Person-Centered Bathing: Long-Term Care Culture Change (Research)

Do you remember how special bath time was when you were a child? Did you have toys floating on the waves of your rolling sea? Were there bubbles sometimes adding magic to the experience of getting fresh and clean? Maybe you still have certain rituals like music, fragrance, and candlelight that take bathing to another level when you want to pamper yourself. These simple treasures can add so much to uplifting spirits. While bathing may seem like a universal activity, individual preferences add personal joy. Shouldn’t nursing homes be sensitive to residents’ personal preferences when they can be implemented?

A research study by the Yale School of Medicine examined the bathing experiences, attitudes, and preferences of older persons through in-depth interviews. Three themes emerged:

1) The importance and personal significance of bathing to older persons

2) Variability in attitudes, preferences, and sources of bathing assistance

3) Older persons' anticipation of and responses to bathing disability

Clearly, their attitudes and preferences are important when person-centered interventions for bathroom design are considered.

My book "Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes” has a chapter titled “Baby Boomer Haven,” which takes readers on a tour of an imaginary nursing home that incorporates best practices currently being used in nursing homes today, but not nearly enough. Of course, innovative bathing systems meeting residents’ needs continue to be invented. The tour is led by a resident in a wheelchair. This excerpt from the tour addresses bathrooms:

“This might be a little unusual, but I just have to show you one of our bathrooms. Using the bathrooms is a pleasant experience here. We have choices about whether we want a shower, a bath, or a sponge bath, and when we choose to take them. The Jacuzzi tubs and music are great motivators to come here. Deodorizers keep our bathrooms smelling fresh at all times. Notice the bright artwork that colors the walls and even the ceilings, so we can admire beauty when we are in reclining positions. We can soak in beauty everywhere we look. These simple touches tell us that somebody thought we were worth the effort.”

Isn’t that what quality of life is all about?

Frances Shani Parker, Author

"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”

“Hospice and Nursing Homes Blog”

Green House Living: Not Your Traditional Nursing Home (Video 4:25 mins.)

A Green House is an example of culture change in long-term care living. The Robert Wood Johnson Foundation provides grant funding for the Green House model on a national level. Green Houses are self-contained dwellings of seven to ten residents who thrive as families in homes built to blend in with the neighborhood. Residents add their personal decorating touches, greet the day when they feel like it, plan menus, and eat with the staff. Mealtimes prepared in an open kitchen are unhurried and socially rewarding. Each elder has a private room and bath with easy access to all areas of the home.

At Green Houses, skilled nursing assistants (CNA’s), referred to as “shahbazes,” coordinate all facets of eldercare life with the support of nurses and therapists. They focus on nurturing, sustaining, and protecting residents. Residents are encouraged to be independent. This video titled “Green House: A Place to Call Home” showcases advantages of Green House living.

Frances Shani Parker, Author

"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”

“Hospice and Nursing Homes Blog”

Culture Change: Nursing Home Dining (Video 2:13 mins.)

Broadwater Health Center (above) in Montana has cooked-to-order breakfasts and multiple-entree noon and evening meals.

The Centers for Medicare and Medicaid Services (CMS) guidelines for state surveyors give detailed information on accessing nursing home compliance with regulations. Recently, the CMS added that nursing homes must support residents' preferences and other efforts to transform nursing homes into homelike environments. Changes mentioned are both environmental and resident-centered. They include activities such as dining, scheduling, bathing, sleeping, and many more beneficial changes that will advance reform in nursing homes.

A hospice volunteer in Detroit nursing homes, I am aware of the great need for reform. Across America, best practices in many nursing homes are far ahead of those in too many others. But improving nursing homes requires much more than environmental enhancements and enrichment activities. Changing the culture of nursing homes successfully requires major shifts in thinking with input from all levels of staff, residents, and community. Incentives encouraging achievement of new and shared goals are also effective. A helpful resource is the National Consumer Voice for Quality Long-Term Care. This organization was formerly the National Citizens' Coalition for Nursing Home Reform (NCCNHR).

In this video titled "Culture Change Dining - Restaurant Style,” we see how residents and staff of Ballard Healthcare have implemented improvements in the dining program.

Frances Shani Parker, Author
Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes
Hospice and Nursing Homes Blog

BlogTalkRadio Interview with Frances Shani Parker, Author of “Becoming Dead Right” (30 mins.)

Earlier this week, I was interviewed by Patricia Grace, a certified senior advisor and host of the BlogTalkRadio Show “Aging with Grace.” This show airs weekly on Monday evenings in Pennsylvania and showcases discussions related to eldercare. BlogTalkRadio is the social radio network that allows users to connect quickly and directly with their audiences. Using an ordinary telephone and computer, hosts can create free, live, call-in talk shows.

Patricia Grace and I covered several topics during our interview. They included the following:

1) Hospice Care
2) Caregiving
3) School-Nursing Home Partnerships
4) Healthcare Research
5) Culture Change in Nursing Homes
6) Ten Tips for Becoming Dead Right

You can listen to the "Aging with Grace" interview here.


Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
“Hospice and Nursing Homes Blog”

Culture Change in Nursing Homes: What Works, What Doesn’t (Video: 1:59 mins.)

Most people agree that changes in the stereotypical, traditional nursing homes are long overdue. What makes a nursing home really feel like home? What needs to happen to make that a reality? What are some of the barriers that negatively impact progress? A University of Pennsylvania research study about culture change in nursing homes focused on these concerns. After staff interviews were done, three nursing homes reported these results:

Barriers to Change

1) Exclusion of nurses to culture change activity (While nursing assistants were not mentioned here, I’m inclined to believe they were also excluded.)

2) Perceived corporate emphasis on regulatory compliance and the "bottom line” (money)

3) High turnover of administrators and caregivers

Promoters of Change

1) A critical mass of "change champions"

2) Shared values and goals

3) Resident/family participation

4) Empowerment at the facility level

Clearly, changing nursing homes successfully involves input
from all levels of staff, residents, and community. Incentives encouraging achievement of new and shared goals are also effective.

You can read more details about this study here.

You can view this video on the importance of inclusiveness in culture change proceedings.

Frances Shani Parker, Author

Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes is available in paperback and e-book editions in America and other countries at online and offline booksellers.

Hospice and Nursing Homes Blog

Culture Change in a Baby Boomer Nursing Home (Video 2:20 mins.)

In my book "Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes,” Baby Boomer Haven refers to an imaginary nursing home based on best practices of some, but not nearly enough, nursing homes that exist today. In the last chapter, Ruth, a patient in a wheelchair, takes readers on a nursing home tour where residents and employees thrive in a culture where they feel empowered and respected. Many aspects of culture change are discussed and in evidence.

Roger Woodruff, Director of Palliative Care, International Association for Hospice and Palliative Care, Austin Health, Melbourne, Australia says of this book tour “I particularly enjoyed the guided tour, conducted from a wheelchair, of Baby Boomer Haven."

Book Excerpt:

“Management and staff have a great working relationship. Together they wrap us in a warm family quilt woven with reassurance. Everybody participates in decision-making and attends workshops, classes, and conferences to keep abreast of best practices in their fields. Various staff members are included in the hiring of new employees and, when appropriate, involved in their training. Periodic meetings are held with all shifts represented, so more in-depth information can be provided concerning patients. Employees take pride in their work and strive to continue our tradition of excellence. We’re all part of the same team, and we’re all cheerleaders.”

In this video, viewers are given an overview of how to implement resident-directed care.

Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
“Hospice and Nursing Homes Blog”

Nursing Home Culture Change: Working with State Regulators (Pioneer Network Video 2:36 mins.)

Many people don’t plan to live their last days in nursing homes. However, with over 37 million Americans over the age of 65, a large segment of them will live and die in nursing homes. Culture change, which focuses on living life with dignity, can include the following:

1) Flexible Schedules

Everybody doesn’t have to eat, sleep, and bathe at the same times.

2) Intergenerational Activities

Relationships between children and the elderly are encouraged. The unique, beneficial exchanges that take place in this context are lacking too often in today’s society.

3) Interactions with Animals

Appropriate animals provide companionship and improved health.

4) Independent and Social Activities

Nursing home residents feel respected when their input is welcome regarding activities they can do independently. They also appreciate social activities that keep them connected with others.

There are several models of culture change for nursing homes. They all respect and incorporate input from residents and staff members in such areas as decision-making and scheduling. The Household Model is a product of the Pioneer Movement. Small groups of residents form households resembling "homes" where they have opportunities to develop quality relationships in a calm environment.

In this Pioneer Network video, Steve Shields describes how his organization approached working with state regulators to remodel an existing nursing home into the Household Model.

Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
Hospice and Nursing Homes Blog

Eden Alternative for Nursing Homes (Video 6:52 mins.)

The following includes an excerpt from my book, "Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes.” The chapter titled “Baby Boomer Haven” takes readers on a tour through an imaginary nursing home based on best practices of some, but not nearly enough, nursing homes that exist today. Animals and children are important additions to culture change of many nursing homes that are moving away from the stereotypical, traditional model.

“Watch out for Diva Dog over there, one of several resident pets. She’s just looking you over to make sure you look her over. In her spare time, she’s a certified psychologist. Other indoor animals on the site are located in our aviaries of brightly colored birds and in our aquariums with fish that mesmerize us with their antics. We have more animals outdoors such as horses and rabbits. It’s fascinating watching how all of our animals relate. They’re a lot like people, you know, and have much more sense than we think they do.

Employees seem to love working here as much as we love living here. Most have years of seniority, and hardly anybody is ever absent. Low staff turnover saves considerable money in overtime and in hiring temporary help. Two things all employees like are our flexible scheduling and childcare on the premises. This allows them to personalize their time and accomplish more at home and at work with fewer worries. If you look to your left through the window of the childcare center, you can see two employees having lunch with their children. The older gentleman is a resident reading to a small group. I love spending time with the little ones. I jokingly call them my little “ankle biters” when they aren’t around. Some of them call me, “Grandma,” and a few like to say “Big Mama,” which really tickles me because that’s what I called my grandmother.”

© Frances Shani Parker

There are several models of culture change for nursing homes. This video examines an approach known as the Eden Alternative.

Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
Hospice and Nursing Homes Blog

Nursing Home Culture Change: The Green House Project (Video 7:33 mins.)

What makes a nursing home really feel like home? That’s a major theme for culture change in nursing homes. Think about how you live in your own homes, and it’s easy to figure out what most nursing home residents want. Cedars Nursing Home in Tupelo, Mississippi is a Green House Project alternative to traditional nursing home living that has put the “home” back in nursing home.

With the intention of developing Green House homes with long-term care organizations around the country, the Robert Wood Johnson Foundation provides grant funding for the Green House model on a national level. At the Green House Project, life in a traditional nursing home has been reinvented. Residents, living in cottages of ten, thrive as families in homes built to blend in with the neighborhood. They add their personal decorating touches, greet the day when they feel like it, plan menus, and eat with the staff. Mealtimes prepared in an open kitchen are unhurried and socially rewarding.

Each elder has a private room and bath with easy access to all areas of the home. Nursing assistants (CNA’s), referred to as “shahbazes” focus on nurturing, sustaining, and protecting residents. Assistance residents receive doesn’t interfere with their independence. View this video of a Green House Project home where home really is sweet.

Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
Hospice and Nursing Homes Blog

Nurses and Nurse Assistants (CNA’s): Stress in Nursing Homes

Who knows stress better than the people who carry it around everyday? These research results came directly from nurses and nurse assistants (CNA’s) in twenty-five nursing homes in North Carolina. This is what they had to say:

Nurses:

The situations most stressful for nurses were not having enough staff, having too much work to do, interruptions, having non-health professionals determine how they do their jobs, poor pay, and being responsible for patients' outcomes. Nurses were more likely than nurse assistants to report stress because non-health professionals (e.g. surveyors) determine how they must perform their services.

Nurse Assistants (CNA’s):

The most stressful situations for nurse assistants included poor pay, not enough staff, and too much work to do. Nurse assistants were more likely than nurses to report stress because they do not have adequate information regarding patients' conditions.

Conclusions:

The findings of this study support the need to increase recognition for nursing, improve staffing, and provide competitive compensation in nursing homes. Were you surprised by these results? I wasn’t either. But it’s still another validation of the staff stress problems and the need for positive changes in nursing home reform.

You can read more about this research in the "Journal of the American Medical Directors Association.”

Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
Hospice and Nursing Homes Blog

Culture Change: Transformation of Four Nursing Homes (Video: 5:16 mins.)

The following includes an excerpt from my book, "Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes.” Baby Boomer Haven refers to an imaginary nursing home based on best practices of some, but not nearly enough nursing homes that exist today.

“Welcome to Baby Boomer Haven! It’s a treasure to have you. My name is Ruth, and I’ll be your tour guide today. The first thing you need to know about our nursing home is that it’s real for some, but imaginary for too many others. Everything we enjoy here already exists in nursing homes scattered throughout America, but not in nearly enough. We’re having this tour today, so you can become familiar with possibilities that all nursing home residents should be experiencing, no matter where they are located.

When baby boomers seeking institutional healthcare show up in the millions, nursing homes like ours should be ready to receive them with welcoming lights shining in every window. Now, more than ever, nursing homes should be focused on ongoing state-of-the-art improvements. The comfortable life we live is as close as society’s handshake with commitment to quality healthcare, particularly for the ill and elderly.

We love many things about living here, but what we enjoy most is that we’re treated with dignity as adults. Our feelings and opinions matter. You’ll understand this better during the tour when you see our physical environment, the freedom we have in deciding how we live within our limitations, and the nurturing manner in which all employees interact with us.”

There are several models of culture change for nursing homes. They all respect and incorporate input from residents and staff members in such areas as decision-making and scheduling. This video from the Pioneer Network captures the transformation of four nursing homes in Anywhere, USA.

Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
Hospice and Nursing Homes Blog

Nursing Home Culture Change: Residents with Dementia (Video 4:06 mins.)

With all my experience as a hospice volunteer in nursing homes, I still have to be consciously aware of how I respond to patients living with dementia. Today I saw an approaching friend pushing her husband in a wheelchair. I immediately called out to her with a greeting. Within three seconds, I realized that I had only greeted her and had not said her husband’s name. I then called out to him.

My friend’s husband has dementia, which refers to a group of conditions that gradually destroy brain cells and lead to mental decline. I’m pretty sure that I would not have forgotten to say his name if he did not have dementia. I would have greeted them together. This is an example of the kind of conscious paradigm shift many of us must make in our thinking if we are serious about improving our interactions with people who have dementia. Culture change in nursing homes must include their unique needs. It is so easy to forget that they are adults with mental challenges.

No one wants to feel ignored, and residents with dementia are often very sensitive. They need to be recognized as contributors to conversations and honored as decision makers. Activities should be available for them to practice organization and communication skills that help them feel more like the adults they are. Time must be taken to investigate and implement activities that will help them experience life as adults with limited abilities.

Culture change in a person-directed environment includes meeting everyone’s needs. In this video, Megan Hannan explains the person-directed needs of residents with dementia.

Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
Hospice and Nursing Homes Blog

Culture Change in Nursing Homes: Sexual Orientation (LGBT)

A supporter of culture change in nursing homes, Barry Berman, the executive director of the Chelsea Jewish Nursing Home Foundation, says his organization sees a need for skilled-nursing services and care targeting the lesbian, gay, bisexual, and transgender (LGBT) market. The building of what will probably be the first skilled-nursing home LGBT facility in America will address that concern.

Due to misunderstandings or intolerance by others, elders of the LGBT community are sometimes made to feel uncomfortable about their sexual orientations and lifestyles. In some nursing home environments, they may be criticized or ostracized for doing what heterosexuals consider normal for themselves during everyday living. This includes such practices as spending time with their partners, reading LGBT materials, and freely sharing personal opinions.

The Chelsea Jewish Nursing Home Foundation will begin construction next year on a $26 million nursing home complex, which will have specialized units for the elderly with specific diseases and needs. Targeted health areas include Lou Gehrig’s disease (ALS), blindness, and multiple sclerosis. One ten-bedroom unit will be used by elderly LGBT residents. The LGBT unit, which should open in 2009, will be called the Elsie Frank House, named after a famous openly gay political leader and the late mother of U.S. Rep. Barney Frank (D-Newton). You can read this “Boston Herald” news article for more information about this specialized implementation of culture change in nursing homes.

Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
Hospice and Nursing Homes Blog

Nursing Home Technology: Wii Video Game (Video 58 secs.)

During the past year, something unexpected has enhanced the culture change in some senior citizen communities. That phenomenon is the playing of Wii (pronounced “we”), a Nintendo video game that leads the nation in sales. Why unexpected? Most of the players have never used a video game before.

This popular cross-generational game is played with a handheld remote control (cutely called a “Wiimote”) that is mounted to the wrist and includes a motion sensor. Players press buttons and move to translate their actions onto a television screen. As complicated as that sounds, the game is very user friendly. Unlike most video and computer games, Wii involves a pleasing combination of mental and physical exercise, along with positive social interaction. There are several digital versions such as bowling, tennis, golf, and baseball. The best way to understand how Wii works is to watch people play. Click here to see a
Wii bowling game in progress.

Frances Shani Parker, Author
"Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes”
Hospice and Nursing Homes Blog

Nursing Home Technology

Part of the culture change that many look forward to seeing in more nursing homes is supportive of technology as a means of providing residents with more independence and dignity in daily living. Of course, the human touch still remains primary in patient interactions with others.

A major problem in implementing more technology is cost. Cuts in funding for nursing homes only make an already difficult situation worse. But we must still address the possibilities, particularly since many technological accommodations are already on the market. Five examples are these:

1) A vacuum assisted sponge that promotes blood circulation at the wound site and sucks out the infection

2) Robots that perform basic tasks that will allow staff to spend more hands-on time with patients and that remind residents of tasks they should do

3) Computer touch screens for nurse aides and others to update patient data at the point of care for immediate access and use elsewhere

4) Remote sensing technology that monitors motion, temperature, pressure on floors, chairs and beds, how patients walk, when they fall, restlessness in bed, as well as patients’ pulse and respiration

5) Wireless call systems that allow residents to call for assistance anywhere in the facility by pressing a button they wear that sends a message to a computer

The reality is that technology is needed to free more staff to handle the increasing numbers of patients who are living in nursing homes. Millions of baby boomers will need services in the very near future. In order to support our aging society, America needs more discussions and funding relating to technology.

At the age of 91, Naomi Long Madgett, Poet Laureate of Detroit, MI, enjoys using technology. Her good choices with the "new stuff" enhance her quality of life. You can read more about Naomi and iPad research with older adults here:

https://www.linkedin.com/pulse/selfie-detroit-poet-laureate-techie-91-ipad-research-parker?trk=mp-reader-card

Frances Shani Parker, Author
Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes
Hospice and Nursing Homes Blog

Changing the Culture of Nursing Homes

As a hospice volunteer in Detroit nursing homes for nine years, I have become very familiar with the kind of culture that is predominant in many nursing home facilities. When I speak of culture in this manner, this is what I mean: Whenever we enter a building, a certain climate or culture greets us. Depending on what that culture is, we sense the possibility of the kind of experience we will have. If unpleasant sights, odors and sounds greet us after we enter, we will certainly draw negative conclusions about what to expect. And we will probably be correct. On the other hand, a culture that nourishes and stimulates appropriately makes us feel welcome, happier and encouraged to return.

Too many nursing homes have structured, unexciting and tense cultures that impact staff, patients, caregivers and other visitors poorly. Among other practices, patients are expected to eat and sleep at the same times on a daily basis, although most people would readily agree that people's natural schedules are not that aligned. The ongoing boredom and loneliness, along with excessive focus on rules and medical procedures, have lost sight of peoples' overall human needs. In addition, there is a layer of anxiety regarding compliance, or lack of compliance, with all the various rules that must be followed, regardless of how they impact people. In urban areas, particularly those that serve low income and racial-ethnic minorities, these factors are especially noticeable.

Fortunately, growing groups of reform-minded individuals are making their voices heard regarding the need for change in nursing home culture. They are not pushing cosmetic changes, but real changes in how people live and work together with a common goal. The focus is primarily patient-centered and encourages their independence. The following are a few of the alternative practices they are promoting to improve nursing homes:

1) Personalized schedules
2) Independent "houses" composing a nursing home
3) Family atmosphere with plants and small pets indoors
4) Regular contact with children through on-site daycare centers and after-school programs
5) More activities and decreased medication

As millions of baby boomers become senior citizens, we will be hearing more about these reforms. Our support will be needed to make these changes real and available to all patients, regardless of where their nursing homes are located. What do you think about changing the culture of nursing homes?

Frances Shani Parker, Author
Becoming Dead Right: A Hospice Volunteer in Urban Nursing Homes
Hospice and Nursing Homes Blog