FRIA's national Best Practices in Nursing Home Care research project examined the main problem areas in nursing home care that concern friends and family members and suggested new attitudes towards caring for nursing home residents.  FRIA looked at real innovation from across the country and found practices that enhanced nursing home resident quality of life.  

If your loved one is experiencing challenges adjusting to life in a nursing home we suggest you discuss Best Practices with your nursing social work department, nursing staff or family council.  Adopting practices like these can be the first steps toward a new caring approach in your relative's nursing home.

This list is only a selection of what we have gathered. There are many more provider-initiated, recognized "best practices"; in books, libraries, videos and family accounts and experiences.

Avoid Weight Loss & Dehydration

• Mobile snack carts
• Appetizing smells and sights of family style meals
• Self-serve juice dispensers
• Clear pitchers to remind residents to drink
• Warm tea and broth as alternatives to ice water

Calm Agitation in Alzheimer's Patients

• Staggered staff shifts for easier transitions
• Rocking chairs
• Touch therapy and massage with aroma therapy
• Evening activity and exercise for "night owls"
• Bathing techniques that allay fear

Make Surroundings more Homelike

• Convert long hall units into smaller households or neighborhoods
• Carpet floors (this can also serve to reduce injury from falls,)
• Add plants and pets
• Extend breakfast times for early and late risers

Use the Best Established Clinical Standards

• Hospice/end-of-life care program
• Multi-disciplined pressure sore prevention program (including nutrition, skin care repositioning reminders, family/volunteer monitoring)

The above examples are practices that have been tried in other facilities that have been shown to be successful in improving care for residents. As families and friends of residents, FRIA believes that you can be a driving force in bringing these kinds of innovative and proven ideas to your relative's nursing home. This effort can be successful if you bring to it commitment and a willingness to work collaboratively with other consumers, nursing home staff and administrators.

Culture Change - A Gentle Revolution

For the past thirty years nursing homes have used a medical model of care where the goal is to cure or treat the acute illnesses that a resident may suffer from.  In this model little thought or emphasis is given to a resident's quality of life or individual preferences for day to day living.

FRIA led a coalition of consumers, providers, unions and civic groups that brought some of the Culture Change Pioneers to New York City. Their reform ideas create a vision and a movement, created by providers and supported by consumers and unions. It recognized that to give truly individualized care to residents, we have to "change the whole culture" of today's nursing homes.

The assumptions are that the hospitalization will be short-term, and that the patient will return to health, their community, and living independently.  But in a nursing home, the situation is entirely different.  Old age, even when there are chronic disabilities, is not an acute illness. It is life.  And the medical model of care does not provide appropriate management structure for just living an individual life: the fit between institutional patterns of behavior and the expectations of residents and the community of people who care about them is not a good one.

Typical complaints from families and friends reveal the problems created by the medical institutional model:

• Call bells go unanswered 
• Length of time waiting to be toileted is often unconscionable
• Warehousing people who are just waiting to die
• Fear of appearing to be a troublemaker and having staff "take it out" on their family member

Culture change reformers are succeeding in creating new models of care for nursing homes. Some elements are:

• Meals and baths are scheduled according to resident preferences rather than to department routines.
• Living units are restructured to make them smaller, and staff reorganized so that nursing, social work, recreation and therapy staff are able to respond more immediately and with more authority to the needs and concerns of residents.
• Decision making about residents is brought to the bedside, placed closer to the resident.
• Certified Nurse Aides (CNA's) are expected to create and maintain relationships with residents; and the qualities of those relationships are recognized as central to excellent care. 

How Culture Change Happens

Committing to Culture Change is a big step for a nursing home.  It takes commitment, understanding and agreement from all staff and several years of struggle to find out how to do it effectively at a particular home.The Culture Change movement is a rich source of best practices with an end result that is profound, long term and on going.

Keep in mind that no two homes can or should go through the process in exactly the same way.  The purpose of culture change is to re-orient nursing homes from an institutional culture that, inevitably, has concerned itself with running smoothly according to institutional routines to a culture that is focus on residents and their daily routines and preferences.