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NURSING HOMES

Last Spring when I agreed to talk to the meeting today on the subject of Nursing Homes I felt very pleased about the invitation. I have spent a very good portion of the last twelve years of my life dealing with Nursing Homes and I felt that this was one field of medicine, and of care of the aged in particular, in which I was most competent to speak. However, I have found it most difficult to prepare my comments today.

Partly I have found it difficult to prepare a talk for a group whose common interest is that of aging but whose background covers wide cross sections of the community with various background knowledge and interests on this subject.

To a greater extent, however, I have wondered what to say in the limited time available. I have decided that rather than extract the literature on this subject I would express to you some personal ideas based on my own experiences, observations and opinions.

I would like to start by setting out some of my philosophy on which my remarks will be based.

To start with, a medical person will look upon it from that of orientation but I also try to look on the subject with some view of the needs of the aging person, Most aging persons have a desire to go on living and living life to its fullest, with complete and independent participation in their community, enjoying all the prestige and dignity that they have earned. Any institutionalization, no matter how fine that facility may be, will be an erosion on this independence that is part of our way of life. All our programs should be geared to maintain that independence but there will always be some instances where the benefits of institutionalization outweigh the desirability of staying independent and at home.

Similarly, institutionalization should do as little as possible to break links with family, friends, and familiar surroundings, whether these be geographic, religious or social.

One of the greatest difficulties is defining a Nursing Home. I shall try to give you a functional definition rather than to try to find a definition that encompasses all forms of institutions in this so-called broad "grey area" of care.

I will first attempt to exclude certain facilities. A Nursing Home should not be a low grade hospital, a chronic hospital or rehabilitation hospital. Some elaborate and excellent nursing homes do approach hospital type of care but I feel very strongly that hospitals should assume the responsibility of providing ail hospital type of care, which normally includes such things as 24-hour nursing and medical supervision, plus laboratory and x-ray services, operating Rooms, and other specialized facilities.

Therefore, we exclude the hospital group., with the highest intensity of care in the acute general hospital. Below the acute general hospital either in sequence or in parallel are the Rehabilitation Hospitals where intensive rehabilitative programs are carried out, and the extended treatment hospital -where prolonged skilled medical and nursing care and continued rehabilitation or maintenance physiotherapy are administered.

I shall now define and exclude nose institutions below the "grey area" nursing home. These are ways of life which range from completely free and independent existence to various degrees of assistance and sheltering from the effects of aging. In addition to the personal private residence, some elderly people live completely independently in rooming houses, some of which cater to older persons, particularly single persons existing on pensions alone, or low income. We then enter the field of elderly persons' housing which offers specialized construction of small, easy to maintain residences., and often financial subsidy

The next stage is the hostel, old folks or residential homes, and in a somewhat parallel level, the foster home in which one or two elderly persons are lodged with a private family to 'whom they bear no kinship,

Maybe we can eliminate the "grey area of care" by looking at the "black and white". We can assume that ill people may be cared for in one or two settings,, the hospital, or their place of residence, Acutely ill persons and those requiring constant skilled care and/or special services are best cared for in a hospital,

All others may be cared for in their residence or under "Home Care Programs". Sometimes the cost of providing such care in the private home, rooming house, or hostel is very difficult and for reasons of convenience and economy we gather people requiring such care together in a communal facility which we call a Nursing Home,

Anything that is provided in a Nursing Home should theoretically be capable of being provided in the patient's own home, and often is. Thus we can reverse our title to define the service in either direction, that is, the concepts of a Nursing Home or Home Nursing are the same with equal emphasis on both words, that is, Nursing Care is the primary service rendered in either setting, although all the other elements of the Home Care Program come into being in either setting. The word "Home" indicates a more permanent and warmer setting as compared with 'hospital' I think we have to recognize Nursing Homes are in many cases the final permanent home of the resident and in nearly all cases a home for a considerable period. It must offer, if possible, all the rights, privileges

and dignities of a home. It should otter the maximum or privacy with opportunities to entertain., freedom to act as independently as possible, consistent with the rights and privileges of others sharing the same facility, and consistent with the responsibilities of those in charge of assuring the safety of the resident.

I have taken some care to define the Nursing Home simply as a variation of Home Nursing as I think this is a key to the two major faults I have seen in Nursing Homes.

The first is that some homes attempt to care for patients requiring skills and services beyond the scope of any nursing home.

The second is that many forget that this institution does in fact become the true home of the resident, and must be designed physically and functionally to play that role,,

Nursing Homes may be classified by several means:

They may be proprietary (operated as a means of livelihood) or nonproprietary (run by public, religious or fraternal organizations).

They may be very large or very small.

In general, the proprietary tend to be small, the non-proprietary large, but there are variations in both, The/ may be specialized institutions or may operate in association with other institutions such as old folks' homes or hospitals.

Finally, I think there is a very important separation between urban and rural institutions where much different patterns must evolve.

The proprietary nursing home has been the most notorious and this is possibly because being the most numerous by far, and having been the most improvised and uncontrolled., it was inevitable that mismanagement would occur. Most of these institutions arose in the past 25 years and particularly in the last 15 years. Typically they have been operated in converted older private homes and started on a shoestring by enterprising individuals of varying motivation, with or without experience in the field. Proprietary homes have served a need which no one else was willing to provide. Most were greatly over-crowded almost of economic necessity, with very little government control and no program other than provision of basic bedside care. I believe that willful mal-treatment was extremely rare but neglect and ignorance were quite common, coupled with the neglect of economic limitations.

With the increased welfare assistance to the aged, their collections became more certain and profit increased.

A non-proprietaiy home tended to be a large institution most commonly run by religious orders with a devoted staff, with accessible voluntary assistance, but largely dedicated to living, custodial care in the backwaters of the mainstream of active medical care.

In recent years both proprietary and non-proprietary homes have been shadowed by the emergence of new hospital facilities and new residential facilities for the elderly. Most recently they have begun to catch up with the other facilities, with the construction of new facilities specifically designed for modern nursing home came and living.

I shall now go on to discuss some factors in good nursing home care. The most important factor is the decision on whom should receive this care and subsequent placement.

At the outset we stressed that institutionalization should be regarded as a failure to maintain independent living. At the same time we should ease the admission of those requiring service 'to good nursing home facilities; we should assure that those who can and those who wish to and could continue outside the nursing home, have every opportunity to do so, The fundamental is a full assessment of the patient's abilities and disabilities prior to admission, including if possible a complete assessment in hospital and a full opportunity to receive the maximum physical and mental restoration that such facilities allow,

Every attempt should be made to fully explore home care or the possibility of day centres, day hospitals, holiday admission to hospital to relieve next-ofkin, the possibility of elderly persons housing or residential accommodation, foster homes, etc Sometimes elderly persons are forced into nursing homes because no alternative exists, Some provision for holding accommodation during acute hospitalization might preserve an independent home life. Financial assistance might be all that is required to keep the person at home or in the residence of a relative.

It is easy to arrange such assessment for patients seeking welfare assistance. Some institutions may request such an assessment of all patients seeking admission. Finally, if an assessment agency offers this service to private persons and earns a reputation of service it will be sought out by private individuals. The team approach is currently stressed in such assessments but 1 personally feel that the team approach can be overdone and all the emphasis going to the needs and rights and professional status of various members of the team, rather than directed to the needs of the patient.

The primary service offered by a nursing home is that of nursing care and the nurse in conjunction with the attending physician is in the best position to assess the degree of nursing care required, and the capability of offering this service in the various institutions at the disposal of the agency. therefore from the agency's viewpoint I feel that the nurse (by that I mean Public Health Nurse) should be the primary patient contact, and supported by welfare and iociai workers on the one side, the attending physician, hospital and agency medical staff on the other.

I started with admitting standards and assessment as these are essentials in defining the group with whom we are dealing- 'The next factor is that of the standard of service offered and control of this standard, These controls can be either by government or otherwise, In the latter there may be certain standards set by associations of nursing homes, code of ethics, etc., and by the motivation of the group, particularly in religious and fraternal organizations but not excluding proprietary operators. However, some formal control or licensing is essential,,

Generally speaking,, nursing home institutions are licensed by an agency of the Provincial Government.

The Public look upon such a license as a guarantee of quality and government must accept this responsibility. A license must not merely denote that on an annual inspection specific physical standards were met. It is better if the licensing agencies can obtain an active liaison with all nursing homes rather than an annual inspection to assess standards,, This liaison should establish an atmosphere of consultation rather than inspection, and should involve the various disciplines such as medical, nursing, social work, dietitian, financial administrative advisers, occupational therapists and physiotherapists.

In the Nursing Home (and in Home Care Programs), the prime distinguishing function is the provision of nursing care and related ancillary services. Because of this I feel that responsibility for licensing should rest with a health agency. However, this responsibility dictates adequate consultation with other interested agencies at all times, particularly social welfare, and less frequently but just as important, fire prevention agencies.

The most important factor in licensing an institution is establishment of the qualifications of the operator. For this reason all licenses must be nontransferable and issued to a responsible individual or organization.

Three important factors must be known about the operator:

1) Motivation 2) The operator's knowledge in the field 3) The economic status of the operator

Motivation is THE most important factor and yet it is the most difficult to assess except in the light of previous performance.

Nursing Homes are complex facilities and the operator must have the know-how in administration of an institution of the type and complexity under consideration. The operator must be able to understand budgeting, planning and all other facets of a business operation. He must understand the concept of illness and health problems in the aged or be prepared to delegate planning of such services to a competent person and allow that person sufficient freedom to carry out the proper program. Many of the past errors in nursing home care have been a result of ignorance and poor management.

Finally, the economic or financial responsibility of the operator must be such that he is capable of meeting desired standards. Nursing Homes commenced on a shoestring must continually cut corners to exist,

A second feature in licensing is the Physical Plant,

A license must assure that this meets minimum standards., We recognize that many of the existing proprietary homes and some of the non-proprietary homes operate in old and inadequate plants, but due to their number and pressure for beds they are being replaced only slowly and must continue to be licensed. The proprietary homes in older residential houses with beds overcrowded into every room should not be tolerated. Day areas must and can be demanded but these places can never offer proper facilities. They are usually too small for economic operation and provision of properly qualified staff, food, social facilities, etc. Many of the older nursing homes are veritable fire traps and where such facilities are used additional care in placement of patients should be exercised so that only those capable of independent egress from the Home should be placed,, Fire warning devices should be included.

In recent years newly constructed nursing homes are providing a very high standard physical plant, wide hallways, wide doors, more private space, especially adapted bathroom facilities, recreation areas, easy entrance, etc. These homes have led to higher rates but there is still better value per dollar spent and we must be prepared to meet these costs.

And now some comments on the home in action.

The factors of management and physical plant have prepared the stage. The performance depends on the staff, The key features are quality and quantity.

Quality refers to both motivation and competence in the necessary fields whether it be nursing, nursing aid, domestic staff, or specialized staff such as social workers, physiotherapists, occupational therapitst, etc.

All efforts must be designed to offer both "nursing care" and "home" atmosphere or setting, Nursing Care should be the responsibility of a registered nurse capable of organizing and directing a program consistent with current trends in the care of the chronically ill and aged.

The traditional nursing home stressed custodial care. The most convenient method of administering this was to the bed patient who stayed quietly in bed all day, received meals at the bedside and was sedated into unconsciousness during the night. The patient remained in bed clothes and dressing gown throughout the day.

Workers in the field of geriatrics have shown repeatedly that which was once considered irreversible senile psychosis may often be the logical reaction to isolation and boredom.

I can recall a personal experience which convinced me of the unbelievable effect of inactivity. A number of years ago we closed a substandard nursing home and moved all the patients to other institutions. I had visited this Home weekly for several years and I recall particularly two residents, one an elderly gentleman, the other a lady, both of whom never spoke a word or answered my questions, who were unkempt and untidy and whom I regarded as being senile. In both instances these people completely changed When I saw them in their new homes within one week. The gentleman told me of his days of professional soccer in Great Britain sixty years before and his employment as a railroad guard. The lady similarly spoke to me cheerfully and at length,

Ambulation and activity are the keys to good care of the aged. 'The patients should be encouraged to get up every day and to dress themselves, which requires more patience on the part of the attending staff. Ambulation decreases the tendency to incontinence.

Many patients are incapable of recognizing or indifferent to changes in their own health. Others may be overly conscious and exaggerate. A skilled nursing staff is on the lookout for these changes and can interpret changes to the family physician or hospital clinic.

The nursing director should assure that adequate reports are kept on patients. In nursing homes these should be-relatively simple but should include pertinent details as to diagnosis, medication, changes in patients. There should be provision for preparation of notes on referral to hospital.

An important aspect in any home and a common complaint are the meals. Variety and palatability are difficult to maintain in any institution preparing meals for many persons and the nursing home is under a handicap as it can seldom hire fully qualified cooks. Food is one of the big items in expense and some corner cutting might be expected here. Starches usually abound and a tendency to obesity will be noticed in many nursing home patients. This obesity immobilizes the aged patient and yet friends, relatives and the patients themselves, are often pleased at the gain in weight and think this is an indication of good food. Many smaller Homes are incapable of planning special diets required by patients. Selection in admissions, administrative advice and the availability of consultant dietitians through the licensing authority can do much to allay this weakness in the smaller Home.

The nursing and social factors are inseparable and complement each other right down the line. The inclusion of day facilities and a program of activity including games and hobbies, television, and even a quiet room for meditation, space for entertainment of visitors, dining room facilities, etc., are essential. Dining can become an activity, a social adventure rather than a mere necessity of sustenance, Mirrors around the Home encourage the individual to take greater personal pride in his appearance. Visiting hours should be liberal and the opportunity for the patient resident to go out visiting should be as liberal as possible, including weekend or week-long holiday stays, Provision must be given to hold beds (i.e., to preserve the individual's "residence") during such absences.

Occupational therapy or diversional activities can be guided by the skilled occupational therapist on an itinerant basis and supervised by volunteers and is of value even to the watchers, For this reason it is often desirable to be carried out in a general room rather than in a secluded hobby room.

Physiotherapy, occupational therapy may also be done by itinerant workers or set up by such workers. Much can be done by nursing and ancillary staff in the home. Where such staff are properly motivated and are numerous enough to allow the time required, much can be done in the way of physical and mental restoration.

One should not hesitate to think of evening school classes as an outlet for some patients. In some areas school boards will provide adult classes within the institution. -Libraries will make "book shelf" loans to such homes, replacing books regularly.

In some instances a nursing home can tie in with a sheltered workshop to offer gainful employment or with guilds to allow residents to offer their skills to useful and helpful pursuits.

Most of what is written about nursing homes appears to refer to the institution in the large urban centre. I would like to make a few special remarks concerning the provision of the same care in a town in a rural setting, in particular our Western Rural setting. I will tie my remarks to a specific instance that I recall from practice in rural Saskatchewan where we had a small, fourteen-bed hospital. An elderly and respected resident of the community had been in the hospital for well over a year with a stroke. He had a bed near the front door and was spoken to by almost every visitor to the hospital. However, we received word he was no longer entitled to hospitalization and should be removed to the Geriatric Centre 40 to 50 miles away by back roads, away from the environment in which he had spent 60 or '70 years of his life.

If he was to have visitors it would be only relatives who would make the trip, and then occasionally in the summer and much less often in the winter. This man's hospitalization would certainly, not have been justified in a city but I think that nursing home type of care should be very closely associated with rural hospitals, as an extra bed or two or a wing or connected building, or at least a building on the grounds of a hospital. This is the only economic way of providing adequate nursing care and very often the availability of nurses of any sort is limited in the rural area.

I would therefore like to suggest that acute general hospital, rehabilitation, extended treatment, nursing home care in rural settings should be offered by one institution and that residential and elderly persons' housing units should be closely associated with the above institution, This might even make the small hospital more economically sound, in the city the specialized institutions can cater to religious, ethnic and other considerations. In the rural area it would seem the non-denominational institution, associated with the medical centre, offers the best solution. To offer, extended treatment facilities on a regional basis in smaller rural areas does not seem logical. 'The patient's own doctor cannot attend him and specialized staff in the smaller extended treatment or personal care of fifty beds would not be justified.

Therefore if a patient is transferred from convenience of nursing and minor physical advantages to another territory under strange medical care the losses in social dissociation may far outweigh any constructive savings. Possibly each local facility- should offer the full range of care with reference to major acute hospitals or rehabilitation centres on a temporary basis where indicated.