Sometimes the best treatment is the right setting

An example of how Environmental psychology can improve patient outcomes

Mary is a patient in a small nursing home. The building is an old home in a residential area. It is marketed as a homey building with caring staff. It has 2 floors with fifteen patients per floor. There is a small dining area and very narrow hallways. The is no nursing station, just a desk in the hallway across from the patient’s charts.

Medications are given via the medication cart and meds are signed off on a computer that sits on top of the cart. Any patient stepping out of their room is in the area of the med cart immediately and all must walk through the narrow hallway where the charts are kept to enter the dining area, which also serves as the patient’s activity and TV room. While most of the residents there are people with medical issues involving rehab Mary is a long term resident with a past history of schizophrenia who now has pronounced dementia. She is a wanderer and will enter other resident’s rooms. At times she will take their belongings thinking these items are hers. She will pick up items from the nurse’s desk as paperwork and even a chart. She is intrusive in that she asks repetitive questions constantly to staff and residents. Staff are constantly telling her to “ get out of that room” or ‘stop interrupting my med pass.” this makes Mary’s mood irritable.

While many patients understand her situation she is an annoyance to those trying to focus on their rehab and staff trying to do patient care. Due to this Mary has received multiple psychiatric evaluation requests to see if anything can be done to stop her wandering and constant questioning. She has been put on a variety of different medications with little benefit. She still wanders and is now a little less steady on her feet due to these meds. This increases her fall risk. Staff feels helpless to solve this problem and several behavioral plans regarding both praise and timeouts have not helped. What can be done?

Mary is in the wrong setting. 

Environmental psychology is an interdisciplinary field that focuses on the interplay between individuals and their surroundings. They design areas that allow for personal space safety and intercommunication comfort. Due to their input, most nursing homes have specialized Dementia Units which are designed for patients such as Mary. They have wide long hallways for wandering. Some even have a track where residents can walk in a circular manner. The nurses stations and charts are in locked areas. Lighting is good, safety systems like camouflaged doors that meet fire safety regulations are in place, and alarms and Velcro gates are used to prevent falls and wandering into other rooms. The staff are trained in dementia care and activities.

The behaviors that frustrate staff and other residents in Mary’s nursing home would be of no consequence in these specialized units. In addition to space for her to wander and the safety features available she would be on much less medication. This would lessen her fall risk and reduce side effects from sedation. Staff would not be trying to redirect her constantly which frustrates and increase her agitation and takes more of the staff’s time to manage.

Patient are often placed in the “wrong“setting due to poor screening processes, a desire to be closer to family, local bed availability, and once there, a desire to keep the bed filled and continued revenue.

Social Service will approach Mary’s guardian about moving her to another facility with a dementia unit. She explains this is not a punitive move and how Mary’s quality of life will improve.  Her guardian agrees that being in the right place is the right and best treatment plan for Mary.

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