The Resident: The Heart of It A home caregiving experience leads to a fresh look at caring for residents in nursing homes.

B Y J o Y S M I T H / L U C I A M . G A M R O T H

T he Omnibus Reconciliation Act (OBRA) of 1987 pre- scribed an extensive attitude change for providers of long-term care. We are now challenged to provide a

homelike environment and an individualized approach to residents with more complex care needs than we previously saw in our setting.

Our organization perceived OBRA as permission and support to reduce the use of restraints and psychoactive medications, to focus our educational efforts on resident rights, and to change the terminology we use in planning care. As a registered nurse administrator, I was both excited and anxious about the OBRA mandate to change our ap- proach to long-term care and yet we experienced conflicting expectations on the part of consumers and regulators. On one hand, expectations were based on a medical model that includes expert nursing and medical management and a phi- losophy of safety at all costs. These expectations necessi- tated more and more paperwork to document nursillg practice and safety precautions. On the other hand, expecta- tions were for "customer satisfaction," resident rights and choice, and a less institutional environment.

Surveyors frequently cite care plan deficiencies in nurs- ing homes, and we were continually frustrated in rewriting care plans to fit their expectations. Care plans in our facility were one to four pages long and detailed. They were not used by staff, who had developed more effective ways to communicate, and they were more multidisciplinary than in- terdisciplinary; nurses and other disciplines usually wrote the care plan before the care conference meetings. Written care plans were sometimes inconsistent with what was actu- ally happening, since staff did not refer to them. Plans did not reflect the nursing and interdisciplinary process that was bringing about the documented outcome. Written plans were

JOY SMITH, BSN, RN, is director of nursing at the Benedictine Nursing Center in Mt. Angel, Oregon. LUCIA M. GAMROTH, PhD, RN, is asso- ciate director of the Benedictine Institute for Long Term Care and an as- sistant professor at Oregon Health Sciences University School of Nursing in Portland, Oregon.

GERIATR NURS 1995;16:113-16.

Copyright �9 1995 by Mosby-Year Book, Inc.

0197-4572/95/$3.00 + 0 34/1/60974

kept at the nurses' station and were not accessible to bedside caregivers.

A Change of Perspective

As we struggled to balance these differing expectations and inconsistent practices, the death of one of our staff nurses helped us to see a new way of looking at care needs in the nursing home. Chris had been fighting breast cancer for a couple of years; bone metastases had developed, and she knew that her time was limited. Chris was an efficient nurse and a perfectionist in performance and appearance: a DON's dream!

As we watched Chris continue to work despite her dete- riorating condition and increasing pain, we became more in- volved in her struggle. She intensely wished to remain

OBRA prescribed an extensive

attitude change for providers of

long-term care.

independent, loved, and respected during her illness. Within 2 months of the time Chris had tearfully shared her diagno- sis, she was chair- and bed-bound at home. Chris requested that she not be alone and that she not be sent any place where she would not have control of her pain management. Chris was expected to die within days, but she lived for 3 more weeks. With the help of hospice staff, her family pro- vided care. When family members became physically and emotionally exhausted, hospice called to request help from our staff. Teams of staff volunteered to spend nights with Chris to give her family some sleep. During the night that I sat with Chris I spent hours thinking of how different it would be if she were a patient in our nursing home, where her other staff friends were "wearing" their respective job descriptions. I thought of all the things that we would do at the nursing center to follow "standard nursing practice" for somebody like Chris (e.g., turn every 2 hours, bathe daily, worry about food and fluid intake, decubitus care). It was most disconcerting! Chris had complete charge of her care

GERIATRIC NURSING Volume 16, Number 3 Smith and Gamroth 113

FIGURE 1. Components of the care plan.

at home though she was unable to move or do anything physically for herself. She directed when and how she wanted her position changed and which pain medication and how much she wanted, when she wanted it, and how she wanted it. We followed her directions and stayed with her until she died. I left feeling that I had done all that I could as a friend and as a nurse. The conflicting ideas of care for Chris at home, versus how I envisioned it would be where I worked, continued to bother me. These experiences led to a 2-year process to ,bring caregiving to l i fe"--a way of thinking that changes the entire approach to resident care. As Chris died, she birthed a new care planning process for our institution.

Our new approach involves considerable education and mutual support, but more than a change in what we do, it is a change in our role with residents and in how we think. We are now partners with residents rather than caregivers, and our plans are more their plans. The goal is to have a care plan that reflects residents' needs and goals and, as much as possible, to retain life as it was for them at home. Staff are expected to challenge interventions and suggestions with the question, "Does this make sense for this resident at this time, and does it reflect the resident's choice?"

Written Care Plan

The written care plan is not one document but a network of documents, which reduces the duplication and places each component where it is accessible to those needing the information. The care plan includes (1) an active care plan, (2) a bedside information sheet, (3) medication and treat- ment sheets, (4) a certified nursing assistant (CNA) flow sheet, and (5) an "alert" charting form (Figure 1). Forms were not changed or added but completed differently and re- located.

Active care plan. On the active care plan we write only things that we expect to change within a 3-month time frame. The active care plan lists five or fewer goals that show the process and reflect current priorities to assess some issue or implement a change. It is kept at the nurses' station, where all disciplines have access to it. Goals are stated in broad statements, such as, "Evaluate methods to maximize independence and safety and minimize restriction" (Figure 2).

Bedside information sheet. The bedside information sheet is used to introduce staff and family members to the resident as an individual, not as a diagnosis or a room num- ber. Statements on the bedside sheet are "I statements" that reflect things about the resident's life and preferences that are important for the staff to know in relating to him or her on a daily basis. For example: "Call me Maggie. I have three children. I like classical music. I get up at 10 AM. I choose my clothing, but please assist me in dressing" (Figure 3). Information is acquired through an interview of residents and families on admission and revised as a resident's condi- tion or preferences change. A representative of each disci- pline completes the appropriate section as he or she visits with the resident.

If cognitively impaired residents are unable to express opinions or choices, family members are asked about the resident with careful attention given to the resident's lifestyle and choices. It is important that the information truly reflects that resident's wishes, as much as possible, and not what the family would choose for the resident.

Formerly, the bedside information sheet was the back side of the care plan form, which was kept in a three-ring note- book at the desk. Now it is kept, with the resident's permis- sion, in a folder in a plastic sleeve above the bed or wherever the resident determines. When it is filled, we move it to the chart as part of the permanent record and begin another form.

The conflicting ideas of care for

Chris at home, versus how I

envisioned it would be where I

worked, continued to bother me.

Medication and treatment sheets. Medication and treatment sheets are kept in binders on the medication carts, and forms are unchanged from ones used previously. The only change is that interventions listed on the medication and treatment sheets are not relisted elsewhere as part of the care plan.

CNA flow sheets. CNA flow sheets have been reduced and are now kept with the bedside information sheets where the CNAs do their charting.

"Aler t chart ing," Alert charting is done by nurses at any time when a temporary care plan would be indicated. It is entered on nursing progress notes and includes a plan.

114 Smith and Gamroth May/June 1995 GERIATRIC NURSING

DATE PROB GOALS #

9/92 #1 Maximize comfort and autonomy

with pain management program

retaining her mental awareness.

I, 9/92 #2 Assess need for someone present

vs. private time and provide for her

choice.

EST. DATE

APPROACH INVOLVED DISCIPLINE

1. Ask her if she's comfortable.

2. Monitor level of consciousness and ability

to control situations.

1. Ask chris da!ly about preferences for

private time, company time and her level

of fatigue

DATE AMENDED

DATE RESOLVED

*See Quarterly Focus Summary for additional goals and information.

Review Date:_ Long Term Care Goals:.

Pdmary Nurse: Physician: Resident: Chris Room and B e d # : . _ _

FIGURE 2. Active care plan.

At first, staff experienced difficulty in deciding between active care plan entries and bedside information. How do you decide whether something goes on the bedside informa- tion sheet or on the active care plan? We now provide staff guidelines for decision making, with clear illustrations. For example, if a person shows restorative potential, the restora- tive plan is on the care plan. If not, staff use CNA flow sheets and bedside information sheets. If the resident is tak- ing psychoactive medications, evaluation must be made on the care plan. If standard care is being given for a diagnosis" or disability (e.g., turn every 2 hours; use egg crate; give oral care; manage incontinence), this information should be on the bedside information sheet.

In other words, we separate maintenance care from active goals and process. "Assess the best method of prevention for recurring pressure ulcers" is an active, interdisciplinary care plan intervention. Managing incontinence is maintenance care; planning a bladder training program or a way to im- prove incontinence management is an active care plan goal. Total activities of daily living care is information, but to change methods or to do a restorative program is an active plan. Some active care plans may be social and pastoral in- terventions only, with all nursing information on the bedside information and flow sheets.

It was difficult at first not to make decisions for people, because nurses are so good at knowing what to do for peo- ple. To avoid making decisions for residents, caregivers ask the following questions:

�9 What are this resident's priorities as evidenced by choices made (e.g., service, comfort, pain relief, food, restorative, exercise, activities, socialization)?

�9 Did the resident, family, and I weigh the burden and benefit of this intervention?

�9 Is this a resident need or a staff need? �9 Is this a standard protocol, or is it specific to this res-

ident? �9 Will this intervention change anything to better ad-

dress a resident priority?

Relationships to Regulatory Process

No new forms are needed, as this is an attitude change not a format change. It is not what forms you use, it is how you use them that matters. The approach is very compatible with the minimum data set (MDS) and the resident assess- ment protocols (RAPs).

If no action is needed on a RAP or triggered item, simply document that on the back of the RAP summary. When an intervention is needed, reference any part of the care plan where the problem is addressed; the facility procedure indi- cates which forms are considered part of the care plan.

Results

We have been using this approach to care planning for 2 years. We have been through two surveys, and each time we have explained the system to the surveyors, shown them

GERIATRIC NURSING Volume 16, Number 3 Smith and Gamroth 115

Bed: I prefer to sleep through the night when that's possible without being awakened.

Transfers:

Ambulations:

ROM:

POSITIONING Bed & w/c: I will tell you when to turn me and

how.

ADLs Oral care:

Bathing:

Dressing:

Toileting:

ASSISTIVE DEVICES

SKIN I have a decubitus and don't want any special RX for it because it is too painfu ! for me to move,

s

NUTRITION Diet: I will loll you what I would like to eat and

drink and when,

Nourishment:

Eating:

I would like to control my own pain medication so I can be alert when I have time with my family.

B.F.S/DB6TJYJ~

would like my bed positioned by the window so I can see out. My favorite music is,,.

PASTORAL

PERSONAL NOTES/SOCIAL ' SERVlCES

It is really important for me to have time with family.

I I would really like to die here at home wlth my family. Please help make that possible.

Address me as: Chris

Review Dates: Pr imary Nurse: Resident: Chris #

FIGURE 3. Bedside information sheet.

where the care plan components are located in the record, and told them how the process works. The first year the sur- veyors remarked, "It looks like a pretty good idea, but we don ' t know if it will work." This past year the surveyors praised the new approach and said we were doing an excel- lent job of implementing the OBRA regulations. The change process itself has concentrated energy on care planning, and consistency and quality have improved as a result.

Two years ago none of the CNAs used the care plan. Now the CNA says, "Well, it depends on what you mean by the care plan. Part of it the nurses use more than I do but the bedside information sheet and the flowsheets are what I use....How often I use them depends on how well I know the resident and whether or not I 've been off for a few days, or if I have a new resident. With a new resident, I use the sheet to find out what is important for the person. I also use it for teaching other people when someone does not understand."

The bedside information sheet is current, accessible to staff who work at the bedside, to families, and to volunteers who sit with residents. It makes staff think about d igni ty- - you cannot ignore that when you are writing something to leave at the bedside.

The new approach is difficult. It is always difficult to stop doing what you have felt secure with and change to some-

thing that no one else has done. Nevertheless, the new ap- proach has made all of us think differently, which has been very helpful; that alteration in perspective is one of the best parts of the change, and much of the good outcome may be due to that. Care planning is definitely more interdiscipli- nary than before: residents, families, and staff cooperate to paint a portrait of the resident on the bedside information sheet. They all attend care conferences where active care plan intervention priorities are decided. When one resident crossed out several areas on her bedside information sheet and dictated changes and another resident's daughter asked for a copy of the bedside information for a scrapbook in memory of her mother, we knew our efforts had made a dif- ference. The process has changed our relationship with res- idents and with other staff on the team, and decision making is strengthened by this teamwork.

The change has been a healthy process to help us look at nursing in the '90s. This new process has challenged us to question interventions we have used for years, such as bowel care, restraint use, meditation use, and to search out each resident's priorities in our planning. We are no longer the parent or caregiver but the partner and advocate to maintain the resident's personhood. When we truly see residents as peers, our partnership will be real. �9

116 Smith and Gamroth May/June 1995 GERIATRIC NURSING