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Creating a Healing Environment

October 1, 2004
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Facilities may be more homelike on the outside-but what about intrinsic culture change? by Allan G. Komarek, PhD, RN

In the late 1970s, Angelica Thieriot created the Planetree Organization in an attempt to personalize, humanize, and demystify the healthcare environment. Her vision was to design healthcare from the patient's perspective, and not just from that of staff convenience. Her plan addressed not only how each facility should be designed from architectural and patient physical comfort points of view but, more importantly, from an intrinsic point of view. That is, her philosophy required caregivers to rethink their paradigm of "giving" care. The new paradigm Thieriot discussed called for a holistic approach that encouraged healing in all dimensions. More importantly, it called for caregivers to rethink their reasons for choosing their career.1

Delano Regional Medical Center's (DRMC, Delano, California) journey with Planetree began in 1989; it was the first long-term care unit to employ Plane-tree principles. Its skilled nursing unit had regularly provided above-average care, but nothing set it apart from other long-term care facilities. Planetree consultants recognized a longing in DRMC's leadership to be different-to serve residents in a nontraditional manner that really made a difference in quality of life.

The Planetree transformation at DRMC included everything from rethinking the space and architecture of the unit to a reevaluation of the way care was delivered. Indeed, the most important change occurred in the way the caregivers thought about what they do. Their paradigm changed from "delivering" care to becoming a "partner" and a "facilitator" in care. In other words, the staff no longer "gave" a bed bath but rather "facilitated" the resident in the process.

This shift in thinking began with DRMC staff retreats, in which the Planetree philosophy was discussed and "resident-centered care" was defined. "Aha's" for each staff member occurred at these retreats, especially through the use of guided imagery. Staff were taken on a mental journey to a time of being ill and being the ones to receive care, and then to a time of caring for a loved one who was ill. These retreats also taught various specific components of Planetree, including art as therapy, music as therapy, and food as therapy. Teams and committees were developed with responsibility to establish each of the Planetree components at DRMC.

Environmentally, the long-term care unit got a face-lift. The change included special homelike rooms for visitation, a kitchen where residents and their families could prepare special dishes, and special "garages" for linen carts when they were not in use.

Although skilled nursing facilities have long been ahead of their acute care counterparts in the physical design of their environments, beautifully designed settings can only go so far in creating a healing environment. They meet the extrinsic needs of the residents, families, and employees, but do they meet their intrinsic needs? Psychologist Abraham Maslow believed that human beings are motivated by their needs and, as "lower order" needs are met, the "higher order" needs become more important to them.2 Using Maslow's Hierarchy of Needs framework, the external environment can only satisfy some of the physical and security needs of resident and families. The caregivers' attitudes and behaviors lend themselves to satisfying their higher order social, esteem, and self-actualization needs. Regarding the latter, "Self-actualization is defined as 'a process of becoming, the process of development which does not end [emphasis added].'"2 This process continues until death and we, as caregivers, have the rare and wonderful opportunity to assist our residents in that process.

Nine components make up the Plane-tree environment: a supportive environment, physical involvement of family and friends, physical environment, respect for the individual, access to information, participation, choice, human environment, and autonomous decision making. As is seen with Maslow's needs hierarchy, realization of these components depends upon the staff's attitudes and behaviors. Following the nine components of the Planetree environment are the nine principles that form the basis of patient- or, in this case, resident-centered care. These principles are human interaction, information, healing partnerships, nutrition, spirituality, human touch, complimentary practice, alternative practice, and healing environments. Again, staff have a key role.

These components and principles can only be achieved through a cultural shift in the organization. The answer lies in creating a resident-centered culture, a culture in which the staff are empowered to make decisions in the best interest of residents and families, and which, in the long run, better serve the organization.

To create a culture where these nine components and nine principles are met, leadership must take the first step in deciding that it is the right thing to do, and then realize that it all begins with staff empowerment. According to Flesner and Rantz, "An empowered staff is a successful agent for residents and can act to assist the residents in meeting their life preferences and goals." They point out, "Management practices, including open communication patterns, participation in decision making by staff, and relationship-oriented behaviors, can positively influence four resident outcomes: prevalence of aggression, restraint use, complications from immobility, and fractures."3