“Empower With Choice”

Effective January 1, 2007, we were mandated by the state of Florida to increase CNA staffing to a ratio of 2:9. Like many others across the state, Palm Garden of Ocala, a 180-bed skilled nursing and rehabilitation center, wanted to find a creative way to use these new staff positions to better serve our residents. We recognized that culture change was essential to fulfilling our promise of quality of care and sustaining or improving the quality of life of our members.

Today’s nursing homes need to become places that allow a member to live life and enjoy his/her surroundings. Too much emphasis is placed on the person’s illness and on ways to cope with institutional surroundings. As the baby boomers age, skilled nursing facilities (SNFs) are becoming increasingly aware of this population’s desires when they enter a nursing facility for care, i.e., they do not want a hospital-like setting, but rather a country-club like setting.

They want private rooms with wireless Internet access, spa-like bathing facilities, beauty/barber salon services, a “happy hour” bar with big screen televisions, and a fully equipped exercise gym with personal trainers. Some will want a pool hall, bowling alley, reading rooms, movie theater, massages—the list goes on and on. Because of this we know that we will no longer be able to function as a medical institution; we must find a way now to become a home.

We believe that quality of care is driven by quality of life and is centered on the individual needs and choices of each member. It is all about having enhanced choices!

The problem

The two scenarios that follow will make readers giggle because all of us in healthcare have seen them more than once.

It is 7 p.m. in any SNF in any town. Ms. Anyone is restless, calling out, and bouncing up and down in her wheelchair a hundred times over the course of an hour, looking for her daughter. Now it is 8 p.m., and that must mean it is bedtime. The CNA takes her to her room, provides p.m. care, and assists her into bed. She is calling out and trying to climb out of bed, so the nurse administers a hypnotic and soon Ms. Anyone is asleep—but she wakes up at 1 a.m. and is climbing out of bed, very agitated. So the nurse calls the doctor, who orders an antianxiety medication. The next day a psych consult is ordered as well, because surely this member must have some psychological disorder.

Another example is a member who is frequently displaying repetitive movements, very restless and, according to the staff, nothing helps. The doctor is called and labs are ordered, and along with the never-ending antianxiety medication, yes, you guessed it: A psych consult and maybe a pain medication are ordered.

Each of these situations created a problem that must be eliminated. The root cause of each situation was really never investigated, it was just assumed. And these are only two of the scenarios that we encountered. Weight loss and in-house pressure ulcers were on the rise as well. We knew we had to find a way to resolve these problems. Improved quality of life had to be at the center of this program. As we began this journey, we knew we would need a little outside help to achieve our dream. As it happened, the same agency that was mandating the staffing increase was also willing to grant us money, if we would take the time to come up with an innovative idea that improved our members’ quality of life and was measurable. Having this opportunity, we set out to build a grant proposal by researching what our members wanted and needed.

With this information in hand, we developed our “Empower with Choice” program and our Quality of Life (QOL) aides. The program is divided into three subgroups and led to the receipt of a $66,000 grant request from the Florida Agency for Health Care Administration to develop them. Our QOL aides are trained in each program and work closely with all departments and individual members to give them more choices in their daily activities, and that special feeling of being appreciated and pampered by all.


The three programs we developed are:

  • Our enhanced bathing program, “SPA-Venture,” is centered on creating a spa-like atmosphere in what were our “institutional” shower rooms. Bathing is a very private experience that can be physically and emotionally cold, sterile, and institutional. We adapted the physical environment to enable the member to maintain as much independence and dignity as possible. A team of QOL aides, supervised by the restorative nurse, provides support for the functioning and maintenance of this program. Each room is equipped with a heated walk-in safety tub, heated towel racks, hair dryers, curling irons, spa robes, and slippers. Aromatherapy is provided to promote relaxation while soft music is playing. As you enter the spas, the first things you notice are the serene murals painted on the walls. You feel as though you are entering into a relaxing, comforting experience where you have no worries. It brings the bathing experience as close to homelike as possible.

  • Our enhanced dining/hydration program, “Dining by Design,” offers our members a choice of when to eat, where to eat, and what to eat, while improving nutrition/hydration. This change provides a sense of control and improves self-esteem. This program is only partially complete, but you will see later in this article the impact we have already made with the changes that have occurred. Currently, we have developed three dining areas.

    Café Ocala is easily accessible and is designed for independent restaurant dining, with expanded hours of service for each meal. You are cheerfully greeted by a host/hostess, who welcomes you and escorts you to the seat of your choosing. A QOL aide offers you a beverage and/or soup. You are then given the meal choices for the day and the assigned staff member takes your order. The staffer then submits it to the dietary personnel who fill your order. Your food choices are then served to you piping hot. When you have completed your meal, don’t be too quick to leave, because the dessert cart is heading your way with choices to satisfy that sweet tooth.

    The Bistro is an assisted restaurant dining program. It is designed for those who require assistance and some retraining (previously known as restorative dining). It is set up with charger plates, linen tablecloths, and linen napkins. This program’s goals are always geared toward realizing the member’s desire to return to the more independent Café Ocala.

    The Veranda is designed for those who require maximum or total assistance with their meal intake (a service previously known as assisted dining).

    For those who choose to sleep a little later, we have a continental breakfast bar in Café Ocala that is available until 9 a.m. serving cold cereals, toasted bagels, juices, and coffee. At 9:30 a.m., the nutrition/hydration cart begins its stroll throughout Cypress Lane and Palmer Place (our LTC units), offering a nice, refreshing beverage to all. Music is playing and everyone knows that the cart is getting close. It will make its final stop outside of the Fun Zone at approximately 10:45 a.m., where our exercise program is just finishing and everyone is thirsty. The cart makes two more trips each day, one starting at 2 p.m. and the other starting at 7:45 p.m. We all need that bedtime snack—mmmmmmm, tastes like home.”

  • Our personal comfort program, “Comfort Zones,” focuses on decreasing behaviors, decreasing pharmacological intervention, decreasing pain without narcotic use, improving quality of sleep, and promoting socialization. Our vision here is to couple our current medication regimens with a program designed to promote well-being. The Comfort Zones were designed with three things in mind: relaxation, fun, and pampering. The Comfort Zones are further broken down into three areas: (1) Two Quiet Zones promote relaxation and well-being with the use of a waterfall wall, low-level lighting, gentle touch meassage, aroma/auditory therapy, soft plush recliners, and rocker gliders. We have recently planted a butterfly garden in front of the window of one of the Quiet Zone areas and this has attracted many more members to come relax and let their worries flutter away. (2) In the Fun Zone there are board games, checkers, puzzles, card games, a large-screen TV with DVD player, and many movies (of course you can always bring your favorite), and a Wii system for the adventurous type. (3) The Pamper Zone is designed to make everyone feel special. We encourage all to come down for a hot shave, a hand paraffin treatment, a manicure, a pedicure, and a hand or foot bubble spa treatment. You leave feeling great.

How to measure?

Our goal was simple: Improve the quality of life for all. But how were we going to measure this? Quality of life builds success with quality of care, so we chose several clinical areas to monitor, took a baseline count of members participating in the dining room, solicited comments from the resident council and family/friends council meetings, and conducted satisfaction surveys. We selected all LTC members to participate in these programs. The goals and outcomes are monitored by the director of nursing, the administrator, and others as assigned. The QOL aides, the restorative nurse, and the floor staff are responsible for facilitating individual participation in the Comfort Zones, SPA-venture, and the Dining by Design programs.

Manageable/reachable goals

Residents who have moderate to severe pain

  1. Encourage residents who score three or higher on the 0-5 pain assessment scale to use the sensory rooms or spas.

  2. Re-evaluate pain assessment scale score post-use of the sensory rooms or spas.

  3. Analyze data collected from scoring to determine benefit vs. nonbenefit of sensory and/or spa use.

  4. Re-evaluate residents with 0-2 scoring who may also benefit from use of sensory rooms and or spas.

Residents who spend most of their time in bed or in a chair

  1. All residents currently bedbound by choice will be offered use of the sensory and/or spa areas on a daily basis.

  2. Of all residents bedbound by choice on the most recent MDS, check how many participated in the use of the sensory and/or spa areas.

  3. Of all the residents bedbound by choice on the most recent MDS, check how many participated in the use of the buffet dining program.

  4. Re-evaluate the number of residents remaining bedbound by choice every 30 days.

Prevalence of hypnotic use more than twice in the last week

  1. Any resident using routine hypnotics will be offered use of the sensory rooms and/or spas prior to bedtime.

  2. Of the residents using hypnotics on the most recent MDS, check how many participated in the use of the sensory rooms and/or spas.

  3. Of those identified residents above that used the sensory rooms and/or spas, obtain orders to decrease hypnotic to PRN. Residents will be encouraged to use the sensory room and/or spas prior to PRN use of hypnotics.

  4. Any resident not using hypnotic medication routinely will be evaluated for discontinuance of medication.

Implementation timetable

30 Days

  1. Educate all on the “Empower with Choice” program.

  2. Meet with resident council to introduce the program.

  3. Establish a committee and subcommittee.

  4. Set up mart cart, dining hours, and nutrition/hydration time cart rounds.

  5. Order equipment and paint.

60 Days

  1. Install new dining equipment.

  2. Assemble and install equipment for the sensory rooms.

  3. Decorate the sensory areas.

  4. Begin training on use of new equipment.

90 Days

  1. Remove old tubs and install new tubs.

  2. Have wall murals painted.

  3. Assemble and install spa equipment.

  4. Train staff.

As you can imagine, there was/is a lot of training to be done. The staff development coordinator would hold primary responsibility for this task, with assistance and guidance from the director of nursing. Individualized specialty training would be performed by the QOL aide assigned to the specialized area. Education was provided at each monthly CNA/nurses meetings and general staff meetings. The administrator conducted department head training and provided the monthly updates at each all-staff meeting. Member education was completed one-on-one and at resident council meetings by the director of nursing or designee. All information and updates are provided in our monthly newsletter for each member, family member, or friend.


We began this project one year ago, and the road has been long and hard, but very rewarding. We will describe the obstacles we encountered, how we overcame them, and the documented successes we have achieved. You will feel our pain when things did not go as planned, our excitement when we achieved even the smallest step toward success, and our undying passion throughout each quarter. At the end you will not only see the clinical evidence that supports the success of this huge project, but also see individualized stories about members of our community whose lives have been improved in every way because of our “Empower with Choice” program.

Our first step in evaluation was very simple: We had to collect baseline data. We used current in-house information, satisfaction surveys, QI/QM reports, pain assessments on all LTC members, the pharmacy report, weight reports, and observation. After collecting these items we placed them in a format that could be easily read and where, at a glance, we could readily see a strength or a weakness.

In the first quarter our hurdles were many and difficult to overcome; so many factors were outside of our control. For example, ordering and obtaining equipment was much more challenging than expected. The amount of time taken to receive equipment once an order was placed took much longer (sometimes months longer) than we were told when calls were placed to develop our implementation plan. The safety tubs, for example, have taken many months for delivery.

The next obstacle was being able to locate outside resources to help educate us and our staff without having to pay a substantial fee. The administrator worked diligently on this and would pass on any leads she found. Then one day: “Bingo!” We were given the name of two individuals who worked together on providing culture change education. One month later we found a consultant, free of charge.

The largest impediment during this first quarter was the one that caught us off guard. We thought we were doing all these wonderful new things, education was in full swing and had been going on for six months, when we hit a brick wall. Fear of change is a powerful barrier and one that is difficult to break down. As the reality of these programs became obvious, the staff, members, and families began to display anxiety about the unknown. We had done what would be considered a wonderful job of providing education. We had educated our QOL aides and empowered them to educate others and provide positive promotion of things to come. But it was difficult at first for them to jump off that ledge and teach someone something new and that very few had knowledge about. They met resistance, but we surged forward, incorporating other staff who showed interest in the education process. We educated our resident council members and encouraged them to “spread the word.” We empowered them to be a part of the process by asking them for guidance on how to build excitement for members.

We made culture change the center of every meeting. It was discussed in nurses’ meetings, CNA meetings, resident council, friends and family council, our newsletter, and even in the halls. We purchased a culture change DVD and allowed everyone in-house to check it out and view it in the privacy of their homes, in small groups, or in one of our structured in-services. We wanted everyone to be a part of what was going on, but many were skeptical and just wanted to ride in the back seat (although a few of late have been heading for the steering wheel!). Although it looks as though we had many obstacles (and, yes, they did prevent us from meeting our implementation plan in its entirety), they did not stop us. We never gave up, and we simply revised the “care plan” and moved forward because we had already begun to see that things can change.

Jennifer Mikula, NHA

Tina Vanaman, RN, DON

Accordingly, the second quarter showed more successes and fewer problems. True, time was never on our side during this project, and we experienced some staffing changes due to a position elimination (remember, we are doing all of this in-house with no formal outside contractors), and this slowed down our progress. Slow vendors and receipt-of-merchandise problems caused a huge delay in progress. We received some equipment damaged, some missing pieces, some incorrect merchandise (ours had been delivered to someone else), and some we didn’t receive at all. But our

new obstacle this quarter was motivation.

Everyone was losing the excitement that took so long to build. With any prolonged project people cycle through excitement, anticipation and, as time goes by, disappointment that things are not moving as quickly as they would like. From this, we learned that you never set definitive deadlines, but simply invite everyone to see the progress we are making and to incorporate their help in moving things along.

By this point in the process, many emotions were felt by all. There were times of heartache, sadness, disappointment, and even questions of “will we ever get there?” Many of us worried about not making deadlines and not meeting our goals in a timely fashion, but we also knew that it is always better to be late completing a task and have it successful than it is to complete a task on time and have it fail. So, we slowed down and took one step at a time, remembering to always smile and be grateful for the small change that we made today that will lead to our success tomorrow.

In the third quarter, our obstacles were fewer—although time had continued to fail to be our friend and, once again, we had revised our plan. The barrier that caused us the most heartache this quarter was the reality that some staff cannot or will not “step outside the box.” Some are not capable of seeing beyond what they “have always done.” They then decide to move on to another place. Unfortunately, this is a reality in our world, and sometimes outside our ability to control, but it is a necessary evil accompanying change and improvement.


Quarterly reports were completed. Daily charting tools were devised for the QOL aides to document attendance, pain scale values upon entering and exiting the area, the service provided, and any comments the member made verbal or otherwise (and body language is the best form of communication for all of these programs). All tools and any written statements from staff or members, families or community-involved personnel were collected, along with the other formal data-collection tools, about two weeks prior to reporting.

All the information was reviewed, including progress on each of our three spas, dining room upgrades, the level of participation in each of the programs, QI/QM reports, satisfaction surveys, and the reduction in members’ pain medications and disruptive behaviors. In general, whether required to do quarterly reports or not, everyone who does any project of any size should have a scheduled reporting procedure. We’ve had many successes over the past nine months. They started small, with an increase in attendance to the dining areas by 30 members, and built to current successes that include actual improvement in peoples’ lives.

To summarize, quarter-by-quarter:

  • In the first quarter we established the restaurant-style dining, complete with a dessert cart and continental breakfast. Our nutrition/hydration cart began its timed rounds up and down the neighborhoods. It only took a few days for the members to learn the “snack” cart was out, and they began to seek it out. We began our comfort zones on a smaller scale and, since our designated areas were not completed, we went room to room and provided as many services as possible at bedside. The manicures were the biggest hit.

  • During the second quarter, weight loss became a thing of the past. The 20 members who had weight loss issues (our targeted group) were gaining weight. The staff, visitors, and members began to embrace the concept and some even joined a culture change subcommittee to offer their support. Programs slowly became a reality as we opened one at a time.

    As the program took hold, in-house-acquired pressure ulcers began to decline and current ulcers healed. Disruptive behaviors began a downward trend. For example, we had one member who had just celebrated her 101st birthday, and displayed very restless behavior, with repetitive verbalizations and movements. She lacked focus and was not even able to answer short questions. She began to visit the Quiet Zones, where she was able to relax and receive one-on-one attention. She soon was observed sleeping for hours in a recliner with soft music playing, aromatherapy surrounding her, and the sound of a waterfall in the background. These days she enjoys a nice back rub or a gentle hand or foot message. Upon waking she is quiet, will answer questions appropriately, and eat 100% of her meals.

  • In the third quarter—the one we just completed at this writing as of June 15, 2008—we developed unparalleled documentation that culture change is better for all. Our attendance at the now five dining areas has quadrupled. The dinner meal still has the lowest attendance, but just this week we were notified that we need to extend these hours as we have run out of room—a great “problem” to have, as it shows our ongoing success. We will once again revise our plan so that we can continue to grow. To demonstrate how effective it is to “Empower with Choice,” we offer these signs of growth: We have a Breakfast Club that meets once a week. It started with eight members and has grown to 28 members. We have added a chef who prepares breakfast to order for each one of the attendees. It has become such a success that we are now looking forward to increasing its frequency in the future.

Our first spa opened in this quarter. Initially it was very difficult to get members to attend but slowly, one at a time, they began to venture into the area to “check it out.” We now are able to accommodate 10 to 12 members per day. Our Pamper Zone is blossoming. It is by appointment only and some members will make appointments, but many just show up. How can we say “not today”? So we don’t say it and we find a way to see everyone. They cannot wait to tell and/or show everyone their new nail polish, talk about the hot shave or the hand paraffin bath they had that took the pain away, or some just want to talk about the new friend they made or the great conversation they had with the QOL aide who provided them with these wonderful services.

In the window of the Quiet Zone we planted a butterfly garden. The butterflies are now visiting along with a few squirrels. The success here is reflected in the decrease in the number of disruptive behaviors seen. Many members who are brought by our staff come in agitated, refusing to eat, or are crying. Our staff is trained to spend a few moments one-on-one with that member to transfer them from their wheelchairs into a recliner or glider, provide a nice foot or hand massage, and to talk to them calmly and softly. On average it takes less than five minutes for the behavior to cease and the member to feel calm and relaxed. As time has gone by, fewer and fewer members are being brought for these reasons. Most attend now because we have all learned what makes that member happy and we want to ensure that it is provided to each and every one of them.

The Fun Zone was very slow to begin. Many members were hesitant to go “play games.” We now have a popcorn machine that we use every day. We conduct exercises in the Fun Zone every morning, with an attendance of approximately 30 to 35 members. There are still slow times and busy times, and the members still need encouragement to play the Wii system and often just like to watch others play. But, as time passes, a few more pick up the remote when they think no one is watching and start moving it around.

See the table (p. 43) for more follow-up data.

Follow-up Data



Current # of members using dining areas



Number of members bedfast by choice



Number of members utilizing hypnotics



Number of members with in house pressure ulcers



Number of members with in house weight loss



Number of members displaying behavior symptoms



Number of members with UTIs



Number of members utilizing antipsychotics



Number of members that are depressed or anxious



Number of members that display mod to severe pain



More results

  1. Staff turnover facility-wide has steadily decreased from 30% to 4.75% over the course of one year.

  2. At the beginning of this journey we selected 20 members who either experienced significant weight losses or were well on their way toward them, and we assessed their responsiveness to attending the dining room, receiving snacks from the nutrition and hydration cart, and developing the self-esteem to say, “I don’t like this, I want ________.” All 20 of these members are no longer a weight concern; they have gained all the weight lost and, in 17 out of 20 cases, gained beyond that and are more engaged in the community. One member improved so significantly with weight control, improved self-esteem, and functional ability that the family was able to take her home. Two other members have shown fluctuations in weight from month to month but are maintaining within acceptable limits and within ideal body weight range.

  3. We have had many other facilities, home care agencies, and individuals come to tour. Our local paper did an article on the positive changes we are making and the trend we are hoping to establish. There are community healthcare providers sending e-mails to others throughout the state letting them know what we are doing and how beneficial it would be for them to come tour our facility and learn from us. The amazing part about all of this is that we have done little to initiate this response. It has been primarily word of mouth.

  4. Last but not least in our successes are individual success stories (see “Success Stories,” p. 42).


This program could be shared with all skilled nursing facilities that are interested in cultural change. The impact is tremendous. With an improvement in all areas of quality of care, we are improving quality of life for our elderly with the respect and the pampering they deserve.

Palm Garden of Ocala, Ocala, Florida

For more information, contact Jennifer Mikula, NHA, Administrator, Palm Garden of Ocala, at (352) 854-6262. To send your comments to the author and editors, e-mail optima0908@iadvanceseniorcare.com.

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