Saint John's Milwaukee

The Saint John's Model for Living holds community as the remedy for institutional living. It is comprised of neighborhoods and each neighborhood is defined by the level of care and service provided. The Tower neighborhood is the ideal neighborhood, where choice, autonomy, individuality, and independence prevail. Both of our skilled neighborhoods, Windsor and Stratford Courts, as well as the assisted care neighborhood, Canterbury, are modeled after the Tower.

In our society today, elders are living longer and as they become more physically dependent, the more human individuality they are forced to give up. Conversely, the Saint John's Model believes that life with meaning is possible each day of an elder's life and defies society's view that aging is a process of diminishment. It challenges the traditional nursing home "way of living" that is practiced in most institutions where systems were created (with good intentions) that deny residents even the smallest amount of control over their lives. For example, a resident admitted to room 100 in XYZ Nursing Home will likely be given the same bath schedule as the resident who vacated the room.

Saint John's On The Lake is working to transform the institutional approach to long term care into one that is person centered. All employees are considered part of this community and they are learning a set of principles and practices that guide care and service approaches through knowing and honoring the person first. These practices provide the basis for creating a daily life worth living again.

What does "person-first" mean?
The principle of personhood and dementia care was first introduced in the early 1980s at the University of Bradford UK by Dr. Thomas Kitwood, founder of the Bradford Dementia Group. Kitwood defines personhood in his book Dementia Reconsidered as: ...a standing or status that is bestowed upon one human-being, by others, in the context of a relationship and social-being. It implies recognition, respect and trust.

Person-first is a set of principles and practices that guide the care and service approaches through knowing and honoring the person before the task. These practices provide the basis for creating a daily life worth living, striving to nurture the mind as well as the spirit, and promoting growth and development for all.

How is this different from the "old model of care?"
For generations, the nursing home "way of life" has been a strong medical model where elders no longer have control such basic pleasures and rights as when they wake up in the morning, what they eat, how they spend their time and when they go to sleep.

Often when elders lose their abilities to care for themselves, caregivers focus only on the elder's physical comfort and safety. Caregivers save time by doing everything for the elder rather than encouraging them to help themselves. The medical model also has a traditional departmental structure, very hierarchical, where decisions are made by management and carried to staff through in-services, memos and instructions. The bulk of decisions are made by department heads, administrators and leadership team based on efficiencies and the ease of monitoring.

Saint John's continues to work on transforming this institutional approach to nursing home care into a community or social model. It focuses on individualized care rising from the individual needs of each person and allowing them to direct their own care. Megan Hannan, MS, an associate with Action Pact, a consulting group devoted to culture change for elders in long-term care, and creator of the Person-First dementia care model, provided train-the-trainer sessions for Saint John's employees. In Person-First, the aim of caregivers is to honor elders by finding ways for them to participate as well as to help the caregiver. Hannan explains in her training that many believe incorrectly that people afflicted with dementia cannot participate in self-directed care or decision-making. In our learned experience with small community circles and through a document called "Windows into the Past, Present and Future", caregivers get to know the resident's story or life history; caregivers help residents to communicate and gain more control of their own care. In a culture change transformation the structure changes where by the decision-making is distanced from the top and closer to residents by empowering the direct caregivers with decisions. The organizational structure is also changed as the leadership is brought closer to the residents and the organization becomes flattened.

Why was it developed?
This model was developed because of a crisis within the Nursing Home industry at large. Nearly five years ago, Saint John's and other homes in the country were experiencing excessive staff turnover rates, mandatory overtime fees, and severe staff and resident dissatisfaction. The leadership team recognized the need for change – which compelled us to research a better work environment for staff and a better way of providing nursing home care and service to residents.

How have residents reacted to this new model?
Saint John's was a fortunate recipient of a grant awarded by the Retirement Research Foundation to help develop our now social model or neighborhood model. The research component was completed by Barbara Bowers, PhD, RN, University of Wisconsin-Madison School of Nursing. The research results can be summarized in the following lists:

Medical Model-Resident Outcomes:

Sad, withdrawn
Loss of privacy
Isolated and deserted
Loss of choice/too many rules
Lack of interest, spiritless

Low expectations/complacent Social Model- Resident Outcomes:

Happy, socially engaged
Valued as a person
Included, attached
Empowered

How is "person-first" beneficial to resident health?
Saint John's health care philosophy focuses on the strength and wellness of an individual in contrast to focusing on illness. Our care giving team no longer wears uniforms because traditional hospital scrubs or white nursing uniforms imply illness. This has made a difference in how residents feel about themselves in their environment. Waking up each day in a place they call home, where relationships between residents, family and staff are the foundation for the Saint John's community and where each person can and does make a difference would be of benefit to any individual's health.

Can you give an example of person-first choice made by caregivers?
One of the most dramatic choices given to residents by caregivers is the opportunity to rise naturally. There was a time not so long ago, when we rousted residents out of bed as early as 5am in order for them to be in the dining room, dressed and ready to receive their breakfast tray by 7:30am (tray meaning no choice). Now residents get up whenever they wish, have breakfast anytime they wish and breakfast is made right in the kitchen next to the dining room in the neighborhood, where a variety of choices are available each and every day.

Food is an important part of the resident's daily life. If a resident expresses a desire for a certain food, it is not unusual for a staff member to run out to a local restaurant to pick up the food of choice whether it is fried chicken, a hamburger, Chinese or barbeque ribs.

What is the most exceptional example of person-first care you have witnessed?
One of our residents was attending a party with musical entertainment, sitting side by side holding hands with his wife. Their free hands were tapping to the music on their outside knees and both were truly engaged in the music and each other. The dentist came to the neighborhood and asked the staff to bring the husband down for a dental appointment. Before our person-first approach, we would not have questioned the dentist and whisked the resident away to honor the time. However, one of our values within our new model is that the person comes before the task. After further questioning, it was learned that the appointment was actually scheduled for later in the day but was more convenient to the dentist's schedule. This was a turning point, we held true to our value system by asking the dentist to keep the original schedule. He is still practicing as our house dentist, but now understands our philosophy quite well and an incident like this has not occurred again.

How have staff reacted to this change?
Research conducted by the UW research team resulted in these outcomes:

Medical Model- Staff Outcomes:

High turnover and absenteeism rates
Lack of caregiver empowerment
Lack of resident-bonding
Distant family/staff relationships
Task oriented
Provides hospital environment

Social Model-Staff Outcomes:

Confident
Teamwork
Empowered
Communicating and building relationships
Taking risks
Learning and growing
Providing home

What differences have you seen at Saint John's as a result of person-first care?
The most dramatic difference is the change within our management team. Our traditional management roles of superiority and control have developed into leadership roles of respect and trust. Partnerships were formed with Action Pact of Milwaukee and Alder Associates of Washington, D.C. to create team alignment, adopt operating promises and become a true community. With team leadership developing healthy practices of team-building and modeling respect and trust to employees, this healthiness has filtered down. As author Tom Kitwood quotes, "The manager's role is thus much more one of enabling and facilitating than of controlling, and this involves giving a great deal of feedback to staff."

This new way of interaction created an environment that broke down the system of powerlessness and low self-esteem felt by residents and caregivers to a new climate of empowerment and self-determination. Spirits have been rekindled and voices are being heard.