Nursing homes! What horrible images those words conjure up for most Americans. Those of us who work in long-term care encounter the public beliefs that taking up residence in a nursing home is an irreversible road to suffering and death. People picture institutions that are cold and sterile environments with hospital-like rooms and long, uncarpeted hallways and institutional colors.
Residents of nursing homes are imagined as frail older folks, who are deteriorating and disabled, existing in rooms shared by like individuals, at best dimly aware of their environments and isolated from the wider society. Time in a nursing home is envisioned as passing slowly with each day regimented and boring.
It is little wonder that many older people in this country fear being "put into" a nursing home, to the point of extracting solemn promises from family never to allow this to happen. Some families suffer great guilt and anguish about the decision to move their older relatives to nursing homes. Nursing home caregivers have low status in the hierarchy of health care workers, evidenced by comparatively low pay and high turnover. Care of residents is directed at treating their individual medical problems, but actually differs little from resident to resident. The staff is clearly separated from the residents by a wide gulf of power and authority. In addition, nursing homes are self-contained communities, usually with little or no connection to the activities of the neighborhoods in which they are located. Nursing home residents are not generally seen as growing, thriving individuals with busy, full, active lives. Building friendships, discovering talents, enjoying involvement with children, families, animals, caregivers, and the greater community are not envisioned as possibilities for nursing home residents.
WE CAN MAKE A DIFFERENCE
Currently, many nursing facilities have thriving environments, where companionship, variety, and spontaneity are part of a nurturing setting. These environments are based on the assumption that older residents are capable of making choices and determining what is best for their well being. Residents are offered maximal autonomy and freedom of choice to accommodate their individual needs, desires, and interests.
These thriving environments are attractive and home-like, designed to fully meet both physical and social needs. Each person has privacy, but not isolation. Residents can exert some control over the design and organization of their environment. Each person's room is furnished with personal belongings to maintain continuity, a sense of ownership, and a feeling of home. Planned activities are aimed at helping each member of the nursing home community achieve a degree of success. There are numerous opportunities for residents to take on various social roles within individual limits, enabling them to remain involved in continuing relationships to the greatest extent possible, and to get pleasure from each day.
Nursing facilities face the challenge of applying thriving concepts to a population that is far from homogeneous with respect to needs, interests, and functional abilities. Emphasis in the facilities must be changed from delivery of custodial care and medical treatment to the creation of an environment that provides the residents with a sense that others care about them and value their lives.
First line staff members participate in decision-making as it relates to all aspects of the environment. The staff has the primary responsibility for enhancing the care setting, which requires training and modeling. This role expansion could increase job satisfaction and encourage personal and professional growth of staff members.
ENHANCING THE NURSING HOME ENVIRONMENT
This issue of the Journal of Gerontological Nursing provides background information on the enhancement of nursing facility environments. The Theory of Thriving (pages 14-22} is offered as a conceptual framework for aging, and readers are encouraged to apply the theory to practice and research on aging. A critical literature review of environmental transformations in nursing facilities (pages 2227) concludes there is a need for research on the use of the natural environment and its effects on older individuals. Types of facilities that have chosen to make substantial environmental changes are described and hints for dealing with barriers to change are provided (pages 2834).
Various methods of environmental enhancement are presented. One is the Eden Alternative™, a process of change in all areas of nursing facilities, targeted at the method of nursing care delivery and the integration of plants, animals, and children into the physical, personal, and social milieu (pages 35-40). Another is Snoezelen®, a form of multisensory stimulation therapy, which has shown some success with cognitively impaired older adults (page 41-49).
It is hoped readers will agree that nursing home environments are an important component in the quality of life of residents and staff. Unfortunately, many environments are built and managed with little attention to the needs of the frail older individuals and staff who populate them. Many of the principles discussed in this issue will interact and some will conflict with each other. Policy and material constraints need to be overcome. For this to occur, more systematic research needs to be conducted on the impact of environmental interventions on the quality of older individuals' lives.