Small changes have big impact on LTC residents’ sense of control, autonomy

When the psychologist arrived at Mrs. Winters’ room, she found her distraught and disheveled. “Last time you saw me I was stuck by that dresser in the corner and couldn’t get out. This time it’s something else!” She shook her fist at the ceiling and looked heavenward. “You know what that aide said to me?” She continued without waiting for a response. “When I told her I wanted to take my shower at night instead of this morning, she said I couldn’t! It was this morning or nothing. Of course I refused. What kind of nonsense is that? I’ve been taking nighttime showers my whole life!”

This article, which follows last month's post on physical design features in the long-term care setting, addresses two additional areas of care that can be modified to offer more control and autonomy to those we serve—scheduling and training. Increasing control is important because residents often enter long-term care due to sudden and unexpected health problems that have thrown them into crisis. When residents perceive control over what is generally a highly structured new environment, it helps them cope with stressors, reduces their depression and anxiety and increases their satisfaction with care


Offering increased flexibility within daily schedules can provide opportunities for residents to have more choice in how their days unfold. They engage in the same activities such as rehab and dining, but they can arrange their days to meet their own preferences rather than subsume their desires to the nursing home schedule. 

Many adjustments in scheduling can be made without dramatic shifts in the staff routine, such as offering residents their choice of shower time. Rather than incorporating a multitude of changes simultaneously, new areas of flexibility can open up sequentially, giving the staff (and residents) time to adapt and to consider other parts of the schedule that can become more adjustable.


Offering more choices for residents will be as successful as the reception from the staff. If resident requests receive sighs, frowns and obvious irritation, residents will quickly learn that the options are for marketing purposes only and that they won’t be implemented without repercussions. In that case, because their wellbeing depends on the good will of the staff, only the feistiest residents will take advantage of newly created choices. 

Ensure the success of your enhanced scheduling features by including the affected staff members in pre-adjustment discussions. Assure staff members that accommodating residents in certain areas won’t lead to chaos—staff members worry about loss of control too—by providing examples of how other facilities have established their programs. Listen to objections and concerns closely and use the team to address the potential problems they raise. (“Ms. Cruz makes a good point. Does anyone see a way to work around that?”) Get them on board and excited and show them how this will lighten their workload once put into practice. (Residents who can choose when they engage in activities are generally less resistant.) Meet again with staff after the program is implemented in order to get their feedback about needed tweaks and adjustments.  Encourage them to share success stories as well as challenges.

Train staff in customer service techniques so that their response to requests is pleasant and accommodating. It will take more than one in-service to undo years of working under a rigid scheduling system. Training can involve information, role playing, observation and retraining until the default response to resident requests shifts from “no, we can’t!” to “maybe we can” to “no problem.”


What follows are some areas of the schedule that can be modified for greater resident choice and some customer service techniques that can be used within each situation to increase residents’ perceived control over their environment. Let the list stimulate more ideas.


  • Allowing residents to choose the time of day they prefer to bathe provides continuity with their past lifestyle.
  • Adjusting bathing schedules as needed on a particular day—perhaps for a special event or because it meets an emotional need—is part of good customer service.
  • If possible, give residents the choice between a bath and a shower.
  • Towel bathing can be a good alternative to showers for residents who don’t like to take baths or showers.
  • Provide a water temperature that suits each resident. Ask them prior to entering the water and double check upon entry that the temperature is suitable. The simple question, “how is the water?” gives a feeling of caring.
  • If the bathing area is set up to play music, give residents a choice in what they would like to hear.


  • Flexible meal times—breakfast between 6-7:30 a.m., for example—means that meals are worked around resident preferences rather than residents working around facility scheduling.
  • More food choices can be offered by increasing the number of alternatives available at each meal.
  • Increase the weekly food rotation from, say, a three-week rotation to a four-week rotation for more food options.
  • Allow residents to choose their dining area—in the room, on their floor, in the main dining room—and have adjustments met with good cheer.
  • Provide flexible seating arrangements so that friends can sit together upon request, or people can choose whether to sit alone or at a communal table.


  • Provide a choice between morning or afternoon rehab
  • If prescribed, inform residents that they can take pain medication prior to exercise to reduce post-exercise pain. Many residents don’t know about PRN medications.

Personal Care

  • Set up care teams that help when others are on break so that residents aren’t kept waiting for “their” aide.
  • Establish and monitor a policy that all staff members knock on residents’ doors before entering the room to give residents more control over their privacy.
  • Train staff to ask, “Is there anything else I can get you before I leave?” This allows an opening for timid residents to speak up and ensures that, for example, the tray table is within reach so that the call bell won’t go on moments after the staff member has left the room.


Small adjustments can make a big impact in the residents’ experience of their stays.  Examine the current procedures, choose one area to make a change and start the movement toward increased resident control.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident's Guide, is a speaker and consultant on psychological issues in long-term care.  For more information, visit Dr. El's website,

Topics: Articles , Clinical , Facility management