Is there a future for nursing homes in Canada?

The high rates of nursing home deaths in the wake of COVID-19 have led to calls for their elimination and their replacement by home care. Based on years of research in Canada and abroad, this article argues that nursing homes are not just necessary, they provide significant benefits for those living in, working in, and visiting in them. In developing this argument, the article begins by setting out why long-term residential care is necessary before moving on to consider the benefits of such care, benefits that go beyond the clinical. It concludes by identifying factors that can make nursing homes a positive option while helping to avoid pandemic horrors in the future.

Introduction

Nursing home deaths accounted for more than 80% of all Canadian COVID-19 deaths in the first wave. This was much higher than the percentage in 16 other OECD countries, where the average was 42%.[2,3] The situation was so alarming that the military was called into five Ontario homes. On withdrawal, it took the unprecedented step of issuing a scathing public report. The story made international news, with the BBC News reporting that the military:

Compiled cases of re-use of unsterile equipment like catheters, of use of expired medications, patients with COVID-19 allowed to interact with healthy residents, abusive behaviour, improper use of personal protective equipment, insect infestations, the delayed changing of soiled or incontinent patients, and forced feedings.

Public outcries were so loud that the Government had to set up a commission of inquiry.

Not surprisingly, calls to close these “institutions” and instead focus on supporting home and community care followed. Such care was argued to be a more cost-effective form of care, one preferred by an overwhelming majority of seniors.

Indeed, in Ontario, nursing homes have long been seen as the last and worst option, as an indicator of the individual’s failure to care for themselves, of the family’s failure to care for them, and of the medical system's failure to cure them. Certainly COVID-19 horror stories mean even fewer seniors now see nursing homes as their first option. However, our years of research into nursing homes in Canada and abroad lead us to conclude that nursing homes are not simply necessary. They can be a positive option.

We base this analysis on three projects. Our just-completed 10-year Reimagining Long-Term Residential Care: An International Study of Promising Practices and our current Changing Places: Unpaid Work in Public Places employ multiple methods, including ethnography. Another current project, COVID-19, Families, and Long-Term Care, analyzes media coverage and our Ontario interviews with families who have or had relatives in long-term care. All this research is informed by feminist political economy theory that recognizes this is mainly care for women by women, many of whom are racialized and/or immigrant women.

Here we begin by analyzing the factors contributing to entry into a nursing home, leading to our argument that even expanded home care cannot address the needs of almost all of those currently living in working in and visiting in nursing homes. This leads us to consider the benefits of congregate care. We conclude by identifying factors that have contributed to the crisis in care and by offering some ways forward to make nursing homes a positive option.

The need for nursing homes

There are various reasons why we need and will continue to need nursing homes and why care at home is not an appropriate alternative for many.

Perhaps most obvious is that many people do not have a home. On any given day in Toronto, approximately 10,000 people are without homes. In addition, many existing private homes are unsuitable for care. Their physical structures can be risky for those who need care or for those who provide for their care, and it would be excessively costly to make them safe. As has become increasingly clear during the pandemic, many homes are also unsafe for older people facing abuse and loneliness.

Another reason is that many people require 24-hour, skilled care. In our Canadian research, families have made it clear that they do not even seek nursing home admission until they have tried all other options and have reached a breaking point. Family member after family member said they were in crisis, that their own health was deteriorating, that they were making financial sacrifices to support care, and that the all-day, all-night care required was beyond their skill and energy. Most of those providing this unpaid care are women. Moreover, the limited number of places available in Ontario nursing homes means few without the most complex care needs get admitted.

One example of many similar stories came from a daughter who reported that her mother had done everything to support her husband who had early onset dementia, including giving up her house to move into an apartment that provided a safer care space. The daughter took early retirement to help, risking her financial security as a result. When her mother went into the hospital for a hip replacement, the daughter moved into her parents’ apartment to care for her father.

[My] dad was just the most wonderful man in the world... Just a gentle, loving dear person. I was ready to murder him after three nights of staying with him. He would constantly get up and he would wander during the night, and come into my mother’s bedroom and he’d say my mother’s name and, “Are you in there?” And I’d say, “Dad, no, mum’s in the hospital, you go back to bed”…And then he’d go back to bed and an hour later he’d get up and come in. So for three nights I had no sleep whatsoever. And I thought how has my mother done this for years?

As her mother’s health continued to deteriorate on her return from hospital, it became more and more obvious that the 24-hour care required could not be provided at home even with assistance from home care.

Another woman described how she struggled for three years to provide care for her husband after he was diagnosed with Alzheimers. Although they had no children, they did get help from friends. Then her husband broke his ankle. “It was a horrific experience. And that seemed to accelerate all his symptoms, the trauma of it, the boot on, he didn’t want to leave it on, anything. Anyway, I managed for a month after we came home”. Then “it became increasingly clear that I couldn’t look after him. He wandered out. He wouldn’t take his medication... I couldn’t, couldn’t really handle it.” Although she “couldn’t bring myself to put him in there,” the doctor insisted.

The work requires skill and effort beyond the capacity of many relatives and requires more than one person to do safely. A resident’s husband described in detail how he tried multiple strategies to bathe his wife who had become both physically and psychologically weak. He ended up putting her in the shower with all her clothes on. Friends assisted but they too found it difficult to help his wife walk, and they all had trouble getting her to eat.

Although 64% of those in Ontario nursing homes have dementia combined with other health issues, a significant number also have a range of physical issues that make them unable to live in a private home. Take the case of a man whose peritonitis led to a serious deterioration and 13 months in a hospital. “I went from 183 lb down to 123 or 122 lb in a month’s time. I just like melted. I was very weak. My muscles were all atrophied…[B]ottom line…they [put me] in a wheelchair and I wound up here...” He had complicated physical needs, no appropriate home, and no family to provide care.

In sum, the overwhelming majority of nursing home residents cannot be cared for in their own homes, especially if we consider the toll taken on their unpaid care providers and those who do not have family to provide support. Moreover, skilled providers too need support from others in order to work safely and effectively, support not available in private homes.

The benefits of nursing home care

Pre-pandemic, most of the scant Canadian publicity on nursing homes focused on exposing what was wrong. And, as we recognized early on in our team, many of us were trained to look for problems rather than for ideas worth sharing. However, residents and their families often had a different view. When we asked a residents’ council if there was anything better about being in a nursing home compared to their private homes, they responded with a unanimous yes. They offered three reasons.

First, they felt safe. This response might seem ironic, given the devastation of COVID-19, but they gave multiple examples. A woman who could not remember to take her insulin after a stroke now was confident that she would always get it. A man no longer feared he would fall, and that if he did, there would be someone to help him get up. Being alone at home during COVID-19 would not have kept them safer in these and other ways.

Second, they had company. Even if they did not enjoy all the other residents, there were enough people to share experiences. They used the example of shared meals and shared visits from families. In their private homes, they would have been all alone. COVID-19 strategies that isolated residents in their rooms just emphasized how important the connections with others are in nursing homes. According to a US report, “strict social isolation has increased depression, anxiety, worsening dementia, and failure to survive.” The same holds in Canada.

Third, they had activities. They acknowledged that visitors often complained that residents sat in front of the television far too often. But these residents said that in their private homes, TV watching was all they would have been doing. At least in the nursing home, there was a variety of activities and outings. Here too COVID-19 meant the absence of activities, emphasizing their importance in the regular functioning of the home.

Based on our research with families, we would add a fourth reason. Families feel relieved that they no longer have to struggle to provide care that puts both their relatives and themselves at risk. Care in a private home too often meant unpaid care by women untrained for this skilled, demanding, 24-hour work. These unpaid women suffered physically from the heavy, constant work, and psychologically from the unpaid worries. They worried about whether their relative had the right medications or whether they would wander away. Families often suffered financially as well. Even those who long resisted having their relatives admitted to nursing homes now say, “I like him being there.” They recognize that care at home had become impossible for them. As one woman said about her husband: “I am at peace kind of now with this service non-stopping,” given that her husband’s demands are non-stopping.

We could also add a fifth benefit, the benefit staff get from working in teams and in workplaces designed for their safety.

In sum, nursing homes can offer better care than private homes for many of those with complex care needs. They can be a preferred option, and a necessary one.

Moving forward

COVID-19 has exposed many of the weaknesses in Ontario nursing homes, weaknesses that have long been identified in the research in other jurisdictions. However, the devastation may contribute to some fundamental reforms. Indeed, if governments do not act on what has been exposed, they are failing all those who live in, work in, and visit in nursing homes.

One obvious reform is to remove profit from nursing home care. Research indicates that profit-taking is a factor in the quality of both work and care.[11,12] According to a systematic review of pre-pandemic research: “FP nursing homes were found to have provided lower quality of care when judged by structure, process, and outcome criteria.”

Nearly 60% of Ontario nursing homes are owned by for-profit companies, mostly corporate chains. Various studies during COVID-19 have demonstrated that death rates from COVID-19 were significantly higher in for-profit homes than in the not-for-profit and municipal homes that make up the rest of the sector.[1,14]

Research on for-profit tends to focus on facility ownership without also looking at the services contracted out to for-profit owners, services such as food, laundry, housekeeping, security, and even management. As our research has shown,[15,16] these services are critical to quality care. When they are contracted out, they undermine the teamwork that is so essential to care while too often failing to provide quality services.

Research has also demonstrated the need for governments to establish and enforce minimum staffing levels and for an appropriate mix of trained providers. In doing so, they must recognize that social care is just as important as clinical care. Multiple studies have demonstrated, for example, the link between staffing levels and quality care and the link between staffing and COVID-19. Ontario has no minimum staffing levels, except for requiring a single Registered Nurse on every shift. The government sets out only limited training requirements for the Personal Support Workers who provide most of the care. Minimum staffing levels would not only relieve the stressful pressure on staff to focus on tasks rather than on care. They would also reduce the pressure on families, and especially on the women in them, to provide unpaid labour to fill the care gaps. Minimum staffing levels could mean as well that families were less pressured to hire private companions. This practice, increasingly common in Ontario homes, creates a particularly exploited labour force made up almost exclusively of racialized and/or newcomer women.

But minimum staffing levels are not enough either. We have for many years maintained that the conditions of work are the conditions of care. Without appropriate conditions and the enforcement of regulations, care providers cannot attend to the individual needs of the residents or provide them with social care. As COVID-19 makes clear, the conditions include among others the need for full-time jobs in single workplaces, organizing work to promote continuity of care, paying living wages, and providing not only personal protection equipment and training for infection control but also physical spaces that promote health.

Most of the staff in nursing homes are unionized. As a result, staff have more benefits and better wages than they would have otherwise, although unions have been less successful in achieving these gains in for-profit homes. In spite of their efforts, however, unions have not been able to ensure full-time employment, prevent the focus on measured tasks, or gain control over work rhythms and schedules. Nor have unions had much influence in designing homes to promote better living and work environments and, during COVID-19, they have had to fight for access to protective equipment. Even with unions, racialized and newcomer women remain disproportionately concentrated in the lowest paid, least powerful jobs.

In addition, moving forward means creating effective ways for all who live in, work in, and visit in long-term care to participate in decision-making and in designing more appropriate physical spaces, strategies that need not mean more money.[15,16] Ontario regulations require each home to have a residents’ council but too often they primarily serve as ways for managers to deliver messages. The same too often also holds for family councils, which regulations allow but do not require. Although unions negotiate over some conditions, their power is limited because they do not have the right to strike and because of claims for management rights.

Ownership, staffing, working conditions, and decision-making structures are only some major issues that governments must be addressed to ensure the benefits of nursing homes are realized. Other issues include systemic racism, sexism, colonialism, homophobia, and agism, issues that go far beyond but necessarily include nursing homes.

Conclusion

Certainly, we need more and better public support for keeping people in their communities. However, we also need to recognize not just the need for but also the benefits of nursing homes. As Ågotnes and Øye explain, there is a “perpetual tension in all nursing homes: whether to prioritize the collective and community or the individual, person-centred needs of residents.” Making nursing homes as good as they can be means balancing this tension in the structure, location, and organization of homes.