Did We Do This?

I think about all the regulations in long-term care today. The number and scope of F-tags are overwhelming. When I wonder how this happened, I look back and think, Did we do this to ourselves?

Thirty-three years ago I began my journey into long-term care as a nurse aide. We weren’t certified-we were trained by a nurse in the facility, and in my case it was Nurse Betty. She had The Flying Nun nurse’s cap and stood over me with smelling salts when I fainted during the shower demonstration.

It was a rural community and the job options weren’t great. I was 17 and my dad wanted me to work and learn to be responsible. But this was the job from hell; I couldn’t even stomach the orientation. I eventually realized I had found my passion: long-term care. I never dreamed I would have so much fun with the residents. We shared stories, played cards, sang old songs, and watched The Lawrence Welk Show on television. We danced around the dayroom to Welk’s orchestra and had wheelchair races in the hallways. We did activities without even knowing it. And instead of turning beds down at 3:00 p.m., we put people to bed when they wanted to sleep. I enjoyed my job.

LEARNING THE ROPES

After high school I started my nursing studies. I worked in medical records and central supply, where they called me Debbie Do because the DON would say, “Debbie do this, Debbie do that.” I finally graduated from nursing school with honors and with my eye on long-term care, which was frowned upon when I was a student. My classmates could not fathom the idea of working in a nursing home. That was where burnt-out, incompetent nurses went. I couldn’t get them to understand that I was following my passion. I was going to be a geriatric nurse and that’s all there was to it.

At the first facility I worked in, I was doing some patient care when I noticed black stuff in my resident’s belly button. With a pair of tweezers, I pulled out a plug of dirt, leaving a red, irritated area in its place. So I started a head-to-toe assessment. The next thing I knew I was dislodging plugs of wax so big they were just sitting at the opening of the outer ear. I instantly became self-righteous and took the collected “specimens” to my supervisor. Unmoved, he told me about pulling a German cockroach out of someone’s ear.

I was a hands-on nurse. I did first rounds and toileted residents with the staff. At 24 years old, I was the only RN in the building after the DON went home and the facility’s youngest nurse by decades. I was idealistic, full of theories, and naïve. The Nurse Bettys wanted to wring my neck. I thought they were long beyond retirement and should give it a try. The aides, now certified, were older than I was and simply despised me. Luckily, only my tires ever got stabbed, and the closest I came to bodily harm was when a CNA defied gravity and flew over the desk for my throat.

Apparently I was asking life-threatening questions: “You gave her a shower? Well, why is her hair still dry?” All I was looking for was quality resident care, but my coworkers perceived this as evildoing.

I soon became a director of nursing. It was a small facility, the perfect starting place for a young DON. We had made progress since the days when I was a nurse aide. We no longer used vest restraints on our residents. We had a new way to control our geriatric population: chemical restraints. The most popular was called haloperidol, an antipsychotic.

The facility had residents needing limited assistance. They also had residents with no personality and flat affects. The first thing I did with the medical director was begin reducing haloperidol use. It didn’t take long for the families to wonder what had changed with their loved ones. (Mom or Dad was smiling again and more engaging than they had been in some time.) It was a wonderful year. The residents were doing great, the families were happy, and I was proud of what I had helped accomplish.

A NEW AGE OF CARE

Life has a way of altering our plans. I started a family and no longer wanted to expend the energy required by long-term care. I was frustrated and feeling disillusioned. I went to a hospital, worked per diem, and had five wonderful years of medical-surgical nursing. I learned technical skills I never would have been exposed to in long-term care. I moved on to part-time home healthcare and eventually telephonic case management, so I could be home for my children.

Years passed and the kids grew. People talk about giving back. I knew the gift I had to give; I should take care of our geriatric population as I would take care of my own grandparents. I worked for a few years a couple of times a month per diem, just to do something I loved and missed. I dabbled with occasional 3-11 shifts and putting in peripherally inserted central catheter lines as a subcontractor, but didn’t really comprehend the extent of the changes that had occurred in long-term care.

My heart still longed for geriatric nursing. I decided to go back to work full time. At my first job interview in 19 years, the DON asked for my resume. I had never even thought about one as I had been out of the workforce so long. She also asked for references. I told her I had been self-employed for years but would give myself a good reference. We talked some more and she gave me a tour of the facility and introduced me to the administrator. I’d like to think I impressed them. The reality was that they were desperate and I was the best of the small pool they had to choose from.

The common sense rules I was familiar with still existed in long-term care. Things like “clean and dirty don’t mix” and “provide privacy during resident care.” But other stuff had come a full 180 degrees:

• Residents had the right to fall.

• Psychotropic medications were monitored.

• Fecal impactions were sentinel events.

• Meals were to be enjoyed and had evolved into fine-dining experiences, comparably.

• There was a program called “Restorative Nursing.”

• HIPAA wasn’t an exotic animal but a serious confidentiality issue.

I know 30 years ago we thought we were taking good care of our residents. I have to believe we just didn’t know any better. There are many things I see today that I didn’t see when I started this journey. Some things are unchanged, some are worse, most are better.

It’s difficult for me to think we needed all these laws to get us to achieve a minimal standard of care. Yet I look around a facility today and no longer see residents curled in the fetal position. The days of contractures being the norm are over. “Restorative” programs provide ambulation and range of motion. Alarms are ringing, but they draw our attention and we’re keeping our residents safe with better observations instead of physical and chemical restraints. Stool softeners are given routinely and impactions are a thing of the past. Fine dining? Well, it’s much finer than it once was; we try to make meals pleasurable experiences.

Long-term care is a different world from what it was when Nurse Betty revived me. It is evolving. It takes time for trials to be assessed, results to be evaluated, outcomes to be correlated, and improvement plans to be implemented. We’ve made great strides in this field. Did we create this regimented, regulated healthcare system as we learned how many conditions are preventable? I don’t know the exact answer, but I suspect we did, because the goal has always been to improve outcomes.

It’s difficult for me to think we needed all these laws to get us to achieve a minimal standard of care.

It’s important for us as providers to raise the bar and set the standard upon hire. Fair, firm, and consistent is the key, and staff development is an integral component to quality care. Ongoing education empowers our staff to understand the why’s of their jobs. I hope we continue to raise expectations, improve outcomes, and treat our geriatric population with respect and dignity-it’s called “personhood” these days.

Every time I enter a facility as a visitor, an IV nurse, or full-time employee, I use the opportunity to make what could be someone’s last day a better day and make them feel like the special person they are.

ABOUT AANAC

The American Association of Nurse Assessment Coordination (AANAC) is a non-profit professional association representing nurse executives working in the long-term care profession. AANAC is operated by nurses for nurses and is dedicated to providing members with the resources, tools, and support they need in their specialized role of leaders and managers in long-term care. For more information, visit www.aanac.org or call (800) 768-1880.

Debbie Langford, RAC-CT, C-NE, is a registered nurse with a board certification in Gerontology. She is a member of the American Association of Nurse Assessment Coordination and currently works as a unit manager on a Medicare unit in Bradenton, Florida. Long-Term Living 2011 May;60(5):42-43

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