How to Foster Self-Determination

November-December 1995

Practical Ways Nursing Home Staff Can Empower Residents

Mr. Lewis is assistant administrator, St. John Neumann Nursing Home, Philadelphia. At the time he wrote this article, he was assistant administrator, St. Francis Country House, Darby, PA.


How can a long-term care facility empower its residents and enable them to become involved in decisions that affect their lives? A number of programs offer traditional and more innovative ways to support nursing home resident independence:

  • Resident council
  • Resident welcoming committee
  • Resident activities committee
  • Food committee
  • Resident newsletter
  • Opportunity to vote
  • Quality-of-life survey
  • Dietary survey
  • New employee orientation program
  • Care planning process

When nursing home residents feel they can make suggestions and participate in decisions, they are more content, making care givers' tasks easier. To help residents achieve a sense of self-esteem and dignity, staff must extend residents every reasonable opportunity to become actively involved in decisions that directly affect them. In fact, the Omnibus Budget Reconciliation Act (OBRA '87) strictly requires facilities to respect residents' rights and encourage independent behavior.

But how can a facility empower its residents and enable them to become involved in decisions that affect their lives? This article outlines a number of programs that offer traditional and more innovative ways to support resident independence. These examples are intended to be practical programs any facility would be capable of implementing.

Traditional Approaches
Resident Council Perhaps the most common approach to helping nursing home residents gain a sense of control over their lives and environment is the resident council. This forum must legitimately enable participants to exercise their rights, to have real opportunities for open discussion, and to effect change.

At St. Francis Country House in Darby, PA, a staff social worker acts as the facility's liaison to the council. Every meeting begins with a review of old business to ensure that concerns raised the previous month are resolved. All department directors make presentations at the meetings and respond to any questions or concerns about their area of responsibility. Within a week of the meeting, minutes are posted for resident review.

The resident council is a springboard for a number of programs to enhance resident involvement in important, not perfunctory roles.

Resident Welcoming Committee The resident welcoming committee arranges for residents who "know the ropes" to visit and provide information and emotional support to new residents. Often new residents receive gifts such as flowers and toiletries from current residents. In some instances, a welcoming committee representative makes three or four visits to help a new resident absorb all the information. There are many nuances to living in a nursing facility, and new residents understand and remember such information better when it is communicated by a peer.

Resident Activities Committee Encouraging involvement in program planning underscores the value of resident self-direction and independence. At St. Francis Country House, members of a resident activities committee meet with staff from a department such as therapeutic recreation services to review future activity schedules and discuss their ideas for programs. Residents often have talents they can share or know of people outside the facility who would be happy to present a program for residents.

Food Committee A food committee is another way to help residents participate in decision making. Residents frequently complain about the quality of food served. A food committee allows them to have a say in the types of meals, desserts, and snacks they are served.

At St. Francis Country House, after the food service director has prepared a new menu cycle and the dietitian has approved it, resident council officers review it. They discuss each meal, and often the food service director and dietitian agree to modify food items. The entire resident council then reviews the new menu cycle. The council also reviews meal schedules in a similar manner, discussing issues such as meal delivery, time taken to serve residents, and food temperature.

Resident Newsletter Newsletters published by the residents can become a marvelous source of information and enjoyment for all residents, their families, and the community. To truly generate feelings of empowerment, a resident newsletter should include columns, facility events, resident information, editorials, and letters to the editor. Newsletters often allow residents to openly express their thoughts and concerns about living in the facility. They also can provide entertainment, such as puzzles, and contribute to a sense of community.

Opportunity to Vote Living in a nursing home should never preclude residents from exercising their rights as citizens of this nation. The steps a facility takes to help its residents become informed and vote in local, state, and federal elections are the basic litmus test of its dedication to the concept of resident enfranchisement.

The facility should help residents who wish to vote get to polling places. Those residents who cannot make it to the polls because of physical limitations must be offered the opportunity to cast absentee ballots. The facility is obligated to ensure residents have the means available to be informed of the issues and candidates before elections (e.g., newspapers, position statements, guest speakers, and discussion groups).

Innovative Approaches
Lee H. Bowker wrote in his book Humanizing Institutions for the Aged: "A fully humanizing institution goes beyond [traditional] service delivery to stimulate residents to be truly active, innovative and creative in their personal lives; political in their congregate activities; and to be the givers as well as the receivers of help and goodwill" (Lexington Books, New York City, 1982).

The following are some more innovative ways to further enable residents to have a genuine impact on facility operation, staff attitudes, and their own daily lives.

Quality-of-Life Survey Residents can be perceptive and, given the opportunity, will conduct proficient environmental and quality-of-care "inspections." At St. Francis Country House, each month resident council officers conduct a quality-of-life survey. Council officers randomly choose the rooms to be surveyed. With residents' permission, council officers check the room using a quality-of-life survey form (see "Resident Council Quality-of-Life Survey" at the end of this article). Negative responses must be noted in the comments section of the form.

Results are presented during resident council meetings (and a copy is attached to the minutes). Problems that need to be addressed are brought to the attention of the department directors responsible for that area during the meeting. The outcome of corrective actions taken is reported during the next council meeting. This process ensures follow-through and underscores the validity of resident input about problems.

Dietary Survey Another activity residents can complete each month is a survey on some aspect of the dietary department operations. St. Francis residents learn how to take food temperatures, how to identify special diets, and what factors go into "tray accuracy." Furthermore, participants learn to observe and record whether food trucks adhere to delivery schedules, how quickly trays are dispensed to residents, and if staff are assisting those residents who require help (e.g., with cutting food).

New Employee Orientation Program Another creative way to help residents feel involved and valued is through a new employee orientation program.

At St. Francis Country House, one or more residents work with the education coordinator to communicate the concept of resident rights. With new employees, residents review the rights promulgated by OBRA and share personal anecdotes that underscore the importance of these rights both to quality of care residents receive and resulting feelings of autonomy and self-determination.

New employees report that, after hearing residents' presentations, they feel sensitized to the importance of adhering to the policies protecting each resident's right to a dignified existence. Many employees note that simply reading a handout is much less effective in increasing their sensitivity to resident rights.

Care Planning Process Residents' participation in making decisions that affect daily life can also be achieved through the care planning process. OBRA irrefutably charges a facility to actively encourage residents to participate in developing their treatment and care plan.

Staff should — verbally and in writing — invite a resident to every care planning meeting that concerns him or her. During the planning process, staff must respect residents' wishes, including the right to refuse treatment. OBRA regulations underscore the absolute right of every capable resident to have a voice in his or her own care and living situation.

To ensure this process is truly accessible to residents, staff must be willing to convene the care planning meetings at the bedside of residents unable to get to a central meeting room. To encourage family involvement, care planning sessions should be held during late afternoon or evening hours — or even on a weekend if necessary. By making reasonable accommodations, a facility will more than likely be in synch with both the intent and spirit of OBRA regulations.

A Worthwhile Journey
The programs and concepts presented here are by no means exhaustive. In those facilities where there is a genuine commitment to residents' rights to exercise control over their daily lives, staff will find creative ways to promote resident responsibility and choice. Administrative staff must visibly support the concepts of empowerment and self-determination.

Permitting each resident to participate as fully as possible in directing his or her own life is truly the practical meaning of empowerment.


Resident Reviewer:
Room Checked:

(1 through 10 — Yes/No)

1. Generally, was the room clean and orderly? (floors, beds, privacy curtains, overbed tables, furniture)

2. Were residents in the room well-groomed? (i.e., hair, fingernails, face)

3. Were residents in the room dressed properly? (remember time of year, clothes clean, not torn or holes, etc.)

4. Did staff (if in room) treat residents with courtesy and respect?

5. Was room temperature comfortable? (cool in summer; warm in winter)

6. Were beds neatly made and call bells visible?

7. Were water pitchers in reach of residents?

8. Was lighting level in room comfortable? (no glare)

9. Generally, was noise level appropriate? (no loud and distracting noises)

10. Were beds and dressers labeled?

11. Room (did)/(did not) have an odor. (Circle one.)

12. Overall rating: (Good/Average/Poor)

(a) Room cleanliness
(b) Resident appearance
(c) Staff/resident interactions

Comments: ________________________________________________________


Copyright © 1995 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

How to Foster Self-Determination

Copyright © 1995 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.