Written by: Pat Armstrong and Susan Braedley

Tumultuous times offer opportunities for transformation. Pandemics, like wars and other tumults, not only expose vulnerabilities and inequities, but offer possibilities for developing collective strategies based on shared needs and responsibilities. The necessity and opportunities for such transformation have become obvious in those places variously called long term residential care, care homes and nursing homes. High death rates resulting from the combinations of COVID-19 isolation, and horror stories of neglect,  along with critical shortages in care staff, have called attention to these homes in ways seldom seen before, raising demands for new strategies for older people’s care -including demands to eliminate care homes altogether.

In Care Homes in A Turbulent Era: Do They Have a Future?  we consider whether and how care homes could be transformed to offer conditions of dignity and respect for all those who live in, work in and visit in nursing homes.  But we go further, to ask, can care homes be transformed to promote pleasure and joy? Our answer to these questions of care home transformation is YES.  But we offer caveats and cautions about the challenges ahead.  Addressing care home issues is not a merely matter of repair or minor reform, although both could provide improvements. To achieve the goals of dignity and respect, care homes need a revolution. This book sets out ways forward. In doing so, it attends to context and populations as well as to other global and local forces, offering ideas worth sharing and promising practices rather than a single model or right way for care homes in the future. And it includes everyone who lives in, works in, manages, and visit in care homes.

This book is innovative in a number of ways.

First, our research team and the methods we employ are innovative, providing an interdisciplinary, international approach to care home questions.  It includes sociologists, social workers, nurses, anthropologists, historians and more who have been researching together on care homes for more than 15 years., Over this time, we have developed enough trust to challenge each other about important issues in ways that help us move forward. We embrace diversity and differences in our group, seeking to learn from these differences.

Our diversity in disciplines and educational backgrounds is our strength, providing us with multiple ways of perceiving care home issues. This not only means that we capture more than we would individually but, in working together, each team member developed a more multifaceted understanding as we learned from and with each other. Our mixed methods (discussed in Armstrong and Lowndes 2018 Creative Teamwork: Developing Rapid Site-Switching Ethnography) also means that we are always comparing and assessing data gathered in different ways, seeking complex, nuanced analyses to inform change.  

Our research teams include those who investigate the available statistical, financial, and other quantitative data available on nursing homes, those who research the history of nursing homes, and those who investigate ownership and other aspects of nursing homes. But unusually, in this project most of our team members –including our most senior members –have spent a long time conducting research in care homes. In six countries and in multiple cities and towns, our teams of about 12 researchers interviewed, observed, and participated in care home life. We worked in teams and shifts, starting at 7 am and continuing until midnight each day throughout the course of a week. Each team included locals and members from the other countries in our project, allowing us to draw on knowledge of the local context as well as on new perceptions from those less familiar with the country and place. Our collective analysis during and after these site studies located our findings within the research we also did on the forces and structures, policies, and practices shaping what we saw and heard.

Second, we assume context matters. In our research we were not seeking care home best practices or one right way. Instead, we aimed to identify promising practices and ideas worth sharing from Canada, Germany, Norway, Sweden, the UK, and the US, while acknowledging the possibility of not finding anything promising. We also learned how hard this is, given that our training focuses more on finding and analyzing problems.

Third, we assume that gender, race, sexuality, and class matter, and not just at the level of individual residents and staff, but as factors shaping care and work at the levels of organizations, systems, and states. And these social relations always matter, albeit in different ways, at different times and in different relationships

Fourth, our concept of care understands care as a relationship. From our perspective, this relationship involves all those who live in care homes, who provide paid and unpaid care in them and who visit in these homes. So, we include not only families and residents but also volunteers and housekeeping, dietary, laundry, security, and managerial staff. In contrast to both those who conceptualize care for this population as the inevitable domination by carers over those who require support, and those who focus exclusively on the needs of either residents or staff, we perceive care as a relationship of mutual trust and respect, requiring conditions that allow care to flourish.  For us, the conditions of work are the conditions of care.

Fifth, and perhaps most importantly, we assume that care homes are not only socially necessary. They can, and indeed should, be places that put life into years rather than years into life, places where people are choose to live and work.

This book draws on our many forms of data, together with our reflections and contemporary debates about nursing home care, going beyond specific evidence to dare to dream about promising ways to practice long-term care.

Avoiding prescriptive formulas and in keeping with our understanding that contexts and populations matter, we do not set out a new care home model. Rather, we identify key principles and some critical ingredients that can be adapted to specific contexts. We invite readers to dare to dream with us, taking inspiration for the care home transformations so badly needed.

What do we suggest? We argue that publicly funded and operated nursing homes have the highest potential to offer the most cost effective, high quality, accessible, and equitable nursing home care. In our chapter on financialization across the care home sector internationally, the tensions between profit and care become clear across the system. Further, the chapter reveals how accountability for care is disappearing in the maze of increasingly complex ownership arrangements across borders that make it difficult to identify who is responsible for a specific care home.

Further, working conditions need to be central to any revolution in care. All staff-including not only those who provide direct nursing care but also those who cook, clean and do laundry need the time, training, teamwork, autonomy, consistent assignment, and  supportive supervision to develop knowledgeable care relationships with residents. This is not possible unless workers have secure employment and sufficient pay to stick with care home work, and conditions that allow them to go home knowing they have provided care, and not just a bare minimum of bodily maintenance. And we must also attend to the working conditions of those who do unpaid work as family, friends, and volunteers.

Over and over, we have found that care homes’ physical environments matter. Important to infection control, safety, welcome, comfort, and mobility, physical environments can also make access to the outdoors inviting and pleasant, provide a sense of belonging in its colours, artwork, symbols, and architecture, make it easier for workers to respond to resident needs, and support families to enjoy their visits with residents. Homes need to bring the outside in and the inside out, integrating with rather than separating from the community. Care homes are not individual dwellings but collective ones, and physical environments need to welcome, reflect, and support all who live, work, and visit them.

We argue that the future of care homes is contingent on whether and how equity and diversity are addressed. Our research shows that care homes have the potential to be collaborative, culturally diverse, equitable organizations with deep, daily connections to the diverse communities and groups who live around them and review promising approaches that can advance this goal.

How accountability is understood, developed, and embedded in processes is also important to care, and not just accountability to funders, but to residents, workers, families, and communities. Instead of reviewing the research on regulation and accountability, one chapter approaches these issues through interviews with those who have spent years studying care homes in multiple countries. More a conversation than a standard academic approach, the participants explore the lessons learned and questions to ask.

And finally, we argue that joy is central to quality in care homes. We discuss ways in which quality assurance methods both support and fail to measure quality of life, quality of relationships, and opportunities for meaningful sharing and pleasure that include all who live, work, and visit care homes. Our analysis includes supplemental or alternative approaches to ensuring quality in care homes, encouraging all those concerned with care for older people to consider the problem of quality by beginning with joy.

Locating the analysis in the research and perspectives of multiple disciplines and scholars from multiple countries, the book challenges readers to go beyond what’s wrong to think about how to make care homes a positive option for provide those who need such care and those who provide it.

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