Review: Elder Care Catastrophe: Rituals of Abuse in Nursing Homes & What You Can Do About It (Jason S. Ulsperger and J. David Knottnerus)

Ulsperger, Jason S. and Knottnerus, J. David. Elder Care Catastrophe: Rituals of Abuse in Nursing Homes & What You Can Do About It. Boulder, CO: Paradigm Press. 2011. ISBN 9781594519079, 222 pp.
Price $ 28.95 (Paper).

As the population rapidly ages and people are living longer, today’s Boomers are faced with the complex decision of determining who is going to provide proper care for their elderly parents.  Dependent upon medical, financial, physical, mental and other specific needs, some individuals may decide to care for their parents on their own while others seek out long-term care facilities such as assisted living, adult day care, respite care or nursing homes that provide optimum care. While finding a facility takes time and much thought, the complexity of the issue lies in finding long-term care where elders are treated with kindness, respect, and cared for as human beings; not abused, neglected, ignored or treated as “impersonal, material items” (84).
Authors Jason Ulsperger and J. David Knottnerus investigate the root causes of abuse in nursing homes and other long-term care facilities based on systematic research and sociological theory to help one understand the different types of nursing home maltreatment.  The book is divided into nine chapters. Beginning with identifying the bureaucracy that encompasses today’s nursing homes and other long-term facilities, the text transitions into the history of nursing home care. Final chapters focus on the organizational dynamics and everyday rituals that can unintentionally lead to elder abuse and neglect.
Although present in the 1960s, nursing home care and maltreatment drastically emerged as a social problem and came to the forefront in the 1970s. This resulted in the establishment of the nursing home reform movement and efforts by organizations such as the National Citizen’s Coalition for Nursing Home Reform (NCCNHR) to continue to assume important roles in the history of nursing homes.  Interestingly as the authors point out, even with the development of the Omnibus Budget Reconciliation Act of 1987 (OBRA) also known as the “Nursing Home Reform Act” (59) elder abuse and maltreatment continued to plaque our nation and impact the care of aging adults.  But why?
Bureaucracy and rules impact the overall care for our elderly.  Rules replace compassion.  Government regulations impact how assigned, everyday duties or “rituals” go unnoticed or undone due to daily tasks assigned to specific employees based on skill/knowledge levels.  Simple things such as removing dirty dishes from the table in a resident’s room or seeing a resident stranded in a hallway waiting for someone to roll them back to their room may not get done if top-level employees are the only ones available.  I totally agree that in our complex world rules are a necessity. However environments where people are dependent on compassion and quality care at a time in their life when they are alone, afraid, and/or ill, rules can contribute to unethical and inhumane care.
This book addresses the core issues of elder abuse and maltreatment and provides case vignettes of everyday situations that long-term/nursing facility residents tolerate due to bureaucratic policies. I was angered when I read many of these short stories which depict bureaucratic induced dehumanization of care. The authors stress the need for culture change; shifting away from the traditional nursing home model (130) to a positive, “resident-centered care” model, thus transforming a facility into a home. The authors remind the reader to acknowledge the elderly for the human beings they are and not “unemotional work products” (83). Engage them, don’t isolate and be responsive to individual needs. Hire employees who have the compassion and desire to care for the elderly and not just fill bureaucratic positions based on policies/demographics.
I would recommend this book to any lay person, healthcare provider, nursing facility employee; or anyone from the Boomer generation who may be faced with the decision of one day finding the proper home for a parent.  This book should be required reading for anyone working in a nursing home or long-term care facility as a reminder how not to treat those they are caring for. Although a quick read, this book provides a wealth of advice and strategies for lessening elder abuse and maltreatment. In one of the chapters the authors compare today’s nursing homes to zoos; stressing the point that residents who are unruly and labeled “troublemakers” are often tranquilized and restrained to protect themselves and those around them much like a zoo keeper would do to a wild gorilla. Both have staff ready to contain unruly creatures that cause disruptions throughout the workday, even if the physical welfare suffers.
Two other types of maltreatment the authors identify is “spoken aggression” and “infantilization” (122). Spoken aggression involves speaking to residents in an intimidating, cold tone or calling names (e.g., calling an older female resident a “mean old woman” or yelling at someone to “shut up and eat your dinner”) (123).  Infantilization is speaking in a condescending way that reduces the status of the resident to a young child (117). Healthcare providers need to be attuned to the subtle nuances that can degrade the status of those they are caring for by treating them like children instead of the adults they are.
The world around us is aging and providing compassionate care is the model all facilities should strive toward. The authors summarize the book nicely by concluding that in order to provide such care, nursing homes must undergo culture changes that downplay bureaucracy, revise staff policies, counter loneliness and isolation from the inside, empower residents and respond to their individual needs.

Diane L. Brown, MS
Program Manager II
Medical College of Wisconsin

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