Journal of Gerontological Nursing

Editorial 

A Different View of Quality Care

Kathleen C Buckwalter, PhD, RN, FAAN

Abstract

These days it's difficult to pick up a newspaper or magazine that doesn't have a feature article or headline screaming something to the effect, "Authorities Detect Rampant Nursing Home Abuse" or "Our Seniors Deserve More than Poor Quality Long-Term Care." These sensationalistic headlines sell papers, and, sadly, many of the articles do chronicle real deficits and abuses, made only more acute by the current nursing shortage and problems related to recruitment and retention of quality long-term care providers. This editorial allows me to present a different view of long-term care and to relate a very positive personal experience with two outstanding care facilities. It also affords me the opportunity to publicly thank the nursing staff and administrators who do such a fine job day in and day out, and to tell them their example makes me proud to be a nurse.

My father, William J. (Bill) Coen, Jr. died February 13, 2002 at the age of 87. He had been ill for many years with a progressive dementia (diffuse Lewy Body Disease) that eroded his cognitive and functional abilities. Although his death leaves a void, I am comforted by the excellent care he received over the last 4 years of his life at two small, rural care facilities in Iowa: Liberty Country Living (LCL) and Atrium Village.

Liberty Country Living is an alternative living facility for individuals with dementia owned and operated by nurses. It is a remodeled family home made to accommodate 14 residents for a 24-hour-per-day stay. It also accommodates 2 to 5 persons per day for day care. The Home is located on 5 acres of land on the outskirts of a small community with mature trees, prairie grass, flower and vegetable gardens, and many opportunities to enjoy the out-of-doors. The Home is certified by the Iowa Department of Human Services as a community-supported living facility. The faculty is private pay because Medicaid will not pay for it.…

These days it's difficult to pick up a newspaper or magazine that doesn't have a feature article or headline screaming something to the effect, "Authorities Detect Rampant Nursing Home Abuse" or "Our Seniors Deserve More than Poor Quality Long-Term Care." These sensationalistic headlines sell papers, and, sadly, many of the articles do chronicle real deficits and abuses, made only more acute by the current nursing shortage and problems related to recruitment and retention of quality long-term care providers. This editorial allows me to present a different view of long-term care and to relate a very positive personal experience with two outstanding care facilities. It also affords me the opportunity to publicly thank the nursing staff and administrators who do such a fine job day in and day out, and to tell them their example makes me proud to be a nurse.

My father, William J. (Bill) Coen, Jr. died February 13, 2002 at the age of 87. He had been ill for many years with a progressive dementia (diffuse Lewy Body Disease) that eroded his cognitive and functional abilities. Although his death leaves a void, I am comforted by the excellent care he received over the last 4 years of his life at two small, rural care facilities in Iowa: Liberty Country Living (LCL) and Atrium Village.

Liberty Country Living is an alternative living facility for individuals with dementia owned and operated by nurses. It is a remodeled family home made to accommodate 14 residents for a 24-hour-per-day stay. It also accommodates 2 to 5 persons per day for day care. The Home is located on 5 acres of land on the outskirts of a small community with mature trees, prairie grass, flower and vegetable gardens, and many opportunities to enjoy the out-of-doors. The Home is certified by the Iowa Department of Human Services as a community-supported living facility. The faculty is private pay because Medicaid will not pay for it.

Atrium Village

Atrium Village

Liberty Country Living

Liberty Country Living uses a social model similar to what has more traditionally been used for persons with developmental disabilities or chronic mental illness. The underlying philosophy of the Home is to provide more normal family-type living, support remaining abilities, encourage family involvement, and include residents in all home activities as appropriate. Residents participate in meal preparation, helping with laundry (especially folding clothes), vacuuming, and other home and garden activities as possible. There is an RN nurse manager and relief RNs to provide RN coverage 8 hours per day, 7 days per week. An RN is on call all other times. The staff to resident ratio is 1:5.

Staff are prepared to work with persons with dementia and their role is to "live" with the residents supporting function, preparing meals and dining with residents, planning and carrying out activities at a minimum of three times per day, and cleaning and doing laundry. Resident outcomes have been very positive with less weight loss, sustained mobility, decreased disruptive behaviors and wandering, sustained continence, and high family satisfaction. Best practices are used in provision of care and the Home serves as a practicum site for nursing, physical therapy, and recreation and aging study students, giving them exposure to positive alternatives to nursing home care for elders with dementia.

My father was the first resident at LCL and remained there for a little more than 2 years, until he became so impaired that he required a higher level of care. Though my father's health was deteriorating, he thrived to the extent possible in this setting. He enjoyed many of the available activities, such as music programs and special holiday celebrations.

Faced with the need to relocate, my family and I were fortunate to be able to transfer my father to Atrium Village, a 20-bed intermediate care center co-located with 30 independent apartments in Hills, Iowa. There are many things I appreciated about the care my father received at Atrium Village. Chief among them were the caring and patient nature of the administration and staff, the emphasis on good basic nursing skills and the individualized attention he received. For example, although my father suffered from dysphagia and was on a pureed diet, the staff always took the time to feed him and make sure he was adequately hydrated. This was both complex and time consuming, with the feeding process often interrupted by aspiration, coughing, and mixing fluids with food thickeners.

The staff knew which foods he especially liked, and socialized with him at mealtime, even though he was virtually non-communicative. Unlike so many residents with dementia, my father maintained his weight until he died, and, counter to the powerful ethnographic work of Jeanie Kayser-Jones, his oral health care was excellent and he was never hungry.

When I visited, I was aware that the staff treated him with individualized attention and affection because they were always able to relate some little anecdote or incident that had occurred (e.g., the time Bill blurted out, clear as a bell, "Just call me Louie!"). Their comments revealed a loving nature and the obvious pleasure they derived in caring for Bill - despite the fact that his care was difficult, complex, and at times unrewarding (i.e., Bill was unable to say "thank you" or acknowledge their efforts because of his incapacity). He was totally bea and chair-bound, dependent in ADLs, and incontinent of both bowel and urine, and yet his skin was flawless until the day he died.

Just like at LCL, my mother, my children, and I always felt welcome at the facility, and were extended an open invitation to participate in activities and meals, for instance, any time of the day or night. The staff was knowledgeable, and always kept us informed of changes in Bill's condition or treatments. They were particularly helpful, respectful, and flexible during the last 5 days of his life.

When Bill died, they grieved with us, and this fall the staff will participate in the Alzheimer's Memory Walk in his honor. I could not have asked for better care, and will always feel blessed for the high quality of care he received in the last few years of his life at LCL and Atrium Village. It is my wish that every family could have this kind of positive long-term care experience.

10.3928/0098-9134-20020901-03

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