Running head: VOA Project 1

VOA Project: Improving Clients Quality of Life

Amber Blankenship RN, Joem Evangelista RN, & Heather Somers RN

Western Washington University

Nurse 432: Community-Based Care for Vulnerable Populations

William Lonneman DNP, RN

June 3rd, 2017

VOA Project: Improving Clients Quality of Life

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Volunteers of America (VOA) is a non-profit organization that serves vulnerable

individuals and families. The VOA provides a variety of programs which include hunger

and homelessness prevention, child/parent mediation services, and behavioral health

services. One VOA program serves individuals who have experienced a traumatic brain

injury (TBI) before the age of 18. Due to their impaired cognitive and/or physical

abilities, they are unable to care for themselves. Currently, there are three individuals who

meet this criteria and are provided supported living services by the VOA. Along with

shelter, the clients have access to food, water, and medical services. Additionally,

caregivers are available 24/7 to help the clients with activities of daily living (ADLs),

provide medication reminders, as well as provide transportation to/from appointments.

Because TBI patients frequently suffer from impaired cognitive and physical

disabilities, safety is a huge concern for this population. They are at an increased risk for

seizures, falls, and impulsive behaviors. After an in-home assessment, two principal

concerns identified were these clients lack of activity to stimulate their minds and the

lack of safe access to their backyard. The focus of this practice experience (PE) project

was to provide literature for the TBI program director which supports the need of safe

access to the backyard. The evidence provided focuses on safety as well as the benefits

associated with increased opportunities for therapeutic activities. Evidence found will be

used to help support a grant proposal to acquire funding for this project.

Primary and Secondary Assessment

The Senior Director of Personal Support Services provided access to client history

as well as the clients physical residence. The house is located in a new, quiet subdivision

of Everett. At the time of assessment, the neighborhood area appeared clean and safe.
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This assumption of safety was evidenced by people walking their dogs during the day and

several pedestrians present during the time of assessment. There were also several parks

and churches in the nearby neighborhood. The house itself was spacious with wood

flooring, two wheelchair accessible bathrooms, three bedrooms, and a backyard. The

sidewalks surrounding the house were wheelchair accessible.

Unfortunately, there are some drawbacks to where the house is located. There are

no clinics, dental offices, or social services nearby. The home is built on a hill, which

poses a safety concern for the clients using wheelchairs. There are no schools, libraries,

youth or senior centers close by, nor are there bus stops or public transportation centers

which results in the clients to be dependent on their caregivers for transportation.

Although there are several disability service agencies in Everett, there are none within a

one-mile radius of the clients home. Because the house is located in a quiet, family-

oriented subdivision of Everett, there is concern for the neighborhoods perception of the

clients as well. It is unclear if the neighborhood is welcoming to the disabled tenants or if

the clients are more isolated due to this difference.

Although the house has been remodeled to fit the clients needs, there is room for

improvement. The backyard is not wheelchair accessible and only has stairs available

from the house to the lawn. The lawn is uneven and inadequately maintained. Other

safety concerns identified include a loose railing and unsteady large trees behind the

property. There is a history of one of these trees falling on the house next door to the

clients home. The bathrooms are small, making it difficult to bathe and transfer the

clients safely.
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These clients receive continuous care. Three caregivers are present at any one

time and are responsible for helping the clients bathe, eat, and perform other ADLs. A

wheelchair-accessible van is also available for caregivers to transport clients for shopping

needs, appointments, outings and other events. These caregivers are required to provide

documentation regarding the clients daily activities, behavior, medication administration,

and any medical emergencies such as seizures or falls.

From a nursing perspective, there are concerns regarding proper transferring

techniques being utilized by staff. After interviews with the caregivers, concerns for

clients impulsive and aggressive behavior were identified. The caregivers also mentioned

a shortage of gloves and other necessary equipment to care for the clients. On the other

hand, the clients expressed boredom and reported the lack of activities. Lastly, the system

used for documentation is not user-friendly and is difficult to navigate causing

incomplete charting entries and improper documentation.

When looking at census data, the Everett area is a good place for individuals with

disabilities. The state average of disabled individuals is 8.9% while Everett has an

average of 12.3% living with a disability (United States Census Bureau, 2016).

Therefore, it could be inferred that there would be more people who would understand

the plight of living with a disability. Unfortunately, the poverty rate in Everett is higher

than the statewide average (United States Census Bureau, 2016). This may or may not

contribute to the high crime rate in Everett. The most reported crime in Everett is theft

(LexisNexis, 2017). This could be a concern for those living with a TBI because their

short-term memory loss could result in unlocked doors and windows.

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Recommendations

Several interventions were considered when preparing for this project. First, the

caregivers could be provided additional training and education on how to de-escalate the

clients during behavioral episodes. Second, providing the caregivers with handouts

illustrating examples of proper and improper charting and documentation could result in a

decrease in documentation errors. Third, the documentation system could be reviewed to

build a more user-friendly program, which would simplify the documentation process for

the caregivers. Lastly, creating simplified versions of behavioral plans in easy-to-find

locations throughout the house was considered in order to reduce the number of

behavioral episodes from the clients and provide quick reference to caregivers during

client outbursts.

While these were valid concerns, a decision was made to prioritize other needs.

De-escalation training was provided for employees during job orientation and the VOA

caretakers felt adequately prepared. Interviews with caregivers communicated that

handouts would not be useful for caregivers as they would not be used. Caretakers were

knowledgeable and felt confident in their documentation system. It was also felt that

current VOA staff would be most appropriate to design suitable programs related to their

daily processes. Many staff-members knew where to find the behavioral plans for the

clients and stated that on-the-job experience assisted more than the these written plans.

As safety is of greatest concern and clients were disregarding personal welfare

due to boredom, the most appropriate intervention was to create safer access to the

backyard. This project could address both safety and activity concerns. It was also

within the scope of this project.

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Due to clients personal budget concerns, the renovation of the deck and backyard

would require funding by state and/or federal grants. In order to obtain these grants, the

VOA must provide written proposals to justify why such funding would be best allocated

toward this project. To present such requests to the state, evidence was provided to the

VOA which supports that safe access to the clients backyard would ensure the clients

safety, result in an increase in daily activity and social interaction, as well as improve

their overall quality of life.

Scholarly articles were retrieved which provided strong evidence supporting the

theory that access to green space would positively influence both mental and physical

behavior (Lee & Maheswaran, 2011). Another article confirmed the outdoor activity,

gardening, to cause a reduction in depression, anxiety, and body mass index (BMI) (Soga,

Gaston, & Yamaura, 2017). A third article addressed safety concerns by providing

evidence supporting environmental factors as a significant contributor to falls in the home

(Northridge, Nevitt, Kelsey, & Link, 1995). A fourth article identified, provided evidence

of increased independence in TBI clients involved in physical activity (Reavenall &

Blake, 2010). Summaries of this evidence were written and provided to the program

director for use in the grant proposal.

Evaluation

Conducting a later assessment evaluating client behavior, interests, and fall risks

would effectively gauge if the clients new access to their backyard improved their

quality of life. These outcomes can be evaluated via in-house inspection or chart audit.

Improved client behavior will be demonstrated by a decrease in aggression towards other

clients and staff, a decrease in desire to leave and an increase in participation in group
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activities. To assess safety outcomes, maintaining accurate documentation on falls or near

falls identifying time of day, cause, and medication usage would be adequate.

Ambers Practice Experience

I enjoyed my time working with the VOA and learning about the assortment of

programs provided to our vulnerable populations. I have only recently learned about the

VOA itself and I am impressed how their TBI program provides such comprehensive care

for their clients. I was excited to learn that the three clients are cared for in a standard

home setting and was pleasantly surprised to find the home in a newer neighborhood

amongst domesticated families. I genuinely hope the three TBI clients find value in the

backyard project once it is constructed and I anticipate a strengthened comradery

amongst them.

Making connections between the availability of services and some of the simple

concepts we take for granted, such as access to transportation, recreational centers, or

even the recently proven greenspace and how these concepts impact community

members, was valuable learning experience. Although these concepts are not new, this

practice experience helped to provide a tangible sense of how life can be amongst

vulnerable populations. It is rewarding to be a part of positive change.

Heathers Practice Experience

Working with the TBI house through the VOA has been an enlightening

experience. Nonprofits often have to stretch resources far in order to provide for all of the

needs of their clients. It's often difficult to staff these houses due to the lack of available

funds to provide decent wages for the caregivers. Because of this, there is a large turnover

with staff and the VOA spends most of its time with caregivers just providing initial
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training. This makes implementing change within a house such as the TBI house difficult

to do without outside help or perspectives. It has been particularly rewarding providing

the outside perspective to help improve the lives of the TBI clients and it is my hope that

Western Washington University RN-to-BSN students can continue to work with this

organization to improve the lives of their clients.

Joems Practice Experience

Partnering with the VOA has been a great and eye-opening experience. Ive

learned a lot about the resources they provide, as well as about the work that they do

aside from caring for clients with TBIs. Its been a pleasure getting to know the mentors

and caregivers. Ive learned that they, as well as many other non-profit organizations,

work incredibly hard to start and maintain programs to support vulnerable populations.

The work that they do is so important in health care prevention and community health

and is incredibly helpful in keeping people out of the hospital or the streets. As a nurse in

the emergency department, Im hoping to take back what Ive learned to tailor my care

for patients requiring more help outside of the hospital.

References
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Lee, A. C. K., & Maheswaran, R. (2011). The health benefits of urban green spaces: A

review of the evidence. Journal of Public Health, 33(2), 212222.

https://doi.org/10.1093/pubmed/fdq068

LexisNexis. (n.d.). LexisNexis Community Crime Map. Retrieved May 26, 2017,

from http://communitycrimemap.com/

Northridge, M. E., Nevitt, M. C., Kelsey, J. L., & Link, B. (1995). Home hazards and

falls in the elderly: The role of health and functional status. American Journal of

Public Health,85(4), 509-515. doi:10.2105/ajph.85.4.509

Reavenall, S., & Blake, H. (2010). Determinants of physical activity participation

following traumatic brain injury...including commentary by Katz-Leurer M and

Hassett L. International Journal Of Therapy & Rehabilitation, 17(7), 360-369.

Soga, M., Gaston, K. J., & Yamaura, Y. (2017). Gardening is beneficial for health: A

meta-analysis. Preventive Medicine Reports, 5, 9299.

https://doi.org/10.1016/j.pmedr.2016.11.007

United States Census Bureau. (n.d.). Population estimates, July 1, 2016, (V2016).

Retrieved May 26, 2017, from

https://www.census.gov/quickfacts/table/PST045216/5322640,53