Culture Change in a Secured Dementia Unit

[ClearBlueOctoberSky]

How have you implemented this?

We have recently gone from waking everyone up when shift starts at 0600, to letting them wake naturally. For the most part, we have about 6 to 8 (out of 22) that are wake and come for breakfast at 0800. Then the rest tend to stagger across the morning, with all resident's up for lunch by 1200 on most days.

I feel that this has worked well for the most part. We have been doing this since a few days before Thanksgiving. For the morning shift, it is calmer, and we have had fewer fights and behaviors. We do have a few residents that will stay in their pajamas most of the morning or all day, which is fine, as our unit is very warm. They are decent pajamas, not hospital gowns.

The PM shift isn't happy because of the few that do stay in pajamas, and then we do have a few that just don't eat breakfast after arising.

Yesterday, we had one resident stay in bed all day. This is a resident that has a habit of not getting out of bed until Noon most days as it is. However, yesterday, while allowing the CNA to change them, they didn't want to get up, not even to eat. That said, they missed breakfast, lunch and dinner. The resident is a diabetic, however, we do not do any accu-checks on, because of continuous refusal, or they would allow the accu-check, then refuse the insulin. I have never seen them run below 100, and tends to go high anyways. The morning Novolog is almost always held, r/t not eating breakfast, and when they allow it, the split Lantus is given at lunch with the MD Novolog and the rest of the AM meds. In addition, I had another resident get up at 1030, have a bowl of cereal (She usually just eats the cereal and toast at breakfast anyways), ate only her dessert at lunch, then go back to bed. She had a rough day the day before with insomnia and increased agitation and exit seeking, wanting to go home and see her family. Her VS were fine, this is behavior that we see on occasion with her.

Today, I had a resident sleep soundly until about 1330 or 1345 r/t them not going to bed until 0400 this am. We just let her sleep, didn't wake her for breakfast or lunch, didn't get her up for her shower, just let her sleep. The PM nurse was upset because we didn't get her up for lunch or her shower. This resident has been starting to flip her day/night schedule for awhile, and usually doesn't get up until 1100 as well. She sleeps in her recliner in the dayroom/dining room, so it isn't like she is isolated.

We don't have an open kitchen yet, however, have continental breakfast available to us in the morning, usually the kitchen is able to make soup and a sandwich after lunch, if we haven't pulled and saved the trays. They get plenty of fluids and snacks through the shift, especially the late risers.

I know that we are having weight issues, and have been having weight loss issues before the two weeks that this new schedule started. I have several that are on supplements, and the most worrying ones are on weekly weights. I understand that this is something that I need to be concerned with. However, for the most part, other than the ones that don't eat well to begin with, we are having increased intake at meals because they aren't sleeping at the table during the meals.

I apologize for this being too long, but I would really appreciate any constructive criticism to make this transition better for everyone involved. My DON has implemented this at her old facility but didn't have this specific type of population, either. I am still a fairly new nurse, having only been at this one facility, and working for just eight months.

I want what is best for my residents, and to decrease the amount of unnecessary anti-psychotics/anxiolytics that are being used for behaviors.

[virgo,student nurse, CNA]

I am not sure what State you are in, but we MUST get clients up, and offer them a meal on the weekend., unless it it is clearly written in their plan to allow them to sleep all day, and that they don't want to eat, with that being said, I DO NOT work in a nursing home every weekend, (I work once every couple months as an Aide) my full time job is working with developmental disabled clients and the above behavior is not allowed. I hope you find the answers, you are looking form

[ClearBlueOctoberSky]

Thanks, Virgo.

I'm in Colorado. We can not go over 14 hours between dinner and breakfast. As it stands now, our Breakfast is being served at 0800, and Dinner is at 0530. The way that we are doing things now, is that those that are up, are offered a "Continental Breakfast." I have the ability to make toast, I'm stocked with cold cereal, instant cream of wheat, hard boiled eggs, and yogurt, pudding and juice. Most are at least cognitively with it enough to tell me if they want something when I ask, those that aren't usually aren't up. We have kept extending the breakfast and lunch times because no one was up. We were really struggling to get people to the dining room and serve within 20 minutes of our cart coming.

We go in and do gentle awakenings if they aren't up, ask if they want to go eat. If they are awake, they are gotten up and readied for the day, and taken to breakfast.

[cwgrlup85, ASN, RN]

I am a director of a dementia unit in Illinois. We allow our residents to sleep in and rise on their own. We have our own kitchen stocked with cereals, bread, yogurt, pudding, eggs, pancakes, and much more. I generally have my cna's get the residents up no later than 11, considering we eat lunch at noon. Those that are up during the night are fed during those hours in order to maintain their weight. I really try to focus on our residents with weight loss vs letting them sleep in. I encourage staff to attempt different times and even with different faces to try getting the resident up without causing behavior issues. We also offer several snack times throughout the day. We also hold resident's meals if they are sleeping through lunch, and offer it again an hour later. State surveyors did not say anything about our daily routine. Just make sure the residents who like to sleep in have that on their careplan. Especially be sure to have the diabetic resident's careplan state her frequent refusals of medication and accuchecks. I would offer juice at least in the am rather than letting her go without anything. Have staff make frequent checks on that resident as well to watch for signs of hypoglycemia. Hope that helps :)

[ClearBlueOctoberSky]

Thanks cwgrlup85. That does help. We are trying really hard to get a steam table setup in our unit for meals. I think the part that I get most frustrated is with the attitudes of some of the staff.

The nurse that has been relieving me has stated that it won't work. They have tried it before and it hasn't worked before. One of the evening aids complained the other day that she still had five residents to put to bed at eight when she is normally done by then.

I can't get them to understand that it isn't about what is better for staff, it's what is better for the residents. Incidentally, where I was struggling to complete my morning med pass on time, and wound up staying late because I was holding off all of my charting, I'm able to time manage better because I am giving their meds as they get up. I have more time to spend with my residents, feed at meals which I do enjoy doing and just overall give each of them the attention that they deserve from me. Not to say that it doesn't get a little hectic at times.

[CapeCodMermaid, RN]

I've worked in places with a wake to dine...breakfast was served buffet style fro 730 till 1030. If people wanted to sleep all day and be up all night, they did. We ordered food for them and heated it as needed. We didn't have any more weight loss than we did before and we had way fewer behaviors. We also had no restricted diets...if a 94 year old diabetic wanted donuts every breakfast, that's what he got.

[ClearBlueOctoberSky]

Thanks, everyone. Lots to think about. It is just a matter of finding the right tweak for us. I am lucky that I have the support of my management team.

[MichelleRN34, ADN, RN]

Thanks, everyone. Lots to think about. It is just a matter of finding the right tweak for us. I am lucky that I have the support of my management team.

I have just started a job at a CCRC who is also going through culture change. Nothing to add to this thread other than it is nice to hear others are doing culture change.

[DSkelton711]

Ha. Our facility uses the term "culture change" all the time. I don't think we are any where close. Hope your residents are doing well with this and that staff will eventually join in.

[MichelleRN34, ADN, RN]

Apparently they have been at it for over a year now....it's an awesome place to work so far.

[Vinniesguy]

It's a great idea. I've worked at places where people are dragged out of bed at 6.30 am and back in bed by 1.30 pm so the evening shift wouldn't get mad. I can see it becoming a problem if someone does shift their pattern, sleeps all day and is awake all night. It happened with a Jewish holocaust survivor we had on my unit - he slept through the day because he felt safe and his wife was usually around but at night he got scared and continually cried out for someone to be with him.

[LTCRN4LIFE]

I have done this too and my first thoughts when reading your post before you said it were: If your not careful you are going to have weight loss...first....next comes Pressure Ulcers.....Contractures and then Depression....

I would opt more for a Walk to Dine program. Form a small committee lead by an aide who volunteers for it. Next pick out those who need to walk. Have them meet in an area(livingroom) then have the rest of the aides walk them together to the dining room and get a new group and do the same. After they eat they meet back at the Living Room for a special dessert or Smoothies.

You will see your weight loss go way down....your falls go down(people are getting stronger) your depression rate go down(people are socializing) your constipation issues improve.....the list goes on and on....less Pressure Ulcers.....(blood flow)

It's one of the best programs I have ever instituted.