By the time most elders reach long-term care facilities they have given up control over much of their lives. Formerly homeowners and managers, wage earners with careers, and parents supervising children, they were the decisionmakers in the family and on the job. Now they are confined to a single room (or half of one) extremely limited in space for personal effects and memorabilia of a lifetime. The door has no lock, no real privacy is possible. Meals, snacks, medications, exercise, time, laundry, and sometimes even the television are controlled by someone else. Doors buzz if they try to go outside alone and someone rushes to ask, "Where are you going?" There is limited to no access to telephones and getting postage or writing supplies may be a problem. To leave the facility one is asked to "sign out" and report one's destination and return time, and may be told to return within a certain time frame. Lights, temperature, and even availability of water are controlled by others. Very personal activities, such as bathing, are scheduled by staff. Elderly clients in a long-term care facility have lost control over most of their lives details and are isolated from most of the community. We then wonder why so many sit staring blankly at the television screen in the lobby or show little enthusiasm for the often juvenile crafts and activities to "stimulate" them.
A sense of powerlessness and isolation is common among elderly clients in long-term care facilities (Atchley, 1994). What can be done by nurses and other health care staff to decrease the feeling of loss of control over self that leads to feelings of powerlessness and low self-esteem?
First, it must be remembered that life is measured day to day by the routines of daily living. Hence, wellbeing can be affected much more by choices related to activities of daily living such as eating, sleeping, and grooming than by larger occasional events which may seem to the caregiver more important or serious. Personalizing routines of daily living begins with an assessment that includes learning the client's typical patterns of response and knowing and endeavoring to understand the meaning to the client of ordering daily life in the particular way (Evans, 1996). This element of caring accomplishes two goals. The nurse has a database which allows the daily routine to be fitted to the client rather than the client fitted to the institution's routine and a message is passed to the client that he is recognized as a unique, valued person.
Elders in long-term care facilities can be given many choices in their daily activities if staff take the time to allow these choices. Individuals usually have an order to their morning routine. Disturbing it can disrupt the pattern of their entire day. Dressing tasks can be structured to conform to these personal habits and kept consistent by keeping nursing staff assignments as consistent as possible, so that each elder's routines are known (Vogeipohl, Beck, Heacock, & Mercer, 1996). For example, providing a "wake-up" cup of tea pre-dressing for one client may make the difference between a "grumpy" or pleasant, cooperative elder. Another elder may want a face wash and trip to the toilet before dressing. Others have a consistent order of the way clothing is donned. It may be irrelevant to the nurse whether "Mr. Smith" puts on his shirt or pants first, but to him it is an important personal choice underlying control over his life. Residents can be offered a choice of clothing in the morning and night wear in the evening. Toiletry carts would allow other choices related to personal routine: brands of soap, toothpaste, dental cream, shaving supplies, deodorant, hand lotion, and even make-up items, perfume, and cologne.
Hogstel (1994, p. 177) associated isolation and nutrition in older adults, noting that adjustment to institutional eating patterns is difficult for elders. She states "Eating should not become a chore or a dietary experiment. It should remain a genuine pleasure at any age. Mealtime should be one of the highlights of each day." Even in longterm care facilities, meals offer an excellent opportunity to arrange choices and allow elders to exercise some control over their own bodies and health. A cafeteria style Une for those able to eat in the dining room with a variety of vegetables and at least two entrees, a salad bar, plus a "waitress service" to carry trays to tables as necessary, and a choice of available tables would allow choices among foods and eating companions. (Menu selections and diet cards can be coded to guide clients and dietary staff for those on a therapeutic diet as shown in Table 1). Cafeteria style may also reduce the herding of everyone to the dining room at exactly the same time. Any long-term care facility has clients from a variety of life settings. Some may be old farmers who have gotten up a 4 a.m. for breakfast every morning for 50 years. As one of the luxuries of retirement others may have formed habits of sleeping in and eating a brunch and supper with a bedtime snack. It may not be possible to cater to the exact habits of every client, but negotiation and client-centered cooperative planning between the dietary staff and the nursing staff can allow some choices. Extra early risers could help themselves or be helped to an early morning drink and a "sunrise snack" while they await the first seating or opening of the cafeteria Une while late sleepers could eat entirely from the continental breakfast bar, since lunch will come earUer for them anyway.
Adequate fluids is almost always a problem with elders with enough impairment to require long-term care, often related to altered adaptive mechanisms required to maintain normal extracellular fluid (Esberger & Hughes, 1989). One can encourage extra fluids and give esteembuilding choices by having a small "open bar" in a room or lounge alcove with a soothing, music -filled ambiance. Clients could choose from the "free bar" or "pay bar" lists of healthy drinks with a bar tab, the latter which is added to the monthly invoice. (Prior arrangement and a signed statement might be necessary legally.) The "bartenders" could be volunteers to lighten staff load, and some of the cognitively able clients might also be able to volunteer. A color-coded "bar pass" to be presented with each drink request could alert bartenders to check special dietary restrictions. Clients with little or no funds for the "pay bar" could earn "bar tokens" in games and competitions as part of the social activities program. Various community groups could be soUcited to assist with such a project, including a "slush fund" to be used at the discretion of die director of nursing for indigent clients. There must be other ways to reach the outcome criteria behind this idea. Only creativity is needed to join basic needs with returning the power of choice to elders in long-term care.
Bathing is another area of life-long habits. There are persons who cannot start their day without a shower and others who relax for sleep in a long evening bubble bath. Each elder comes to the nursing home with his or her preferred type and time of bathing, and most admission assessments ask for that information. Rarely does the nursing care plan reflect these habits, and they are almost never considered in implementation of care. Most commonly there are bath lists drawn up for the convenience of the work load of the staff, and clients are expected to rigidly comply. Given the need for hygiene and sometimes the altered mental status of the client, there are still other options. If bath lists are made in negotiation and compliance with the client's lifetime habits as a priority, the number and types of bath to be done morning, afternoon, evening, or very early morning can be taken into consideration for staffing ratios, rather than vice versa. We are aware that too frequent bathing makes the usually dry skin of an elder drier, but where is it written that an elder must have only two baths each week? If a client wants a nightly soak in the tub to relax and ease aching arthritic joints, then apply moisture-based skin lotion liberally and encourage extra fluid intake. If someone has been a "Saturday night bather" for many years, supplement tub or shower baths with "wash-ups" as necessary. Water-based lotion once or twice a day will provide moisture and stimulate circulation keeping the skin soft, supple, and pleasantly scented. It is the client's body, after all, The nursing goal is adequate hygiene and skin care. Methodology should remain the choice of the client or family if the client is cognitively impaired.
Exercise and rest are other areas where power is sometimes unnecessarily removed from the client. Unless ordered by the doctor or a part of a designated physical therapy routine, the independent ambulatory or assisted ambulatory (e.g., wheelchair, walker) client in a long-term care facility may be either regimented or neglected. Either routine removes liberty of movement. Planned "walks" are almost always confined to the halls and lounges of the facility, whatever the weather, and are done at the convenience of the nursing staff. Those left to find their own exercise, if any, are also usually expected to stay within the facility halls and lounges. Some facilities provide outside opportunities, but how used are they? For example, a long-term care facility has a fenced "backyard" with a gazebo and a concrete sidewalk to and around the gazebo, a very safe place for elderly clients and even Alzheimer's clients to walk or sit and enjoy a sunny day. However, this area is rarely used. Why? The access is through a room used at mealtimes as an assisted dining room. Between meals it is empty, the door is closed, and there is no light. Elderly people with deficits of sight and thought are not inclined to wander through dark rooms to get outside. A few simple interventions such as leaving the light on and the door open and planning some social activities regularly in the gazebo could heighten awareness and encourage the use of this area.
Refocused Nursing Assignments
Most long-term facilities publish a monthly newsletter and calendar of events. A newsletter is an excellent tool for offering choices of both individualized and group activities. The newsletter can offer a "menu" of choices of group activities for exercise and recreation. Residents can select activities in which they wish to participate. Volunteer or nursing staff should be assigned to provide assistance with the selection process as needed. Choices might include walks at malls, tracks, or parks with transportation by the facility van or bus, or athletic competitions planned and adjusted by the physical therapist to be safe and within the capacity of participants, an "elderly Olympics" for example. Participation in charity walks with previous negotiation to allow shorter times and distances for the elders, or pairing wheelchair occupants with a "pusher" from a community civic or church club could provide both exercise and socialization with the local community. A variety of games such as wheelchair volleyball or kickball, juggling with scarves, line dancing, and wheelchair square dancing are also appropriate choices. Time to assist sensory or cognítively impaired clients to read, comprehend, and make selections from these choices must be factored into staff assignments. Newsletters need not be simply left on a bedside table. They can provide the agenda for therapeutic social conversation between nursing staff and the client while staff members assist with physical needs. Providing copies of the newsletter to staff members and placing it in areas where staff take lunch or break times may encourage staff to participate in dialogue with the elders about activity choices and remember to schedule any assistance the client may need to participate in their plan of care for the client that day.
The typical nursing home lobby on any mid-morning or mid-afternoon will be filled with people sitting, all turned in the direction of a television, most not watching. This passivity more likely exhibits depression or boredom rather than rest. As Thomas (1992) has pointed out, depression in later Ufe need not be more long lasting than in younger life. Long-term care routines which follow assemblylines of dressing, grooming, and feeding with "parking* clients in a lounge communicate a lack of caring. Furthermore, most of these elderly residents have some degree of sensory deprivation and/or physical immobility. Thus, although placed in a group setting, when left to their own devices, residents are actually ignored and isolated. Such scenarios lead to a sense of despair and depression (Feii, 1992).
Why not break up the large lounges into interest areas? An alcove with large print books and current magazines and comfortable chairs and love seats with places for wheelchairs to get close to bookshelves will entice elders. Another alcove could contain games set out ready to play. Activity directors or aides can move among clients stimulating choices of activities and facilitating resident interaction. Smaller lounges with soft music playing and volunteers to help residents choose gentle music to relax or nap in the recliner would also provide a restful atmosphere. Smaller television areas, with large screen televisions if possible, allow smaller groups of residents who really want to view TV to successfully negotiate choice of programs. Sitting closer to the set may also compensate for vision and hearing deficits. A simple remote control device shared among residents allows additional independent choices. Variety will return some power to the client through choice. The varied stimuli will also be good intervention strategy for depression.
Inadvertently, the social interaction of most long-term clients is severely limited. With no transportation to church unless friends or family live nearby and are willing to transport, they are limited to whatever chapel or song services the nursing home arranges. Yet a significant number of residents could still function at and enjoy church. For example, a church van or bus route may be used on Sunday to drop clients off and pick them up after church. In some communities, a Wednesday night bus route might also be needed. Again, the facility newsletter would be a good avenue to allow residents to vote on some of the social activities in which they would like to participate or attend. The social director could use the ballots in planning the next month's social calendar. The elderly need not be prisoners in the longterm care facility in this age of mandated handicapped access which has opened most public theaters, restaurants, and sports arenas to all citizens. Describing a study of men with an average age of 70 years (Bartko and Patterson as cited in Kart, Metress, & Metress, 1992, ?. 38), Kart reports a strong correlation between "the complexity and variability of a day's behavior and the likelihood of survival." Thus, choices between varied social activities would not only return power to the patient, but also could lengthen the life of the client. While social activities are not the direct responsibility of the nurse in most long-term care facilities, the nurse is the coordinator of the resident's interdisciplinary health plan as well as an advocate for the resident. Thus, the nurse has responsibility to participate in planning and evaluating an activity schedule which enhances the health of the client.
Circles of friends and family are also interrupted when a move to a long-term care facility occurs. A good social history inclusive of an address list of family, friends, club and social groups which were previously used by the client as well as past services, offices, and honors could assist the nursing and social service staff to facilitate social interactions to transcend the move into long-term care. An "open house" specifically for the client, inviting friends to visit and become familiar with the new surroundings of the client would be a good beginning. Invitations to card clubs, quilting circles, or poker groups to move some meetings to a club room or the client's room could keep other social services going. As these strategies are implemented, other less social or more isolated elders will have an opportunity to see and try social activities which might not have occurred to them, or for which they did not have the social resources to implement. Interaction with the resident's family and friends will give the nurse an opportunity to collect important data to add to the resident's assessment. These may include clues to communication styles and language usage as well as factors in the client's former life which relate to compliance with the health care plan of the client. Intervention strategies could then be developed which more closely correlate to the resident's life patterns, interests, and behaviors.
Low-Cost Changes in Long-Term Facilities
A nursing facility that implemented even a few of these strategies would be required to review carefully its management philosophy and style. In the average nursing home, the stated management philosophy speaks to resident rights and individualized interdisciplinary care. Implementation of care more often focuses on time and task management in which residents are expected to comply with routines perceived to be most efficacious for staffing and completion of tasks.
There are long-term care facilities in which clients are automatically awakened at 4 a.m., groomed, and placed in the lobby to await a 7 or 8 a.m. breakfast. There is no choice for clients. In fact, such practices are justified by current staffing patterns. For example, the night staff are usually fewer in number. If they are responsible for assisting 15 residents each to be groomed and ready for breakfast at 7 a.m., in reality they may find it difficult to develop a routine and schedule which allows resident choice. Management which reviews and finds incongruence between philosophy and style of management can work out this problem. The key is a change of focus. First, consider client needs and autonomy, then determine efficient and cost-effective ways to provide the care. Suggestions for refocusing nursing assignments are listed in Table 2.
The nurse manager or clinician in a long-term care facility is in a position to be the innovative change agent and advocate for older adult clients. It is quite possible that, as with most change, both the facility staff and clients would experience some initial anxiety. The professional nurse role in long-term care allows the nurse to actively structure change and its effects on the staff. As power is returned to the client, and the elderly patient's self-esteem is improved, coping strategies increase and depression decreases (Valente, 1994). This leads to a more self-sufficient client who engages in more self -care, reducing the work load on the staff, a clear benefit to all levels of staff and administration, as well as the client. Changes leading to this outcome will, in the long term, become popular with staff. Most importantly, elders in nursing homes would function at maximum autonomy. Far from being ultra-idealistic and exorbitant in cost, providing variety and choice in long-term facilities is very achievable. Low-cost changes that can facilitate client autonomy in long-term care facilities are suggested in Table 3. Most necessary changes can be made through adjustment of staff scheduling, inservice education, well-organized nursing assignments, and creative use of facility and community resources. These recommendations are just the beginning of many innovative and practical possibilities to maximize client choice and autonomy.
The implications for professional nurses employed in long-term care facilities are evident. Professional nurses in long-term care facilities are nurse managers, resident care coordinators responsible for assessment and care planning, and some are even faculty administrators. Such nurses are in a position to create new plans of care which personalize and empower clients. Through staff inservice education and role modeling these nurses can also demonstrate the clear advantages of empowered clients in compliance with care and staff satisfaction. The professional nurses also have the ability to promote changes in facility management, staffing patterns, and routines through well-written and professionally presented cost-effective proposals. Administrators and boards listen to ideas which lower costs and/or promote facility reputation and recruitment of residents. It is indeed the professional nurse who is the key to creating a long-term care facility environment which allows residents to complete their life with autonomy and choice.
- Atchley, R. (1994). Social forces in aging, Belmont, CA: Wadsworth Publishing Company.
- Esberger, K., & Hughes, S.T. (1989). Nursing care of the aged. Norwalk, CT: Appleton & Lange.
- Evans, L. (1996). Knowing che patient: The route to individualized care. Journal of Gerontological Nursing, 22(3), 15-19.
- Feil, N. (1992). Validation. Cleveland, OH: Edward Feil Productions.
- Hogstel, M. (1994). Nursing care of the older adult. Albany, NY: Delmar Publishers, Inc.
- Kart, C., Metress, E., & Metress, S. (1992). Human aging in chronic disease. Boston, MA: Jones & Bartlett.
- Thomas, J. (1992). Adulthood and aging. Boston, MA: Allyn and Bacon.
- Valente, S. (1994, December). Recognizing depression in elderly patients. American Journal of Nursing, 19-25.
- Vogelpohl, T, Beck, C., Heacock, P., & Mercer, S. (1996). "I can do it!" dressing. Journal of Gerontological Nursing, 22(3), 39-42.
Refocused Nursing Assignments
Low-Cost Changes in Long-Term Facilities