Created by an administrator struggling to jump-start culture change in her care community, Through the Looking Glass is a unique program that changes staff attitudes and teaches the importance of person-centered care practices by placing staff directly in the shoes of residents—with remarkable results. Here, program creator Leslie Pedtke tells the story of her employee, Leah, who participated in the program, living as a resident with body alarms, and the weight of the lessons that experience taught her.
This post was excerpted from What Living as a Resident Can Teach Long-Term Care Staff: The Power of Empathy to Transform Care by Leslie Pedtke, Copyright © 2017 by Health Professions Pres Inc. All rights reserved.
“I hate my body alarm.”
When we began Through the Looking Glass in the fall of 2009, we were using personal body alarms on our residents to prevent falls. At one time, over half of our residents were wearing some kind of alarm. Think about that. About 40 people were attached to a box that monitored their movements. Some had multiple alarms, one for the bed and one for the chair. Imagine how much noise all of those alarms created.
One day, I was walking past a woman in her wheelchair, and she stopped me and said, “I can’t move in my chair because this thing will go off.” She had her hand on the string that ran between the clip attached to her sweater and the alarm box. We did that to her. It broke my heart. We made her anxious and afraid to move even the slightest inch because we were too afraid she would fall. We did not involve her in the decision to add the alarm to her wheelchair. Her safety was most important to us. Her dignity took a back seat. She was not a person. She was a fall risk who we needed to keep off the floor.
The concept of eliminating the use of the alarms was alarming itself. Many staff members believed that if we stopped using alarms, our residents would be constantly falling. One certified nursing assistant (CNA) went so far as to say that I must not care about our residents, that I must want them to fall. When I shared the story of the woman in the hallway who told me she could not move for fear of setting off her chair alarm, the staff sympathized with her but still felt strongly that her safety was more important. There was no way for them to know how she felt.
We slowly began to decrease the use of the alarms by first examining the amount of falls a person had had within a 3- to 6-month period. We were more willing to risk removing the alarm if a person had not fallen in several months.
Put the person before the task
Eliminating alarm use is a process. I would never suggest to any community that they eliminate them all together without putting another process in its place. For us, that other process was not a less-restrictive restraint, but rather our team digging deeper into what was actually causing the falls in the first place. We had to put the person before the task and stop using the alarms as a babysitter.
By the time the first two Through the Looking Glass participants had moved in, we had managed to decrease our alarm use to eight residents from about 40. While this was a huge accomplishment, we still had not eliminated their use entirely. We were still compromising the dignity of eight residents with this fall prevention practice. These last eight alarms became the focus of our first group of participants, each of whom had to live in the same room with a resident who wore a body alarm as well as wear a body alarm at times during their stay.
Leah was working as a CNA at the nursing home and wanted to move in because, “It’s a chance to realize what the residents experience on a day-to-day basis, and at the end I hope to become more empathetic.”
She drew the following diagnosis: You have congestive heart failure. You have a personal body alarm in bed and in your chair because you are weak and at risk for falling. You must be assisted to and from the bathroom and use a wheelchair for long distances.
Leah moved in with an air of cockiness about what she was embarking on. She would zoom around the facility in her wheelchair with a this-is-easy sort of attitude.
“I can’t imagine what it must be like to be wearing this thing if you have dementia. It must scare the crap out of them.”
Leah was the first participant who had to wear a body alarm. By the end of her first day, she learned that being that active in a wheelchair would not be quite as easy as she thought. Her alarm was constantly standing guard, monitoring her every movement and reminding her when she was moving in a direction she was not supposed to.
This restriction was reflected in Leah’s first journal entry:
Day 1: The excitement of moving in and having all the employees come in to meet me made the day seem to fly by. After supper, however, the newness of the situation had worn off, and the reality of it all has begun to set in. I’m normally very independent and constantly occupying my time. Now, I barely move, and my alarm starts dinging. It’s quite frustrating. I’m also having a hard time falling asleep. I’m accustomed to silence and pitch-black dark conditions.
After Leah’s first night, she drew the challenge “Room Change.” At first she was excited about this because her first roommate needed a lot of assistance at nighttime, which was interrupting Leah’s sleep. But with her room change, she still had to deal with the sound of alarms:
At first I was getting more sleep, but then my new roommate had bed pad alarms, and from 3:00 a.m. to 6:30 a.m. she was up in 20-minute intervals.
It did not take long for Leah to say that she hated her body alarm as well as her roommate’s. Quite the change for someone who before participating in the program had thought it was a great idea to use alarms on the residents to keep them safe.
That morning, after a night with very little sleep, Leah said, “I can’t imagine what it must be like to be wearing this thing if you have dementia. It must scare the crap out of them.”
Of course it does! It also inhibits the residents from getting a good night’s sleep, which puts them at an even greater risk of falls.
Could that be right? Using body alarms can actually cause falls? Yes, they can. Eventually, the staff became immune to all of the alarms going off. They could not possibly keep track of 40 alarms going off, and after so long we did not even hear them anymore. The amount of extra noise body alarms cause in your community wears on everyone who lives and works there.
“You really want me to wear someone else’s clothes?”
Leah’s roommate would often walk to the bathroom before a staff member could even get to her. Thankfully the roommate never fell during Leah’s stay, but she did give Leah a colorful narration about how often the alarm sounded.
Leah was beyond exhausted and irritable by her third day living in the nursing home. She was not buzzing about in her wheelchair anymore. She would not even visit with her peers anymore.
That same day, she drew the following challenge: I tried to get up on my own and fell. I hit my head and need to have neurological checks every 2 hours for 24 hours.
Think about how little sleep she was getting. Our bodies do not function well on just a few hours of sleep at a time. Leah also was not eating much, which was putting her at an even greater risk for falls. Her mood was also diminishing.
I continued to push Leah with challenges, and the next afternoon she drew, We lost your cigarettes.
I heard Leah yelling in the dining room. She could not take it anymore! She had reached her maximum stress threshold. I took her back to her room so she could calm down. She did yoga stretches to relax, and, much to her relief, her grandmother brought her another pack of cigarettes.
At lunchtime on day five, she drew the following challenge: Your clothes have been mixed up in the laundry and you are wearing someone else’s outfit.
That was Leah’s breaking point.
“You really want me to wear someone else’s clothes?” she asked with pleading eyes.
Leah packed her things and moved out that day. I could not believe that out of all the challenges she had been put through—body alarms, a room change, very little sleep, lost cigarettes—that this was her breaking point. She later explained to me, “I take care of that person and I know how incontinent she can be sometimes. Even though I knew the clothes were clean, I just couldn’t make myself put them on.”
Sometimes you just have to live it to figure it out
With the practice of consistent caregiver assignments and specific interventions for the residents, we were able to eliminate personal body alarm use. At the time, we were the first community in our area to do so. It became such a big deal that I had to inform our hospital discharge planners that it was a practice we felt we could no longer justify. Some families chose our home for their loved one in part because we no longer used alarms, while other families were afraid to choose us because we were not using them. Eliminating their use became one of our first “nonnegotiable” practices. We felt so strongly about not using personal body alarms that we were willing to risk a family choosing not to have their loved one live with us. We also provided a lot of education to our residents, their families, our staff, and even the Illinois Department of Public Health surveyors.
If you are still using personal body alarms for fall prevention, ask yourself, “Are we doing this for staff convenience or to protect the resident?” This is a really tough question to face. It was a tough dose of reality for us as well.
Leah’s roommate did not need an alarm for fall prevention. We only thought we were protecting her. Or maybe we were more worried about protecting ourselves. Sometimes you just have to live it to figure it out, which is exactly what Leah had done.
Fall reduction (notice I did not say fall prevention, because we will never prevent all falls) has to be a proactive approach. To be, you have to treat the problem, not the symptom. Anticipating the needs of those we are caring for is really hard to do if you have not developed a close care partner relationship with them. This was a great lesson in transforming our culture away from being reactive to situations and adopting more proactive approaches. We no longer used the alarms to tell us when a person was about to fall or had already fallen. Eliminating the alarms forced us to communicate with each other as well as with our residents to get at the heart of what was causing the falls.
Read the book!
What Living as a Resident Can Teach Long-Term Care Staff
The Power of Empathy to Transform Care
By Leslie Pedtke, L.N.H.A.
Copyright © 2017 by Health Professions Press, Inc.
In this book, learn about the innovative Through the Looking Glass program, that puts staff in the shoes of the resident. Staff experience first-hand the challenges residents face by simulating a diagnosis and living alongside residents. The lessons learned create more empathetic and compassionate caregivers, improve care practices, and enhance well-being for both staff and residents. Learn how to set up this program in your organization and how it will help you eliminate personal body alarms, decrease falls, reduce use of psychotropic medications, increase staff retention and satisfaction, and be a more proactive community.