Snoezelen Activity: The Good Shepherd Nursing Home ... - AgingMO

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Snoezelen Activity: The
Good Shepherd Nursing
Home Experience
De Minner, BSN, RN, BC; Patty Hoffstetter, RN;
Linda Casey, RN; Delores Jones
J Nurs Care Qual
Vol. 19, No. 4, pp. 343–348
c○ 2004 Lippincott Williams & Wilkins, Inc.
Care of the resident with dementia can be both challenging and unpredictable. Activities provided
for nursing home residents often have rules and may be a source of frustration for residents with
advancing dementia. Snoezelen ® , or multisensory therapy, offers a failure-free activity in an enabling
environment that can both stimulate and relax the resident with dementia. Good Shepherd
Nursing Home in Versailles, Mo, undertook a 1-year outcome-based quality improvement project
to find if use of Snoezelen therapy could reduce the number of behavioral symptoms that residents
were suffering from. While there are still barriers to the use Snoezelen therapy, employees at Good
Shepherd Nursing Home believe that the use of Snoezelen therapy has been a successful and rewarding
experience for both residents and staff members. Key words: dementia, interventions,
nursing home care, quality improvement, Snoezelen therapy
CARE of residents with dementia is one
of the most challenging aspects of longterm
care. Staff members often feel that it
is difficult and unpredictable. Dementia not
only affects every realm of care but also has an
impact on the quality of life for those who suffer
from it. Recreational activities have been
used as a way to introduce pleasurable experiences
that provide elderly residents with
the opportunity to attain happiness and purpose
and to improve quality of life. 1 Most activities,
however, have rules that need to be
followed. Because of this, these activities can
create a stressful environment with pressure
on the resident with dementia to conform.
These pressures may lead to disruptions in the
activity and frustration for participating residents
both with and without dementia.
From the Sinclair School of Nursing, University of
Missouri – Columbia, Columbia, MO (Ms Minner);
and the Good Shepherd Nursing Home, Versailles,
MO (Mss Hoffstetter, Casey, and Jones).
Corresponding author: De Minner, BSN, RN, BC, QIPMO
Project, Sinclair School of Nursing, University of Missouri
– Columbia, Columbia, MO 65211 (e-mail:
minnerd@health.missouri.edu).
Accepted for publication: November 21, 2003
Snoezelen ® is an attractive alternative because
it places the resident in a failurefree
environment with no rules and gives
him/her control over interactions within the
environment. 2 It can also create a trusting
relationship between participating caregivers
and the resident by modifying the caregiver –
care receiver relationship during the session
to one of equal footing. 3 This article is a report
of a nursing facility’s experience implementing
and evaluating Snoezelen therapy as an activity
for residents with dementia. The word
Snoezelen has become a registered trademark
of Rompa ® Inc of Chesterfield, England.
BACKGROUND
Snoezelen therapy is a multisensory therapy/activity
that involves a room furnished
with comfortable seating, low lights, bubble
tubes, music, lava lamps, aromatherapy,
and a variety of other sensory equipment4 (M. Stickland, unpublished data, 1996). The
Snoezelen room is designed to gently stimulate
the primary senses of sight, hearing,
touch, taste, and smell without placing intellectual
demands on the individual. 3,4 A staff
facilitator gradually introduces the resident to
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the room’s activities and environment, allowing
him or her to experience and interact with
the room’s sensory offerings in a way that the
resident finds comfortable. The word Snoezelen
is a combination of 2 Dutch words that
mean sniff and doze. 3,5–7
Snoezelen therapy was based on the findings
of research done in the 1960s as the
result of sensory deprivation that occurred
in institutionalized individuals. 2 Expansion to
use for children with autism, behavioral disorders,
and developmental disabilities soon followed.
Since the early 1990s, it has been used
throughout Europe and Australia for individuals
with dementia. There is not an abundance
of literature on Snoezelen, and most of what
is available comes from Europe.
Research on Snoezelen therapy consists primarily
of small, anecdotal studies. Most findings
report positive effects on the mood and
behavior of subjects 3,5 (M. Stickland, unpublished
data, 1996). While Baker et al 3 found
that Snoezelen therapy had no significant effect
on the behavior of their subjects in a
day care setting, they reported a decrease
in the number of behavior symptoms associated
with dementia in the same subjects in
their homes. In both settings, subjects in the
Snoezelen group talked more spontaneously,
recalled more memories, and used more normal
sentence length than did the control
group.
The effects of Snoezelen therapy on concentration
also have been studied. Pinkney 8
reported that music relaxation therapy and
Snoezelen therapy had equally positive effects
on the behavior of his subjects; however,
Snoezelen provided a more global stimulation
in the area of concentration. Ashby et al 6 studied
the impact of Snoezelen on the concentration
and responsiveness of subjects with
profound, multiple handicaps. After Snoezelen
activity, the authors reported that subjects
were able to demonstrate an increase
in the number of movements toward task
completion.
The intent, purpose, and format for use of
Snoezelen was explored by Hope. 9 On the basis
of his data, he raised questions about the
location of the room within the facility and
impact of staffing problems, and explored the
use of group experiences in the Snoezelen
room. Hope concluded that it was necessary
to develop goals and a care plan for residents
using the room, and also to employ a key person
or champion to be in charge of and promote
the room’s use within the facility.
THE GOOD SHEPHERD EXPERIENCE
Good Shepherd Nursing Facility in Versailles,
Mo, struggled with many of the same
issues that plagued other nursing homes.
These included staffing problems, challenging
behaviors of residents with dementia, and use
of psychotropic medication. Snoezelen was
first brought to their attention by a professor
and nurse researcher/consultant from the
Sinclair School of Nursing at the University of
Missouri – Columbia, who had traveled to Australia
and found the concept in use there for
residents with dementia. The facility waited
a year, looking into other options, before considering
use of the therapy in their facility. The
registered nurse (RN) manager of the tender
care unit (TCU), a unit for residents with dementia,
reviewed the material she had been
given and further researched Snoezelen as a
possible therapy. She then took a proposal to
the administrator and director of nursing.
Finding the space
An unused chapel, approximately the size
of a resident room, was converted into the
Snoezelen room and a dimmer switch installed
for the lighting. Because the facility
was concerned about expenses, they looked
for ways to make some of the necessary equipment.
A bubble tube was made out of an
old aquarium and a new aerator. Other equipment
and furnishings consisted of a comfortable
rocker, a bean bag chair, a lightening
ball, hanging plastic beads, vibrating pillows,
a lava lamp, an aromatherapy diffuser, a tape
player, a lighted picture with moving waterfall,
colored lights, and a reflecting mirror.
Most Snoezelen rooms have some standard

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equipment, but there are no specific guidelines
and so the room can be furnished according
to the facility’s needs and budget. Although
these items can be purchased through
occupational therapy catalogues, many of
them can be found in department, toy, or novelty
stores.
Implementation with staff
While there are different models of implementation,
the facility chose to use a single
facilitator model. 9 With this model, one individual
is responsible for scheduling, room upkeep,
charting, championing the room with
staff, and facilitating the residents who use
it. Good Shepherd administration believe this
model offered better utilization, consistency,
and conformity, and would have the least effect
on staffing in the nursing home. The RN
coordinator of the TCU acted as a resource to
the facilitator and to the rest of the staff members
regarding the use of Snoezelen therapy.
She was available for questions/consultation
about use of the room, the resident’s response
to the environment, and ways to improve use
and response.
Choosing the facilitator
The staff member selected as the facilitator
was a certified nurse’s aide (CNA) and certified
medication technician (CMT). She was a
long-term employee with excellent communication
and interaction skills and work ethic.
Nursing management also believed she was
intuitive about resident needs. Several oneon-one
training sessions were held by the
RN coordinator of the TCU for the facilitator
regarding concepts, use, scheduling, interaction,
and charting in the room.
Education
Two inservices were held with all of the
staff to inform them about the Snoezelen activity,
concepts, and use. During the second
day of new employee orientation, each new
employee is taken to the Snoezelen room by
the RN coordinator, director of nursing, or the
administrator to experience Snoezelen activity
first hand. No subsequent inservices on
Snoezelen Activity 345
multisensory therapy have been held, but the
Snoezelen activity is mentioned in other inservices
on behavior and dementia.
Identifying residents
Potential resident participants were chosen
by the RN coordinators on each nursing unit.
Residents who exhibited multiple episodes of
difficult or potentially dangerous behaviors,
such as constant wandering, were given priority.
All potential residents were thoroughly
assessed for any indication of cause of behavior
such as pain or illness. Behavior description
and tracking sheets were done for each
resident on all 3 shifts. Only 5 residents were
chosen for the initial stages of the Snoezelen
activity to allow the facilitator to concentrate
on the learning process and become comfortable
with helping residents use the room.
A total of 19 residents made visits to
the Snoezelen room during the 1-year time
period. Behaviors of participating residents
were tracked and trended, and a Snoezelen
therapy schedule was planned for each by the
unit care plan team according to individual
needs. 9 For example, one resident’s confusion
and behavioral symptoms usually started to escalate
immediately before shift change. Staff
had made several attempts to engage the resident
in other activities at shift change but
to no avail. Once the escalation of behavior
started, any type of care became difficult for
the rest of the evening. According to the individual
plan of care, the resident was taken
to the Snoezelen room at 3 PM. The resident
usually remained involved in the activity for
30 minutes. Even though the room was used
by the resident only 3 days a week, a decrease
in behavioral symptoms and confusion
in the evening resulted, and staff members
were more easily able to engage the resident
in care.
EVALUATION
Data were entered on residents’ behavior
before, during, and after the room’s use for
a 1-year period to evaluate the effectiveness
of the room in decreasing behaviors for this

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outcome-based quality improvement project.
The Comfort/Discomfort Scale (CDS) from
the Queen Elizabeth Center, Ballarat, Victoria,
Australia, was used to gather data (M.
Stickland, unpublished data, 1996). This scale
is an amended version of the Discomfort
Scale-Alzheimer’s Type (DS-DAT) developed
and tested by Hurly et al. 10 The DS-DAT contains
7 negative and 2 positive behaviors and
was found to be sufficiently reliable and valid
for the measurement of discomfort. Negative
behaviors are noisy breathing, negative vocalizations,
sad facial expression, frightened facial
expression, frown, tense body language, and
fidgeting. Positive behaviors are content facial
expression and relaxed body language. 10
Positive behaviors added to the DS-DAT
to complete the CDS are content facial expression,
relaxed body language, positive vocalization,
smile, positive gestures, positive
noise expression, and positive interactions
with people or objects. There is no evidence
of testing done on the CDS by the Queen Elizabeth
Center, but the equal number of positive
and negative behaviors allowed easy data analysis
and comparison of pretime and posttime
periods for the Good Shepherd project.
Outcomes
A total number of 324 room visits were
made by 19 residents over the project
time frame. Using the CDS, behaviors were
recorded by the facilitator before, during, and
approximately 1 hour after interaction in the
room. Notes about room interaction such as
preference of activity and responses were
kept by the facilitator on the same form. The
mean number of negative behaviors exhibited
per resident before room visits was 2.1. The
mean number of negative behaviors per resident
during and after the activity was 0.9 and
0.8. The mean number of positive behaviors
exhibited per resident before room visits was
3.7. The mean number of positive behaviors
exhibited per resident during and after the activity
was 5.3 and 5.1 (Fig 1).
Potential benefits
Because even a small reduction in the number
of negative behaviors can have a positive
effect on the milieu of a nursing facility, Good
Shepherd believes this outcome-based quality
improvement project has been a success. In
addition to an increased number of positive
behaviors, and a decrease in negative behaviors
during and after the activity, management
believes that the care has become more person
centered. Staff members appear to better
understand the need for residents to have
some control over their environment even if
they are in a debilitated state. While not a
cure-all for the difficulties of dementia care,
Snoezelen therapy is another option that may
be helpful for the residents. Because of referrals
from all levels of staff, aides have become
more involved in problem solving, and
Figure 1. Mean number of positive and negative behaviors for 19 residents before, during, and after each
therapy session. Data were compiled after 324 Snoezelen room visits.

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communication between levels of staff has
increased.
There also are anecdotal incidents that underscore
resident comfort and enjoyment. For
example, a resident with dementia and a history
of anxiety approached a staff member
on a particularly difficult day and asked to
be taken to “that relaxing room.” After a frustrating
incident that occurred before the session
started, one resident threw pillows in
the room and then went to sleep. Another
resident, after looking at the lights projected
on the wall in the room, asked the facilitator
how she kept all the flowers so beautiful. According
to the facilitator, “The resident may
not know what you mean when you talk to
them about the Snoezelen room, but they sure
know what it is when they get there.”
If possible, residents are taken regularly
before most behaviors are known to occur
based on assessment, tracking, and trending.
For those patients whose behaviors occur
with no predictable pattern, or are continuous,
a schedule is still planned. Incidental, unplanned
visits for residents who are familiar
with the room have been successful in relaxing
them. At present, there are plans to train
more staff in use of the room and also to involve
the occupational therapy department in
planning, resident assessment, and development,
since much of the literature on Snoezelen
therapy is found in occupational therapy
journals.
Barriers to use
Barriers to use of the room still exist. Adequate
staffing is one of the greatest barriers.
When staffing is a problem, the room’s facilitator
is often pulled away from the room to
work as an aide or to administer medications.
Nursing and aide staff turnover also decreases
the understanding of the staff about concepts
of the room. Good Shepard is planning to hold
more Snoezelen inservices for staff members,
in addition to orientation, to address turnover
and knowledge base. The RN coordinator of
the TCU also has left that position and transferred
to another unit that is not dementia
related. While she still serves as a resource
Snoezelen Activity 347
to the Snoezelen program by answering questions
about the room and its use, she does not
have as much time to devote to it.
Implications for use in other areas
Snoezelen therapy for nursing home residents
with dementia is only one of the uses reported
in the literature. Its use in Europe and
Australia for children with autism, developmental
disabilities, and behavioral disorders
has been reported but not extensively studied.
Ashby et al6 reported on the use of Snoezelen
therapy for people with profound developmental
disabilities. Use of multisensory therapy
in the management of persistent pain was
discussed by Schofield. Some patients after
use of multisensory stimulation experienced a
decrease in pain, an improved overall sense of
well-being, and improved sleep habits, which
were cited as reasons for continued study. 7
Snoezelen therapy is also being used successfully
in some pediatric hospital settings to
give ill or injured children a sense of stimulation,
recreation, and control within the hospital
environment. 11 The benefits of Snoezelen
therapy appear to be connected with stimulation
of the senses, a relaxing environment, a
sense of control that the activity may in some
way restore to the individual, and the development
of a more equal relationship with a caregiver.
Snoezelen concepts and its use need to
be studied in more depth to better understand
the effects and benefits of its use among different
populations. Further research also would
contribute to the development of guidelines
that could further legitimize this activity and
potentially lead to greater use.
SUMMARY
Care of residents with dementia is one of
the most challenging aspects of long-term
care. Staff members in long-term care facilities
often look for opportunities to connect
with residents. Snoezelen therapy provides
an enabling, a failure-free, and a stimulating
and relaxing environment in which the resident
with dementia is free to interact without
rules. It also provides an activity that presents

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the resident and caregiver as equals, allowing
a bond of trust to develop that may carry
over to interactions outside the room. For
Good Shepherd, this outcome-based quality
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