Journal of Gerontological Nursing

Letters to the Editor

Abstract

As Ms. Tolley described and I also believe, there are numerous ways in which nurses can inexpensively and easily enhance resident autonomy. Promoting choice related to bathing routines, daily clothing, activities attended, and some aspects of the dining experience, as well as promoting greater consistency in nursing assignments are strategies that may contribute to the enhancement of resident autonomy. Provision of choices such as these probably do not require the addition of staffing resources. Enhancing staff sensitivity and thoughtfulness to issues of personal autonomy have more to do with value and attitude formation than with issues of staffing and reimbursement.

However, this is not the entire picture. As Rosalie Kane so aptly stated, the "three enemies of personal autonomy for nursing home residents are: routine, regulation, and restricted opportunity" (Kane & Caplan, 1990, p. 19). In the real world, enhanced variety and choice is often associated with increased costs. The carefully prepared meal and individualized service associated with the dining experience in a fine restaurant understandably costs more than the standardized preparation and presentation of a meal at a McDonald's-type establishment. Some choices that may in theory be provided to residents may be beyond the capacity of the nursing home to afford.

The challenge to nursing directors is to identify the current routines of nursing practice or nursing home life that present barriers to resident autonomy and to identify those which may be reconfigured with minimal cost and conflict with current regulatory enforcement.

We will always benefit from asking residents and families what issues of choice and control matter to them. It may be that we are surprised by which issues actually concern the residents and how they might differ from what we think should be matters of concern to them.

Nursing efforts directed at clinical research and regulatory reform may also contribute to the promotion of resident autonomy. More nursing research on the relationship between nursing practice patterns in the nursing home and resident perception of autonomy is needed. Working to change how nursing home regulations are enforced is another way nurses can promote the creation of a practice environment in which innovations, such as those described in Ms. Tolley's article, are the rule, rather than the exception.

REFERENCE

Kane, R., & Caplan, A. (1990). Everyday ethics: Resolving dilemmas in nursing home life. New York: Springer.

Mary Ellen Dellefield, RN, MS

San Diego, California

Response

Ms. Dellefield's comments exemplified the kind of professional reflection that is needed. No "automatic bias" is intended in my observations of nursing home residents. Unlike the casual observer, both Ms. Dellefield and I are professional nurses who have the assessment skills to identify the difference between engagement in the environment and boredom or depression. Unfortunately, in a career spanning more than 30 years of nursing, most of it inclusive of some involvement with older adults, I have seen and continue to see far too many instances when the response of the resident is considered adequate if the resident is quiet and compliant.

If one suspects that the client is seriously neurologically and/or cognitively impaired, there remain techniques to assess and even engage such clients. Naomi Feil's Validation Therapy can be taught to all levels of nursing home staff Her easily readable book, Validation, the Feil Method, How to Help the Disoriented Old-Old (1992), should be read in every facility dealing with the elderly.

Ms. Dellefield's quotation from Rosalie Kane is particuUrly to the point. It is my contention that in the real world one can overcome "routine, reguUtion, and restricted autonomy" without significant increases in cost or staff. My article gave a few specific…

NURSES NEED AfIANAGEMENT SKILLS

To the Editor:

Nurses must avoid becoming prisoners of a health care system that imposes so many time constraints they are unable to implement the most basic interventions as described in "The Value of Listening, History, and Personality" by Kathleen C. Buckwalter, RN, PhD, FAAN and Kathleen Sherrell, RN, PsyD (Journal of Gerontological Nursing, Vol. 24, No. 1, January 1998). With the length of hospitals stays decreasing, nurses must learn to use time wisely. Educators must focus more heavily on nursing management.

Currently, nurses often find themselves thrown into a chaotic environment lacking the skills to plan, organize, and perform satisfactorily. In addition, nurses conform to the chaos rather than striving to alter it. This lends itself to poorly managed care which fails to meet the needs of clients and uses time and resources ineffectively.

Nursing management is vital to the survival of the nursing discipline in health care delivery. It is the process by which nurses practice their profession. It is the tool necessary to prioritize the care of patients while assisting them to improved health or sometimes to a peaceful death (Swansburg, 1993).

Nursing as an institution does not manage care, time, or resources; nurses do. They are the backbone of the discipline and can be more productive and efficient with strong management skills. Improved performance will relieve some of the time constraints resulting in increased implementation of basic interventions. This type of care will more adequately meet the clients' needs and at a price they can better afford.

REFERENCE

Swansburg, R. (1993). Introductory management and leadership for clinical nurses. Boston: Jones and Bartlett.

Sandra D. Bollier, RN, BSN

Sherman, Texas

Response:

Many thanks to Ms. Bollier for her thoughtful letter in response to our Geropsychiatry column on "The Value of Listening, History, and Personality. " We could not agree more about the need for today's nurses to have increased management skills. I can well remember the culture shock of graduating from my BSN program having successfully mastered many 8-hour 1:1 practicum experiences and being thrown into my first real-world clinical experience (as a Navy nurse at the peak of the Vietnam War) where I was expected to manage Urge wards with hundreds of acutely ill patients and numerous Corpsmen.

In an unpublished study, Sherrell and Wadner used a Nurse-Typology in observing Head Nurses as they worked. They found an average of 40 role switches every hour, which clearly exemplified the complexity of the position. On follow-up interview, all of the Head Nurses stated that they had been placed in their positions because they were good clinicians and had little or no formal management training.

Fortunately, in many schools of nursing, curriculum changes are underway at both the undergraduate and graduate levels that introduce students early on in their educational experience to the challenges of current health care systems, new models of delivery, leadership issues, and contemporary management problems they will likely encounter. Certainly, the movement toward advanced nursing practice has increased our emphasis, and appropriately so, on practice management issues. Readers who are interested in a related approach to nurses becoming "prisoners of the health care system" are encouraged to read 25 Stupid Things Nurse Do To SelfDestruct (1995), written by Allen, Brady, and Vonfrolio and published by Power Publications.

Kathleen C. Buckwalter, PhD, RN, FAAN

Iowa City, Iowa

FEEDING ALTERNATIVES FOR GERIATRIC PATIENTS

To the Editor:

I am a Head Nurse on a 40patient geriatric, long-term unit and am looking for information on feeding geriatric patients. More specifically, I have noted severely demented patients who have difficulty sucking on a straw, mimicking breast-feeding behaviors I noted when I breastfed my children. I am curious to know if there could be any correlation because a large portion of our geriatric population were probably breastfed as babies.

I also wonder if there are alternative means of feeding liquids to this group, to improve their intake. Do you know of any information that might be useful in this area?

The facility's dietician did research on this topic on the World Wide Web but could not locate anything. Perhaps you could direct us as to what topic to look for?

Thank you for your assistance.

Lori J. Fafard, RN

Esetauket, New York

Editor's note:

The Journal welcomes readers' responses to these questions. Please send responses to: Managing Editor, Journal of Gerontological Nursing, SLACK Incorporated, 6900 Grove Road, Thorofare, NJ 08086, or fax (609) 853-5991, or e-mail mlong@sUckinc. com.

VIEWS ON PROVIDING NUTRITION AND HYDRATION

To the Editor:

In a recent article in the Journal of Gerontological Nursing entitled, "A Compassionate Response Toward Providing Nutrition and Hydration in Vulnerable Populations" (Vol. 24, No. 2, February 1998), Monica J. Cox, RN, CS, MSN, MPH, GNP forcefully argues to provide artificial nutrition and hydration to every patient who is unable to take sustanance through normal means. In taking this position, she joins a number, although a minority, of thoughtful and important ethical commentators.

However, Ms. Cox's article has the potential to seriously mislead readers about the legal status of artificial feeding. Her selective interpretation of several state court decisions that are more than a decade old implies that legal precedent supports her ethical argument. In fact, the very opposite is true. In the United States Supreme Court's decision in Cruzan v. Director, Missouri Department of Health (1990) (which Cox fails to mention), Justice O'Connor clearly stated:

Artificial feeding cannot readily be distinguished from other forms of medical treatment.... Whether or not the techniques used to pass food and water into the patient's alimentary tract are termed "medical treatment," it is clear they all involve some degree of intrusion and restraint. Feeding a patient by means of a nasogastric tube required a physician to pass a long flexible tube through the patient's nose, throat, and esophagus and into the stomach. Because of the discomfort such a tube causes, many patients need to be restrained forcibly and their hands put into large mittens to prevent them from removing the tube. . .. A gastrostomy tube or jejunostomy tube must be surgically implanted into the stomach or small intestine.... Requiring a competent adult to endure such procedures against her will burdens the patient's liberty, dignity, and freedom to determine the course of her treatment. Accordingly, the liberty guaranteed by the Due Process Clause must protect, if it protects anything, an individual's deeply personal decision to reject medical treatment, including the artificial delivery of food and water (p. 289).

Thus, the legal environment within which clinical and moral decisions must be made in no way requires, or even encourages, the universal initiation or continuation of artificial nutrition and hydration. Moreover, Ms. Cox has a moral responsibility to inform new patients or their surrogates of her vitalist position on this issue, so the patient or surrogate can timely transfer to another provider in the event that they choose to retain their option to avoid the torture of futile feeding tubes in the future.

REFERENCE

Cruzan v. Director, Missouri Department of Health, 497 U.S. 261, 110 S. Ct. 2841 (1990).

Marshall B. Kapp, JD, MPH

Dayton, Ohio

Response:

In response to Dr. Kapp's critique of my article, I direct the following comments. The ethical integrity of my practice as a gerontological nurse practitioner appears to be in question, as Dr. Kapp directs his comments toward my vitalist position. As I stated in my article, my role as advocate, counselor, educator, and healer of the human spirit is to guide patients and/ or families through a process, not to change their perspectives but to enable them to make informed choices with the patients' central autonomy as paramount.

In the words of Florence Nightingale:

Nursing is an art; and if it is to be made an art, it requires as exclusive a devotion, as hard a preparation, as any painter's or sculptor's work; for what is the having to do with the dead canvas or cold marble, compared with having to do with the living body - the temple of God's spirit? (Calabria & Macrae, 1994, p. 282).

These words have been especially meaningful for me as I have stood by bedsides and watched families anguish over the decisions they have made to withdraw or withhold nutrition and fluids from their loved ones. Death from dehydration, which I have seen over and over again because I do not interfere with those decisions made by families, is extremely difficult to watch by everyone involved in the care of these patients.

One of the dissenting judges in Brophy v. New England Sinai Hospital, Inc. (1986) vividly described this type of death which I have witnessed so many times:

Removal of the nasogastric tube would probably lead to various effects from the lack of hydration and nurtition and ultimately, death. The man's mouth would dry out and become caked or coated with thick material. His lips would become parched and cracked. His tongue would swell, and might crack. His eyes would recede back into their orbits and his cheeks would become hollow. The lining of his nose might crack and cause his nose to bleed. His skin would hang loose on his body and become dry and scaly. His urine would become highly concentrated leading to burning of the bUdder. The lining of his stomach would dry out and he would experience dry heaves and vomiting. His body temperature would become very high. His brain cells would dry out, causing convulsions. His respiratory tract would dry out, and thick secretion that would result could plug his lungs and cause death. At some point within 5 days to 3 weeks his major organs, including his lungs, heart, brain, would give out and he would die (p. 1182).

Yes, this does happen for it is I who have stood at bedsides and have seen the anguish, and it is I who have received the panicked phone calls from nursing home staff "to do something. " Yes, I selectively chose my words. I chose words that had meaning for me just as you have selectively chosen words that appear to have meaning for you. It is obvious to me that you are not or have ever been involved in direct patient care. I would suggest you revisit this topic and speak to nurses who witness this event day after day in our vulnerable nursing home populations.

In the words of Albert Schweitzer, Nobel Peace Prize winner 1952, "If a man loses reverence for any part of life, he will lose reverence for all of life" (1906, p. 106). Yes, I am a vitalist; however, I am first a nurse, and I will keep my patients in my heart, but the silence will also speak.

REFERENCES

Brophy v. New England Sinai Hospital, Inc., 497 New England 2nd Division 626 (Mass. 1986).

Calabra, M., & Macrae, J. (Eds.). (1994). Suggestions for thought by Florence Nightingale: Selections and commentaries. Philadelphia: University of Pennsylvania Press.

Schweitzer, A. (1906). The quest for the historical Jesus. London, England: Oxford.

Monica J. Cox, RN, CS, MSN, MPH, GNP

Dunedin, Florida

IN PRAISE OF PATIENT AUTONOMY

To the Editor:

I appreciated the article in the Journal of Gerontological Nursing by Mattie Tolley, RN, MS, entitled, "Power to the Patient" (Vol. 23, No. 10, October 1997) regarding patient autonomy in nursing homes. She addressed a fundamental issue that nurses need to be sensitive to in their practice with older adults in the nursing home setting. I want to comment on a few aspects of the article that caught my attention. Without knowing a resident well, it is difficult to determine what the "bland stare" of that resident at the television screen signifies. The stare may be a manifestation of an absence of a sense of well-being or it may be an expression of the highest level of engagement with the environment that the resident is capable of manifesting. Nursing homes are filled with people who have significant physical and cognitive deficits. As uncomfortable and unbelievable as it may be to the casual observer, sometimes seemingly aimless activity is a "personal best" for a resident. I do not mean to suggest that blank stares never indicate an impoverished care environment, but there are a fair amount of times when they do not. We need to be careful about having an automatic bias that care in nursing homes is inadequate until proven otherwise.

As Ms. Tolley described and I also believe, there are numerous ways in which nurses can inexpensively and easily enhance resident autonomy. Promoting choice related to bathing routines, daily clothing, activities attended, and some aspects of the dining experience, as well as promoting greater consistency in nursing assignments are strategies that may contribute to the enhancement of resident autonomy. Provision of choices such as these probably do not require the addition of staffing resources. Enhancing staff sensitivity and thoughtfulness to issues of personal autonomy have more to do with value and attitude formation than with issues of staffing and reimbursement.

However, this is not the entire picture. As Rosalie Kane so aptly stated, the "three enemies of personal autonomy for nursing home residents are: routine, regulation, and restricted opportunity" (Kane & Caplan, 1990, p. 19). In the real world, enhanced variety and choice is often associated with increased costs. The carefully prepared meal and individualized service associated with the dining experience in a fine restaurant understandably costs more than the standardized preparation and presentation of a meal at a McDonald's-type establishment. Some choices that may in theory be provided to residents may be beyond the capacity of the nursing home to afford.

The challenge to nursing directors is to identify the current routines of nursing practice or nursing home life that present barriers to resident autonomy and to identify those which may be reconfigured with minimal cost and conflict with current regulatory enforcement.

We will always benefit from asking residents and families what issues of choice and control matter to them. It may be that we are surprised by which issues actually concern the residents and how they might differ from what we think should be matters of concern to them.

Nursing efforts directed at clinical research and regulatory reform may also contribute to the promotion of resident autonomy. More nursing research on the relationship between nursing practice patterns in the nursing home and resident perception of autonomy is needed. Working to change how nursing home regulations are enforced is another way nurses can promote the creation of a practice environment in which innovations, such as those described in Ms. Tolley's article, are the rule, rather than the exception.

REFERENCE

Kane, R., & Caplan, A. (1990). Everyday ethics: Resolving dilemmas in nursing home life. New York: Springer.

Mary Ellen Dellefield, RN, MS

San Diego, California

Response

Ms. Dellefield's comments exemplified the kind of professional reflection that is needed. No "automatic bias" is intended in my observations of nursing home residents. Unlike the casual observer, both Ms. Dellefield and I are professional nurses who have the assessment skills to identify the difference between engagement in the environment and boredom or depression. Unfortunately, in a career spanning more than 30 years of nursing, most of it inclusive of some involvement with older adults, I have seen and continue to see far too many instances when the response of the resident is considered adequate if the resident is quiet and compliant.

If one suspects that the client is seriously neurologically and/or cognitively impaired, there remain techniques to assess and even engage such clients. Naomi Feil's Validation Therapy can be taught to all levels of nursing home staff Her easily readable book, Validation, the Feil Method, How to Help the Disoriented Old-Old (1992), should be read in every facility dealing with the elderly.

Ms. Dellefield's quotation from Rosalie Kane is particuUrly to the point. It is my contention that in the real world one can overcome "routine, reguUtion, and restricted autonomy" without significant increases in cost or staff. My article gave a few specific suggestions, but I am certain there are creative, innovative nurses practicing in long-term care situations who have designed other, perhaps better, strategies. Hopefully, this dialogue will continue with responses from additional nurses who share creative approaches they have implemented. Such field data could stimulate the very research Ms. Dellefield suggests and which I certainly endorse.

REFERENCE

Feil, N. (1992). Validation, the Feil method, how to help the disoriented old-old. Cleveland, OH: Edward Feil Productions.

Mattie Tolley, RN, MS

Weatherford, OkUhoma

10.3928/0098-9134-19980701-04

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