Episode 8: The Future of Nursing Homes
In this episode: have you ever thought about nursing homes as an opportunity?
Featuring Professor Susan Braedley (Professor of Social Work and Director of the Institute for Political Economy at Carleton University) talking with host Sally Chivers about:
- Why nursing homes still matter
- Nursing homes as vital public services
- How the conditions of work are the conditions of care
- Possible futures of nursing homes, bleak and hopeful
- Finding meaning in nursing home life
Read Susan Bradley and Pat Armstrong’s new book Care Homes in a Turbulent Era: Do They Have a Future? (Free to download)
Find more promising practices for nursing home care in the short, free books our research project published with the Canadian Centre for Policy Alternatives:
- Promising Practices in Long-term Care: Ideas Worth Sharing
- Negotiating Tensions in Long-term Residential Care: Ideas Worth Sharing
- Physical Environments for Long-Term Care: Ideas Worth Sharing
- Exercising Choice in Long-Term Residential Care
Read more about the poor house legacy of nursing homes in this chapter by James Struthers (free to download)
Learn more about the Re-Imagining Long-term Residential Care project.
Wrinkle Radio is a proud member of the Amplify Podcast Network. We are grateful for funding from the Social Science and Humanities Research Council of Canada and support from Aging in Data and VoicEd Radio.
This episode includes music by ArtMusic via Pixabay; Duce Williams, Ziv Moran, and Michael Shynes via Artlist and Valentin Sosnitskiy via Freesound (CC Attribution 4.0).
Susan Braedley 00:03
Nursing homes can be hubs of community interactions, just like schools can be, like day care centers can be, like shopping malls can be, like swimming pools can be, and we have seen that in many places. And so I see nursing homes as full of potential. I see the opportunity for meaningful, high quality work and meaningful, high quality care that is necessary in our communities.
Sally Chivers 00:41
Welcome to Wrinkle Radio, where the stories we tell about aging matter. I'm your host, Sally Chivers, and I am so glad you're here. I'm joined for the next two episodes by Professor Susan Braedley. We're going to be talking about nursing homes in a couple of different ways. For this episode, we're going to focus on the future of nursing homes.
Sally Chivers 01:16
Nursing homes are such an obvious focus for Wrinkle Radio. They're one of the possible fates that people fear the most about growing older. People don't want to have to move out of their homes; they don't want to have to live in institutional care. And in the early days of the Coronavirus pandemic, people who weren't already afraid of that possible future were given lots and lots of reasons to become afraid. And before I talked to Susan about what there is, and isn't to fear about living in a nursing home and working in a nursing home, I wanted to ask her really directly, why she bothers to work on nursing homes anymore, when it really is the case that most people don't want to live there. Shouldn't we just get rid of them?
Susan Braedley 02:10
Well, Sally, you know, I'm delighted to have this question asked really directly. It's one that consumes me. You know, a lot of the people that are approaching nursing homes as something that needs to be ended are coming from the disability community and disability theory. With the increasing use of nursing homes for younger people with complex disabilities who will live for decades in these institutions that are not designed for them. I'm incredibly, incredibly supportive of their view that this population should not and does not belong in nursing homes. In Ontario, we know 10% of residents are these younger people. And that is growing. And I think for those folks, nursing homes can be carceral. So I'm incredibly sympathetic to that view, understand it, but when it is extended to an older population and different issues, I think it is an overstatement and misses an opportunity. And that's what I see nursing homes as.
Sally Chivers 03:19
that's Susan Braedley, Professor of Social Work and Director of the Institute for Political Economy at Carleton University. Among many studies and publications about nursing home care, she is co-editor of a new book about the futures of nursing homes. So she knows what she's talking about when she describes nursing homes as an opportunity.
Sally Chivers 03:43
The idea of nursing homes as opportunity really goes against the grain. The more common story and you can see this across the movies, which as you know, I love to study and learn from: what happens is a person becomes unable to stay at home, even if they want to. And it's this utter failure, their body will fail on the screen before you, their family members will have tried so hard but have to give in, the social structure and the healthcare workers who are supposed to help can no longer do so while the person lives at home. And so the only way really in the popular culture idea of nursing homes that nursing homes come across as an opportunity is as an opportunity for family members to get a break. But that's not quite what Susan was talking about.
Susan Braedley 04:36
I see nursing homes as a form of social security. Nursing homes are paid for through a combination of payment. One is that the individual pays for their room, their accommodation, and then their care and their medical treatment, et cetera is covered by the state. Also the buildings themselves no matter whether they're owned by a for profit or nonprofit or a municipality, all of those have been built with state support. So I see, as a resident of Canada, as a citizen, as someone who is, you know, sees myself as a member of an active public, I see nursing homes as part of the public. It is something that is supported by us. And it is something that if we got rid of it, we have lost the opportunity to create a fantastic public service.
Sally Chivers 05:33
I love this idea of the nursing home as almost like the public library that I talked about last episode with Nicole Dalmer, a public institution with specialized knowledge, specialized services, designed to change with the times, meet people where they are, and be there for anyone in the public who might happen to need it. And that's part of what Susan explained to me drives her to continue studying nursing homes.
Susan Braedley 06:04
I think that when one is very frail, and ill, I don't want people who don't know what they're doing messing with my body. I want people who really know what they are doing. I want a physical environment that is accessible and safe for me, and where I'm not lonely, and where I have things that are meaningful to do with my limited ability to do them. I need an environment where I can have a balance of activity and rest that is supported by people that are sensitive to what I am living, and what I am going through. This is incredibly difficult to provide in a private home. Where, you know, in Canada, we have an increasing number of people living alone, where our extended family systems are dispersed geographically so that we are living in different countries, even different neighborhoods. I mean, if you live in a big city, even getting across town can be a challenge in the middle of the day. I also think that our relationships with extended family are better, we can have warmer, more close and delightful relationships with our family when they are not burdened by having to wipe our bottoms, and puree our food.
Sally Chivers 07:35
So you might have thought that an episode on the future of nursing homes was going to be really depressing, pretty bleak future unless we abolish them altogether. Instead, what I'm hearing is there's an opportunity here for us to improve as a society and develop an existing public institution into something really robust that would better suit the people who are there, so they could be cared for better. It could also help improve family relationships that can be strained as healthcare needs develop. And beyond that, Susan explained to me that there's an opportunity to die better in a nursing home.
Susan Braedley 08:16
Nursing home residents don't tend to come home again, they tend to die in the nursing home. And so the opportunity to offer high quality hospice and palliative care in the nursing home setting and produce the opportunity, the conditions for a good death, not only for the person who is dying, but for the people around them. That potential is also in nursing homes where people have access to the right medical care, but not in a heavily medicalized setting like a hospital.
Sally Chivers 08:53
I think one of the reasons people are afraid of moving into a nursing home, and then the whole nursing home becomes this kind of haunted house of the public moment, is a fear of death. We've talked about the fear of death on past episodes, when we were speaking with Albert Banerjee about Aging for Mortals and how we might age better if we acknowledged that our lives do have limits. This was a really fascinating way to think about people's fears of the nursing home. People are afraid of the nursing home because they know it's the last place they'll move before they die, or their family members know that or both. And Susan frames this as another opportunity to provide hospice-like care on a longer term basis. Because most hospices that I'm aware of are relatively short term. You don't move in until you're within a few weeks of death. We have a lot of reasons now from Susan for why to take nursing homes seriously, why to study them, how they are opportunities, but she offered even more.
Susan Braedley 10:07
Not everyone has a safe home. We talk about aging in place, aging at home, but not every one's home is safe in terms of the physical environment, not everyone's home is safe in terms of the psychological environment. Not everyone's home is safe in terms of the finances, to me to ensure that people have a home that is affordable, accessible, and safe, in all those ways is up potential of nursing homes. Now, of course, do nursing homes realize this? No. In many cases, they do not. And that is what our research is about is realizing that potential.
Sally Chivers 10:57
Nursing homes are opportunities; they're full of potential. Susan has explained that really well from the perspective of people who live there, and family members whose loved ones might move in. You don't get to be the director of the Institute for Political Economy, as Susan Bradley is at Carleton University without knowing that the conditions of workers are also incredibly important to how nursing homes can fulfill their potential.
Sally Chivers 11:29
I first met Susan, when we were both members of a research team. Our research team was trying to improve nursing homes. And so we studied them by going to nursing homes in six countries. We went to Canada, Norway, Sweden, Germany, the United States and the United Kingdom. And while we were there, we would pair up with another researcher. And we would watch what happened through the course of the day. And then we also interviewed as many people as we could. We were trying to find something that we called promising practices. So in interviewing, it was really important that we considered all perspectives. We interviewed residents, their family members, volunteers, members of the local community, kids who came in and helped out, care aides, nurses, administrators, maintenance staff, people who worked in the kitchens, the people who did the laundry, anyone who had a stake in how the places functioned. Our research question, if you put it in its really most simple form, was, is a good place to work a good place to live? That question is more complicated, of course than it sounds. And it came out of the Principal Investigator Professor Pat Armstrong's decades long point. She had been explaining in so many ways, and so many healthcare sectors, how the conditions of work are the conditions of care. And that sentence, it's one of those things that make so much sense when you hear it that you think everyone must have already known it. But it still can be hard to picture and explain. We saw plenty of proof of it, of how the conditions of work are the conditions of care in nursing homes during our research. So I asked Susan to give me a couple of examples of how that plays out on the ground.
Susan Braedley 13:34
I want you to imagine that you are a frontline care worker and you are walking into work at 645 in the morning, your shift will start at seven, you walk into a room where you change your clothes from your street clothes into your work clothes, you have a locker, you have a shower there and you are able to put on clothes designed for that environment, your hair is clipped back and ready and you walk into a room. There's other workers there you're chatting and the workers who are coming off shift are sharing with you what's happened overnight. They're giving you an update verbally on how the residents night has been and you're able to ask questions and everything. It doesn't take long. It's maybe a five to 10 minute exchange as they're coming off shift and you're going on. You're fresh in your scrubs or your clothes that you're wearing and you go up and you are aware that Mrs. Augustine has had a really rough night and so you just listen at her door. It's all quiet and you decide that you know you're not going to get her up or attend to her because she's had a rough night and so she's able to rest. But you also heard that Mr. D'Agostino is already awake and that he's looking for companies. So you start with him. You go in, you say, "Mr. D'Agostino, how are you doing this morning? I heard you were up, I thought I'd come in and give you a hand? Are you ready to get up?" So you help him to the toilet and start asking him what clothes you'd like to wear that day. You change the sheets on his bed and get him going. Right away, I'm describing an environment where very simple working conditions are good conditions for these two residents. You can see the connection right away in the story.
Sally Chivers 15:29
That is sounding really promising and like a decent place to work and even a decent place to live. I'm having trouble picturing how else it would be structured though, because everything Susan described seemed so simple and straightforward and logical. So she spelled out the alternate scenario for me.
Susan Braedley 15:49
Contrast that with a worker who comes in at 645 and is expected to be wearing the clothes she will work in that day. She's been on the bus for 45 minutes and is concerned about somebody coughing beside her on the bus, but doesn't really have a lot of time to scrub up. There's no exchange with the workers overnight. There's just some hurried notes in a book. But she's aware that she has nine people to get ready for breakfast and so needs to get going right away. She goes in and starts with Mrs. Augustine, who she always has. Mrs. Augustine has had a terrible night, she's finally gotten to sleep just recently, and now is interrupted by this worker who is saying Mrs. Augustine time to get up time to get going and is hurrying her out of bed. Mr. Augustino, on the other hand has been up for a while. He's restless and anxious to get out of bed. He really needs to go. He's been waiting, and he's uncomfortable. I think this illustration is just the beginning. I could tell you a whole day. These are ways in which the conditions of work are the conditions of care. And yet it is just as simple as having exchange rituals and a good change room and the opportunities to use them often simple things.
Sally Chivers 17:09
Having a change room for workers and exchange rituals that are simple and seamless in the nursing home. That does sound so simple. And we know from our research, it still isn't how it's done in many places. It took us a while to watch how things happen in these different places and compare them to figure out which simple things do make a difference. We did find other promising practices, some of them just as simple. You can find out more about them in a series of free books that our project put together. You can download them from the Canadian Centre for Policy Alternatives website and even though it's a Canadian website, the practices are applicable internationally. I'll put a link to them in the show notes for this episode. You can find them at Sallychivers.ca/wrinkleradio. Those short books are from before the Coronavirus pandemic. And it's quite surprising and remarkable how relevant they remain despite how public opinion and the landscape has shifted. More recently, Susan Braedley with Pat Armstrong has co edited a book called Care Homes in a turbulent era: Do they have a future? We know from hearing from Susan so far that she does think they have a future. But it's still not clear to me what that future is. So I asked Susan to paint me a portrait of what the future of nursing homes looks like.
Susan Braedley 18:46
Well, I'm going to paint the bleak one first. The bleak future is that long term care is not deemed worth spending money, time and energy on. That there's no wins to be made in there and that nursing homes basically become the 21st century poor houses again.
Sally Chivers 19:09
We haven't really talked about this yet. This is another reason why long term residential care or nursing homes or care homes and we've been using those terms interchangeably in this episode. These places have a history that comes out of the poor house, a place people went when they didn't have means to support themselves. Professor Jim Struthers, who was another member of our research team, taught us a lot about why the legacy of the poor house haunts nursing homes today. The poor house legacy is part of why nursing home care feels like a failure. There was a stigma associated with going to the poor house and in fact, sometimes the very buildings that were poor houses got turned into nursing homes. So it wasn't just in the imagination. You might be walking through the doors of the very place that a generation ago meant that you hadn't succeeded in supporting yourself or your family hadn't succeeded in supporting yourself. So you can see why Susan draws on that bleak past to talk about a potentially bleak future.
Susan Braedley 20:22
So we retreat to the past. This would be easily done by continuing to restrain funding for long term care, to not insist on standards for care, including hours per resident per day that are about direct care and not about spending time filling out forms to go to the government, about really robust requirements, supportive inspections. I would like to see a totally public system. I think in many jurisdictions, that possibility is slipping away from us. And I worry about long term care homes becoming profit sources for huge financial corporations where ownership is so dispersed, where one corporation owns the building, the other manages the other provides the care workers in ways that make accountability almost impossible, and is happening through financialization of long term care where organizations are in chains and picked apart in so many ways, where ownership is often offshore and incredibly difficult to trace, and accountability disappears, so that the minimum becomes what's provided. And people that go there are considered really the new abject citizen. This is a future that I think all of us are terrified of. And yet the seeds of that future are in the present. So that is, to me the worst case scenario, and the one that keeps me researching every day and advocating every day.
Sally Chivers 22:04
Okay, we were warned, but that is bleak. And we started out by hearing about nursing homes being full of potential and being opportunities. So let's hear the other side of that coin.
Susan Braedley 22:19
The best scenario to me is that we see investments in long term care homes, and I'm going to speak from the Canadian context, that really are similar to the expenditures of some other countries in the OECD. So I'm not looking for outrageous amounts of spending. I'm just looking for comparable spending in Canada to what many other countries already spend on much better long term care home settings. If they can afford that percentage of GDP of gross national product on long term care, then why can't Canada? I argue that Canada can afford that, but is choosing not to afford that. And therefore we can do it and create a better system here. And I would suggest that other countries that are spending low percentages of GDP, the US is another one, on long term care could look at that data as well. Then I think that we can think about long term care quite differently than we have been. And one of the main differences is to be thinking about this as a public service that we would all want to use and work at that is located in our communities, rather than on the edges. And that is part of surroundings that we all live in. I am thinking for example of a long term care home I was at recently in Denmark, in that long term care home was situated the community swimming pool, a bowling alley, and a gun club. In addition, there was a large community room that not only held events at the long term care home, but was used broadly by the surrounding community as a community space. And of course, all the residents benefited by having all the people running in and out of this building. The other thing about that is that when you run in and out of the nursing home all your life, you know, you go to swimming lessons there when you're a kid and you go there for birthday parties to bowl, the nursing home doesn't become a scary place. It doesn't have a nightmare feel to community people. This is something they know. They know the people that live there. They know that people that work there. It's a familiar place and it totally changes it. It also means there's lots of activity for the people that live there to participate in and they are part of the community, not outside it. Those are my gentle dreams.
Sally Chivers 24:50
That strikes me as a place where I might want to work and I might want to live. And it sounds like the seeds for that future for nursing home care are also already planted. So it's a question of public investment. And yes, that does involve investment of money. Not quite as simple as just saying we shouldn't have for profit ownership in nursing homes, but choosing to direct collectively our public resources into them, so that that isn't needed and isn't even possible. And in order to get there, in order to buy the public into that idea, having a nursing home, that contributes to a community's life makes a lot of sense, so that the nursing home would change from being a failure, something no one ever wants to go to, into a place that some people go to to live, some people go to to work, some people go to to play, and some people go to to do all three.
Sally Chivers 26:05
On Wrinkle Radio, our guests are expert researchers in the field of age studies. But everybody is aging. And the topics that we discussed affect each of our guests personally. I always invite our guests to talk to me about how that happens for them. We're going to hear more about that in the next episode of Wrinkle Radio with Susan Bradley. But before we go, I want you to hear a story she told me about an experience visiting her grandmother in a nursing home.
Susan Braedley 26:37
I was fortunate to have my grandmother, I was well into my 50s before she passed away at 104. She lived in a nursing home in her last years with fairly advanced dementia. I went to see her and she told me that she'd been golfing. And I was assuming that this was part of her dementia. And so she started telling me in detail that she had been golfing, that they'd had someone help her. And then she took her hands and she showed me how she had arranged her hands on her golf club with her thumbs down. And it was actually the way that you do hold a golf club. It was the actual thing. So I began to be more curious. I was thinking, Okay, this is really interesting. And, you know, I was just sort of going along with the story asking her about how she had enjoyed her golf, and then learned that indeed, they'd set up putting green in the grounds of her nursing home and that a golf pro was volunteering their time to come and give them a little golf lesson. Grandma, who had always been an athlete who had never played golf was spending some of her days learning to play golf and continuing to do new things, to challenge yourself to develop new relationships, and to experience joy. And you know, I hope that I'll take a page from my grandmother's book.
Sally Chivers 28:06
I had asked Susan to tell me how she expected to continue to experience joy as she ages. That might seem like a random question to ask an expert on nursing home care. But over the course of a decade, Susan gradually convinced our research team that not only is dignity possible in nursing home care, so too is joy... and that is going to be the topic of the next episode with Susan Braedley.
Sally Chivers 28:41
This has been a Wrinkle Radio. I'm your Host Sally Chivers. Thank you for listening. I want to say a special thank you to Stephen Hurley of voice at radio. They host the show on their platform, and he has been an incredibly generous mentor. Wrinkle Radio is a proud member of the Amplify Podcast Network. Please listen to their other podcasts. They are magnificent. We are also sponsored by the Aging in Data research project funded by the Social Science and Humanities Research Council of Canada. Now, please, if I could, could I ask you to tell your friends, tell your neighbors, tell your parents tell your kids, tell your colleagues, tell your students, tell your local nursing home and remember, don't panic! It's just aging.