ABOUT THIS MODULE
  
  Included here you will find 11 pages of a 38 page educational module
  which is intended for use by nursing homes who wish to promote more
  social, nontraditional models of long-term care. The intent of the PEAK-
  ED project is to assist organizations in implementing progressive,
  innovative approaches to care that should make a significant difference in
  the quality of care and the quality of life for those living and working in
  long-term care environments.
  To receive the module in its entirety, please send an email to
  gerontology@ksu.edu with the following required information:
  
  þ    Name of Individual and title
  þ    Name of Organization/Facility
  þ    Complete mailing address including zip code
  þ    Telephone number
  þ    Email address
  
  A CD (or email attachment when possible) will be sent with the module
  along with forms to complete which will enable our project to track the
  number of people and hours spent reviewing/implementing these ideas.
  CD's will be sent free of charge to any nursing home in Kansas, and will
  be sent to those outside Kansas for a fee of $24.00 to cover costs of
  materials, postage and handling. For further information on the PEAK-ED
  project please email gerontology@ksu.edu.
    
  
  Pioneering
  Change
  
  Creating Home
  Education Module
  
    to
  Promote Excellent Alternatives in Kansas   
             Nursing Homes





Table of Contents
Creating Home

Course Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Pretest . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 
Creating Home . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 
     Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
     Creating a Community of Care . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
     Activity: Understanding Environmental Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 
The Human Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 
     Person-Centered Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . 10
     Involving Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 
There's No Place Like Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
     Plants and Animals Improve Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 
     Aesthetics are Important . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . .14
     Providing Visual Pleasure and Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 
Building Happier Residences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .16
     Making Bathroom Functionality Comfortable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
     Redesigning Dining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
     Using Outdoor Spaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
     Activity: Starting a Garden . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Designing for Community and Comfort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 
     Implementing Environmental Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 
     Changing Perceptions and Building Community Support . . . . . . . . . . . . . . . . . . . . . . . . 28 
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . 31
Post-test . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Pretest and Post-test Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 
Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38



Course Objectives:


     1. To instill a better understanding of the important role environmental factors play in the
          development of community and culture of a nursing home.

     2. To develop an appreciation for how fostering resident, family, and staff interactions
          and cooperation in decision making can improve relationships and quality of life.

     3. To recognize the importance of structural redesign and innovation as a key component
          of culture change in nursing home care.

     4. To consider how environmental culture change can improve relationships with the
          larger community.

     5. To understand how all of these factors come together to create a more holistic and
          healthy nursing home environment.

Creating Home
                                
Introduction

Previous modules examined how human
interactions can improve the overall
culture and quality of life in nursing
homes.  In this module human
interactions and behaviors will be
considered within their overall
environmental context.  Nursing homes
are interdependent, interconnected
networks.  The goal of a nursing home
should be to make those environmental
networks holistic, proactive, and
mutually supportive communities of
care.   In order to do so, it is important to
first understand how the term
environment is used in this module.

The environment, quite simply, is
everything that composes a given
community.  The environment includes
the people, plants, animals, and nonliving
things in that community.  For our
purposes, the environment consists of
residents, their families, staff, nurses,
administration, hallways, plants, animals,
carpeting, bathrooms, lights, walls, and
anything else that is found in a nursing
home.  All of these things come together
to form the environment as is shown in
this diagram. 


Activity

This module breaks tradition with the
layout of previous modules, just as
nursing homes are breaking tradition in
their approach to residents' care.  Unlike
previous modules, the activity for this
section appears at the beginning instead
of at the end.  Before continuing, take
some time to do this activity.  Eventually
it can be done with staff and residents as
well. 



Think about this
question: What
makes a home a
home?  There is no
right or wrong
answer here, just write
down thoughts and feelings. 
Do not feel limited to the space provided
here, use a separate sheet if more space is
needed. 
_________________________________
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Now consider the following:  What are
the various factors (anything from people
or architecture, to animals, food, etc.)
that make a nursing home different from
a traditional home?  How are human
relationships different? 
_________________________________
_________________________________
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_________________________________
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Take a moment to consider what you
wrote.  Most likely all of the items listed
relate to the various environmental
factors that exist inside a traditional
family home or a nursing home.  Think
about this module as a tool to use in
bridging the differences listed above.

Creating a Community of Care

Fostering and maintaining positive
environmental changes within a nursing
home can lead to dramatic
improvements.  Imagine a home where
residents are happier, more 
active, and more content.  Family
members are more supportive of the
home and are involved in the care
of their loved ones. 

Staff enjoy their work and develop
meaningful and lasting relationships with
the residents and their family members. 
All of these positive changes can be
encouraged through effective
environmental design and innovation.

The ultimate payoff of effective
environmental change is the creation of a
more holistic environment.  This is an
environment concerned with the person
as a whole rather than concentrating on
the individual components of a person's
life.  Environmental factors can help
reaffirm resident autonomy and dignity
and encourage family involvement in
resident care.  Environmental
innovations can help create and support a
proactive network of caregivers working
to meet residents' physical, emotional,
spiritual, and intellectual needs.  Those
same innovations can also help build
more positive relationships with the
community outside the nursing home.  In
short, effective environmental
management can transform a nursing
home into a caring community.

This module examines several nursing 
homes that have (and are) adopting
environmental modifications of varying
types to improve the lives of their
residents.  It outlines how environmental
change can help foster a greater sense of
community within care homes and foster
family involvement in care giving
decisions.  Further, it examines how to
create structural designs that reinforce
community and cooperation and how to
modify existing spaces to increase their
homelike feel and usability.  In
conclusion, it looks at how positive
environmental changes within a home
translate into improved relationships with
the larger community a home serves.  All
of these innovations and examples,
collectively, can help create a more
holistic community.

Case Study

Looking back, Edna remembered how
she'd often thought of Harbor Sunset
Retirement Center as being "like a
hospital" when she first arrived.  For the
first four years she lived there a
centralized nurses' station sat in the middle of the building's
four long residential wings.  This made her
feel it was always easy to locate a nurse. 
When renovations and additions to the
building began Edna had worried it would
become more difficult to access direct care
due to the removal of the central nurses'
station.

Now that the initial renovations were
complete, Edna realized the nurses were
still there when she needed them even
though they weren't constantly visible. 
She had grown to enjoy the smaller
community spaces where residents could
gather to talk with one another.  It was
easier to communicate without the noise
and bustle of the old nurses' station. 
Something about not having the nurses'
station in the middle of the resident
community made life seem more normal. 

When they renamed the home Seaside
Village, it seemed to signal the beginning
of a new community, not the end of a
journey.  Edna felt truly at home in the
newly remodeled space.  "A new home,"
she thought.  "Yes, that's exactly what it
feels like now."

Discussion: Take some time to reflect on
the following questions. You may wish
to use them to begin a group discussion:
     
1. Where are the social centers in your
nursing home?
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2. If residents and staff are currently
congregating at a nurses' station for
social reasons, where might this
interaction be encouraged if the station
was removed?
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_________________________________
_________________________________
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_________________________________

3. How easy is it for residents to access
help so they feel secure?
_________________________________
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4. How could this sense of security be
maintained if the central nurses' station
was removed?
_________________________________
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Activity: Understanding Environmental Interactions

The following activity is very flexible.  It can be done privately by administration and/or
management to gain a better appreciation for how environmental factors influence one
another.  It can also be incorporated into brainstorming sessions with staff, residents, and
family members by using a poster board or presentation easel to help them think about the
nursing home in an environmental context.  Positive environmental factors can be
considered, discussed, and improved over time through feedback and cooperation.

Consider the following environmental factors.  Under the appropriate headings, write the
potential benefits and drawbacks of each issue.  Think about how these factors can be
improved.  Some of the items listed may not be relevant to your particular nursing home. 
Might they provide some benefit to residents and/or staff if they were?  Why or why not? 
Feel free to add other examples for consideration and discussion.                 



Environmental
Factor
How can this
factor
potentially
affect residents?
How can this
factor affect
residents'
families?
How can this
factor affect
staff?
Who else
might be
affected by this
factor? Why?


Room size(s)
Carpet or wall colors
Pictures
Bathroom design
Plants
Animals
Other:

There's No Place Like Home

The "nursing home" of today did not
exist prior to the 1960s. The creation of
Medicaid and Medicare mandated that
persons with chronic diseases could not
live indefinitely in hospitals. No one had
any idea where these people should go,
so someone decided that new homes
would be created using a
hospital design. While these homes were
meant to be residential in nature, they were
developed using a medical model and
became clones of hospitals. This is why
older nursing homes little resemble
"homes."

Quality of life in nursing homes is
heavily dependent on resident comfort.  
There are few things in life people enjoy
less than going to a hospital.  If a nursing
home feels like a hospital, how
comfortable can the residents possibly
be?  Hard floors, nurses' stations,
regimented cafeterias, bare walls, and
equipment laden bathrooms can all take a
psychological toll on a resident. 
Hospitals can instill a feeling of
helplessness as patients must follow the
facility's established rules and the
decisions made by their physicians;
patients often feel they have little control
over their lives (Allshouse 1993).  If a
nursing home feels like a hospital, it can
send the same message to its residents. 
Nursing homes should feel like a home 
first, a community second, and a place of
physical health care somewhere down
the line.  The visibility of professional
healthcare and its intrusiveness into the
lives of residents should be minimized
without diminishing its availability.

Plants and Animals Improve 
Quality of Life

Almost every home in the United
States has a plant of some type.  The
presence of plants tends to have a
soothing and calming effect on
people.  Houseplants also
improve the indoor environment by
purifying the air of gases released by
humans and synthetic materials while
releasing more oxygen (Wolverton
1996).  Plants can improve the aesthetics
and quality of life in a nursing home as
well.  Indoor plants provide all residents
easy access to plants and their benefits,
so the Eden Alternative suggests that
nursing homes focus on plants inside the
home before focusing on outdoor
gardens (Kreidler 2002).  Care must be
taken when nursing homes are selecting
plants to use inside to avoid plants that
trigger residents' allergies.  More
information about the use of plants in
nursing homes will be provided in the
next module about nursing home
activities.  

Animals can bring joy to residents'  lives
as residents interact with and care for the
animals.  Care must be taken to ensure
that any animals brought into a home are
well groomed and of a friendly
disposition.  Research suggests that it
may be better to begin with smaller, less
excitable dogs and/or cats than large,
boisterous animals (Sampsell, 2003). A
few residents may not enjoy animals or
may have allergies, so any visitation by
or adoption of animals at a nursing home
should be done with residents' concerns
and feedback in mind.  Of course,
animals introduced into the community
should be free from any detectable,
transmittable illnesses (Weinberg, Fuchs,
Pals, and Call, 2004). 

Some nursing homes have adopted the
Eden Alternative, a program which
includes integrating plants and animals
into the home in addition to other culture
change innovations.  Other care homes
utilize approaches that work for them. 
At Wesley Towers in Hutchinson,
Kansas, the administration
continues to integrate
plants and animals into the
community where
appropriate.  Among the
home's permanent animal
residents are birds in three
aviaries.  Other animals
come as companions to
human visitors of the home.

Occasionally, tensions have surfaced
when nursing homes have initiated plans
to include plants and/or animals without
significant resident feedback.  Whether a
care home incorporates them on its own,
or decides to incorporate them as part of
a pre-existing program like the Eden
Alternative, the decision should be made
with the full participation of residents,
their families and staff.  The goal is to
build a better home for those being
served.  Decisions that alter the living
environment within a home should be
made by the people who live there.
More information about pets and plants
will be offered in the next module about
nursing home activities. 

Aesthetics Are Important

If a person went to a friend's home for
dinner and saw linoleum flooring, plastic
commercial grade chairs, and a cafeteria
style folding table they probably
wouldn't find the dining area very
homelike.  Choosing the appropriate
furnishings, floor coverings, and d‚cor
can go a long way toward making your
nursing home feel more comfortable.

Let's start with the most basic: fabrics. 
Many traditional care homes lack
carpeting or large rugs because hard
floors are viewed as more sanitary and
easier to clean. However, hard
floors transmit noise, generally
feel cold, and give a nursing home an
inhuman, purely functional feel. 
Although maintaining a clean and
healthy environment is important, it
shouldn't be done at the cost of resident
comfort.  Traditional materials could
stain and retain bacteria and germs, but
textiles have come a long way.  There are
a wide variety of furnishings and fabrics
available that are easy to clean and can
handle a great deal of use.

At Meadowlark Hills in Manhattan,
Kansas new treated fabrics are widely
used.  These fabrics have been immersed
in a formula that adheres to every fiber,
making them impervious to spills, bodily
fluids, or other hazards.  These
innovative new materials allow the home
to incorporate comfortable, colorful
carpeting and furnishings without
sacrificing cleanliness.  Residents are
able to enjoy a variety of furnishings for
recreation and relaxation, while staff and
administration are saved much of the
extensive care and replacement that
accompanied older textiles (Lindstrom,
2004a).

Photos courtesy of  Kent LaCombe


Carpeting helps insulate rooms against
excessive noise.  It is also more
comfortable and warmer than a hard
floor.  As in the case of furniture
covering and fabrics, durable and easily
maintained carpets are widely available
for use in nursing homes.  Some patterns
and colors work better than others.  If a
floor covering contains a dark
background with bright highlights, it can
interfere with depth perception and
balance (Lindstrom, 2004a).

In addition to upholstered furnishings
and floor coverings, functional hallways
can be made more appealing through the
addition of pictures, sculptures or
statuary, or (depending on their location)
windows.  In the case of artwork,
residents themselves can be
involved in the creation and display of works
(Zinn, 2001). Particularly
artistic residents could be encouraged to contribute or
design workshops might be implemented
for larger groups.  As is the case with
anyone's artwork, a resident's permission
must be obtained before putting his or
her work on public display.


Visual Pleasure and Support
 
The appropriate use of lighting
is an important building block of
effective and enjoyable aesthetics. 
Indirect lighting sources
can help offset the institutional feel that
can accompany fluorescents  (Lindstrom,
2004a).  At Wesley Towers in
Hutchinson, Kansas, CEO Ray Vernon
pointed out administration is constantly
trying to "better use lighting, colors, and
patterns" in their home (R.V., personal
communication, May 10, 2005).  

Balancing resident needs with effective
lighting can be a challenge, but it is a
rewarding one when effectively met. 
Adjusting shades throughout the day can
help reduce glare and excessive
light in rooms with large or
numerous windows in
sunny areas. At night rooms
require light sufficient for
residents to find their
way to the bathroom but not so much
light that it affects residents' ability to
sleep. (Lindstrom, 2004a).