For the last decade, I have led an international, interdisciplinary team that has been looking for promising practices in long-term care. In addition to doing the traditional kinds of research that looks at things like administrative data and funding, we did what we call rapid, site switching team research that involved taking a team of 12 into long-term care homes in Norway, Sweden, Germany, the UK, the US and four Canadian provinces. Each team was international and interdisciplinary. We observed and interviewed over the course of a week (see Pat Armstrong and Ruth Lowndes, eds. Creative Teamwork: Developing Rapid, Site-Switching Ethnography, New York: Oxford University Press, 20018). During the site visits and afterwards, we spent a lot of time discussing and reflecting on what we saw and heard.
The care I am talking about is that provided in what are most frequently called nursing homes. These are homes that provide 24/7 nursing care and, in Canada at least, are heavily subsidized from the public purse. They are licenced by governments for a specific number of beds. The Canada Health Act prohibits fees for medically necessary hospital and doctor care but not for the range of services provided in these these homes. All these homes are heavily regulated by the provincial/territorial governments that are primarily responsible for long-term care and these governments determine the criteria for entry, with variations among jurisdictions in application processes and criteria.
These homes have fees, set by the government, that usually vary with the kind of room-private, semiprivate, or basic. The fees vary across Canada, although not by a lot, and are set relatively low. All provinces and territories provide subsidies for those unable to pay even these fees, although the provinces and territories differ in whether they take resident assets into account in determining these subsidies (See Martha MacDonald, M. Regulating Individual Charges for Long-Term Residential Care in Canada. Studies in Political Economy 95. Regulating Care, pp. 83-114, 2015). The nursing and medical care, as well as the cleaning, the food, the laundry, the security, supplies and the administration are all provided as part of the package. So money should not keep you out of a Canadian nursing home. What will keep you out is the shortage of beds for those who qualify. All jurisdictions have long waited lists.
These homes differ from places usually called retirement homes. Entry into them is determined by the owners, and so is being told to leave. Most are owned by for-profit companies, with Chartwell being the largest. They are largely unregulated by the government, except under landlord and tenant legislation. The tenant pays the full costs of all services, although governments may provide some publicly-funded home-care within them.
I keep hearing that more than 9 out of ten older people do not want to enter a nursing home and that those numbers are going up with the disaster that is COVID. That’s a good thing, given that less than 4% get into a nursing home. Indeed, a significant number of people want and need nursing homes. Our project has been about making nursing homes as good as they can be, not about rejecting them. We don’t think there is one perfect model for doing so, in part because both context and populations matter. What works in Edmonton may not work for an Indigenous community in northern Alberta. But we do think there are ideas worth sharing.
Based on our research, I want to turn to eight areas we have identified to look for or to change. There are more we can talk about in the discussion if you wish
Increased staffing of direct-care workers results in fewer negative health outcomes for residents. Inadequate staffing levels are strongly correlated to burnout among health-care workers, higher likelihood of workplace injury, and result in high rates of staff turnover – all of which impact the quality of care they can provide residents.[ii]
And according to Parkland, Alberta has not studied staffing levels so we don’t know how much care is provided. But before the pandemic some families were hiring private companions for their relatives the barring of families during the pandemic made it very clear the extent to which homes relied on thus unpaid labour to make up for the gaps in care left by low staffing levels.
It is not only entire facilities but also services within them that are being handed over to for-profit companies, blurring the lines between public and private. Some not-or-profit homes are even managed by for-profit ones, often importing problematic practices. Which brings me to my fifth point.
While food has received some attention during COVID, with the military reporting cases of malnutrition, less attention has been paid to clothing. Yet we heard from residents, staff, and families that clothes are essential to our dignity and our sense of self. They are an indicator of care and of a life outside the nursing home but only if there is space for residents to bring their favourite clothes from home, only if they can be appropriately washed and only if staff has the time to help people dress. Too often we were told of mother’s favourite sweater returned half the size or not returned at all, because it was either lost or given to someone else. In a Swedish home we studied, there was a small washer dryer combination in each resident’s bathroom and the staff could easily put clothes on the delicate cycle and infection danger was reduced by keeping laundry in the room. How clothes and laundry are dealt with also has a major impact on how a home looks and smells. We decided not to do a site visit in a Texas home because it stunk the minute you walked in the door. (See Pat Armstrong and Suzanne Day Wash Wear and Care: Clothing and Laundry in Long-Term Residential Care Montreal: McGill-Queen’s University Press,2017).
Cleaning has also emerged as critical in the time of COVID but there is little talk about how important cleaners are to other aspects of care. We heard regularly from residents and staff about how cleaners were often the people they talked with on a regular basis, people who helped keep them connected, entertained, and valued. That was much less likely to happen when cleaning was contracted out.
Let me end by saying there are good nursing homes in Canada. Indeed, when we ask residents if there is anything better about living in a nursing home compared to their previous home, many say yes; they feel safe, have company and activities, few if any of which they would have at home. There is certainly significant room for improvement, as multiple studies and COVID have. But by drawing our attention in such a shocking manner, the pandemic disaster has also given us the opportunity to work together to make nursing homes as good as they can be.
You can find our many publications on our website https://reltc.apps01.yorku.ca/publications but I would draw particular attention to the following which are available for downloading without cost
Armstrong, Pat and Lowndes, Ruth, eds. Negotiating Tensions in Long-Term Residential Care: Ideas Worth Sharing. Canadian Centre for Policy Alternatives, 2018.
Download the book here or as an eBook with Apple books here
Armstrong, Pat and Daly, Tamara, eds. Exercising Choice in Long-Term Residential Care. Canadian Centre for Policy Alternatives, 2017.
Download the book or e-book with Apple books here
Armstrong, Pat and Braedley, Susan, eds. Physical Environments for Long-Term Care: Ideas Worth Sharing. Canadian Centre for Policy Alternatives, 2016.
Download the book or e-book here
Baines, Donna and Armstrong, Pat, eds. Promising Practices in Long Term Care: Ideas Worth Sharing. Canadian Centre for Policy Alternatives, 2015/16.
Download the book or e-book here
[i] Harrington, Charlene et al. The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes Health Services Insights. 2016; 9: 13–19.
Published online 2016 Apr 12. doi: 10.4137/HSI.S38994
Pat Armstrong is a Canadian Sociologist and a Distinguished Research Professor at York University.
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