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Taking a stand on seating in long-term care

July 24, 2012
by Mitchell S. Elliott, AIA
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It is always interesting when a building environment issue drives an operational question, which leads to a passionate, cross-functional discussion.

Recently we walked into a newly completed addition to one of our long-term care facilities. This addition has a rehab focus which includes additional resident rooms in a connected household concept. Because of the rehab component, we tend to provide more seating in the dining room than the resident capacity to accommodate guests. We find that resident family members will join us for a meal more frequently in a rehab-focused household as compared to a LTC household.

Upon entering the household after breakfast, we found nearly half of the dining room chairs lining the walls of an adjacent living room space near the dining room. With one of our vision statements of stewardship in mind, our interior design coordinator asked, "Did we purchase too many dining room chairs?" In the spirit of our team-member focused strategies, we began asking "help me understand questions" of the household staff.

What we found is that many of the residents or patients are eating meals while sitting in their wheelchairs. With so many wheelchairs at the tables, those dining rooms chairs seemed to need a new home. As good designers and leaders we continued to ask questions. Was sitting at the dining room table in a wheelchair a resident/patient preference? Was this a staff preference? Were the resident families involved? What was nursing's opinion? Who placed the "extra chairs" in the living room? Housekeeping? Nursing? Dietary? Why didn't the architect (me) design more storage near the dining room for all these chairs? That was actually a question running around in my head that the staff could not possibly answer! This complex issue resulted in many yes, no, maybe and "I have no idea" responses to our questions.

We took our questions to the next level of expertise. These same questions were brought to our operations team who have incredible insight in the areas of nursing, dietary, life enrichment, environmental. In the past our organization has implemented a "walk to dine" program. We have also promoted the philosophy that a wheelchair should only be used for transportation, not sitting for any length of time. I love that concept.

Time after time, we realize that our processes and philosophies have to be revisited and reiterated constantly. What are the practicalities of transferring a non-ambulatory resident from a wheelchair to a dining room chair, and back again, three times a day? What if the resident, in their mind, doesn't want to "go through the hassle" of that transfer? What if a skin condition drives the need to avoid the wheelchair for a prolonged time, against the desire of the resident? How long does it take to transfer a resident from a wheelchair to a dining room chair? Does this "activity" contribute to the quality of the dining environment for the resident, especially those who are ambulatory? How much do we "institutionalize" our residents by passively convincing them that sitting in the wheelchair in the dining room "is easier for everyone"?

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Mitch,
Thanks for writing this. I have been aware of the need to transfer residents out of wheelchairs for many years, but recently it was brought to my attention again because of my wife's involvement in caring for a friend at Evergreen. The resident has little recourse when staff say they don't have time to transfer, and soon the resident looses the strength to make the transfer. When the resident is left in the wheelchair, their life is unnecessarily medicalized, which is a significant problem in LTC. Even though the average amount of staff time spent daily by staff addressing true medical needs (medications/treatments) of LTC SNF residents is probably between 1/2 and 1 hour, the traditional practice is to medicalize the rest of the day. Not transferring from wheelchairs is one of those practices. We need to give this issue more attention. David Green

Mitch and David,
I have worked on long term care for 17 yrs. Although your thought on transferring residents from a wheelchair to dining room chair sounds great in theory, in reality most of the cognitive residents decline that service in the facilities I have worked in. Taking them out of the wheelchair takes away their independence to come and go as they please. Most residents do not want to sit and wait to be transferred in and out of a wheelchair. Just because visually it may be more appealing, doesn't necessarily reflect the residents choice. With government cuts, there will be less staffing and thus longer wait periods for someone to come along and help transfer. Just think, would you want to wait if your dining and have an urgency to go to the bathroom. It's quicker if you can just unlock your wheelchair wheels and go. Wheelchairs can be designed for longer sitting periods rather than just transport. Wheelchairs are like legs for some people. They are their independence!...Natalie

I am a family member of a resident in a LTC setting. I agree with this concept of getting people out of wheelchairs IF POSSIBLE. When my mother first entered the nursing home she was ambulatory, although only for short distances. She was not allowed to get out the wheelchair (fall risk) and was not transferred into a chair at meals although at first she would have been able to do so with assistance. Within 3 months she was unable to walk on her own (although she was in rehab to be able to do just that). At this point in time my mother requires a lift for any transfer. She is afraid of it and cries each time. To transfer her 6 additional times during the day would definately NOT be in her best interests. It would also be disruptive to the those around her. Not to mention the additonal time it takes for staff to hook her up - with stafifng levels I just don't see it happening many places! I think David Green is right when he says it should be the resident preference. It is gratifying to see people in the field who truly care and who are looking to improve the environment of those in long term care. Never stop! In doing so the focus must always be on what is best for INDIVIDUALS not one rule for all.

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MElliott

@MitchellElliott

www.vetterhealthservices.com

As Chief Development Officer, Elliott serves on the Executive Leadership Team for Vetter Health...