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"Empower With Choice"

September 1, 2008
by Jennifer Mikula, NHA and Tina Vanaman, RN, DON
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Effective January 1, 2007, we were mandated by the state of Florida to increase CNA staffing to a ratio of 2:9. Like many others across the state, Palm Garden of Ocala, a 180-bed skilled nursing and rehabilitation center, wanted to find a creative way to use these new staff positions to better serve our residents. We recognized that culture change was essential to fulfilling our promise of quality of care and sustaining or improving the quality of life of our members.

Today's nursing homes need to become places that allow a member to live life and enjoy his/her surroundings. Too much emphasis is placed on the person's illness and on ways to cope with institutional surroundings. As the baby boomers age, skilled nursing facilities (SNFs) are becoming increasingly aware of this population's desires when they enter a nursing facility for care, i.e., they do not want a hospital-like setting, but rather a country-club like setting.

They want private rooms with wireless Internet access, spa-like bathing facilities, beauty/barber salon services, a “happy hour” bar with big screen televisions, and a fully equipped exercise gym with personal trainers. Some will want a pool hall, bowling alley, reading rooms, movie theater, massages—the list goes on and on. Because of this we know that we will no longer be able to function as a medical institution; we must find a way now to become a home.

We believe that quality of care is driven by quality of life and is centered on the individual needs and choices of each member. It is all about having enhanced choices!

The problem

The two scenarios that follow will make readers giggle because all of us in healthcare have seen them more than once.

It is 7 p.m. in any SNF in any town. Ms. Anyone is restless, calling out, and bouncing up and down in her wheelchair a hundred times over the course of an hour, looking for her daughter. Now it is 8 p.m., and that must mean it is bedtime. The CNA takes her to her room, provides p.m. care, and assists her into bed. She is calling out and trying to climb out of bed, so the nurse administers a hypnotic and soon Ms. Anyone is asleep—but she wakes up at 1 a.m. and is climbing out of bed, very agitated. So the nurse calls the doctor, who orders an antianxiety medication. The next day a psych consult is ordered as well, because surely this member must have some psychological disorder.

Another example is a member who is frequently displaying repetitive movements, very restless and, according to the staff, nothing helps. The doctor is called and labs are ordered, and along with the never-ending antianxiety medication, yes, you guessed it: A psych consult and maybe a pain medication are ordered.

Each of these situations created a problem that must be eliminated. The root cause of each situation was really never investigated, it was just assumed. And these are only two of the scenarios that we encountered. Weight loss and in-house pressure ulcers were on the rise as well. We knew we had to find a way to resolve these problems. Improved quality of life had to be at the center of this program. As we began this journey, we knew we would need a little outside help to achieve our dream. As it happened, the same agency that was mandating the staffing increase was also willing to grant us money, if we would take the time to come up with an innovative idea that improved our members' quality of life and was measurable. Having this opportunity, we set out to build a grant proposal by researching what our members wanted and needed.

With this information in hand, we developed our “Empower with Choice” program and our Quality of Life (QOL) aides. The program is divided into three subgroups and led to the receipt of a $66,000 grant request from the Florida Agency for Health Care Administration to develop them. Our QOL aides are trained in each program and work closely with all departments and individual members to give them more choices in their daily activities, and that special feeling of being appreciated and pampered by all.


The three programs we developed are:

  • Our enhanced bathing program, "SPA-Venture," is centered on creating a spa-like atmosphere in what were our "institutional" shower rooms. Bathing is a very private experience that can be physically and emotionally cold, sterile, and institutional. We adapted the physical environment to enable the member to maintain as much independence and dignity as possible. A team of QOL aides, supervised by the restorative nurse, provides support for the functioning and maintenance of this program. Each room is equipped with a heated walk-in safety tub, heated towel racks, hair dryers, curling irons, spa robes, and slippers. Aromatherapy is provided to promote relaxation while soft music is playing. As you enter the spas, the first things you notice are the serene murals painted on the walls. You feel as though you are entering into a relaxing, comforting experience where you have no worries. It brings the bathing experience as close to homelike as possible.

  • Our enhanced dining/hydration program, "Dining by Design," offers our members a choice of when to eat, where to eat, and what to eat, while improving nutrition/hydration. This change provides a sense of control and improves self-esteem. This program is only partially complete, but you will see later in this article the impact we have already made with the changes that have occurred. Currently, we have developed three dining areas.