Many readers are familiar with people with dementia who want to “go home” when staff members leave at the end of their shifts or who “shop” for belongings in the drawers of other residents. It can be challenging for staff to redirect individuals intent upon leaving and upsetting for the people who are being prevented from going where they want to. “Shopping” is likely to irritate those whose dressers are being ransacked, creating ill will between neighbors on the floor.
In the Netherlands, a facility called Hogewey or “Dementia Village,” has created an entire town set up for residents with severe dementia. They’re encouraged to wander and shop and can spend the afternoon outside, coming home at the end of the day. Their homes have different lifestyle themes, such as culture or crafts or religion, increasing the chances that elders will be living with others that share their interests.
Someone posted a story I Liked on Facebook about an 85-year old woman who graduated from college and already had a job offer. “She’s my new hero!” a Friend commented. That got me thinking about all the resident heroes I meet at work every day. They’re the ones who help me along the journey to having the kind of life I can look back on without regrets when I’m in my nursing home room in my senior years.
Lesson No. 1: Chutzpah
Back when I first started in long-term care, I was called upon to work with many younger residents who were admitted to the facility as a result of unfortunate incidents that occurred while they were taking a walk on the wild side. Their still-wild ways weren’t going over so well in the nursing home, but I admired how they stood up for themselves and their rights.
“Everyone knows not to mess with me,” one young lady declared, “because if they do, I’ll have a hit put out on them.” Wow! Now that’s assertiveness! I thought to myself, as I worried about the nuances of phrasing a request to a coworker.
Yes, threatening to put out a hit on someone was on the extreme side of the assertiveness scale, but wasn’t it possible I was too far on the mild side? Those young residents helped me edge a notch or two closer to asking for a reasonable amount of what I want and need from others.
Lesson No. 2: Keep on keeping on
Nina and Roberta had a routine. In the mornings, they sat in the lobby and greeted all who entered the facility. At lunch, they went from table to table and wished everyone well before dining. In the afternoon, they visited the very ill and prayed with them before returning to the lobby to welcome the evening shift.
In a private discussion with Nina, she talked about her younger years when she preached with her sister on the streets of New York City. Nina is my role model because she lived her whole life doing what she loved, adjusting for changes along the way.
In long-term care we spend a lot of time focused on the physical health of those in our care. With increased emphasis on culture change and the update to the MDS (and hopefully as a result of this column), we’ve begun to address the mental health of our residents more adequately.
We do this not only by assessing the needs of individuals, but also by creating a healing emotional environment for all residents. It’s easier for our staff members to create an emotionally healing environment for residents when the work environment is psychologically healthy for them.
Employee involvement includes efforts to involve employees in decision-making and give them more opportunity for autonomy.
Work-life balance is a recognition that responsibilities outside work can impact on performance on the job, leading to programs that assist workers in managing childcare, eldercare, financial crises, etc.
Employee growth and development focuses on offerings that provide employees with the opportunity for new skills and experiences such as coaching or mentoring, continuing education, tuition reimbursement, etc.
Health and safety comprises programs that work to maximize employees’ physical and emotional health such as stress management programs, adequate insurance, healthy lifestyle motivators, safe practices training on the job, and Employee Assistance Programs (EAPs).
Employee recognition includes ceremonies that acknowledge individual and group contributions to the organization, performance-based bonuses and pay increases, and acknowledgement of milestones.
The benefits of a psychologically healthy workplace
According to the APA Center for Organizational Excellence, which has been honoring exemplary company practices since 1999, having a healthy workplace isn’t just good for employees. A psychologically healthy environment can reduce staff turnover and absenteeism, improve performance, and enhance the quality of services provided.
On Monday, I blogged about a contest to transform “a day in the life of the resident.” I like this contest because it asks staff members for their often-overlooked expertise, and is designed to improve life for the residents, centering the nursing home day around their needs rather than vice versa. I got an update on Tuesday from Dave Sedgwick, initiator of the Ensign Group’s $150K e-prize contest. He reports not one, but two winners, with $100K going to Brookfield Healthcare in Downey, California, and a $50K Special Honors prize to Julia Temple in Englewood, Colorado.
Brookfield’s winning entry focuses on the theme of being a “Brookfield Zero,” meaning zero deficiencies on surveys, and has customer service at its core. According to their application, they used to be a “traditional” nursing home — “bland, generic, colorless, and flavorless,” until they made the decision to “show the world that skilled nursing facilities are no longer a place to die, but a place to live, learn, and grow.” Some of the highlights: They harnessed the passion and enthusiasm of their staff to create programming that engages the residents, such as tai chi and computer classes. Showers are provided by two dedicated “shower girls” who offer them at the frequency requested by the residents. Nurses answer the call bells as soon as they’re rung, and all staff members greet resident requests pleasantly. To compensate for a small parking lot, valet parking is provided. Brookfield’s application is in the form of a recipe book to encourage replication of their process.
Special Honors were given to Julia Temple, based on their “jaw-dropping” transformation of a facility for residents with dementia. Dave reports that when he entered the facility on the day Ensign acquired it, he was, for the first time in his career, afraid of being in a facility. At that time, it was common to observe physical restraints of agitated residents in order to administer sedating medication. Now, he describes the environment as “peaceful, loving, calm, and productive .” Using the Allen’s Cognitive Levels model to assess the abilities of residents, Julia Temple groups residents into neighborhoods based on their abilities, and offers programs to enhance their experience at each level. They also emphasized increasing the involvement and satisfaction of staff members. For example, they created an employee council to improve communication between management and caregiver, and a wellness program that, among other offerings, provides free massages to staff members on their lunch breaks.
While some of the innovations in the contest facilities required site renovations, more of the changes leading to success were focused on rethinking systems and improving customer service — something that can be accomplished by every facility, everywhere.
Back in August 2011, I posted about A Contest for Person-Centered Care, run by the Ensign Group, asking those working at their facilities to transform “a day in the life of the resident.” The goal was to change the daily experience of the resident as a cog going through the wheels of the nursing home routine, and to create an environment that adapts to the residents as individuals. The prize: $150,000
I spoke recently with Dave Sedgwick, who initiated the contest in his role as VP of Organizational Development and President of Ensign Facility Services, to find out the latest on the e-prize.
Me: What were you hoping to see from the contest?
Dave: What we expected was what a lot of people did – the staff looked at how limited the choices were of the residents and how constrained they were by requirements of the facilities/environments, in terms of eating, bathing, etc. We expected to see more choices, and we were looking to see more little changes that make a big difference — something as simple as not placing a resident on a pvc-type shower chair wrapped in a sheet, but instead to change them in the shower room.
There’s a poem called The Calf-Path, by Sam Walter Foss, about how a calf went down a crooked path, and that path become a road, which later turned into a highway. We tend to go down the same path just because that’s the way it’s been done before. We were hoping to create new paths.
Me: What surprised you about the contest?
Dave: I was surprised at the level of emotion of the caregivers, judges, and others involved in the contest. The status quo in most organizations is that the know-it-all of corporate figured out the jigsaw puzzle of how things work and the staff should follow along. The e-prize is the ultimate show of trust in the staff as the ones who know the residents and can express their passion, pride, and creativity.
Me:How did you engage the staff in this effort?
Dave: Each administrator had to solve the puzzle on their own of how to get the staff together to address the e-prize contest – it was announced at a meeting, and there was a follow-up call regarding whether or not they wanted to participate. Participation meant they had to contribute several hundred dollars to the pot. 100% did this, but some could only do this because they had other things going on. 75% worked on it but didn’t follow through with the applications in a timely manner. We had about 20 applications (out of about 80 facilities).
Me:How did you pick the winner?
Dave: We wanted the ideas of the winner to be replicable throughout the facilities. We wanted to look at system changes that have a big impact and don’t cost a lot of money.
Me:Who won the contest?
Dave: We plan to announce the results on May 7th. We’ll surprise the winners at their facility and stream the announcement live for Ensign employees.
For more about the e-prize and to hear about the finalists, visit the e-prize website. I’ll update my site with the contest winner ASAP after it’s announced.
The video clip I posted last week from the movie Alive Inside: A Story of Music and Memory has “gone viral.” There were well over 6.5 million views as of last Saturday, when I saw the documentary and post-film discussion and spoke with Dan Cohen, the social worker who started the ipod project. Here are a few points I took away from the experience that might be helpful for readers considering individualized music for their residents with dementia:
While all music can be beneficial, studies of the brain show that different parts “light up” when a person hears the music that is most connected to them. In other words, individualized music has a greater impact than the songs played for a group.
The music that tends to resonate most for people is that heard during their formative period of about 15-24 years old.
Dan Cohen’s Music and Memory organization has an 5-hour inservice that trains staff on how to use the devices with the residents, and answers common questions such as those regarding infection control and on securing the ipods so they don’t get lost or stolen.
The time spent by staff on the program is more than made up for in reduced time in other areas because the residents tend to be happier and more cooperative.
There have been people living with advanced dementia in every nursing home I’ve been in. They sit silently in chairs and recliners, lining the hallways or packed into the day room, where the TV creates the illusion of a pastime. This residents often seem unreachable, locked in their own private worlds, not responding to questions or efforts to involve them in activities. What if we could bring them alive again through music? In this video, Oliver Sacks, MD, provides commentary as music transforms a man with dementia. The clip is part of the documentary, Alive Inside: A Story of Music & Memory.
I always enjoy reading about senior recreation programs that offer options way beyond bingo. Not that there’s anything wrong with bingo, but when it’s my turn, I’ll be looking for a nursing home with a substantial activities schedule. A reader — thanks, RR — informed me of the success of the college-level psychology courses he organizes at his assisted living facility. (When it’s my turn, maybe I’ll teach one of those…) The New York Times article excerpted below describes a collaboration between Carnegie Hall musicians and Beth Abraham nursing home that gave residents the experience of a lifetime.
If you’ve heard of an interesting or unusual program for seniors, especially those in the nursing home, please share it in the Comments section.
Weakened by Age and Illness, Hands Teem With Creativity
By SUZANNE DeCHILLO/The New York Times
Published: February 12, 2012
Through the Musical Connections program, residents at Beth Abraham Health Services like Richard Ivory were given the opportunity to collaborate with musicians from Carnegie Hall’s Weill Music Institute in creating and performing original pieces.
Ms. Previte, 72, who is chronically ill, writes lyrics. She scribbles the words on the back of nursing home menus, mostly songs about love lost or love found.
For two weeks, she joined six other residents at Beth Abraham Health Services in a collaboration with seven chamber music players from Carnegie Hall’s Weill Music Institute, whose Musical Connections program aims to bring music to a wider audience, in healthcare settings, prisons, homeless shelters and senior service organizations.
William Losefsky, Director of Safety, Security & Emergency Management for the New Hampshire State Veterans Home contributed today’s post. I found it very touching, and I’d like to hear more ways in which nursing homes acknowledge the loss of their residents. If you have a ceremony you’d like to share with MBNH readers, please email it to me via the Contact Me button, or add it to the Comments section at the bottom of this post.
The Final Salute: One long-term care facility’s strategy to say farewell with dignity and respect
Imagine sitting down to breakfast and then noticing that one of your fellow residents is not sitting in his customary spot at the breakfast table. That is when fellow residents would first find out that one of their comrades had passed away. Earlier in the evening the resident had expired and was shuttled out the freight loading dock into a waiting hearse. This was how the death process was dealt with before we instituted the “Final Salute” protocol.
The New Hampshire Veterans Home felt that the resident was welcomed through the front door as a new admission and he should go out that same front door on his final departure. We then worked on coming up with a process that is now known as the “Final Salute.”
We put together a process in which we place an American flag over the gurney of a deceased resident. We then escort the body and lead the deceased resident to our common area by the dining room. The residents are called to attention by the resident council president. We created a short final prayer that is read:
(Resident’s Name) is now leaving the veterans home on his/her heavenly departure. May (Resident’s Name) now rest in peace. We thank you for your honorable service to your country in it’s time of need.
We then salute the deceased resident and the resident counsel president chants “two” and a uniformed security officer escorts the body down the elevator to the main entrance of the facility. The American flag is then removed from the deceased resident prior to being loaded into the funeral director’s vehicle and the flag is then ceremoniously folded and prepared for further service. We announce over the public address system that the resident has passed and we ask for a moment of silence as we ring a brass bell 3 times in somber remembrance of the resident.
Many of our residents pass away at a hospital. We designed a plan for that as well. If the resident passes away from the facility we continue to have the procession walk. Instead of escorting the deceased resident’s gurney, the security officer carries a crisp folded American flag. The security officer walks the length of the hall and stops at the exact location as if the body was at rest. The same exact ceremony is conducted with the security officer holding the flag in symbolic remembrance of the resident.
We slowly integrated having the escorting security officer wear white gloves. Many of our officers keep their shoes and boots at a high level of readiness as General George S Patton was well known for saying “You are always on parade.”
This “Final Salute” protocol has been extremely well received by the residents as they now have proper closure in saying good bye to their comrade in arms. The final salute was recognized in the Quality of Life Award in New Hampshire and was given a standing ovation.
The first time we did this, we were amazed at the military bearing that a 90-year old wheelchair-bound war veteran was able to muster. Many stood up from their wheel chairs and others had to use two hands to snap a salute due to a stroke. It greatly moved the staff as well as the residents and visitors. All we could think of is that we should have been doing this sooner.
A long-term care facility is the last home a person will have and their passing should be something more than a ride through a loading dock. My intent is for others involved in long-term care to read this article about the Final Salute in the hopes that other facilities might take up the practice in honoring their residents who pass. The process does not have to be as elaborate as ours and can build over time. I would suggest involving the residents and the resident council as much as possible.
William R Losefsky CHPA, CMI, CPM, CIRM
Director of Safety, Security & Emergency Management
Volunteering in a nursing home can be a rewarding, life-changing experience for many people and for a variety of reasons, some of which I’ve posted below. Please add your thoughts in the Comments section.
The Savvy Resident’s Guide is a quick read and a great way to get an overview of how nursing homes work and what residents are thinking. Go into the nursing home prepared. The guidebook is available on Amazon in print and Kindle editions.
1. A little goes a long way: if you can push a wheelchair safely from one location to another, or sew on a button, you can be a hero.
2. For those considering a new career, it’s a great way to see if you’re interested in working with older adults. Based on US demographics, we’ll be needing a lot of folks who enjoy working with “people of age.”
3. Feeling lonely? A nursing home is like a small town. It won’t be long before everyone is happy to see you and greets you by name.
4. It puts your problems into perspective.
5. You can benefit from the experiences of others. Learning about life from those who have lived for a while is an invaluable gift.
6. You’ll fall in love with a new oldster every week.
7. Death won’t seem so scary after a while, but rather a natural and expected passage.
8. You’ll hear living history every day, if you take the time to listen.
9. Your time commitment can vary from daily to once a year and everything in between, making it an incredibly flexible way to give back to the world.
10. As you’re referring to the “nice-looking 86-year old lady” and the “handsome new guy on the second floor,” you’ll realize you don’t look so bad either.
On Monday, I blogged about a contest
