The Home in Nursing Homes

By: Rebecca Kaebnick

The sitting room, living area, and community space of the skilled nursing facility in my grandparents’ staged living community was often the hallway. There was a harshly-lit room with tables and a TV around the corner, and a cafeteria-like dining room down the hall. However, the aides tended to gather residents in the hallway, lined up in their wheelchairs in front of the nurses’ and aides’ station. The forbidding front of this station, a pedestal for charts and computers, was an impossible height for many of the wheelchair or walker-bound residents. Strung along this main hall and around some corners were the residents’ spaces, not quite oriented to watch the activity outside the windows, but not quite arranged to focus inward, on each other, either.

On paper, this wing had it all: compliance to health codes, caring nurses and aides, physical therapy. In fact, the facility was top-of-the line. But there was also an unsettled feeling that upset any possibility for a homey feel. Time moved bizarrely: residents sat silently in their rooms or in their wheelchairs in the hallway while the aides swept around and shifts turned over; the clock by the aides’ desk seemed to be counting down to many things and to nothing. When my family visited, we perched in odd places around my grandmother’s room, or gathered near the doorway. When we passed residents, we did not feel as if we were supposed to smile and greet them; one does not greet patients she passes in a hospital, and that’s what it felt like. This was a place where people were on their way to somewhere else; like a hospital, nurses and visitors and patients moved in and out, but these spaces were not a home.

Why are such facilities like this? If they were designed differently, could they feel different? While many of the residents living in this area need careful medical attention, this phase of life is not just about medical and physical care, and doesn’t always have to feel like a hospital.

There are some successful efforts to break the mold, mainly sprung from the culture change movement in the nineties to “deinstitutionalize” nursing homes. The Green House project, developed in the early 2000s, is a key example of an accessible and efficient elder care home that still manages to create a more hospitable environment. Green Homes look more like houses than institutions. They are set up like family residences too, with a living room containing a hearth, a dining table seating all 7-10 of the residents, and the appearance of few medical instruments and technology. Green Homes redesign personal and communal space to make residents feel they are living in a home, rather than a glorified hospital, and give nursing assistants the role of “universal workers” who do everything from dispensing medications to cooking dinner. They have more interaction with residents than do aides in traditional nursing homes, and reportedly increased job satisfaction. The new physical characteristics of the homes and different roles of the aides reconfigure interactions between residents and staff, between residents, and even between residents and their family, during visits.

Another inspiring nursing home is Beatitudes Campus in Phoenix, Arizona. In a New Yorker article published last May, “The Sense of an Ending,” Rebecca Mead describes efforts made to replicate the comfortable, residential feel like that of the Green Homes in a more traditional facility. Tena Alonzo, the Beatitudes director of education and research, adjusts details of a resident’s lifestyle in unconventional ways that can make the resident much more comfortable. For example, a resident’s bed is lowered when there is a higher risk of falling out during the night. The “neighborhood,” as the staff call the facility, is not run on strict schedules; individuals create their own timetables based on what works for them. Food is available around the clock. The layout of the space and interactions between residents and staff are influenced by the characteristics of dementia, not by what is the cheapest or easiest. Instead of a heavy metal door at the entrance of the facility, residents are more subtly reminded not to wander by a velvet rope, like that of a classy restaurant, and a large black carpet, which dementia patients don’t like to walk on because they might interpret it as a hole. Alonzo develops strategies like these to make residents comfortable in more respectful and logical ways than those of traditional nursing homes. She also wishes for the staff to be more understanding of the lifestyle and needs of their residents; she encourages the staff members to try acting as residents for a day, in situations that can be embarrassing or uncomfortable, such as wearing a diaper.  This is another take on the Green House “universal worker” idea, to create more equal and warm relationships between residents and their caretakers. Mead mentions several other establishments that apply concepts similar to Alonzo’s. Like Beatitudes, the Pioneer Network in Chicago attempts to satisfy residents without the heavy use of psychotropic medications. The Isabella Geriatric Center and the Cobble Hill Health Center, both in New York City, are working to integrate Alonzo’s ideas into their practices.

In a study  published in The American Geriatrics Society Rosalie A. Kane et al. assess the success of Green Houses, finding that “GH residents reported significantly higher satisfaction with the nursing home as a place to live than residents of the [comparison facilities].” These feelings of comfort and happiness go hand-in-hand with particular trends in emotional and physical health, such as depression and the loss of independence in a set of activities called Activities of Daily Living, which include eating and using the bathroom. Alonzo and her co-director, Long, found strong trends in weight-maintenance and even healthy weight gain among their residents, due to their adaptive, flexible eating and daily schedules. Pam Belluck, in her New York Times article “Giving Alzheimer’s Patients Their Way, Even Chocolate,” cites various studies showing that space, activities, and medication can be adapted to make a dementia patient more comfortable. Making the lights brighter can have a big effect. Prescribing medication specifically for pain instead of an antipsychotic for dementia can keep side effects under control. Alonzo’s tendency to allow residents comforting rituals, such as sucking on chocolate and playing with dolls, has scientific basis: habitual pleasurable activities have been proven to correlate to depression and decreased cognitive activity. Belluck mentions a University of Iowa study that found that although many dementia patients no longer have the strongest memories, a happy mood can persist hours after the activity ends.  Living in an environment that makes them happier has significant effects on many dimensions of the residents’ health, interpersonal relations, and can help them see themselves as people fit to live in a real home, even if it requires some new accommodations.

If my grandparents’ experience is typical, then it is difficult for the average elder care consumer to ascertain just how homelike the nursing facility is when looking at retirement communities.  Many attempt to channel cheerfulness and hospitality into their built environments by adding special features to their more independent-living wings— fire-lit libraries, easy-access greenhouses, and welcoming dining rooms. Yet it is just as important for the visitor to learn about the functional wings. Maybe consumers do not expect areas designated for increased medical attention to have the same atmosphere, or maybe these areas are just not fully presented to them. Do companies tend to push some aspects of the independent living options and downplay some of the dependent ones? When potential customers visit, they may be more focused on the near future, when they will be living in the apartments and visiting the dining rooms. It is hard to fully picture a time when one’s health may have changed enough to need around-the-clock care, but many will arrive at that point.

Welcoming and peaceful environments seem even more important in the wings where residents deal with more advanced conditions and illnesses. Many residents, like my grandmother, juggle health-related anxieties with the pressure of moving somewhere entirely unfamiliar. Much of the stress my grandmother experienced seemed to be derived from a feeling of displacement. She was always someone who took great pains to make her living space feel like hers, and in this wing she lost this capability. Green Houses and Beatitudes illustrate that it is possible to unite medical care to homeliness, even though a straightforward set-up following the lines of a hospital wing might seem more efficient. Green Houses are certifiedskilled nursing facilities, run by a dependable team of certified nursing assistants, and a “clinical support team” made up of professionals who supervise the medical experience of the residents. Half of the residents in the studied Green House were certified dementia patients, and InformeDesign, a research tool for design professionals, asserts in a short piece about Green Homes that this model could be applied to “even the most heavy-care facility.” Quality of care is not compromised in this environment; reports on the quality of care by the Green House residents overall were either at the same level or better at the Green Houses than at the comparison nursing facilities. At Beatitudes, the directors found that patients were happier months after their arrival, and sometimes were able to make health gains: one resident was able to stop taking insulin because she began eating so well. Beatitudes won an award from the American Association of Homes and Services for the Aging. These models have found ways to successfully integrate medical technology and accessibility into a warm environment.

The basic premise of the Green House project is to find a way to make living areas cohesive units in which the medical structure isn’t the dominant aesthetic factor, detracting from the quality of life of the residents. While it is unclear how affordable Green Houses are, and it is true that the movement is not big enough to be an option for everybody, the success of Beatitudes proves that the goals of the project can be successfully applied to traditional models that still make up the most common elder care options. Beatitudes’s innovations go farther than the built environment, to making the schedules and activities of the patients, and the responses of the staff to residents’ distress, more adaptive to the individual patients themselves. Learning this makes me optimistic and hopeful that this trend will grow. Thinking back to my grandparents’ situation, I can see that my grandmother would have been well suited to be cared for by a collection of staff who are not afraid to make unconventional changes to make a resident more comfortable. Green Homes and homes like Beatitudes take the time to organize themselves according to what they see helps their patients, not according to tradition. They create environments in which conversation between residents, and between residents and staff, is encouraged. Visitors can join the residents in these spaces, bringing in pieces of the outside world but at the same time integrating themselves into this life, at least for a day. The residents can feel like they belong there; they aren’t stored in their rooms or lined neatly in the hall. Instead they can congregate around a puzzle, meet with a friend, pick out a book for themselves. They don’t just stay here until the end—they live here, enjoying each moment with vigor.

Rebecca is a junior at Ithaca College where she is majoring in Sociology and minoring in Spanish, art, and honors. She is interested in issues relating to globalization and vulnerable populations.