Creating Home in the Nursing HomeA National Symposium on Culture Change and the
Environmental Requirements
Household Models forNursing Home Environments
Gaius G. Nelson President
Minneapolis, Minnesota, USA
Quality of Life To Live in Fullness
Finding FlowThe Psychology of Engagement with Everyday life
Mihaly Csyikszentmihalyi
Life is:• What we do
• How we feel about it
• Who we do it with
We depend upon the company of others
Finding Flow Being in harmony with what we Wish • Feel • Think
Optimal Flow Experiences require:
• Clarity of goals• Immediate feedback• Challenge equal to skills
Flow activities often lead to a loss in Sense of Time
Improving Quality of Life Engineering daily life to maximize flow activities
The Quality of Experience in Everyday Activities
Based on daytime activities reported by representative adults and teenagers in recent U.S. studies.
The typical quality of experience in various activities is indicated as follows: – negative; — very negative; • average or neutral; + positive; ++ very positive
Productive Activities Happiness Motivation Concentration Flow
Working at work or studying – — ++ + Maintenance Activities
Housework – – • – Eating ++ ++ – • Grooming • • • • Driving, transportation • • + + Leisure Activities
Media (TV and reading) • ++ – – Hobbies, sports, movies + ++ + ++ Talking, socializing, sex ++ ++ • + Idling, resting • + – — Sources: Csikszentmihalyi and Csikszentmihalyi 1988; Csikszentmihalyi and Graef 1980; Csikszentmihalyi and LeFevre 1989; Csikszentmihalyi, Rathunde, and Whalen 1993; Kubey and Csikszentmihalyi 1990; and Larson and Richards 1994.
Improving Quality of Life High Flow potential activities
Individual Focused
• Working• Studying• Hobbies• Sports• Driving• Movies
Relationship Focused
• Working
• Hobbies
• Sports
• Talking
• Socializing
• Having Sex
Improving Quality of Life High Flow potential activities
Relationship Focused
• Hobbies
• Sports
• Socializing
Chicago TribuneFebruary 16, 2007
Joystix.com
Improving Quality of Life Creating Relationship Enabling Environments
• What is my relationship with myself?
• What is my relationship with culture?
• What is my relationship with the natural world?
Henry David Thoreau - The Walden School
• Locks in existing models• Creates repetitive and predictable environments• Eliminates potential innovation• Based upon regulatory expedience• Minimum standards become maximum
allowances
Form Follows Regulation The Creation of Unintended Consequences
Requirement:
• Bedrooms must exitthrough a corridor
• Maximum distance of120’ to the nurse station
• Visual control from anurse station
• Maximum of 60 bedsper nursing unit
Form Follows Regulation The Institutional Nursing Home Model
Result:
• Double-loaded corridorslined by bedrooms
• 120’ corridors withdayrooms at the end
• Dominant nurse station atcorridor intersections
• 60 beds per nursing unitwith large centralizeddining & social areas
• Providing a variety in scale and quality of environments
Hierarchy of SpacesCreating Appropriate Transitions
• A redistribution of Activity Spaces
• Activating the Corridor
• Improved hierarchy of transitions
Hierarchy of SpacesAn Early Concept for Nursing Homes
Hierarchy of SpacesThe Household is Born
• Small scale environment
• Discrete clusters
• Decentralized social andstaff areas
Gaius Nelson @ KKE 1987
• Reduce the scale
• Use understandable andidentifiable spaces
• Provide the appropriateHierarchy of Space
• Enable movement
• Provide access to nature
Creating Home in the Nursing Home By Creating Relationship Enabling Environments
Living in a HomeCreekview at Evergreen - Household Model
• Small scaleenvironment
• Ease of access• All activities of daily
living in one setting
• Understandable spaces• Recognizable from past
experience• Variety of choices
Living in a HomeCreekview at Evergreen - Household Model
• Open access to thenatural environment
• Variety of exterioractivity settings
• Outdoor backyard
Living in a HomeCreekview at Evergreen - Household Model
• De-institutionalized
clinical resources
• Comfortable, non-
threatening environment
Living in a HomeCreekview at Evergreen - Household Model
• Independent houses
• 10 private resident rooms
• Specially trained staff provideall care and household duties
Living in a HomeThe Green House® Model at Traceway
DESIGN 2004
• Hearth Room
• Open Kitchen
Living in a HomeThe Green House® Model at Traceway
DESIGN 2004
Belonging to a CommunityThe Green House® Model at Traceway
• Residential homes within aneighborhood setting
• Support services are availablefrom the main campus
DESIGN 2004
Design for Aging Review7th Edition
Belonging to a CommunityCreekview at Evergreen - Neighborhood Place
• Variety in spaces andpotential for interaction
• Places to meet others• Participation in larger group
activities• Variety of activity settings• Understanding one’s heritage and
shared experience
Belonging to a CommunityCreekview at Evergreen - Neighborhood Place
• Nursing Home Entry
• Creekview Café• Aquatic Center
• Fitness Center
• Aerobic Studio
• Therapy Services
Connecting to the Larger WorldCreekview at Evergreen - Creekview Center
• Creekview Café bringscommunity into thecenter of the nursinghome
• Provides a reason to justhang out
• Opportunity for plannedor chance meetings
Connecting to the Larger WorldCreekview at Evergreen - Creekview Center
Connecting to the Larger WorldCreekview at Evergreen - Creekview Center
• Membership programthrough Senior Center
• Involvement of UWOshkosh - Learning inRetirement
• Activities for all agesand abilities
• Overlapping and contradictory regulations
• Fire safety from fireplaces and kitchens
• Resident safety in kitchens and food-borne illness
• Corridor width and extent of handrails
• Direct staff supervision and distance requirements
• Accessibility for frail individuals and assisted care
• Furniture flammability standards
Common Regulatory IssuesImpediments to Creating Home
• Local zoning and licensing• Building and fire codes• Local food service inspections• State health department• CMS State Operations Manual• Accessibility standards• Unwritten Policies and procedures
Regulatory JurisdictionsOverlapping and Contradictory Regulations
• CMS should encourage states to consolidate reviewof nursing homes under a single agency
• States should require plan reviews and inspections beprovided by the same person
• Consistent interpretations of codes and regulationsshould be documented at State and Federal levels
Regulatory JurisdictionsOverlapping and Contradictory Regulations
• Wood burning and gas-firedappliances are not allowedwithin smoke compartmentscontaining resident sleepingareas.
Fire Safety IssuesFireplaces & Kitchens Open to Corridors
DESIGN 2004
• Cooking facilities arerequired to be protected inaccordance with NFPA 96,using a commercial venthood and special firesuppression systems.
• Electric fireplaces areallowed in some jurisdictions,however, many others allowonly decorative hearths.
DESIGN 2004
• Alternatives to NFPA 96 mustbe researched and allowed forsmall-scale food serviceoperations including withinhouseholds and facility cafésand delis. (see NIST Special Pub. 1066, 2007)
Fire Safety IssuesFireplaces & Kitchens Open to Corridors
• Residents need protected accessto potentially dangerous itemssuch as hot surfaces, kitchenutensils and cleaning chemicals.
Dangers in the KitchenResident Safety & Food-borne Illness
• Kitchen equipment, foodpreparation surfaces andcabinetry are required to meetNational Sanitary FoundationInternational (NSFI) standardsfor commercial food serviceoperations.
• Provide reasonablerequirements for securingchemicals and other dangerousitems while allowing for normalactivities and daily experiences.
Dangers in the KitchenResident Safety & Food-borne Illness
• Provide standardized waivers forsmall-scale food operations.Undertake research as to the truedanger of food-borne illness fromresidential equipment, cabinetsand surface materials.
• Protrusions greater than 3 1/2”are not allowed in the 8’-0”corridor width. Exit corridorsare to remain unobstructed.
CorridorsRequired Width & Extent of Handrail
• Handrails are required oneach side of the corridor.Corridors are not required tobe enclosed by walls.
• Reduce required width ofcorridors. Research exit widthrequirements using actualevacuation methods that donot include transport by bed.
CorridorsRequired Width & Extent of Handrail
• Exempt handrails alongspaces “open to corridor” andallow handrail to bediscontinuous for furniture andother elements includingdisplays and artwork.
• Many States require that directvisual control of corridors beprovided from a nurse station.Why is a nurse station needed?
Staff SupervisionDirect Visual Control of Corridors
• It is often required thatresident rooms be located amaximum distance of 120feet from a nurse station.
Nurse
• CMS could stipulate that nofixed location is required as a“nursing station” or staff area.
Staff SupervisionDirect Visual Control of Corridors
• Without a required stafflocation, distancemeasurements are no longermeaningful.
Nurse
• Accessibility standards are notdesigned for frail individualsor those requiring assistance.
AccessibilityFrail Individuals & Assisted Care
DESIGN 2004
• Allow standard waivers fromaccessibility requirements toprovide of older populations.Support research andmodifications to ADAAG.
AccessibilityFrail Individuals & Assisted Care
DESIGN 2004
• Flammability standards requirecommercial furnitureconstruction within publicoccupancies, including nursinghomes.
• Local or state fire marshalsoften limit upholsteredfurniture to one personal item.
Furniture Flammability StandardsCAL 117 & CAL 133
• Require acceptance of the firesprinkler exception that allowsunlimited quantities ofupholstered furniture notmeeting commercial standards.
Furniture Flammability StandardsCAL 117 & CAL 133
• Personal choice should takeprecedence over inappropriateenforcement of in flammabilitystandards.
Working Toward ChangeState and National Efforts
• Monitor legislation and rules
• Find diverse affinity groups
• Form and join group workingtoward change
• Conduct research
• Educate constituents
• Participate in consensus basedstandards organizations
• Replicate past successes
• Educate lawmakers on issues
• Require research to supportregulatory requirements
• Be persistent
SAGESociety for the Advancement of Gerontological Environments
• Not-for Profit 501 (c) 3
• Multi disciplinary organization
– Owners & Operators
– Clinicians
– Architects & Designers
– Regulators
– Consumers
– Educators & Academicians
• DESIGN magazine project jury
• Education & Research
– Post Occupancy Evaluations
– National conference presentations
SAGE PrincipalsSociety for the Advancement of Gerontological Environments
• Physical safety and psychological security
• Environment as a therapeutic resource
• Holism and well-being
• Resident rights and personal autonomy
• Communities and relationships
• Support of caregivers
• Function enhancing technology
• Creating and evaluating
www.sagefederation.com
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