A Different Way To Distinguish Between Good, and Bad Nursing Homes
Many years ago, when I was still a student nurse, part of the study program I had to undertake related to the work of the sociologist Erving Goffman. It didn't take long for me to appreciate just how profound and timely Goffman's insights were. What I could not appreciate was the timeless nature of his observations and how they would continue to influence my views of the worth of institutional settings like nursing homes.
Goffman published his work on institutions in 1961, in a book called ‘Asylums: Essays on the Social Situation of Mental Patients and Other Inmates'. At that time many people with chronic conditions and illnesses such as Alzheimer's disease, were actively separated from society. Goffman described their care in large de-humanizing institutions he called ‘total institutions'. His work is as important today because it helps to remind us of the negative aspects of care settings.
A total institution is a place where the residents, or inmates as Goffman referred to them, live, eat, sleep and play. They are restricted from contact with the outside world. Within the walls of the institution people are managed in groups and they have strict daily routines. There are clear boundaries between patients and staff, where they inhabit separate worlds and have only limited interaction. In these places patients experience a loss of identity. Sound familiar?
Anyone who has worked in care homes for people with dementia will recognize some aspects of Goffman's descriptions. It is certainly true that today, as in previous years, people with Alzheimer's are at risk of receiving very poor care in some facilities. Regimes can be regimented and de-humanizing and residents have very limited privacy. For the resident choices are limited and any requests for a break or interruption in routine can be met with a frosty if not hostile reception.
But let's not be too negative. Routine is important for both patients and staff. People with Alzheimer's tend to find disruptive routines anxiety provoking and confusing so a balance need to be struck to meet the needs of patients and staff. Make no mistake, nursing homes are hard work. The volume of work is demanding and staffing levels can be inadequate even in the better establishments. However, there are still too many understaffed, poorly trained and poorly managed homes that fail to care adequately for their client group.
Smaller care facilities can help prevent a sense of crowd control. Legislation helps minimize poor care and elder abuse. As a caregiver I would be encouraged by the sort of nursing home that welcomes support from the local community, where relatives are encouraged to visit at any time of the day or evening and where residents go out frequently to join in local activities. Good practice and high resident visibility is good for the care facility as it can act as a good advert for future customers!
If you are looking at placing your loved one in a nursing home think about the issues of the total institution that Goffman highlighted nearly 50 years ago. Ask questions about the management of care, staff to patient ratio's, routines, ways in which privacy is ensured and individuality and self-respect maintained and most importantly, how their residents have a voice in the care they receive.