The changes, which go into effect on June 17, 2009, are intended to support efforts underway to transform nursing homes into “homey” environments through both environmental changes and resident-centered caregiving. Whereas in the past, these changes were sometimes stymied by fear that regulators would cite organizations for deficiencies, CMS is now making it clear that the OBRA regulations should be interpreted to support personal choice in the full range of daily activities, including waking, bathing, dining, and sleeping. The new guidance also calls for visitors to have 24-hour access to residents, regardless of familial relationship.

The new interpretive guidelines call on nursing homes to begin or to continue de-institutionalizing their physical environments. Suggestions include: reducing noise such as overhead paging and alarm bells, eliminating nursing stations, taking down institutional signage, and refraining from serving meals on institutional trays.

Get ready for the complaining. Eliminating nursing stations!?! But how can they expect us to do our work…But we can’t…and so on.

Pony up folks. Culture change is much needed process and we’ll all be better off with it. Allowing the residents to control their environment and choices is really a human right. Safety, and all those other excuses we tend to use, are just that: EXCUSES. We don’t want to give up our “power”. It’s not about us. It is about our customers- the residents.

Some Culture Change Sites of Interest:
Pioneer Network

Check out the PN’s vast selection of resource links HERE.

1) Tell us what you do for a living- how you became a consultant to nursing homes…what led you to this career; what are the goals of your service; and, to what extent are CNA’s involved with your work?

I grew up in the nursing home industry — my father was the night charge nurse at a local facility and also held an administrator’s license for many years. When I was in college, I started working as a CNA and found that I enjoyed it so much that I switched colleges in order to get my nursing degree. As a CNA, I was intrigued by all the things “they” didn’t seem to want me to know, like quality improvement, financial management, the federal regulations, etc., and after researching all of these things on my own, I came to the conclusion that “they” didn’t seem to know these things themselves.

I then started doing some freelance consulting work on my days off to help facilities out with these issues, and eventually wound up starting a consulting firm last fall. My firm specializes in helping nursing homes with quality improvement and surveys. As far as CNA involvement goes, I do my best to persuade facilities it is in their best interests to allow CNAs to be heard, because they know more about the nursing home and its residents than anybody else does. CNAs are a tremendous, largely untapped resource.

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2) What is the profile of the average nursing home that seeks your services? Are they good places who want to do better, or, are they under federal/state scrutiny for poor surveys and the like?

The average nursing home brings me in because they feel that they have no other choice, due to a lengthy history of poor surveys. It usually isn’t a pleasant thing for me, because I’m an unwelcome visitor bringing up problems that the facility wishes didn’t exist. A few nursing homes call on me because they actually do want to improve the quality of care they provide, and that is always a joy.
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3) Surveys: Most nursing home management literally “freak” out when it’s “that” time of the year. In your opinion, why does this happen? How can this get better? I’ve seen many administrators beef up nursing staffing, demand maintenance staff stay on overtime to clean and paint and dietary depts. are ordered to cook up meals that are not what is usually served. I don’t know too many aides who haven’t seen this phenomenon occur during a survey.

There are two underlying goals here from the administration’s viewpoint: (1) Avoid getting cited for any serious deficiency, because that could result in fines, loss of funding, and negative publicity. (2) A facility’s performance on survey is part of the administrator’s evaluation from his or her boss. The “freakout” occurs because everyone waits until the last minute to prepare for survey. It makes much more sense to keep the facility in a constant state of survey readiness than to go crazy when the window opens up.
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4) At your blog, you often tell readers that involving/educating CNA’s in the fiscal aspects of running a nursing home is productive and helpful. Do you any specific examples of how management can start such a process?

I think the best way to approach this is to educate all staff on the importance of the MDS, because that document the sole determinant of how much money the nursing home makes for each resident. Accurate ADL coding is not the only part of the MDS that CNAs are involved with. The importance of restorative nursing should also be taught — the MDS will pay the facility a slightly higher reimbursement rate for each resident receiving restorative services.

Also, if two different types of restorative nursing are provided to the resident at least six days a week, that would count as low level rehabilitation, which would shoot up the reimbursement rate dramatically. Another area in which the CNA can be involved is with budgeting. I firmly believe that the DON should be open about the budget and solicit opinions from all nursing staff on how it can be improved.

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5) CNA’s often want to KNOW how they can help facilities DO better- in all areas. They also have knowledge about things they believe could make facilities better. How can management draw out this knowledge from CNA’s?
They should ask, but do so actively. By this I mean just ask the CNA what needs to be improved instead of putting up a suggestion box. Asking the CNA what the nursing home is doing right, and what needs to be fixed, takes virtually no time and greatly improves morale.

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6) At your blog I’ve read posts about how you perceive some nursing home managers as looking down upon their aides. Issues such as sitting at a nurse station reading a paper are often things we get “spoken to” about. You advocate that management take a softer approach to this sort of thing. Can you explain why the softer approach could benefit the facility?

In the vast majority of nursing homes, anyone who isn’t a licensed nurse (or doesn’t have a desk job) tends to be viewed as second class citizens and have all of these arbitrary, asinine rules thrust upon them. A softer approach would result in better morale and lower turnover. People who aren’t respected will quit. I have noticed that the turnover rates are dramatically lower at facilities where CNAs are allowed behind the nurse’s station (this rule is a pet peeve of mine) and don’t have all these crazy rules to follow.

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7) Do you believe most Administrators and DON’s truly respect the CNA’s? I ask this because of the turnover rates at so many nursing homes. It’s high. Aides will stay employed at a place that treats them well and respects them- regardless of the pay. Can management do better in this area and if so, how?

Ask any administrator or DON, and they will quickly respond that yes, we do respect the aides, they work hard, I couldn’t do their job, blah, blah,blah…I believe that they truly do think that they have respect for CNAs, but oftentimes the folks who are supposedly respected would say otherwise. Yes, management *could* do better, but I can’t tell you why they won’t.

Perhaps it’s a fear of change — this attitude is prevalent throughout the industry. The first thing that has to happen is a demonstration on the part of administration that they really do care. Perhaps the administrator and DON could work the floor. After that, the things that need to happen are greatly increased staff education, coaching supervision instead of discipline, and a peer mentoring program.

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About resident abuse issues: Do you think CNA’s should have a better base of education on this? The current courses brush over the subject but it’s a problem in so many facilities. How can resident care be better with the limited training CNA’s now receive?

Without training, it can’t be better. Training needs to focus on attacking the root causes of abuse — dealing with burnout, addressing challenging resident behaviors, etc. There is a really good curriculum for this stuff available, and I believe there is a link to it on your blog as well as mine.

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Be sure to visit Matt’s blog HERE: Setting The Nursing Home On Fire

I asked Donalyn for an interview here, to get her thoughts and opinions on this issue. Presented here, is the interview which was conducted via email.

1) How long have you been a Thanatologist and what prompted you to get into this profession? What are your perceptions of the death process in institutions such as nursing homes? At your site you offer workshops for staff. I strongly believe this education is needed. How many workshops have you done? Who attends the program? Are CNAs a part of them?

DG: I’ve been a Thanatologist for 30 years now. My dad was a physician, my mother is a nurse, so I was raised in a medical household. I was a Candy Striper at a local hospital in high school, and all the jobs I’ve had since then were in hospitals or nursing homes. I’ve been a medical secretary, transcriptionist, dr’s assistant, nurses aide, Activity director, and a social worker.

Some more liberal homes now allow residents in to see the person who is dying, or the deceased person. Sort of closure. That’s the way it SHOULD be. Why hide the dying/dead? I also am a Certified Music Practitioner, and play therapeutic bedside harp for the dying. I am on call at local nursing homes and a hospital.
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2) What has been your experiences in nursing homes/long term care facilities with regard to residents’ end of life care? What is the ideal environment for a dignified death within the boundaries of the average nursing facility?

DG: You know how busy nursing homes are= who has time to sit and visit with residents, never mind sit with someone who is dying. That’s why I created the Good Endings Program, with the Vigil Team= we recruited volunteer staff to sit with the dying, around the clock. It is a great program, and many nursing homes around the world are following the program and creating their own programs.

When a resident is “actively” dying, there should be some kind of protocol= the staff should make time to go in and visit/say goodbyes to that person. CNA’s are the ones who work closest to the residents. They’re kind of like extended family. They should be allowed to be with that person if they want.
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3) Is staffing an important factor in EOL care? Many residents do not have family that can be with them during their last hours; some facilities will ask an aide to sit with the dying resident and provide optimal care, while others will not. What are your thoughts on this?

DG: I think every facility should have a specially trained group of volunteer staff, who when a person is dying, should be the ones to provide the last care of that person.

Some residents have family who want to be there all the time, and only need some respite care- example- meals brought in, someone to stay if they need to take a break. For those who have no families/friends, that is a definite focus for someone to be there for them. Some people can’t deal with death and dying, and that’s ok. They can assist in other ways. There’s no shame in it, and a person shouldn’t feel guilty because they don’t want to be there.
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4) Hospice vs Nursing Home Staff: The differences you see

DG: Many nursing homes have outside hospice people coming in to see hospice patients. Nursing home staff are always there, and see the patients constantly. Hospice personnel come in for specific times and visits. They’re not always around. Hospice is a good program- they have volunteers who are a big part of hospice work, but they have their time constraints.
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5) CNA’s: What should their roles be in EOL care?

DG: CNA’s should be allowed to be a part of end of life care, to work along with the nurses, if that’s allowed. Every facility is different. Everyone is so busy and overworked. Our vigil team members will often go in during their breaks, and many will come in before or stay after a shift to sit with people.
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6) Many CNA’s know little to nothing about the religious beliefs of residents; we get basic rundowns on cultures and the like. Should CNA’s have better understanding of religious values in the context of death?

DG: In my Good Endings publications, there is a Teacher Resource packet= it’s 29 pages of everything you wanted to know about death, dying and bereavement, and information on religions/culture. Very important. NEVER push your own religious beliefs on anyone, and ALWAYS know something about a patient’s culture! Lot’s of things to be aware of.
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7) CNA classes don’t do a good job preparing the students for death and dying and all the emotions that come with it. We’re taught signs of impending death and about post-mortem care, but in clinical terms mostly. How could this be improved?

DG: I created the Good Endings program specifically for nursing home staff to provide them with the basics of death education. They should be given information on the physical aspects of dying, as well as the emotional ones.

My Good Endings Guide, a 12 page booklet, is used for this purpose. Facilities should have in service workshops once or twice/year for ALL staff members on death and dying. We’re all going to face it in our lives. It should be mandatory for ALL STAFF. I provide training workshops for healthcare personnel in nursing homes, hospice programs, hospitals, healthcare agencies= anywhere where requested. I speak at conferences for all types of groups (social workers, activity professionals, etc.) I also teach Death, Dying and Bereavement at a local college. We’re ALL going to die and we should know how to deal with it.
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CNA’s are often close to their residents. When they pass away, we’re expected to “carry on” and perform our duties with as little interruption as possible. The emotional aspect of losing a favorite resident is hard on the aides. How can management support the aides and nurses, and other staff who are grieving?

DG:When a resident dies, at some of the homes I work with, a sympathy card is passed around for staff to sign and write memories, and then given to the family. Some light a battery lit candle and put a rose up on the nurses station to symbolize there was a loss.

They do know that they can always call me at any time if they want to talk. And talking does help- even if it’s while you’re working, during a break….it’s good to get your feelings out. Working in a nursing home, there’s always going to be another death coming up. Administration should be welcoming of any kind of emotional assistance for their staff. You’re lucky if you get a concerned, involved Administrator/DON.
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Donalyn’s web site is HERE. Make sure you visit it and check out her program. She also offers in house trainings for facilities located in the north east US.