The following question was asked of the readers of the Journal of Gerontological Nursing:
How do you attempt to bring some normalization into your residents' lives (e.g., promotion of the familiar, allowing some control in decision-making)?
On admission to this facility, the social worker gathers background information from the residents and/or their family members) who accompany them by using the minimum data set instrument. Sections A.B. and A.C. are especially helpful when trying to promote normalization in the residents lives after admission. We have had preadmission conferences where the care plan team meets to discuss customary routines and special likes and dislikes regarding their activities of daily living. We strive to provide a home-like environment in which residents and their families are encouraged to bring personal items including furniture and pictures from home to place in their rooms.
The residents are allowed to make decisions regarding their care with as little guidance as possible. These decisions may include when and what type bath they take, what clothes to wear that day, or they may choose their meals from a menu (if on a regular diet). We offer a morning worship service every Sunday in the chapel located in the front of the facility. Other activities of choice are offered daily, and extra effort is given to provide materials needed for special hobbies and crafts. For example, one wing at the facility plants a garden where fresh vegetables can be harvested. Also, residents are encouraged to help tend the various plants throughout the facility, and for those residents who enjoy the company of animals, we have birds, fish, and even a cat named Socks. Residents who have left pets at home are allowed to have them brought in by family and friends as long as their shot records are current and a copy is given to the facility.
The facility strives to be a familiar home atmosphere with a mission to provide superior continuing care retirement living and a working environment that nourishes the human spirit and preserves personal dignity by addressing the whole person in an atmosphere which witnesses Christian values and love.
Melissa Gramling, RN
The Methodist Oaks
Orangeburg, South Carolina
Our unit is called the SSU (special support unit). We work very hard to have consistent staffing to provide continuity of care with the staff being specially trained in the Gende-Care concept of dementia care. The atmosphere is very home like, including pets. We have monthly resident counsel meetings held by the activities department. The residents choose what activities they want to participate in. We are also very fortunate to have a community full of talented volunteers who share their musical gifts, as well as other talents, with our residents, and of course, all holidays are made special. The family members are encouraged to participate in residents' care and are invited to all activities.
Most of the residents participate in the daily exercise program. Current events are read from the newspaper and our residents usually have something to say about whatever is going on.
The residents choose where they want to go on outings, and they have done such things as going on a boat cruise on Lake Coeur d'Alene, to a farm to see and touch farm animals, shopping, and to favorite restaurants for lunch. For the residents who cannot or do not want to go out, special things are brought to them such as take-out food and movies.
We are currently remodeling the unit to include an addition of a "safe" kitchen and a quiet room for the residents. The kitchen will allow even more participation and choice of cooking projects.
Our dining area is set up caférestaurant style, and meals are served family style with residents choosing what they want to eat. Residents and families decorate their rooms however they choose.
These are some of the ways we attempt to bring normalization and quality to our residents' lives.
Carolyn Fisher, RN
Charge Nurse, Specialist Support Unit
Cheney Care Center
I feel the primary step in promoting the familiar and bringing normalization into the residents' lives is to "do with" and not "do to" the residents. In my work as Nursing Service Manager for Retirement Management Company, I travel from the east coast to the west coast and all over Kansas. As a former Director of Nursing Service and now as a consultant, I have the unique advantage of visiting with many residents who make their home in our facilities.
In those facilities that truly use the nursing process and allow residents to fully participate in the assessment and care planning, it becomes very clear the residents are not patients but people. This I believe is the key to recognition and validity of individualized care which equates to knowing the whole person and providing service with respect and dignity and thus achieves the goal of providing a feeling of well-being to the residents.
At the core of this well-being is the spirituality of each resident. Residents who feel a sense of purpose and tell me that "this is home" are residents who have a sense of normalcy and well-being. These residents have a sense of hope and feel secure that they are living in an environment where they are respected and can make choices.
These residents who feel that they have control and make their own choices live in a facility where everyone from administration to direct caregivers knows and understands this is the residents' home. Providing services in this environment means each member of the team must understand the concept of being a servant.
Conversely, the facility that places emphasis in meeting regulation and providing a home-like, beautiful, artificial surface frequently has disregarded the residents' comfort and sense of normalization. We must remember it is possible to provide good care despite of all the regulation - this simply means that we support the residents' choice to be free and live in their own place and home above all else.
I believe residents that have dementia have taught us this important lesson. We now understand that when we step into the residents' world, when we truly try to know and understand the core of the residents, no matter what the degree of impairment, we can connect and observe a sense of peace and serenity. These residents who can no longer communicate their needs but whose behavior has meaning implores us to know them.
I believe that it is this knowing of our residents and allowing this principle to guide us that provide residents a sense of normalcy.
Marvel F. Birchfield, MSN
Nursing Services Manager
Retirement Management Company
Our veterans wear their own clothes, use their own showers and toiletries, and have their own bulletin boards by their beds. On the bulletin boards, displays of family pictures and important events are safely hung. Our programs are brief, 20 to 30 minutes, and include singing the oldies, looking at scrap books, and walking outside. Our higher-functioning veterans assist with cleaning tables, folding washed clothes, and wiping off chairs.
M. Joyce Weise, RN, C, BSN
Roseburg Veterans Affairs
Dementia Special Care Unit
Try to keep holidays and daily living with input from clients to help them feel included. Buy undecorated cookies and let them frost them. Some of worst dementia clients can do this well. Try to help them feel in control with regard to when they are ready for bed, for example. Keep food always around, such as fruit, which also helps bowels and lowers the use of laxatives.
E. Jane Pavelko, LPN, CRTT, CPFT, AAS, RCP
Co-Administrator and Co-Owner
Peveloko's Personal Care Home
Cherry Tree, Pennsylvania
Human beings have a great need for touch. Geriatric residents have been removed from the familiar family environment with daily touch contact and thrust into an environment where touch can be extremely mechanical. In long-term care it is important to establish meaningful human touch and not just the touch of incontinent care, dressing a person, or giving them a bath. It is a heartfelt hug, a hand across the shoulder, or sitting next to the person with a hand touching a leg. Normalcy is daily human touch with the intent to heal or to bond.
Elizabeth L. Plimpton, RN, BSN
Beverly Health Care of Bloomington
This facility encourages residents to bring familiar items with them to decorate their rooms. We also ask what their preferences are as to food, bath time, and their special interests, and try to incorporate this in their daily routine. A few years ago, we started family-style dining. We set the dining tables with china-type dishes on cloth tablecloths, and cloth napkins are used. If at all possible, our residents sit in regular dining-room chairs. The residents seem to really like this.
Connie Ferrei!, RN
All residents are encouraged to bring as much or as little of their own furniture. They can hang pictures and put up shelves.
Residents are encouraged to choose bath days and times. Some residents opt for a continental breakfast at a later hour rather than a full breakfast earlier.
Sue MacKenzie, RN, BSN
Director of Nursing
Our nursing home encourages the residents to bring some furniture, pictures, knick-knacks, television, and reclining chairs from their homes or apartments (of course, space allows only special things, not a whole room set-up). We hang their precious family pictures, paintings, wreaths, or door designs to make it more home-like.
As far as decision-making, the residents are given choices daily. For example, we ask: What dress or outfit would you like to wear? What activities would you like to attend, if any? What would you like for lunch, this or this? Would you like to get up now or in another half an hour or hour? We want them to still have some control in their lives in our nursing home. They have a right to say no.
Debra A. Kahnke, LPN
Director of Infection Control/Staff
Ten Broeck Common Long-Term Care
Lake Katrine, New York
Humor is a wonderful way to bring normalcy into the lives of the elderly. People tend to open up more and relax with someone who is real and shows human warmheartedness, sensitivity, and a true sense of caring. I act real.
Also, children and pets are incorporated into the patients' daily lives, which makes for great entertainment on a regular basis.
Carol Musselman, LPN
Assisted Living Facility
Chapel Hill, North Carolina
One of the things our facility does to bring some normalization to the residents' lives is to have Happy Hour on Friday evening. The residents enjoy nonalcoholic beer and wine, snacks, and music.
A way we allow control in decision-making is to allow residents to choose where they sit in the dining room. Some of the residents always sit at the same table, and others enjoy sitting with different people each meal.
Mary Wine, ASN, RN
Staff Development Coordinator
Sunrise Care and Rehabilitation for
Bringing normalization into residents' lives may be a tough job, but we have all got to do it. The primary solutions may sound simple to comprehend but they also can be challenging to apply. This is because each and every answer requires us to move from an outdated definition for a concept to one that is not only more scientific but also a part of a new theoretical framework.
Because of this, we are compelled to redefine ourselves as well as our relationships with the people who receive our services and the environment in which we practice. Therefore: 1) Nurses, who were once known as caregivers of "sick" people, now are known as advocates for humans at any and every point in the life course; 2) Residents, who were once thought of as dependent patients recovering from acute illnesses, are now considered people with multiple chronic conditions which cannot be cured, but these conditions must not replace their senses of identity and purpose; and 3) The environment which was once thought of as a paternalistic institution is now reclassified as a neighborhood community that fosters a sense of belonging and purpose for each individual who lives in their autonomous home. Normalizing begins with these concepts and their definitions.
Although the central core that defines gerontological nursing practice has evolved from caregiver to advocate, this shift in defining basic practice has not been exclusive to the field of gerontology. Instead it has become central to the profession of nursing. Using our efforts as members of the National Gerontological Nurses Association (NGNA) and the National Association of Directors of Nursing Administration in LongTerm Care (NADONA/LTC) to work with our professional organization, the American Nurses Association (ANA), can only help to normalize our own perceptions of nursing as well as how we are perceived by others.
After we help clarify that nursing practice is based on working with people, not patients, we then can advance the understanding about why our clients also are known as residents. Although many of our clientele Uve on a group campus, for most of them that campus is now their home, regardless of their functional status. Therefore, gerontological nurses who work on a long-term care campus actually normalize by serving as classic community health nurses, working with groups of individuals from where they reside.
It was easy when we only learned about pathology, the sick role (Parsons, 1951), and the stages of illness (Suchman, 1972). The acute condition coupled with our use of Maslow's hierarchy justified our imperative to temporarily focus on stabilizing life by removing the disease. However, after we became aware of the distinction between acute and chronic conditions as well as the fact that the chronic ones could not be cured, we needed a new framework from which to operate after the life-threatening illnesses had been treated. Lubkin (1995) deserves equal recognition for her solid work in compiling concepts about chronic illnesses. Her comprehensive findings serve not only to help us understand the rights and responsibilities of those with chronic illnesses but also to show us how and why the chronic illness trajectory cannot serve as the primary framework for understanding our senses of identity, purpose, and belonging. In the future, as we study additional theorists of human motivation and their work continues to be coupled with Hardy and Conway's (1988) points on role theory, we have the formula for normalizing everyone's perceptions of what it means to be a resident.
Finally, we have the two-fold concept of environment 1) that of the community where we Uve which, regardless of its size, must provide senses of belonging and purpose that are generated from the ambiance of a neighborhood and 2) that of the home where we Uve which, regardless of its square feet, must provide not only senses of belonging and purpose but also the opportunity for preserving our individual rights (e.g., autonomy, confidentiahty, dignity, individuality, privacy). Examples of movements to normaUze can be found at both of these levels: Bond et al. (1996) studied organizational culture to develop the neighborhood model, and Thomas (1998) has made an effort to develop the home environment.
Much work has been done to empower us to be change agents who reshape thinking based on the advancement that has been made regarding each of these concepts: nurse, resident, and environment. However, without 1) the critical thinking it took to question tradition, 2) the research needed to support the new evidence, 3) the educational efforts that disseminated these findings, and 4) the political action necessary to advance the standard of practice into law, we would not be where we are today. The strides we have made because of these steps should only inspire us to accompUsh more. From research to education to practice, these are exciting times to be a gerontological nurse. Our accomplishments are rooted in the essence of the verb to normaUze because we are advocating for the intended functions of solid designs.
Bond, G.E., Fiedler, F.E., Keeran, C.V., Ogden R., & Richardson, M. (1996). The neighborhood concept as a model for long-term care. The Journal of Long Term Care Administration, 24(2), 27-32.
Hardy, M.E., & Conway, M.E. (1988). Role theory: Perspectives for health professionals (2nd ed.). Norwalk, CT: Appleton & Lange.
Lubkin, I.M. (1995). Chronic illness: Impact and interventions (3rd ed.). Boston: Jones & Bartlett.
Parsons, T. (1951). The social system. New York: Free Press.
Suchman, E. A. (1972). Stages of illness and medical care. In E.G. Jaco (Ed.), Patients, physicians, and illness (2nd ed.). New York: Free Press.
Thomas, W.H. (1996). Life worth living: How someone you love can still enjoy life in a nursing home. Serburne, NY: Summer Hill Company.
Barbara Hassinger Conforti, MSN, RN, CS,
Lancaster Institute for Health Education
School of Nursing
This question was submitted by Virginia Burggraf, RN, C, DNS, Grants Development Coordinator, and Richard J. Barry, MDiv, MLS, AHIP, Librarian, American Nurses Association, Washington, DC. Their commentary follows:
The term normal has various meanings. In the context of a nursing home or care faciUty normal is defined by each individual resident's life, the community of residents, and the staff of the facility. Normal is established patterns of behavior and activity that make our gift of life unique in the world. The context, whether personal home or nursing home, sets the parameters that shape that particular life. Moving into a nursing home can approximate some of the familiar, but never replace it. Positive, supportive, autonomous, respectful, familiar, friendly, comforting and compassionate are some of the elements that can be found in any home.
E. Plimpton, defines normalcy as "daily human touch with the intent to heal or to bond". She discusses this as a need when residents are removed from the family environ ment. It is in a family setting that physical touching that communicates care and concern is experienced. This touch is different from the touch necessary to steady frail legs or to lift a someone with weak muscles. M. Birchfield further elaborates on the need for f amilies and residents to participate in thenassessment and care planning.... "it becomes clear the residents are not patients but people". The MDS, as mentioned by M. Grambling, offers us the opportunity to make an initial impression of a facility that cares, is interested appropriately about an individual's past, and welcomes them warmly. Sections A.B.5 (Residential History 5 Years Prior to Entry) and A.C (Customary Care) can tell us what we as care providers need to be attentive to help this person adjust to new surroundings and what will stimulate and encourage them to continue to develop as a person. An historical perspective as well as a profile of favorite foods, and routines can be a beginning entry into an individual normalization care plan.
B. Conforti has provided us with the theoretical framework for the why of normalization in the nursing home. Her concept is based on a need for nurses to redefine their role with their older patients/residents. Her belief is that nurses must be advocates, the chronically ill elderly must maintain their individual sense of identity, and the nursing home is a community fostering a sense of belonging and purpose.
Moving from the familiar to the unknown can be traumatic, and we can never quite place ourselves in the position of a nursing home resident, unless we have the lived experience. We can never replace the view from the front window of our home, or the neighbors we have lived next to for forty years. Leaving behind that part of the world that we have carved out for our self to enter into an institution will never be easy. Nurses working in nursing homes, or assisted living complexes, can attempt to make it more normal for those who dwell in that community. Then the transition can be less traumatic by being surrounded by objects that are familiar and comforting, linking us to the past in positive ways to deal with the present.