Tag F741 Non-Pharmacological Approaches – Assisting outdoors in the sunshine and fresh air

CMS Tag 741 includes a long list of examples of individualized, non-pharmacological approaches to help meet behavioral health needs. We will be reviewing all of them. Food preferences, exercise, pain relief, individualizing sleep, dining, bathroom routines, preferred lighting, comfortable sound levels, assigning staff to optimize familiarity and consistency and meaningful activities according to the person’s interests and goals have been discussed in previous articles and now we highlight:

CMS Tag F741 Non-pharmacological approaches.

Examples of individualized, non-pharmacological approaches to help meet behavioral health needs of all ages may include, but are not limited to:

• Assisting the resident outdoors in the sunshine and fresh air (e.g. in a nonsmoking area for a non-smoking resident);

The topic of going outside fits moving away from traditional, institutional “activity programming” to intentionally focusing on normal, real life. In the warmer months I suggest figuring out how to practically live life outdoors. If you aren’t already, consider becoming passionate about helping people get outside. We all know the benefits. Sunshine resets our circadian rhythm which helps us sleep better, vitamin D strengthens bones; both reduce falls and depression. In fact, isn’t it ironic that sundowning means a person needs more sun. Isn’t sad we make it a medical condition when really, it’s just normal. Don’t most of us yearn for the sunshine? I guess maybe I have sundowning too. Help people get more sunlight, preferably going outdoors and offer and encourage and invite people to spend time near windows.

People living in a nursing home took up smoking in order to be able to get outside!

The irony. Taking up an unhealthy habit to support a healthy habit of getting outdoors. I’m shaking my head. I’m sure you are, too.

One home asks, “Would you like to dine inside or outside?” Does yours?

It is pretty common that getting outside is important to most of us. This is reflected even in regulations and the MDS as many of you know. CMS Tag 636 Comprehensive Assessment … according to the resident assessment instrument/MDSSection F Activity Preferences, asks a person to rank the importance of going outside to get fresh air when the weather is good.

Benefits of increased sunlight exposure are improving mood, may help prevent cancer by increasing Vitamin D, reduce agitation and daytime sleepiness, reduces risk of bone fracture as a result of increase of D3, improves sleep quality (Mead M. N. (2008). Benefits of sunlight: a bright spot for human health. Environmental health perspectives, 116(4), A160–A167. https://doi.org/10.1289/ehp.116-a160).

Get nurse colleagues, but really the whole community – families, visitors, individuals themselves, colleagues of all professions – to promote getting outside for the health benefits for all of us.

SUNdowning = Needs SUN; Sunshine improves Sleep

Isn’t it interesting, we use fancy terminology in this work with precious people? I’ve been reminded and I love passing it on that the term sundowning simply means a person needs sun. Glorious sunshine offers so many benefits. One is resetting our circadian clock. Circadian rhythm refers to our body’s light = awake, and dark = sleep rhythm.

And it helps; sunshine reduces sundowning. After sharing this tip with colleagues, they reported back to me that they helped a person with cognitive change who “sundowns” to get more sun during the day. “It works” they said, observing he did not get as agitated when the sun was going down. It makes me so happy that we can help meet this need for more sun in the natural purview of our work, how about you? What a gift we can give people to give them more sun and sunshine.

I recommend making getting outside in the warmer weather the focus. The focus. Personally, I would just make it thepriority during the nicer weather. Of course, hold events outside but also just dedicate time to going outside. Perhaps exchanging events in order to schedule Getting Outside on the calendar. You only have so many hours. Certainly take this idea to those who live there to decide. An administrator I know told her activity team she wants there to be two opportunities each day for people to go outside!

Increased sunlight exposure reinforces each person’s natural sleep cycle. Open room shades and blinds in the morning. Increase sun exposure in early morning and late afternoon. Exposure to sunlight for 30 – 60 minutes is recommended (Mead M. N. (2008). Benefits of sunlight: a bright spot for human health. Environmental health perspectives, 116(4), A160–A167. https://doi.org/10.1289/ehp.116-a160.).

Not only is getting outside included in federal regulations and the federal MDS assessment it is also considered a culture change practice in the Artifacts of Culture Change tool:

Artifact 45. Each resident’s care plan includes preferences and accommodations needed for going outdoors. (Artifacts of Culture Change 2.0/Artifacts – Assisted Living)

Another recognized culture change practice brings these together:

Artifact 48. Each resident’s care plan includes customary preferences for a good night’s sleep, e.g., lighting, pillows, blankets; acknowledging that preferences may vary on a daily basis (www.pioneernetwork.net/artifacts-culture-change/).

Consider exposure to sunlight during each person’s care plan process as it can help people sleep better. Offering sitting near a window can help get some sunlight. Check this out from CMS Tag F915 At least one window to the outside, Guidance: “… this requirement was included to assist the resident’s orientation to day and night, weather, and general awareness of space outside the [home]”. Teach everyone to offer sitting in front of a window instead of the common institutional practice of just blindly “parking people” in front of the television. We mean well to give something to do like the television but let’s teach the importance of sunshine and to at least offer the choice to sit in front of a window.

Garner support for this aspect of quality of life – required at Tag F655 that contributes to health. Getting outside, getting sunshine, getting vitamin D helps to sleep better. Being well rested prevents accidents/prevent falls required at Tag F689 Accidents.

Lean into and live up to these good regulations. Ask some different questions; not only is it a good idea but also because we are supposed to. If you don’t work in the federally regulated setting, consider these as excellent standards of practice. Focus on getting more and more people outside more and more.

Going outside helps improve sleep and prevent falls both of which improve quality of life. We must get that good news out.

Carmen Bowman, MHS, Regulator turned Educator of Edu-Catering: Catering Education for Compliance and Changing Institutional Culture is an activities/engagement/community life, regulatory compliance and culture change consultant.  She offers new or not-yet-qualified activity director consultation and personalized continuing education for professionals/teams/associations. At www.edu-catering.com join The Be Encouraged Blog, Become a Leader of Normal Life with the eResource GUARDIANS OF NORMAL LIFE: How Activity/ Recreation/ Engagement/Community Life Professionals can Save the World of LTC and share with your team the eBook Individualizing Medication Administration using Regulations. At the Edu-Catering YouTube channel, see documentaries that highlight changed cultures.