Green House Blog

A Nurse Says, “Safety Third”

We could entitle the latest “Let me say This about That,” Nurse-Speak for Dummies as Mary Hopfner-Thomas, my co-host, and I (two non-nurses) unpack the conversation between two nurses, Green House Senior Director Susan Ryan and Tammy Marshall, chief experience officer at Thrive Senior Living. Tammy said, “There is a way of knowing that nurses have…that is unique to our profession…it is the gift of this time, because it is addressing the invisible needs of a person.” Their discussion, on episode 3 of Elevate Eldercare, echoes a guest column in McKnight’s in which Tammy said that nurses will see us through the pandemic. The focus of the conversation was not on the technical skills of nurses, but rather how to couple the technical skills with the human element—to see each person and support their individual needs, the task of nurses and non-nurses alike. 

Tammy Marshall, chief experience officer, Thrive Senior Living

As Tammy shared, COVID-19 has given us a magnifying glass and exposed the good things as well as the challenges in economics, leadership, long-term care, and basic humanity. 

Mary and I reflected on their conversation as a discussion in contrasts: Pathogenic vs salutogenic, adaptive vs technical leadership, and certainty vs ambiguity. I was fascinated to learn new terms from Tammy and then dive deep into the origins and applications in today’s world. Pathogenic is the treatment of the disease and it’s the most common way healthcare is delivered in our Western society. But Tammy reminded us that the U.S. is the most flagrant user of pathogenic model with regard to COVID-19. It would appear we keep using the same method and expect different results. Isn’t this the definition of insanity?

I was fascinated by Tammy’s mention of salutogenesis, so I did a deep dive into it. I learned that Microsoft Word does not recognize as a real word, as evidenced by the red squiggles appearing each time I type the word. Salutogenesis is defined as the “origins of health.” It was coined by Aaron Antonovsky in the 1979 book, Health, Stress and Coping. The chief question in the salutogenic model is “what makes people healthy?” Tammy answered this with a harken back to the basics of nursing a la Florence Nightingale: good nutrition, fresh air, sunlight, sleep, and movement. 

Mary was particularly struck by the simplicity and yet brilliance of this basic approach, and we agreed that a good question we can all ask is, “What would Florence do?” Imagine if long-term care providers approached care by seeking to answer the question, “What is the most healing environment for each elder?” and “How might things be different?” These questions move us into what Tammy described as “adaptive leadership.” It’s about asking the right questions and believing there is more than one right answer. It pushes us toward creativity. 

As Tammy described the steps she and her team took communicate with elders and staff, she noted that “we crave certainty.” COVID-19 has given us a lot of uncertainty and ambiguity. What is open or not open, how do we best stay safe, will schools open or not, should we or shouldn’t we do X, when will this end? I loved how Thrive Senior Living developed a compulsive communication strategy to give as much certainty as they could, with a measure of openness and transparency.

As part of our discussion on surplus safety, Mary and I shared one of our favorite Atul Gawande quotes from his book, Being Mortal: “We want autonomy for ourselves and safety for those we love.” As Tammy notes, safety needs to come in third, not first, as is the case in so many nursing homes. That discussion got me thinking—I’m blessed to be a grandmother to a wonderful almost one-year-old. A couple weeks ago I babysat her, and she crawled to her favorite end table with the coasters she loves to bang on the table. She was standing, but not quite an independent walker. She lost her balance, fell, and hit her toothless gums on the table. There was a looong silence before the heart wrenching wail. And there was blood. Never, ever, ever did I want I my precious granddaughter to experience pain or injury. But I do want her to walk independently, to gain confidence in herself, to know that if something happens, I will be there to love and support her. My job as grandma is to love her, foster her growth and development, and keep her safe. Safety third. 

How can we get more comfortable with that kind of an approach with elders? I know there are so many things about how the one-year-old and the frail 90-year-old are different. And yet, they, like all of us, may not be as different as we want to believe. In my opinion, safety third could be a gamechanger in long-term care. The Green House Project’s Best Life approach to supporting elders living with dementia calls this embracing the dignity of risk. 

On “Let Me Say This About That,” I introduced Tammy as a thinker and as someone who challenges me to think. She certainly delivered on that account and I hope Mary and I will likewise challenge you to think deeply about these important topics. In fact, you may want to go back the original Elevate Eldercare podcast and listen to the Susan and Tammy discussion one more time!

Listen to the podcast here:

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Marla DeVries is director of resource development for The Green House Project and cohost of “Let Me Say This About That,” the Friday Recap of the Elevate Eldercare podcast.

Safety, danger and risk: The environment as crucible for lifelong development

As many of you may already know, Bill Thomas and I came up with the notion of “surplus safety” in 2009 during a class in the Erickson School Master’s degree program to characterize the result of a culture of safety that does harm by preventing people from achieving future development that comes from taking risks and learning from the resultant success/mistakes. Since then, we and others have been working on the concept to refine the concept, catalogue its many manifestations, the roles of various stakeholders, and how current regulations and practices frame the issue and potential solutions. We learned in our Surplus Safety Symposium last September, sponsored by the Hulda B. and Maurice L. Rothschild Foundation, that was attended by over 50 stakeholder representatives that safety and risk have numerous definitions and a complex relationship with issues like choice, legal liability and OBRA 87. Carmen Bowman, culture change advocate and Symposium planner and leader, blogged about, there are a slew of reasons why this culture prevails. Let’s be clear about something: safety is good; danger can be bad, even very bad. Risk, or the probability that the outcome will be different than expected, is what lies between danger and safety. Risk has two variants: downside risk- the probability that the outcome will be worse than expected, and upside risk, the probability that the outcome will be better than expected.

We know that human development and growth doesn’t take place without taking risks. If the person is to survive, he/she must get good at knowing the difference between upside and downside risk, and how likely each may occur as a result of any action. The human brain seeks novelty – that is what is behind learning and increased competency. In environments with little or no novelty, the brain will motivate the person to search for it mentally by using their imagination, or physically, by scanning the environment for new information and moving toward it. Human development is predicated upon the dynamic of person-environment interaction where the person tends to engage with stimuli that are just different enough from what it knows to be interesting and therefor inspire exploration resulting in a modification of its store of knowledge. The child’s developing motor maturity and brain work in tandem and rely on this to happen so that the person becomes able to live safely on his/her own. This dynamic relies on engaging with the environment so as to learn about what is out there, what is safe, what is dangerous, i.e. how to improve upside risk and reduce downside risk, and what must be done to safely expand and differentiate knowledge and autonomy.

Three concepts are important here:

1. Safety and danger are distributed along a continuum of risk that in large part varies according to an individual’s abilities and judgment and environmental conditions at any given time. Risk happens, then, in the context of person-environment interaction. What constitutes safe and risky behavior changes as we grow from infancy and develop more competencies and better judgment of our risk tolerance and probability of success in doing anything. Risk is a factor that goes into each person’s motivational calculus before an action and is the result of a subjective appraisal made by a person and/or persons in their environments (or memories of what they said) based on a sense of the specific skills needed for success and if the person has them. Sometimes the risk assessments are congruent, sometimes widely incongruent – and arguments ensue. For example, a person may decide that it’s safe to walk around their neighborhood. The relative safety or danger depends on any given day on factors such as the time of day, weather, kind of neighborhood, orientation ability, gait and balance, vision, etc. of the person. This is true for a person at any age.

2. Risk, a broad territory that lies between safety and danger, is relative to each person’s competencies, and is an appraisal in the person’s mind that is the product of an assessment of his/her ability to produce an outcome that is at least equal to or better than expected when they contemplate the action and its results. If the probability of success is less than expected, depending on one’s risk tolerance, the behavior may not be initiated. A person may take a chance, or decide it’s not worth the risk. But it is important to remember that what I decide is relatively dangerous for me because I lack the requisite skills for success may be for pretty safe for you. So except for extreme conditions, like jumping out of an airplane without a parachute where the danger is so high that it is universally considered to be a sure recipe for danger and therefore a bad idea, risky behavior exists along a continuum for and among people. That is, the probability of a better or worse outcome than expected (our definition of risk) is not fixed. It is a variable depending on how well the risk taker appraises his/her ability be safe and avoid danger that would cause grave harm. When the appraisal is not made and the person takes a risk that has not been appraised, we call it impulse.

3. Development is a big factor in diversifying the range of actions that each person comes to see as acceptable risks. In fact, we can think of development in one sense as a process of taking risks and learning how appropriate the risk assessment was and what we can and can’t do. In that process, the most important result is learning what we are capable of and where we need to improve our abilities and knowledge to reduce danger in pursuit of a goal and thereby lower risk. The older people become, the more individualized and diverse become the range of skills, risk tolerance, risk aversion and what is considered a good risk worth taking. Physical limitations, wisdom and interests, as well as the proximity of needed resources are some of the factors that determine which risks people will take as they age. In extreme situations, elders may take greater risks when a particular goal is perceived by them to be important that appraisals of potential danger are minimized. That is, they are worth the risk. This happens, for example, when people feel desperate, are bored, feel that they are in danger, or have lost contact with their actual skill levels such that they remember themselves as they once were but not as they are now.

Changing the culture in environments where elders’ development is not blocked as they age through surplus safety practices means that at a minimum, we have to come up with accurate, reliable ways to assess each elder’s risk tolerance, accuracy of their future planning strategy for appraising the expected outcome of an action, and their readiness to act safely in light of the attendant dangers. Bill [Thomas] and I have taken great care to specify that this does not mean that all downside risk is bad and all upside risk is good. Our intention is that places where elders live develop ways to promote opportunities for continued development by optimizing conditions where upside risk can be found, downside risk reduced, and danger and safety go from being seen as binary and age specific (something is safe or dangerous for everyone who is old) to a portfolio of individualized opportunities for growth that meet the needs of all who live there depending on each one’s risk tolerance. Our task is to go beyond anecdotes and develop research programs that test these concepts to that we can affect policy and society at large.


Dr. Ronch is a nationally renowned expert on improving the treatment and mental well-being of elders. Prior to coming to the Erickson School, Dr. Ronch was Vice President of Resident Life, Mental Health and Wellness for Erickson Retirement Communities, where he was responsible for developing person-centered, strengths-based approaches to best serve the mental wellness needs of Erickson’s over 20,000 residents on 18 campuses.  He has been on the faculties of Vassar College, the University of Miami and Dutchess Community College. His numerous publications include the critically acclaimed Alzheimer’s Disease: A Practical Guide for Families and Other Helpers and The Counseling Sourcebook: A Practical Reference on Contemporary Issues (winner of the 1995 Catholic Press Association of the United States Book Award). He is co-editor of Mental Wellness in Aging: Strength Based Approaches (winner of the 2004 Mature Media Award), and Culture Change in Long-Term Care – the first text published about culture change in aging services.

He is currently working on co-editing a new two-volume set called Making the Case for Culture Change in Elder Care, due out in 2012.  His numerous journal articles and professional presentations include contributions in psychotherapy and counseling with the aged, care of persons with Alzheimer’s Disease and related disorders, caregiver issues, staff training and service delivery issues in geriatric care. He has also been named a Fellow of the New York Academy of Medicine.

Surplus Safety: A Symposium To Redefine Risk

Drs. Judah Ronch, Dean of the Erickson School of Aging, and Dr. William Thomas, founder of the Eden Alternative and Green House Project, have coined a new term and developed a new concept called surplus safety. Instead of risk meaning the possibility that only something bad might happen, they teach that the real definition of risk is the possibility of an unanticipated outcome. They further explain that there are two kinds of risk, upside and downside. Downside risk is an outcome that is worse than expected and upside risk is an outcome that is better than expected. They point out that our obsession with downside risk unfortunately leads to the taking away of any chance of upside risk for those living in long term care environments and that we prevent outcomes better than expected (upside risk) because we our obsessed with minimizing the risk of a worse outcome. Dr. Thomas as a physician and Dr. Ronch as a psychologist point out that no other part of the human life cycle allows this removal of upside risk. For instance, we do not restrain toddlers as they try to learn to walk because they might fall. Not too many people talk about our development and growth at an older age but thankfully they do. Each advocate that our human development includes a balance of both upside risk and down side risk.
The current landscape of safety where the current conception of risk includes only downside risk – in which harm may come to elders if they attempt certain activities such as getting out of bed – has resulted in very restrictive policies and practices, such as bed and chair alarms. Many safety measures, such as alarms, are designed with only downside risk management in mind i.e. preventing falls. However, the upside risk of preserving one’s ability to continue walking and to keep their balance and strength are not evaluated. Nor is the other downside risk of losing these abilities talked about. Nor is the quality of life considered according to the person of being immobilized by an alarm or agitated or isolated. Therefore, there is a strong need to look at upside risk management in addition to the traditional focus of managing downside risk.

Thus the first-ever Surplus Safety Symposium was held on September 12 – 13, 2012 in Baltimore, MD. Many thanks to the Hulda B. and Maurice L. Rothschild Foundation for funding and to the Erickson School for hosting this event.
Approximately 50 stakeholders from a diverse group of constituencies discussed the current state of the safety landscape. Experts addressed the areas of: Policy as Written and Interpreted; Risk Assessment Methodologies; Case Law; Management and Workforce Conditions; and Resident Perspective presenting key issues and identifying levers of change. Workgroups then recommended ways to implement a strategy to change how risk is perceived, understood, managed and regulated.

The goals for the two-day symposium were to:
1. Identify strategies to promote a full evaluation of risk vs. potential outcomes in long term care.
2. Reframe the current concept of safety to better balance both upside and downside risk potential.
3. Identify codes and standards which should be addressed in order to better balance upside and downside risk.
4. Identify stakeholder groups to enlist in seeking necessary code and standard changes.

Some ideas collected (not consensus) were the following:

• Consider using probability instead of potential for harm in the CMS scope and severity grid; gather the research to back the use of probability of harm instead of potential which can be anything.
• Consider adding to every regulation “if the resident desires” or “according to the resident;” for example, Tag F363 Menus be followed if the resident desires.
• Discontinue making policies for the 1%, make the policies for the 99%. Broad global policies limit life for the 99%, individualize polices by stating that individual care plans will be adapted for each person in relationship to risk, safety, etc.
• Copy the CMS survey process for homecare where whatever provider has done is recognized and considered into survey findings.
• Incentivize like Colorado P4P bonus reimbursement and Ohio Medicaid Reimbursement where homes must implement a subset of person-directed practices in order to receive full reimbursement.
• Include each person’s goals for themselves and their perspective on risk. This should be individualized based on how much risk they want/can tolerate. Kind of like investing in 401K plans, some of us prefer low risk, others moderate or high risk. Risk needs to be determined by the Elder primarily, and not by surveyors, corporate leaders or other professionals who assign this determination based upon what they think is best for all parties involved.
• Concept of safety is one dimensional regarding the body. Need to add mind/spirit, psychosocial.
• Immediate Jeopardy includes potential for harm which is so very easy to cite, easier to cite IJ than a G. This needs to change because it has the greatest sanction associated with it – possibly move potential for harm somewhere lower down on the grid.
• Equitable attention to all relevant regulations; treat all requirements the same. Preventing accidents is just as important as resident has the right to refuse medical treatment or right to choice.
• Eliminate FOSS/federal surveys as they are over burdensome and do not result in better care for residents; redirect those resources to training of how culture change practices embody intent of OBRA ’87 Nursing Home Reform Law and current regulations.
• Explore legal strategies to promote resident choice and consistent enforcement of all regulations.
• Recognition that accidents happen – differentiate between accident and neglect/systems failure.
• Reconsider the current metrics for success and incentives: do we incentivize surplus safety or highest practicable physical, mental and psychosocial well-being?
• Research the benefits to upside risk.

As you can see, many good ideas on how to eliminate surplus safety were collected. According to Rob Mayer of the Hulda B. and Maurice L. Rothschild Foundation, this is just the start. Be on the alert for more to come. In the meanwhile, do whatever you can to promote the balance in every person’s life of both upside and downside risk. Better yet, do all you can to promote that the person continues to be the boss of their life. Promote this daily with persons you serve. Call for meetings with your survey agency that is to serve the persons living in nursing homes and assisted livings in your state. Lean on your state culture change coalition to bring up these issues in already-established stakeholder meetings. Don’t wait for someone else to do something. See what you can make happen. Go get famous. Eden has a great motto: “It’s Time.” Actually, it’s past time. We all want better.

Carmen Bowman, Regulator turned Educator, owner Edu-Catering: Catering Education for Compliance and Culture Change and Facilitator of the 2012 Surplus Safety Symposium