Shara Stodola, RN

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“Citing outstanding continuous quality efforts that eased pain and the use of restraints for elders, QSource, the quality improvement organization for the Centers for Medicare and Medicaid, honored Bordeaux Long-Term Care as the 2004 Beacon Award winner at its annual quality conference…” “With its commitment to continuous quality improvement paramount in its mission, Bordeaux Long-Term Care was awarded two of ten statewide awards by the Tennessee Health Care Association…” “The Bordeaux Babes and Camp Bordeaux were honored with special resolutions by the Metropolitan Council for their outstanding service to the Nashville community and to the residents at BLTC respectively…”

In this era of excessive regulation, newspaper exposés, and almost obsessive cost-cutting, what kind of nursing leader could help design such innovative programs, so improve the quality of life for residents, and simultaneously help create a satisfying work environment for staff? Nurse Leader was determined to find out and share that leader's story with its readers.

Shara Stodola graduated from the University of Texas Health Science Center in Houston, where she worked as a staff nurse in pediatrics. Because of her interest in both children and psychiatry, she moved from general pediatrics to psych, where she focused on working with children who had been physically and sexually abused. From there, she went to management, working in various positions at a small facility in Houston. Then she was recruited to be an assistant director of nursing (DON) at a large regional psychiatric facility in Omaha, Nebraska, where she was in charge of both adolescent psychiatry and geriatrics.

From there, Shara went to Nashville to assume a position as a nurse manager (she wanted a “slower pace” because she had two children under 2 years of age!). Unfortunately for her plans for a slower pace, the DON left, and Shara was promoted to that position. So, in 1999, when TennCare was adopted and psychiatric facilities started closing, Shara—again hoping for a slower pace—accepted the position of nursing supervisor at a local long-term care (LTC) facility. That position lasted for 6 months before she was again promoted to DON.

According to Shara, “This was such an eye opener; it was every bit as fast paced as any acute facility, and the regulations were unbelievable! Since that time I have continued in several facilities as the DON. In the three facilities I remained 2 to 5 years. In the long-term care industry, the tenure for a DON is around 6 months.”

With this as a backdrop, Nurse Leader began the following interview.

What made you want to be a nurse?

That's easy: I have wanted to be a nurse for as long as I can remember. I was born with bilateral hip dysplasia, but it wasn't discovered until I was 18 months old. The late discovery made the interventions very difficult: I had many years of spica casting, bracing, traction, lengthy hospitalizations, and 17 hip surgeries before I finally was able to walk at about the age of 6. Because I spent so much of my early childhood in and around hospitals, I saw who made the biggest impact on patients: the nurses. I wanted to be one of them!

What do you find most satisfying in the work you do?

I get the opportunity to change another person's life for the better each day. All nurses have this opportunity, but as a nurse executive, you can have a significant impact on many people. In LTC we really get to know our residents and their families, and we get to see progress.

You talk about your passion for vulnerable populations. Can you tell us why?

Given my experiences as a child, I clearly identified with patients since I had been a patient most of my life! I think that my passion for working with both children and the elderly came naturally. My mother is a schoolteacher who owned and operated a day care center. When I was in high school, I worked at the center with the children and loved it! At the same time my grandmother lived with us, and she developed Alzheimer's. So I saw the many problems firsthand, starting with watching and caring for someone you love slowly die each day. Later, when I began working in psychiatry, I was exposed to situations where both children and elders were abused, and I certainly wanted to do something about it. Advocating for these two populations was where I belonged, although I did not know how I would end up working with both until I began working with the Eden Alternative.

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I also have to be honest. Although the health care system in this country has done great things for me (as I am nearly bionic), I have seen the system from both sides. I became a nurse out of an admiration for nurses, but mostly I became a nurse to make it better for patients. I border on fanatic as an advocate. It is my passion, and I am very outspoken about it.

What is the Eden Alternative? Who developed it and why?

The Eden Alternative is the brainchild of Bill Thomas, a Harvard-educated physician who initially trained as a trauma specialist. Thomas tells the story of how, when working in an upstate New York ED, he was approached by a nursing home administrator to be an attending physician in an adjacent nursing home. After a few months, he noticed that the death rates of the residents he admitted were much higher than he expected. So he did an unprecedented thing: he began to spend a lot of time just hanging out and watching what went on in the facility day and night. Initially, staff members were suspicious, but they soon forgot he was there.

One of the residents developed a rash, and after he examined and prescribed for her, he asked if there was anything else he could do for her. She made eye contact with her beautiful blue eyes and said, “Doctor, I am so lonely I do not know what to do. I feel like I am dying of this loneliness.” Thomas had no idea how to respond to her, but he could not get her beautiful piercing eyes out of his thoughts.

Based on his initial observations and a literature review that indicated that medical science had nothing to offer for loneliness, he came up with an hypothesis of sorts: the bulk of suffering in long-term care is due to the three plagues: loneliness, boredom, and helplessness. The biggest problem with nursing homes is that they were modeled after hospitals. To tell the truth, elders in LTC have more in common with people in prisons than they have with either hospitalized patients or persons living at home. They have been “sentenced” to live in an institution for the rest of their lives. The problem with nursing homes is the model, not the caregivers.

The Eden Alternative moves away from the institutional model. It's called Eden because Thomas figured that God didn't place human beings in institutions; He put them in the Garden of Eden. So, this model that adheres to a set of principles based upon an ideal place to live. The Eden Alternative is about putting decision-making back into the hands of the residents or those closest to them, which in nursing homes is typically the certified nurse technicians. In my experience licensed nursing staff have been the biggest champions of this cause and are both relieved and eager to empower others. This model also incorporates a philosophy that keeps residents in close and continuing contact with plants, animals, and children. This way, we truly can make this a home for them.

How did you go about creating such a radical culture change? Who was involved, what steps did you take, and how long did it take?

At the previous facility it was a long but rewarding journey. It took about 5 years, and the journey continues today. Everyone was involved—RNs, LPNs, CNTs, recreational therapists, physical therapists, occupational therapists, speech therapists, housekeepers, office staff security officers, maintenance staff, volunteers, families, and administrative staff. In short, everybody is involved. We formed an Eden steering committee that included residents. It was a very large, 420-bed facility, government owned and operated, and very bureaucratic.

I initiated the change by starting an intergenerational program where the children of the staff and grandchildren of the residents came to “camp” 2 days a week and spent these 2 days having fun and building relationships. The children also came to camp throughout the year on teacher in-service days, snow days, and holidays. They were trained by rehab in the proper ways to push wheelchairs, operate a Geri-chair, and deal with people who have disabilities. Nurses taught the children hand washing and how to interact with elders with dementia. My two daughters were in the charter group and continued throughout their high school years. They return to visit the residents even though I no longer work at the facility. Obviously, they formed some pretty strong bonds with the residents!

I knew from previous experience that starting a program that incorporates children is less controversial than one that involves pets. At the same time, I began the empowerment process in several ways. First, all patient restraints were carefully removed, taking great care to put solid systems in place to address fall risk. We then wrote a “bring your pet to work policy.” Initially only a few staff brought our pets, then slowly others joined them, and in about 2 years we had 45 pets registered and coming on a daily basis. Then the facility itself adopted several pets from animal control, and they live at the facility 24 hours a day. When I left, the facility had two dogs, one cat, two chinchillas, and numerous birds.

We worked also with the residents to create a neighborhood. The children held free garage sales where the residents chose items for their own space to help de-institutionalize their rooms. The facility held Klown Kollege where residents, staff, and kids went through classes and became official therapy clowns. Slowly but surely the culture changed for the better. Residents and staff were happier, and the atmosphere was more open and home-like. And a facility that had previously had less-than-stellar surveys received multiple awards for quality, and local newspapers published articles about our programs. Then we began to work toward our ultimate goal: person-centered care where residents' wishes were honored. In traditional LTC facilities, life evolves around medications, meals, and bingo. We were focused on creating a true home.

I have been employed at the Tennessee State Veterans Home less than a year and have just begun this journey again. The facility is a state-owned, and the past 9 months have been spent on building strong clinical systems. The facility has literally been under siege by regulatory bodies. I had to focus on building a stronger infrastructure, so that the Eden Alternative could be successful. The care was very good, but so many consultants had been called in to help that staff were tired, frustrated, and upset. Residents and families were afraid the facility would be closed.

Nonetheless, we are in the initial stages: the bring-your-pet-to-work program has begun. We are implementing consistent staff assignments and plan to begin a formal intergenerational program very soon. The staff are very receptive. We already have had community events that have drawn people into the facility. I can't wait to start the next steps because this is the real change, and it happens at a much faster pace. The resident council and the executive director are all on board.

What is different about the challenges nurse leaders have in LTC?

We face many of the same challenges found in acute care, but there are two areas that are unique to the LTC industry. Perhaps the biggest challenge is the ageism rampant in our society, and that includes nurses. In survey after survey, 80% of people say that they would rather die than go into a nursing home. When I was in nursing student, I was actually told that the only nurses who work in nursing homes are those who are not skilled enough to work in hospitals.

This certainly is not true. Geriatrics is a specialty area, and LTC is not what many think. It is true that the LTC system is broken, culture change is badly needed, and there are some really bad facilities, but, in my opinion, these are in the minority. In fact nursing home quality has continued to improve over the past decade. The problem is that we are trying to improve a model that is not ever going to be great in its current configuration.

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Nurses need to support nursing across all settings. When we send our residents to an emergency room, they often are treated with disdain by the other nursing and medical staff. Value judgments are made based on age and preconceived beliefs about nursing homes, even before the clinical assessment is performed. This, obviously, gets in the way of providing care for the elders across the continuum. Our medical director is board certified in geriatrics, internal medicine, and palliative care. Yet, when she calls an ED to give a report to the emergency physician, they seem to assume that she is not a qualified practitioner!

The next challenge that is not often understood by our acute care counterparts is the sheer weight of regulation. As a registered nurse and an American citizen, I have to wonder why we have chosen such a punitive approach to a system charged with caring for the frail elderly and those who are disabled. Certainly, quality must not be compromised in any way, but the LTC survey process is both subjective and flawed.

The real question is, why does CMS need an LTC enforcement division at all? About 2% of elders receive care in LTC; this means 98% are at home. As baby boomers age, the numbers will grow exponentially and the real core issue will be cost. As a nation, we will not be able to afford the cost of care unless something changes drastically. What we need as a country is an honest dialog about the real issues we face in health care, including how we are going to care for elders. Instead, it seems the regulatory bodies have determined to go after the long-term industry and cite deficiency after deficiency, charging heavy fines. One Tennessee facility was fined $650,000 for one missed PT INR with no negative outcomes. Ultimately this does nothing to improve care! I agree that things need to change, but as a geriatric advocate I am concerned at how it is being handled.

How are leaders in LTC engaging in succession planning?

This is critical question in the LTC industry. In many states, almost 90% of DON positions are filled with contract personnel. There are multiple ads in the local newspapers, and the headhunters' calls are relentless. No one wants to be a DON in LTC these days because they are blamed whenever a survey does not go well. The truth is that multiple citations can result from one single event, such as one missed lab. The liability in some states is huge. Moreover, in nursing no one has to work under those conditions. Jobs are plentiful and the nursing shortage is very real. Why work in the harshest regulatory environment in the country when other options are out there? However, this job can be very rewarding. When people in the community find out you work in LTC, they say, “It must be very hard. You must be a special person to work there.” The real inside scoop is the elders are wonderful. It is an honor to have the opportunity to be their caretakers, and many staff members are the most compassionate human beings you will ever meet.

Since LPNs are not typically hired in hospitals, LTC offers an opportunity for them to build leadership skills. LPNs are the primary licensed caregivers, although I have always ensured I had RNs in leadership positions, which is particularly important because the acuity today is so high. Encouraging LPNs to become RNs is the best succession planning for LTC. Encouraging CNTs to become LPNs and RNs is even better. Empowerment is the key.

How did your nursing education prepare you for your current role? What suggestions do you have to enhance the education of nurses to care for vulnerable populations?

I graduated from an excellent university in an exciting Houston medical center, where hospital after hospital line the streets. The emphasis was on cutting edge technologies, and the focus was oncology, pediatrics, cardiac surgery, and trauma. My education really did not prepare me to pursue geriatrics. We did have some course work in geriatrics, and our first clinical experience was in an LTC facility, but the real emphasis was in other areas. I do not recall one professor who presented with passion a love for geriatrics.

I think the educational preparation of nurses should include much more information on geriatrics and a great deal more about the change in the attitude and culture of LTC. It needs to be taught by passionate role models. Geriatrics need to be respected as a specialty.

As a whole our society is focused on youth, so what suggestions do you have that could help society to think differently about the elderly?

When you think about the lengths our society goes to fight normal aging, it is mind-boggling. Even being a grandparent these days is not acceptable. Just think of the names used by many NOT to be called grandma or grandpa! My grandparents were and still are my favorite people on earth, and I can't wait to be one myself.

My two daughters, ages 17 and 18, attended the explorer program at a local hospital presenting nursing as a career choice. I was really excited as there were around 300 kids attending the session. When it started, the kids were asked to go around the room and introduce themselves and tell what area of nursing they were interested in pursuing. Over 90% said they wanted to be pediatric nurses. I was proud when both daughters said they weren't sure whether they wanted another health-related field, but they definitely want to work in geriatrics.

I am not sure what I have done to change the mindset, but when I do public speaking, I bring it up, even though sometimes it makes people uncomfortable. People need to think of the messages they are sending. I cringe when I hear people telling the elderly how young they look. One former resident actually answered, “What makes you think looking young is a compliment?”

Based on your own experiences, how would you market this nursing specialty to the next generation of nurses?

I tell the truth! I love LTC and have no desire to work in a traditional hospital/medical model nursing home. Culture change and the Eden Alternative and person-centered care are wonderful, and you have the satisfaction of knowing your patients and seeing the results of your efforts! The Eden Alternative is going to change every nursing home in America; LTC will not look the same in 10 years. The model used in the past doesn't work. Home and community-based services are great, and they do not compete with LTC. We are all striving for the same thing: 80% of American should not have to say they would rather die than go into a nursing home! Nurses who work in LTC are not second rate; it is a specialty—geriatrics! I invite them to come and see what is really going on. If more nurses visited LTC facilities and saw culture change in action, they couldn't help but get excited and go away with a different opinion.

From your perspective, what changes do we need to make to our health caredelivery system to better care for vulnerable populations?

CMS has made videos supporting Eden and culture change, and they emphasize how you can comply with regulations and implement Eden. CMS and other regulators are all too happy for facilities to change, but they do not seem to recognize that the regulations are too oppressive. The regulations are truly the holy grail of the medical model, and they must change. They were written over the decades when the institutional model was the preferred model, when being like a hospital was the goal. It is no longer the goal.

People do better at home. Everybody knows this. So elders need to be enabled to stay home when they can, with the help of home and community-based services. When that is not possible, we need an LTC system that offers a true alternative “home.” Until the adversarial relationship between regulatory bodies and the LTC industry changes, the frail elderly and disabled will suffer. There are a lot of staff members working in this industry who are true elder advocates and who suffer along with them. I am a patriotic American, I am passionate about my country, and I am confident that my government can change to meet the needs of the most vulnerable citizens.