KNOWING THE PATIENT – PERSON CENTERED CARE

Knowing the patient?  We never knew Mabel.

Mabel died today. Minutes later, a nurse hurried down the hall carrying two old books. She stopped and excitedly showed me what the staff found when they cleaned Mabel’s room. She held up books on physics. “Mabel wrote them! Can you believe that? I never knew she wrote anything.”

We had cared for Mabel for six years, but none of our staff knew she had written any books. When she came to us, Mabel was already afflicted with Alzheimer disease. We learned later, after her death, that Mabel had been a prominent physicist.

As I listened to the nurse, I thought. Wouldn’t it have been wonderful if Mabel could have enjoyed our expressions of respect, awe, and admiration? Now it was too late.

That true story isn’t an isolated instance. Too often the nursing home staff learns information about residents from reading the obituaries. The individual life stories never make it to direct care staff, even if it had been told to social workers on admission. The story had been diluted to minimum facts on a fill-in sheet at the back of the chart under the social service tab.

Book excerpt from: Please Get To Know Me – Aging with Dignity and Relevance

In this time of cost cutting, healthcare workers managing more than one job to make ends meet, and the multitude of problems with patients requiring more care, it is hard to get to know the patient.  This book provides the information for anyone, friend or family member to become actively involved in a patient’s care.  When there is a patient and a caregiver involved, it is the family who knows the patient and can provide that bridge between the two.

Click on the picture of the book, on this page, learn how to become part of the team creating person centered care for your love one.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

SHOPPING FOR A NURSING HOME – WHAT DOES PERSON-CENTERED CARE LOOK LIKE?

PART III

Having regular access to the out of doors has been found to be necessary for happy and healthy living.

  • A protected outdoor space, garden or patio where residents can come and go independently.
  • Outdoor garden spaces are provided in raised beds so persons in wheelchairs as well as standing residents can participate in gardening.
  • A safe outdoor walking or wheelchair walkway that is not part of the city landscape.
  • Over head paging is used only in emergency situations.
  • Children are welcomed into the nursing community on a regular schedule
  • Community groups are invited to use space within the home and residents are welcome to join the community events.
  • Home has guest rooms available for residents out of town visitors.
  • Home has a cafe or restaurant on the campus available to residents and visitors.
  • A kitchen is made available to famlies with a refrigerator, stove and sink.
  • Staff are scheduled to work with the same residents on a regular basis.
  • The regular nurse and nursing assistant are included in the quarterly care conference.
  • The staff wear street clothes not uniforms.

While touring a nursing community be aware of how often you are greeted by nursing home staff. Just as when staying at a fine hotel, and employees greet you asking if there is anything they can do for you. A nursing community should display that same feeling of sincere welcome.

Great questions to ask staff as you tour are “how long have you worked here,” and follow up with “what do you enjoy about your job here?”  Happy people will want to tell you all about all of the great things about their job and nursing community. Happy and enthusiastic staff will be the most important item on your checkoff sheet.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

SHOPPING FOR A NURSING HOME – WHAT DOES PERSON CENTERED CARE LOOK LIKE?

PART II

What to look for when searching for a person-centered center:(continued)

  • Private rooms – the best choice for person centered living
  • Privacy enhanced rooms – where a resident can access their space without going through the roommate’s space
  • No traditional centrally located nurses stations
  • A personal window looking out to nature – not past another resident’s space
  • Bathroom is wheelchair friendly – sinks are able to roll wheelchair under – mirrors are positioned where a seated person can look in the mirror
  • Bathrooms and entrance doors have adaptive handles
  • Residents and families are welcome to decorate and personalize  their room
  • Extra lighting is available on request
  • Individualized heat and air conditioning controls in every room
  • Individualized refrigerators in residents rooms
  • Workout room is available to residents
  • Bathing rooms have an additional heat source
  • Towels are heated for baths
  • Gift store is on site or a cart is used for personal care products
  • Personal clothing is laundered in the unit where the resident lives – not sent to a whole facility laundry somewhere in the basement

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

SHOPPING FOR A NURSING HOME – WHAT DOES PERSON CENTERED CARE LOOK LIKE?

PART I

Hopefully if you have been touring nursing communities, the term person centered care is familiar. Healthcare workers are becoming comfortable with this terminology, yet many would not be able to say just what this looks like. Person centered care can be many things and it would be hard to find one community that is doing everything.

What to look for when searching for a person centered care center:

  • What kind of dining experience do they provide? Restaurant style, (where someone takes your order), buffet style where residents help themselves or staff assist the, family style  where bowls and platters are served on the dining table, 2 hour dining where residents can decide within a 2 hour window when they want to eat, or the 24 hour dining where the kitchen is serving around the clock.
  • Snacks and drinks are available 24 hours a day (and are always free)
  • Baked items are made and baked in kitchen in the resident’s living space
  • The community celebrates individual birthdays as well as a monthly group celebration
  • Special amenities are available such as massage or aromatherapy
  • There is a dog or cat who lives in the community (this is a very important question when there are allergies)
  • Better yet the community allows for the resident to bring their own cat or dog to live in the community
  • Residents are able to make choices: when to get up in the morning, when to go to bed, when to take a shower or bath, and are able to bathe as often as they would like
  • Living areas include a kitchen, dining area, and living room – a self contained household
  • No centralized nurses station – a person centered community looks like a home and no home has a nurses station

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

HOW TO CHOOSE A NURSING HOME FOR A PERSON WITH DEMENTIA Part III

A term that has gone out of use in the nursing home community is “custodial care,” and with good reason. The current term for care is “person centered care.” These terms are the difference between living and existing.

With custodial care you are existing but do people only want to exist? Existing means to; be present, to be alive, to be in existence, and to be surviving. Custodial care meant that the nursing home was protecting the elderly. They were charged with safe keeping and at times total guardianship of the elderly in their care. As was frequently said at that time, patients were kept “clean, dry and visitor ready.”

With time, thinking changed in the nursing home community, and people started to think about how they would like to be taken care of. Being clean, dry and visitor ready didn’t seem all that appealing. Now the thought is, if you look at all of your favorite activities over a period of time, and realize that you will never again do those things, how would you feel?

Take Ann who is now in her early seventies. Ann loves to cook, especially she likes to make soup. She makes two different soups every week. She likes to bake, making her favorite pumpkin muffins often, freezing them and eating them infrequently for a treat. Ann was a school teacher for many years and now works as a teacher’s assistant three times a week. She really enjoys staying in touch with the school atmosphere, other teachers and of course the children. Ann loves music, she sings in her church’s praise choir and she enjoys playing the piano. Ann also loves to knit and does her own small art projects making bookmarks as gifts for friends. She enjoys getting together with family and friends as often as she can.

Going to a nursing home in the future where she would only exist wouldn’t work for Ann. Living compared to exiting means; continuing your life style, maintaining your habits and activities, remaining active and relevant through being busy. Having dementia or not Ann would want to continue to; enjoy being with children, having her favorite foods, doing art, listening to music, being social, and remain connected to her faith.

Finding that nursing home that understands “person centered care,” and the concept of living over existing, is the best choice for a nursing home, for a person with dementia.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

HOW TO CHOOSE A NURSING HOME FOR A PERSON WITH DEMENTIA Part II

The choice of a nursing home has everything to do with the needs of the person with dementia. Look closely at what the reason is for the placement. Has this person just begun behaviors that the current caregiver can no longer handle? Is this person in another nursing facility that is just not meeting their needs? Is this a very large person, and the caregiver can no longer physically handle the work involved in their care?Match the reason to the services that the nursing home offers.

If the patient is always trying to walk away, question nursing home personnel about their security measures. They should have electronic monitoring systems that assure families that patients cannot leave the nursing home unattended. There should be hourly safety checks in place on all three shifts, so that a staff member is actually seeing where this patient is and what they are doing. There should be a picture of this patient at the reception desk as well as an alarm at all doors, connected to the monitoring system. The staff should indicate to the visiting family, where the security cameras are as well as who is monitoring the cameras.

If the patient needs placement because they have become more agitated and physically aggressive. Ask detailed questions about what kinds of medications the nursing home uses for behaviors. Ask what kinds of other non-drug related ways they work with the difficult patient. What does the activity program look like, and how many activity staff does the nursing home employ. There should always be an emphasis on the use of activities and getting to know the patients likes and dislikes (person centered care). The nursing home personnel should verbalize that they only use medications for behaviors as a last resort. Those types of medications should be reviewed  on a regular basis with ongoing plans for medication reduction.

If the large size of the patient is a consideration, ask about the nursing home’s equipment. Look at the size of the beds, and types of mattresses. A very large person will tend not to re position themselves  in bed as often as a slim person. This lack of movement as well as the additional weight of the person can be a cause of skin breakdown. While asking about available mattresses is an important question for any patient, it is even more so for the very large patient.

There are as many reasons for placement in a nursing, as there are patients needing placement.  Most families tend to not relocate their loved one once a choice has been made. Finding that right place where not only the patient feels comfortable but the family as well, is all important for a sucessful placement.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

HOW TO CHOOSE A NURSING HOME FOR A PERSON WITH DEMENTIA Part I

Choosing a nursing home for the person with dementia, is about where the person is in their disease process, as well as what their finances are and will be. The competition is currently very high for nursing homes caring for persons with Alzheimer’s disease.  This climate has brought forward many, very innovative programs. Programs that include plants, animals, special menus and dining options, activity programs for special interests, art, music, and the list goes on.  When a person is in the early stage of Alzheimer’s disease, they are more able to make use of special programs. Later in the disease process the person will have less interest or ability to participate in such programs.

Because many of the high end programs are usually found in private pay facilities, when assessing the elder’s finances, it makes good sense to use those resources when the elder can most enjoy them. Knowing that there is a progression to this disease, and that there is a slow decline, helps in planning. In the early stage of the disease, more funds should be available not only for the nursing facility but also for community events.  Going on outings, shopping, to a movie, out to lunch, to the zoo, etc., these opportunities need to be available.

When visiting a nursing home ask to see the activity calendar. Look for not only internal opportunities but for those outside events. Ask how they are funded, does facility have their own van, do nursing assistants accompany the elders as well as activity staff.

I well remember a nursing home that sponsored an outing to the zoo for its patients. The patients who participated were in early stage of Alzheimer’s disease.  Everything was going fine until the first patient went to sit down on a park bench and missed the bench falling to the ground. About 30 minutes later a second patient did the same thing. (both without injury)  The nursing home administrator decided it was time for this group to return to the facility. Thereafter a group never went out without a member of the nursing department, trained in Alzheimer’s care, in attendance.

Ask if there is a special memory loss unit? Is there a director of that unit? Interview the director and inquire not only about their program but also how they assess their patients for activities. The director should use terms like “person centered care” as well as vocalize an interest in your loved one’s history and “favorites.” Favorite foods, beverages, sports, music, any art interests, and more questions that would help the facility to design a program for your loved one.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

PERSON CENTERED CAREGIVING, MEANS HAVING A RELATIONSHIP

Person centered care means not only knowing an elderly person you are taking care of but knowing them so well that you have a relationship. When two people are in a relationship they know so many small things about the other. What are the elder’s favorite foods, drinks, as well as what does she really dislike. What are her favorite activities and what activities can she live without. Who are her favorite people and having easy access to these people so that you can always reach them for her.

Person centered care-giving means the control, is always with the elder. Having control, means giving the elder choices all day long. At every interaction, whether choosing what to wear in the morning, what to have for breakfast or where to go for a walk. Letting the elder know that you take their concerns first over any chore or task you need to do.

Knowing the elder’s usual routine, is she an early riser or likes to sleep in, makes all the difference. I took care of Carl who was difficult to say the least. He seemed to wake up grumpy and stayed that way all day. I was just about ready to give up, when his daughter shared that her mother had brought Carl a cup of coffee in bed every morning all their married life. Knowing this was the definition of, person centered care for Carl.

Bringing Carl his cup of coffee in bed made all the difference to him. This now was his routine, and he started the day happy, gone was grumpy Carl. The family is always the bridge between the elder and the caregiver. The family knows those seemingly small things that make up person centered care, that don’t turn out to be small at all.

Letting someone know that they are more important, and spending time with them is more important than any chore, is empowering to the elder. It puts me in mind of a poem found on stitched samplers and framed in babe’s rooms. It starts out “cleaning and scrubbing can wait till tomorrow – quiet down cobwebs, dust go to sleep”, (my tweak) Grandma needs me now and Grandma won’t keep.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

6 REASONS THE BEST CAREGIVER TAKES THE TIME TO DEVELOP TRUST

In 1950, Erikson talked about the basic concepts of trust vs mistrust in the development of an infant. This led to the concepts of patients having trust in their nurse, that also implies, someone they can rely on. The person caring for them that they have confidence in for continuous care, the person that they trust, and who gives them hope.

When there is a trusting relationship:

  • the patient is more likely to share information with the caregiver.
  • the patient is going to be more willing to cooperate with treatment.
  • the patient demonstrates that she knows the caregiver has her best interest at heart.
  • the patient who trusts will have decreased negative physical concerns.
  • the patient who trusts will experience fewer behavioral problems.
  • the patient will experience less stress.

This is not a social relationship due to the fact that the focus is always on the patient not the caregiver. The caregiver doesn’t share their personal problems with the patient. But, rather focuses their attention on the patient and the patient’s needs.

Listen, show and tell, to develop trust. Show your concern and respect for the patient. Show concern by being very sensitive to pain, discomfort, hunger and thirst. Show respect by being very sensitive using the patients preferred name, awareness of the patient’s age and to privacy issues. Listen to the patient, and let her know that you are taking her thoughts and ideas seriously. And, tell the patient often that you will be there, reassure that you will take care of her, tell her that you want her to be comfortable and happy. Tell her, that it means a lot to you to be able to take care of her.

When the relationship is well established it can certainly become social as the patient and caregiver bond through activities, shared laughs and experiences. But the first work of the caregiver is to build trust. The caregiver who is either unwilling or unable to put another person first, and develop that trust, will never be that best caregiver.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

THE NURSING CARE PLAN

The Nursing Care Plan is what directs all of the care of the patient. In a nursing community, when a new patient arrives the care plan is started immediately. At first it might only be a rough outline of the challenges the patient faces. Maybe the patient has had recent surgery and has a wound that needs to be tended to. Or the patient might have been admitted due to a recent fall or injury.  The staff needs to immediately know about safety precautions and the amount of assistance the patient needs on admission.

Within hours of admission that preliminary care plan is replaced with a complete plan created by all facility departments. These individual care plans are developed after extensive assessments. Now the patient who has fallen has had; a complete plan written by physical therapy, occupational therapy and if needed speech therapy, as well as:

  • nursing care plans for safety, how much assistance the patient needs to walk, stand up from a chair, even turn in bed, if the patient has safety risks due to dementia what does the confused person need to be safe, nursing care plans for every medication the patient is on from diuretics to psychiatric medications, nursing care plans for the nursing assistants for basic care – if the patient wears upper and lower dentures, does the patient go to the bathroom independently or does he wear incontinent products, how much assistance does the patient need to dress, bathe etc. nursing care plans for every disease process the patient has such as diabetes, congestive heart failure, arthritis etc.
  • social service care plans are where you would find out if the patient is a smoker or not, information about the family, especially if there is a problematic relationship, information about mood especially if the patient suffers from depression, information about the language the patient best communicates in and social services will track information from all departments to determine a discharge date
  • activity care plans will tell staff what specific interests the patient has, if he is religious to make sure he doesn’t miss any religious services, does he like animals, gardening, art, music, live entertainment, all of those activities available in a nursing community
  • dietary care plans these plans range from what the patient likes to dislikes, dietary restrictions and dietary needs  as well as how independent the patient is in eating or drinking

At first the care plan reflects the immediate problems, then after complete assessment it includes all the information necessary to take care of a person. Then the staff begin the real work of getting to know the patient, many times through family interview. Knowing the patient was a night worker and might still in old age like to be up at night, or that the patient was in the military and likes things as well as himself very neat.

This very personal information turns nursing care plans into person-centered care plans, by far the best kind of plan of care.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing