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Individualizing Mornings

Tip Sheet


WHAT IT IS:

We all have our own morning routines. Individualizing mornings means honoring each person's customary routines for when and how they awaken and start their day. For "early birds" this may mean access to early morning coffee and the newspaper. For "night owls" it could mean a late morning bowl of oatmeal. Some people wash up and dress before breakfast while others linger in their nightclothes. Some like active engagement and others prefer quiet time. Individualizing mornings starts with a gentle awakening, in which staff know and follow each resident's customary routine for waking and starting their day. CNAs come in to a person's room at their usual waking time and ask quietly if the person is ready to get up. If so, they then assist residents with their normal morning routine. If the person isn't ready to get up, CNAs come back a little later. Meals, medications, treatments, appointments and other daily activities are built around the resident's customary morning routines.

WHY IT IS IMPORTANT
We all have our own internal clock, often referred to as a circadian rhythm. Left to our own schedule, we tend to wake up at around the same time every day. When we are awakened too early or from a sound sleep, it can leave us feeling out of sorts. Homes that recognize the importance of honoring each resident's individual and unique sleep patterns support residents to awaken by their own internal time clock. This ensures that residents get adequate sleep.

Sleep is essential for human life. It is a restorative period in which our body's healing process is activated and our bodies get necessary rest. When we wake residents too early to accommodate a set breakfast time or medication schedules, we throw residents off their own rhythms. This adversely affects all aspects of their physical, mental, and psychosocial well-being – their mood and expressive behavior, appetite, balance, energy, and memory.

Individualizing mornings allows each person to have their own good start to the day, and also lessens the stress for staff. This seems counterintuitive when staff feel so stressed by the current rush to get everyone up, washed, dressed, and to the dining room for a set breakfast time. The stress comes from trying to take care of everyone at once in a short period of time. Spreading the waking process up according to residents' own patterns staggers the demand for staff assistance with daily care and with eating and for equipment such as the sit-to-stand lifts.

The adherence to routines that emphasize nursing home schedules and tasks at the expense of individual, customary routines create poorer outcomes for residents. The time crunch can contribute to residents' agitation and falls. Having a large meal set in front of someone before they are fully awake may result in the food not being eaten and the resident slumped and sleeping over the food.

This interconnection between customary routines and quality outcomes is codified in the Nursing Home Reform Law and the federal regulations. The law requires that homes provide care and services to "attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident." The regulations state under self-determination and participation, that: "The resident has the right to—
  1. Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care;
  2. Interact with members of the community both inside and outside the facility; and
  3. Make choices about aspects of his or her life in the facility that are significant to the resident."

This is an area that is gaining additional attention in the survey process as well. The CMS Quality of Life surveyor guidelines explain that "Choices over schedules include: waking, eating, bathing, and going to bed at night, as well as health care schedules," and state that the facility must:
  • Actively seek information
  • Be "pro-active" in assisting residents to fulfill their choices
  • Make residents' choices known to caregivers
Surveyors ask residents whether they are able to awaken and eat according to their own routines. The CMS Partnership to Improve Dementia Care references these customary routines as surveyors explore the root cause of use of antipsychotics in response to a resident's distressed behaviors.

HOW TO DO IT
The four foundational practices will help you know and follow residents' customary morning routines. Consistently assigned CNAs know their residents' schedules and organize their work accordingly. For residents who cannot verbalize their morning routine, consistently assigned CNAs know residents' cues about whether they are ready to get up. They share this information in the assessment and care planning process, and at huddle, and use it to organize other schedules, such as therapy, meals, medications, or treatments accordingly.

  • Give residents time to return to their normal routines. If you are transitioning from tightly scheduled mornings to individualized mornings, your residents will be transitioning too. People adjust their sleep patterns as the need arises, and residents become institutionalized to the facility routine. So if you have been waking residents who had been used to sleeping later in their own home, it will take time for them to revert to their natural rhythm. When you ask when they would like to wake up, they usually answer in relation to the current schedule, choosing not to miss breakfast, an appointment, or an activity that they have learned is only offered at a set time. They will need to know that you will adjust the schedule according to their natural patterns so that opting to sleep in or wake early won't make them miss out on activities that they enjoy. Consistently assigned CNAs know and accommodate residents' as best they can within the existing schedule and can work with residents to determine their natural waking time when your systems support more individualized mornings.
  • Learn customary routines in time for the first night and the first morning. As the consistently assigned CNA helps a new resident settle in, ask about the person's normal routines. If the resident is unable to share this information, ask a family member who knows the answer. Share this information in the shift huddle so that staff know and can follow the resident's routines from Day One. Share the information with other departments so that meals, medications, treatments, therapy and other appointments can be set accordingly.
  • Practice gentle awakening. Glenridge Living Community in Augusta, Maine uses a system they call gentle awakening. Staff learn each resident's natural sleeping pattern and organize their mornings accordingly. If someone cannot tell the staff their preferred time, the CNA will go into their room and gently touch their shoulder. If the resident is awake and indicates they want to get up then that is what they do. If the resident is still soundly sleeping then the CNA quietly leaves and checks back in 15 minutes. After the first few mornings, the resident's dedicated CNA knows what time to come into the resident's room. CNAs say it is far easier to assist a resident who wants to get up than to try to assist someone that they have woken out of a sound sleep and who does not want to get up. They also say residents are "better natured" and less agitated when they get the sleep they need.
  • Address the impact on other systems. Individualizing the morning routine for residents impacts many other care delivery systems. For example, you'll need to build more flexibility into the availability of your dining services. You may have to rethink when rooms are cleaned if they are typically cleaned during a set breakfast time or when large group activities are scheduled if they occur in the same area as dining. Medication routines will have to follow the resident's routines, as will treatments and appointments. Medications can be prescribed and administered "upon rising" and "with meals." These systems changes are not impossible to do, but they will take thinking through with all of the affected departments.
  • Start small and adjust as you go. As with any major change, it is best to start small, and learn as you go. For example, while over the long haul, you'll need to make food available to accommodate the wider range of waking times, you may elect to start by offering coffee and a continental breakfast for residents who wake up early. Pilot test this practice on one neighborhood. It may be easier, for example, to start with residents in a short-term, rehab area who are still on their regular body clocks. Start with staff who are most eager. Expect to adjust continually as you learn more. Have regular time for the staff involved to talk through how it is going, or what might be needed. Monitor all vital clinical areas. For example if you are worried about weight loss or skin for someone who sleeps late, pay careful attention so that you can make adjustments at the first sign of a concern.
  • Reassure staff. Reinforce to staff that working with residents and honoring their preferences will not result in chaos. There will still be routines developed, they will just be based on resident choice and not institutional requirements.
  • Expand breakfast times and options. Use hotel-style cold cereal dispensers and crock-pot like kettles for serving hot cereal; they keep it warm for long periods of time, without overcooking it. You probably already have followed time preferences for some residents or had occasional special cook-to-order breakfast days. Build on these experiences - if you can do it once or in exceptional cases, then how can you make it the norm? Use the exceptions and special days as pilot learning opportunities. Reflect: What did you need to do to get it done? How can it be done daily instead of on special occasions?

RESOURCES
Pioneer Network
  • Pioneer Network's website provides links to many affiliate organizations with resources to support homes in individualizing the morning routine.
  • The National Learning Collaborative's Webinar 7 features a team of staff from a nursing home, sharing information about how to operationalize morning routines. Webinars are available for a fee for five on-demand viewings of each webinar. All 12 webinars are also available for purchase as a set of discs, at a discounted rate. To purchase viewings of one or more of the webinars, or the entire package of 12 webinars, go to Pioneer Network store.
  • This tip sheet is from the Pioneer Network Starter Toolkit: Engaging Staff in Individualizing Care. The entire toolkit, with additional tip sheets, starter exercise and resources, is available at www.pioneernetwork.net/Providers/StarterToolkit
Advancing Excellence in America's Nursing Homes www.nhqualitycampaign.org
Data collection can help determine whether the changes being made are working, and continue to work. The Advancing Excellence in America's Nursing Homes campaign has the tools and excel sheets for collecting data on consistent assignment (are we REALLY doing this?) and on Person Centered Care (are the wishes and preferences of the residents actually being delivered, and are the direct care workers attending and participating in the care plan meetings?), as well as other organizational and clinical goals. www.nhqualitycampaign.org

B&F Consulting www.BandFConsultingInc.com videos:
  • Gentle Awakening, excerpt from Culture Change in Long-Term Care: A Case Study of Glenridge Living Community in Augusta, Maine
  • Operationalizing Gentle Awakening, excerpt from CMS surveyor training webcast From Institutional to Individualized Care, Part One


Download Individualizing Mornings Tip Sheet (PDF)

Starter Toolkit Home          Step One          Step Two          Step Three          Self-Assessment
Prepared by B&F Consulting for Pioneer Network's National Learning Collaborative on Using the MDS as the Engine for High Quality Individualized Care. Funded by The Retirement Research Foundation.
All webinars in this series are available as archived recordings at
http://eo2.commpartners.com/users/pioneerlive/all_series.php.
In addition, the full series is available as packaged DVD set in the Pioneer Network store.