Physical and Organizational Changes Support Each Other

“The smaller the group of residents, the easier it is to be resident-centered. The more individual needs there are to be met, the harder it is to give individualized care.”

The transformation from institution to home could be called a Cinderella story. The outcome is nearly unrecognizable from the nursing home that once was. Had Cinderella’s fairy godmother not changed her rags to glamour, she would not have been able to go to the ball. However, Cinderella’s gown and glass slippers could only take her so far. She had to deal with the step-mother and ugly step sisters in order to get to her prince and happily ever after. Like in this fairy tale, the transformation of a nursing home must be both physical and organizational in order to institute long-term change. In addition to addressing the many areas that need to be changed, the physical and organization systems support each other. You can’t make made-to-order breakfasts for residents without a localized kitchen and the kitchen is worthless unless there are plans for using it.


Here we will take a look at the many facets of nursing home life at the different levels of transformation based on the Grant-Norton Tale of Transformation book and DVD: Transformational, Neighborhood and Household.


The smaller the group of residents, the easier it is to be resident-centered. The more individual needs there are to be met, the harder it is to give individualized care. The fewer residents the staff work with, the greater the opportunities for growing relationships.


Transformational: Continuing to operate in hallways as in the traditional stage, there begins to be more of a sense of camaraderie as staff begins to work in teams with one another.


Neighborhood: Neighborhoods are often bound by the structure of the building. This wing becomes a neighborhood, that hall served by that nurses’ station is a neighborhood, etc. Differentiation becomes important and with that, the possibilities of more resident choice. Care starts to be more individualized. Community starts to blossom.


Household: The smaller number of residents (usually 12 - 20) living and working in the household are more like family. Staff support is more responding to spontaneous needs and desires than a list of things that need to be done for the resident (i.e. waking, eating, bathing, activities) which couldn’t happen were the group of residents larger.


Transformational: Some choice of foods or continental breakfast and/or snacks may be implemented. However, a centralized kitchen away from the residents does not allow them to experience its smells and sounds and heart of the home.


Neighborhood: A neighborhood kitchenette, if it’s possible, allows for some food prep to be done near residents. It can be supported by dietary staff assigned to assist in it. The neighborhood starts to have some autonomy in its food choices for snacks and alternates and can create opportunities to assist in dessert prep and activities. Extra, small space can be made into a pantry which stocks residents’ favorite snacks or a breakfast nook where a few residents could dine together or a resident could host guests.


Household: A household kitchen allows the kitchen to be the heart of the home. As food and dining are determined in the household, there is no dependence on a dietary “department.” Versatile workers can be supported as it makes more sense that many can deal with the kitchen. Also, residents can aide in food and dining prep and clean up. Residents and staff use kitchen the way we all do at home.


If a physical kitchen isn’t there, there continues to be dependence on dietary department that cannot accommodate as much individual choice regarding meals. If a kitchen is there but not the organizational redesign to support it, it becomes a regulatory and logistical nightmare.


Transformational: Bathing Without a Battle techniques can be implemented even though there is still the long trip to the bathing room that still looks institutional. A bathing schedule set by staff and residents becomes possible.


Neighborhood: Residents bathe how and when they’d like. Homey touches like wallpaper border, towel racks and decorations warm up the appearance of the room. These changes may be decided by the staff and residents of the neighborhood.


Household: Bathrooms are completely redone to be more homey. Lift-and-dunk is replaced by side-entrance bath and shower. Music, lighting, heat lamps and other small touches make bathing an enjoyable, relaxing experience for elders.


There is no reason why Bathing Without a Battle techniques cannot be used even without any physical changes to the bathroom, and it should be one of the first steps in transformation. However, obviously it is more comfortable when in a vulnerable position when visual cues tell you that you are safe, warm and comforted. Again, the smaller the group of residents, the easier it is for individualized care. Cutting down on the rushing occasionally attached to bathing will make for a more relaxing experience for all involved.

Living Areas

Transformational: People hang out in their rooms, hallways or around the nurses’ station. Staff and residents begin to look for spaces conducive to friends gathering, family visiting and individual activities. While staff may be encouraged to visit with residents more, the setting is often not ideal.


Neighborhood: Neighborhood teams are working to create homey spaces and the organization often seeks some renovations, even if at minimal cost. Outdoor patios, a neighborhood square, removing nursing station to convert to living areas and perhaps even some small underused space that has been converted to a reading or breakfast nook give options for atmosphere and inspire community and conversation.


Household: Each household has its own living room and perhaps rooms for residents to host visitors or “front porch” and outdoor patios. Spending time in any of these places happens as spontaneously as we would move around our homes. There are places to be alone, with a friend or family member, with a few other residents or several.


Living spaces make the difference between hospital and home. They must be natural because hotel-like areas are too formal and not comfortable. These areas are key to growing relationships. It is hard to have one without the other.

Resident Rooms

Transformational: Residents most likely have roommates but are encouraged to use their own things, such as blankets, knick-knacks and photos to personalize their rooms. It is a place you “stay” not “live.”


Neighborhood: Residents bring their own furniture as well as personal items, may still have roommates.


Household: Residents rooms are filled with their personal possessions and may have choice in wall color or paper and window treatments. They have private rooms or divided doubles with private spaces.


Residents cannot feel “at home” unless they have space to themselves where they can have privacy. It is hard for staff to truly see the nursing home as the residents’ home and that they are aiding them in their home without this.

Nurses’ Station and Med Pass

Transformational: There is still the usual nurses’ station, or perhaps it has been reduced in size to increase living space. The med cart is still used for med pass.


Neighborhood: The nurses’ station is often removed and replaced with a friendly desk. Med carts may continue but nurses are working with residents and their doctors to liberalize their med plans to better parallel waking and bed times. Some innovative organizations are eliminating med carts and instituting meds in the residents’ rooms.


Household: Traditional “central command” has been replaced by a small residential desk tucked somewhere in the living area with a private dining room or other area being able to be occasionally used for private conversations between a nurse and a resident (and/or family). Meds can be stored locked in the residents’ rooms and med schedules can be altered to “upon rising” or “evening” to give more flexibility in the resident’s schedule.


Of course, you must comply with state and federal regulations regarding nurses’ station, HIPAA, etc. but the goal is to make nursing service the vital (but quiet) underpinning, less obvious in these people’s home. This area is the best example of balancing compliance and quality of care with quality of life. It is the icing on top, the final trick for the blending of the physical and organizational spheres. Not finding the balance can throw a wrench in the whole thing.


Perham Memorial Hospital and Home in Perham, Minnesota recently won the Minnesota Health and Housing Alliance’s Excellence in Practice award for their implementation of this very aspect of the Household Model. Watch a video explaining what they did, as well as how and why they did it.

Public Areas and Visiting Spaces

Transformational: Perhaps some homey touches have been added, but generally the only place for visiting is still in the resident’s room that is shared by a roommate.


Neighborhood: Small spaces may have been set up with a few chairs for visiting.


Household: Residents may host guests and may even offer refreshment. Family members may share meals with the rest of the household. Family and friends are encouraged to visit in the household living area or private dining room. There may even be a separate suite for family members to stay in as a resident is dying so that they may be close to him or her throughout. This could include a table and chairs, a hide-a-bed couch, a private bath and a sink and small refrigerator.


Making the residents’ home inviting is key to their connections to the rest of the world. Their friends and family should be able to visit them in the same way they did at their own house or apartment. Residents having the space, atmosphere and refreshments to host is key to claiming the household as home and giving residents purpose. Without these things, the resident is still isolated from the greater community. The uninviting, institutional atmosphere is a barrier to guests. Both physical and social atmosphere should be inviting. If one or the other is not, it sends mixed or ineffective messages.

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