occurs when the relationship among the three entities is mutually engaging, supportive, and harmonious. Conversely, a failure to thrive occurs when discordance exists among the person, the human environment, and the nonhuman environment. When thriving occurs, certain critical attributes are noticeable in the person: social connectedness, finding meaning in life, adaptation, and positive cognitive/affective function.

Principles of Enrichment

Enriched environments are created by incorporating three main principles:

•  All three elements of person-centered care (clinical care, socioresidential elements of the physical environment, and overarching human factors) must be integrated, as discussed earlier. In a person-centered environment, care delivery is congruent with the values, needs, and preferences of care recipients (Eales et al., 2001). Health care professionals empower residents to assert their rights and preferences. This empowerment is achieved through a bonding between residents and caregivers who place supreme value on listening to the individual’s preferences while offering professional advice and instruction on the risks and benefits of the choices the resident wants to make. The resident’s freedom to take some risks is respected, but it calls for greater staff vigilance.

•  The environment provides a moderate degree of positive stimulation and distraction. Prolonged exposure to low levels of environmental stimulation can lead to boredom, negative feelings, and depression. In the absence of positive distractions, patients begin to focus on their own problems and end up increasing their level of stress. Positive distractions elicit good feelings, hold attention, and generate interest. Happy faces, laughter, people passing by, pets, fish in aquariums, birds, flowers, trees, plants, water, pleasant aromas, and soothing music can all be positive distractions. Negative distractions, on the other hand, are stressors. They simply assert their unwanted presence because it is difficult to ignore them. Visual stimulation from pictures, artwork, and television watching can be positive for patients, but abstract art and uncontrolled loud noise from television are negative distractions.

•  Thriving is not entirely a function of external stimulus. Thriving also requires solitude, reflection, introspection, spiritual contemplation, study, and a sense of one’s individuality and self-worth. Contemplation and inner reflection often occur in a passive relationship with serene natural surroundings. On the other hand, thriving also requires active engagement in meaningful social relationships, caring for live plants or animals, lending a helping hand to a fellow patient, playing with children, or working on hobbies such as gardening or woodworking. In its ultimate sense, thriving is achieved when a person feels a deep sense of belonging to and connection with the physical environment comprised of people and things, and also feels closeness to a Supreme Being in accordance with one’s own belief system.

Culture Change

The ideas presented in this chapter are at the heart of what has been loosely referred to as “culture change.” As a working definition,  culture change  refers to 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 all organizational levels of the nursing home, including residents, direct care staff, management, and the physical environment (Shier et al., 2014).

Culture change is achieved mainly by blending three key factors. The first two listed here have already been discussed earlier:

  1.  In newer and older facilities alike, culture change begins by integrating the three elements of person-centered care (see Figure 7–1). For example, in the traditional nursing home culture, the resident must comply with schedules and routines preset by the organization. Through culture change, residents and staff design schedules that reflect the residents’ personal needs and desires. For instance, within reason, residents can decide whether they prefer a shower or a bath in the morning or in the evening (Andreoli et al., 2007).

  2.  Creating an enriched environment that offers opportunities for positive stimulation and distraction, minimizes negative distractions and stressors, and also enables residents to find times and places for solitude and reflection.

  3.  Empowerment of associates is the third key element. Culture change requires a new mindset on the part of both management and associates. Empowerment requires a change in management philosophy and practice. As a guiding principle, administrators and department managers start treating their associates as they would want the associates to treat the elders. There is no room for practices that devalue workers, most of whom are women who typically earn just a little above the federal minimum wage. Empowerment also requires a decentralized management approach in which decision making is taken back to the elders, the families, and caregivers; and these stakeholders are given a voice in the elders’ daily routine and life.

Advocates of culture change also recommend adopting the practice of  consistent assignment  whereby caregivers are assigned to the same residents. It is assumed that forming a bond between residents and caregivers may bring increased satisfaction to caregivers and lead to better quality for residents. Consequently, a large number of nursing homes have started to use consistent assignment (Doty et al., 2008). However, research to date has shown inconsistent effects of consistent assignment on quality outcomes (Roberts et al., 2013). Caregiver and resident preferences regarding consistent assignment have also shown mixed results (Rahman et al., 2009). On the other hand, there is some preliminary evidence that consistent assignment may help lower absenteeism and turnover among caregivers (Castle, 2013).

Groundbreaking Work of the Pioneer Network

The Pioneer Network played a critical role in advocating culture change in nursing homes. It began as a grassroots movement of caregivers, consumer advocates, and others who were concerned about the quality of life in even some of the finest conventional nursing homes. Beginning in 1997, nursing home professionals and advocates, referred to as “pioneers,” began informal meetings to define common areas of endeavor and opportunities for bringing about a cultural change in nursing facilities. A few nursing home professionals, who had already experimented with some innovative approaches, were invited to share their experiences with various stakeholders that included regulators, nursing home administrators, directors of nursing, and social workers. Subsequently, regular meetings of the pioneers led to the formation in 2000 of a formal organization, named the Pioneer Network. Since then, it has evolved into a growing national movement with formal coalitions established in more than 30 states. The network has continued to make a meaningful impact in the areas of education and advocacy to influence public policy.

The organization has worked tirelessly to partner with local and state governments and the Centers for Medicare and Medicaid Services (CMS), all of which have endorsed the principles of culture change. Ongoing efforts are being made to find linkages between creating a culture change and compliance with nursing home regulations. As a result of these efforts, even changes to the Interpretive Guidelines are being made in the State Operations Manual used for surveying nursing facilities.

How to Bring About Culture Change

There is no single model of culture change because of several variables involved. For example, leadership, ownership, financial resources, and case-mix factors vary from facility to facility, making it difficult to implement one standard model, if one could be developed. Moreover, numerous possibilities of arrangements exist to bring about culture change that can differ rather substantially from one facility to another. Even at that, it remains a work in progress. These same variations have made it extremely difficulty to empirically test the outcomes of culture change.

Even though there is no standard process to bring about culture change, it is no longer a novelty or a fad. It is the wave of the future that is unstoppable. Facilities that do not adopt this growing movement will be left behind and find themselves in an uncompetitive position, and perhaps out of business at some point.

As a start, nursing home administrators and leaders need to change their mindset established in the “old school” of nursing home management. They can start working with one of the three key factors mentioned earlier, and gradually, over time incorporate elements from the other two. For example, a good starting point will be to change management practices, which do not require any capital outlays. Staff training in the principles of culture change, training of managers in staff empowerment, educating residents and their families and involving them as the facility plans to make transitions toward culture change, and joining a state-based Pioneer coalition to increase one’s knowledge about culture change can certainly put the organization on the right track. Gradual changes in the physical environment can follow. The high cost of constructional modifications could be a deterrent. Also, many of the older buildings may present daunting challenges because of their layout and lack of available space that must be devoted to providing essential services such as nursing care and rehabilitation. Yet, facilities can enrich their existing environments, implement person-focused changes in the processes of care delivery, and make quality improvement a top priority. A facility built with a modern architectural design, but providing impersonal care of poor quality will in time not be able to compete against an older facility that excels in delivering high-quality person-centered care and offers an enriched environment in which the patients can thrive.

Doty et al. (2008) demonstrated that a greater degree of adoption of culture change results in greater benefits in terms of staff retention, higher occupancy rates, better competitive position, and improved operational costs. It is also surmised that, compared with previous generations, baby boomers entering retirement will be more inclined to search for LTC options that promote comfort and quality of life in an environment comparable to their own homes (Ragsdale & McDougall, 2008).

Contemporary Models of Culture Change

The Eden Alternative

In the early 1990s, Dr. William Thomas, while working as a physician in nursing homes, undertook a pilot project sponsored by the state of New York. Working with the staff in an 80-bed nursing home, which served mostly patients with dementia, Thomas developed some new ideas and a set of principles for creating a garden-like environment. As an advocate for change, Thomas explained:

I want an alternative to the institution. The best alternative I can think of is a garden. I believe when we make a place that’s worthy of our elders, we make a place that enriches all of our lives—caregivers, family members, and elders alike. So the Eden Alternative provides a reinter-pretation of the environment elders live in, going from an institution to a garden … There are kids running around and playing. There are dogs and cats and birds, and there are gardens and plants. I want people to think that this can’t be a nursing home. Which it isn’t—it’s an alternative to a nursing home. … The future of caregiving belongs to people and organizations who can dream new dreams about how to care for our elders. (McLeod 2002, pp. 14–15)

Eden Alternative, a trademark of its founding organization, entails viewing the surroundings in facilities as habitats for human beings rather than as facilities for the frail and elderly, as well as applying the lessons of nature in creating vibrant and vigorous settings. It is based on the belief that the companionship of pets, the opportunity to give meaningful care to other living creatures, and the spontaneity that marks an enlivened environment have therapeutic values (Eden Alternative, 2002). One of the main objectives of Eden Alternative is to banish from the lives of nursing home residents the loneliness, helplessness, and boredom that Thomas called “the three plagues of nursing homes” (Bruck, 1997). To counteract these ills, residents need companionship, variety, and a chance to feel needed (Stermer, 1998).

According to the 10 principles on which the Eden Alternative is founded (Exhibit 7–1) the antidote to loneliness is meaningful contact with plants, animals, and children, as well as easy access to human and animal companionship; the remedy for helplessness is giving as well as receiving care; and the cure for boredom is unexpected and unpredictable interactions and happenings in surroundings that deliver variety and spontaneity. Among methods to build relationships between staff members and residents, alternative means of healing such as massage therapy and aromatherapy are suggested, based on the belief that a back-rub or foot-rub may eliminate the need for sleep-inducing medications, and the belief that the smell of lavender or peppermint can have a calming effect.

Edenizing  is the expression used for achieving culture change by implementing the Eden principles. For a long time, many nursing homes have, at least to some extent, involved their residents in nature-oriented activities such as pet therapy, gardening, and nature walks. Programs in collaboration with local schools and day care centers have also been developed to promote intergenerational companionship. Edenizing more fully incorporates the concepts of biophilia. It promotes surroundings rich in plants, animals, and children. Involving the residents in the care of plants and animals, and in interaction with children enriches everyone’s lives. A facility can have an on-site child day care center, providing opportunities to integrate child care with the care of the elderly. Children playing with toys in the facility’s living room, or playing outdoors on a swing and slide set add to variety and spontaneity. But edenizing goes beyond these steps. It also incorporates other aspects of culture change, such as resident and caregiver empowerment.

Exhibit 7–1  The Eden Alternative Principles

  1.   The three plagues of loneliness, helplessness, and boredom account for the bulk of suffering among our Elders.

  2.   An Elder-centered community commits to creating a Human Habitat where life revolves around close and continuing contact with plants, animals, and children. It is these relationships that provide the young and old alike with a pathway to a life worth living.

  3.   Loving companionship is the antidote to loneliness. Elders deserve easy access to human and animal companionship.

  4.   An Elder-centered community creates opportunity to give as well as receive care. This is the antidote to helplessness.

  5.   An Elder-centered community imbues daily life with variety and spontaneity by creating an environment in which unexpected and unpredictable interactions and happenings can take place. This is the antidote to boredom.

  6.   Meaningless activity corrodes the human spirit. The opportunity to do things that we find meaningful is essential to human health.

  7.   Medical treatment should be the servant of genuine human caring, never its master.

  8.   An Elder-centered community honors its Elders by deemphasizing top-down bureaucratic authority, seeking instead to place the maximum possible decision-making authority into the hands of the Elders or into the hands of those closest to them.

  9.   Creating an Elder-centered community is a never-ending process. Human growth must never be separated from human life.

10.   Wise leadership is the lifeblood of any struggle against the three plagues. For it, there can be no substitute.

Courtesy of Eden Alternative. Available at: http://www.edenalt.org/about-the-eden-alternative/mission-vision-values.

Eden Alternative has become an international organization. Its philosophy has been adopted in some 20 different countries that include Canada, the United Kingdom, Australia, New Zealand, and several European nations.

Edenizing may pose some risks in the form of allergies, injuries, and illnesses.  Zoonosis  is the transmittal of infections from vertebrate animals to humans. Examples of zoonotic diseases include dermatophytosis, psittacosis, bartonellosis, toxocariasis, pasturellosis, Q fever, and leptospirosis (Guay, 2001). However, potential problems can be managed with appropriate veterinary care and infection-control practices.

Proponents of Eden Alternative explain that their approach is not a quick fix for serious problems. Not every facility should embark on making such changes. Acceptance of the Eden Alternative by staff members and their training are necessary prerequisites because, right off the bat, questions come up about the staff’s extra responsibilities of caring for the pets and cleaning up after them. Particularly in unionized facilities where union–management contracts prescribe tasks and duties of staff members, edenizing can be challenging. Costs of training and implementation may be another deterrent. Also, the quality of life in long-term care facilities can be improved in ways other than edenizing. Changing an organization’s culture takes time, effort, and leadership skills. Implementing the Eden principles can take an estimated 3 to 5 years (Hannan & Schaeffer, n.d.).

The Green House Project

An outgrowth of Eden Alternative, and also a brainchild of Dr. Thomas, the Green House Project takes edenizing a step further by revolutionizing the way in which nursing home services are organized and delivered in small-scale settings. In the New York State pilot project described earlier, Thomas experimented with restructuring the caregiving staff into permanent care teams designed to serve a particular “neighborhood” of elders according to their special needs. The teams—consisting of nurses, social workers, housekeepers, dietary employees, and members of the activities staff—tried to adapt the traditional largescale caregiving approach for smaller groups of residents. Each team participated in extensive training in communication, teamwork, and problem solving. In the Green House model, these organizational ideas are applied to physically distinct small-neighborhood architectural units. Also, unlike edenizing a large institutional structure, the Green House model relies more on natural outdoor activities, such as watching and feeding birds and squirrels, and less on indoor pets because the small design of the buildings allows ready access to the outdoors (J. Rabig, personal communication, September 25, 2003).

The term  Green House  stands for architectural renderings of small freestanding cottages, each designed to house just 10 to 12 residents who live together in a homelike setting ( Figure 7–7 ). The freestanding cottages are spread across a campus ( Figure 7–8 ). The first Green House project in Tupelo, Mississippi, opened its doors in June 2003. Since then the model has been adopted by a number of nursing home organizations across the nation.

Figure 7–7  Ten-Bed Skilled Nursing Green House (Methodist Senior Services, Tupelo, Mississippi)

Reproduced with permission from The McCarty Company, Tupelo, Mississippi. Courtesy of Stephen Ladd.

Each Green House has self-contained private rooms that include a commode, a sink, and a shower. To accommodate even the frailest elders, rooms are equipped with ceiling lifts for transferring. The lift operates on a ceiling track that runs from the bed to the bathroom sink and commode. The residential units are connected by short hallways to a central hearth room, open kitchen, and dining area. Other amenities include a spa room, laundry room, alcove, and storage space. The small size eliminates the need for nursing stations and medication carts. The nurse call system is wireless, using silent pagers that can be activated from pendants worn by the residents (Rabig & Thomas, 2003). In all aspects, the Green Houses fully comply with Life Safety Code® and other building and safety standards (National Fire Protection Association, 2009).

Figure 7–8  Overhead Perspective of Green Houses (Small Residential Structures Spread Across a Campus)

Reproduced with permission from The McCarty Company, Tupelo, Mississippi. Courtesy of Stephen Ladd.

Each Green House is staffed by cross-trained nursing assistants, who do cooking and cleaning in addition to delivering personal care. The Green Houses are supported by the traditional organization of a skilled nursing facility nearby in which functions such as professional nursing, rehabilitation therapies, medical records, accounting, billing, purchasing, and plant maintenance are located (Rabig & Thomas, 2003). The cross-trained, self-managed worker teams create a decentralized organizational structure that modifies the typical supervisor–subordinate relationships. Interdisciplinary clinical support teams that include physicians, nurses, therapists, social workers, dietitians, and others located in the support organization carry out individualized clinical assessment and care planning and visit the elders to meet their treatment needs. Clinical practice guidelines based on medical research and standards, as well as emergency protocols, are developed for use by caregivers (Rabig & Thomas, 2003). The degree of collaboration and communication between nurses and assistants generally varies, but nurses retain oversight of clinical functions (Bowers & Nolet, 2014).

Individual choices and preferences are preserved by allowing the elders the maximum possible latitude in establishing their own daily routines for sleep, rest, meals, personal care, and activities. Elders are also encouraged to participate in meal preparation, gardening, cleaning, and laundry work. Weekly joint meetings or “house discussions” between elder assistants and elders provide feedback on quality of care, identify unmet needs or concerns, and give input for household decisions (Rabig & Thomas, 2003).

To promote bonding between assistants and elders, the two groups sit around a large common dining table and together enjoy a family-style meal. The assistant may help feed the patient sitting in the next chair. Even tube-fed patients may be brought to the dining table for sensory stimulation from the music, the chatter, and the aroma.

The Green House model has become the subject of ongoing research, which shows that the family-like environment has been well received by residents, visitors, and staff (Cutler & Kane, 2009). Some recent findings suggest that, compared to traditional nursing homes, the Green House model requires a higher ratio of nursing assistants, but overall staff time (combined nursing and nonnursing) is slightly less (Sharkey et al., 2011). Self-reported quality of life by elders living in Green Houses is higher and there is less decline in activities of daily living (ADL) functions (Kane et al., 2007). Research also demonstrates that changing the physical environment is not always sufficient; the staff need to assist residents and take advantage of the setting, consciously avoiding old habits (Cutler & Kane, 2009).

Environment for Patients with Dementia

For people with dementia, small groupings of residents in a homelike environment provides a more effective therapeutic setting. The smaller scale of the living quarters reduces stress that such patients may experience from the overwhelming effect of being placed in complex, unfamiliar surroundings. This is because a link to the person’s past home environments becomes essential for exercising his or her remaining capabilities. In dementia patients, long-term memory generally remains relatively intact until the later stages of the disease (Cohen & Day, 1993).

In a pilot study, Brush et al. (2002) found that improved lighting and table-setting contrast had a positive effect on food consumption and functional abilities of patients with dementia. Generally, a moderate level of stimulation from the environment is best. When the environment provides too many stressors and fewer opportunities to relax, dysfunctional behaviors are observed among patients with dementia (Rader, 1991). Unpleasant sounds, intense lighting, and bold colors produce a high level of stimulation that causes stress. For patients with Alzheimer’s, sharp color contrasts and patterns can be disturbing; pastel colors tend to work better (Kretschmann, 1995). Noise control is particularly important; excessive noise has the most damaging effect on people with dementia (Dewing, 2009). “One has to wonder about the number of drugs that could be eliminated and a better life provided if we would just provide a calm, quiet and soothing atmosphere that does not provoke agitation, fear or anxiety” (S.O. Berg quoted in Benbow, 2013).

Patient safety is an important factor. Electronic guards to prevent wandering are essential. Protected pathways for wandering, residential kitchens and laundries, and contained outdoor gardens are particularly helpful in caring for patients with dementia (Regnier, 1998). Nature-related activities are often an essential but unused therapeutic resource (Day & Cohen, 2000). Connection to nature extends to people’s interaction with animals. There is some evidence that meaningful decreases in agitated behaviors and improvements in social interactions of dementia patients can occur as a result of pet therapy (Richeson, 2003).

Terminology for Review

autonomy

biophilia

consistent assignment

culture change

edenizing

enriched environments

Green House

intimacy

person-centered care

sick-role model

thriving

wayfinding

For Further Thought

  1.  As a nursing home administrator who has just been appointed to manage a skilled nursing facility that was built in the 1970s, how would you go about delivering person-centered care?

Case

Edenizing Gone Awry?

In the certification survey of a facility, eight deficiencies were cited, including one for inadequate supervision of residents. The CMS imposed penalties, and the facility appealed. On appeal, the case came before an administrative law judge. In his decision, the judge upheld the deficiencies and the fines imposed based on the care of eight residents, seven of whom had sustained repeated falls and one resident was injured during transfer when a mechanical lift that was ordered by the resident’s physician was not used. Three of the deficiencies were classified as “immediate jeopardy”, which carried a penalty of $3,050 per day.

Prior to the incidents, the facility had implemented the Eden Alternative program, which was supported by the facility’s medical director. During the court hearing, the facility’s administrator argued that Eden promotes residents’ mobility and ability to express preferences, recognizing that there will be ensuing risks and that Eden promotes allowing residents to take reasonable risks and enjoy the last years of their lives. The administrator further asserted that the state’s legislature had mandated that facilities employ the Eden Alternative program in care delivery. The facility’s medical director testified that the facility “embraces the philosophy of a resident-centered environment. We promote residents making their preferences known. Even if these preferences are considered by some to be poor, we recognize that permitting freedom and quality of life includes risks.”

Questions

1.  What main lesson can you derive from this case?

2.  Based on what you would have learned in previous chapters, did the facility follow the law?

3.  Was edenizing a mistake? If not, how could the nursing home administrator have prevented the deficiencies while also edenizing the facility?

FOR FURTHER LEARNING

Eden Alternative

http://www.edenalt.com

The Green House Project

http://thegreenhouseproject.org/

The Pioneer Network

http://www.pioneernetwork.net

REFERENCES

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