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

• 1.     Location matters. In the 1960s and increasingly now, homes are located outside the urban core where land is cheaper. Many residents told us that there was nothing more boring than watching the grass grow. They want to see people and activity. In a Manitoba home we saw few residents looking at the lovely stream and deer at the back of the home and instead watched the parking lot and shopping centre at the front. Speaking of parking lots, transport is also an important aspect of location. We were called by a remote community in Canada asking for help in resisting a move to the outskirts. It would make it difficult for staff and families to get there without public transit, especially in winter, and for doctors to get to hospital services they might need. Indeed, distance to other services should be taken into account. One of the most attractive homes we were in was in Norway, where the nursing home was in the building that also housed the town swimming pool, and cinema, a library, a cafe and a daycare. There as a shopping centre and a church virtually outside the door. Families combined visiting with other activities and residents could be part of the scene, without as they said, putting the boots on. 
• 2.     Staffing matters. It seems just common sense. That common sense has been demonstrated in study after study; namely, the kind and amount of staff matters.[i] More than a decade ago, when fewer residents had complex are care needs, research demonstrated that there should be at least a minimum of four worked hours of nursing care per resident per day. Few Canadian jurisdictions set minimum staffing hours and none of those minimums are as high as 4 hours. Actual hours are much less. To quote Alberta’s Parkland Institute,

• 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.

  
  

• 3.     Conditions of work matter. As we like to say in our team, the conditions of work are the conditions of care. In a study we did with health care workers over a decade ago, Canadian respondents were more than 6 times as likely as the Nordic ones to say that they faced violence on a more or less daily basis. The resident populations were quite similar, but the Nordic staffing levels were much higher, and the staff had more autonomy as well as higher pay. Conditions also include more full-time employment that allows staff to know residents and each other while avoiding having to seek work in several homes, an issue made visible by COVID. Opportunities for on-the-job training are also critical as care becomes more complex. There are many more critical working conditions, like the focus on tasks and the high illness and injury rates linked to time pressure and poor equipment. Indeed, our high turnover rates and staff shortages are related to the conditions of work.

• 4.     Ownership matters. In Canada, publicly funded nursing homes take three forms: government-owned, not-for-profit and for-profit. Although in the past many of the for-profit ones were what were called small mom and pop homes, now most are corporate owned. Ownership varies significantly across Canada, with none of the homes in New Brunswick publicly owned compared to all of the homes in Canada’s north.  Just over a quarter of homes in Alberta are for-profit compared to a majority in Ontario.[iii].Research before the pandemic demonstrated that in for-profit homes both staffing levels and pay were lower than in not-for-profit or government ones while more of the workers were part-time. There were more hospitalizations and bed ulcers, to name only some of the differences in care. When COVID came along, more residents died in for-profit homes while research showed that profits still went up. In short, less money goes to care in for-profit homes and some public money goes to profit rather than to care (See Pat Armstrong and Hugh Armstrong, eds. 2020 The Privatization of Care: The Case of Nursing Homes New York: Routledge).

• 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.

  
  

• 5.     Services matter. These are places where people live and we call them homes, albeit of a special kind. That’s one of the many reasons to pay special attention to food, clothing, and cleaning. For many, meals are the highlight of the day. They are not only a means to satisfy hunger but also an opportunity to be social. When food is privatized, cooked off site, lumped on full plates and delivered by strangers, it brings little joy. Indeed, it often turns residents off eating entirely. Meals could also provide an opportunity for staff to sit and chat while they are assisting people to eat but too often time pressures prevent this social exchange. We have watched staff have to jump from table to table to help several people eat or sit and document how much people eat while they eat.

• 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.

  
  

• 6.     Regulations matter. When we looked at what happened when a nursing home scandal erupted in any of our six countries, we found that the most common response in North America was more regulations (See Lloyd, L., Banerjee, A., Harrington, C., Jacobsen, F. F. & Szebehely, M. “It is a scandal!”: Comparing the causes and consequences of nursing home media scandals in five countries. International Journal of Sociology and Social Policy, 34(1/2), pp. 2 -18, 2014). However, instead of focusing primarily on the big structural issues like staffing levels and training or creating the conditions for teamwork and for staff to apply their skills, the regulations that followed tended to provide more, and more detailed, rules to staff and residents and to require more detailed reporting. So, for example, to address issues of malnutrition and isolation, we got regulations requiring everyone to be in the dining room by 8 am rather than ensuring that the meals met residents’ preferences and that there was enough staff to sit with residents or to allow residents to decide when they wanted for breakfast. More detailed regulations around falls often meant residents were put in wheel chairs rather than providing enough staff to ensure that residents didn’t fall while walking. In Norway, I watched a therapist urging a resident to walk, pushing him to take steps. I asked her if she was afraid he would fall and she said sometimes residents fell but if they did fall, the team talked together about whether it could have been avoided or not in order to assess future strategies to prevent falls. We need regulations, and their enforcement, but we need to make sure we are regulating appropriately for care.

• 7.     Size matters. There is a lot of discussion now about how homes should be small in order to be more homelike. There was no question in our team that the common 32 or more residents in each unit that we saw in Canada were not homelike and that the four or even five bed rooms were inappropriate in so many ways, although I did interview one man who said he loved it. It reminded him of growing up in a kibbutz. However, you can have small units in larger homes and there can be advantages of larger homes. For example, larger homes can have your own therapists, dentist etc. Larger homes can have more flexibility in terms of juggling staffing and they can achieve economies of scale while leaving a smaller footprint. Moreover, just as we talk about increasing the density of cities, we can also provide more accommodation in larger homes, as long as we make the units smaller, as we have seen in some Canadian homes. How small is an open question. Our Nordic colleagues thought maybe their units for 8 are too small. 

• 8.     Joy matters. We have become so focused on safety and on keeping people alive that we too often forget about joy. In a German home we studied they talked about putting life into years, rather than years into life. We were in Canadian homes that would not allow soy sauce because it was too salty. Without sou sauce, food was tasteless for those residents who has used soy sauce all their lives. We saw alcohol forbidden in many Canadian homes, in contrast to the UK home that brought a resident her traditional gin and tonic each morning. Joy means focusing at least as much on the social as on the medical, recognizing loneliness and depression can kill. It means allowing some risks because life without risks is boring. 

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

[ii] Parkland Institute (2021) Time to Care Staffing and Workloads in Alberta’s Long-term Care Facilities https://www.parklandinstitute.ca/time_to_care

[iii] CIHI (2021) Long-term care homes in Canada: How many and who owns them?

https://www.cihi.ca/en/long-term-care-homes-in-canada-how-many-and-who-owns-them

Pat Armstrong is a Canadian Sociologist and a Distinguished Research Professor at York University.