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Health SA Gesondheid (Online)
versão On-line ISSN 2071-9736
versão impressa ISSN 1025-9848
Health SA Gesondheid (Online) vol.19 no.1 Cape Town Jan. 2014
The GAMMA® nursing measure: Its development and testing for nursing utility
Hendrik J. LoubserI; Judith C. BruceII; Daleen CasteleijnIII
ISouth African Database for Functional Medicine, South Africa
IISchool of Therapeutic Sciences, University of the Witwatersrand, South Africa
IIIDepartment of Occupational Therapy, University of the Witwatersrand, South Africa
BACKGROUND: In the specialised nursing fields of gerontology, oncology, rehabilitation and home-based care where people live with permanent or temporary disabilities, nurses are I unable to perform routine and empirical scoring of their patients' abilities to live independently, because of the lack of valid nursing measures indicating patients' frailty or vulnerability. These independent living abilities are also referred to as the instrumental activities of daily I living (IADLs).
OBJECTIVES: To provide nurses with a nursing scale, named the GAMMA, which enables nurses I to routinely observe, score and record their patients' IADLs and to test its nursing utility.
METHOD: A study with two sequential phases was done. Firstly, descriptive data were collected I from key informants, namely a registered social worker and two registered nurses, skilled in caring for disabled persons living in long-term care facilities. The data were analysed using inductive content analysis techniques in order to design and construct the GAMMA nursing scale. In the second study, the utility of the GAMMA was studied by training and testing the application of the GAMMA within a group of registered nurses (n = 5) working in three I retirement villages. After four months, focus group interviews were conducted with the registered nurses in order to explore the GAMMA's nursing utility. Descriptive data were analysed using deductive content analysis techniques.
RESULTS: The outcome of the study provided good results. High levels of agreement between I participants confirm the GAMMA's acceptance, usefulness and confidence as a nursing scale to empirically establish the transition of nursing care between independent living and assisted living.
CONCLUSION: The GAMMA has the characteristics which allow it to be used routinely as a nursing scale in gerontology, oncology, rehabilitation and home-based care nursing processes.
AGTERGROND: In die gespesialiseerde verpleegareas van gerontologie, onkologie, rehabilitasie en tuisversorging waar pasiënte leef met permanente of tydelike gestremdhede, is verpleegkundiges nie in staat om gereeld en empiries te bepaal wat hul pasiënte se vermoëns is om onafhanklik te lewe, as 'n aanduiding van hul verswaktheid of broosheid nie. Die vermoëns om onafhanklik te lewe word ook na verwys na as die instrumentele aktiwiteite van daaglikse lewe (IADLs).
DOELWITTE: Om die verplegingswetenskappe te voorsien van 'n skaal, genoemd die GAMMA, wat die verpleegkundige in staat kan stel om as roetine prosedure pasiënte se IADLs waar te neem, te meet en te noteer, en om die nuttigheid van hierdie skaal vir verpleging te bepaal.
METODE: 'n Studie met twee opeenvolgende fases was gedoen. Eerstens was 'n ondersoek geloods om beskrywende data te versamel van 'n geregistreerde maatskaplike werker en twee geregisteerde verpreegkundiges wat ervare is in die versorging van gestremde mense wat in lang termyn fasiliteite woon. Die data was geanaliseer met induktiewe inhoudstegnieke om die konstruksie van die GAMMA te ontwikkel. In die tweede studie was die GAMMA se bruikbaarheid vir verpleegkundiges bestudeer deur eers opleiding en toetsing aan geregistreede verpleegkundiges (n = 5) te bied in drie aftree oorde. Vier maande na implementasie het 'n fokus groep met die geregistreede verpleegkundiges vergader om die die GAMMA se nuttigheid vir verpleegkundiges te evalueer. Beskrywende data was geanaliseer met behulp van deduktiewe inhouds analiese tegnieke.
RESULTATE: Die uitkoms van die GAMMA het goeie resultate opgelewer. Daar was hoë vlakke van aanvaarding, betroubaarheid en vertroue in die GAMMA as 'n empiriese verplegingsskaal om die oorgang tussen onafhanklike en ondersteunende lewenstyl te bepaal.
GEVOLGTREKKING: Die GAMMA het die eienskappe om as roetine prosedure gebruik te word as 'n verplegingsskaal in die gerontologie, onkologie, rehabilitasie en tuisversorging verplegingsprosesse.
All longitudinal studies exploring a person's degree of frailty or vulnerability should include the patient's ability to live independently in their chosen environment, usually their own home. The independent living abilities are also referred to as the instrumental activities of daily living (IADLs). Although most research in the area of IADLs continues to be in the science of gerontology, insights into IADLs are also valuable in the rehabilitation sciences, convalescent care and for people living with physical, mental or intellectual disabilities.
The first IADL scoring framework was published in 1969 by Lawton and Brody in their classic article, Assessment of older people: self-maintaining and instrumental activities of daily living, using the phrase 'instrumental activities of daily living'. IADLs are human functions that underpin and sustain more nuanced and complex social activities than the well-known activities of daily living (ADLs). The original Lawton and Brody IADL items include the abilities to use a phone, do shopping, prepare food, do housekeeping, do laundry and to manage one's own transportation, medication and finances. These IADLs are considered to be the minimal daily functions a person must be capable of in order to live independently. Losing one or more of these activities increases the risks with regard to living independently. This correlation between IADL measures and the ability to live independently unlocks the possibility for the nurse practitioner to both measure and quantify the nebulous concept of frailty and vulnerability from its onset and through its progression. Although the terms frailty and vulnerability are mostly associated with the end stages of the ageing process, they also refer to disabled and vulnerable people who are not necessarily old.
According to Pel-Littel et al. (2009), nearly all studies in clinical frailty report deterioration in the person's IADLs. The most common characteristic associated with the elderly person's frailty is an unstable physical and mental condition and diminished physical reserves. When these reserves are exhausted, the decline in daily functioning manifests itself. Markle-Reid and Browne (2003) refer to this critical point where the balance is disturbed as being the indicator that the frailty threshold has been exceeded. Thus, the extent to which deterioration of IADLs is detected becomes a determinant of the onset of frailty in elderly or disabled persons.
According to Lynch (2004), physical ageing is associated with a progressive loss of muscle anabolic hormones and growth factors, leading to loss of muscle mass (sarcopenia), a slowing of movement and a decline in strength. These factors increase the risk of injury from sudden falls in the frail elderly and leads to growing dependence on others to accomplish even the most basic tasks required for independent living. There is a debate as to whether these intrinsic changes are immutable or reversible. However, there is a definite need for restorative nursing strategies that can slow the effects of ageing on muscle function and restore muscle size and strength in the frail elderly in order to maintain or even improve their quality of life.
The consequences of frailty are usually measured in terms of mortality, morbidity and institutionalisation. The frail population, as a result of either the ageing process or disability, are vulnerable to increasing dependence and are at a higher risk of being institutionalised (Bandeen-Roche et al. 2006). They therefore risk a lower quality of life than their non-frail peers (Strawbridge et al. 1998). Their unstable physical and mental condition and diminished physical reserves also leave the frail elderly vulnerable to illnesses and at risk of injuries requiring admission to acute nursing care settings (Van Helden et al. 2008). Pel-Littel et al. (2009) report an absence of a gold standard to measure frailty, meaning that it is not yet possible to comment on the validity and reliability of the diagnosis of frailty. Although a limited number of total frailty tests have been developed, little is known about their validity.
Problem statement
The consequences to the nursing profession of not being able to measure physical frailty and vulnerability mostly relate to the planning and management of nursing services to these populations. In South Africa, the gerontological nursing services have a structured approach in supporting the independent living needs of elderly persons. This usually starts with periodic home visits to older persons living independently in order to assess their needs for supportive services. These nurses are known as 'cottage nurses' in the retirement village industry. If nursing support is required and rendered, allowing the older person to continue to live independently, the person is considered to be receiving 'assisted living nursing services'. When the burden of rendering assisted living services reaches a distinctive peak, the older person is triaged, depending on the need, to either frail- or Alzheimer-institutionalised living nursing services. Finally, the end-of-life care needs are taken care of, with an emphasis on dignity preservation. These levels of care, settings and services are all managed by the nursing profession and are based on rendering functional support to the elderly person. However, without an empirically-sound measurement of elderly persons' functional abilities to live independently, the triaging of an elderly person between these interfaces remains subjective and often becomes a matter for debate between the elderly, their families, the nurse and the management team of the retirement village. This is even more so when the high costs of rendering assisted living and frail care are taken into consideration.
Purpose and objectives
The purpose of this study was to avail nurses with an objective and useful nursing scale that can be used routinely to score their patients' IADLs. To achieve this, two objectives were identified, each to be achieved in sequential phases:
• Firstly, to design and develop the GAMMA as a nursing scale that will allow the nurses to observe, score and record their patients' IADLs routinely. • Secondly, to test whether the GAMMA has nursing utility, that is, whether the GAMMA is acceptable enough to the nurses, to the extent that they would embrace it as a useful nursing scale to be used routinely.
Restorative nursing activities include the observation of frail and vulnerable persons performing their daily IADLs, whilst scoring and recording their performance of these activities. Nursing auxiliaries (NAs) and caregivers (CGs) provide 90% of the care at this patient-nurse interface (Resnick 2004), but they are currently unable to provide a scoring for the daily IADLs as no such nursing scale exists. This leaves the nurses without any empirical data regarding patient frailty and vulnerability on which to base their restorative nursing assessments and care plans. Furthermore, there are no routine longitudinal datasets on patients' restorative outcomes. This study will contribute to such data and resolve this paucity.
Definition of key concepts
The name GAMMA refers to the third letter in the Greek alphabet and is the third in a suite of routine nursing measures being developed by the researchers. In Figure 1, a graphic impression of the items measured in the GAMMA is presented and in Figure 2, a decision tree is presented in order to illustrate how nurses arrive at these categories.
Restorative nursing
Sister Verah McIver, in 1967, created an ability-enhancing nursing model through training programmes for NAs and management and supervision programmes for registered nurses in charge of units. She called it the Restorative Nursing Care Model. Contemporary definitions refer to it as an enabling nursing process aimed at promoting physical and personal independence in order to restore the dignity and wholeness of the patient or disabled person (Mantle & Funke-Furber 2003).
Nursing utility
The utility of an instrument is the degree of conviction the users have regarding its usefulness in their professional practice (Toomey, Nicholson & Carswell 1995), taking into consideration application practicalities such as relevance, suitability, feasibility, accuracy, comprehensiveness, credibility, flexibility, value and adaptability (Barbara & Whiteford 2005). As the GAMMA is intended to serve the nursing profession, this article would refer to its nursing utility.
Scale versus measure
In general, the terms 'scale', 'instrument', 'test', 'tool' and 'questionnaire' may all refer to the concept of producing numerical scores in order to explain a phenomenon at an ordinal level (Bond & Fox 2007). However, none of these terms refers to a 'measure', which identifies a higher level of measurement qualities, namely linear interval characteristics
(Stevens 1946). During its development, the GAMMA is ordinal in nature and should be referred to as a 'scale'. Only when the GAMMA's construct validation with Rasch analyses has been proven successful, may it be referred to as a 'measure' (Loubser 2012).
For the sake of uniformity, 'patients' include all clients, residents, persons, elderly persons and people living with intellectual, physical and/or mental disabilities receiving any extent of nursing care.
Independent living
Independent living refers to patients who have the ability, self-reliance and self-confidence to continue living in their own home without supervision or support.
Assisted living
Assisted living refers to patients living with frailty, disability or an impairment that requires on-going supervision and support in order to continue living in their own home.
Registered nurse
A registered nurse (RN) is a person who has completed a four-year academic programme in nursing or a two-year bridging programme at an accredited Nursing Education Institution (NEI) and who is registered with the South African Nursing Council.
Nursing auxiliary
A nursing auxiliary is a person who has completed a one-year academic programme at an approved nursing school and who is enrolled with the South African Nursing Council as a nursing auxiliary.
Research method and design
A study with two sequential phases, as described below, was executed sequentially in order to satisfy the two objectives mentioned previously.
First phase: Development of the GAMMA
Research design
A qualitative, exploratory and contextual research design was followed in the development of the GAMMA. Qualitative research seeks to understand the actions and processes within the specific context of restorative nursing for persons requiring assistance with regard to living independently. Explorative research actively examines this interface as the specific phenomenon of interest rather than merely observing and reporting (Lobelo 2004:20). A panel of experts in assisted living were selected purposively to be involved in the review of existing instruments and their revision and development so as to comply with nursing utility specifications. The participation of experts, according to Foxcroft et al. (2004), contributes significantly to the content validity of the expected scale.
At the onset of the study, three key informants were selected based on their expertise in restorative care. They were a social worker with extensive practical experience in designing restorative methods for people with intellectual disabilities to live independently and two RNs. The first RN had 17 years' experience working as a 'cottage nurse' in a large retirement village; and the second RN had 11 years' experience working in the community rendering home-based care to patients requiring convalescent care after discharge from acute or subacute facilities. These three participants were selected purposively for their expert intuitive knowledge gained from their extensive experience in the restorative care of three diverse groups of patients, all at risk of frailty and vulnerability and thus requiring similar considerations.
Data collection
Unstructured individual interviews were held with each of the key informants so as to explore and understand what their daily tasks entailed, why they were doing what they were doing, what they hoped to achieved and, finally, how they knew they were successful in what they were doing. The discussions were open but at the same time focused on probing their perceptions of what is considered to be improvement or decline and how they could recognise a change in the patient's ability to live independently. These interviews were recorded and transcribed and field notes were taken.
Following key informant interviews and the documentation of the data, the Lawton Scale (Lawton & Brody 1969) was introduced to each informant individually in order to verify its usefulness in their work environment. Their individual responses were documented carefully in field notes.
Data analysis
When data saturation had been achieved, the interviews were stopped and data analysis commenced. An inductive content analysis technique was used as no previous studies were found to have dealt with this particular phenomenon. Firstly, using the Lawton Scale as the departure point, consensus was achieved on the core items that infer to the wider concept of independent living. Consensus was achieved on eight items, which then served as the coded descriptive dataset for content analysis. This was followed by an analysis of each item in order to establish a framework of categories representing seven sequential steps of ability from 'not able at all' (score 1) to 'fully able' (score 7). The informants participated not only in the design and development process, but also in the reviews, editing and final approvals. When completed, the GAMMA manual for training, testing and credentialing of prospective users was concluded.
The informants' collective concern was that the Lawton Scale was not an observational scale but a questionnaire that would introduce bias from discerning patients dreading change. However, they were satisfied that the structure of the Lawton scale could be converted into a routine nursing scale. With the Lawton Scale's potential to be developed into an ordinal nursing scale, the participants proceeded with the reconstruction of the Lawton Scale in order to perform an empirical assessment of their patients' independent living abilities. This reconfiguration of the Lawton scale was facilitated by means of probing questions. The advantages of the unstructured interviews were that participants' non- verbal behaviour and mannerisms could also be observed and answers could be clarified if misunderstood.
From the onset, there was consensus that the GAMMA must satisfy the following four objectives:
• The GAMMA must be useful at the nurse-patient interface when independent living abilities are a concern. The GAMMA scores must facilitate a uniform language in IADL restorative nursing.
• The GAMMA instrument must improve the quality of IADL restorative nursing services.
• The GAMMA must fit into the nursing process and care plans for persons living independently.
Finally, the first study resulted in a GAMMA scale consisting of eight items as illustrated in Figure 1 and an organised structure of the categories of the item 'Eating' as illustrated in Figure 2. Because of space constraints, the remaining items cannot be published.
Meal preparation
The definition of meal preparation is the ability on the part of the subject to prepare a nutritious meal. This includes: (1) planning (setting up a nutritional menu and shopping list); (2) setting up (e.g. using microwave/kettle, etc.); (3) preparing (e.g. peeling vegetables, making a sandwich, etc.); (4) cooking (e.g. boiling, frying, grilling, baking); and (5) dishing up (e.g. laying out eating utensils, dishing food onto plates or into storage containers, etc.).
Second phase: Establishing nursing utility
Research design
To establish the GAMMA's nursing utility, a qualitative exploratory descriptive design was followed. Focus group interviews were used to collect narrative data as nurses described their experience of implementing the GAMMA over a period of five months.
Population and sampling
To prevent bias when testing nursing utility, a new nursing population, unfamiliar with the GAMMA, was required to provide the information to analyse its nursing utility. Five registered nurses working in three retirement villages for a minimum period of three years were selected purposively because of their skill and good intuitive understanding of their client's ability to live an independent life. During the course of their work, they have observed their patients performing their daily IADLS without applying a scale or any other type of nursing measure. None of these nurses were involved or had any previous knowledge of the GAMMA or its development. Once their voluntary participation was confirmed, they were issued with the GAMMA manual, then trained and tested until they were proficient in the application of the GAMMA. No further exclusion criteria were applied.
Data collection
The RNs were originally asked to do a cross-sectional score of all the residents in their retirement village as additional information during their nursing assessment. However, once they experienced their ability to place an empirical value on a previously nebulous quality they collected scores longitudinally on their more vulnerable patients in assisted living units. The patients were observed according to the training manual and the nurses arrived at a specific score. The scores were recorded empirically in hard copy in the nursing records. The nurses could also plot the scores on the radar graph (Figure 1) in order to view the patient's ability graphically. A software database was provided for use in the importing of the GAMMA scores and to generate radar graphs of patient abilities, which could be printed as hard copies.
A focus group session was held with five nursing participants to explore the usefulness of the GAMMA in the nursing care plan of retirement villages. The participants were given the opportunity to express themselves in as much detail as possible. The exploratory nature of the research helped the researcher to gain a deeper understanding if, how and where the GAMMA changed their work experience. The discussion followed a semi-structured approach, whereby the four objectives for the development of the GAMMA (detailed under 'Data collection') were used to verify and simultaneously collect the richness of the descriptive information. Mannerisms and non-verbal behaviours were observed and recorded and statements or comments could be clarified if misunderstood. The interview was recorded and transcribed.
Data analysis
In the first phase, the GAMMA was developed with informants experienced in the observation of patients with impaired IADLs. As a result, the GAMMA can be assumed to have a high degree of nursing utility (Hsieh & Shannon 2005). Therefore, a deductive approach to content analysis was followed by creating a coded framework for analysis using the same four broad objectives used in the development, namely:
• Determine usefulness at the nurse or patient interface (code A).
• Facilitate a uniform language (code B).
• Improve the quality of nursing services (code C).
• Fit the nursing process and care plans (code D).
As a result, the four objectives were posed as four broad questions to the participants in order to retest the assumption that the GAMMA does indeed have good nursing utility. These four questions were thus anchored as the four categories for deductive content analysis (Hsieh & Shannon 2005).
Ethical considerations
This study was approved by the Human Research Ethics Committee (Medical) of the University of the Witwatersrand and an ethical clearance certificate (M 10524) was obtained in May 2010. Written approval from managers of the clinical facilities was also obtained. The purpose of the study was explained to the participants before data were collected. The participants gave written informed consent to be involved in this study on a voluntary basis. Participants could exercise their right to withdraw from the study at any time without penalty or prejudice. The researcher also ensured anonymity and privacy and the protection of participants against discomfort or harm, be it physical, emotional, spiritual, economic, social or legal.
The four criteria of trustworthiness, namely credibility, dependability, confirmability and transferability, were adhered to. Credibility was achieved by prolonged engagement with the participating nurses, allowing enough time during the interview to verbalise their perceptions regarding the development and utility values of the GAMMA. Sections of this study were also examined by internal and external examiners as part of a PhD thesis awarded by the University of Witwatersrand.
Dependability was achieved by means of a detailed description of research methodology, peer review and triangulation of sources, namely empirical data and literature control, as well as through the use of a coding process during data analysis.
Confirmability was achieved through the use of a detailed description of the research process, as well as during data collection through unstructured individual interviews where audio recordings were used and detailed field notes taken.
Transferability was achieved through the purposeful selection of the sample, as well as a dense description of the research methodology and results of the study, so that researchers who are interested in conducting similar research could be thoroughly informed.
In an attempt to convey the richness of the data as expressed in the language used by the participants in the focus group, any direct quotations used must be interpreted as coming from a spokesperson in the group when expressing an experience or opinion. Some responses are paraphrased, rather than providing direct quotes. The codes (A1, B2, etc.) were used to classify the relevant response under the coded framework when doing the data analyses.
The nurses agreed that the GAMMA empirical scores and radar graphs of patient functioning 'really give you a picture of the residents' ability' (A1) to continue living independently. Importantly, the GAMMA 'helps to evaluate the person with a holistic approach as it shows how the person functions as a whole being' (B1). As a result, it also gives the nurses a new and 'more comprehensive awareness of the needs of the residents' (A2, B2, C1, D1) which would enable them to continue living independently. The ability to record this status empirically and to monitor functional ability empirically over time in a resident facility is of particular significance.
With the GAMMA scores now available and illustrative of what the patients are capable of and what they are not, the nurses have become aware of their own shortcomings in rendering appropriate supportive services in order to address patient needs. Nurses now realise they need to 'totally move away from the old way of nursing and caring' (A3, C2) by first evaluating the patient's capabilities and then find new techniques and care plans with regard to 'trying to help the person to continue in a process of being able to help himself for as long as possible' (A4, C3). Nurses have also discovered that by continuing with the traditional methods of nursing care, they were 'giving help without specifically doing something to slow the process of decline' (A5, C4). It has become clear that they should move away from the ever-increasing nursing support to rather focus on early intervention with restorative methods and techniques in order to 'keep them [the patients] independent for as long as possible' (A6, C5, D2). Evidently, nurses in geriatric nursing have become aware that their main focus can no longer only be 'structured around the medical side, maintaining hygiene and manage medication' (A7, B3, C6, D3). This will have to include techniques 'to secure independent living for as long as possible' (A7, B3, C6, D3).
The GAMMA seems to be particularly useful in its ability for the early identification of preventative problem areas that can be resolved with pro-active restorative nursing, allowing residents to maintain their independence longer. For this reason it is a valuable tool for the cottage nurse as it 'makes her look at [be aware of] the various segments of what is going on in the independent and assisted living scenarios' (A8, D4). Previously, the 'items addressed by the GAMMA were overlooked, taken for granted, or nurses were not even aware of its importance to promote independent living' (A9, B4, C7). Following on this evidence, the participants concurred that the GAMMA nursing scale is useful and contributes significantly to the nursing care plan and process.
The caring professional nurse's motto is 'I want to help you', but then they wrongly identify nursing tasks to make the person dependent on the nurse. The 'GAMMA has changed this mind-set' (A10, C8, D5). With the comprehensive view rendered by the GAMMA, the nurse is now compelled to make a paradigm shift when considering what nursing techniques the patient requires in order to maintain their independence. For this reason, 'the GAMMA should form an integral part of the nursing process' (D6).
The participants, however, warned that by nature nurses are very task oriented and the difficulty is going to be to turn the staff away from this, toward a restorative approach in maintaining the patient's independence. However, with proper training, support and supervision, nurses envisage that the implementation of the GAMMA will benefit everyone. Currently, every nursing day is inundated with nursing tasks and, as the residents become older and frailer, these tasks increase. The value of the GAMMA nursing scale lies in its ability to diagnose the primary causes of oncoming frailty much earlier and to point out the area where early restorative support is needed in order to maintain independence for as long as possible (A11, C9, D7). Training of nursing auxiliaries should be focused not only on how to use the scale but, more importantly, on 'looking at what the scale is pointing out to you and trying to better that [weaknesses] rather than listing it as a new nursing task' (A12, C10, D8). To entrench this 'new way of thinking' might be a challenge, but if successful, it would reduce the nursing burden of perpetual task rendering (A13, C11, D9). The consensus was that the GAMMA will facilitate this process and 'at the end, it is going to be easier on all the staff from not being task orientated [sic]' (A14, B5, C12, D10).
The participants were determined that, if implemented correctly, the GAMMA will facilitate major improvements in the quality of nursing of older persons (C13). If nurses merely observe and record the GAMMA indicators and do not act upon them appropriately, the quality of nursing care will not be enhanced (C14). Implementing the GAMMA requires a comprehensive care team which includes the non-nursing staff members such as the observant caregiver, gardener, cleaner, reception staff, administration person and, most importantly, the manager. The care team also has to include the patient and/or resident and their family members. 'The simplicity of the GAMMA includes everyone' (B6). Everyone must be aware, observant and report to the nurses when they observe any changes in patients (B7). However, it is the nurses' responsibility to score, record and respond both appropriately and timeously.
Interesting and unforeseen evidence was provided on the improvement of communication and relationships between the nursing professionals and the village managers and trustees. Nurses have found the GAMMA scores and radar graphs to be a useful tool and language in communicating meaningfully with the managers and village trustees about the aging residents' abilities and needs (B8). The nurses reported a sudden clarity and interest shown by the managers and trustees (B9). This new simplistic intelligibility has motivated 'managers [to] request that all new prospective residents are screened using the GAMMA nursing scale and radar profile to establish (and communicate) the level of care to be provided' (B10). The nurses also reported significant buy-in amongst 'managers [with regard to] use [of] the GAMMA as the point of departure at meetings with the nursing staff' (B10). Furthermore, the managers also 'request the GAMMA scores and radar graphs as an information briefing before entering into family meetings on resident issues' (B11). The GAMMA scores also seem to help the 'manager to have a better understanding of the nursing complexities' (B12), thereby initiating a more reassuring relationship when nurses have to implement new and creative restorative techniques in order to facilitate independence.
In some retirement villages, the auxiliary nurses had already been given an informal GAMMA introduction. 'High levels of acceptance and job satisfaction amongst the auxiliary nurses' were reported (A15, B13, D11). With their new intelligence, the auxiliary nurses communicate continuously and test their scores with the other nursing staff, report when they observed increased scores as a method of seeking acknowledgement and seemed eager and ready to implement the GAMMA officially. 'They are like a sponge ready to draw up the knowledge' (A16, B14, C15, D12).
In the last question for suggestions on improving the GAMMA, a concern was raised that the GAMMA item that scores self-medication creates a problem. As the Medicines and Related Substances Control Act 101 (South Africa 1965) on medication stands now, the GAMMA score 4 on self-medication cannot be utilised as Medicines and Related Substances Control Act 101 forces nurses to fill the daily boxes, thus arriving at a score of 3. This irregularity in nursing logic might impact on the validity of the GAMMA. In the final analysis, a suggestion was put forward to consider collapsing the two items pertaining to transport, for example, home-care accessibility and commuting, into a single item. The nurses also remarked that the emotional stability item is not an easy item to observe and might require further work.
In concluding the interview, a nursing professional in the position of retirement village manager provided the following conclusion:
'[it seems that the GAMMA] brings the quality [of nursing] care to its rightful position. Quality care can now be processed, managed and maintained in a very scientific way. It is important as it forms an integral part of the nursing process. You got quality care that you can measure and that is very important. The results you get with the GAMMA scores allow you to maintain and enhance quality care ... and you can calculate it [provide empirical proof].' (A17, B15, C16, D13)
Prior to the GAMMA nursing scale, nurses working with elderly, frail and disabled persons were not able to establish empirically whether their patients benefited from the care they receive. This also puts nurses at a further disadvantage as they cannot manage the nursing process without measurements. Without a measure to provide empirical evidence of a patient's functional gains, the emerging science of restorative nursing (Resnick 2004) may lack scientific merit. These studies are the first of, hopefully, many research papers that will pre-empt the development of a new branch of nursing science: restorative nursing science in South Africa.
Without any training in restorative nursing techniques, nurses working with frail and disabled patients have discovered by themselves when implementing the GAMMA that it is not their primary task to do everything for the patient, but to score and assess the patients' functional ability and to find ways and means to improve the previous score. This was explained by a respondent in the second study that nurses became aware that 'looking at what the scale is pointing out to you and trying to better that [weakness] rather than listing it as a new nursing task' (C1). This finding indicates that the GAMMA has the potential to transform nursing from an input-driven science to a patient outcomes-driven science. To achieve this, nurses have recognised that they must adopt the basic principles of restorative nursing (Resnick et al. 2009). In practice, this new awareness has many beneficial implications for the nurses. It has challenged nurses to substitute their monotonous and laborious task-directed input approach with personal challenges and achievements that are evident in their patient outcomes. The results further indicated that the ultimate beneficiaries are the patients who regain their independence. This has improved the quality of the nursing process significantly.
More interesting was the observation that the GAMMA facilitated a new universal language at all possible levels: (1) the retirement facility management requires GAMMA scores on patients at their meetings, (2) the auxiliary nurses find it useful to apply in their daily interactions and (3) the gardeners, drivers, cleaners and administration staff all become aware of the person's functional status and report back to the nursing staff if they observe a change. The GAMMA created a standardised format for a comprehensive care team to work together, focusing on the same goal, namely, improving patient functionality. This is a patient evidence-based outcomes approach.
Limitations of the study
Had time and cost not been constraints in this study, the sample should also have included other case-mixes such as persons living with intellectual disabilities, congenital disabilities, post-trauma disabilities or chronic or terminal disease that render them progressively disabled.
The RNs reported that high levels of acceptance were found amongst the auxiliary nurses in the use of the GAMMA. In retrospect, it is a key limitation of this study that auxiliary nurses were not included in the second phase of this study.
Future education and training programmes that prepare practitioners for care of the aged and for persons living with physical and intellectual disability should include training in the application of the GAMMA nursing scale. It should also include restorative care-plan methods and techniques to help patients advance on their GAMMA scores. Furthermore, professional nurses must implement the restorative care mindset into the nursing process and discover ways to manage it effectively.
The change from traditional curative practice to restorative practice is a necessary mindshift that many nurses may find difficult. Changing the nursing focus from implementing nursing tasks to actively improving patient independence will require on-going motivation and reassurance of RNs and other categories of caregivers. This study showed that the GAMMA could an important facilitator for the process.
A recommendation for further research is to follow up this study with an investigation to establish whether the GAMMA scale can also function as an interval measure, meaning that its construct validity must be subjected to Rasch analyses. However, the follow-up Rasch analysis can only be completed when enough GAMMA scores have been collected. The Rasch results will guide the researcher with regard to verifying the potential structural weaknesses in the scale that must be rectified before it satisfies to the characteristics of an interval measure.
Finally, the recommendations from the participants on improvements of the GAMMA must be addressed.
Strong implicit and explicit evidence supported the GAMMA's nursing utility with regard to facilitation of a restorative nursing process. It has made the nurses aware of the value of having the IADLs embedded into the restorative nursing process. This was manifested in the ease with which the extended care team are able to recognise, observe and express the GAMMA scores in their daily routine and, implicitly, with the apparent new awareness that improvement in GAMMA scores has a direct correlation with improvement in the patient's independence and resultant wellbeing.
The GAMMA was developed by South African nurses for South African nurses in order to render better restorative nursing care for patients requiring IADL functional gain. The nursing participants in this study were very receptive with regard to developing and applying the GAMMA. The nurses reported the GAMMA to be a useful nursing measure that would improve the quality and effectiveness of nursing care for patients with restricted independent living abilities.
The authors would like to acknowledge the nurses that participated voluntarily in the study and also their colleagues from the School of Therapeutic Sciences at the University of Witwatersrand for their support as peer reviewers in the study, specifically Dr Marietha Nel for her scientific and language editing.
Competing interests
The South African Database for Functional Measures (Pty) Ltd provided financial support for this study. Although the SADFM gave written permission to publish this article and although the copyright of this article vests with the publishers, the patent rights of the GAMMA vest with the SADFM (RSA patent registration number 2008/09086).
Authors' contributions
This article was based on the primary research done by H.J.L. (South African Database for Functional Medicine) under the supervision of J.C.B. (University of the Witwatersrand) and
D.C. (University of the Witwatersrand) for the PhD thesis titled 'The validation of nursing measures for patients with unpredictable outcomes'. The draft was formulated by H.J.L. and J.C.B., with D.C. contributing to the finalisation of the article.
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Hendrik Loubser
PO Box 2356
Houghton 2041, South Africa
Email: email@example.com
Received: 26 Apr. 2013
Accepted: 28 Oct. 2013
Published: 03 Mar. 2014


text:
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subset: commoncrawl


text:
Wednesday, 28 April 2010
ewe must try this: runny cheese fun with torta cañarejal
I've been eating 'funny' (as one of my grandmothers used to say) cheeses for very many years. My dad has always loved cheese and, way back when I was a wee thing, at the end of each week, instead of spending his wages at the pub, he used to seek out the best cheesemonger he could find. Armed with his parcels of cheesy goodness, he'd then stink out his fellow commuters on the train home. My, how they must have loved him, particularly in the dog days of summer. You have to bear in mind, too, that this was back in olden times when most folks were used to little more than plastic cheese, and Red Leicester represented the height of exotica. Looking back, I'm surprised MI5 weren't watching such a dangerous subversive.
Roll on a few decades and both his and my love of weird and wonderful cheeses happily endure. Lord knows how many I must have tried, eaten, and generally gorged on, but the figure must run into the many hundreds. I love them ALL. (Well, all except the fudgy Norwegian Gjetost, which - try as I might - I just can't get along with. It messes with my tastebuds and brain.)
But until a few days ago, there was one cheese that I'd not come across before. It was being pushed forward by my local deli, owned by two chaps who have a particular penchant for all things Spanish and Italian. And that's it, at the top of my post - torta cañarejal, a Spanish ewe's milk cheese.
So far, so cheesey. I asked about it. 'Slice the top off, dip things like crudites into it, and eat. You don't have to do anything to it - no baking, no nothing.'
Crikey. So that's one over on Vacherin, then, isn't it? No baking, even. Dippy cheese to go, no less. How very fab. Better give it a whirl, then.
And so we did.
Step 1. Slice the top off. This, I can do.
Step 2. Have crudités prepared for dunking. This I can do, too. We have carrots, roasted cauliflower (in rapeseed oil), and baby potatoes slathered in butter and wild garlic. Oh, and some leafy green stuff to cancel out the cholesterol, natch.
Step 3. Dunk. Easier said than done. This baby is VERY runny. In fact, a spoon is a good plan.
Step 4. Repeat.
Step 5. Repeat.
Step 6. Repeat until fade.
But the fun doesn't end there. Oh, no. Here's where there's another advantage over Vacherin - you can eat the outer, firmer layer and rind! That's if you have any room left. I didn't, but still went ahead anyway. Some things are just too good to pass up.
Torta cañarejal is not only good, it's a must if you're a cheese-lover. It's mellow but with a distinctive tang of sheep, slightly sweet (Ferran Adrià used to serve it with red fruits and honeyed meringues, apparently), and creamy. It has something of a Camembert about it, but is infinitely more interesting than that.
But, best of all, it's possibly the most edible fun you can have with a whole cheese. For 2 cheese lovers, it's the perfect tasty, simple, and sharing meal. Well, I say 'perfect'. Let's just say it's all fine and dandy until the level of the runny cheese starts getting low. At that point... well, it can become a bit of a no-holds-barred fight to the finish ;)
Do you love someone enough to give them the last scoop of runny cheese? Share one of these (or a Vacherin, if you must - though you'll find they've just gone out of season now) and you'll soon find out...
27 comments:
- Niamh said...
OH, Helen! SWOOOON! Where can I get me some? I adore ewes cheeses -my favourite by far. I've got to try it.
- 28 April 2010 at 14:16
- Signe said...
Love it! I had this for the first time and it was AMAZING, such good gooey cheese. Lovely post :)
- 28 April 2010 at 14:20
- Catalan Cooking said...
I love that cheese. We had it at the class and it was very very popular. Beautiful photos to drool at.
- 28 April 2010 at 14:24
- Becci said...
I gotta get me some of that. It looks like heaven.
- 28 April 2010 at 14:30
- Choclette said...
Great post, great cheese - at least you make it sound great. I certainly want to try it!
- 28 April 2010 at 20:13
- Helen said...
Absolutely gorgeous - I mean - melted cheese. Incredibly, other half hates melted cheese so I would have to eat the whole thing myself. Shame. I would have to dunk bread in it. Healthy!
- 28 April 2010 at 20:30
- Helen said...
Oops, effed up my commenting there didn't I...
- 28 April 2010 at 20:30
- Kavey said...
We had some of this at Rachel's Catalan Cooking class and it was amazing, utterly fabulous.
MUST get my hands on more...
- 28 April 2010 at 22:06
- Sarah, Maison Cupcake said...
Oh wow! And I love your "ewe" pun!!
- 29 April 2010 at 08:10
- aforkfulofspaghetti said...
Niamh - I think Brindisa will be a good bet... ;)
Signe - thanks, Sig
Catalan Cooking - I'm not surprised it was very popular. What's not to love?
Becci - yes, yes, you have
Choclette - do!
Helen - best thing of all is that you don't have to do any melting...
Kavey - yes, you must!
Sarah - hee hee... ;)
- 29 April 2010 at 08:51
- Helen (Fuss Free Flavours) said...
Oh my that does look good.
There are very few things better than a non melted liquid cheese.
- 29 April 2010 at 22:18
- Jacqueline said...
Nom nom! I love it, must get my hands on some :)
- 29 April 2010 at 23:20
- meemalee said...
I'm not really a cheese person, but I really, really like Vacherin so I know I'll adore this :)
Love the gooey pictures!
- 30 April 2010 at 12:39
- pigglet said...
any idea where i can get some? i am in sussex.
it looks soo yummy
- 1 May 2010 at 21:50
- Foodycat said...
How gorgeous! I'm amazed that it is that runny at room temperature!
- 2 May 2010 at 14:57
- aforkfulofspaghetti said...
Helen - couldn't agree more ;)
Jacqueline - yes, you must!
meemalee - if you love Vacherin, you'll love this
pigglet - a good cheesemonger should have it (if they don't - ask them to stock it!). If you don't have one near you, try http://www.brindisa.com/
Foodycat - quite a revelation, isn't it?
- 3 May 2010 at 11:04
- Margaret said...
Mmm you have sold me on this one. No baking and a runny cheese too, I will have to look out for this.
- 4 May 2010 at 13:55
- Katie said...
Should this cheese even be legal?! Definitely one to be rolled out for a cosy night in with my fella.
I tried Ewe's milk ice cream recently (well iced dessert but you can't call it that coz it hasn't got enough fat in it!) and it tasted super lush! I know it's not cheese, but have you tried it?
- 4 May 2010 at 21:11
- Helena Lee said...
What a fantastic step-by-step guide - reading this before breakfast is a baaad idea (awful pun - sorry!) x
- 5 May 2010 at 09:16
- Pam said...
Oh, there's nothing better than cheese! I love this and can only imagine how good it tastes!
- 5 May 2010 at 16:18
- George@CulinaryTravels said...
Oh my, I have got to get my hands on some of that. It sounds amazing.
- 6 May 2010 at 10:55
- Cynthia said...
I've never had any ewe cheeses :(
- 6 May 2010 at 21:53
- Heather said...
I can't get along with gjetost either. It wants to be chocolate.
- 8 May 2010 at 17:29
- Sophie said...
Waw!! What a superb & divine looking cheese!! Thanks for introducing it to me!!
I will thry this lovely cheese!
- 9 May 2010 at 16:53
- Lizzie said...
HOLY MOLY! That looks brilliant. Great pics.
- 16 May 2010 at 22:53
- Yelp Clone Script said...
Nice post. Great blog. Thanks for sharing.
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- 8 July 2011 at 09:49
- Esther Fuentes said...
Nice blog and amazing post!
I'm from Barcelona, and I'm so surprised that you know these cheese. I love cheese from everywhere, but I have to recognized I didn't know this one.
I try to find these cheese, as soon as possible!!!
If you love this kind of cheese try to taste "Torta del Casar"http://www.sierrademontanchez.es/producto_de_extremadura-212-hp_manjar_extremeno. It's one of the best creamy cheese of Spain. Kind regards,
Esther Fuentes
- 9 May 2012 at 00:12


text:
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text:
Truth be told, I still purchase cow's milk for my daughters (gasp I know). I also on occasion drink it myself in the form of a latte, which honestly is quite rare as I prefer an Americano or regular coffee over many special drinks.
A couple months back I was having some away time to write and noticed the coffee shop offered almond milk. This isn't too surprising to find in a place like Bellingham with independent coffee shops, but it's also not the norm. So, I took the barista up on the offer and bought a maple (almond milk) latte (yes real maple syrup). Upon the first drink...bleh. I'm a firm believer in giving food second & third chances. Another drink...ugh, no dice. It tasted like uncooked bacon or something. Not the most appealing taste lingering on one's tongue.
I would give that boxed almond milk another chance a couple other times; but, to no avail, the uncooked bacon taste. It was then and there I would pick up the anchor and make some at home. I was certain it was the additives in the milk that made it less than appealing. Sure enough, my homemade almond milk was superb. That already milky-like taste in almonds came through in the milk. Steamed some up for lattes and it was no different. Plus, super easy to make without utilizing a Vita-mix or Blendtec blender. Use this in place of the milk to make your homemade Pumpkin Spice Latte.
Homemade Almond Milk (printable recipe)
You can use a linen kitchen towel instead of cheesecloth, just not terry cloth. You can also keep the almond pulp to use for future baking. Simply spread on a parchment lined baking sheet and bake for 15 minutes at 350. Cool and store in fridge or freezer.
1/2 cup raw almonds
3 cups water
2-3 Tb pure maple syrup (grade B)
1/4 tsp Celtic sea salt
- Soak almonds in a jar covered with purified water (using your Brita works fine) overnight or 8 hours.
- Rinse your almonds, discarding the soaking water.
- Place almonds & 3 cups water into a blender. If using a regular blender (non-Vita-mix or Blendtec), fold a kitchen towel and place on top of lid. Puree or liquify the almonds & water until almonds have been thoroughly pulverized. This can take about 45 seconds.
- Take cheesecloth, folded, and line it in a sieve. Put that cheesecloth lined sieve over a bowl and pour the almond mixture through. The cheesecloth will catch the almond pulp.
- Take the ends of the cheesecloth and wrap it up, in order to keep the almond pulp inside and squeeze the remaining milk out.
- Add the maple syrup for taste to add a bit of sweetness. Or if you are avoiding extra sugars, don't add it. **You could use honey instead, or use a couple medjool dates while the almonds & water are being blended.**
- Store in the fridge for 3-5 days, or check for smell. If it tastes sour, then it's time to throw it out.


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Can You Ever Have Enough Tools?Posted in Features on May 18, 2013
If you're like us here at OFF-ROAD, you probably do a fair bit of your own work on vehicles and have started to accumulate the tools you need for that type of work. Basic tools are great in the beginning, but when you're trying to reach those hex heads nestled high up under the dash or snake your hands deep into the engine bay, a greater variety of tools can speed up the job, help you avoid deep frustration, and save some skin on your knuckles.
Now, I'm not saying you need to spend a fortune on every cool tool under the sun. But, a good variety of standard and deep well sockets, extensions with universal and flex joints, and various wrenches all have their place in tight spaces and for work comfort. The right tools can turn a dreadful maintenance job into a far more tolerable task. Here are a few tools I've added in my garage to do just that.


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(CNN) -- The Economist Intelligence Unit will publish a report -- The Austere Traveller -- in February that will show that business travelers' expectations are changing.
Budget with a twist: a former Pan Am Boeing 747 has been transformed into a hostel in Stockholm, Sweden.
Economic pressures mean executives now care less about luxury. Instead they are going back to basics.
In 2009 we will be traveling less, for shorter periods and trading down in hotels, airlines and restaurants.
On this month's show, in the face of austerity, we're all about solutions to the credit crunch.
In-flight Earners: The airline industry has had a tough year with rocketing fuel prices, bankruptcies and takeovers.
We look at some of the ways in which airlines have managed to raise a bit of revenue and weather the economic storm.
One example is onboard advertising. Telecommunications company AT&T and Canadian Tourism Board have placed their ads on the back of fold-away trays, overhead compartments, even on sick bags.
January sales: More than ever, hotels are feeling the pressure to keep their occupancy levels up.
The Hoxton Hotel has put on sale 500 rooms for $1.5 (£1) and another 500 rooms at $41 (£29). The first time £1 rooms went on sale last year, all 1,000 rooms were sold within 11 minutes.
Lapse of luxury: Six months ago, industry experts believed that the private jet sector was credit crunch proof. That is now not the case. The value of private jet firms is tumbling and firms are canceling orders. We take a closer look at the private jet sector.
Virtual reality: Corporate travel budgets have been cut back. If senior executives are downgrading, middle management and lower aren't traveling at all and are video conferencing instead.
There have already been incredible technological advances in video conferencing through tools such as teleprescence that brings breathtakingly-real images of people into rooms via plasma screens.
Musion has now developed an even better solution: holographic conferencing. Richard Quest interviews the creator from Germany about the new system and how it will offer solutions to business travelers.
The jumbo hotel: It's not all doom and gloom. Business travelers can still search for bit of effervescence in their trips even when the purse strings have been tightened.
Take the Jumbo Hostel next to Arlanda Airport in Stockholm, Sweden. This is the first aircraft in the world to be converted into a hotel. The former Pan American Boeing 747 has been re-designed to hold 25 rooms, each with a bunk bed, an overhead luggage compartment and a flat-screen TV. The best room, of course, is in the cockpit.
CNN's Adrian Finighan spends a night at the 747 hostel.


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Kate Hudson and Matthew Bellamy at Tribeca Premiere 2013
Kate Hudson Wears White For Her Premiere Night With Matthew
Kate Hudson, in a white Jenny Packham dress, posed on the red carpet with her fiancé, Matthew Bellamy, for the Tribeca Film Festival premiere of The Reluctant Fundamentalist in NYC on Monday night. When Matthew wasn't by her side, Kate smiled for the cameras with her costars Riz Ahmed and Kiefer Sutherland. Kate's big festival night comes after a busy day of press — check out four quick quotes from our interview with Kate yesterday!
She also enjoyed a jam-packed weekend in the Big Apple as she celebrated her 34th birthday with her boys, including sons Ryder and Bingham. On Sunday, Kate, Matthew, Ryder, and Bingham caught a performance of Stomp. The foursome's time together in Manhattan will come to a close soon, though, since Matthew is heading to Canada for a string of tour dates with Muse this week.


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Statement of Style 2008
Architectural adornments amp up the style in these showhouse rooms
Just as a theater's heavy curtains are raised to reveal an opening scene, a showhouse with rich architecture sets the stage for good design. Check out this year's bests in show—a trio of beauties that use architectural adornments as the backdrop for delight.
Mansions and Millionaires
Mill Neck, Long Island
If finding a room with interesting architecture is half the battle of exceptional design, then Eileen Boyd has won this one. Known for her brilliance in creating graphic color schemes and geometric furniture arrangements that paradoxically have soft edges, Eileen turned this octagonal living room of a Long Island Tudor Revival home from white, traditional, and predictable to handsome, current, and fashionable.
An unexpected Gustavian gray milk paint applied to the paneling and moldings creates a quiet envelope for a mélange of modern furnishings punctuated with exclamation points of saturated taxicab yellow. "I wanted to unify all of the paneling and moldings with one color so they wouldn't compete against each other," explains Eileen. "I relate color to music, and on their own, neither the gray nor the yellow works for me. But together, they are harmonious and complement each other perfectly."
Centered on the room's multi-paned windows, the seating area is a lesson in balance. A raw linen sofa with accent pillows in stone, yellow, and a bright, luminous blue captures the main focus. Flanking each side of the sofa, venerable tufted-back chairs are given a contemporary lift with yellow fabric and black frames.
Photography: Bruce Buck
Produced by Bonnie Maharam
Interior Design: Eileen Kathryn Boyd, Eileen Kathryn Boyd Interiors, 251 Main St., Huntington, NY 11743, and 225 E. 76th St., Suite 5C, New York, NY 10021; 631/427-6400, ekbinteriors.com.
To blur the edges of grids on the paneling and windows, elegant drapery panels in a gray-and-white burnout floral pattern cascade from moldings to the floor. A width of yellow grosgrain ribbon trimming the edges of each panel unites the other jolts of yellow. The ribbon is pierced with silver nail heads that give the draperies a controlled bit of metallic shine.
To make the room a multi-task area, a glass-and-stainless-steel desk reads modern, while a vintage French cane-backed chair contributes soul and a suggestion of history. A pair of matching faux-crocodile upholstered ottomans provide additional seating. A chaise in a natural tone is enlivened by a sunny piece of artwork painted by Eileen herself as a solution when she couldn't find another piece that was the right scale and color for the wall.
Sofa ("Park Avenue,'' custom, designed by Eileen Kathryn Boyd); chair ("Park Avenue Occasional,'' custom, designed by Eileen Kathryn Boyd); ottomans ("Alice,''custom, designed by Eileen Kathryn Boyd): Duralee Fine Furniture, 866/565-7731, duralee.com, trade only.
Sofa fabric ("Solid''/Smoke #31455-352); chair fabric ("Solid''/Sun Ray #31376-483); ottoman fabric ("Vinyl''/White #90764-18); blue pillow ("Solid''/Baby Blue #31904-277); yellow pillow ("Solid''/Sun Ray #31376-483, with "Solid''/Smoke, linen, #31455-352); white geometric linen pillow ("Novelty Linen'' #41938-118); drapery panels and pillow fabric ("Foliage''/Pewter #20868-296); striped bolster; gray pillow (custom): Duralee Fabrics, 800/275-3872, duralee.com, trade only.
Drapery ribbon trim; drapery hardware: M&J Trimming, 800/965-8746, mjtrim.com.
Chaise (custom); glass/chrome desk; chair (vintage); artwork and accessories; carpet (taupe sisal): Eileen Kathryn Boyd Interiors, 631/427-6400.
Cube tables: Kolkka Furniture, 650/365-0303.
Custom top on cube tables: Silestone by Cosentino USA, 800/291-1311, silestoneusa.com.
Lantern: Smith & Hawken, 800/981-9888, smithandhawken.com.
Twig table: Michael Aram, 866/792-2726, michaelaram.com.
Blue lamp: Arteriors Home, 877/488-8866, arteriorshome.com, trade only.
Chandelier; urn (vintage); chaise fabric; yellow painting (Printemps, by Eileen Kathryn Boyd): designer's collection.
Floor lamp: Origina, 416/752-6800 and 214/655-6141, originacanada.com.
Floor lamp: IKEA, 800/434-4532, ikea.com.
Ceiling vinyl wall covering ("Cirque du Cirque Cycle'' #G5324823): Wolf Gordon, 800/347-0550, wolf-gordon.com.
Wall paint ("Himalayan Trek'' #1542): Benjamin Moore & Co., 888/236-6667, benjaminmoore.com.
Once they have launched their careers, many creative types stretch far beyond what they learned in school. But for Long Island-based Eileen Boyd, the fundamental principles she absorbed as a student at Parsons School of Design in Manhattan help her create a look that is striking and uniquely her own. "I like the recipes in geometry, which take me back to my college roots, where there are always procedures," says Eileen. "The basics always work for me."
San Francisco Showhouse
San Francisco, California
Wild horses wouldn't have dragged designer Geoff De Sousa and his assistant, Sarah Puls, from this challenging project, but the pair did draw inspiration from the steeds. The design duo transformed the ballroom of a grand 1890s San Francisco manse into an elegant living room for a modern-day family. Using a mix of opulent textiles, antiques, contemporary furnishings, and an eye-catching reverse-glass painting of galloping horses, they created a luxurious space that's comfortable for both everyday living and formal entertaining.
The handsome palette features an unusual combination of navy blue and rust, selected to give warmth to the north-facing room. The dark scheme mellows the architecture of what Geoff says was formerly "one hard, white box." Paper-backed silk fabric and heavy cornices applied to the walls also soften the room, as does crown molding painted a coordinating shade of navy that marries the walls to the ceiling.
Because the onetime ballroom has generous square footage, the designers broke the space into two intimate areas by placing a modern hammered metal library table in the middle to set parameters. At one end of the room, the color scheme in a casual setting features a blue sofa, mismatched leather chairs, and a low bench where stacks of books reside. Matching modern chandeliers light and unite each area.
Photography: James Carrière
Produced by Heather Lobdell
Interior Design: Geoffrey De Sousa and Sarah Puls, De Sousa Hughes, 2 Henry Adams St., Suite 220, San Francisco, CA 94103; 415/626-6883, desousahughes.com.
At the opposite end of the room, three sets of French doors soaring close to ceiling height provide the perfect showcase for elaborate window dressings—pinch-pleated panels of wool appliquéd in velvet and blanket-stitched in cream—that hang from cornices designed to mimic original woodwork.
Against the wall of French doors, a sofa in rust-colored mohair anchors a formal grouping that includes symmetrical pairs of bentwood chairs, tufted black-vinyl chairs, faux-bamboo side tables, and table lamps with leather-wrapped bases.
To make the preexisting tall mirrors on the French-door wall look aged, a decorative artist gave them a gold-bronze rub.
"The best way to build a room with personality is by mixing old with new to achieve a 'collected over time' appearance," says Geoff. "Many of the pieces I use in my rooms are not old, but they have mystery and a story to them."
Blue sofa ("Frank #1''): Mattaliano through De Sousa Hughes, 415/626-6883, mattaliano.com.
Sofa fabric (Mohair/Charcoal #3762/18): Myung Jin Textiles through De Sousa Hughes, 415/626-6883.
Cocktail table in front of blue sofa ("Farallon,'' cast bronze with leather top): Tuell & Reynolds, 707/669-0556, tuellreynolds.com. Available through De Sousa Hughes, 415/626-6883.
Chandeliers ("Lumière''); painting (Seven Horses, by Jean de Merry); leather wing chair ("Aland''); leather (#9 with light distressing): Jean de Merry, 310/289-0991, jeandemerry.com, trade only. Available through De Sousa Hughes, 415/626-6883.
Black chair: discontinued.
Chest behind wing chair ("French Deco Moderne Walnut Chest'' sold as pair): Robollo Home, 415/575-1776, robollo.com.
Painting above bookcase (Golden Head, by Nathan Oliveira): John Berggruen Gallery, 415/781-4629, berggruen.com.
Floor lamp ("Leather Wrapped Tripod Floor Lamp'' by Adnet, France, c.1950s): Monument, 415/312-4065.
Floor lamp (Italian, brass-and-glass): Ed Hardy San Francisco, 415/626-6300, edhardysf.com, trade only.
Bookcase (antique, "French Double Arch Steel''): De Sousa Hughes, 415/626-6883.
Bench (weathered): Coup D'Etat, 415/241-9300.
Library table: Odegard Inc., 800/670-8836, odegardinc.com, trade only.
Bronze heads (by Nathan Oliveira): John Berggruen Gallery, 415/781-4629.
Antique rug: Peter Pap Oriental Rugs, 415/956-3300, peterpapp.com.
Rust-colored sofa ("Christoph'' ); chairs flanking sofa ("Frank #4 Rockefeller''): Mattaliano through De Sousa Hughes, 415/626-6883, mattaliano.com.
Sofa fabric ("Town Nubuck''/Roan): Dualoy Leather, 212/736-3360, dualoy.com. Available through De Sousa Hughes, 415/626-6883.
Rust-and-blue pillow (Italian, 1960s linen velvet): Epoca, 415/864-6895.
Blue-and-charcoal pillow (wool sateen and mohair velvet appliqué/Glacier): Holland & Sherry, 212/355-6241. Available through De Sousa Hughes, 415/626-6883.
Custom embroidered fabric panels ("Trellis'' in Copper, Dijon, and Gray, chain stitch embroidery): Judy Ross Textiles, 212/842-1705, judyrosstextiles.com.
Welt ("Town Nubuck Suede''/Roan): Dualoy Leather, 212/736-3360, dualoy.com.Fabric and panels available through De Sousa Hughes, 415/626-6883.
Table ("Conrad'' in Maccassar Ebony): Mattaliano through De Sousa Hughes, 415/626-6883, mattaliano.com.
Crystal box ("Wavelet''): Baker, 800/592-2537.
Black vase: designer's collection.
Side tables flanking sofa: Epoca, 415/864-6895.
Black table lamps (antique, Danish wallpaper roller table lamps): Coup D'Etat, 415/241-9300.
Barrel chairs (antique): Coup D'Etat, 415/241-9300.
Table between barrel chairs ("Ramille Occasional''): Mattaliano through De Sousa Hughes, 415/626-6883.
Chandelier ("Lumière''): Jean De Merry, 310/289-0991, jeandemerry.com, trade only. Available through De Sousa Hughes, 415/626-6883.
Sheers ("Istra''/Cashew #7305/06): Romo Fabrics, 800/338-2783, romofabrics.com. Available through De Sousa Hughes, 415/626-6883.
Drapery panels ("Sateen Linen''/Caramel #SQ11114); appliqué fabric ("Concierto Cotton Velvet''/Camel #DE10377): Holland & Sherry, 212/355-6241. Available through De Sousa Hughes, 415/626-6883.
Drapery fabrication: Horner & Co., 415/564-2385.
Fabric on walls ("Titan Silk''/Navy #139): Bart Halpern Textile Collection, 212/414-2727, barthalpern.com, trade only. Available through De Sousa Hughes, 416/626-6883.
Floral arrangements: Joseph Andrade Floral, 415/863-8000, jafloral.com.
Mirror: Paige Glass Co., 415/621-5266.
Pedestal and urn: M B Jessee Painting & Decorating, 510/655-7000.
Designer Geoff De Sousa approaches rooms as if they were sculpture gardens, featuring interesting shapes that work with the other players to create a dramatic look. "I prefer furnishings and accessories that are sculptural—with their own personalities so they can stand on their own."
Mansions and Millionaires
Lloyd Neck, Long Island
To interior designers, an empty room is a laboratory for testing great design. For Keith Baltimore, interesting furniture ensembles and a modern approach solved the dilemma posed by the cavernous space of a traditional living room with classic architecture. "Scale is important in every room but must be played with especially carefully in a large space," says Keith. "There were tricks I used in this space to make a statement about geometry and scale."
To ensure the picturesque views through the windows wouldn't be obstructed, Keith picked tailored furniture with low backs for the large space. Three matching 90-inch-long sofas upholstered in natural-colored linen and piped in contrasting chocolate brown play off the dramatic red sateen accent at the bottom of the drapery panels.
Photography: Bruce Buck
Produced by Bonnie Maharam
Interior Design: Keith Baltimore, The Baltimore Design Group, 35 Main St., Port Washington, NY 11050; 516/944-2400; fax, 516/944-3009, baltimoredesigncenter.com. E-mail: firstname.lastname@example.com.
Furniture ensembles similar in scale and style but incorporating different shapes are grouped at either end of the room: A pair of chaise longues in linen fabric that matches the sofa rest on either side of a long marble-topped coffee table. Both furniture arrangements are defined by textural sisal rugs, one positioned on the diagonal.
Beyond the exaggerated drapery hems, injections of red pop up throughout the room, tying elements together. Just one example is atop the intricately molded fireplace mantel, where a row of silver mercury glass vases containing small bunches of red roses are simple in concept but deep in graphic impact.
"The repeated red forms give the idea of rhythm and motion," explains Keith. "Especially with a large room, you want people to get constant reminders of what the entire space is about all the way through."
Near the door frame, two side chairs with delicate carving on their backs flank a Chinese-inspired stainless console table base where a painted black wood box rests.
Furniture and accessories (unless detailed below): The Baltimore Design Group, 516/944-2400.
Beige drapery fabric: Robert Allen, 800/333-3777, robertallendesign.com, trade only.
Red drapery fabric: Beacon Hill, 800/333-3777, beaconhilldesign.com, trade only.
Sectional sofa; sofa fabric; coffee table; black end table; leather ottoman; chaise; chaise fabric; marble-topped coffee table: Swaim, 336/885-6227, swaim-inc.com.
Floor lamps: Visual Comfort & Co., 713/686-5999, visualcomfort.com, trade only.
Area rugs: Merida Meridian Inc., 800/345-2200.
Paint ("Decorator White''): Benjamin Moore & Co., 888/236-6667, benjaminmoore.com.
There are plenty of opportunities for bold surprises in a room, but designer Keith Baltimore prefers to create interest with a twist on subtle, classic details. "With the large scale of this room, oversized furnishings to fill the space would have been expected," says Keith. "Instead, I played with the lines of the fabric and kept the furniture simple so the fabric could get the attention."


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These barrel bottom mirrors over the vanity...
feeding turkeys (besides corn they also like Chex, cinnamon toast and CHICKEN in case you were wondering)...
I loved your pics from Portland. Thats actually my old stomping grounds. I grew up about 10 minutes from there and my family is still in the area. Next time you are there, you should check out the Pepper Club. My aunt owns it and cooks there.
I would love to go on a little getaway with my hubby. Looks like you had such a nice time. That gold overlay looks awesome, I have a pedestal table like that that needs a redo, hmmm!
Ahhh, uninterrupted conversations! Imagine! Your break looks fabulous - good on you. The CG overlay looks amazing too. Look what happens when clever people get together. Have a lovely week. Annie x.
Nice tour and how lucky for you to be able to get away!
I love the Old Port....I went to college about a half hour away and became quite familiar with the un bar hopping scene there :)
I love Portland, they have the cutest stores and restaurants. What a fun weekend your husband and you had! Its always nice to get away and recharge the batteries every now and then!!
Okay, wow, that is almost too much goodness in one post. Those customizable lamps are the bomb. What a great resource. We used to have a Company C rug in our playroom when we had hardwood floors in our old playroom/house. So cute. And I think I saw that colorful chandy at Market - maybe Cyan Design? I think of O'verlays all the time. So sorry Cheryle almost lost a thumb. Yikes. And the turkey thing made me giggle! Have a great week!
Absolutely love this post--especially the comment about the raccoon eyes and the fact that turkeys like CHICKEN! Ewwww! Haha. ;-)
I LOVE that you and Censational Girl got together to create one fabulous table. My two favorite blogs. Awesome. Hoping we get to do that Overlay ceiling design very soon in our project. Stay tuned...
Where can I get these high gloss lamp shades? C Company website doesn't seem to carry any, and I can't find anything online. Any ideas?
The manager at the Portland store did say they were a new item and wasn't sure if they were on the site yet. I would call the shop, they do ship and can help you with pricing.