Enhance Front Line Staff's Capacity to be Responsive Ready to Roll ? As an administrator was giving a visitor a tour of his 'culture change' facility he seemed surprised to see a resident dressed and in a wheelchair. When he asked the staff member about the resident her reply was, "none of us could come up with a good reason why she was in bed all the time so we decided to get her up and dressed and we've noticed that she seems to be more responsive to us." This staff was empowered to step outside the limits of a task-oriented environment to respond to the "persons" in their residents. Potterfield calls staff's "power to use more judgment and discretion in their work and to participate more fully in decisions affecting their working lives" (1999, p. 2), empowerment. Others may call it self-management, or employee involvement, or participative management. But whatever one calls it - it needs to be a part of culture change. Only when staff become empowered are they truly able to empower residents. (Lustbader, 2001) When a facility changes from a centralized form of management with standardized procedures to a team environment with individualized responses at the resident level, the organizational culture is altered. In order for this change to occur there must be changes in management processes and staff work assignments. Although participative practices appear to have initial short term costs for consulting and training, they are small when compared to the long-term benefits. When 150 companies were classified by their financial performance and work practices over five years and the high performing vs. low performing organizations were compared, organizations that were financial high performers also tended to have cultures that emphasized people, used a participative style of management, encouraged creativity and retained employees who had clear goals for the organization and themselves (Kravetz, 1988). Likewise, Yeatts and Seward (2000) found that nursing home teams where leaders encourage participation, where management's unspoken message is that the team holds the primary responsibility for monitoring its own performance, and where good information sharing and help can be counted on from management, were more likely to be high performing. For front line workers, "studies of the relationship between job satisfaction and turnover rates identified the management style of the organization including the promotion of worker autonomy as the most important predictor of good outcomes" (i.e., lower turnover and higher worker job satisfaction of front line workers) (Stone, 2001, p. 53). When the cost of replacing one CNA can reach $4,500 (Maun, 2002a) it also makes good economic sense to give ownership to these front line workers, allowing them to respond to residents' needs and work situations in their own fashion. Objectives relating to front line staff empowerment include: provide consistent staffing, develop self-managed work teams, eliminate middle layers of management, implement cross training for staff, involve nursing assistants in care planning, enable nursing assistants to handle scheduling, modify hiring and retention practices, and develop pro-active relationships with surveyors. When significant changes are planned, good communication with regulators is advantageous. Since staff turnover rates in Kansas are high, we have added hiring and retention practices. Remember... "Participative work practices are significantly associated with decreased turnover, increased productivity and improved financial performance." (McLagan & Nel, 1995, p.32), paraphrasing (Huselid and Becker, 1995). Provide Consistent Staffing When a network of unit-based teams serve small groups of fifteen to twenty residents and nursing assistants are consistently assigned to the same small group, they get to know these residents' needs and desires well. Trust and understanding builds. "Individual preferences are learned. Friendly greetings are exchanged. Warmth develops and care is given and received with greater ease. This consistency enables staff to trust each other enough to spell each other when patience or stamina flags. Greater emphasis throughout is on relationships, rather than tasks." (Lustbader, 2001, p. 190) "When continuity of care is not maintained there is less likelihood that the staff is aware of the many needs and preferences of the nursing home residents" (Yeatts & Seward, 2000, p. 359). When service focuses on the "holistic needs of the elderly residents instead of orienting their care around procedures and tasks. . . and where permanent assignment of nursing assistants to residents exists," elders' quality of life increases without additional cost (Cox, et al, 1991, p. 6). Less than two years ago when administrator Joanna Randall started working at Olathe Good Samaritan, half of the workforce was agency help. One of the first things she did was sit down with her department heads and 'dream' about long term plans without any fiscal restrictions. Then they began to talk about what might be possible within a two year range. They realized none of their dreams could be accomplished without a stable workforce that enabled continuity of staffing. Together, they made a commitment to end using agency staffing and accomplished that goal as of July 9, 2002. As they hired staff to replace the agency workers, they restructured job positions and started 'Operation Line in the Sand,' meaning no staff member 'hits the floor' without orientation. They have five hours of initial orientation and then have from a minimum of four days up to two weeks of training with a mentor staff member. Since the organization is no longer paying agency fees, it has been able to hire a nurse educator who does in-house CNA training, continuous on-the-floor education and in-service classes, as well as helping on the floor as needed. They also have hired part-time PRN (as needed) personnel. PRN work includes four shifts a month with two shifts on the weekends. These and other changes have allowed Olathe Good Samaritan to form neighborhoods with consistent staff. One of the hallmarks of new models of care and the use of self-managed work teams is permanent, consistent staffing. In addition to no longer using agency help, Brewster Place in Topeka combines behavior-based interviewing, peer interviews, and a comprehensive new-employee orientation process to help them make the right selections for employment and get new staff off to a good start. When someone needs to be hired for a work team, a CNA is included as part of the interview team since CNAs will be working directly with the new hire. As a result of these changes, Brewster Place no longer uses agency help and their turnover rate has gone from over 100% to 56%. They anticipate this rate will go even lower over time as their workforce becomes more and more stable. Other facilities realizing decreases in staff turnover due to eliminating agency workers and committing to permanent staffing include The Cedars, Meadowlark Hills, Mennonite Manor, Lakeview Village, and The Kansas Masonic Home. Learn More... To learn more about staff empowerment you'll want to read Dale Yeatts' work on self-managed work teams. You can find additional references in the resource section. Develop Self-Managed Work Teams "In a team environment people are not managed, controlled, or supervised. They are led by their mutual vision of the organization's purpose and its goals. The foundation of a team environment is the organization-wide system which supports the teams." (Ray & Bronstein, 1995, p.15) Self-managed work teams (SMWT), sometimes called self-directed work teams, are autonomous work groups of three to fifteen employees who handle both the technical and management responsibilities of their work. More work can be achieved because they are not only responsible for the consideration of the residents assigned to them, but they decide how the work will be accomplished each day, from scheduling to performance assessment (Yeatts & Hyten, 1998; Orsburn & Moran, 2000; McLagan & Nel, 1997). Incorporating SMWTs has the potential of increasing employee satisfaction and reducing turnover in nursing homes. Yeatts and Seward found that the nursing home whose teams they studied in depth in 2000 had a turnover rate of only 20% for the whole facility. The home had been using SMWTs for several years. The most effective teams in nursing homes are permanent, cross-departmental and include all personnel that directly or indirectly affect residents. An early model for this was Providence Mount St. Vincent in Seattle. Because many staff worked only in their own departments, they had little contact with the residents and no real ability to see things through residents' eyes. In 1990, they gradually broke up the huge departments and put staff members in small, multifunctional teams that now directly serve the groups of about 20 residents (Boyd, 1994). A neighborhood concept of service in which smaller groups of residents are supported by the same consistent group of workers makes team development possible because the team is focused on the same residents. A number of Kansas facilities including Brewster Place, The Cedars, Meadowlark Hills, Medicalodge of Gardner, Parsons Presbyterian Manor, and Windsor Place (Coffeyville) have adopted this concept. "The comparative advantage of a team is not in simple execution of the work. It is, instead, in a team's flexibility, adaptability, diversity (for example, in member knowledge, skill, and experience), and capability to learn and change over time." (Hackman 1990, p. 474) Just as small groups do not automatically become well functioning teams, teams once formed cannot consistently maintain a high level of performance unless the culture of the organization supports the teams. When CEO Monte Coffman arrived, Windsor Place was operating in the red and the state was ready to close it. His response was to create a servant leadership philosophy with his staff. Since 1995, they have met weekly to learn about new ideas and to reinforce concepts learned previously. These actions help maintain high quality performance and strengthen organizational support. Turnover has dropped every year, from 97% in 1995, to 38% in 2002. Windsor Place is now a place where numerous staff members have brought family members to live. An organization's stated and lived philosophy must facilitate and encourage employee involvement. This participation should involve the development of organizational systems and supports that enhance team performance and extend to such areas as reward, training and systems for information sharing. The organization's goals and strategies for work teams need to develop, nurture and provide boundaries to guide the work teams. This formal communication needs to clearly enumerate all constraints such as budget limitations, quality standards, legal and ethical restrictions, and technical requirements, as well as point out areas where the team has complete autonomy such as task assignments, determining training needs, and scheduling (Yeatts, D. & Hyten, C. 1998). Learn More... Servant leadership is a philosophy that advocates increased service to others, taking a holistic approach to work, promoting community, and sharing of power in decision-making. (Greenleaf, 1991) Meadowlark Hills uses learning circles to enhance team building and community. Learning circles are small groups of people who meet regularly to learn about and discuss areas of concern with the purpose of planning ways to resolve issues. Learning circles can be initiated for neighborhood work teams, residents, residents and work teams, families, leadership/management, or any configuration of people who have a need to communicate regularly. There are some factors organizations should consider and implement as they begin to empower staff through the transition to self-managed work teams. Jack Orsburn and Linda Moran (2000) identified some of the lessons learned from early adopters of self-directed work teams in a variety of business settings. They are shown in the table on the next page. Remember... "When a situation arises in which a decision must be made, the individual or team who owns the decision must decide how to decide." (McLagan & Nel 1995, p. 111) Photo courtesy of Meadowlark Hills Some Lessons Learned from Early Adopters About Self-Managed Work Teams (Orsburn & Moran, 2000) Self-directed work teams need to look to resident expectations and work flow then make decisions themselves instead of looking to a manager to tell them how to schedule and do their work. Organizations need to put in place systems to reinforce and support work teams. Self-directed work teams have to be linked to the larger organization to keep abreast of the company goals and outcomes. Managers need to know how to coach and support the team--this is particularly important during the transition phase of changing to a self-directed work team environment because new teams are very tenuous. It typically takes 18 months to shift to self-directed work teams. Team development more resembles chaos theory than a linear progression. Incidental learning is important to team development. Eliminate Middle Layers of Management Wendy Lustbader of the Pioneer Network believes that nursing homes are complex organizations that often spend too much time and too many resources to alleviate tension and conflict between departments with their multiple layers of management. Rather, there should be unit-based teams who manage their own budgets and personnel to fulfill the desires of the residents they serve. (Lustbader, 2001) Eliminating middle layers of management does not necessarily mean that staff members will be eliminated, but it does mean that jobs will change. In the early 1990's when Gary Daniels, Superintendent of Parsons State Hospital and Training Center, an ICF/MR facility (Intermediate Care Facility for the Mentally Retarded), decentralized and established person centered support, he assured his staff that he would not put anyone out of a job, but he did impress on them that everyone's job would change. Now decisions are made at the resident/team level rather than filtering through several layers of management. The outcome is a much more responsive process. Total Quality Management (TQM) is the avenue initiated by Jon Covault at Golden Heights Living Center in Garnett to analyze how well they are meeting their resident's needs and desires. TQM is a concept which infuses quality throughout every activity in a company and gives workers instead of managers the responsibility for achieving the standards of quality (Daft 1994). Golden Heights Living Center has regular quality council meetings. They have had permanent consistent staffing for quite some time because they found it was a better way to serve their residents. Once a year they conduct three customer surveys, one of residents, one of staff and one of families to see how well they are accomplishing their goals. When interviewed about how decisions were made for her household at Meadowlark Hills, a staff team member said the key was who would be affected by the decision. If it required a facility-wide policy change, it would be made at the administrative leadership level, but only with input and participation from the household teams. Very few, if any, daily decisions require this intervention. Most are made within the household by the residents and staff involved. These decisions can range from something as important as making decisions about whom to hire to as small as "do we feel like welcoming visitors in a tour group today?" One of Gary Daniel's ways of determining how well a nursing home responds to residents is by asking the question, "What would it take if a couple of your residents wanted to go to Dairy Queen for an ice cream?" If the answer is very much more complicated than "we just get in the car and go" there are probably too many levels of management. Implement Cross Training for Staff Implementing cross training for all staff levels helps establish a supporting environment throughout the facility. (Lustbader, 2001) Many organizations are re-examining the role of specialization that was developed 100 years ago. A narrow job design made it easy to train and replace workers and facilitated central control by a supervisor. However specialization leads to perceptions that 'it's not my job' and drives up the cost of doing business over time (Ray & Bronstein, 1995, p.98). Cross trained, highly capable staff are essential for supporting residents' independence and exercise of choice (Mueller, 2002). The concept is that as many people as possible in the nursing home have the ability, flexibility and responsibility to respond to a resident's need. Although one rationale has been that meeting the needs of people with dementia becomes much easier when all staff are seen as capable of helping out and have been trained in ways to respond with sensitivity (Rader, Doan, & Schwab, 1985), the philosophy is applicable to all residents. Similarly, it has been recommended that all staff should be required to get food handler's permits to put them in compliance with state and federal regulations when they want to help a resident make a snack, such as a sandwich or a slice of toast to go with an afternoon cup of tea (Boyd, 1994). If housekeeping staff are cross trained as nursing assistants, they can assist with toileting and bathing when residents prefer such help, rather than according to an institutional schedule (Lustbader, 2001). Cross training can provide variety and enjoyment for front line staff as well. For example, CNAs at Cumbernauld Village in Winfield have been cross trained to provide activities and are regularly scheduled for an 'activity shift,' just to have fun with the residents. This innovation creates an enjoyable way to help ease out of the task-only mind set that has permeated the jobs of front line workers for so long. Meadowlark Hills has cross trained their staff and no longer use the traditional job titles to designate positions. Their team leadership model includes a leader, process coach, timekeeper, scribe and team members. All team members are expected to listen, participate fully, share leadership and facilitation skills, volunteer for tasks, and accept the different team roles as needed. The team leader does not have to hold certain degrees or credentials--he or she may have been a licensed administrator, a CNA or a housekeeper. Meadowlark Hills' Team Roles are held by all team members on a rotating basis so all learn and grow; the traditional leader's role is to mentor other team members' growth. Leader - Sees the big picture, sets direction, inspires, keeps team focused on mission Process Coach - Assures all contribute, encourages focus, provides feedback on process Timekeeper - Assures keeping to agenda, reflects time regularly, clarifies time assigned for activities Scribe - Takes notes, details action steps, publishes/distributes notes, agenda, documents, etc. Implementing a new model and changing long-standing patterns of behaviors and rewards is not an easy thing to do. Brenda Thornton, administrator of Parsons Presbyterian Manor, speaks of the reluctance of CNAs to relax concerning task scheduling and spend time with residents. She says, "I can understand their reluctance; in the past I remember telling a CNA that she was behind schedule and did not have time to read to a resident now I'm saying take the time to read to residents if they want you to." Staff members are going to remember the many times they have been told to stick to their tasks. Involve Nursing Assistants in Care Planning "CNAs quickly gain personal knowledge of the residents they assist on a daily basis. CNAs learn firsthand about residents' needs and preferences, including sufficient detail to make care plans fully individualized, realistic and comprehensive. CNAs must serve as resident advocates and always be an integral part of care planning conferences." (Lustbader, 2001, p. 190) Care plan meetings bring together the resident, family members and staff to develop a formalized plan of care for their resident. Nursing assistants have not been integral to these discussions. A study by Banaszak-Holl and Hines (1996) on job design and organizational structure found that nursing homes that substantially involve their CNAs in care planning have lower rates of CNA turnover. When CNAs gave only advice and suggestions for the care plan, turnover was reduced by 33%. When CNAs participated in care planning meetings, turnover was lowered by 50%. Homes with no CNA involvement in care planning (used as controls for the study) maintained the traditionally high turnover rates. When Evelyn Walters, Cornerstone Village, was administrator at Frankfort Community Care Home, Inc., she implemented a CNA Care Advocate program. CNAs were assigned as advocates for individual residents. Assignments came from all shifts not just the day shift. The CNA was the liaison between the facility, the resident and their family. The CNA Care Advocate sets up doctor appointments, makes sure the resident's family knows when the resident needs new socks, etc., and is the primary activist for the resident. In a staffing arrangement such as this, the CNA Care Advocate is the natural selection to attend 'their' resident's care planning meetings. With only four care plan meetings a year per CNA, scheduling becomes easier. Scheduling seems to be the greatest difficulty for the many homes that have attempted but have abandoned the idea of including CNAs in care planning meetings. In the homes that have experienced such a setback, administrators seem to recognize the need to include CNAs, but encounter competing needs for the time required. Management must have a strong commitment to including CNAs in the care planning meetings and repeatedly communicate this to their teams in order for this to become a reality in the nursing home. Managing one's own schedule becomes a vote of confidence repaid many times over. Thomas, 1994; Thomas, 1999 Enable Nursing Assistants to Handle Scheduling Enabling nursing assistants to set their own schedules and to be actively involved in team development gives them control over their daily lives, which in turn enhances their capacity to ensure that residents remain decision-makers in their own care. (Lustbader, 2001) When front line workers have more control over their work, they respond with an increasingly durable commitment to providing the best possible service. They come to understand which staffing patterns are needed and begin to consult with one another. The skills of independence and problem solving gradually accumulate, as do the habits of trust and cooperation (Thomas, 1994; Thomas, 1999). Some of the neighborhoods at The Cedars in McPherson have implemented self-scheduling. The schedule is set out a month ahead. Staff note times they want to be off the schedule and their preferences for working. The team leader then uses this information to map the final schedule for the month. After the final schedule is posted staff members still have the freedom to trade and adjust times but they must get someone to cover for them without causing an overtime situation. Staff members are happier with their schedules and call-ins are almost non-existent since going to this system. Although Life Care Center in Wichita is still in the planning stage of setting up neighborhoods with consistent staffing, their dietary manager uses a similar scheduling system for dietary staff. She too believes this system has reduced her call-in rate considerably. Once teams are established they should handle their own scheduling since the team is most knowledgeable in forecasting when staffing should be heavier. When staff are aware of budget restrictions and staffing regulations, and management takes staff member needs into consideration, staff members generally are willing to work together to meet resident needs and expectations. (Lustbader 2001). In Reducing Turnover and Improving Health Care in Nursing Homes, Yeatts and Seward (2000) advocate self managed work teams where the teams "work together daily, depend on each other to get their work done, and routinely make management decisions related to their work"(p. 366). One example of the team making decisions formerly made by management is deciding who would work on Christmas Day. Higher involvement in decision making, along with team cohesion and cooperation, resulted in low turnover rates. Successful Hire Rates Traditional interviewing 14% Behavior based interviewing 55% Modify Hiring and Retention Practices Hiring an entry-level worker costs a minimum of $2,250. This cost merely includes the basics of certification, orientation, advertising, unemployment compensation, administrative costs and other direct costs found on a financial statement. Costs actually run much higher when morale issues, marketing concerns, survey compliance and overall accomplishments of the organization are included (Maun, 2002a: 2002b). The purpose of an interview is to identify and hire candidates who will perform well and want to remain with the organization. This is achieved by assessing a candidate's technical abilities, personal preferences and behavior patterns. Tests, academic achievements and related work experiences can measure technical abilities. Past behavior in specific situations will indicate more accurately a candidate's personal preferences, attitudes and behaviors. A person can have the skills and knowledge to do the job, but may not have the inclination to do it. Kansas Nursing Home 2001 Turnover Data (Kansas Department on Aging) Administration 35% Nursing (Nurses, Nurse Aides) 86% Aides (Nurse, Med, Restorative) 98% Room and Board 81% Other Health Care 40% Plant Operating 49% Behavior based interviewing is a technique from the corporate world. Employment literature indicates a strong trend towards this type of interviewing. It is based on the belief that past behavior and performance predict future behavior and performance. Thus, how someone has acted or responded in the past is probably how they will handle themselves in the future. Instead of asking theoretical questions, or questions regarding how one might behave in certain situations, the interviewer asks for specific examples of how the person did behave in past situations. This type of interview is structured and generally relies on the same set of questions being asked of each candidate for the job. It goes beyond determining whether a person can do the job. It better indicates if a person will do a good job, how it will be done and to what extent. Although more time consuming than the traditional approach, Zack & Van Beusekom (1996) found that behavior based interviewing has a successful hire rate of around 55% whereas the successful hire rate of traditional interviewing using situational questions was only 14%. A successful hire is described as a good match between the job and the employee which brings better job performance and satisfaction for the employee and lower turnover for the organization (Zack & Van Beusekom, 1996). Brewster Place in Topeka set a date after which they would no longer employ agency help. To meet their deadline and successfully carry out the no agency rule, they revamped their employment practices. All employees involved in the interview process now are trained to use behavior-based interviewing. Those involved in the interview process at Brewster Place are the director of human resources, the department head, and a member from the work team that the new employee will be joining. They now believe they are doing a better job of hiring the right people for their work teams. After making the effort to hire good team members, actively encourage their retention. Dana Rice, administrator at Minneapolis Good Samaritan Center, believes that when you provide resources for personal and professional growth, employees stay longer. Although there are scholarship programs to help staff members who wish to further their education and become nurses, many front line staff do not want to go back to school. However, even when employees are satisfied with their current positions, most still have a desire to learn and grow. Minneapolis Good Samaritan developed 'Good Sam U' as a response to the perceived need. Courses are offered outside of work hours without pay and are in three different areas: Gerontology/Long-Term Care, Life Enrichment and Work Performance. Some classes are available in the community, such as financial planning and drug addiction education; others consist of videos and reading with a post test. 'Good Sam U' is open to all staff members. After successfully completing 15 hours in each area participants receive a certificate and a pay raise in addition to their normal annual raise. Photo courtesy of Windsor Place Develop Pro-Active Relationships with Surveyors "...Nursing home regulations are blamed for routines, for facility-developed house rules, and for cost-saving measures." (Kane, 1995, p. 83) The survey process is perceived as such a threat that many nursing homes will devote considerable energy to eliminating as much risk as possible (Freeman, 1990; Lustbader, 2000). It is not that regulations do not permit the culture change initiatives that would enhance resident autonomy and choice, but that providers fear they may be judged poorly. Many providers in Kansas feel that the key to successful change is pro-actively developing lines of communication with state regulatory agencies as well as their own regional surveyors. Discussing possible change interventions before they are implemented assures greater understanding and collaborative efforts to comply with regulations while redesigning care models. " The spirit of cooperation between long term care providers and surveyors is the fuel of creation, resulting in new models of care that move the quality curve forward, enhancing the lives of those we mutually serve." Joseph F. Kroll, Director Bureau of Health Facilities Kansas Department of Health and Environment The administrator at Mennonite Manor, Judith Wineland, suggests that part of their success with the survey process is nurturing a professional relationship with surveyors. That process includes reciprocal open lines of communication. She felt that the relationship improved when she and the surveyors discussed behaviors used during the survey that seemed intimidating to the staff. Dawn Veh, administrator at Wesley Towers, Hutchinson, who also has been very successful in developing cooperative relations with surveyors, has taken a different approach. The team has chosen to approach the regulatory process as though it were a challenge or a game and they win by learning the regulations front to back. In fact, she uses her regulatory notebook as bedside reading. The staff are also expected to know the regulations well so they'll be able to respond to the surveyors if they express a concern. This knowledge also allows staff to be more creative about how resident desires can be met while still complying with standards and guidelines. Another regulatory issue involving surveyors is quality assurance. Wesley Towers' Quality Assurance Program is based on continuous service improvement and has been quite effective. Teams meet monthly to discuss issues and current reading assignments. Staff members volunteer for one of ten teams which discuss: upkeep of the survey book, infection control, incidents and accidents, wound and skin care, and behavior. One team is called the 'paper' team and is charged with reviewing all the forms used by the organization. Initial improvements were "huge" after the committees were first formed but continue now as baby steps. Occasionally the organization's teams will conduct their own research related to the things they are studying. They did a hand-washing study, but the amount of research is limited by the lack of time for data collection. Establishing a Home A Moving Experience For many years, Mrs. Forsythe lived in her cherished apartment at Bluestem Park Village, surrounded by friends and staff members she loved. Always highly opinionated, she had fashioned an independent life for herself and she wasn't about to let anything change that, even when she suddenly had to be hospitalized. After many talks with her daughter, she decided to move into the health care unit. Because the staff knew her so well, they helped Mrs. F. and her family to maintain Mrs. F.'s identity with the move. She brought her bureau, draperies, and some other prized possessions with her to her private room. Once a week, as had always been their custom, she enjoyed a glass of wine with her best friend in the evening. Because the staff knew her well, it was easy to help her to develop her own schedules. Mrs. Forsythe was never able to return to her apartment before she died, but she, her daughter, and the staff who loved her felt good knowing that she was at 'home' to the end. What are the first things that come to mind when you hear the word 'HOME'? What is most important to you? When people are asked to define what 'home' means, mention of physical aspects come long after words such as security, privacy, family, comfort, and the like -- all feelings rather than just physical structure or objects. Many things from the past as well as in the present contribute to these feelings. Thus, objectives in this section include to promote a sense of community, include family members in decision-making, redesign institutional structures, and create a holistic environment. Although regulations decree that nursing homes provide a homelike environment for residents, for many residents the nursing home in reality is their final home. For example, some places use the term household to emphasize the concept of residents establishing a new home for themselves. Over the past ten years, many researchers have worked to define the essence of what a long-term care setting should provide to include basic aspects associated with 'home' (Regnier, 2002). The Home Quality Framework, which identifies social, organizational, and environmental expectations is one helpful way to think about these needs (Brummett, 1997). Brummett's Home Quality Framework Self-Protection / Self-Symbol A place where you can express your identity and have it reflect how you expect to be perceived by others Vessel of Memory / Vessel of the Soul A place that holds objects and symbols that represent memories of your personal family life Connectedness / Belonging A place where you give and receive affection and love and connect with family, friends and peers Center / Origin A sacred place from which you move out into the world Familiarity / Order A place of comfort and relaxation that you know and understand well Stability / Predictability A place where relationships are known to you and change only when you wish Privacy / Territory A place for reflection and solitude and that allows you to set clear boundaries and control them Security / Safety A place that offers you sanctuary and shelter from the elements and unwanted intrusions Control / Autonomy A place where you can exercise control over your environment Choice / Opportunity A place where you can explore your interests and engage in interactions with others (Brummett 1997: Regnier 2002) Promote a Sense of Community "The life of the community provides a structure for belonging, a collective voice, and a place for individuals to tell their personal stories." (Lustbader, 2001, p.192) Most of us recognize differing levels of community. It is possible to feel a sense of community within our workplaces, within our households, within our neighborhoods. A community may be broader in scope and be our town or the surrounding rural area or a school district. While the physical environment does not define community, it can help structure it. Environments and even their names can create unique types of communities within the nursing home. "Let's use a 'household' as an example....In most people's experiences, a household is more than simply a collection of bedrooms with an associated staff work space. A household suggests a style of interpersonal relationships more casual and like family which are based on patterns of close-knit living activities." (IDEAS Institute, 2003a, p. 2) Small households can help family members know the other residents better, and they often include them in their visits. Families are also more at ease coming to group gatherings. Site visits have allowed us to discover that each organization thinks about community differently. Some foster close inter-personal relationships within 'households,' while others embrace a larger 'neighborhood.' A few have indicated to us that they have lost some of the larger community sense with the restructuring of their physical environments into smaller residential units. Most organizations do not have the luxury of having the space for both large and small communal living. Liberal Good Samaritan is one of the rare organizations that has had ample room for creating a variety of communities. Residents may gather in their own neighborhood living areas but the day we visited many of them were singing with staff members in the large group living room. Other residents were enjoying the pleasant weather in the central courtyard with the in-house day care children. Communities can celebrate the rituals of life through daily gatherings. "New members are welcomed, teachings are shared, the events of the world are discussed and the passing of friends is mourned" (Lustbader, 2001, p.192). Problems in the community may be heard. Sometimes solutions will be reached, sometimes not, but it may be enough just to be heard (Barkan, 1981). These 'meetings' can be informal such as the 'coffee klatches' at Mennonite Manor in South Hutchinson or formalized through 'learning circles' which are regularly held at Meadowlark Hills, Manhattan. Another way to create or sustain community is to take on group volunteer projects. At The Life Care Center in Wichita, Diane DeLoach, activity director, involves residents, staff and family members in volunteer projects. During the Christmas holiday season, they were collecting shoe boxes and filling them with toys to send overseas. Working together to help others is a good way to create a sense of common goals and feeling needed. For additional ideas about creating a stronger sense of connection with the larger community as well as the immediate living environment, see 'Enhancing Community Involvement' on pages 68 to 75. As Dorothy said, "There's no place like home." Include Family Members in Decision Making "Inviting family members into the decision-making process is especially important when risks must be taken to promote their relative's autonomy and freedom of expression. Once they feel fully informed, most family members become willing to take calculated risks in the interest of improving their relative's quality of life." ( Lustbader, 2001, p. 191) Families perceive good quality care by the staff as largely dependent on family participation and input (Bowers, 1988). In addition, the provision of good quality care requires a collaborative process between family and staff rather than a division of tasks between them. Family involvement in nursing home decision making serves to individualize care and provide a continuing link to the resident's personal history and preferences (Rowles & High, 1996). Knowing this vital information is essential in order to provide the alternatives and specific activities that create resident-centered support. At Larksfield Place, in Wichita, family members are provided with a written Job Description to help them with their new role. The job objectives are to "Provide information and other support that will provide the highest quality of life for his/her loved one during their stay at the Health Care Center at Larksfield Place," and 20 essential functions are described. The staff of Lakeview Village collaborate with family members of residents to create a resident history which is hung inside each resident's door. At this point the life histories are forms printed in large type on 11 X 17 paper and include information about former careers, hobbies, where they grew up, likes and dislikes. However, other ideas could be to type the histories in story form on decorative paper and then frame them, or to create a framed collage of written and pictorial materials. Developing these kinds of histories might be a project for an intergenerational program. Admission to a nursing home is a major life event both for older people and for family caregivers, who can benefit from orientation and family support programs. There is a need to create a partnership between staff and family to facilitate the care of the older person and the family's need to remain involved. Family members mentioned that attending a voluntary, professionally led family support group was helpful (Nolan & Dellasega, 1999). Photo courtesy of Windsor Place Family members u Do not give up their involvement in the life of their older relative when they move to a nursing home. u Feel that they are the ones who take the initiative to establish a working relationship with the staff at the nursing home. u Want more spontaneous information from staff, particularly about the relative's daily life. u Need for relatives to have opportunities to talk with staff under relaxed conditions. u Generate many feelings based on staff behavior toward both the older relative and the family. u Do not communicate their understanding of the challenges faced by staff to that staff, nor do they explicitly tell staff about positive or negative experiences (Hertzberg, Ekman, & Axelsson, 2001). Brewster Place offers an orientation program for families of new residents. In addition to a booklet that answers commonly asked questions, a staff member contacts family members within 48 hours of admission to make plans to meet with the family and to see if they have any immediate questions or concerns. Instead of simply handing family members their handbook for residents and family that lists key personnel and explains the services and practices of the community, they meet face to face with individual families to describe the Health Center's vision, mission, and philosophy. At the same time, they provide information about services families can expect to receive, resources available, schedules, staffing patterns, care plan meetings, as well as address any concerns the family members may have. Re-Design Institutional Structures "Universally, homes function for people in so many important ways, both physical and psychological, that they become symbols that involve all aspects of our lives." (Frank 2002, p. 9) Although the physical environment does not determine a sense of community or being at home, it plays a critical role in these outcomes. Even facilities that are unable to undertake major renovation can establish home-like features in selected areas, make adaptations, and institute practices which create a feeling of being at home. Architectural renovation can allow for both privacy and community (Lustbader, 2000). These 'baby steps' typically are quite affordable and do not cause as major a disruption as that created by complete remodeling. Wesley Towers has made design changes in both their dementia care and health care environments that provide examples of modest changes that have clear resident outcomes. The goals of the redesign for Ralph Thorne Center at Wesley Towers were to make an isolated and spread-out environment more manageable and to provide a home where residents had better control and wayfinding/orientation cues. Decisions were guided by the eight therapeutic goals for such environments that could be measured using the Professional Environmental Assessment Protocol (Cohen & Weisman, 1991; Lawton, et al, 2000; Norris-Baker et al, 1999): safety and security, orientation and wayfinding, provision of privacy, support functional abilities, quality and quantity of stimulation, opportunities for personal control, facilitation of social contact, and continuity with the past (memories, familiarity). The renovation addressed these goals in ways that were meaningful for many of the residents who came from more rural backgrounds: creating a country kitchen and dining area, and a living area connected to a covered porch and secure garden area. The redesign required giving up a total of four rooms, two on each wing. A number of positive outcomes were noted. The temporal and activity patterns made possible by the new design made residents more comfortable and provided a stronger connection to past routines (being aware that a meal was being readied in the country kitchen, etc.) Two notable resident outcomes were the success of dining (resident weight gain became an issue) and the reduction of agitated behavior. Staff retention increased substantially, and some staff in other locations requested reassignment to Thorne. Several families of cognitively-able residents living in heath care even requested that their family members be transferred because of the qualities of the remodeled environment. Knock, Knock.... The impacts of the design changes, such as front door entrances to households, was noted by a family member coming to visit her mother for the first time since the remodeling. The daughter contacted the administrator to ask how to get in to see her mother. When he suggested that she ring the doorbell and someone would come to the door she was at first put off, "You mean I have to ring the doorbell to get in to see my own mother?" The administrator responded, "It's between you and your mother how you come and visit her in her own house." The idea that her mother was 'residing' in a place like a nursing home was so foreign to the daughter that at first the concept of a front door to the house was not associated with the setting she had been accustomed to visiting. Meadowlark Hills Photo by Lyn Norris-Baker Hester Care Center: After*Hester Care Center: Before** Plans courtesy of Migette Kaup, IIDA A more recent project at Wesley Towers has been the remodeling of the Hester Care Center (providing skilled health care but not dementia care) to increase opportunities for resident autonomy and independence as well as easier access to dining and social activities. One room on each of the four hallways was sacrificed to create a living and dining space (with adjoining porch and courtyard access) for residents living on that hall. In order to maintain the same number of residents, several private rooms were converted to accommodate two people. In order to maintain continuity with many residents' past experience at Wesley Towers, the environment was designed to be similar to the independent living apartments. Outcomes of this renovation are still being documented, but it is clear that reducing the very long distances required to reach the dining/activity room has decreased the time and dependence on staff required. Another consequence is the greater flexibility residents have in their routines and the energy residents can now devote to activities other than coming and going from meals. A number of organizations, including Liberal Good Samaritan Center as well as Wesley Towers, have chosen to give up some resident rooms or transform private rooms into two-person rooms in order to increase the common spaces as they converted to a neighborhood model. Tom Shumate, the administrator of Liberal Good Samaritan Center, noted this can require readjustment of staffing levels as well as reconfiguration of spaces. Since both financial limitations of some residents and the need to create households or neighborhoods may require the continued use of two-person (not semi-private) rooms, innovative ways to enhance privacy in these spaces are essential. Olathe Good Samaritan, Aberdeen Village and Meadowlark Hills are some of the organizations in Kansas which have enhanced privacy in shared rooms. One option is to construct a wing wall perpendicular to the exterior wall, dividing the room so that each person has a window. Another option when room size exceeds the minimum is to construct a wing wall parallel to the exterior wall with a window for ventilation and access to a natural light between the beds, in addition to the traditional privacy curtain. In some cases, the bathroom opens onto a transitional space between the public hallway and the resident's individual space. Crestview Manor Photo by Gayle Doll Simply creating smaller living and dining spaces is not enough. Furnishings and activities in those spaces must do their part in making a home. For example, the 'country kitchen' is a popular design alternative to provide both activities and meals for a household. However, it is easy for this space to be underutilized for both routine and special activities if residents and their families are not actively involved . By contrast, the country kitchen in Meadowlark Hills' memory-support assisted living household is used extensively. In addition to typical meals and activities, residents enjoy many social and family events, such as tailgates during football season and birthday parties. Another example is providing ways to personalize the living areas. Are residents encouraged to bring their own furniture into this space as well as into their bedrooms? Are there the kinds of opportunities for activities that residents are used to doing in their own living or family rooms, such as watching television or playing the piano? Are there display spaces so that residents can share important mementoes and pictures with other members of the household? For example, at Larksfield Place residents' photos are grouped together in a display. At Meadowlark Hills, the shelves in one household contain a group 'family portrait' of all the residents intermingled with portraits of both resident and staff families. Wandering and pacing also need to be accommodated creatively. Providing areas that are both agreeable and safe for residents to move through may reduce burden for the nursing staff and provide more comfort and satisfaction for all residents. Larksfield Place Photo by Linda Gray Creating Residential Spatial Relationships and Privacy Adapted from 'The Familar Institutional Model and Shape of Nursing Home Behavior' by Migette Kaup (2003) The spatial order of the design before the remodeling mimics the dominant pattern for many health care facilities built since 1960 (Schwartz, 1996). It organized the most public spaces, corridors where all persons at the facility (including visitors) circulate freely, in direct relationship to those spaces that should be the most private in a residential setting, residents' personal sleeping spaces and bathing areas. The transitional features between these polar ends of the privacy hierarchy were limited to individual doors to buffer the sights and sounds of public activity. This approach to nursing home architecture was most certainly a response to regulations that required that all resident doors be visible from the nurses' station. This requirement, however, can now easily be achieved through non-obtrusive observation using video technology. Another problem is the lack of spaces that are semi-private. Based on the large groups and variety of people who come together in the rooms associated with eating meals or watching TV, these domains take on semi-public patterns of behavior. Semi-private spaces in the original plan were reduced to one or two isolated rooms designated for resident use with their families such as quiet rooms or 'parlors.' The result is an overall environment that is perceived by residents as belonging 'to someone else.' This lack of spatial identity and sense of ownership by residents was noted in early discussions with administrators and became a primary design criteria for the new spaces. Two key design concepts were used to respond to these needs: residential scale and spatial organization. The larger environment was divided into three distinctly identifiable households, reducing the scale of areas that are shared by an identifiable group (See 'After' plan). This reduced scale supported the objective of increasing the residents' ability to identify with a family unit. The second key feature was the access to each of the households. Each household has a unique residential front door with a doorbell that is used to request entrance to the semi-public social space within the household. Meadowlark Hills: Before** Meadowlark Hills: After* Plans courtesy of Migette Kaup, IIDA Architectural features now provide the full continuum of public to private spaces starting with a transitional space created at the front porch and then continuing past the front door. Once a visitor is invited into the home, they step into a social area that includes both a living and dining space. These spaces are connected visually to the outside and natural daylight flows into the setting. Bedrooms and bathing areas are beyond the living room, down a transitional corridor that reflects a similar arrangement to a typical single family home. The opening to the hallway is reduced and the lighting in the hallway is slightly dimmer signaling a transition to more quiet semi-private and private spaces beyond. Spaces for residents and their 'invited' guests are along this transitional space. Residents go to bathing rooms or other private and semi-private spaces without having to cross over semi-public or public domains, thus increasing privacy and dignity in a way that more closely models traditional residential patterns. Within each of the households, dining and entertaining activities are supported in semi-public spaces through the presence and placement of furniture and equipment that is reflective of patterns found in a home. For example, residents often display 'family pictures' of activities that they engage in as a group in the semi-public living rooms of their household. Similarly, in semi-private spaces, rooms for domestic tasks are equipped with features that allow residents (and their visiting family members) to launder personal items independently in a location that is convenient to their private bedrooms. These levels of personalization within spaces contribute to a new perception of what it means to live in a nursing home. Care staff have documented changes in the behaviors and expectations of residents and their families as they have interacted in the new spaces over time. They note increased visitation, socialization, and relationship building among residents within the households as well as families of residents. Create A Holistic Environment "The idea is to so thoroughly infuse the nursing home environment with normal life that the transition between the home and the outside world is seamless." (Barkan, 2003, p.2) Advocates of new models of care believe that nursing homes must be holistic environments that are connected to the natural world that surrounds us. For example, a major component of the Eden Alternative is the incorporation of plants, animals, and children into the environment, and the Pioneer Network believes that dogs, cats, birds, plants, children, and gardens accessible to everyone can help transform an institutional environment (Lustbader, 2001; Thomas, 1994). Access to the natural environment provides an always changing source of stimulation that requires little effort to appreciate. Being aware of nature and changes in seasons, weather, and time of day can both help maintain a connection to the larger world and assist with orientation to time and place. Having access to developed outdoor areas either through being directly in the environment or being able to view it through windows is important for residents and staff. People exposed to stressful conditions (similar to those a nursing home resident might experience) recovered faster from the stress, and reported more positive feelings, when exposed to the natural environment rather than an urban one (Ulrich, Simmons, Losito, Fiorito, Miles & Zelson, 1991). Although actual access is preferable, even simulating the natural environment can help. The Apostolic Christian Home in Sabetha has a high acuity wing situated in an older part of their building. They were aware that other residents and visitors thought of it as a place to die and a place to be avoided. To counteract this tendency, a 'neighborhood street' effect was designed. Local talent was used to create murals and an outdoor feeling for very little expense. The positive outcome has been that this hallway is now one of the most frequently visited locations in the building. One study simulated two different environments in two different hallways a home and an outdoor natural environment. They added benches and used inexpensive materials including visual cues (posters of natural landscapes or home scenes, plants, a sitting area for home), auditory cues (audiotapes of appropriate sounds), and olfactory cues (aromatherapy scents suggesting home or nature). Residents spent more time in the enhanced hallways than when no changes had been made, and sat on the benches more often (Cohen-Mansfield & Werner, 1998). Residents with cognitive impairments showed a trend toward less trespassing, exit-seeking, and other agitated behaviors, and were observed to show more pleasure in the enhanced hallways. Staff members and family members expressed a preference for either of the enhanced environments over the regular one, and for the natural environment over the representations of home situations. Liberal Good Samaritan Center Photo by Gayle Doll Liberal Good Samaritan Center has taken bold steps to enhance the holistic quality of their environment. Replacing the centrally located nurses station with an indoor courtyard including natural lighting, live plants and a large fountain, provides a feeling of being outdoors. The sound of water is calming and the natural materials used to construct the fountain are visually pleasing. The pond contains several gold fish as well as a turtle. A brick walkway leads from the entrance and encircles the fountain. Park benches are placed around the fountain. All of the work on this fountain area was done in-house which adds to the sense of ownership. Many facilities are currently working on similar projects, including the Parsons Good Samaritan Center. They also have created an indoor area with a pond where their nurses station once stood. Brewster Place wanted to improve an existing enclosed courtyard area which is visible through large picture windows in the corridors and from residents' rooms. The administrator, staff and residents worked together with Professor Chip Winslow and graduate students from the Department of Landscape Architecture at Kansas State University to design a garden that used Eden Alternative principles to stimulate all of the senses. The project was funded through private donations and named gift opportunities. A local nursery did the plantings and the local fire department constructed a children's playhouse as a service project. Sculptures were provided by a local artist whose parents reside at Brewster Place. The final project is a lovely place where residents and their families enjoy gathering, and where staff enjoy activities such as cookouts. Brewster Place Photo by Gayle Doll Exterior environments that are part of many nursing homes often are underused. Reasons can include lack of awareness of the benefits to residents of being outdoors, concern of exposing residents to heat or cold, and lack of staff training on creative ways to use gardens and courtyards for activities. Positive physiological outcomes of exposure to sunlight can include a cost-effective way to increase the synthesis of Vitamin D, reduced anxiety and stress hormones, reduced blood pressure, better regulation of circadian rhythms (appreciated by night staff in particular), and alleviation of seasonal affective disorder (Brawley & Troxel, 2002). At times of the year when using exterior courtyards is limited, sunrooms can provide some of the same solar benefits. A frequent stereotype of designers is that all older residents wish to do is sit and watch, so providing flowers and birds is sufficient. All one has to do is think of residents with dementia to know that this is untrue, and that any outdoor space must provide for walking and activity as well as watching. Outdoor spaces, patios and sunrooms can integrate use by visitors as well as residents and staff, providing interesting activities to watch. Warm and inviting areas to sit allow children to play outside while residents can watch and visit with the adults. Plants can serve a number of different purposes both inside the home and in adjacent exterior spaces. As described on page 18, opportunities for residents to be responsible for the care of a living thing such as a plant can foster feelings of control and enhance quality of life. For many older Kansans, nurturing plants, whether in their homes, gardens, or fields, has always been an important aspect of their lives, and the activity sustains continuity with the past. Being able to see and care for plants creates positive connects to a familiar past. Plants can also provide aesthetic and functional benefits. Various non-toxic plants can provide not only visual interest, but opportunities for touch and smell, while seasonal blooms can remind residents what time of year it is. Potted plants can be moved in or out of doors as the weather warrants. When used in large spaces, they can create visual separation to provide smaller, more intimate areas within the larger room. This is particularly useful in large activity and dining rooms. Brewster Place has many plants in their sunroom in special care. A person from a local nursery comes periodically to check to see if any of the plants donated by family are toxic. Sandstone Village Photo by Gayle Doll Involving children in intergenerational interactions is another aspect of creating a holistic environment; these initiatives are discussed as part of the section on 'Enhance Community Involvement.' Many Kansas nursing homes are enjoying the benefits of pets in the facility. A recent study found empirical evidence to suggest that as little as 30 minutes per week spent with animal assisted therapy reduced loneliness significantly (Banks & Banks, 2002). Special considerations are necessary when bringing animals into the facility. Will they be happy adapting to community life in the nursing home? Are there residents who will be made uncomfortable? Most organizations require a screening period to see if the animal will fit in. Costs must also be considered - in addition to basics such as food, there are items like veterinary care. It may be possible to find community resources to help. For example, Sandstone Heights in Little River has found a veterinarian who will provide free services. There are many success stories. One is Mennonite Manor, where residents are encouraged to bring their own pets, and where more than 30 cats, dogs, birds and fish reside.