Consider this common scenario: Mr. Smith, a resident with dementia, is scheduled to have a bath on Tuesday, but he’s combative. “Even veteran staff may be set on the idea that Mr. Smith has to have a bath today no matter what,” says Ann Wyatt, a palliative and residential care consultant for CaringKind in New York City. “Therefore, an experienced certified nursing assistant (CNA) tells the new staff member or the agency staff member who is assigned to Mr. Smith, ‘I know how to handle him when he gets upset. I’ll deal with it.’”
That’s not the example that directors of nursing services (DNSs) and other nurse managers should want staff to set for newcomers, says Wyatt. “It doesn’t benefit the resident—and it makes your staff’s work harder. Maybe Mr. Smith doesn’t like baths, and bathing at the sink with a washcloth would be more appropriate for him. Everyone needs to be tuned into the mindset that you want to find any way that you can to make all residents, including residents with dementia, more comfortable.”
Discomfort is often caused by the facility’s routines, not anything that the resident is doing, stresses Wyatt. “So, finding comfort should always be the priority—and that begins with knowing the resident through their history and preferences.”
“‘Know each person’ is the first of the Pioneer Network principles,” points out Joan Devine, RN, LNHA, the Weldon Springs, MO-based director of education for Pioneer Network. “As a stand-alone, it’s probably one of the most critical principles, but it’s also a key component of another Pioneer Network principle, ‘Relationship is the fundamental building block of a transformed culture.’”
Especially in the ongoing staffing shortage, nursing staff and the rest of the interdisciplinary team may be so focused on meeting the clinical needs of each resident that they forget to pay attention to who the resident is as a person, says Devine. “And that really ought to be your primary focus. A resident’s clinical picture is a part of who they are, but it doesn’t define them.”
Knowing the residents and having relationships with them as people—not just as patients—is central to both resident safety and resident-centered care, says Devine. “It will help your team provide better service for residents. The challenge is: How do you make that happen?”
Take a temperature check
Whether person-centered care can work comes down to organizational culture, especially for nursing homes that rely heavily on agency staff, says Devine. “You have to have buy-in on two levels. First, your culture must be grounded in relationships with all of your staff. If it isn’t, your staff certainly won’t see the value of relationships with an agency staff member and won’t make them feel welcome so that they become more engaged and do a better job with the residents.”
Second, the organization has to practice the value of knowing the individual every day, says Devine. “If you don’t show day in and day out that the resident matters as a person beyond their medical needs, you won’t be able to communicate that to any staff no matter what process or tool you put in place.”
Design from the floor
DNSs should be careful not to design a plan from the office, says Devine. “If you want to figure out how to enhance the value of agency staff being with your team in a way that incorporates the resident’s story, get your team to brainstorm with you. You don’t want a well-intentioned policy that sits in a pile and is not practiced. You have to drive this with the people who are most impacted—the direct-care staff and also the residents themselves. Give them a voice, listen to what they say, and make sure you incorporate that into what you do.”
Don’t stop with the MDS—drill down
“MDS section F (Preferences for Customary Routine and Activities) provides great information that the interdisciplinary team needs to know, but on its own, it’s not enough to tell the team what the resident’s real preferences are,” suggests Devine. “For example, section F can tell you that a resident has a strong preference for a tub bath. However, for most people, a pleasant bathing experience involves more than just the type of bath. The resident may want to take tub baths in the morning vs. in the evening, or the type of soap or towel they use may be important.”
Providers need to address two key questions, according to Devine:
- How do we identify and then ask the right questions to obtain the most critical information about the resident’s history and preferences?
- How do we conduct that assessment in a process that is doable?
“You can create an elaborate tool, but if staff don’t have time to use it, it won’t do any good,” says Devine. “In addition, you need to ensure that the information you collect isn’t too cumbersome for staff to have the time to read and know. Otherwise, it will just sit in the chart, which is a common problem in nursing homes.”
Assessment tool options: PELI
Preferences for Everyday Living, a research and evidence-based practice organization headquartered at Miami University in Oxford, OH, works to advance preference-based, personalized care for nursing home residents and other older adults using community-based long-term care services and supports. “This organization has a significant focus on how to collect and then help the team operationalize meaningful resident preferences,” says Devine.
Based on its Preferences for Everyday Living Inventory (PELI) scientifically validated tool, Preferences for Everyday Living offers several free PELI questionnaires, as well as a sample policy, that can be used to inform care planning and improve staff and resident interactions, including:
- The 12-page PELI-Nursing Home-MDS 3.0 Section F-Version 2.0 uses the questions in section F and then builds on them. For example, if a resident says that it’s very important for them to listen to music that they like, there are six follow-up questions, including: Which kinds of music do you like? Do you have favorite musicians or musical groups? And which ways do you listen to music?
- The 39-page, 72-question PELI-Nursing Home Full Version 2.0 is an expanded version of the section F tool, covering preferences in five areas: social contact, personal development, leisure, living environment, and daily routine. For example, questions that providers may want to include in a customized assessment include: How important is it to you for staff to show you respect? In which ways do you like staff to show you respect?
- The 39-page, 72-question Rainbow PELI-NH-Full Version 2.0 also covers the section F questions but targets the specific needs of Lesbian, Gay, Bisexual and Transgender (LGBT) nursing home residents. For example, questions that providers may want to ask these residents include: How important is it to you to do what helps you feel better when you are upset? Which things help you feel better when you are upset?
- ComPASS-16 is a free web-based app that incorporates the section F-based PELI tool with resident satisfaction questions that can be used to track satisfaction over time and identify areas for improvement.
Assessment tool options: Beatitudes questionnaire
Palliative Care for People With Dementia: Why Comfort Matters in Long-Term Care, the palliative care guidelines that CaringKind published in 2017, includes a one-page questionnaire for gathering resident-specific information, says Wyatt. “What Caregivers Should Know About Persons With Dementia (page 45) was developed by the Beatitudes Campus in Phoenix, AZ. It has questions for your staff to ask the resident or family about the resident’s life history, such as: Where was the resident born? What were their parents’ names and occupations? If they have siblings, what are their names? What is their spouse or partner’s name, and do they have special memories of their wedding and honeymoon? What are their children and grandchildren’s names? What was their occupation? Did they have a favorite job?”
The tool also provides more in-depth information on the resident’s personal preferences, says Wyatt. “This covers a wide range of preferences, such as their spiritual affiliation, leisure activities, music, food and drink, special food preferences while ill, clothing preferences, shaving needs and razor type, and even their preferred forms of comforting touch. For example, some people don’t like it at all, while others like to have their hand held or to be hugged.”
There may not always be an answer to every question, notes Wyatt. “However, what these questions do is provide cues to what might matter to that resident, giving staff information about how to connect with the resident on a personal level, as well as how to make the resident more comfortable.”
Make key resident preferences part of the plan of care
Cookie-cutter resident care plans are still a problem in many nursing homes, says Wyatt. “Adding resident preferences can help ensure that each care plan is individualized and person-centered. Of course, preferences can change due to old age and sometimes due to dementia too. However, if a preference has an impact on direct care and how it should be provided, then it needs to be in the care plan. That is what the care plan is for.”
When preferences that impact direct care aren’t included in the care plan, nursing home staff—and certainly agency staff—won’t know about it, says Wyatt. “Therefore, that same problem will occur again and again. For example, a resident at one facility became combative whenever they wore the color red. Even if you removed all red clothing from her wardrobe, it still needs to be in the care plan because there could be a laundry mix-up, and the staff member who is helping her get dressed that morning needs to know not to use the red shirt they find in the drawer. Once you learn about a preference that affects direct care, you must incorporate it into the care plan.”
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