Rethinking the Use of Position Change Alarms
By Joanne Rader, Barbara Frank, Cathie Brady
January 4, 2007
Personal alarms are alerting devices designed to emit a warning signal when a person moves in a
way perceived to put them at risk, usually for falls. The most common types of devices are:
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A cord attached to the person’s clothing with a pin or clip and ending with a magnet or pullpin that activates when the person exceeds the length of the cord
Pressure sensitive pads for chairs, wheelchairs and beds that activate when there is
decreased pressure
Pressure sensitive mats for the floor that activates when pressure is increased
Light beams on the bed or door that activate when the person crosses the beam.
The Omnibus Reconciliation Act of 1987 (OBRA 87) implemented in 1990, resulted in a dramatic
shift in thinking and practice related to the use of physical restraints and falls. The Quality of Care
regulations to implement OBRA 87 require that there be no decline in a person’s physical, mental,
or psychosocial well-being, unless such a decline is an inevitable consequence of the person’s
disease or condition.
Restraints cause declines in a person’s physical, mental, and psychosocial well-being. By keeping
people from moving, restraints adversely affect people’s respiratory, digestive, circulatory, and
muscular systems, contribute to depression and isolation, and inhibit sleeping as well as
independent eating, drinking, toileting, and natural repositioning. As nursing home staff came to
understand the detrimental affects of restraints and changed practice, the use of position change
alarms became wide spread. However, just as restraints cause harm by keeping people from
moving, so do personal alarms. Meanwhile, there is no evidence to support alarms’ usefulness in
preventing falls or injuries. In fact, in most cases, falls continue to occur. In spite of that, staff, and
sometimes families, gravitated to the use of alarms, and surveyors in many states began looking
for them as part of the documented safety plan.
Quite often, staff respond to the alarm by directing a resident to sit back down instead of assisting
residents with whatever is generating their movement (discomfort with the current position, a need
for a drink, the bathroom, or simply a need to move). Often staff respond to the alarm and not to
the person.
In addition to the harm alarms cause by immobilizing residents, and having no evidence that they
prevent falls or injuries, they are difficult to utilize in a consistent way for a variety of reasons:
•
•
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Many persons dislike them and repeatedly hide or remove them
The device can malfunction (cord breaks or detaches, battery dies, alarm fails to go off or is
slow to respond)
If too many are in use, the warning signal loses its effectiveness at alerting staff.
Rethinking the Use of Position Change Alarms
Page 2
For the person, there can be numerous negative consequences to his/her quality of life and
mobility:
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•
•
•
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Alarms create noise, fear and confusion for the person and those around them. For
example, one gentleman would duck down when he heard the alarm as he was interpreting
the sound to mean incoming missiles, bullets from his World War II experience
If staff tell the person to sit down when the alarm goes off, the underlying need causing
them to want to move is not being address
As the use of the alarm decreases the person’s overall mobility, he/she may be more at
risk for fracture when he/she falls since the person may have increased weakness and
osteoporosis and decreased balance and endurance
The alarms can be experienced as embarrassing and an infringement of freedom, dignity,
and privacy
Skin break down can occur from being immobilized, and afraid to shift position or body
weight while sitting for prolonged periods of time, or while lying in bed at night
Sleep may be interrupted, or even impossible when residents lie still for fear of setting off
the alarm if they shift their position or being awakened by the alarm
Loss of independent bowel and bladder function can occur.
Clearly there are many people in LTC who are at risk for falls and injury and who need to have a
safety plan in place. These plans need to be highly individualized and based on a thorough
assessment of the risk factors that exist within the person and her/his clinical condition, in the
physical environment and also the organizational environment. The alarms provide a clear
example of an intervention that by attempting to prevent the risk of falling may actually increase
the risk of serious injury from falling. They give a false sense of security and at the same time,
absorb an inordinate amount of staff time responding to the alarm. In most cases, the best way to
prevent the risk of falls with injury is to promote residents’ balance, endurance, and overall
mobility.
The residents’ wishes and preferences have to be considered. If persons do not have cognitive
impairment and are informed of the risks, they have a right to be mobile, even if that involves
falling. If the person is cognitively impaired, his or her expressed wishes must be factored in.
These wishes may well be expressed through behaviors that demonstrate any discomfort from the
person’s perspective. For people who are cognitively impaired, the alarms are particularly
upsetting. They have been found to induce agitation during the day and interrupt sleep at night.
Lack of deep sleep compounds agitation, and contributes to loss of appetite, and decreased
balance and endurance. The medications used to treat agitation and sleeplessness often pile on
to the problems.
Rethinking the Use of Position Change Alarms
Page 3
For people who have had a recent change in health and ambulatory status (e.g., amputation, hip
replacement, stroke or debilitating acute illness), there may be some value in using an alerting
device temporarily as a reminder of the need to call for assistance. In a sense it acts as a
substitute call light for at risk people who may not remember to use a call light. It might also be
helpful in assessing the needs and patterns of newly admitted residents. Given that there is no
clear evidence of the efficacy of the devices in reducing falls or injuries, any prolonged use should
be very carefully and routinely assessed against the multiple adverse consequences that can
inhibit healing. In some cases, premature and prolonged use of alarms contribute to such a severe
decline in a resident’s function that it may unnecessarily turn short-term residents into long-term
residents. People who came to the nursing home to recover may never go home.
Originally alarms were designed for very short-term use to learn a resident’s patterns. These
patterns can more easily be learned through individualized care. Staff would have time for
individualized care if they were not responding to so many alarms. However, when an alerting
device is documented as being part of the short-term safety plan, staff have a responsibility to
assure that they are being used as indicated in the plan (e.g., placed correctly on the person,
length of cord adjusted properly, in good working order). If this is not done or if the resident
consistently tries to remove it, the facility will be viewed as having not followed the person’s safety
plan and be at risk for deficiencies. So the reasonability of the plan has to be considered. It makes
no sense to create a plan that you know the resident will consistently foil.
Since our culture tends to be over-protective of elders and to seek solutions in technology, and our
traditional nursing home culture tends to focus on risk prevention instead of health promotion, it is
easy to over rely on these devices. Because there is potential for harm, we need instead to find the
underlying causes of falls and instability, and develop individualized approaches that take into
account the strengths, possibilities, wishes and needs of each person. So when considering using
personal alarms, it is important to ask, “Will this cause immobilization and isolation for this
person?” “Will this really increase the person’s safety or is it more to help the caregivers
(family and professionals) feel they are doing something?”
As a culture we need to come to terms with the fact that in our long-term care settings we are
working with the frailest of the frail much of the time. Some are going to fall, get injured and even
die as a part of normal life and risk taking. There is no way to prevent all falls and people coming
into new settings have an increased risk of falls. We certainly don’t want to contribute to their risk
of injury from falls by immobilizing them and causing their decline. The best we can do is work to
strengthen balance and endurance and know as much as we can about the person. By doing so,
we can respond to his/her needs and help him/her sleep, drink, shift, and move as safely, freely
and comfortably as possible with our assistance when needed. With this approach, we can try to
create plans of care that meet the unique needs of each person.
Rethinking the Use of Position Change Alarms
Page 4
As with any significant change in clinical practice, it is important to start slowly. In order to remove
position alarms, identify residents who can most easily have a decrease in the amount of time
alarms are in use for them. Remove the alarms a few hours at a time. Have all staff involved in
watching and learning together, identifying any possible concerns, as well as possible strategies.
Make sure to give staff the help and support they need as they proceed. Work together to mitigate
risks and put in place the necessary interventions to meet residents’ needs and build their capacity
to function without alarms. Each success will teach you more about how to take on the next
challenge.
You may want to start by putting an alarm on yourself, and having all who will be involved in an
alarm elimination effort do the same. Wear the alarm for 30 minutes and then discuss the
experience together. You’ll be surprised by how uncomfortable it is and how much it has the
psychological effect of restricting your movement. This kind of personal experience is a great
teacher.
Essential ingredients for a successful process include:
•
•
•
•
•
•
•
•
Consistent staffing so that staff know residents well and work well with each other
Daily meetings on the unit where you are changing practice to discuss what staff are doing,
learning, and needing
Consistent communication across shifts to share information, ideas, and experiences
Interdepartmental communication so that all who are on the floor can be knowledgeable
partners in the effort
Coordination with care planning processes
Inclusion of the physician
Review of factors contributing to risk of falls (e.g. medications, diet, activity, footwear, etc.)
On-going communication with resident and family throughout the process and full inclusion
of their input into decision-making.
For more information on how to eliminate alarms, see Nursing Home Alarm Elimination Program: It’s
Possible to Reduce Falls by Eliminating Resident Alarms by Brenda Davison, DON, Jewish Rehabilitation
Center of the North Shore, Swampscott, MA. The article is available at www.MassPRO.org. Brenda shares
her story on the CMS Surveyor Training web cast, From Institutional to Individualized Care, Part One:
Integrating Individualized Care and Quality Improvement, November 3, 2006, available from
http://cms.internetstreaming.com. Copies of this program, and the accompanying train-the-trainer manual
and handouts, can be obtained from the National Technical Information Services at 5285 Port Royal Road,
Rm. 1008, Sills Bldg. Springfield VA 22161. Phone number: (703) 605-6186.
This material was prepared by Quality Partners of Rhode Island, the Quality Improvement Organization Support Center for the Nursing Home
Quality Initiative, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. Publication number: 8SOW-RI-NHQIOSC-072208-1.
Focus On CAREGIVING
DAVID FARRELL, BARBARA
FRANK, CATHIE BRADY,
MARGUERITE MCLAUGHLIN,
AND ANN GRAY
A Case For Consistent Assignment
When caregivers get to know their patients more intimately, it opens the way
for improved quality and a reduction in staff turnover.
ONSISTENT ASSIGNMENT—
C
having the same caregivers consistently caring for the same
patients on at least 85 percent of their
shifts—sounds like a simple enough
concept.
But while it has proven to be a foundational first step in moving facilities
from an institutional model of care
toward a person-centered model, studies show that it is currently practiced
in only about 10 percent of the nation’s
nursing facilities.
Recently, a group of 254 nursing
facilities completed a one-year pilot
program as part of a Centers for
Medicare & Medicaid Services (CMS)funded study called “Improving
Nursing Home Culture.”
Participants presented their results
at an outcomes congress held in
October 2005, and many identified
consistent assignment as an essential
element of their successful improvement in both quality of care and staff
retention. The results of the CMS
study confirm the findings of 11 other
in-depth studies that cite evidence for
consistent assignment as foundation
for quality improvement.
Turnover Affects Quality
While providers, working with quality
improvement organizations (QIOs)
over the past three years, have made
significant progress on the quality
measures, it is clear that nursing facility staff turnover and high staff vacancy
rates are significant barriers preventing
breakthrough levels of sustained
improvement.
The American Health Care
Association estimates
that there are more than
100,000 vacant full-time
nursing positions—
including registered
nurses (RNs), licensed
practical nurses (LPNs),
and certified nurse assistants (CNAs)—and an
average turnover rate of
more than 70 percent in the nation’s
nursing facilities. Turnover leads to
People
choose to work
in long term care
because they care
about their work
and the people they
care for.
staff instability and vacant shifts,
which, in turn, result in rushed, depersonalized care. Providers with severe
staffing issues are unable to focus on
quality improvement until they can
stabilize their staffing.
To address this concern, Quality
Partners of Rhode Island and the
Colorado Foundation for Medical
Care recently concluded the aforementioned CMS-funded study to explore
strategies for improving the nursing
facility culture.
Nursing facilities worked with their
local QIOs in an effort to shift from
institutionally driven care to more per-
son-directed care and
found that they needed
to establish consistent
assignments to structurally hard-wire the
relationships needed for
caregivers to know
patients’ individual
needs.
A Holistic Approach
Consistent assignment, also known as
primary or permanent assignment,
means that RNs, LPNs, and CNAs are
given the opportunity to get to know
their patients intimately.
The more prevalent approach to
scheduling is to assign caregivers on a
rotating basis, so they move from one
group of patients to the next after a
certain period of time, usually weekly,
monthly, or quarterly. Experts estimate
that 90 percent of nursing facilities
have policies that require staff to rotate
their assignments.
The pilot demonstrated that the one
key to transformational improvement
in patient care and quality of life
involves a holistic approach to quality
improvement that embraces the quality
of work life of nursing facility staff
with a commitment to individualized
care. This holistic approach focuses on
DAVID FARRELL, MSW, and
MARGUERITE MCLAUGHLIN, MA, are
project managers and ANN GRAY is an
intern with Quality Partners of Rhode
Island, Providence, R.I. BARBARA FRANK,
MPA, and CATHIE BRADY, MA, are consultants with B&F Consulting, Warren,
R.I.
Provider • June 2006 47
Focus On CAREGIVING
key areas that impact organizations and
individuals, including the nature of the
environment, care practices, work
practices, leadership, family and community, and government.
A key tenet of quality improvement
says that “every system is perfectly
designed to achieve the results it gets.”
In order to have different outcomes, it
is necessary to examine the root causes
of current outcomes and examine the
systems that produced them. It turns
out that low staff morale and high rates
of turnover are often directly related to
the longstanding practice of rotating
staff assignments. In long term care,
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48 Provider • June 2006
the work has inherent meaning for
people attracted to caring for others.
Yet management systems such as rotating assignment can interfere with,
rather than support, the caring connection with patients that often draws
individuals to caregiving work in the
first place.
Building Relationships
According to research published by the
late Susan Eaton, in “What a
Difference Management Makes,”
retention is all about relationships, and
relationships are at the heart of a good
working environment. This includes
relationships with co-workers; across
departments; with supervisors; with the
organization; and, most importantly, in
the case of long term care, with
patients and their families.
The National Citizens Coalition for
Nursing Home Reform has confirmed
that patients and their families value
the quality of the relationships they
have with the frontline caregivers more
highly than the quality of the medical
care and the quality of the food.
People choose to work in long term
care, and stay in the field, because they
care about their work, the people they
care for, and the people they work
with. They want to make a difference
in people’s lives.
Time and again, studies show that
leaders who implement systems that
foster and support these caring relationships have an easier time retaining
staff. With consistent assignment, it
has been found that staff not only
develop closer relationships with
patients for whom they are caring, but
with co-workers as well. Conversely,
the system of rotating staff assignment
continually severs relationships and
inhibits caregivers’ ability to recognize
patient declines and consistently
address care needs.
What The Literature Shows
There are many reasons that long term
care managers believe rotating staff
assignment is effective. Some of the
Focus On CAREGIVING
most common reasons center on issues
such as fairness, preventing staff
burnout, and the need for all staff to
be somewhat familiar with the needs of
all patients.
In other facilities, managers discourage strong relationships between staff
and patients to shield staff members
from experiencing grief when patients
die. Finally, some are opposed to consistent assignment because they do not
want individual staff members to be
unfairly “stuck” with “hard-to-carefor” patients.
However, these reasons for rotating
assignments are not supported by
research. In fact, rotating assignments
actually exacerbate low staff morale,
leading to staff burnout, call-outs,
quitting, and overall instability. A thorough review of the literature found 11
research articles that support the practice of consistent assignment over
rotating assignment, including:
n Barbara Bowers, in “Turnover
Reinterpreted: CNAs Talk About Why
They Leave,” found that rotating staff
made CNAs feel less valued for their
skill, experience, and knowledge of the
patients. “CNAs defined good caregiving as based on the establishment and
maintenance of good relationships with
residents,” Bowers wrote. “CNAs felt
any disruption to these relationships
was detrimental to the quality of the
care provided and the quality of residents’ lives.”
n Suzanne Campbell, in “Primary
Nursing: It Works in Long Term
Care,” evaluated the effectiveness of
primary nursing, another term for consistent assignment, and found that for
patients:
— One year after implementation of
primary nursing there was a 75 percent
reduction in the incidence of decubitus
ulcers.
— After implementation of primary
nursing, rates of patient discharge to a
lower level of care increased by 11 percent, while in-patient death rates
decreased by 18 percent.
— Two years after institution of a
primary nursing system there was a 36
percent increase in the number of
ambulatory patients.
Campbell also recorded the effects
on nursing staff and found that:
— One year after implementation of
primary nursing, the turnover rate was
reduced by 29 percent.
— One year after implementation,
nurses reported feeling more accountable by 26 percent, more able to make
and implement nursing decisions by 40
percent, and more able to plan and
implement nursing care by 22
percent.
When switching from rotating
Provider • June 2006 51
Focus On CAREGIVING
assignment to consistent assignment,
managers should expect some concern
from staff, who have generally been
told in the past that the rotating staff
model is best. Managers should inform
staff that based on a number of studies
there is new information and that the
facility must make changes to reflect
this new knowledge and implement
better practices. Addressing staff concerns will be the key to success in making the transition. Following is a
process that managers can follow when
initiating the transition to consistent
assignment:
1.) Call separate meetings on each
nursing unit with all of the CNAs from
the day shift and with all of the CNAs
from the night shift.
2.) Begin the meetings by explaining
that nursing facilities that have
switched to consistent assignment have
52 Provider • June 2006
improved quality of care and life of the
patients and the quality of work life for
the staff.
3.) Place each patient’s name from
the unit on a Post-it note and place all
of the Post-it notes on the wall.
4.) Ask the group of CNAs to rank
each of the patients by their “degree of
challenge,” with No.1 being relatively
easy to care for and No. 5 being very
difficult (time-consuming and emotionally draining, for example). Let the
CNAs agree on a number for each
patient and write that number on the
patient’s Post-it note.
5.) Allow the CNAs to select their
own assignments. Assignments are
considered fair when each CNA in the
group has amassed the same degree-ofchallenge total. For example, one No.
4 patient is equal to two No. 2
patients. Therefore, the CNAs may
not end up with the same number of
patients to care for. Relationships with
patients are important and also should
be part of the decision-making process.
The sequence of rooms is less important. However, proximity of the residents is important.
6.) Continue meeting every three
months, or more frequently depending
on the facility, to reexamine the assignments in order to ensure staff feel that
they are fair and relationships with the
patients are going well. ■
For More Information
■ For additional material on consistent assignment, see the change idea
sheet on consistent assignment at
www.riqualitypartners.org/nursing_
homes/wfr_train_3.php.
HATCh
Holistic Approach to Transformational Change
Consistent Assignment
Definition: Consistent assignment (sometimes called primary or permanent assignment) refers to the same caregivers (RNs,
LPNs, CNAs) consistently caring for the same
residents almost (80% of their shifts) every
time they are on duty. The opposite of consistent assignment is the practice of rotating staff
from one group of residents to the next after a
certain period of time (weekly, monthly, or
quarterly). Facilities who have adopted consistent assignment never rotate their staff.
A few strong arguments for adopting consistent assignment include:
•
Relationships form over time – we do not
form relationships with people we infrequently see. To encourage and support relationships, consistent assignment of both primary staff and ancillary staff is
recommended.
•
Relationships are the cornerstone of culture change.
•
Residents who are cared for by the same
staff members come to see the people who
care for them as “family.”
•
Staff that care for the same residents form
a relationship and get great satisfaction
from their work.
When staff routinely work together, they can
problem-solve and find creative ways to reorganize daily living in their care area.
•
Consistent assignment forms the building
block for neighborhood-based living.
•
•
•
When staff care for the same people daily
they become familiar with their needs and
desires in an entirely different way—and
their work is easier because they are not
spending extra time getting to know what
the resident wants—they know from their
own experience with the resident.
When staff and residents know each other
well, their relationship makes it possible
for care and services to be directed by the
resident’s routines, preferences, and
needs.
Change Idea Sheet-Consistent Assignment
Typical issues: When employees are not given a
consistent assignment they are not as likely to
build relationships with their co-workers or with
residents that create a deep sense of satisfaction
and “knowing”. Rotating staff means that each
time there is a rotation or change in assignment
the staff person has to take the time to figure out
what the needs are of each new resident they are
caring for and how to work with their co-workers
for the day. This constant changing is hard for
both residents and staff. Most of the care being
done is very intimate personal care and residents
Page 1 of 6
Consistent Assignment-Page 2
find it hard to have strangers caring for their
intimate needs, and to have to explain their
needs time after time to new caregivers.
When staff is unfamiliar with each other it is
harder for them to have good teamwork together.
language found under F241 Dignity, F242 SelfDetermination and Participation, and F246 Accommodation of Needs all include the nursing
home’s responsibility to create and maintain an
environment that supports each resident’s individuality.
Barriers: Many times frequent changes in
shift and assignment are the result of short
staffing. When there is not enough staff, the
organization responds by plugging holes in
the schedule with an available CNA. In
other situations, the policy of the nursing
home is not to let people get attached to each
other in the mistaken belief that if a close relationship develops and the resident dies the
staff member will be inconsolable. Certain
nursing homes don’t think friends should
work together. Still others prefer that everyone is trained on every unit and available everywhere. Others do not want staff to be
“stuck” with “hard-to-care-for” residents.
Ironically, inconsistent assignment exacerbates instability in staffing and conversely,
consistent assignment fosters stability. Call
outs and turnover are reduced when meaningful relationships develop in which workers
know they are being counted on and respond
by making sure that the care that is needed is
given.
The practice of consistent assignment provides
staff and residents the opportunity to build strong
relationships that result in staff knowing and
supporting each resident as an individual. It
helps create an environment that promotes staff
to learn about and support a resident’s likes,
preferences, and interests, which is directly supported by the intent of the quality of life requirements.
Regulatory Support: There is no regulatory
requirement mandating the practice of consistent assignment. However, this practice can
contribute to successfully meeting regulations
found under the Quality of Life and Quality
of Care requirements of the federal regulations in OBRA ‘87.
The interpretive guidelines for F240 Quality
of Life states, “The intention of the quality of
life requirements specify the facility’s responsibilities toward creating and sustaining an
environment that humanizes and individualizes each resident.” Additionally, regulatory
Change Idea Sheet-Consistent Assignment
Strong caregiver-resident relationships can also
lead to positive quality of care outcomes. Meeting the intent of the Quality of Care requirements found in OBRA ’87 is heavily dependent
on the direct caregiver implementing the resident’s care plan (F282 Services provided by
qualified person in accordance with each resident’s written plan of care.) If staff has the opportunity to work with residents on a consistent
basis, then staff will be more familiar with care
plan goals and treatment objectives. This can
result in consistent implementation of care plan
approaches. It also provides opportunities for
staff to promptly identify when care plans need
revision due to a resident’s refusal, preferences
related to treatment, or a decline in the resident’s
condition (F280 A comprehensive care plan
must be – (iii) Periodically reviewed and revised
by a team of qualified persons after each assessment.)
The better that staff know each individual resident that they work with, the more likely the intent of the Quality of Life and Quality of Care
requirements will be met.
Page 2 of 6
Consistent Assignment-Page 3
Goals:
• To strengthen and honor care-giving relationships
•
To stabilize staffing and establish strong
relationships between residents and staff
and among co-workers to provide continuity, consistency, and familiarity in care
giving.
Making the Change: There are many ways
to undergo the change process. A good start is
to think about who can help and to plan in a
systematic way the necessary steps. Ensuring
that its not a top-down edict but a shared
commitment on the part of the community
based on need creates a climate ripe for
change. A helpful tool can be the Model for
Improvement that uses the PDSA Cycle
(Plan-Do Study-Act). This is a way to systematically go through a change process in a
thoughtful way.
Sometime, after having this conversation a
committee will be energized and ready to try
everything. After all, they are all great ideas that
will benefit residents and staff in the long run.
It’s also a homegrown solution to a problem or
challenge faced by the organization. Though
tempting, it is important not to try all of these
ideas at once. Try one idea, roll it out on a small
sample or pilot, test it, measure it. If it’s not
working tweak it. This process is called a PDSA
cycle. It looks like this.
Plan: Each PDSA cycle has an objective and a
measure. In this phase, create it.
DO: Activate the plan & collect data using the
method the team decided upon to measure your
success. As much as possible do this on a small
scale. Don’t try the change on the whole home;
try it on a few people or a wing, unit or
neighborhood. Small is better. You can keep
tweaking and adding to your sample as you see
success.
With your committees and groups ask:
1. What are we trying to accomplish? (Better
relationships; less turnover of staff;
greater satisfaction among families and
residents?) Naming and articulating what
it is that you are trying to accomplish will
help you months from now (when you are
in the thick of things!) to remember the
original intention of the change.
2. How will we know a change is an improvement? This is the question that begs
a measurement response.
3. What changes can we make that will result in an improvement? Go study your
subject-find out what others have done,
take a road trip, phone a friend, go to a
Pioneer conference, talk with experts-ask
others to do the same.
Change Idea Sheet-Consistent Assignment
Many teams go as far as Plan-Do. Some teams
become very involved in the doing but sometimes find themselves in the midst of many failures without knowing what went wrong or why.
The process invites the team to study their activity to ensure they are heading in the right direction. Even finding that one is heading in the
wrong direction can offer valuable feedback to a
committed team. The next step then, is the study
phase.
Study: Test the hypothesis out. Stay open to the
possibilities. There are many things you might
find happen that you didn’t expect. Be sure to
note these unexpected gains.
Sometime, after having this conversation a
committee will be energized and ready to try
everything. After all, they are all great ideas that
will benefit residents and staff in the long run.
It’s also a homegrown solution to a problem or
Page 3 of 6
Consistent Assignment-Page 4
challenge faced by the organization. Though
tempting, it is important not to try all of these
ideas at once. Try one idea, roll it out on a
small sample or pilot, test it, measure it. If it’s
not working tweak it. This process is called a
PDSA cycle. It looks like this.
This entire process can be done in a very public
way by using storyboards to journey the process.
Remembering to celebrate the success of the
process is an important feature of the story helping staff, families and resident alike to witness
the ongoing efforts made to improve the home.
Plan: Each PDSA cycle has an objective and
a measure. In this phase, create it.
Measuring Success: Here is a simple way to
calculate/measure consistent assignment efforts.
1. Collect one week per month of staff assignment sheets (filled out by the nurse on the
unit at the beginning of each shift). Gather
this information for each unit in the facility
for both day shift and PM shift from the past
3 months.
DO: Activate the plan & collect data using
the method the team decided upon to measure
your success. As much as possible do this on
a small scale. Don’t try the change on the
whole home; try it on a few people or a wing,
unit or neighborhood. Small is better. You can
keep tweaking and adding to your sample as
you see success.
Many teams go as far as Plan-Do. Some
teams become very involved in the doing but
sometimes find themselves in the midst of
many failures without knowing what went
wrong or why. The process invites the team to
study their activity to ensure they are heading
in the right direction. Even finding that one is
heading in the wrong direction can offer valuable feedback to a committed team. The next
step then, is the study phase.
Study: Test the hypothesis out. Stay open to
the possibilities. There are many things you
might find happen that you didn’t expect. Be
sure to note these unexpected gains.
Act: Once you have completed the process
identified above you have a more complete
understanding of the challenge or problem.
Now armed with very specific information
and data you have three options:
•
•
•
Adapt the change
Adopt the change
Abort the change
Change Idea Sheet-Consistent Assignment
2. Choose 4 full-time (5 shifts per week) CNAs
to track, 2 from day shift and 2 from PM
shift from one unit.
3. The goal is to measure how often these
CNAs took care of the same residents. In order to determine which residents/rooms to
track with each CNA, look at the first 3 days
of assignment sheets and determine the group
of residents/rooms each care giver has been
assigned to. For example, if one of the
CNAs was assigned to a group for two of the
three days you were looking at, this would be
the group that you would assume the caregiver is consistently assigned to. This will be
the group of residents to track with the CNA.
4. Now, look at all 21 days worth of assignments and calculate how often each CNA
was assigned to the same rooms that you established was their primary assignment.
5. Because there are seven days in a week but
the CNAs only work five, caring for the
same group of residents five out of seven
days equals 100%. Four out of seven days
equals 80%, etc.
Page 4 of 6
Consistent Assignment-Page 5
6. Add up all four of the CNAs numbers
over the three weeks you examined to get
the total percentage of time the same
CNAs care for the same residents.
Example:
CNAs
Mary
Jay
Sam
Maria
Total=
For one unit
Week 1 Week 2
3/5
5/5
5/5
4/5
4/5
4/5
3/5
5/5
Week 3
4/5
5/5
5/5
2/5
Total
12/15
14/15
13/15
10/15
49/60
•
•
•
82% of the times the full-time CNAs care for the
same residents on this unit.
they need to change their schedule or call in
on a scheduled shift.
Find out who on staff enjoys floating or prefers various assignments rather than destabilizing the whole staff by making everyone
float.
Have inter-shift communications among all
staff from each work area, in which personal
information about how each resident did for
the day is shared, so as to ensure a smooth
hand-off.
Figure out when the busiest times are in accordance with the residents’ patterns, and adjust schedules to have the help that’s needed
during those times.
Have regular housekeeping and food-service
staff working with each care area.
Note: This assumes that the leadership team is not
rotating the CNAs quarterly.
•
Questions to Consider:
• How does familiarity and routine help increase comfort and competence?
• How important are relationships to residents? To caregivers? To co-workers? To
quality care?
• How does teamwork help improve care?
• Would you like different people toileting
and bathing you each day?
• Would you like having a different team
each day?
• What do residents experience when they
have frequent changes in their caregivers?
• What do staff experience when their assignment is routinely changed? How does
that affect their relationship to their work?
When new staff is brought on, assign them to
one work area so that they are familiar with a
group of residents and co-workers and acclimate
to the work with them.
Change Ideas:
• Make a mutual commitment to consistent
assignment – for staff that commit to a
certain set schedule, commit back that
they can count on that schedule.
• Find out from staff what their preferred
schedule and assignments would be.
• Create teams that work regularly together.
• Ask teams to work with each other to provide back-ups and substitutes for when
Change Idea Sheet-Consistent Assignment
Process to change from rotating assignment to
consistent assignment:
1. Bring together CNAs from each shift. This
might require having a number of separate
meetings. Be sure everyone is included.
2. Begin the meeting by explaining that nursing
homes that have switched to consistent assignment have proven to the improve quality
of care and life of the residents and the quality of work life for the staff. Suggest that we
pilot test consistent assignment and see how
it works.
3. Place each residents name on a post it note
and place all of the post it notes on the wall.
4. Next, ask the group to rank each of the residents by degree of difficulty with number 1
being relatively easy to care, number 3 in the
middle and number 5 being very difficult to
Page 5 of 6
Consistent Assignment-Page 6
care for (time consuming, emotionally
draining, etc…). Let the CNAs discuss
each resident and come to an agreement.
Write the number on the resident’s post it
note.
5. Then, allow the CNAs to select their assignments. Assignments are fair when the
numbers assigned to each resident add up
to the other totals of the other CNA assignments. Therefore, if one assignment
has six residents and another has eight
residents but the degree of difficulty numbers total 27 then the assignments are fair.
Relationships with residents are important
and also should be part of the decision
making process. The sequence of rooms
is less important.
6. Meet every three months to reexamine
that the assignments, based upon degree
of difficulty, are still fair.
4.
5.
6.
7.
8.
Resources:
1. Centers for Medicare & Medicaid Services (CMS). 5.0. What a difference
management makes! Nursing staff turnover variation within a single labor market
[Online]. From: Appropriateness of
Minimum Nurse Staffing Ratios in Nursing Homes. Phase II Final Report, Dec
2001. Available:
http://www.cms.hhs.gov/medicaid/reports/
rp1201-5.pdf, 15 Sep 2004.
2. Weech-Maldonado R, Meret-Hanke L,
Neff MC, Mor V. Nurse staffing patterns
and quality of care in nursing homes.
Health Care Manage Rev. 2004 Apr-Jun;
29 (2): 107-16.
3. “What a difference management makes!”
by Susan Eaton, Chapter 5, Appropriateness of Minimum Nurse Staffing Ratios in
Nursing Homes (Phase II Final Report,
December 2001). U.S. Department of
Change Idea Sheet-Consistent Assignment
9.
Health and Human Services Report to Congress.
“PEAK: Pioneering Change to Promote Excellent Alternatives in Kansas Nursing
Homes” by Lyn Norris-Baker, Gayle Doll,
Linda Gray, Joan Kahl, and other members
of the PEAK Education Initiative.
http://www.ksu.edu/peak/booklet.htm
Burgio L.D., et al. Quality Of Care in the
Nursing Home: Effects of Staff Assignment
and Work Shift. The Gerontologist 2004
44(3): 368-377.
Campbell S., Primary Nursing: It Works in
Long-Term Care. Gerontological Nursing
1985, issue 8, 12-16.
Cox, C., Kaesner, L., Montgomery, A.,
Marion, L. Quality of Life Nursing Care: An
Experimental Trial in Long-Term Care.
Journal of Gerontological Nursing 1991, issue 17, 6-11.
Patchner, M. Permanent Assignment: A Better Recipe for the Staffing of Aides. Successful Nurse Aide Management in Nursing
Homes 1989, 66-75.
Grant, L. Organizational Predictors of Family Satisfaction in Nursing Facilities. Seniors
Housing and Care Journal 2004, volume 12,
3-13.
Created and distributed by:
Quality Partners of Rhode Island designed this material
under contract with the Centers for Medicare & Medicaid
Services, an agency of the U.S. Department of Health and
Human Services. Contents do not necessarily represent
CMS policy.
Updated: August 31, 2007
Contributors include:
Quality Partners of RI
RI Department of Health
B&F Consulting
Page 6 of 6
Communication Map For a Resident’s First 24 Hours Staff Experience From arrival til bedtime The first night The first morning First full day What Information Do Staff NEED to know about a New Resident? Who has that Information? How can staff who need it get it in time? B & F Consulting www.BandFConsultingInc.com w
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Person-Directed Care
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Regulations
Leadership
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has a picture of roses in a
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Leadership
Leadership
Leadership
Community
Community
Community
∅
∅
used to love the smell of
bacon cooking
Regulations
wife died a while ago
Regulations
Regulations
wife was Shirley
Financial Resources
Financial Resources
Financial Resources
drove a hook and ladder
for the fire department
Regulations
Person-Directed Care
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is a night owl
Regulations
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Family
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Regulations
fell his second night here
Regulations
admitted thru short term
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Family
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Family
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came to B two months ago
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Financial Resources
sleeping pills PRN
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Catholic
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sometimes has a few
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morning
Leadership
Leadership
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Community
Community
Community
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Community
Community
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Family
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can toilet himself
Financial Resources
is taking meds for
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Regulations
Person-Directed Care
Model
Regulations
Person-Directed Care
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Regulations
has a UTI
widower for 12 years
Leadership
Leadership
Leadership
Community
Community
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constipated
Financial Resources
Financial Resources
incident report on him
for hitting the night aide
Regulations
Person-Directed Care
Model
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∅
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Family
Family
Family
Regulations
his daughter visits,
usually on the weekends
Leadership
Leadership
Leadership
Community
Community
Community
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ambulate 2X daily
Leadership
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bed alarms
Financial Resources
recovering from a
broken hip
Regulations
Person-Directed Care
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Regulations
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needs incontinence
checks at night
Financial Resources
gets easily agitated
Regulations
Person-Directed Care
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incident occurred while
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Regulations
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Financial Resources
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has Red Sox sticker in
his shadow box
Regulations
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worked the evening shift
at the fire department
incident occurred
during morning care
Leadership
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Community
Community
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during bathing, while in
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used to keep a bird feeder
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has lived alone a long
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recommend increase meds
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Regulations
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∅
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HATCh
Holistic Approach to Transformational Change
The Sleeping & Waking Experience
anxiety, agitation combative behavior, and
other declines. Medications given in response
to these effects, or to help residents sleep, often
times exacerbate the situation.
Background: A facility’s care routines can
sometimes unwittingly deprive residents of
deep restful sleep. These care routines are at the
heart of the nursing home’s culture. All work
and assignments are organized around these
routines. To change them will have an impact
on the facility as a whole. The care routines
continue because staff is not aware of the iatrogenic affects of sleep deprivation.
Typical Issues: Residents are awakened and
put to bed according to the facility’s schedule.
To ease the burden on the in-coming day staff,
the night shift awakens some residents and gets
them ready for the day. Sleeping residents are
awakened during the night to take temperatures, give medications, monitor for incontinence, insert suppositories, or even to hydrate
them. Some homes have gone so far as to have
the night staff provide care such as clipping
toenails. Sleep, for many residents, is compromised by bed alarms. Facility floors are cleaned
and shined with noisy machinery during the
night when hallways are clear.
Residents who are sleep deprived experience a
range of typical effects of sleep deprivation including: lethargy, loss of appetite, depression,
Change Ideas-Waking & Sleeping
Barriers: There are many “organizational efficiencies” that prevent organizations from providing residents with a good, full, restful
night’s sleep. Providing a climate where residents can sleep through the night and awakening based on their biological clock would require a great deal of rethinking about common
ingrained institutional behavior. The changes
have been successfully managed by many organizations that began the dialogue with the
question, “What would it take to sleep through
the night here?” People realized that the nightly
skin checks, floor buffing schedules, and suppository schedules, to name just a few organizational efficiencies, would need to be redesigned.
Regulatory Support: OBRA ’87 fully supports
this area of change. The regulatory interpretive
guidelines for F240 Quality of Life, found in
OBRA ’87 states, “The intention of the quality of
life requirements specify the facility’s responsibilities toward creating and sustaining an environment that humanizes and individualizes each
resident.” F242 Self-Determination and Participation includes language that gives the resident the right to “choose activities, schedules,
and health care consistent with his or her interests, assessments and plans of care….” It also
provides the resident the right to, “make choices
about aspects of his or her life in the facility that
are significant to the resident.” F246 Accommodation of Needs also has language in the interpretive guidelines that states, “The facility should
Page 1 of 5
The Sleeping & Waking Experience -Page 2
attempt to adapt such things as schedules, call
systems, and room arrangements to accommodate residents’ preferences, desires, and unique
needs.” Implementing care schedules around the
natural rhythms of a resident’s waking and sleeping routines are clearly supported by these regulatory requirements.
Additionally, the resident assessment process and
requirements outlined in F272 Resident Assessment also provide support for structuring care
giving around the preferences and routines of
each individual resident. This regulation requires
nursing homes to use the Minimum Data Set
(MDS) assessment to gather information necessary to develop a resident’s care plan. Section
AC. Customary Routines of the MDS includes
three areas regarding a resident’s sleeping routine
that should be assessed and considered when developing a care plan:
Section AC. Customary Routine
1. Stays up late at night (e.g., after 9 pm)
2. Naps regularly during the day (at least
1 hour)
3. Wakens to toilet all or most nights
Centers for Medicare and Medicaid Services
(CMS) Resident Assessment Instrument (RAI)
Version 2.0 Manual includes the following language to explain the intent of gathering this information from residents upon their admission to
a nursing home:
“…The resident’s responses to these items also
provide the interviewer with “clues” to understanding other areas of the resident’s function.
These clues can be further explored in other sections of the MDS that focus on particular functional domains. Taken in their entirety, the data
gathered will be extremely useful in designing an
individualized plan of care.”
Some nursing homes have voiced concerns that
the requirement for frequency of meals served to
residents is a barrier to implementing care schedChange Ideas-Waking & Sleeping
ules based on a resident’s customary waking and
sleeping routines. F368 - §483.35(f) Frequency
of Meals requires each resident to receive and the
facility to provide at least three meals daily. It
also includes that there must be no more than 14
hours between a substantial evening meal and
breakfast the following day. Some providers have
interpreted this language to mean that all residents must actually eat promptly by the 14th hour,
which makes it difficult to honor a specific resident’s request to refuse a night snack and then
sleep late. Based on this interpretation, nursing
homes are often hesitant to implement an individualized, resident-centered approach to waking
and sleeping for fear of being noncompliant with
this regulation. However, this interpretation is not
necessarily intended by the regulation.
In December 2006, the Centers for Medicare &
Medicaid Services (CMS) provided the following
language clarification regarding frequency of
meals:
The regulation language is in place to prevent facilities from offering less than 3
meals per day and to prevent facilities from
serving supper so early in the afternoon
that a significant period of time elapses until residents receive their next meal. The
language was not intended to diminish the
right of any resident to refuse any particular meal or snack, nor to diminish the right
of a resident over their sleeping and waking
time. These rights are described at Tag
F242, Self-determination and Participation. It is correct in assuming that the regulation language at F368 means that the facility must be offering meals and snacks as
specified, but that each resident maintains
the right to refuse the food offered. If surveyors encounter a situation in which a
resident or residents are refusing snacks
routinely, they would ask the resident(s) the
reason for their customary refusal and
would continue to investigate this issue only
if the resident(s) complains about the food
Page 2 of 5
The Sleeping & Waking Experience -Page 3
items provided. If a resident is sleeping
late and misses breakfast, surveyors would
want to know if the facility has anything for
the resident to eat when they awaken (such
as continental breakfast items) if they desire any food before lunchtime begins.
This clarification clearly promotes a resident’s
right to choose and to exercise his or her autonomy. It also provides nursing home providers
with some assurances that the regulations and
regulatory agencies are supportive of individualized care that provides options for resident choice
of waking and sleeping routines and meal times.
To view the entire CMS clarification go to
CMS’s website at:
http://www.cms.hhs.gov/SurveyCertificationGen
Info/downloads/SCLetter07-07.pdf
and waking routines. Establish a system for
learning about people’s patterns as part of the
welcoming in to the nursing home for new residents.
Making the Change: There are many ways to
undergo the change process. A good start is to
think about who can help and to plan in a systematic way the necessary steps. Ensuring that
its not a top-down edict but a shared commitment on the part of the community based on
need creates a climate ripe for change.
With your committees and groups ask:
•
•
•
For more information in creating individualized
care-giving schedules, see the CMS broadcast,
“From Institutional to Individualized Care, Parts
I and III” at
http://cms.internetstreaming.com.
Goal: To support residents’ health and well
being by helping them have deep sleep through
the night, by shifting from institutionally driven
routines to routines that follow people’s natural
rhythms of sleeping and waking. Another goal
is to support better relationships between residents and their caregivers by allowing caregivers to respect people’s individual routines and
set their care giving schedules around what
works for each resident.
Infrastructure Helpful to Support the
Change: Establish a work group with staff
from all departments to identify and implement
the changes needed in order for residents to return to their natural patterns for sleeping and
waking. Adjust clinical care, staffing schedules,
and routines for food service, housekeeping and
maintenance to accommodate individual residents’ needs and preferences related to sleeping
Change Ideas-Waking & Sleeping
Number of residents who sleep through the
night
Number of residents who wake of their own
accord
Pre and post data on agitated behavior;
anxiety meds; bowel and bladder continence; UTIs; skin care; weight change; mobility; social engagement; staff-resident relationships; staff workload.
PDSA Cycles: The Plan – Do – Study – Act
Cycle is a way to systematically go through
quality improvement in a thoughtful way.
With your committees and groups ask:
1. What are we trying to accomplish?
(Greater choice for residents, better sleep
hygiene, a less institutionalized setting,
resident choice over their desire to stay in
bed, go to bed late) Naming and articulating what it is that you are trying to accomplish will help you months from now (when
you are in the thick of things!) to remember
the original intention of the change.
2. How will we know a change is an improvement? This is the question that begs a
measurement response. (We had low satisfaction in the area of resident choice and
now look!; as a result of this change we
Page 3 of 5
The Sleeping & Waking Experience -Page 4
have more people able to ask for things and
have their needs met!; our resident feel
more rested, there are fewer combative incidences, less frequent falls )
direction. Even finding that one is heading in
the wrong direction can offer valuable feedback
to a committed team. The next step then, is the
study phase.
3. What changes can we make that will result
in an improvement? (Eliminating a harsh
bed-check process in the night with lights
on etc; Implementing a “gentle awakening
process”; changing the way we think about
breakfast to allow people to sleep. Go
study your subject-find out what others
have done, take a road trip, phone a friend,
go to a Pioneer conference, talk with experts-ask others to do the same.
Study: Test the hypothesis out. Stay open to
the possibilities. There are many things you
might find happen that you didn’t expect. Be
sure to note these unexpected gains.
Sometime, after having this conversation a
committee will be energized and ready to try
everything. After all, they are all great ideas
that will benefit residents and staff in the long
run. It’s also a homegrown solution to a problem or challenge faced by the organization.
Though tempting, it is important not to try all
of these ideas at once. Try one idea, roll it out
on a small sample or pilot, test it, measure it. If
it’s not working tweak it. This process is called
a PDSA cycle. It looks like this.
•
•
•
Plan: Each PDSA cycle has an objective and a
measure. In this phase, create it.
Plan: Engage a committed group of people to
consider, discuss and explore better sleep hygiene for residents based on residents obvious
sleep deprivation and associated problems.
DO: Activate the plan & collect data using the
method the team decided upon to measure your
success. As much as possible do this on a small
scale. Don’t try the change on the whole home;
try it on a few people or a wing, unit or
neighborhood. Small is better. You can keep
tweaking and adding to your sample as you see
success.
Many teams go as far as Plan-Do. Some teams
become very involved in the doing but sometimes find themselves in the midst of many
failures without knowing what went wrong or
why. The process invites the team to study their
activity to ensure they are heading in the right
Change Ideas-Waking & Sleeping
Act: Once you have completed the process
identified above you have a more complete understanding of the challenge or problem. Now
armed with very specific information and data
you have three options:
Adapt the change
Adopt the change
Abort the change
This entire process can be done in a very public
way by using storyboards to journey the process. Remembering to celebrate the success of
the process is an important feature of the story
helping staff, families and resident alike to witness the ongoing efforts made to improve the
home.
Do: Track the sleep of five resident volunteers
who have minimal medical, hydration or treatment needs. These volunteers will be given the
opportunity to awaken by their own natural
body clock for two weeks.
Study: What time they awaken over the two
weeks, mood, and appetite using simple tools.
Determine if residents have a greater sense of
rest and peace.
Act: Consider a small group of people who
have incontinence to initiate the next cycle.
Page 4 of 5
The Sleeping & Waking Experience -Page 5
Explore how to maintain skin integrity while
allowing for better sleep.
Innovative Change Ideas:
Homes that have undergone change in the domain of waking and sleeping consider these
questions in their change process:
•
•
•
•
•
•
•
•
•
•
•
Would you be comfortable sleeping here?
With this bed and pillow?
How can sleep be made comfortable?
Where could you start your change process?
What are all the factors that must be considered from each department in order to
make this change?
What could be improved in the following:
lighting, noise, bed comfort, privacy, and
clinical care to help with sleep?
What evening activity and food do people
who like to stay up want available?
If it the process changed how would staff
and residents benefit?
What are the medical consequences of sleep
deprivation on health and well-being?
What negative outcomes are we causing by
constantly interrupting the sleep of our residents?
How would residents and staff benefit from
how awakening happens?
What is the importance of sleep hygiene for
physical and mental well-being?
residents. J Gerontol Nurs 2001 Jul; 27 (7):
30-7.
Created and distributed by:
Quality Partners of Rhode Island designed this material
under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of
Health and Human Services. Contents do not necessarily
represent CMS policy.
Updated: August 31, 2007
Contributors included:
Quality Partners of RI
RI Department of Health
B&F Consulting
Resources:
1. Cruise PA, Schnelle JF, Alessi CA, Simmons SF, Ouslander JG. The nighttime environment and incontinence care practices
in nursing homes. J Am Geriatr Soc 1998
Feb; 46 (2): 181-6.
2. Esser S., Wiles A., Taylor H., et al. The
sleep of older people in hospital and nursing homes. J Clin Nurs 1999; 8: 360-8.
3. O’Rourke DJ, Klaasen KS, Sloan JA. Redesigning nighttime care for personal care
Change Ideas-Waking & Sleeping
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