Dr. El

It’s the week of Independence Day and freedom is on my mind. Residents frequently speak to me of their dissatisfaction with the limitations on their liberty, from being told to sit in a communal room when they want to be alone, to needing a family member to sign them out on pass.

“Me and the other inmates,” they say, trying to use humor to cope with their confinement. 

Constraints on residents are generally due to a combination of factors, first and foremost being the physical and/or cognitive impairments that led them to require rehab or nursing home care. Psychotherapy often addresses residents’ feelings about having become ill through aging, accidents, life choices and other circumstances and it can reduce some of the blame of the nursing home for curbing their freedom. 

It must be acknowledged, however, that there are many aspects of long-term care itself that limit residents, including the facility’s desire to protect residents from harm and themselves from litigation, regulatory requirements, risk-avoidance policies and routines (because “that’s the way it’s always been done and we keep passing surveys”) and inadequate staffing. 

As we celebrate our freedoms in the country this week, perhaps we can consider ways in which to create a better balance between the need to provide a safe environment for residents and their right to make their own choices.  

Below are just a few of the many aspects of care that could be adjusted for increased autonomy: 

  • Reevaluate practices that restrict residents as a matter of routine and consider instead ones that are based on their capabilities. For example, rather than disallowing all motorized wheelchairs, offer the opportunity to residents who are found to be physically and cognitively capable, pass a periodic “driver’s test” and follow established guidelines for use.
  • Regularly evaluate dietary restrictions. Upgrade from purée to ground to chopped to regular whenever possible; eliminate sodium or sugar prohibitions when no longer beneficial.
  • Celebrate birthdays with a special meal, allowing residents to make requests and making it easier for them to tolerate limitations throughout the year.
  • Provide outdoor spaces not just during scheduled activities but available to residents and their visiting guests throughout the day. In locations where outdoor activities are seasonal, make preparing the patio for use a high-priority task and add shelters and outdoor heaters so that the season is as long as possible. Ensure outdoor spaces are truly accessible by providing push-button access and smooth, wheelchair-friendly surfaces.
  • Hold as many outdoor recreational activities as possible and conduct rehab sessions al fresco when feasible.
  • Create an atrium or a screened indoor area to give residents sunshine and a refreshing breeze when getting outside is impracticable. 
  • To promote movement and reduce restrictions on standing and walking, enlist the recreation and rehabilitation departments to lead exercise classes, refer residents for brief stints in rehab, train family members to walk the halls with loved ones, and encourage aides to have a short dance with capable standing residents rather than yelling at them to sit down.
  • Use care plan meetings to evaluate each individual’s services for areas where autonomy and choice can be increased.

To increase staff comfort with these changes and to reduce the likelihood of negative repercussions, review potential policy changes with the legal department and discuss decisions with the ethics committee as needed. Document, document and document the reasoning behind the choices made and the efforts the team is making to balance safety with resident rights.

In addition to barbeques and fireworks, creating more opportunities for resident independence is a fitting way to honor our country’s freedoms.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition andGold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her award-winning website at MyBetterNursingHome.com.