Thinking outside the box

One day in 1941, George de Mestral returned from hunting in the Swiss Alps. He picked the burrs from his dog’s fur, looked at one under the microscope and found that hundreds of tiny hooks would attach the burr to anything that was similar to cloth. He brought Velcro to market in 1948.

A few decades later, researcher Spencer Silver tried to create a strong glue and ended up with a weak one. Arthur Fry, his church choir mate, was irritated that the paper-slip bookmark in his hymnal kept falling out. Their friendship led to the creation of Post-It Notes in 1970.

These and other accidental discoveries, from corn flakes to antibiotics to the microwave, all bear witness to the same axiom: To leap ahead, you should think outside the box. As in other industries, long-term care has its sacred cows, unexamined ways and hallowed traditions that we would rather not question. We do not speak out at unrealistic regulation and mindless practices advocated by experts, regulators and researchers—some of whom are modern-day “emperors with no clothes.” We play the good soldier. We do not think outside the box.

We have spotlighted and celebrated CNAs, DONs and administrators who have worked within and around the system to launch programs that have moved their nursing care to a higher plane. Yet, for the most part, custom and regulation rule the day, fencing in our imagination, steering our thinking, research and ideas along well-worn ruts. Here are two examples of thinking outside the box.   


Advocates who promote person-centered care in nursing homes bemoan that nursing home life runs on institutional logic. It minimizes resident choice, limits resident autonomy, flattens out individuality and demands conformity. New residents soon surrender their personal preferences and accept institutional routine. Their satisfaction scores may actually be more an indicator of how thoroughly they have internalized institutional dictates.  

Now, think outside the box. When the new resident falls in line and complies with nursing home routine, does he or she succumb and surrender to the institution? Or is he/she making a smart, healthy adjustment to one’s new environment? Survival is our elemental need; adaptation is our primary tool. No one lives in a perfect world, enjoys a perfect family life or works in a perfect setting. So we learn to trim our expectations, to adapt and to settle for a reasonable happy. If unwilling or unable to adapt, we may pay a price in illness, depression, alcoholism or suicide. Therefore, when we interpret a resident’s conformance as surrender, we may also fail to applaud a silent victory of the invincible spirit within an aging body.

The satisfaction of long-stay residents with their nursing home, although high, still lags behind the satisfaction level of short-stay residents. The former have lived in a nursing home for quite some time—a third for more than three years. These residents have seen it all; they can discern the token gesture from genuine concern. They have wisely learned that a good life comes to one who negotiates, accommodates and compromises. Unobtrusively, they have lowered their expectations but not surrendered their humanity or individuality.


Ads on billboards, in print and digital media have so effectively spread the notion that elders are often bruised and abused in nursing homes that most of us wonder how much abuse and violence does occur in nursing homes. Much evidence challenges that view: If nursing homes were dangerous, why would families and residents recommend their nursing home to others as excellent places to receive care? Why would they say that their highest satisfaction comes from feeling safe?

Now think outside the box. Abuse is common in nursing homes, but it is directed mostly against caregivers. Some residents with an intact mind and a sharp tongue verbally abuse, hurl racial epithets, humiliate and provoke their caregivers. They were mean, vengeful and nasty in their younger years; they have reached old age uncleansed and unredeemed. They target CNAs. Residents with dementia on occasion discharge a volley of creative insults. And CNAs are routinely accused of everything from stealing dentures to gross physical abuse.

When innocent, a CNA pays an undeserved price. Regulation requires he or she be investigated. The CNA is presumed guilty and bears the burden of proof. Deposition and testifying demean the CNA. When the ordeal ends, the scars and stigma linger; they strain friendships and affect the aide’s career.

A study conducted in 2010 in nursing homes in Maryland and Maine, found that residents and visitors routinely attack CNAs and other caregivers. In a three-month period, residents and visitors attacked half of the caregivers at least once; a quarter of the caregivers were attacked repeatedly.

A nursing home, a prison and a mental asylum are settings where clients may turn violently on those who serve them. But unlike the other two, a nursing home does not routinely train CNAs to deal with difficult residents and visitors. As to the risk of physical harm, nursing homes rank among the most dangerous workplaces, which gives us all the more reason not only to appreciate caregivers for the care and concern they give to our seniors, butalso to admire the courage they show in choosing to work in a nursing home.


If you think inside the box, start to think outside of it. Importantly, find out who put you in the box, in the first place.

V. Tellis-Nayak, PhD, a medical sociologist, is a Senior Research Advisor at the National Research Corporation. He has been a university professor, has conducted research in the United States and abroad and has authored books and articles. He can be reached at

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