Wheelchairs. It seems like they are everywhere we go within the walls of so many nursing homes. Many believe they are a needed, if not required, piece of equipment. For some residents, the wheelchair is their ticket to independence. For most though, it’s a one way street to declines in almost every aspect of life. How many residents do we see slumped over in these chairs, belted in, reclined or otherwise forced to stay in them? Do we see the connection between wheelchair use and physical decline?

I can attest to this over dependence on wheelchairs. It starts out innocently enough- the aides are working short (again) and meals are being served. Time is short. Residents walk slowly. It’s easier to just pop them into a wheelchair and push them to the dining room. Or to the bathroom. Or to the activity room…and so on. Soon, the resident begins losing their confidence and desire to walk themselves. Perhaps they’ve had a fall and we are nervous to let them walk again…whatever, it’s insidious and sneaky- this overuse of chairs.

Provider Magazine has an excellent article (PDF) about wheelchair use, or more like, abuse. The article stresses that nursing home culture includes having so many residents sitting in these chairs that it’s almost expected. The article highlights one facility that decided to end the abuse, and how the residents have benefited. The Administrator started this process and walks readers through the steps she took to go “wheelchair free”…

WHEN FOREST AT DUKE, A continuing care retirement community in Durham, N.C., began planning its renovation and expansion, Leslie Jarema, administrator and director of health services, seized the opportunity to dramatically reduce wheelchair use in the community. “My many years in nursing home environments convinced me that wheelchairs created the discomfort that resulted in many negative outcomes and behaviors of residents,” says Jarema.

She has a tough policy:

Jarema instituted a new policy that limits the use of wheelchairs to two purposes: to enable a resident to be independent in ambulation or to transport a resident from point A to point B.

So, even the common “Walk-to-Dine” programs aren’t acceptable here, it seems. This isn’t a bad thing.

And what happened?

For the residents of Forest at Duke, the outcome of the wheelchair policy was nothing but positive, Jarema says. Dignity, comfort, improved skin condition, and residents’ range of motion were improved. “But there are some less obvious, more subtle outcomes,” she says. For example, the feel of the home became quieter, calmer, and more visually appealing. “The new program has totally eliminated the residents who typically sit around the nursing station crying out in discomfort.”

Jarema admits that the new policy meant more work for staff, who at first put up some resistance. “Even families and some residents resisted the initiative,” she says. “But one
must be committed and convinced that this change is for the better. Perseverance, persistence, and patience go a long way in achieving this highest level of functioning for our residents by getting them out of wheelchairs.”

A few reasons to re-consider the over-use of wheelchairs:

Over the years, the image of someone who resides in a nursing facility has become synonymous with an elderly person seated in a wheelchair. According to a study in the Journal of Rehabilitation Research and Development, wheelchairs provided to the elderly are often the wrong size, are in poor repair, are unsafe, and have fixed armrests and foot rests—factors that could lead to “poor posture, pain and discomfort, decreased sitting tolerance and function, decreased mobility, and pressure ulcers.” The authors conclude that psychological factors associated with “inadequate or inappropriate mobility devices” include loss of self-esteem, depression, diminished quality of life, and social isolation.

Does your facility abuse the use of wheelchairs? Are residents transported and then kept in the chairs as a means of convenience? Do you think it could be better to go to a policy such as highlighted in the article? What steps can CNA’s take to prevent this dependence upon wheelchairs? And who is more dependent: The resident or the CNA?

Video 3 and 4 here, from the series.

I found these videos at YouTube and thought it would be a good resource. I’m including them here in two posts…

Transfer Techniques p.1 of 4

Video Two from the series.

Transfer Techniques p.2 of 4

A what?

Thanatology
The study of death and dying, especially in their psychological and social aspects.

I have never heard of this profession until I received an email from a woman who does this for a living. And I am amazed.

From Donalyn’s web site:

Dr. Donalyn Gross, PhD., LCSW, CMP, Thanatologist
D. Gross, PhD., LCSW, CMP, Thanatologist, has worked with the terminally ill and their loved ones for over thirty years. She has worked in hospitals, correctional systems, been a hospice volunteer director, has taught college courses in death and dying, and gives workshops on death and dying issues.

Donalyn created a program called Good Endings.

At her web site, Donalyn offers training materials for nursing home staff who work with people who are dying- so this encompasses all nurses and CNA’s of course:

GOOD ENDINGS-Caring for the Dying Resident-A Guide Twelve page booklet dealing with the end of life issues for those in the nursing home and health care agency field. Provides strategies and insights for caregivers. It includes Five Stages of dying, Problems Associated With a Terminal Diagnosis, How We Can Help The Dying, Physical Signs of Active Dying, and After A Death. $2.00 each booklet plus s/h.

We have written here many times how CNA’s are not prepared to deal with the emotional aspects of the death process. We even lack good training when it comes to Hospice practices in all honesty. I think any education on this matter is worthy of having on hand. Donalyn sells booklets which can be shared with staff and perhaps an in service can be developed based on her program. She offers on site training for nursing homes located in the North East region of the US.

Additionally she offers CD’s with her own music, which she uses harps as a means to relax people who are in the process of dying. She authored an article on this topic at Long Term Care Living recently.

Be sure to check this out. The booklets alone would make an excellent addition to Staff Develop book resources.

Frances Shani Parker used to be a school principal. Then she became a hospice volunteer and has written about her experiences in nursing homes. I received a copy of her book and it is excellent. I recommend it to anyone who works in a hospice setting, and for all CNA’s as well. I will venture to ask that DON’s and Administrators have a look too. Sometimes people in higher places at nursing homes forget some of Frances’ important lessons.

You can purchase her book HERE.

Also, Frances has a blog HERE.

Provider Magazine, a long term care trade publication, has an excellent article up about how CNA documenting can be streamlined and made much more efficient and, productive. In less time.

Read on (PDF File)

A new pressure ulcer reduction program—known as On-Time Quality Improvement for Long Term Care(On-Time)—was developed by the Agency for Health Care Research and Quality (AHRQ) with support from the California Health Care Foundation in an effort to close the gap between staff knowledge and staff practice.
[…]
Since certified nurse assistants (CNAs) spend the most time with residents, they are frequently the first to notice subtle health status changes; however, their observations often never reach the team members who are formulating care plans. In addition, nurses are sometimes reluctant to use CNA
documentation because it may not accurately reflect resident health status and is often incomplete.

More:

There are three key components of the On-Time program:
*Assessing current CNA documentation, streamlining CNA documentation, incorporating best practice elements into daily charting, and consolidating CNA documentation into one form;

*Establishing audit and feedback processes to confirm CNA information completeness and accuracy;

*Integrating weekly reports that identify at-risk residents into care planning processes and structures.

Sometimes I wonder about ALL the documenting we do- is it helpful, is it really necessary and, who reads it? Where does it all go? AND how much of the paperwork is geared towards making someone’s else’s job easier? Hmm.

Implementing The Program
Successful implementation of the On- Time model entails the following three steps.
Step One: Streamline and standardize CNA documentation to capture relevant information. The heart of the On-Time program lies in the daily care documentation conducted by CNAs. Prototypes of the CNA documentation form and the On-Time reports are the starting point for implementing the program.
During the first stage of the initiative, documentation forms currently used by CNAs are reviewed; cross-referenced against regulatory requirements, facility care protocols, and best practice elements; and compared to the On-Time CNA form prototype.
[…]
The result of this process is the development of a new CNA form designed to include best practice elements and to eliminate both redundancy and documentation of unessential items.

READ the entire article HERE; this is a PDF file and it’s very worth printing and saving. Any efforts to reduce the amounts of paperwork is worth looking into. CNA’s and nurses spend astronomical amounts of time writing, checking, noting and reading many forms, sheets, records, logs..much of it is inefficient and wasteful.

The National Association of Health Care Assistants- NAHCA- used to have a magazine for CNA’s called “CNA TODAY”- it ceased publication a couple years ago. NOW, they introduce a new magazine for ALL direct care workers in the nursing field, titled, “MY CAREGIVER”.

From the MY CAREGIVER web site:

My Caregiver is a quarterly magazine published by the Academy of Certified Health Professionals (ACHP) for and about health care assistants and their role in long term care. It is a special magazine, a publication virtually every person in the long term care industry will want to read.

With a circulation of 10,000, we reach nursing assistants, Directors of Nursing, facility Administrators, nursing home residents, and their families, product manufacturers, policy makers, and other health care associations.

The first issue of My Caregiver debuted March 2008. It evolved from the original CNA Today magazine to focus on health care assistants from diverse settings in long term care. The original magazine, CNA Today, launched June 2001 and was unveiled at the NAGNA National Convention.

Now My Caregiver will prove to be a remarkable resource for information on long term care for all who perform the role or duties of a nursing assistant, regardless of title.

The magazine is published quarterly and costs $15.00/year for non NAHCA members; $10.00/year for members.

NAHCA’s main web site is HERE.

One of the things so many people like about the Culture Change movement is the upside down chain of command structure. Residents call the shots; next the CNAs have this “power”. Nursing homes that are seeking to change their culture often do a lot of window dressing but actually change very little of the management and leadership culture. Fear is the reason for this.

When a facility is looking to really change, actions do speak very loud. Pioneer Network has been working tirelessly to assist nursing homes and assisted living facilities with culture change. Matt over at Setting The Nursing Home On Fire found this gem of an article at the Pioneer site:

Low Cost Practical Strategies to Transform Nursing Facilities
it is a pdf report.

One of the things I noted quickly was the attention to the staff break room. When the staff are respected and trusted, it shows in many ways. Having a retreat style break room is a viable and cheap idea most nursing homes could manage. With the right motivational leadership, the nurses and aides would be more than willing to assist with creating this room.

Staff Amenities
Overall Goal:
Routinely staff members have been assigned break room space in the basement of a facility that is
furnished with cast offs, has equipment and appliances that often malfunction, and space that is expected to serve the dual purpose for staff who want to socialize as well as those who want a quiet time. Reverse this trend and provide staff with an abundance of spaces including tables in main dining room, a computer station and quiet space for reading or meditation.

Really now? Do staff need all this? DO we really care if our break room is nicely outfitted with decent working microwave ovens and fridge large enough to accommodate ALL our bagged meals and drinks? And who has a computer in their break room? Management would never trust the staff to go online because they might be wasting time, right?

Get with the times, management.

Examples of Improvement Strategies:
• Enhance the staff break room. It should have good lighting, comfortable chairs, conversation arrangements, appliances that work, flat surfaces for both eating and writing and a quiet corner

• Provide computer area or computer station for private staff use

• Designate a table and regular day as “give-away or exchange” where children’s clothes, extra produce from gardens, reading material, videos, and other items can be exchanged or given away

• Provide prayer corner or small meditation room designated for staff

• Encourage staff to use lounge or dining spaces to hold baby or wedding showers or other celebratory events. Invite residents to participate along with members of the community

A big bulletin board might be the only resemblance to the “old” break room.

Wow. Comfortable chairs and seating arrangements that mirror a living room more than a waiting room? Why not? When respected, staff deserve such spaces. Most of the furnishings for such spaces can be purchased cheaply through group purchasing associations, trade group memberships and, the old fashioned way- yard sales and thrift shops.

Another GREAT source of help is the resident families. I am quite sure most would donate a chair or small table; an area rug and some table lamps. The residents themselves could make wall quilts and other artwork. Bookcases and ottomans (YES- so the tired feet of CNA’s have a place to rest UP on);
everyone has a book or two they would be willing to give to the new staff LIBRARY located in the break room (same with DVD’s and the TV/Player to go with it).

Think outside the lead box. A transformation can happen within a week if it is truly wanted. Under the culture change movement every room has significance and front line staff have much more value and respect.

Check with your supervisors first, but note CPR guild lines are changing.

NEW YORK (AP) - You can skip the mouth-to-mouth breathing and just press on the chest to save a life. In a major change, the American Heart Association said Monday that hands-only CPR - rapid, deep presses on the victim’s chest until help arrives - works just as well as standard CPR for sudden cardiac arrest in adults.

Experts hope bystanders will now be more willing to jump in and help if they see someone suddenly collapse. Hands-only CPR is simpler and easier to remember and removes a big barrier for people skittish about the mouth-to-mouth breathing.

“You only have to do two things. Call 911 and push hard and fast on the middle of the person’s chest,” said Dr. Michael Sayre, an emergency medicine professor at Ohio State University who headed the committee that made the recommendation.

Often we hear the terms Restorative Nursing and Rehabilitation Nursing- the two terms are confused and intermixed in conversations and services. While similar, there are a few major differences between the two:

Rehab is a higher level of skilled care. Services are always provided by licensed staff- physical and occupational therapists and their assistants; Speech-Language Professionals, Nurses and others. Services are billed for by the hour. Government and insurance plans will only reimburse services delivered by licensed professionals. The use of CNA’s in Rehab is limited- and any care they provide is not “billable”. This means services provided by a CNA are not paid for. In Rehab, the CNA is not considered a professional.

Restorative care, on the other hand, is provided by nursing staff, including CNA’s. It is provided 24 hours a day, 7 days a week. Nurses can assess residents for needs and create special programs designed to restore or maintain the residents’ current and previous levels of physical health.

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