Kendal has many achievements to be proud of, but it is perhaps most famous for a program it promoted for three decades, starting in the 1980s, called “Untie the Elderly”. It led to major changes in nursing-home care throughout the US and the world. It’s an amazing and sprawling story whose dimensions can only be hinted at in a single blog post. I know I’ll be writing more about it later, but I decided that the best introduction is an example of how it worked in practice: the story of a confused man and his upset wife.
From its inception, Kendal has never used restraints to keep confused residents from wandering. It has never used them to prevent frail residents from falling. Kendal has always worked out other methods to cope with these problems without subjecting residents to the indignity of being physically restrained.
When Kendal was founded, in the 1970s, physical restraint of nursing-home residents was common. Over a quarter of residents in Pennsylvania nursing homes were physically restrained, and it was accepted as standard practice at the time. It took a while for the world to recognize how unusual Kendal’s practices were, but as the uniqueness of Kendal’s approach became clear, Kendal went on a mission to change the standard practices of the elder-care industry.
Eliza Lewis (a resident here whose husband, Lloyd, was the first Executive Director of Kendal) gave me a copy of the case study below, which was written by Beryl Goldman. Eliza also put me in touch with Beryl, who spent most of her 30-year Kendal career as Kendal’s Director for Outreach, promoting the Kendal “non-restraint” philosophy, which became known as “Untie the Elderly”. Now retired, Beryl lives at her home a few miles north of Kendal. This is her account of an event that took place several decades ago at Kendal at Hanover.
More than 20 years ago, a tall, strong, confused resident was hospitalized after attempting to climb out of a third story window at one of the Kendal communities. While in the hospital, he was physically restrained to prevent him from getting out of his bed and chair, and hopefully to avoid any falls or injuries to himself or others. This man had worked for the CIA during his career and, in his confusion, appeared suspicious of others, and moved to periods of combativeness.
His wife, one of the founding leaders of the organization, was quite supportive of the non-use of physical restraints position taken by Kendal and spoke to others about the value of maintaining one’s freedom and autonomy. That is, until this hospitalization. When he returned to Kendal accompanied by his wife, she came armed with a vest restraint from the hospital and instructed the skilled nursing staff to use it on him. She explained that while she fully supported the non-restraint philosophy, this situation “was different.”
When the staff met with the two of them and explained how they would use other means to keep him safe but avoid restricting his movement with the restraint, she brought her concern before the full residential population in a public forum. There she voiced concerns that her husband would fall and/or injure himself or others.
Even though community and corporate staff were there to respond, it wasn’t necessary. Other residents stood and kindly reinforced the value that was so near and dear to all of them. Cognizant of the community’s non-use of physical restraint philosophy, they encouraged her to work through her fears with their support. The end result was a beautifully shared outcome. Here is how the solution unfolded and what makes Kendal such a unique organization.
Through collaboration, the resident, his wife, and the interdisciplinary team discussed his behaviors and considered the possible reasons for why they occurred. Was he in pain, was he afraid, was he bored, was he in search of someone or something? There were many opinions and suggestions. What they all did agree on was that he had always been an extremely active man, so to restrict his movement would cause frustration and create additional mental and emotional anguish for him.
So together they developed a 14-hour, highly-detailed, individualized care plan that included coffee in the morning with the administrator or an administrative staff person, riding in the bus while other residents were being transported to doctor appointments, attending scheduled programs with his spouse and friends, working with the maintenance department on the community campus preparing soil, planting bushes and trees, and other basic garden tasks. All departments were involved for one or more 30-minute periods of each day. Caring for him was a shared responsibility that built comradery among everyone in the community and gave great support and relief to his concerned wife.
This is not the outcome that would be expected in a nursing facility that is simply being run “by the book.” In this case, physical restraints were ultimately avoided, and that provided the man with an important sense of freedom and dignity, but that is just one aspect of this story. Let’s take a look at other aspects that make it unusual.
- A highly personalized plan. A great deal of time and thought obviously went into the creation of a detailed, unique plan that addressed the needs of this particular resident.
- A process that did not simply accept the wife’s initial demands. The whole community (and especially the residents) was able to come up with a creative solution that satisfied the needs and concerns of both the man and his wife. She was the person responsible for his care, and it would have been easier to acquiesce to her demands. But that would have meant ignoring what the man himself wanted.
- A cooperative effort by various departments and several residents. The plan that was developed for this resident required many different people, both residents and staff, to take responsibility for the man’s care. Many of those involved were not “professional” caregivers.
This represents Kendal at its best. It is an example of the value Kendal has traditionally placed on the dignity of every person, on the responsibility we all have to each other, and on the obligation each of us has to take action when we see a need.
Ultimately, the “Untie the Elderly” project resulted in changes in practices and regulations throughout the industry. Over the course of many years, the use of restraints was all but eliminated. But that is a story for another blog post (or several).
This is all part of our legacy as Kendal residents. Through this program, our predecessors changed how the elderly were perceived, and that led to changes in how they were treated. Kendal was the recipient of awards, accolades, and national press coverage. Is Kendal going to rest on its laurels, or will we find new areas where we are called take a leadership role? That is up to us.
Bravo, George! This is a real contribution to strengthening our institutional memory and to Kendal’s courage to go beyond “best practices” so-called by adhering to our values.
Thanks, Tom. To put it another way, this story asks us to consider: are we guided by what the regulations require (and permit) or by what the person needs?
Really wonderful article, George – detailed and thoughtful and such a great example of the best of Kendal. Now is the time for such reminders and inspiration. A week each in Chester County Hospital and Westmorland have raised and stirred in me many observations and ideas about the current challenges of long-term care, which I will share once I get my energy back. Thank you for this timely and heart-filling piece. 🌱Megan
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Welcome back, Megan. Once your energy permits, it would be great if you were interested in writing a “guest post” for the blog about your observations as a patient.
Really great explanation of the possibilities and Kendal’s commitment to not using restraints. Thanks for sharing!
Use on alarms for persons who are in danger of falling is not restraints and can keep frail persons safe when falling is inevitable if the person does not receive instant attention when getting out of bed or out of a chair. Kendal does not use this means of keeping people safe and has resulted in falling and broken bones.