UAlbany MPH student Alexandra Smith, a certified dementia practitioner and nursing home administrator, discusses the artificial sky project she led at the Our Lady of Mercy Life Center in Guilderland, NY. The installation is the first of its kind in a nursing home in the U.S. The artificial sky is made up of a series of seamless panels that use high luminance lighting to create an imitation blue sky and sunlight and AI technology to mimic how the sky appears at various times of the day. Alexandra discusses the project -- from start to finish to ideas for future related research -- and talks about the impact the artificial sky is having on residents and their families, and the nursing home's staff.
Alexandra Smith's LinkedIn page
University at Albany School of Public Health
UAlbany News Center article: MPH Student Brings First Artificial Sky to Capital Region
James A. Eddy Memorial Geriatric Center
Light and Health: Light and Older Adults
Artificial Sky and Mark Jenzen
About Mark Jenzen: Founder & CEO Mark Jenzen is a service-connected disabled veteran who spent quite a bit of time in and out of hospitals, not only with his own military-related training injuries, but also helping to improve outcomes for family members battling cancer.
The Engagement Ring, Episode 24: Alexandra’s Sky – Bringing the Outdoors In
[Lively, upbeat theme music plays as program host Mary Hunt introduces the program and plays excerpts from the program.]
ANNOUNCER/MARY HUNT:
Welcome to The Engagement Ring, your connection to an ever-widening network of higher education professionals, scholars, and community partners, working to make the world a better place. I'm Mary Hunt. Today on the podcast…
ALEXANDRA SMITH:
Growing up, not many little girls dream of being a nursing home administrator, but I did.
ANNOUNCER/MARY HUNT:
Focused is one way to describe UAlbany MPH student Alexandra Smith. Creative is another. For her student internship. Alexandra spearheaded a highly innovative project designed to enhance the well-being of the residents of the memory care unit at a nursing home where she formerly worked.
ALEXANDRA SMITH:
Research just kept screaming at me the importance of being outside, having natural light. And so, I started really thinking about what's a cool way to change their physical environment and maybe improve their everyday lives.
ANNOUNCER/MARY HUNT:
Alexandra, a certified dementia practitioner, led the effort to bring an artificial sky to the Our Lady of Mercy Life Center in Guilderland, New York, the first such facility of its kind in the U.S. to do so. The artificial sky is made up of a series of seamless panels that use high-luminance lighting to create an imitation blue sky and sunlight, and AI technology to mimic how the sky appears at various times of the day.
ALEXANDRA SMITH:
It's so important to find things without medication because the Baby Boomers are getting older every day, and this dementia is going to be one of the biggest burdens on our health care system.
ANNOUNCER/MARY HUNT:
Here's my conversation with Alexandra Smith…
MARY HUNT:
Welcome to the podcast, Alexandra.
ALEXANDRA SMITH:
Thank you so much for having me.
[Theme music fades out.]
MARY HUNT:
What a cool idea! Where did the idea for an artificial sky come from?
ALEXANDRA SMITH:
Thank you. Yeah, so, it is a very funny story. Actually, it's hard to talk about where the idea came from without talking about where the money comes from. So, the Eddy Endowment, I work for St Peter's Health Partners, and every year there's an opportunity for innovative projects. And innovative projects have to have certain criteria to be approved by the endowment, which is just a lump sum of money that's available every year to the particular facilities that are in St Peter's Health Partners. And really, I heard about the opportunity to apply for this grant, and I started to think about who in my nursing home at Our Lady of Mercy Life Center, Guilderland, New York, who could benefit the most from an innovative project? And it really ended up being the only people that I have passionate, you know, hope and want to better their lives would be the elders that have dementia at Our Lady of Mercy. And so, I started really thinking about what's a cool way to change their physical environment and maybe improve their everyday lives. And that's when we ended up landing on the artificial sky.
MARY HUNT:
When you say we, was this an idea that you collaborated on with others?
ALEXANDRA SMITH:
Absolutely. Oh yes, absolutely. So really at the time, I would say the majority of the leadership team, so that’s social work, nursing, the administrator, the director of nursing, everybody, I guess I would say that everybody started thinking about different things that we could use… interventions, ideas that maybe would help the memory care residents. But we ended up finding the artificial sky. I was really tapped for the research, because at the time, I was fresh out of grad school, my first masters at Utica, now University. At the time, it was Utica College, and really, they looked at me and they said, well, you're, you know, the young, young student, why don't you go out and find something cool for dementia, non-pharmacological interventions. So those interventions that don't require medicine, because we're always trying to de-prescribe, we don't want these people that have this disease to be on a bunch of medications. And that's when I really found this amazing research that RPI, actually at the lighting Institute… Mariana Figueiro, I believe, that’s how you pronounce her name… she really started talking about the importance of the circadian rhythm being a blue light receptor, which means that a circadian rhythm that's disrupted by dementia really needs blue light to reset it, make it so that it works at peak performance.
MARY HUNT:
We've all heard of circadian rhythms.
ALEXANDRA SMITH:
Yes.
MARY HUNT:
In a nutshell, what's a circadian rhythm? I think of it as something that's associated with my sleep.
ALEXANDRA SMITH:
Exactly. That's exactly what it is. It is the ability for your brain to wake up in the morning and then go. Back to sleep at night, and that's so important for your regulatory system, not only with REM sleep, that's where you learn, but you learn processes. You learn behaviors. You really build patterns. You connect on patterns. And just being able to sleep soundly really impacts your mood, your physical senses, how you react to things, and a lot of those negatives of the circadian rhythm are impacted by dementia. And the symptoms that come from dementia can be because of the lack of sleep. We talk about sundowning a lot in dementia, and that is when these symptoms… so the wandering, agitation, crying out, restlessness really increase. They ramp up in the evening time, and that's a lot to do with the lack of the circadian rhythm.
MARY HUNT:
What kind of benefits did you hope you would see in the well-being of the residents of the nursing home?
ALEXANDRA SMITH:
So, really, anybody that's experienced somebody with dementia or a loved one or has been to a nursing home that has a memory care unit, you can see it's almost an uncomfortableness in their own skin, and they're asking, I want to go home. I want to go home. And really the fear that they have, the inability to rest, the agitation, the wandering is all because of symptoms of their disease, and really I wanted to find something that would give them peace, something that would help with those behavioral symptoms. And I hate the word behavior, because it's really them trying to express to us an unmet need. And that's a lot of what I do at my now nursing home, Eddy Memorial, is try to educate the staff that any type of behavior, so agitation and aggression, anything like that, is the resident trying to communicate to us that something's wrong. Whether they're tired, they're hungry, they are uncomfortable, they're in pain, they're trying to communicate something to us. And a lot of the time it's just boredom and uncomfortableness and so really trying to hopefully with the artificial sky, limit those behaviors would not only give them a better day-to-day experience, but it would help the families have meaningful visits, because a lot of people have a difficult time coming to a nursing home because of the whole negative connotation that comes with it, right? But also the staff… caregiver burnout is tenfold, I would say, in a memory care unit as opposed to a traditional long term care unit, and really just helping the behaviors decrease would improve the residents lives, the family's lives, as well as the staff lives.
MARY HUNT:
I think too for the folks who are residents of the nursing home, probably not often or easy for them to get outside to travel, to shop, to be out with family, so much of them probably spend most of their time inside the walls of the nursing home, which is nice as it could be, like any institution there’s often a sameness to a hospital setting or to a healthcare setting,
ALEXANDRA SMITH:
And that's a big part of the research that I… so when I spoke about how, you know, the team kind of tapped me to start looking through research… what could help those in a facility experience a better day-to-day, this whole concept of a biophilic design, which is taking architecture and nature and combining the two and utilizing this evidence-based design practice. You know, the buildings that were built in the 70s and 80s, which is many of our nursing homes, did not take that into account. They did not take into account that the sky is the largest common thing that everybody looks at. It's the shared nature experience. Everybody at some point, whether you're, you know, 1000 miles away, or you're right here in Troy, we're looking up at the sky. And all of a sudden we put these residents, these elders, into a nursing home whose units are in the basement. We get no natural light, and we talk about, you know, seasonal depression, and even me and you right, we get seasonal depression. Research just kept screaming at me the importance of being outside having natural light. There was research that I found that talked about people in offices that have windows call out a fourth less than people that don't have windows. So really, the experience of the residents not going outside, the staff not being outside, the families coming to a dark, lower-level structure, all just kept saying, we need to bring the outdoors in.
MARY HUNT:
What's the first thing you do when you go outside, you look up and you say, oh, what a beautiful day with a blue sky. And that really is the first thing that I think strikes you when you go out in morning.
ALEXANDRA SMITH:
Yeah, absolutely.
MARY HUNT:
Let's talk about what it looks like. So first of all, where did you place the artificial sky in the nursing home setting? How large is it?
ALEXANDRA SMITH:
So, I don't have the specific length, but I can tell you that it was a very difficult decision to figure out where we were going to put it, because a lot of our residents are unsafe in their rooms, and many hospitals and I believe the artificial sky creator Mark Jenzen, he's a veteran. He's a great man. He's out of Detroit, Michigan. He created it because of his mom and her… some disease, some process that she had… she was unable to go outside and he just kept thinking about the importance of his mom being outside. And so when we were talking to him, he was thinking, you know, in every single room there should be a panel And that really wouldn't help my setting, because the issue is the residents can't be alone in their rooms. They’re fall risks. They have safety issues. So, we were thinking to ourselves, what is the main area that everybody kind of hangs out in, and that's the dining room. So, most of the residents always are in our dining room. And the dining room is quite large, and so it actually is the largest artificial sky structure. It goes it spans from one end of the dining room to the other, and it's a seamless sky, so there are no lines through the panels. So really, the residents, they comment on the weather quite a lot, while they look up at the sky.
MARY HUNT:
So it's working.
[Laughter]
ALEXANDRA SMITH:
So it’s working. So, they really don't know that it's not the truth. They think they are outside.
MARY HUNT:
Is it fluid? Is it a stationary sky. Do things move? Are there clouds?
ALEXANDRA SMITH:The clouds move. There's even some birds occasionally that flitter on by. And I, you know, the coolest thing that I thought that Marc was able to do with this sky was that it mimics the the daylight in the evening of Albany, New York. So, this is not… you're looking at. You're not looking at the Bahamas. You're not looking at, you know, if you looked up, there's not palm trees, right. Because we don't have palm trees in Albany. But if you look up, you really… it mimics the outside. So, when our sun starts to set, when me and you are looking at a sunset, so are the residents.
MARY HUNT:
So, it changes over the course of the day? Does it get dark as an evening sky too?
ALEXANDRA SMITH:
Yep, it flows. It goes from morning to high noon and then all the way back down into the evening time. And that's really supposed to help trigger the brain to say it's time to settle down for the evening now. Ii's time to get ready for bed. And really, because we at one point in time, were always outside, and that's why our brain is so used to watching the sun rise and waiting for that different lighting to tell us when it's time to start to wind down for the day. And the residents never had that. They had the fluorescent, bright white light that always was triggering their brain to say, it's up. We got to go. We got to get ready. Because even in the evening time, the nurses are passing meds, CNAs are trying to do the p.m. care. So, getting them ready for bed, all of that with lights on, whereas me and you I mean, at home, I dim my light. I get ready for bed. I go to bed in a dark room. But in the nursing home, the hallways always have lights on. So, it's very it's very interesting to see the difference in the lighting in the morning, mid-morning, afternoon, and then the evening, because there is a difference. It goes from a bright white to a cooler, down to a warm, almost orange.
MARY HUNT:
I have skylights. I'm thinking of it, yeah. So, when you talk about this, I think how much I enjoy those.,
ALEXANDRA SMITH:
Yeah, absolutely. And it’s so important to find things that are non-pharmacological, again, without medication, because the Baby Boomers are getting older every day, and this dementia is going to be one of the biggest burdens on our health care system, so putting in a light to maybe help stem the behaviors and end that caregiver burnout is such an easy thing to do, especially if we're trying to move into the future building new nursing homes, why not just automatically have that ability to have the light instead of maybe, you know, putting us in the basement and it being dark all the time, which really just confuses the residents even more.
MARY HUNT:
You started this project, I understand, and then stopped, and then changed positions, but you went back to the project during your master study at UAlbany.
ALEXANDRA SMITH:
I sure did.
MARY HUNT:
Tell me how you incorporated it into your research. Also talk about what kind of data you collected. And what was your method for collecting that data?
ALEXANDRA SMITH:
I actually got overzealous, and I was really, of course, trying to showcase everything right? And so, I worked with Amy Dr Amy Teale, who is a part of the Sunnyview Research Institute, which is a part of St Peter's Health Partners. And she's so brilliant. And, you know, I shot her an email with100 things I wanted to look at. You know, fall rate, anti-psychotic use, SSRI use, behaviors, sleeping patterns, staff satisfaction. I was whipping all these things out at her, and she kind of said, hold on, you can't look at all of it. Why don't we pick the top ones? And so, what we really looked at was the rate of falls.,.. so how much the residents were falling. Typically, it was due to when I looked at the pre-data, the pre-installation data, a lot of it was restlessness. They were just trying to get up and go for a walk. They just wanted to move. They were bored. Could the sky change that? Would it make them want to stay in the dining room longer, looking up at the sky and having a sense of calm… that relaxation response that we all get right when we look at the beach or up in a mountain. Could the fall rate decrease and could the staff satisfaction increase? And at the beginning of this project, that's not really what I was in in it for, not that I don't love my staff, but really my passion is the residents, but with the pandemic hitting, looking at the turnover rate of staff skyrocketed, and could we have an edge up on our competition. A lot of these staff members go where the money is, which I completely understand, but is this something that's going to keep them here longer. have them have buy in to Our Lady of Mercy? Because, let's face it, caregivers are not a dime a dozen anymore. We cannot find them to save our lives, and if we can keep CNAs and LPNs satisfied in their role longer with something like the artificial sky, could we, you know, again, get staff that other buildings are really desperate for.
MARY HUNT:
What were your findings?
ALEXANDRA SMITH:
There is less falls for the residents that are in the underneath the artificial sky than there were pre-Installation. Staff satisfaction was difficult because we didn't have that raw data pre-sky that we could compare it with, but what we did do was find we have a unit that is on the same level as the Guadalupe Unit, which is the memory care unit, same exact level, but it's not a memory care unit. That staff scored lower in satisfaction, higher in attendance issues than the staff that were working under the sky. So, it wasn't a one- for-one comparison, but it did show that there was improved staff satisfaction and attendance under the sky.
MARY HUNT:
Interesting. You said you had lots of other questions you wanted to ask. Is this an ongoing project, or do you plan on going back and revisiting some of these questions too? And what might some of those questions be that you’ll look at going forward?
ALEXANDRA SMITH:
I really wanted to look at antipsychotic use. I felt like that was the biggest indicator for me of whether the sky was proof of concept. So when I submitted the design in 2019, January of 2019, and it was approved, and then, you know, the whole world kind of stopped in February and March, especially for nursing homes, that was my biggest point that I wanted to make, was that something like this, this non-pharmacological intervention, could stop us from having to utilize very scary medication for a disease that those meds aren't supposed to be prescribed for them. Yes, do they work? Sometimes, but not a overall brushstroke of these medications work. So, what could I find that really impacted the behaviors without using a medication? So that's my biggest... I really wish that we could go back and look at that, and I know that some people at Our Lady of Mercy are still looking at that.
MARY HUNT:
What did your advisors or your faculty members at UAlbany say when you said, you know, for my internship, I want to work on this artificial sky project, I'm curious what their response was and if they supported you in the project, or how did you work with others at UAlbany?
ALEXANDRA SMITH:
Brenda Kirkwood, she is amazing. She is my advisor. She absolutely said go for it. This sounds amazing. This sounds exactly like we want our students to be doing. I had her full support, full advocacy for anything that I needed. So really, just all-around positive feedback. Really, really special UAlbany’s really supported me in all of this.
MARY HUNT:
This is your second master's in the area of public health. Tell me, why are you pursuing a second? How do you expect that that will make you a stronger professional or improve your skill set? Why the need for a second master’s?
ALEXANDRA SMITH:
So, the first masters was in healthcare administration with a focus on long term care. But the more I worked in nursing homes, the more I realized that policy and advocacy and opportunities in the community is what's actually spearheading and leading the day- to-day occurrences that are happening in a nursing home. And I felt like my first masters, especially with Covid… once Covid hit, I thought I need to do something else. Not that I wasn't happy with my career path. You know, becoming a nursing home administrator is all I ever wanted. Growing up not many little girls dream of being a nursing home administrator, but I did, and I'm finally one. And you know, my dream has come true. But it just felt like to be able to impact a population on a broader scale, I needed a master's that really reflected public health and proved that I could change policy and procedure at a broader level than just one nursing home. I wanted to change all of the nursing homes, not just the one where I'm the administrator.
MARY HUNT:
Great ambition. Alexandra, this was the first of its kind in a nursing home in the United States. So, you must be hearing from others. I'm imagining. around the country, at other locations.
ALEXANDRA SMITH:
Yeah, we are.
MARY HUNT:
What are you hearing? What are they asking?
ALEXANDRA SMITH:
A lot of how does it work? What should we do? When should we do it? How did you know that this was going to work for you? And the truth is, for everybody listening, I didn't know it was going to work. This was an absolute proof of concept design. That's what the Eddy Endowment does. It takes innovative research and tries to see if it will work so that we could duplicate it in other nursing homes. So honestly, I didn't know it was going to work. I kind of looked at the research, looked at the opportunity, and hoped for the best, and now that it seems to be working, it does get exciting to think maybe others are going to do it as well.
MARY HUNT:
Any advice, guidance, tips, hand holding for anybody who might want to take on an artificial sky project, and whether it's in a nursing home hospital setting or any kind of healthcare setting,
ALEXANDRA SMITH
I would say you need buy in from your staff. The staff really are the biggest either supporters or possible naysayers. I mean, I can tell you, in the beginning, the very beginning, when we implemented the sky, I had a lot of staff telling me, it's too bright, it's too bright, it's too bright. I feel like I'm in the sun. One person tried to say they got a sunburn from it, which is not possible, but explaining to the staff the positives before doing it. I had a lot of staff meetings. I tried to explain to staff the importance and how it's going to help. And even then, we still, of course, had complainers. Um, but really, having staff and family buy in is huge.
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MARY HUNT:
Well, this is a fantastic idea. Congratulations.
ALEXANDRA SMITH:
Thank you.
MARY HUNT:
Great idea, and a successful project, and being the first to try something that wasn't easy, but obviously has great payoffs for the residents.
ALEANDRA SMITH:
Absolutely. Thank you so much.
MARY HUNT:
Sure. Thank you for being my guest. It was really a pleasure.
ALEXANDRA SMITH:
Nice to talk to you. Thank you.
ANNOUNCER/MARY HUNT:
Alexandra Smith is the executive director of the James A. Eddy Memorial Geriatric Center in Troy, New York. She earned her master's degree in healthcare administration and continuing care management from Utica College, and is currently pursuing an additional master's degree in Public Health from the University at Albany. To find more information about Alexandra's artificial sky and other resources related to the podcast, visit The Engagement Ring online at the dash engagement dash ring dot simplecast dot com. The Engagement Ring is produced by the University at Albany's Office for Public engagement. If you have questions or comments or want to share an idea for an upcoming podcast, email us at UAlbany O P E at Albany dot E D U.
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