© Gudmund Ågotnes, 2017
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Why nursing homes and why hospitalizations? The simple answer is because they, when combined, are simultaneously important
It is an aim to speak about and to the practitioner, and, simultaneously, to the social sciences. Those who, from this book, expect concise recommendations to be applied within a field of practice will be disappointed. Rather than creating or even recommending practices, I seek to understand them, or more precisely; understand from where they are generated. It is still a most profound wish (and hope) that such an approach will be of relevance and interest for the field of practice. While it is not a main objective to speak on behalf of the practitioners in nursing homes, I believe this book can be read as an implicit advocacy for them - by describing the difficulties and the uncertainty caring staff have to relate to, and by describing the perpetual ambiguity influencing their work.
I am grateful for the help and support from many friends and colleagues, too many for all to be mentioned. Professors Karin Anna Petersen and Frode Fadnes Jacobsen should receive the largest amount of gratitude (and blame for any shortcomings); always helpful and inspiring. A very special thanks should also be directed to Staf Callewaert for an early and profound interest in the project and to Knut Ågotnes for guidance and discussions towards the latter phases. I am also indebted to the research project «Re-Imagining Long-Term Residential Care: An International Study of Promising Practices», by primary investigator professor Pat Armstrong, for including me in their project, and for conversations and practical help within and outside «my» project.
I am forever indebted those who hosted me for shorter and longer periods during fieldwork and other forms of data collection: the municipality for facilitation, the administration in the nursing homes for opening their doors, and the caring staff for sharing, showing, including and forbearance. All have been generous, some for granting formal access, some for that and much more: fearlessly sharing without receiving.
And, of course, to
The main objective of this book is to analyze how and why nursing homes vary in practices of hospitalization of elderly residents. This objective will be approached through an analysis of
Research literature states that rates of hospitalizations vary considerably between nursing home institutions, also within smaller geographical areas. In this book, explanations, causes and connections of practice are sought after through the analysis of factors on an institutional and structural level, and can, as such, be regarded as a supplement to the existing «knowledge bank» primarily addressing patient characteristics in analyses of hospitalizations from nursing homes.
The study aims to demonstrate how decisions regarding hospitalizations are derived from an
Fieldwork, in the form of participant observation, has been conducted at six nursing homes in Norway, and two nursing homes respectively in Canada, the United States, and United Kingdom. The primary methodological approach is supplemented with interviews and statistical data.
Residents of nursing homes are frequently hospitalized. They are also hospitalized differently: nursing homes have different thresholds of when to hospitalize residents and when not to. Given the gravity of such decisions – hospitalization for the frail elderly nursing home resident can be confusing, difficult and even deadly – such a variation appears as confounding.
The question constitutes the foundation of this book. However, discussions and analyses will also cover practices in general in nursing homes, because the one cannot be understood without the other. Practices of hospitalization are not, as will be demonstrated throughout this book, predetermined either by patient characteristics, institutional characteristics, or structural frameworks. Nursing homes do not hospitalize frequently or infrequently exclusively because they have a certain segment of residents, exclusively because they are small or large, or exclusively because of the presiding legislation. Rather, practices of hospitalization are generated by those who practice, and are bounded in space by being shared within a collective of agents. Nursing homes hospitalize frequently or infrequently because of the incorporated practices of the respective nursing home staff, in other words. As such, practices of hospitalization are also related to the overarching question of practice in general. It will be argued that
The aim of the book is to contribute to the realm of understanding and explanations, rather than to evaluate and recommend practices for nursing homes. The aim is not to identify a correct set of practices, but rather to understand and describe how practice «works». As such, the analysis is
It will be argued that practices of hospitalization cannot be understood solely through an analysis of the inherent characteristics of the institutions in which they are performed. Nor can practices of hospitalization be understood solely based on the specific decision-making process; that is, in total isolation from their wider surroundings. Rather, practices of hospitalization relate to an encompassing and general set of «how things are done», which are identifiable and bounded in time and space; described in the analysis as
The nursing homes within the sample should not be considered representative of nursing homes in general, not even of nursing homes in Norway. The nursing homes are, however,
The undertaking of identifying practices that can be labelled as «representative» is also problematic. I will argue that the ways of doing things in nursing homes –
Problematic aspects of generalization notwithstanding, hospitalizations still happen, with considerable consequences for those involved. The institutional or local development of practices is no less real, relevant and important, even though they do not mirror that of
There are far too many aspects of nursing home life relevant to the specific study of hospitalization and the more general study of practice, for all to be included in the present analysis. Some elements, therefore, have been left out, leaving us with aspects of nursing home life more directly connected to practices of hospitalization.
The book is divided into four overarching parts (totalling 10 chapters), comprising an introductory part and an analysis in three parts. The introductory part consists of an introductory chapter, background and context of the Norwegian health care system (
The study is primarily directed towards nursing homes in Norway. As the dynamics at play have a general quality, as will be argued, the succeeding discussions will hopefully have resonance outside the sector in question as well as outside our small country.
The primary sample of the study consists of six nursing homes located in a Norwegian municipality. Only nursing homes with exclusively long-term beds are included. Long-term bed institutions must all relate similarly to the inherent dilemmas of whether or not to hospitalize their residents from what is considered their «home», and they share many of the same organizational characteristics, to which we will return.
The nursing homes included are to be found at the top and the bottom of a table of hospitalization rates including all nursing homes in the municipality. Three nursing homes with high hospitalization rates, and three with low rates are included in the study. In the nursing home with the highest rate of hospitalization, residents were 4.9 times as likely to be hospitalized compared to the nursing homes with the lowest rate. Of the six nursing homes included, two were public, three private non-profit, and one private for-profit.
Shortly after the selection process, the first phase of the data collection - multi-site participant observation - was conducted in all six nursing homes, in one nursing home at a time, for a two-week period. The fieldwork for each nursing home lasted on average five days per week, close to a full working day each day. Each fieldwork session started out with semi-structured interviews with the administrator, followed by semi-structured interviews with one or two head nurses in the units. This was followed by a «tour» of the facility, used both as an opportunity to get to know the units, and for residents and staff to be introduced to me and the project, albeit briefly. Typically, this was all completed within the first day of the fieldwork, leaving the remaining days for observational studies. Following the main objectives of the project, it was important to get as close as possible to the actual interaction among staff, and between staff and residents, as early in the project as possible. Consequently, as much time as possible was spent in the nursing home units. This general approach seemed to work well, and was therefore repeated at all six institutions. A majority of time was spent in one unit, again based on the objective of getting an in-depth knowledge of everyday life, as opposed to a broader overview of the organization as a whole. At the starting phase of each period of fieldwork, it was important not to overwhelm staff and residents (and the researcher). An approach was adopted of easing staff and residents into the (prying) presence of the outsider, while increasing the time spent in the units throughout the two-week period. This seemed to be a reasonable strategy; the staff certainly seemed to be more comfortable as time passed, paying gradually less attention to the researcher. Towards the end of the first week and for the remainder of the stay, the researcher spent entire shifts in the units, alternating between day- and evening-shift, with the former predominating.
During this phase of fieldwork, the role of the researcher at the institutions was closer to that of an observer than that of the traditional anthropological participant observer. Several hours were spent each day in the units, often in one sitting, observing everyday life. More often than not, the researcher would be seated in one of the common areas, trying to come to grips with, while simultaneously not interfering with, the flow and routines of staff and residents. That being said, it would be naïve to think that the researcher does not influence the object or phenomenon of study. Both during these two weeks and in a later, longer period of fieldwork, the researcher was, in many ways, an anomaly at the nursing home, not just as a «researcher», but also as a male in a predominantly female work environment, who came from a non-nursing background. Conversely, being an outsider, and being viewed as such by the insiders, also had its advantages: basic and naïve questions about the everyday life in the nursing homes could be asked, and were answered without hesitation or (apparent) scepticism. Being the unskilled outsider, in other words, provided an entry point to a form of informal rapport between the researcher and the staff members.
This phase of research was by no means limited only to observing; staff and residents would contact the researcher for small and large matters, all day, every day, and increasingly throughout the two weeks. Initiating conversations with residents also became more «natural» after a while. It seemed strange, problematic even, not to talk to residents while sitting in «their» common rooms, especially since the busy schedule of the staff seemed to leave them incapable of spending «quality time» with residents. Most of the residents welcomed all forms of interaction, and seemed to be deprived of outsiders to talk to. The conversations with staff also increased gradually, perhaps because of the increased interaction with residents, perhaps because the staff became familiar with the strange outsider. As much time as possible was also spent in the nurses’ station, during morning and afternoon report meetings and during lunch; the only occasions where most of the staff were gathered at the same time. The nurses’ station was an important arena of study as the dynamics of interaction in many ways contrasted with that of the rest of the nursing home. Not only were residents (for the most part) excluded from this arena, but it was also rare to have more than two staff members gathered for more than a minute outside the nurses’ station; the busy schedule of everyday work simply did not allow for it. The nurses’ station also allowed for a glimpse into the more informal aspects of work in nursing homes, as staff members would talk more freely amongst themselves, and to me, before or after report meetings, or during short coffee breaks.
After the first phase of short-term fieldwork and a period of data analysis, one of the six institutions was chosen for long-term fieldwork. The site for the long-term fieldwork, called
As for the role and physical positioning of the researcher during fieldwork at Acre Woods, there are more similarities with than differences from the short-term fieldwork. The role as «the observer» was, however, not as strictly maintained as previously, and became less defined as time passed. The role was not intentionally discarded, but was gradually altered through the influence of others, staff and residents equally, as they wanted and expected more involvement, feedback, conversations and small-talk. Towards the end of the fieldwork, the researcher’s involvement at the nursing home had changed to include doing smaller chores initiated by staff, residents, and gradually, by myself, such as fetching and reading newspapers, refilling coffee and accompanying a resident to the activity centre.
The physical positioning, movement and interaction during fieldwork at Acre Woods was also similar to that of former fieldwork, particularly regarding an emphasis on common rooms, the nurses’ station and hallways. In short, the biggest difference between the two phases was the longevity of the second phase which facilitated understanding and analysis of how practice is generated in a unit, while building on experience from and knowledge of other units and nursing homes.
Observational studies in nursing homes were supplemented, primarily in parallel, with other forms of data collection. Data on the formal characteristics of residents transfers to the specialized health sector was collected for a six-month period at Acre Woods (see
Data on overall staff characteristics was collected for all six nursing homes, including information about age, tenure, gender, number of staff positions (percentage) and types of positions (permanent/non-permanent staff), all measured against the different professional groups (registered nurses, assisting nurses, assistants). The data was gathered directly from the institutions, providing up-to-date overviews of current staff (see
Data on residents’ characteristics was collected from Acre Woods. While raw data on staff characteristics was gathered from the institutions’ electronic personnel programs (albeit these differed from institution to institution), the same could not be done for residents; this would not be possible without getting access to personalized information. Instead, data was collected manually, primarily from the respective unit leaders (see
After this relatively long period of data collection, all data, field notes, preliminary interviews and register data, were systematized and analyzed. Based on this analysis, unstructured interviews were conducted at each site with two or three informants, either from middle- or from upper management. A total of 15 interviews were carried out at this stage, adding to the interviews of a more informal character done at the beginning of the preliminary fieldwork. Nursing home- and unit leadership were targeted for this part of the data collection, as the previous parts, especially the fieldwork, primarily dealt with staff working more directly with residents. The interviews, conducted in one setting each time and lasting from 25 to 120 minutes, were based on an informal interview guide, and conducted at the respective nursing homes during working hours.
Also in parallel with the data collection described above, the researcher participated in a large international research project addressing promising practices in long-term residential care in North-America and Europe, titled «Re-Imagining Long-term Residential Care: An International Study of Promising Practices» (
In addition to what could be considered original data material, considerable emphasis and time was directed at the relatively extensive research literature covering the topic of «hospitalization/transfer from nursing homes» (see
Having Bourdieu’s theoretical universe as a pragmatic orientation rather than a governing schematic, methodological considerations are also affected. For Bourdieu, techniques, methodology, epistemology, theory of science and «theory» in general are inexplicably linked and overlapping (see also Prieur
As such,
Placing himself between or beyond (depending on how one reads) the traditions of subjectivism and objectivism, Bourdieu points to epistemological shortcomings on each side. Objectivism and/or structuralism, sometimes also referred to as structural objectivism (Bourdieu & Wacquant
«The objectivist point of view» can be distorting and reductionist, by projecting a «scholastic» logic of automatism, when applied to the study of practice. That is not to say that Bourdieu treats structural influences as non-existent, or as overtly relativistic, as seen within epistemological traditions described as «subjectivistic»:
To simplify a complex and nuanced theoretical framework: Bourdieu’s agent can be found caught somewhere between structure and agency, his actions neither pre-determined nor completely rational or conscious, neither completely mechanical nor instrumental. For our benefit and in this context, the methodological implications of such a position are vital. Given such a position, understanding
Returning to the methodological implications of such a position, Bourdieu argues that there are three aspects of agents’ accounts that are problematic for the researcher (Bourdieu
Such a position has explicit implications for the form of and reliance on interviews, which it has been argued elswhere as the:
The misrepresentation of the agent by the researcher not only arises from relying on native accounts, but also from a tendency or a desire by the researcher to create representations that follow the structure and system of rules
The subtlest of pitfalls for the researcher, describes Bourdieu, is that descriptions of such patterns of practice are based on a vocabulary of rules, describing a social practice that relates to other conditions than that which is governed by rules (Ibid.). Practice, rather, should by studied for what it is, and not what is said about it. Or, as Jenkins´ summarized Bourdieu´s epistemological critique:
Bourdieu addresses these structural discrepancies, which must be understood actively and approached by the researcher as part of a practice that can be
The approach can still be
While the latter sub-chapter is primarily concerned with what has been described as a first
For Bourdieu, participant objectivation, not to be confused with the anthropological practice of writing oneself into the text, is the most challenging of scientific exercises, as it implies a break from all that is taken for granted. While stated as challenging, such a position can also be met with a fundamental critique in my opinion: the sociologist is presented as the sole agent capable of transcending the structuring forces hidden to all.
Although such a critique may not be thoroughly addressed by Bourdieu, he does provide some more or less detailed accounts of the researcher’s endeavors in achieving a second break. The second break implies an analytical step away from the practice of the researcher (Bourdieu et. al.
In doing so, in my opinion, the role of the researcher is not only scrutinized but also made relevant, perhaps to the degree of representing an elitist position, for which Bourdieu can be criticized. Implied in this reasoning, although fairly hidden, lies an «objective truth», that is; available and objective knowledge can be comprehended and conveyed (albeit not readily available) by the researcher (as opposed to the informant). As such, the researcher is empowered; she
I believe that the strength (and simultaneously perhaps also the weakness) of this project lies in its many mothers and the different environments it addresses. This study, a bastard of sorts, applies a mode of analysis of a social phenomenon typical for sociology, adopts a sociologically oriented theoretical framework, applies methodological approaches and textual presentation typical for social anthropology, while simultaneously addressing a field of science best labelled as «health» or «nursing science». As such, this project can be labelled ambitious, perhaps also as pretentious, but also, simplistic and uncomplicated in a fundamental sense: the object of study has been the governing factor, rather than scientific techniques or traditions.
The design of the project excludes potentially interesting and relevant areas of interest. Some areas not covered were done so by choice, other perhaps more problematic deficiencies are involuntary. I hope that these limitations are amended by continuously reflecting over their significance.
Although a significant period was spent at several nursing homes, the researcher did not observe as many concrete cases involving a hospitalized resident as perhaps one would expect. Hospitalizations did not occur on a daily or even weekly basis, and many occurred at times when the researcher was not present (at night-time, for instance). Several such incidents are still included, through retrospective discussions and presentations of them by those involved. For several of these incidents, the researcher was familiar with «the cases» (and caring staff was familiar with the researcher’s interest in them) as the decisions had the form of ongoing deliberations spanning several days, rather than sudden and/or acute occurrences. However, the primary empirical attention has been directed towards
A contextual attribute of great importance for the practice of hospitalization not thoroughly discussed, is the organization- and location of hospitals (alternatively emergency wards) in relation to nursing homes. As the study is situated in one municipality, where all nursing homes are within reasonably similar distance to local hospitals, this aspect will remain under-communicated. For nursing homes elsewhere, however, distance to hospitals might be of great significance, also regarding hospitalization (see for instance Vossius et al.
The term
The term
The primary protagonists of this book will be labelled
As already made clear, this study predominantly draws its data from two, related sources: fieldwork conducted at six nursing homes in a larger city in Norway and fieldwork conducted in eight institutions (six of which are outside Norway). The former will be considered primary, the latter supplementary. In the discussions of international or cross-jurisdictional relevance, the six nursing homes from Norway will be labelled «the national sample», the remaining nursing homes «the international sample». In other discussions, the label «our nursing homes» or «our sample» will refer to the primary institutions: six nursing homes located in a larger Norwegian municipality.
One of the advantages of doing fieldwork for an extensive period of time at a nursing home is the possibility of observing the interaction between staff and residents over time, in different periods and stages of a resident’s life at in the nursing homes, and, in some cases, from the very beginning of their stay.
Cate is, as all her co-residents, not capable of properly caring for herself. She had been living alone, taking care of herself, with no help except from close family members, before suffering from a stroke. The stroke left her incapable of walking and her speech was left severely slurred. Of all the residents in the unit, Cate struck me as the loneliest and as the one with the most desperate need for attention and affection. This was despite the fact that, as I later found out, a daughter visited her almost every day, visits which she seemed to treasure and enjoy.
Cate moved into the nursing home shortly after I started my extensive fieldwork in the unit. She moved in on a Friday afternoon during early winter. I first met her the following Monday. At the time, I did not know of her arrival, only that another resident had died shortly before, which always meant that another resident would be moving in shortly after. When attending the morning report meeting on Monday morning, Cate was pretty much the sole focus. The assisting unit leader was in charge and described how Cate’s first days had been. Usually, a single resident did not get the sole attention of the morning report meeting, but it was deemed necessary on this occasion. Cate had, according to the assisting unit leader, been
During the week, I met, observed and talked to Cate every day. Before supper on Monday, she sat in the small common room together with the usual group. To my surprise, she was calm, smiling, and talked to several of the other residents, who, although having great difficulty in understanding her, tried their best to include her. Cate was, then and in general, extremely outgoing, always trying to make contact and smiling to everyone approaching her. On this particular day, and as usual, she was well dressed, wearing nice jewellery, and, even though having a somewhat untidy hairdo, presented herself as a «nice lady». She immediately took a liking to me, perhaps mainly because she felt lost and lonely and I could give her more attention than the caring staff could afford. She waved me in, smiling, giving the impression of having something urgent and important to convey, of which I did not understand much. All the same, she responded gladly when I simply smiled back or said
The following day, Tuesday, Cate’s behaviour was very different, and resembled the description of her by the assisting unit leader. Sitting in the same common room, with the same co-residents, at approximately the same time, she now cried and sobbed, trying to get the attention of everyone walking by. Now, she seemed to be seeking attention to comfort or help her, rather than simply someone to talk with. One of her neighbours addressed me:
The following day, Cate was better, but not completely. She alternated between short rests (finally caving in for lack of sleep, I thought) and being uneasy and restless. Her restlessness was not as distinct as the previous day, however, and talking to her seemed to calm her down. She did not need a member of the caring staff present at all times, but they often checked in on her.
The fourth day, Thursday, saw another change: for the entire day, she was all smiles, seeking contact with everyone around her, laughing when someone approached. She had a habit, exhibited that day, of grabbing your hand, grasping on to it and giving it gentle strokes, while at the same time keeping you close. Cate also had found her appetite again, which had been missing for the two previous days. During the afternoon report meeting an assisting nurse conveyed her thoughts, saying that Cate was much better, but that she did not understand if it was a question of adjusting to the nursing home, recently administered medication or a passing physical illness that had led to the change.
The following week, Cate’s situation had changed yet again. For the first two days of the week, she was again very restless and uneasy. At the Monday morning report meeting, a registered nurse explained that Cate had
For the next three days, someone was by Cate’s side at all times. Usually it was a student (the nursing home had just received nursing students on internships in the nursing home from a university college), sometimes assisting nurses or assistants, sometimes me. For most of the time, she had to be walked around the unit; simply sitting and talking to her did not calm her for long. Therefore, and unlike any other residents, she attended all report meetings and other meetings in the office of the unit leader, always enjoying herself and, apparently, relishing the attention. As opposed to the previous week, the report meetings now revolved more around Cate’s psychotropic medication, of which several had been tried out. The assisting unit leader and another registered nurse talked about the different kinds of medication, which they in turn had discussed with the physician, and debated their respective effects with the rest of the staff. The general consensus was that none of the psychotropic medication had the desired effect.
On the fourth day of the week, Cate’s state changed abruptly once more. She appeared to be a totally different person than previously in that week, smiling, talking and being generally positive. In contrast to earlier, she did not doze off regularly or express feelings of pain. An assisting nurse told me Cate had slept through the entire night. Cate sat by herself most of this day, together with co-residents in the small common room, occasionally talking to other residents and staff who walked by, smiling to everyone who met her gaze.
Postscript:
About four weeks later, during a holiday period, Cate fell again, this time causing more damage than before. While attending an activity in the activity centre, without any staff from the unit present, she had fallen and broke a bone in her hip. Details around what happened were difficult to get hold of (I was not present), no one seemed to know exactly what had happened. Later, when talking to one of the activity personnel, it became clear that she had become restless during one of the activities and tried to stand up. The activity personnel further explained that Cate had stumbled on something on the floor and hit her hip on the floor when she fell. She made a point about the fact that no members of staff from the unit had accompanied Cate. Cate had been hospitalized immediately after the incident, and had returned to the unit shortly thereafter. Following the hospitalization, Cate was put on another, presumably stronger, scheme of psychotropic drugs, which had a marked and lasting effect on her: from this period and for the remaining six months of my fieldwork, Cate became calmer, had fewer changes in mood, and fewer «bad days». She did not fall again. However, Cate also became far more docile, sleepy and less enthusiastic. She seemed to me to be in a constant state of drowsiness, seldom showing her outgoing and enthusiastic features that both caring staff and residents appreciated.
Primarily as we find Bourdieu’s critique of the methodological approaches in anthropology (for example Bourdieu
A term difficult to translate from the Norwegian «å finne roen».
Contextual and structural features to which nursing homes relate do not determine practice at the nursing home, as will be argued. In general, to synthesize an argument discussed in more detail later, contextual and structural features can be viewed as a road map (Prieur & Sestoft
While empirical data and contextual features from Norway will be primary, discussions will also have relevance outside of Norway. The first part of this chapter, describing different contextual layers to which nursing homes relate, is primarily directed towards readers not overtly familiar with healthcare in Norway, giving brief, general summaries of the respective topics.
Norway, as a welfare state, offers what is defined as «universal benefits and services» to its inhabitants. Education, financial benefits and healthcare, should, according to this doctrine, be provided based on need rather than affluence or social status. Although the term «universal» might not be technically accurate in the sense of offering
Nursing homes have played a pivotal role in Norwegian eldercare for decades, and remain today an exceptionally important institution for the care of the elderly, even compared to other Scandinavian countries (Armstrong et al.
In 2009 the total number of care recipients in long-term beds in Norwegian nursing homes was 34 800. This figure amounts to almost 1 percent of the total population, far more than any comparable country
While this emphasis on public care is and has been a national endeavor, the implementation of care for the elderly takes place at the local level. In Norway, primary health care is decentralized: the municipalities are responsible for providing care for the elderly, including nursing homes, assisted living and home based care, while the specialist health care sector, including hospitals, is governed by the national health directorate. The separation and cooperation between these levels of care has been the focus of much public and scientific debate, especially concerning the transitions between the levels of care.
Most nursing homes in Norway consist of both long-term beds and short-term beds (or alternatively rehabilitation beds). Some, a minority, have only long-term beds, while a few have short-term beds exclusively. Short-term beds are either located in a separate unit, or integrated in the long-term bed units, depending on the size of the nursing home. Usually the short-term beds are in a minority compared to long-term beds at an institution. In the municipality hosting this study, a significant minority of nursing homes are exclusively for long-term residents (including all nursing homes within our sample), while a very small minority are exclusively for short-term residents. The number of short-term beds, although a minority, has increased in recent times, perhaps as a consequence of a new health reform, the so-called Coordination Reform.
Nursing homes in Norway can be further divided into public, private non-profit and private for-profit. The division is similar to the organization of long-term residential care in the rest of Scandinavia and North America, while being distributed differently: there are more public and less for-profit nursing homes in Norway. The majority of nursing homes are public, quite a lot are private non-profit, and a few, mostly in the larger cities, are private for-profit.
Within the municipality included in this study, institutional size varies considerably, from that which can be considered small (even by Norwegian standards), with approximately 15 residents, to that which can be considered large by Norwegian standards, with well over 100 residents. The average size of nursing homes is over 50 beds. A small majority of nursing homes are public, many are private non-profit, while a few are private for-profit. Most of the nursing homes combine long- and short-term residents. As for Norway in general, the nursing homes that combine long- and short-term beds have more long- than short-term residents.
Recipients of care partly finance the primary healthcare sector through payment for services offered calculated in relation to individual income
The financing model results in two, perhaps paradoxical, traits of Norwegian nursing homes:
Depending on the size of nursing homes, the total number of administrative staff will differ, as well as the types of administrative positions. While all nursing homes have a head administrator, often but not always a nurse, usually only larger nursing homes have one or several positions hierarchically placed between head administrator and unit nurse, typically called «head nurse» and/or «head of development», filling the role of middle management. Similarly, only larger and medium sized nursing homes have specific positions for finance and other administrative tasks, while smaller nursing homes divide these tasks between head administrator and unit nurse.
The caring staff at Norwegian nursing homes generally consists of registered nurses with a minimum of three years university/university college education, assisting nurses
Physicians’ services for residents of nursing homes fall under the jurisdiction of the institution (through the municipalities), rather than the respective residents. There is no national norm or regulation stipulating coverage of physicians (per resident or otherwise) in nursing homes. Instead, the institutions are, by law, obligated to offer physicians’ services to its residents by having a physician «connected to the nursing home», in some form. This arrangement is contrasted to practices where residents’ private physicians follow them into the nursing homes, as seen in many countries such as Denmark and Germany (Vossius et al.
While physicians are employed differently from nursing home to nursing home, the total coverage of physicians in nursing homes should also be noted. On average, there is one fulltime physician position per 127 nursing home beds in Norway, while for hospitals the coverage is one position per two hospital beds (Husebø & Husebø
Most nursing homes, usually depending on size, have staff for maintenance and cleaning separated from the caring staff. In general, larger nursing homes have a more distinct segregation of professional groups and a more distinct separation between professional and non-professional groups, compared to smaller ones. Most nursing homes will employ maintenance and cleaning staff themselves rather than outsourcing, although this trend is changing. When it comes to kitchen staff, generalizations are less adequate. Some larger nursing homes still have their own on-site kitchen, preparing warm meals for the whole institution, while smaller nursing homes and increasingly larger ones as well, order meals from outside, to be heated on-site upon arrival. The former nursing homes will have separate kitchen staff, working exclusively with food preparation, while the latter will not, leaving the tasks of food preparation and presenting to caring staff.
The 1950s saw the rise of both older people’s homes
Such an intended function was both costly and not necessarily attuned to the characteristics of the nursing home residents, especially towards the end of what has been characterized as
In parallel with the organizational changes, political discourses about nursing homes have changed since the 1980s; nursing homes are increasingly seen as a place for permanent residence, accentuating the need to be «home-like» in political documents. (Hauge
In total, «institutional care» in Norway has in recent history been more or less synonymous with nursing home care. As we shall see, there is a gradual and increasing change away from this widespread notion. Somewhat parallel to but also following the change from older people’s homes to nursing homes, Norway saw another shift: a great increase in assisted living facilities and home based services compared to nursing homes. Relative to the size of the elderly population and contrary to popular belief, the number of beds in nursing homes has decreased from 1989 to 2006 (Gautun & Hermansen
The difference between the number of potential care recipients and the number of available beds in nursing homes is especially evident in larger cities. Registered nurses working in municipal health- and care services state that long-term beds are not sufficiently available today, especially in larger cities (Gautun & Hermansen
The emphasis on care at home or in assisted living facilities should be seen as a direct result of policy priorities, especially the «Action Plan for Eldercare»
One can make the argument that these developments, the strong emphasis on medically oriented care in nursing homes, and the increase in home help care and assisted living, have contributed to a larger division of care for the elderly. There is a large gap in services offered between these alternatives, even though assisted living facilities (a category in itself composed of different variations and categories) can be seen as a form of buffer between services offered in nursing homes and home help care. The threshold for receiving a long-term bed in a nursing home is far higher than for receiving home help care. Partly related to this discrepancy, partly to deal with the organizational distance between the general and specialized care sector, 2012 saw the heavily debated Coordination Reform (Stortingsmelding no. 47
The development of assisted living facilities and home help care can be interpreted in different ways. It can be interpreted as a return to the principle of «care at the lowest, most effective level possible», as assisted living facilities can be said to imply less of a change to residents’ lives than nursing homes. The development can also be seen as being connected to a devaluation of the importance of long-term institutional care, where «the home» is seen as the ideal form of care for the elderly as opposed to «the institution». Alternatively, assisting living facilities can be viewed as the «new form of nursing homes», as an alternative form of long-term residential care offering, in many cases, 24 hours of available care. It has also been argued that there might be financial incentives to prioritize assisted living as opposed to nursing homes for the municipalities, as a larger bulk of reimbursements (particularly payment of rent) is covered by the federal government (Næss et al.
The organization of nursing homes in Norway varies between regions as well as between cities and rural areas, both in regards to coverage (number of beds relative to number of elderly in need of beds) and level of staffing (Gautun & Hermansen
Municipal autonomy in organizing and prioritizing nursing home care also leads to local variation in ownership status. One municipality might have only public nursing homes, while the neighboring municipality, with a different politically based leadership, might have outsourced all nursing home care to a private for-profit company. While the latter is rare, it is not exceptional.
The regulatory framework for Norwegian nursing homes can be divided into three interconnected levels: national health legislation, supervision and auditing on a county level and inspections by the municipality. All nursing homes in Norway are subject to health legislation (as opposed to for instance Sweden, where they are part of social care), formally under to the domain of the Ministry of Health and Care Services. Still, as we shall see, the bulk of the regulatory framework for nursing homes is placed at a local level of governance, the municipalities.
Municipal autonomy in providing care for the elderly is reinforced by the lack of strict government laws, regulations and guidelines for nursing homes, especially concerning patterns and level of staffing, and organization of work. The main instruments of regulation for municipal elder care do not specify how services should be organized, for instance, but rather state that written procedures should be in place (Vabø et al.
Besides the requirement to have written procedures and to have a physician and registered nurse available at all times (but not necessarily on-site), guidelines for staffing can therefore be described as general. While nursing homes are obligated to have
Focus on the specific phenomenon of hospitalization, or in more general terms the transfer of residents from nursing homes to other (predominantly within the specialized) levels of care, is for the most part absent from national legislation. National legislation does cover treatment considered «life-prolonging» however, stating that residents can refuse when capable of doing so. When not, next of kin are given the legal right to consent to what is
«The Norwegian Board of Health Supervision» is the nationally recognized office responsible for the supervision of nursing homes’ adherence to national legislation. While being a national institution under «The Ministry of Health and Care Services» and responsible for the overall supervision of healthcare
Aside from potential inspections from «The Norwegian Board of Health Supervision», it falls on the municipalities to evaluate and regulate nursing homes. As such a responsibility is placed on the municipalities, local variations are also found in this area. Typically, nursing homes are measured on
Within our municipality, a designated political-administrative department is formally responsible for all nursing homes. Both public and private nursing homes operate with a large degree of autonomy. Private nursing homes are eligible for inspections and must report to the municipality, but to a lesser extent than for public nursing homes. Meanwhile, the day-to-day business of operating the nursing homes is solely up the institutions themselves, including public nursing homes. Municipal representatives inspect all nursing homes annually. These inspections are for the benefit of the municipality and are not shaped or controlled by the federal government, nor does the municipality report its findings to the federal government. Even though not in the form of a regulatory body, the municipality is still heavily involved in providing services for nursing homes, particularly public ones, especially regarding employment of physicians and provider agreements covering various forms of goods and services.
Within the municipality, all general practitioners are obliged, through an operations agreement, to perform a portion of their workload at a nursing home or equivalent institution
The respective nursing homes must also relate to and communicate with the municipality regarding the intake process for new residents, regardless of ownership status. The municipality has sovereign authority in distributing residents to nursing homes, usually, but not always, related to geographical proximity. While this structure is universal within the municipality, the actual relationship and collaboration between nursing homes and municipal representatives differ regarding the intake process of new residents (see
The development and organization of nursing homes, assisted living and home-based care is related to the characteristics of the care recipients, and, at the same time, to how care recipients are viewed by policymakers. Relatively more recipients today receive care at home or in assisted living facilities than in nursing homes, while residents of nursing homes are reported to have increased need for extensive care (SSB
The development of the organization of care for the elderly, regardless of possible changes to the elderly population in general, has an effect on which segment of the elderly population resides in nursing homes. Municipalities, especially the largest,
The general perception of the frailty of nursing home residents is supported by recent, national research: 76 percent of all residents of nursing homes are considered to have
The elderly population in the municipality included in this study resembles that of Norway in general. Both populations can, in an international context, be described as homogeneous with respect to wealth, social class and ethnicity. Still, being a larger municipality, there are areas within its limits generally more affluent than others. Compared to Norway in general
In general, for the municipality and for Norway in general, nursing homes are increasingly a home for the frailest, oldest and most dependent elderly. When an elderly person is admitted to a long-term nursing home in Norway today, the chances are that the said person is in need of frequent and diverse care, has some form of dementia
The nursing home, as an institution, holds a significant historic and sociocultural position in Norway. Partly based on Norway’s particular geography and topography, the nursing home has a local and national importance, surpassing that of alternative institutions, also compared to other countries. Even so, the number of nursing home beds has been in decline, both in total and relative numbers, while home-based services and assisted living facilities are on the rise.
Perhaps paradoxically, nursing homes in Norway can be described as exhibiting features of both variation and uniformity. The form of governance (municipal autonomy), lack of specific national guidelines and regulations, as well as Norway’s geography and topography, lead to variation, or perhaps more precisely
Rates of hospitalization from nursing homes are considered high in Norway, an assumption confirmed by the few studies addressing the issue explicitly (Graverholt et al.
Applying quantitative, retrospective designs, similar to the design opted for by a majority of the international research literature, relevant studies point to high rates of hospitalization from Norwegian nursing homes compared to similar international studies. Graverholt, addressing the occurrence of
While two of the studies do not offer explanations for the relative high rate of hospitalization, Graverholt suggests that it can be connected to the fundamental understanding of the function of nursing homes in Norway and which treatments they should offer (et al. 2011). Based on such an understanding, it is hypothesized, Norwegian nursing homes might be more inclined to hospitalize frail residents than in other countries, specifically for acute conditions and palliative treatment (Ibid.). Conversely, the study also points out that the oldest residents in nursing homes are less likely to be hospitalized than their younger co-residents, adding to a confounding area of research - to which we will return in
Even more interesting in our context than the overall rates of hospitalization, is the variation in hospitalization rates between institutions and regions. Institutional rates of hospitalization from within the same municipality have been shown to vary considerably: from 0.16 to 1.49 hospitalizations per person per year on average (Graverholt et al.
As for the overall rates, explanations for variation are not considered to be within the scope of the cited studies, although they do offer some suggestions. Vossius
How «attitudes» and «professional cultures» can influence decisions of hospitalization and thus explain potential variation of practices of hospitalization, will be addressed in the analysis. In doing so, the existing body of literature on the topic will be supplemented. The analysis of «professional culture» and «attitudes» will be added to by means of analyses of modes of employment for physicians, coverage of the different professional groups and significance of families of residents, among other potentially relevant factors. These two levels of analysis - one relatively exact and measurable, one complex and immaterial – will be fused together by treating the former not simply with regards to their formal qualities, but also how such qualities relate to «culture» and «attitude». Physician hours per resident will be analyzed in terms of implications for collaboration between physician and caring staff, for instance. The analysis of variation of hospitalization, I will argue, presupposes such a complex approach.
Estimates from other countries are far lower: 24 percent for the United States and 18 percent for the United Kingdom (Phillips et al.
In 2012 a federal rapport estimated that approximately 0.43 percent of the total population resided in nursing homes in the United States. As opposed to the mentioned number for Norway, this estimate includes short-term beds (National Center for Health Statistics
Including older people’s homes. Coverage, while high in total, varies somewhat between municipalities (
For all expenditure on public healthcare in Norway it is calculated that 85 percent is covered by the government, while 15 percent is covered by direct payments from the recipient (Stortingsmelding nr. 26
A term combining the Norwegian professional titles of «hjelpepleier», «omsorgsarbeider» and «helsefagsarbeider», and equivalent or similar to professional titles elsewhere such as «licensed vocational nurse», «licensed practical nurse» and «auxiliary nurse».
More than 50 percent of nursing homes will employ physicians through the municipalities in smaller positions, as larger nursing homes employ a larger relative bulk of physicians’ services, thus increasing the overall percentage of physicians’ services in full-time positions.
«Gamlehjem» or «aldershjem».
«Pleiehjem»
Relative municipal autonomy is deeply entrenched in the Norwegian political history. Although recent political changes might alter the organization of municipalities (towards larger), municipal autonomy is still presented at an ideal to strive for: «
Translated from «Lavest- effektive- omsorgsnivå», «LEON» for short (see also Jacobsen
«Handlingsplan for eldreomsorgen» (Stortingsmelding nr. 50
The national average of the number of residents in institutional care has decreased by 0.4 percent from 2013 to 2014, and by 1.8 percent from 2010 to 2014 (
The national average of physician hours per week per resident for nursing homes is stated to be 0.49 (2014) by Statistics Norway (
My translation from:
In addition to child welfare and social care.
Specified in the operation agreement as being «public work» of which nursing homes is one alternative. Income for «duty work» at nursing homes is based on a fixed amount, and is considered less than income from a private GP position (Stortingsmelding nr. 26
Compared to other European countries, Norway has a relatively small population of «immigrants», or people not born in the country: 13 percent, most of whom originate from other European countries and can be described as «work migrants» (Stortingsmelding nr. 26
In the research literature, «dementia» and «Alzheimer’s» are alternately used to refer to the same diagnosis or disease. I prefer to use «dementia», as the term also covers «vascular dementia» (or dementia developed post-stroke), not technically classified as «Alzheimer’s». When referring to researchers’ explicit reference to «Alzheimer’s», the latter will be used.
All three studies retrieved their data from the records of ambulance services, from which, it is argued, «
For the sake of anonymization, our six nursing homes will not be presented in detail. Some information, which either could be identifying or is not considered crucial, will be left out, while still preserving the most important traits of the nursing homes. Some minor details about institutions and residents will also be altered throughout the discussion, to limit the possibility of recognizing individuals and/or institutions. As briefly mentioned in
While the typical characteristics of a nursing home can be explained easily in general terms, getting an impression of how everyday life in a nursing home unfolds can be more challenging, especially for the uninitiated. The typical events of a day at Acre Woods can therefore provide some insights into life in nursing homes. The excerpt is a synthesis of several days, highlighting typical occurrences, while noting daily variations when relevant. Introduction: Setting: The daily routine: The day-shift starts at 7.15 when the first batch of the day-shift arrive (others start later at different times) and overlaps with the night-shift until 7.30. Most of the day-shift start at 7.30 and go directly to a report meeting with a registered or assisting nurse who was present at the report meeting with the night staff. From 7.45 until approximately 9 all nurses and assistants are busy with morning routines in the residents’ rooms. A few residents have already been attended to by the night staff, and wait in their rooms before «being taken out» by the morning staff. Usually they have to wait until the morning staff have seen to the rest of the residents. The majority of residents will be attended to by the morning staff. The rhythm of events is predictable: unless there has been a special event during night-time or early morning, the same residents will be attended to at the same time, in the same sequence, every day. To organize the exact sequence of morning care, the staff is divided into two groups, each responsible for half of the residents. Some residents, a minority, need two staff members present during morning care, while others, also a minority, only need help with parts of morning care, most likely dressing and parts of the care connected to personal hygiene, and are self-sufficient when it comes other parts, such as going to the toilet. A few residents, typically two or three, will not be given their morning care at this time, as they have expressed the view, verbally or otherwise, that they want to stay in bed longer. All caring staff are busy inside the rooms of the residents at this time. When staff have finished the morning care for a resident, the resident is helped (a great majority of residents need some form of help moving to and from their rooms) to get to the large common area, where breakfast is served later, or to one of the smaller common areas. Other residents, meanwhile, will remain in their rooms until breakfast is served there. The same residents will eat either in the common areas or in their rooms, every day. A majority of the residents will eat breakfast in the large common area, and will be seated there while waiting for other residents or breakfast to be served. The common areas are gradually filled until 9.00. Depending on how fast the caring staff complete the morning care routines (depending on level of During this period, and usually starting some time before, a nurse, usually the assistant unit leader, will administer the morning medicine. In addition to the registered nurses, several of the assisting nurses have taken the «medical course» making them eligible for administering medicine. This is a time consuming process, as it has to follow the correct procedures of checking medical journals and charts, and because a large majority of residents receive some form of medication. In the period shortly before breakfast, until halfway through breakfast, all caring staff are busy delivering medicine, preparing and serving breakfast, helping residents to and from the common areas and helping residents eat. Only three or four residents (a distinct minority) can make their own way to the common area, and can leave on their own. The rest need help, either to be transported to and from the common room, or to be fed. As mentioned, this is a hectic period for the staff; they will not have time for anything else, besides these necessary tasks. As time is of the essence, staff must change swiftly from one task to the next, and will have few opportunities to talk to residents aside from giving short comments. Towards the end of breakfast, things start to calm down. Some of the staff will find time to eat or drink a cup of coffee, or to sit and talk to residents for a short period. Residents in need of help, to get to the toilet or back to the rooms for instance, will more often than not cut these moments short. Meanwhile, breakfast is being cleaned up by caring and kitchen staff. About half of the residents who attend breakfast will stay behind either in the main common rooms, or in one of the smaller ones. Immediately after breakfast, the caring staff gather in the nurses´ station for reporting and further planning of the day. Most of the staff will be able to attend from the beginning, while some will arrive during the meeting or miss it altogether, either because of not finishing their respective tasks, or by an unforeseen task. If the unit leader or the assistant unit leader is attending (usually one, seldom both), one of these will take the lead. Depending on who’s attending, who’s leading the meeting and the general mood of the day, the meeting will proceed and focus on the remaining caring responsibilities and the organization of these responsibilities. Some days this is done swiftly and the topic often drifts to other, less serious matters. Most days, however, the staff only have time for the absolute necessities. If many experienced caring staff members are present, the morning rituals of the caring procedures are done more swiftly. Less time is also needed for planning and delegating if many experienced nurses are present; they know what to do and do not need to be told or to discuss amongst themselves. More often than not, a significant portion of the morning care will still remain at this point, consisting of residents who have not yet risen from bed, showering, or tasks connected to treatment of sudden illnesses, for instance. In addition, appointments for hairdressing and foot therapy are made most days. Caring staff have to prioritize accompanying residents to these appointments, as they are time specific. The appointments need to be addressed in detail at the report meeting, not only for the sake of the staff, but also to make sure that the residents are able to attend, which for various reasons usually connected to their physical wellbeing, is not always the case. The activities of the day, organized and taking place in the large common room of the nursing home, will also be discussed, specifically with regards to who is eligible for the respective activities, and which caring staff member should attend. The latter will depend on the needs of the respective residents as well as the availability of staff. The meetings are informal in form; everyone is allowed to speak their minds, if not expected to. However, a select few usually have the center of attention, either by raising points or objecting to suggestions from the leaders. Should the planning not take the allotted time, the remaining minutes are used for a highly appreciated coffee break and small talk. Usually, there is no time. From 10.15 until 11.30 three separate events occur at the same time: the remainder of morning care is finished, fruit is served, and the activity center is opened. The remainder of the morning care is the most time- and resource-consuming for the staff. Most of the caring staff will be busy with morning care until lunch, tending to residents who are bedridden, or have chosen to stay in bed late. Other residents will need to be helped when going to the toilet or to be accompanied to the hairdresser. At 10.30 fruit is served. Every resident will get a plate of fruit and a glass of lemonade. The designated kitchen staff will prepare the fruit, while some of the caring staff will help serve and help some of the residents to eat. The activity department, serving the entire nursing home, will arrange some sort of activity for the residents every working day. The activities will occur somewhere between 10.30 and 12.30, but not for the entire time. On average two residents from the unit will participate. Caring staff seldom have to stay by the resident’s side during the entire activity. Sometimes it is necessary to accompany a resident, especially if the resident is thought to be «restless». If caring staff have to accompany a resident, the remaining caring staff will have difficulty in getting the remaining work finished in time. The original plan, devised at the morning meeting, will often not be fulfilled as intended; sometimes because the residents do not want to attend, but most often because staff get derailed by other tasks. From 11.30 until 12.30 the staff have their lunch break. They are meant to divide themselves in two groups, with half an hour each, but the hectic schedule seldom allows them to. Most days the caring staff will eat when they can, and when it is suitable for others, usually for less than 30 minutes. There is a canteen available for all nursing home staff, but it is almost never used by caring staff from the units. For the caring staff, eating in the canteen is impractical, both in regard to the general hectic schedule, and the potential occurrence of an unforeseen event, leaving them, on most days, in the unit for the entirety of their shift. Right after their lunch, caring staff start the preparations for dinner. Dinner is served around 13.00. Before this time, the frantic pace in the unit settles down remarkably. Morning care is now finished and most of the residents are resting or sleeping. The designated kitchen staff get help from several others in setting the table and rearranging the dining area. Other caring staff will finish whatever work is left over, work that is not top priority but still needs to be completed: changing beds, sorting clothes and making sure the different remedies and equipment are in place. Others will gradually get residents ready for supper; always in the same order, and always seated at the same place. As for other meals, residents are «made ready» for dinner well in advance, giving the caring staff the opportunity to get through all their designated tasks. When dinner is served, most of the caring staff will sit beside residents in need of various forms of assistance while eating. After dinner, many residents are accompanied back to their respective rooms, one by one. Some stay behind in the common rooms. Like breakfast, most residents will eat dinner in the common rooms, while a minority will be served in their rooms. After dinner, the unit once again settles into a calmer pace. Most of the residents are sleeping, either in their rooms or in the large common room. A gradual shift of staff occurs between 14.00 and 15.00. Because of the extremely intricate shift plans, the respective shifts (day, evening and night) start and end at different times. Some will end their day-shift already at 14.00, while others will remain until 15.00 and will be able to attend the report meeting with the evening-shift, most of whom start at 14.00. The report meeting is between 14.00 and 14.30. Important messages concerning specific residents are the main topic of the meetings and will take most of the time. Compared to the day-shift, evening-shift staff do not spend much time on overall planning of the shift, primarily because they know that they have to be flexible regarding which tasks to do at what time, as there are relatively few staff members in relation to number of residents. There will always be enough tasks to fulfil, but it is hard to know which ones will be the most pressing. The evening-shifts are extremely hectic from beginning to end. This seems to be connected to levels of staffing: usually (not taking into account sick leave and unexpected events) there is one caring staff member for approximately five residents, including the designated kitchen staff. The latter will alternate between kitchen duties and caring tasks more frequently than during the day-shift, as there are fewer tasks in the kitchen and more pressing demands relating to resident care. Still, when meals are prepared, each of the remaining caring staff members have to attend to more residents, making for a busy time and few opportunities to do anything other than what is absolutely needed. As opposed to the day-shift, there are few other staff in the unit at this time (physicians, maintenance staff, activity personnel and unit leaders). At all times there is one registered nurse on evening-shift serving the entire nursing home, hereafter called «the on-duty nurse», available for questions from and advice for the staff in the unit. After the report meeting, there will usually be tasks to be performed consecutively during the entire shift. Coffee is served immediately after the meeting, usually with biscuits. At this time, more residents than before will remain in their rooms. The caring staff, therefore, constantly move between rooms, the kitchen and the common rooms. After coffee, the caring staff immediately start to administer medicine, together with other minor tasks that need to be addressed: cleaning, helping residents with their toilet visits, helping residents to and from their rooms, preparing for evening meals, and preparing for the bed routines. The one activity that dominates the entire shift more than anything else is the bed routine. The bed routines are time consuming and therefore have to be done simultaneously with other tasks. Bed routines usually start at about 16.00. It is noticeable how similar the routines of helping residents to bed are from day to day. Regardless of who is on shift, the same residents are put to bed at the same time and in the same sequence, every day. As mentioned, this routine is done simultaneously with other tasks, partly because it lasts for a long time period. The routines of helping residents to bed are also connected to other tasks: when a resident has gone to bed, other tasks relating to the resident (such as helping with food, helping to and from the toilet, personal care et cetera) are also considered completed. Gradually then, from about 16.00, the total amount of tasks remaining for the evening-shift, diminishes. In this sense, and taking into account the hectic schedule of the evening-shift, the caring staff are strongly incentivized to attend to residents relatively early. The residents can be divided into three groups in regards to how the staff relate to their bed routines: 1) residents who stay in the common area and are not capable of expressing the desire to go to bed; 2) residents who stay in their rooms, and; 3) residents who stay in the common room and who are able to express the desire to go to bed. The residents are almost without exception put to bed in the sequence of 1, 2 and 3. Within each of these categories we also find clear regularities in when residents are helped to bed. Category 1 consists of residents who stay in the large or the small common room during large parts of the day, have great physical caring needs, and/or advanced dementia and, consequently, difficulties in communicating. This category consists of 5-6 residents. Many of these residents are not capable of expressing their wishes concerning if and when they want to go to bed. Furthermore, regardless of being capable or not, residents are rarely asked whether or not they want to go to bed. Several of the residents have severely diminished physical capacity, and therefore are considered by staff to be «hard to care for» in the sense of being physically straining, prompting two or more staff members per resident. The need for two staff members per resident inclines staff to start the bed routines earlier for those particular residents. After the bed routines are completed for category 1, the tasks connected to these residents will, as mentioned, be considered completed for the day. As residents are taken to bed, then, the total amount of tasks lessens, and time can be spent on other tasks, such as preparing evening meals, the bed routines for resident category 2, and other minor tasks postponed until now. During the first 5-6 hours of the evening-shift (from about 14.00 until approximately 19.30), there are few opportunities for staff to have a break or to spend «quality time» with residents. Given that six residents are in bed, it will now be 17.00 and the bed routines remain for a majority of residents. However, the remaining residents are easier to cope with than the residents already in bed. The remaining residents can be divided into residents who stay in their rooms, and residents who are still in the common rooms. The groups are evenly sized. Those who usually stay in their rooms, category 2, are a mixed group when it comes to physical and cognitive skills while those who usually stay in the common rooms, category 3, are relatively functional both physically and cognitively. From approximately 17.00 until 19.30 the staff tend to the bed routines for resident category 2. Some of these residents will also need two staff members present during the bed routines. During this period, especially towards the end, the evening meal is prepared and served, and the staff can take a short break to eat or to talk to residents who are still awake. However, caring staff still have to be careful in timing their breaks, and can seldom take a break at the same time. As the evening unfolds, the tempo of the units settles, since more residents are «finished» and the ratio of the number of staff to residents gradually changes. Towards the end of this period, evening meals are served to those who remain in the common rooms and to those who wish to have evening meals served in their rooms. The last category of residents, residents who have chosen to remain in one of the common rooms, spend this relatively quiet time eating the evening meal, watching television (which is on more or less all the time), and talking to staff who can finally afford to spend time with the residents. Most of these residents will go to bed between 20.00 and 22.00, after expressing the desire to do so, as opposed to other residents. Consequently, depending on the respective residents´ mood for the day, the exact time when they go to bed will vary from day to day, again in opposition to other residents, who do not have a say in the matter. The evening-shift concludes with a report meeting between the evening- and night-shift at 22.00. As with other report meetings, this is almost exclusively oral, even though it is expected from the leadership that caring staff should read up on residents in the electronic journal system. The night-shift is usually relatively uneventful, barring the occurrence of an unforeseen event. The night-shift staff follow a designated pattern of doing rounds in the rooms, checking up on residents, providing medication and changing the sleeping position for those in need. Residents can, as often happens, become restless during the night (see example from Cate,
If an outsider were to describe the defining characteristics of the unit, the most noteworthy would probably be the long corridor, the constant movement of the staff, and the relatively clear distinction of resident groups (from both residents and staff). The long corridor, identical to the corridors of the other units in this nursing home, is important in the sense that it influences the level of mobility for residents and staff alike. The corridor is long, reaching from one end of the unit to the other, in one straight line. Consequently, staff and residents have to cover large distances throughout the day. Staff constantly have to move from one part of the unit to the other, taking up a fair amount of their precious time. Residents, most of whom are immobile to start with, have to cover a relatively large distance to get to their meals or to the toilet, especially if they are so unlucky as to have a room at the end of the corridor. The corridor also makes having an overview over the entire unit difficult. This physical layout is a contrast to most other nursing homes, where the corridors are shorter and often centered by a nurses’ station or a large common room from where one can observe the respective corridors.
The constant movement of the staff is immediately noticeable in the unit. While this is a common observation at most if not all nursing homes, it is particularly apparent in this one. The constant movement of the staff is connected to the physical layout of the unit, but also, in my opinion, to something else. More so than at other nursing homes, and even in other units of this nursing home, caring staff are not supposed to have a slow pace, or to take breaks of any meaningful length, either for themselves or with residents (see also Jacobsen
Of the six institutions, two are located in the city center (Acre Woods being among those), while four are suburban. Two of the institutions are public, three are private non-profit (Acre Woods being among those), while one is private for-profit. The selection includes a disproportional number – four - of small nursing homes (between 20 and 40 beds). One of the included nursing homes is medium size and one is large (Acre Woods)
All six nursing homes, regardless of total size, have some form of physical division of space, albeit in differing forms. The administration, for instance, is distinctively separated from the resident area, often by floor. The resident areas, the units, meanwhile, are separated from each other, in different forms. For all nursing homes except one, units are clearly separated by distinct entry points, usually a door with the name of the unit written on it, and by different forms of decoration or color schemes inside. At Uagodou, there are no barriers between the units; they are simply located in different corridors. Five of the nursing homes have relatively small units, with 8-12 residents, in line with recent policy trends. The last nursing home, Acre Woods, has larger units, with over 15 beds on average. Four of the nursing homes have separate units for residents who are considered to be a challenge to either control or care for, typically occupied by residents who are considered to have aggressive dementia. These units are defined as «dementia units», and have, in varying degrees, more security measures in place, especially locked entry points, and/or better staffing. All dementia units are separated from other units by floor.
Aside from administration and resident areas, all nursing homes have some sort of common area for visitors and/or residents. For three of the nursing homes these areas are larger and more commonly used than for the other three nursing homes. The common areas are located on the ground floor and serve both as activity centers for residents, who can attend organized activities with residents from other units during daytime, and as meeting points for when visitors come. For the other three nursing homes, the common areas are small, not commonly occupied by residents for longer periods of time (at least not in an organized form), but accessible for visitors and staff, sometimes accompanying a resident.
The caring staff constitutes, in several ways, the core of the nursing home. It is primarily to them that residents and visitors have to relate, while other professional groups, at least to some degree, are in place to better facilitate the relationship between caring staff and residents.
The caring staff at our nursing homes and, I would argue, nursing homes elsewhere in Norway, are relatively homogeneous regarding gender, age and social class, all themes we will return to. They are, however, increasingly heterogeneous regarding ethnicity. There is, in other words, increasing diversity of country of origin for caring staff, especially for nursing homes in the larger municipalities, such as ours. As our nursing homes do not vary substantially regarding cultural diversity of caring staff – a substantial number of assistants and assisting nurses at all nursing homes are foreign born, as are a minority of registered nurses at most nursing homes
While such sentiments were prevalent among many caring staff members and top administrators at our nursing home, they were not observed among residents, save for very few exceptions; most residents seemed either indifferent or appreciative towards diversity among caring staff members, focusing on the
As a collective group, caring staff are dominant in nursing homes, dwarfing all other professional groups combined in sheer numbers. On average, the institutions in our sample have 70 caring staff members, including all caring staff in permanent positions (although with differing size of position), and excluding staff under temporary contracts, short-term temporary staff and students on internships. The total number of caring staff varies from 27 to 159, depending primarily on the number of residents in the institutions and the average size of positions in the respective nursing homes.
More relevant than the total number of caring staff is the
In nursing homes within the sample, in the municipality in general and in Norway, women are the majority; both residents and staff are predominantly female. Residents within our sample are between 70 and 90 percent female, while caring staff are almost exclusively female. On average, our nursing homes employ two male caring staff members in different types of positions. Although nursing homes are «gendered» institutions and work environments, for reasons of limitation the theme will not be discussed. Gender is still encompassed in the analysis, implicitly, for instance regarding «the hardship and toil» at the nursing home (
Another topic that speaks about nursing homes as a typical female-dominated work environment is the overall size of position for all caring staff at all institutions: 55 percent. Many caring staff members, especially assisting nurses and assistants, would prefer, if possible, larger positions, while pointing out that management will not offer full-time positions to better suit their needs relating to the overall shift-plans for the institutions. Although the nursing homes vary somewhat (as we shall see) concerning the respective size of positions, full-time positions for assisting nurses and assistants are considered rare and attractive. Management and a minority of caring staff members would typically argue that the low average size of position is a result of employers being flexible and offering positions suited to individual needs. A substantial number of assistants and some assisting nurses, meanwhile, are employed in temporary positions (often for a small number of hours). As mentioned, our nursing homes vary regarding the use of temporary positions, as they did in providing data of such use. Regretfully, the data on this is severely lacking, and should be added to by accounts from several administrators, pointing out that assistants and, to some degree, assisting nurses are employed on temporary contracts out of necessity, in part caused by sick- and maternity leave. Contrary to such sentiments, administrators at Cloud House and Emerald Gardens stated that all positions were permanent, while data from Acre Woods and Durmstrang suggest relative low figures for
The average size of positions at our nursing homes ranges from 51 to 72 percent. Acre Woods, by far the largest institution, has the lowest average size of position, while Emerald Gardens has the highest average size by far. The latter can be explained by the respective nursing homes’ practice of employing assistants in far higher positions than other nursing homes (average size of position for assistants for the other five nursing homes is relatively low – see later – thus decreasing the total average for size of position). The average size of position for the respective professional groups is 76 percent for registered nurses, 68 percent for assisting nurses and 26 percent for assistants
Both total and institutional numbers for the respective professional groups, as well as size of positions, are interesting in themselves, but have limited relevance when not taking the number of residents into account. All positions within what has been categorized as caring staff, amount to 232.1 full-time positions when combined. Total caring staff full-time positions amount to 0.879 positions per resident in total. In other words; there is almost one full-time position, either registered nurse, assisting nurse or assistant, for each nursing home resident. It should be kept in mind though that the 232.1 full-time positions are spread relatively «thinly» over 422 actual positions, most of which are part-time. In other words,
The institutional average of full-time caring staff positions per resident varies somewhat between the six institutions, ranging from 0.72 to 1.07 full-time equivalents. The anomalies are to be found at each end of the spectrum, while the other four nursing homes have a similar coverage of caring staff per resident. An interesting point should be made about the two anomalies, Galactic Manor (highest) and Emerald Gardens (lowest). Although opposites for our sample when considering coverage of caring staff per resident, these are the two institutions that most closely resemble each other when considering general characteristics. Galactic Manor and Emerald Gardens are the only two small private non-profit nursing homes in our sample, and have almost the same number of residents. It should also be noted that the nursing home with the highest level of total staffing (Galactic Manor) also has the highest number of registered nurses.
The average number of full-time positions of registered nurses per resident for all six institutions is 0.26. For each full-time registered nurse, there are four residents on average, in other words. The coverage of registered nurses per resident varies significantly between institutions, ranging from 0.14 to 0.54 full-time registered nurses per resident. Even when excluding the largest anomaly (Galactic Manor), the nursing home with the highest coverage of registered nurses per resident has a coverage of more than twice that of the lowest. The total number of full-time assisting nurses per resident for all six institutions amounts to 0.51. There is moderate variation between the institutions (ranging from 0.37 to 0.57). Total and respective numbers for assisting nurses should be read in conjunction with the coverage for registered nurses: nursing homes with better coverage of registered nurses tend to have lesser coverage of assisting nurses and vice versa. Assistants, as opposed to registered nurses and assisting nurses, are a small group both in total numbers and in number of full-time positions per resident. In total, there are 0.15 assistants employed per resident, while there is a significant institutional difference, ranging from 0.07 to 0.28.
Age of caring staff is perhaps mostly relevant when seen in relation to experience, especially in our context. Age should still be mentioned, since there are distinct patterns within each professional group. The average age for all caring staff is 41 years old. The average age of registered nurses is 42 years, of assisting nurses 46 years and 41 years for assistants. There is remarkably small variation between institutions; all follow the pattern of assistants, registered nurses and assisting nurses in ascending order of age, while the relative difference between the groups is similar for all nursing homes. It should be noted that while registered nurses and assisting nurses are relatively homogeneous in age, assistants vary significantly, from 18 to 67 years old.
Experience, measured in tenure at the respective institutions
Experience within the respective professional groups follows a distinct pattern: assisting nurses have the longest experience by far (11 years and 9 months when combining all nursing homes), followed by registered nurses (6 years and 7 months) and assistants (3 years and 3 months). All included nursing homes follow this pattern. Assisting nurses are highly experienced at all nursing homes included, a point I will return to in the analysis, exemplified with the average level of experience of 15 years and 5 months at Emerald Gardens. Registered nurses are generally also highly experienced, but differ considerably within each institution; some are new, some have been at the nursing homes for many years.
To summarize, caring staff at our nursing homes have a relatively high level of experience and knowledge from within their respective units and nursing homes, but not a high degree of stability, in the form of full-time positions. This will be a central element in the analysis: many caring staff members do not work in the respective nursing homes as regularly as possible (for them) or perhaps as would be ideal (for the residents). Many caring staff members say that such a situation is not ideal: assisting nurses with smaller percentages of full-time positions state that they would prefer larger positions. As a general rule, registered nurses are more often offered full-time positions and/or can have a size of position in accordance with their individual preference, while many assistants would prefer only to work part-time. Our nursing homes, then, employ many caring staff members, perhaps more than ideal, as opposed to prioritizing
Measuring levels of physician coverage at the respective nursing homes proved a difficult task, as all nursing homes have different arrangements with their physicians including (for most) a great deal of flexibility with regards to time spent at the nursing homes and availability outside time spent at the nursing homes. Reliable data on physician coverage was provided from three of the nursing homes. For the remaining three, data on physician coverage was gathered, but as its accuracy is uncertain, this data will not be included. At Acre Woods, two physicians are employed by the institution, totaling 0.39 physician hours per week, per resident (that is approximately 20 minutes per resident per week). At Durmstrang, employing a consultant, physician hours per week amount to 0.27 (approximately 15 minutes). Both of these figures are calculated based on
The
Staffing levels for caring staff, and coverage and types of employment for physicians will be treated, in the following discussions, as significant for practices of hospitalization.
While a description of the number of caring staff per resident can provide an indication of
All six nursing homes have intricate shift plans, describing not only the division of the respective shifts, but also many variations within a shift, the preparation of which takes a large part of the unit leadership’s time. The shift plans are intricate and complicated for several reasons. The total number of staff employed is high, even for the smallest nursing homes; the shift plan has to adhere to relatively strict national work regulations (in contrast to the form of other regulations); many caring staff members have less than full-time positions; and there is a relatively high level of short-and long term sickness absence in addition to maternity- and other forms of leave. Data on sick leave was only provided by one nursing home, Acre Woods, registering 10.4 days per full-time position annually, on average, while I did not obtain data on the level of different types of leave.
The occurrence of sickness absence and regular staff on leave makes shift plans not only difficult to construct, but also difficult to maintain; short-term sickness absence, especially, cannot be planned for, making filling vacant positions a constant battle at all nursing homes.
Evening-shift at Emerald Gardens: At the start of the evening-shift most of the shift workers were present at 14.00, even though they were supposed to start later. Two of the day-shift workers, including the unit leader, remained even though their shift had ended. The other day-shift workers had already left. As the first part of the evening-shift was relatively quiet, most of the staff gathered at the nurses’ station, preparing themselves for the shift or talking privately amongst themselves. The two who had remained from the day-shift worked diligently on getting staff to cover for vacancies the next day. One of them, the unit leader, was on the phone, while the other, an assisting nurse, went through a telephone list of possible temporary staff (to my understanding, a list of known temporary staff who had worked at the nursing home on some occasion). When they did not succeed, they discussed who of the regular staff could potentially cover the vacant shifts the following day. After about twenty minutes, they still had not found anyone to fill the positions. The two decided to call it a day and leave, after discussing the matter with one of the assisting nurses on evening-shift, who took over the job. Meanwhile, three other caring staff members had gathered at a table in the nurses’ station, going through their respective shift plans, figuring out when they were on shift the coming week and discussing when the different day-shifts (six in total) started and ended. The assisting nurse given the job of filling the next day’s vacancies said she had to try calling later, because it was too time consuming to do now. Before leaving for other tasks, she explained that the shift plans were complicated and difficult to fill, especially during the summer.
The six nursing homes all have different routines when it comes to filling temporary vacancies. Some use temporary staff agencies either exclusively or in part (considered expensive, but reliable), some have lists of former students and others who have volunteered to be used as temporary staff, while all nursing homes must relate to the dilemma of whether or not to fill temporary vacancies at all. All six nursing homes combine the use of either temporary agencies or known replacements with the practice of not filling temporary vacancies
A common trait for all nursing homes when replacing caring staff members, either for short- or long-term sickness absence, holidays or shorter leaves, is the tendency of replacing a caring staff member with members from a lower (in terms of formal education) professional category: a registered nurse is replaced by an assisting nurse, and an assisting nurse is replaced by an assistant. This practice seems to be a common trait for nursing homes in Norway and elsewhere (see also Holmeide & Eimot
The challenge of maintaining the intended shift plan, which in itself can be said to include only a minimum of needed coverage (see Monday morning, undisclosed nursing home. There are only three caring staff members present, two have called in sick, and they have not been able to get anyone to cover yet, an assisting nurse explains in a relatively calm moment after breakfast:
As described, the types of employment and size of positions vary considerably for physicians, more so than the general composition of caring staff. At some larger nursing homes physicians are employed at close to or full-time positions by the institutions, while physicians at smaller nursing homes, strictly speaking, are working compulsory time away from their primary employment. Related to their mode of employment, it will be argued that the communication and collaboration between caring staff and physicians also vary considerably. Similarly, and relationally, the amount and forms of communication
At Acre Woods and Durmstrang, caring staff could contact physicians at their own convenience; in the evening and at weekends for instance. At Durmstrang, the physician was also available at night and on holidays. The remaining four nursing homes had other, more limited arrangements with their physicians; either in the form of no contact outside office hours (physicians could be contacted at their physician’s office during office hours, if available, but not at other times), or at certain specific times. At most of these nursing homes the physician could be contacted outside hours spent at the nursing homes, but were often difficult to reach. At one nursing home, for instance, the physician would return calls after 15.00, in many cases several hours after a potentially acute incident. Consequently, caring staff in the respective nursing homes adopted different procedures as to whether or not they contacted the physicians´ services at the emergency ward or not, and to what degree they were directly involved in communication and collaboration with family.
The difference between
The multi-faceted and dynamic relationships between residents and staff will be presented and discussed throughout this analysis. As background information, it might therefore be beneficial to have an overview of the general characteristics of residents from the sample
The average age of all residents in Acre Woods is 89.2 years. Residents in dementia units are on average younger (86.6 years in average) than others. 71 percent of all residents are considered to have dementia
Overall, but excluding the dementia unit, resident groups are strikingly similar from one unit to the next. For all categories, with minor exceptions for incontinence and the ability to wash independently (slightly higher in one unit for both categories), units appear to have a similar composition of residents. Average age, for instance, only varies by 0.3 years, between the somatic units.
Although reasonably indicative of the general characteristics of nursing home residents, data such as these fail to demonstrate the variation of nursing home residents, especially when it comes to alertness, speech and ability to communicate with staff. An example, taken from my very first visit to a new unit, can illustrate such a variation, although it should be mentioned that the protagonist, Anny, is not your average nursing home resident (if such a thing exists): Morning at Coruscant. One registered nurse, two assisting nurses and one nursing student are in the unit attending to the residents before, during and after breakfast. The residents are at different stages of their morning routines; some are eating, some are being prepared for breakfast in their rooms; while some are waiting for staff to attend them. I am «guided» by an assisting nurse to one of the residents sitting alone while eating breakfast (
As a general point, families of residents will be mentioned throughout, when deemed relevant to understanding the practices of the caring staff. Families of residents
Some are more ambivalent towards family members, conveying a mismatch of expectations between the family and the institution:
Notwithstanding the general importance of family members for the potential treatment of residents and the differences in approach towards families, families at our nursing homes are still not a prominent part of everyday life (see also Hauge Coruscant, May 16th (the day before the national holiday of Norway): The administration at the nursing home have made arrangements with the neighboring kindergarten so that the children will walk past the nursing home in a traditional parade. As the kindergarten is closed on the 17th, they are visiting one day early. At one of the units, residents and staff alike are ready and excited. At about 10.30 all residents in the unit are gathered in the common room carrying flags and looking out the window. Even a bedridden resident has been wheeled in. Most smile, anticipating the arrival of the children, while a few doze off. Four caring staff members are present, visibly excited. When they see the children arriving, the unit leader makes an impulsive decision, opens the door to the garden area outside and shouts towards the adults accompanying the children, asking them to please walk through the unit and not just pass it by. They comply. About 40 children walk through the unit, cheering and waving their flags. The spectacle is over in just three minutes. One of the caring staff members, an assisting nurse, is crying, while two others have tears in their eyes. Most of the residents are smiling and several are talking about «the beautiful children». The rare occasion became the talk of the unit for weeks to come.
In the same way as family, volunteers also do not influence the everyday life at our nursing homes to a high degree. Nursing homes in Norway have, in general, fewer volunteers than their international counterparts, related to the position of the public sector within Norwegian healthcare. Only one of our nursing homes – Emerald Gardens - had volunteers contributing on a regular basis, while most others had volunteers, mostly in the form of entertainment, contributing sporadically.
Although family members of residents do not generally influence the everyday life in our nursing homes, I will argue that they – by the ways they are approached and engaged – are highly influential for practices of hospitalization. As we will return to: family might not explain overall rates of hospitalization, but can contribute to an understanding of how and why nursing homes differ in practices of hospitalization.
For a six month period all hospitalizations of residents (or rather «transfers from the nursing home to hospitals») were registered by caring staff at Acre Woods. The data was meant to be a supplement to the qualitative data on decisions of hospitalization, by providing an overview of the overall occurrence of hospitalizations at the nursing home, and by providing added information from units in which the researcher did not spend much time. As such, the data did not cover
The information was registered on forms detailing time of transfer, type of transportation, reason for transfer, and, if available, effect of transfer (what happened to the resident). Each unit, through the unit leader or assisting leader, was responsible for filling out the forms, which facilitated an analysis of potential differences between units. All transfers from nursing homes to hospitals, including non-acute, were included, with the aim of providing an overview of the different variants potentially defined as hospitalizations.
While all transportations from the nursing home to hospitals were supposed to be registered within the six month period, they were, in all likelihood, not. Although the respective units were reminded of the forms every week, a majority of them seemed not to prioritize them, although they would not express such a lack of interest to the researcher. Generally, as will be discussed in
Transfers to hospitals did not increase during the summer holidays, according to the data set. Considering the relative downsizing of overall staff, use of temporary staff and consequent lack of experienced staff (to be discussed in
Although faulty through being based on self-reporting, the data-set still point to potential areas of further study, particularly pertaining to the significance of level of experience of staff.
Measuring the size of nursing homes is arbitrary, at least when comparing internationally. I therefore proclaim the right to categorize our nursing homes as «small, medium and large», based on a local scale, where small can be considered up to 40 residents, medium up to 70 residents, and large above 70 residents.
The data on staff characteristics provided by the nursing homes did not include information about nationality or country of origin. Such data was not gathered systematically by the researcher, giving us an overall, but not exact overview.
And increasingly so, based on national statistics for the health- and social sector in general, stating an increase in the work force of 7.4 percent of employed staff with a «foreign background» between 2013 and 2014 (
A substantial number of caring staff members have obtained the title of «registered nurse» from their country of origin. In most cases, these accreditations are not transferable to Norway and/or imply further training in Norway, which a minority «can afford», as they formulate it. A majority of caring staff members with foreign accreditation as «registered nurses» are given the title of «assisting nurse». Some, a minority, have or are undergoing further training to get accreditation in Norway.
Totaling 10 300 in 2014 for the entire health- and social sector in Norway, many of whom (close to 21 percent) are from Sweden (
The national average for the entire health- and care sector in 2014 was 35 percent (
Similar to the national average of 40 percent in 2014 (
Higher than the national average of 25 percent in 2014 (
For the remaining two nursing homes, data was not provided. At Galactic Manor, temporary positions were used extensively especially for assistants and assisting nurses who, in many cases would hold two or more temporary positions at the same time, making data difficult to generate.
Although technically not a «professional» group, assistants will, for simplicities sake, be described as such.
Regretfully, I was only able to gather a tenure list for staff at four of the six institutions. While all institutions were willing to offer anonymized information about tenure, only four had such information stored electronically, and were able to provide it. One institution did have the data on written, individualized personnel files (which I opted out of viewing), while another simply did not have the information.
The tendency of not filling vacancies, arbitrarily or systematically, was not found in a study on patterns of sickness absence representative for all nursing homes in Norway (Holmeide & Eimot
Referring to regular staff and the possibility for them to cover temporary vacancies.
Indicating, in my opinion, that this was very late.
Data for resident characteristics were difficult to get access to and time-consuming to analyze. None of the nursing homes had generated overall data for all residents, but rather individualized data stored on electronic or written personal journals. Getting access to these would imply breaching the ethical approval for the project. I therefore opted to gather generalized data on residents for one of the nursing homes, Acre Woods. The data was obtained by interviewing unit leaders, who either knew the information sought after, or provided it through the journals, in an anonymized form. As such, no data that could be connected to specific residents was given.
Based on the discretion of unit leaders, rather than electronic journals. Journals are not always updated, as evident both at our nursing homes and elsewhere. Selbæk (et al.
Some of which might be continent during day-time, but not at night (when they wear diapers).
Defined as «the ability to eat a majority of the meal independently, rather than being fed, if the meal is prepared and presented in an adequate manner».
Including the ability to walk independently with aids (such as «walking frames»).
«Family» will be used as a collective term covering «next of kin», «relatives» and «visitors» (visits by others than family members were rare at our nursing homes, but are still included for the sake of simplicity), also combining the Norwegian terms «familie», «pårørende» and «besøkende».
In these chapters, I will present and analyze how hospitalizations, as a theoretical construct
First, research on hospitalizations from nursing homes will be presented and analyzed, from which areas or approaches that are not extensively covered will be isolated. I will argue that this study can be seen as a supplement to the presented research literature (representing a dominant doxa), by covering areas and approaches not extensively covered and adopted.
These areas, most notably a focus on potential rather than actual hospitalizations, the potential interrelatedness of conditions and factors influencing decisions, and the everyday practices of institutions will be addressed in
Current and influential literature on the subject of hospitalizations from nursing homes will be presented to identify potential areas not extensively covered by the literature. By doing so, a presentation of the literature’s findings (what it presents as influential for practices of hospitalization) will be given, but also an understanding of how and why studies are undertaken in a certain manner. Is there, in other words, a dominating doxa on this particular field of research?
As
Furthermore, doxa will, by my understanding, refer both to
Doxic representations in the research literature will in this chapter be presented and analyzed in relation to orthodoxic (explicit maintenance of the dominating doxa) and heterodoxic (explicit deviations from doxa) representations, distinguishable from doxa by
The literature covering the topic of hospitalizations from nursing homes, explicitly or implicitly, is large in size and scope. For simplicity’s sake I will therefore focus on literature addressing the specific topic of hospitalization from nursing homes as a main area of research, first internationally and then for Norway. As the research literature, even when only including literature explicitly focusing on hospitalizations, is extensive, most of the referenced studies will be presented briefly, by synthesizing content and approaches, without, I believe, simplifying.
«Hospitalization from nursing homes» has been a much studied topic for several decades, especially in North America. This emphasis can be attributed to a general consensus about the negative impact hospitalization has for those involved, both personally for the residents/patients and financially for the institutions (OIG
Overall, the research literature on hospitalization from nursing homes is strikingly similar in research design and methodology, although with some notable exceptions. A large majority of the research literature has the form of relatively short research articles published in medical and/or health oriented journals, and usually follow the structure and outline typical in the medical science field. Research articles typically use retrospective analysis of the occurrence of hospitalizations derived from large databases of patients, institutions and/or jurisdictions, resulting in a relatively large population sample. A majority of studies originate from North America, most from the U.S., where the topic of hospitalization has been a widely discussed topic for decades. Recently, other countries seem to be following suit. Typically, in the case of the U.S., the population sample incudes one or several federal states, as opposed to a city, county or smaller region. The population sample is typically analyzed in accordance with one or several corresponding factors, respectively. For instance, the population sample, «hospitalizations from nursing homes in Texas», can be measured against institutional numbers, for example of «size», «number of registered nurses hours per resident per day», «number of Medicaid patients», and/or «number of residents over 85 years of age». The factors are then analyzed in accordance with relevance for hospitalization, and typically ascribed a strength of correlation; «size» might be considered to be significantly correlated to level of hospitalization, while «coverage of registered nurses» is considered to be moderately significant. The potential significance of the connection between the respective independent variables is, as will be shown in more detail later, seldom studied. Some studies do, however, break with the commonly adopted designs and approaches, adding valuable and supplementary insight to the object of study.
Hospitalization can, as will be discussed, be defined as an event occurring when a resident of a nursing home is transferred to a hospital or an emergency ward, either planned or acute, for some form of medical treatment. While some of the research makes a point of separating transfers from nursing homes to a) hospitals and b) emergency wards, and some separate a) planned hospitalizations and b) acute hospitalizations, far from all do. An operationalization or a definition of «hospitalization» is often missing, while those who do operationalize or define do not always concur. Even though definitions of what constitutes a hospitalization differ or are absent (Castle & Mor
Rates of hospitalization, then, appear to differ between institutions. To use the second review as an example: the probability of being hospitalized varies 6.5 times from lowest to highest. Some articles have also argued that variations in rates of hospitalizations differ between institutions within smaller geographical areas (Carter
Why is hospitalization, even given the premise that its occurrence is relatively high and that nursing homes’ practices might vary, a relevant topic for research? Most research articles answer this question by stating that hospitalization for many patients is not beneficial (Ackermann
Few articles deal directly with
The definition of what constitutes an «avoidable» or «potentially preventable» hospitalization and which conditions are included in such a definition differ between researchers (Grabowski et al.
To summarize, nursing homes hospitalize a lot, and they hospitalize differently. Hospitalization is understood as unnecessary or unwarranted for many patients. We have, in other words, a different way of operating for something that is not beneficial or at least ambiguous in effect. It seems, in a majority of the research literature, to follow that someone, somewhere is over-treated. If not, someone somewhere is undertreated, but given the high annual hospitalization rates, this seems more unlikely. In other words, the research literature has uncovered a problem, to which there should be a solution. The solution, within a majority of the research literature, is sought after by looking for
The majority of research, or what is understood as doxic representations within the research literature, is divided when answering this question: reasons for hospitalization are either connected to patient or facility specific factors (Carter & Porell
This question can be further divided into several subsections. Some focus on general characteristics of patient demographics (such as age, gender, education and ethnicity) (Grabowski et al.
Somewhere between the realm of patient and facility specific factors lies the related topic of how specific conditions or diagnoses are
Even though resident level factors can contribute to a heterogeneous patient demographic and thus can explain some of the variations in rates of hospitalization, especially across large geographical areas, it has been argued that such explanation factors are far from sufficient, in addition to producing contradictory findings (Carter & Porell
It has been suggested that up to 48 percent of all hospitalizations can be explained by socio-cultural, rather than medical factors (Cohen-Mansfield & Lipson
Financing/Ownership/Profit status: Generally it is argued that chain-affiliated nursing homes have a higher rate of hospitalization than non-chain affiliated nursing homes (Carter & Porell
Nursing home size: In many of the research articles nursing home size is said to be more directly correlated to rates of hospitalization (Anderson et al.
Nurse staffing patterns: The ways in which nursing home staff influence hospitalization has been covered extensively by the research literature (Anderson et al.
In general, the topic of staffing patterns is widely debated, but without, it has been argued, sufficient attention to how professional groups interact and how the institutional context as a whole can serve as a premise for decisions on hospitalization (Grabowski et al.
Physician staffing patterns: Based on the premise that avoidable hospitalizations exist, one would think that increased coverage of physicians decreases hospitalization. Some studies have found this association to have some merit (Intrator et al.
Turnover/job satisfaction: The literature on this topic is extensive, covering level of turnover for different professions (administrators, physicians, RNs, and LPNs), number of tenured staff versus temporary staff, as well as how these different factors affect outcomes for patients. High turnover rates are associated with negative outcomes for patients, including elevated rates of hospitalization (Collier & Harrington
To summarize, a large portion of the literature has drifted away from only focusing on characteristics and composition of patients as explanations for varying institutional practices, to including factors related to institutions and policy. Some argue explicitly for the need to study facility level factors or socio-cultural aspects for a balanced and thorough understanding of the mechanisms leading to hospitalization (Carter
Another segment of the research literature can be isolated and treated as distinctively separate from the majority of research based on differences in design and approaches: research with the overall common denominator of being «qualitative». «Qualitative research» is a vague and wide-ranging term, as is the application of the term for research on hospitalization from nursing homes, most notably in two recent literature reviews (Arendts et al.
In the most recent review (Laging et al.
The included qualitative research is somewhat more varied regarding country of origin than the majority of research, although still predominantly from North America (two from Norway, four from Australia, four from Canada and seven from the United States). The research is not as varied regarding applied methodological approach: a large majority (14) utilize interviews and focus groups (either in isolation or in combination) as their main approach, while the remaining three use observation and/or participant observation as their main approach (all of which also used interviews). Of the three, two applied a longitudinal or prospective design (Kayser-Jones et al.
The literature is relevant for our purposes as all studies have a common trait in covering the topic of how and why residents of nursing homes are transferred from the nursing home in cases of acute illness or approaching death, either explicitly or implicitly. Even though research varies in its specific area of interest (dying residents versus all residents, hospitals versus emergency wards, perceptions of practice versus conducted practice, for instance) the respective emphasis on influential factors for transfers are strikingly similar. Recurrent themes and emphases can be synthesized into five areas: four specific - the role of nurses, physicians, family and availability of treatment options, and one conceptual - a focus on the decision-making process.
The role of nurses and/or registered nurses in decisions to transfer residents out of the nursing home is given substantial emphasis in the research literature, pointing to their explicit or implicit influence on most decisions. Such an emphasis is a contrast to other segments of the research literature, in which the role of the physician is primary:
While the general emphasis is directed towards the influence of nurses and registered nurses, and the importance of sound coverage of these groups, some of the studies also point to composition of staff, or skill-mix, as influential in the decision process (Arendts & Howard
The role of the physician is less emphasized than that of the nurse in this part of the literature. The physician is typically presented as having varied influence on transfer decisions when discussed (Laging et al.
The largest difference of attributed emphasis on decisions of transfer between this and other parts of the literature revolves around the role of the family of residents. Potential pressure from family to transfer or not to transfer residents (more often the former) is accentuated in several studies and is noticeably missing from other segments of the literature. Family of residents is pointed out to be generally influential, through interaction with physicians, nurses or both (Arendts & Howard
The topic of treatment options or services is also covered in other segments of the literature, but is approached somewhat differently in the qualitative literature. Rather than exclusively addressing the
As evident in the review of these four areas highlighted by the qualitative research, the general emphasis for most studies, regardless of approach and attributed significance, is on the decision-making process leading to transfers, as opposed to outcome of transfers. It would appear that when such a shift in focus is made; that is from being exclusively directed towards the patient or towards characteristics of the institutions, nurses and families are attributed increased significance. As such, the perspective is moved from facility specific factors to processual dynamics. Nonetheless, not all areas of the decision-making process are extensively covered by this part of the literature, most notably missing being
The qualitative studies provide insight into aspects not covered by other parts of the literature. Still, these studies, although addressing additional or supplementary areas of interest, remain limited. Much has been confirmed since the first groundbreaking study of Kayser-Jones (et al.
The literature on nursing homes in Norway is fairly rich in size and scope. Few, however, address the topic of hospitalization from nursing homes directly, as does the research literature from other Scandinavian countries. A few studies do, nonetheless, stand out, briefly described in
Two of the previously cited studies analyze the influence of institutional conditions for the occurrence and variation of rates of hospitalization, Graverholt by analyzing the significance of size, location, ownership and types of beds on rates of hospitalization (et al.
Although these studies do not attempt a wide-ranging analysis of the
Regardless of the reasons for overall rates of hospitalization,
To summarize: there are distinct similarities in design and approach between the respective segments of the Norwegian and international literature, even though the Norwegian literature is small in size and on average relies on a smaller population sample. As such, the Norwegian research literature referenced follows the pattern of the international research literature of being grounded in different research traditions that do not overlap, in which one tradition appears to represent a dominant position; the doxa within the field of research. The quantitatively oriented studies, for instance, seem to share the international literature’s emphasis on variation as empirically surprising and/or normatively problematic. Nursing homes should hospitalize similarly, it is implied.
In sum, the international, and to some degree the national, literature on hospitalization from nursing homes is rich in size and analyzes a large variation of relevant factors connected to rates of hospitalization. It is somewhat varied when it comes to methodological approaches and research designs, although qualitative studies are in a minority, especially for observational studies looking beyond
Based primarily on the prevalent study design and approach, leading to what can be described as doxic representations, the research literature on hospitalization from nursing homes is dominated by certain perspectives and emphases. A similar argument was made in a thought-provoking theoretical review of research on nursing home residents in emergency departments (McCloskey & Hoonaard
I will argue that sufficient emphasis has not been placed on a)
Research about the decision making process relating to hospitalization is substantial in terms of the number of articles addressing the topic, both in the qualitative literature and other segments (Brooks et al.
This apparent paradox, that studies on variations do not incorporate that which is varied, has been addressed by Cohen-Mansfield, arguing that the initial process must be identified and understood for a complete analysis of the decision making process (Cohen-Mansfield et al.
As seen, an emphasis on the organizational characteristics, as a supplement to patient characteristics, is warranted, as is an emphasis on the decision-making process as a supplement to organizational characteristics. Even though the different segments of the research literature analyze the influence of various factors on rates of hospitalizations, most of the research literature overlooks the potential
Exceptions are to be found within each segment of the literature. The work of McGregor et al. (
The need to analyze the connection between relevant factors is not only a question of epistemology and methodological approach (being quantitative or qualitative), but is also related to the general attributes of nursing homes, to what nursing homes «are». «
In the majority of the research literature, representing the research doxa, the general topic of the interaction between staff and patients is not covered. Little emphasis is placed on the
This area of research marks the greatest contribution of the qualitative research literature, by focusing on decisions made in nursing homes by those involved. Although the segment represents a much-needed supplement to the existing knowledge bank, it also has its limitations. Only a few studies within this segment of the literature actually study the process of decisions, while most analyze agents’
The study of everyday practice can, in addition to its intrinsic value to the understanding of decisions and variation of decisions, also uncover contradictions to «rules» (being concrete or conceptual). The «rule» of physicians’ presence in nursing homes being a fixed entity at Norwegian nursing homes (Graverholt et al.
The research literature, which can be said to be composed of a dominant and an opposing research discourse, is, in my opinion, representative of a doxa that results in certain limitations. These limitations - that which remains undiscussed – can be seen as relating to the chosen research designs and approaches, which limit the gaze with which nursing homes are studied.
As will be argued, including those who are not hospitalized (but could have been) is an important approach to the analysis of variation between nursing homes. Furthermore, a focus on potential hospitalizations leaves the researcher capable of analyzing how factors can be interrelated (
See Kayser-Jones´ groundbreaking ethnographic study (
While prevalent in many countries, advanced directives are not common in Norway. Even the most common form of «life testaments» are not widespread, nor are they legally binding (Schaffer
Of the 14 studies utilizing interviews and/or focus groups (Laging et al.
Seven of the 17 studies are first authored by registered nurses (Laging et al.
See also Zimmerman (et al.
An exception to this tendency is a subtheme dealing with communication between NHs and hospitals/emergency wards (Brooks et al.
As argued in
I will argue for the need to understand how relevant factors interplay inside, and not just across, the walls of the institutions. The actual decisions made at the institutions are dependent on many, related considerations, not easily accessible to the researcher, or even to the practitioner herself, and not necessarily transferable from one nursing home or jurisdiction to the next. Often many of these factors interact dynamically to influence the decision-making process, making it more complex and more challenging to analyze. Nursing homes «(…)
Furthermore, a broad-ranging analysis of factors influencing the decision-making process can be a key to understanding the variations in rates of hospitalization, as it may unveil how different factors can be relevant in different places at different times, thus perhaps explaining
To make sense and make progress in a potentially extensive, complicated and multi-faceted area, only a selection of the many potentially relevant factors at play in nursing homes are included. The factors included are based on those given the most emphasis in the different segments of the literature presented, also including issues not covered extensively by the literature, but potentially of significance. Based on these considerations, an analytical division has been constructed between a) the overall structural framework potentially influencing decisions on hospitalizations (national legislation, for instance), and b) conditional influences related to the characteristics of the respective institutions and/or staff. These factors will be analyzed in relation to what extent they
«Structure» and «context» can be, and have been, understood and referred to in several, not necessarily compatible ways. Here, the structural framework will be referred to as the overall, generic context, the macro-level, to which all nursing homes must relate. These elements, most notably national (or regional, depending on the country) policies, laws and regulations, and the general financial framework and mechanisms affecting both the nursing home industry and the daily operation of specific institutions, are elements to which all nursing homes must adhere, as is their very nature. These two aspects of the structural framework will be treated superficially in the following; primarily addressing to what degree they influence and/or determine the everyday practices in nursing homes. I will argue that within a shared context, which for our case is primarily a national context, nursing homes relate similarly to the structural framework. This provides nursing homes with a set of non-specific premises creating a space in which practice can be generated.
In the case of Norway, governance, responsibility and accountability are placed primarily within the domain of the respective municipalities. As such, the model of governance in Norway can facilitate differences
From the perspective of our nursing homes, as will be discussed later (see
However, certain aspects of the financial framework provided, as for national policies and regulations, leave room for local and varying interpretation, and consequently also for variation in practices. Nursing homes can
The independent financial choices nursing home institutions can and, to a certain extent, have to make, are also evident with regard to equipment and food. A majority of nursing homes in our municipality, especially public ones, have, in an attempt to save revenue, outsourced production of warm meals to larger kitchens, located at other nursing homes. While such a financial effect can be debated, private nursing homes have autonomy in deciding whether they should provide warm meals themselves or not, as they also decide on using other sources of food. Public nursing homes have less autonomy in this matter; only a few larger institutions prepare their own meals. Provider agreements with various sources of goods follow a similar pattern; public nursing homes adhere to the municipal provider agreements, while the private sector can choose to, or not.
Both of the examples of filling vacancies (for all nursing homes) and ordering of goods (particularly for private nursing homes) point to
In general, the structural framework, provides nursing homes with comparable premises, but also a substantial element of autonomy and choice. As such, the structural framework does not
Institutional specific factors, as described beneath, include a variety of factors to which nursing homes must relate or by which they are influenced. For some of the factors, particularly size and physical layout, nursing homes have little room for influence or choice. Even so, nursing homes do differ in size and physical layout, have to relate and adapt given their size and layout, and are influenced on several levels by the respective characteristics of their size and layout. For other factors, such as staffing patterns and treatment options, nursing homes can influence the respective characteristics. Nursing homes can choose to have more registered nurses on rotation than the minimum or the average, and they can choose to offer intravenous treatment. The few included factors in the following, are included based on their varying significance for the development of sets of practices in nursing homes, including decisions on hospitalizations.
Nursing homes vary greatly in
Regarding
Coverage of physicians has, according to the reviewed literature, produced varying effects for rates of hospitalizations. There seems, however, to be agreement on the general point that inaccessibility of physicians is influential for practices of hospitalizations (Jablonski et. al.
The positioning of nursing homes towards treatment options should, in my opinion, be viewed as individual, unique and as non-determined by their respective characteristics. However, some connections between treatment options and other institutional conditions can still be found. The offer of treatment options relates to the size of nursing homes; the larger tend to have more treatment alternatives than the smaller, particularly intravenous therapy, perhaps as a result of economy of scale. Treatment options
The factors discussed in this chapter will be revisited throughout the analysis, adding detail and nuances, while a more theoretical discussion of
Generally, the influences on practices in nursing homes are complex: they influence differently, at different times and different places; their effects are non-determinant. Consequently, the study of what practices, such as hospitalizations, are affected by, should include analyses of a multitude of potentially relevant factors, including their relational, and not simply respective, influence. Based on such an understanding a preliminary model of the relationship between the structural framework, (a multitude of) institutional conditions and practices can be drafted:
This preliminary, generic model outlines the general dynamics of influence for nursing homes, rather than depicting a static and/or precise mode of influence for specific nursing homes. It points to tendencies rather than rules. I will, however, argue that the tendencies outlined are relevant for all nursing homes, both regarding the relationship between a structural framework, institutional conditions and practice, the institutional conditions which are at play and the given emphasis on relevance of the respective institutional conditions (as illustrated through size of circles).
The structural framework and institutional conditions discussed, which I will argue are the most promising given the sample and its context, do not, collectively and respectively, determine practices such as hospitalization. Rather they provide premises from which practice is generated.
Rita, a resident of Acre Woods, was, as Alice, (see
When talked to, Rita would give clear and comprehensible answers, but she never started a conversation and did not seek attention. To the surprise of a caring staff member who did not know her, she would give clear, matter-of-fact answers when spoken to, sometimes also correcting the staff member’s ways of doing things. She came into the large common room for meals, but stayed in her room at most other times. Sometimes she would sit in a chair in the corner of the main common room, alone, keeping her thoughts to herself. In my eyes, she seemed content, perhaps at ease with there not being much more to her existence, waiting for the inevitable end. During a morning report meeting in Two days later, the assisting unit leader updated the caring staff about Rita’s situation. She had been operated on, apparently successfully, but had had to stay at the hospital a little while longer for observation. Rita had caught pneumonia, which, combined with the operation, was a cause for great concern. Whether or not Rita had caught pneumonia before or after her fall was uncertain. The assisting unit leader added, this time opening the floor for feedback and discussion as opposed to simply informing the rest, that Rita´s fall might have been caused by her catching pneumonia, making her even more physically frail than before. She asked the others how they had found Rita´s state in the days leading up to the fall. An assisting nurse said that she was in poor condition, but did not know about her having pneumonia. Another said that the pneumonia might have been in the beginning stages, and had intensified since arriving at the hospital. A week later, Rita returned to the unit. She was now temporarily bound to a wheelchair, and mostly stayed in her room. She seemed to have recovered somewhat from the pneumonia, as she dined with the rest of the residents in the main common room on several occasions. Her state quickly deteriorated though. At the evening report meeting about a week after her return, a registered nurse, who had discussed the matter with the physician and the unit leader, informed the others that the end was approaching for Rita. Two of the assisting nurses nodded, giving the impression that they knew about Rita’s state. It seemed that Rita had once again caught pneumonia, and that treatment did not help. She was permanently bedridden, and Two days later, Rita´s closest family members, who had already been informed of the situation and had been to visit Rita, were called upon to be with Rita for her last hours. An extra assisting nurse was called on duty for the night-shift, to help provide Rita with palliative care. In addition, the night duty registered nurse was available in the unit for most of the night. Rita died, as she had lived in the unit, quietly, the same night.
The scope and content of regulations and guidelines specifically on practices of hospitalization have caught the attention of some research (see
Translated from the Norwegian «Stoppet å ta til seg næring». «Nourishment» refers to the intake of both food and liquids.
Hospitalizations, I will argue, are seldom easily identified or measurable events, clearly separated from other events, or even the normalcy of nursing home life. «Hospitalization» is not necessarily easily measurable for the researcher, nor is it easily identifiable and resolved by the practitioner.
Hospitalizations are difficult to concretize because of potentially different interpretations of what is defined as acute, of the places to which nursing home transfers are made (hospitals and/or emergency wards) and of the degree of treatment and time of stay at the receiving institution.
Even though hospitalizations can take different shapes,
As mentioned in
First, hospitalizations from nursing homes can be considered acute, or not. Acute hospitalizations are generally considered to be hospitalizations where residents of nursing homes suddenly (but not necessarily unexpectedly) become ill, and where the severity of the illness is considered to be such that treatment at the hospital rather than in the nursing home is warranted. Separating acute and non-acute hospitalizations seems, at first glance, to be useful as they clearly pose considerably different procedures and dilemmas for staff, and entail greatly different consequences for residents. Many residents of nursing homes need to visit the hospital, regularly and irregularly, for planned controls, checkups and evaluations. This can be connected to a more or less chronic diagnosis, cancer for instance, or to a less serious and passing diagnosis not considered acute, but still serious enough to warrant a visit to the hospital. The extent to which nursing homes use hospitals for such services can vary based on what the nursing home can offer in medical treatment, which again can be related to distance to hospitals. For some forms of treatment, however, nursing homes always have to refer to hospitals for planned controls and evaluations. Some residents visit hospitals for controls and checkups regularly for chronic diagnosis, perhaps once a month.
Scheduled controls and check-ups are common in nursing homes. Keeping in mind the age, frailty and comorbidity of most nursing home residents, many of them need medical treatment surpassing the expertise of the respective nursing homes. In many cases, this expertise is connected to chronic or recurrent diseases, making treatment at hospitals a continuous event. For the staff, such «hospitalizations» pose significantly different challenges than more acute cases. The main task is not to identify, understand and decide upon the nature of residents’ ailments, and consequently whether or not the residents will benefit from the hospitalization, but is rather connected to organization and logistics, aspects that are not welcome challenges in the hectic schedule of nursing home life.
It should also be noted that if such controls and check-ups were defined as «hospitalizations», it would significantly change the rate of hospitalizations for many nursing homes. When including controls and check-ups (which were excluded from the original sample), one resident in a small nursing home suffering from a chronic diagnosis implying regular controls at the hospital, can result in a relatively high rate of hospitalizations for the entire nursing home, even when excluding all other hospitalizations.
However, not all hospitalizations can be neatly categorized as either «acute» or «non-acute». Many residents of nursing homes are in a more or less constant state of illness. The threshold of when their state of illness changes from what can be considered manageable to acute can therefore be gradual and diffuse. There may not be a defined, fixed period of time when this occurs, nor does it manifest itself as a specific episode. Thus, categorizing as «acute» or «non-acute» is difficult for the researcher and might even be misleading; caring staff might understand and define hospitalizations differently than the researcher, for instance. To complicate matters, caring staff might also have different understandings of both the severity and suddenness of residents’ illnesses, often based on differences in experience and knowledge of specific residents. The diffuse and unclear development of residents’ illnesses, then, also makes the understanding, evaluation and decisions about residents’ well-being complicated and diffuse. Many residents are in a more or less constant state of being eligible for hospitalization, making the decision process for the staff ambiguous, constant and difficult: Acre Woods, Monday morning, in the office of the unit leader. The unit leader updated me on the current events of the unit, after the weekend. She told me that a resident had died during the weekend, on late Friday evening. It was Ester, who
Another example can further illustrate the difficulties in interpreting residents and their ailments, even for experienced nursing home staff: Acre Woods, Monday morning. I had been away from the unit the previous week, and knocked on the door of the unit leader, hopeful of getting an update of recent events. She greeted me, said that now was a good time and asked me to sit down. There had been one incident in particular the last week, she said. One of the oldest residents, Helga, had been hospitalized. On Monday morning, she had complained about her foot to an assisting nurse, when given morning care. The assisting nurse had not given it much thought as there was no visible damage to the foot. Some hours later, the unit leader continued, she complained again, when being served dinner. A registered nurse had taken a look and noticed that the foot had turned white. Immediately she suspected a thrombosis, I was told, in the area around the groin. A physician, not
The term hospitalizations Acre Woods, Monday morning, report meeting. The meeting revolved around an incident happening the previous Friday. Many of the caring staff attending the morning report meeting had not been on shift since the incident, and therefore needed to be briefed. The oldest resident of the unit, Inga, had fallen at approximately 17.00, one of the registered nurses informed the rest. The registered nurse had been on shift when the incident occurred. According to the registered nurse, Inga, who can walk with assistance, had slid out of her chair, while in her room. Being alone when it happened, it took some time before anyone noticed, the registered nurse continued. She explained that they were not sure about what had happened and how serious it was, so they had called the emergency ward. Inga was transported to the emergency ward by ambulance, and had x-rays taken there. The x-rays came back negative, so she was returned to the nursing home, the registered nurse concluded. There was a brief silence, indicating that no one had any questions either about the incident or how to care for Inga after the fall.
Relating to the issue of emergency wards versus hospitals, hospitalization may refer to Emerald Gardens, discussion with unit leader in her office. The unit leader:
The unit leader’s comments relate to several aspects of hospitalizations, some already covered. How a nursing home relates to hospitalizations is not simply dependent on the respective characteristics of nursing homes and hospitals, but is also connected to local and national structural frameworks, such as locality of hospitals and, in this case, the Coordination Reform. The effect of the latter, the untimely return of residents to the nursing home, poses significant challenges for the staff of the nursing home, accentuated by the frailty of nursing home residents. The case of Asgeir also speaks to a point made earlier: residents transferred regularly to the hospitals for check-ups could significantly increase the rate of hospitalizations for the nursing home.
Should these latter examples be defined as hospitalizations? Most would agree that the example of Inga does not constitute a hospitalization; she was simply checked at the emergency ward, and returned to the nursing home immediately. But where should the line be drawn? An hour at the hospital, five hours, or twenty-four hours? Or, should the distinction between hospitalization and non-hospitalization rather be based on a division of evaluation and treatment, excluding residents being evaluated and including residents being treated for ailment or illness? This poses another question: what is «treatment»? Again, where should the line be drawn? The case of Asgeir illustrates the difficulty of isolating specific criteria: some of his transfers could be construed as check-ups, while others implied a more comprehensive treatment regimen. The example also highlights another point, not discussed previously: if the resident is returned to the hospital immediately after being sent to the nursing home, should it be considered two separate hospitalizations or one continuous event? As for the topics of acute versus non-acute and hospitals versus emergency wards, the majority of the research literature does not concern itself explicitly with these latter questions. Hospitalization is usually understood as a resident being transported from the nursing home to a hospital, with sporadic emphasis on time of stay at hospitals (or emergency wards) and even less emphasis on the degree of treatment during the stay at the hospital (or emergency ward). Cloud House, 11.15 on a weekday. I am in the office of the unit leader who previously has told me that she
When considering the totality of these challenges, defining and understanding hospitalization for the researcher becomes a complicated task. These challenges point not only to difficulties for the researcher, but also to the multi-faceted and varied nature of hospitalization itself. Hospitalization is not a specific occurrence, easily categorized and generalized, but unfolds differently, has different scopes, different meaning definitions and severely different consequences for residents. That is, of course, not to say that some specific episodes fit well with the general notion of what a hospitalization is: Acre Woods, evening-shift on a weekday. I have made an appointment with the on-duty registered nurse to follow her from 16.00 to 22.00 17: We are in the office of the on-duty nurse, where we have talked about my project, the function of the on-duty nurse, and how a shift usually unfolds, for about thirty minutes. Meanwhile, she has been reading reports and notes from previous shifts. The phone rings. After a short conversation she tells me that one of the residents is ill. She would like to attend to the resident as soon as possible. The physician had seen to the resident earlier, sometime before 15.00, she tells me, and told the unit staff to wait until the next day. The registered nurse presents the information factually and soberly. 17.10: Together we go to the unit and greet an assisting nurse quickly (there are no registered nurses on shift in the unit). The on-duty nurse is led to the room of the resident. She enters while I remain at the entrance of the door. The on-duty nurse sees to the resident and tries to establish contact with her. The resident lets out some guttural noises, but I am not sure if they are responses to the nurse or not. After about three minutes of evaluation from the nurse, where she continuously has eye or physical contact with the resident, the on-duty nurse asks the assisting nurse to fetch equipment to measure the resident’s fever. The assisting nurse returns two minutes later and says that she cannot find the equipment. While the assisting nurse is present, the on-duty nurse rolls her eyes and shakes her head. She tells the assisting nurse to go to another unit to find what she needs. The assisting nurse returns three minutes later. Together they measure the resident’s fever. The on-duty nurse says that it is 40 degrees, higher than what she would have liked. Meanwhile, the on-duty nurse attempts to establish contact with the resident, speaking to her while getting slurred responses, difficult to interpret. The on-duty nurse says that she believes that the resident has pains in her abdomen. She asks the resident several times about this. The on-duty nurse then asks the assisting nurse if the resident is usually this unresponsive, whereupon the assisting nurse says that she usually can express herself easily. This concerns the on-duty nurse, who decides to measure the EKG of the resident. We leave for the medicine room and collect the relevant apparatus. After measuring the EKG level of the resident, the on-duty nurse tells me that it is high, much higher than what she would have liked. She pauses for a couple of seconds, considering the situation, visibly concerned. At this point, the on-duty nurse seems to acknowledge a seriousness in the situation, not evident earlier. She noticeably increases her pace and chooses to focus solely on the resident, and not me or the assisting nurse. The on-duty nurse decides to give the resident Paracetamol rectally, and gets help from the assisting nurse. I leave the doorway and wait in the hallway until they return. 17.20: The on-duty nurse and I return to the office, where she intends to call the next of kin. She does not tell me a lot of what is going on, but rather gives short, descriptive explanations of her plans. After finding the information about the next of kin, the on-duty nurse talks to her for about five minutes. Again, in a factual manner she tells the next of kin what has happened to the resident, and says that she thinks it would be wise to call the on-duty physician at the emergency unit and ask for an immediate hospitalization, 17.30: The on-duty nurse tries to call the on-duty physician at the emergency unit, but is told that the physician 18.00: We return to the resident’s room. The on-duty nurse measures her fever again. It remains high, approximately 45 minutes after getting medication, which unsettles the on-duty nurse. 18.10: Back at the office, the on-duty nurse once again phones the next of kin to given an update on the situation. Soberly, she runs through the turn of events, and adds that she thinks the resident will be sent to the hospital. She finishes the conversation by promising to phone again when she knows more. 18.25: The ambulance arrives. The on-duty nurse receives a phone call upon arrival and meets the two ambulance workers shortly thereafter by the elevator. They have brought a large stretcher. The ambulance workers and the on-duty nurse immediately go towards the resident’s room, where the assisting nurse awaits them. The on-duty nurse and one of the ambulance workers discuss whether the resident should go to the hospital or the emergency ward. The ambulance worker, a young man, says that the on-duty nurse should call the nursing home physician, and that this is the correct procedure if they should go directly to the hospital. This visibly annoys the on-duty nurse. She raises her voice when she replies 18.50: We follow the ambulance workers to the elevator and return to the office. She calls the next of kin and updates her about the situation. Afterwards, she tells me that it is time for her rounds, which she was supposed to do earlier, but has not had time for because of the incident with the resident. I join her. 21.30: The on-duty nurse finally finds time for a small break. I join her in the canteen. After a while, she changes the topic of our conversation to the previous incident:
In this case, the resident experienced an acute and severe physical crisis, for which she could not receive adequate treatment at the nursing home. She was transported to the hospital where she received extensive treatment, before dying two days later. As such, this particular instance serves as an example of «a typical hospitalization», consistent with the criteria discussed. This instance, both for the untrained observer and for the registered nurse, seemed like a clear-cut example where hospitalization was the only sensible outcome. Such is not always the case, however. Most decisions on whether to hospitalize or not, are difficult and filled with ambivalence, implying not only a multitude of different skills for those involved in the decisions, but also a change in approach for the researcher studying variation of practices connected to hospitalizations.
Hospitalizations appear seldom as precise and concrete.
I will argue that the researcher can transcend some of the challenges connected both to the measurement and to the analysis of variations by altering the general approach to the study of hospitalization commonly adopted. Instead of focusing on Acre Woods, morning on a weekday. Morning report meeting, which mainly revolved around a resident who had fallen ill the previous evening, has just ended. I remain in the nurses’ station, while a couple of assisting nurses finish their coffee before hurrying off to their designated tasks. Most of the caring staff have already left, some for the rooms of the residents, some for the large common room, and one for kitchen duty. The assisting unit leader, who led the morning report meeting in the unit leader’s absence, enters after a short errand to talk to the physician. The assisting unit leader, a hardworking and diligent registered nurse, well-liked by staff, is at this point well known to me. Of all the staff in the unit, she has struck me as the most «professional» in the sense that she seldom presents opinionated statements, but rather sticks to a factual and somber presentation of events and explanations. She sits down beside me:
The suggested approach can account for the complicated and ambiguous dilemmas caring staff are influenced by when considering the well-being of their residents. Furthermore, an emphasis on
Alexandra (see also excerpt in After supper on a weekday, Alexandra had fallen in her room. An assistant had accompanied her from the large common room to her room for a nap (Alexandra often walked by herself with the aid of a walking frame, but sometimes got help from staff as well, especially when getting up from or into a chair or bed). The assistant had left Alexandra in a chair in her room while fetching a beverage from the kitchen area, when Alexandra, apparently, had risen by herself to lay down on her bed. The assistant found her by her bed shortly after, moaning and with a gash on her forehead. Alexandra was disoriented and could not account for what had happened or whether or not she was hurt elsewhere. After Alexandra was found, things transpired quickly. The assisting unit leader and another registered nurse arrived, and evaluated Alexandra’s condition before calling the physician. From what I could understand at the time – not trying to interfere – the physician and the registered nurses had difficulty in ascertaining the gravity of Alexandra’s condition: she could not talk, but seemed to be in pain, in addition to the cut on the forehead, which was bleeding profusely. Together they decided to call an ambulance to take Alexandra to the emergency unit for x-ray. The ambulance arrived shortly thereafter, taking Alexandra away. The next day, the assisting unit leader, in the absence of the unit leader, updated me on the situation. Alexandra was discussed at the report meeting later that day and the days to come. The assisting unit leader, who usually expressed herself with confidence and professional certainty, was uncertain of how to proceed and wanted to discuss the matter with the rest of the caring staff members. The emergency ward had informed the nursing home that Alexandra needed One week later, Alexandra’s state had not improved considerably. She was still weak, immobile and still suffering from the consequences of the fall, to the surprise of some of the caring staff. Others, at least two experienced assisting nurses, were not surprised, saying, in hindsight, that they I did not come back to the unit for another five days. When back and going down the hallway, I noticed that the door to Alexandra’s room was open. A staff member from the nursing home’s maintenance department was changing the linoleum on the floor, while all other furniture and signs of Alexandra were gone. Alexandra had died two days before and the nursing home was expecting a new resident the following day. A strong smell of glue had spread across the hallway, while all traces of Alexandra were gone.
All evening and night-shifts have one registered nurse serving as the duty nurse for the entire nursing home. The on-duty nurse is available for all units. Even though some of the units might have a registered nurse on staff for a given evening-shift, there will still be an on-duty nurse available. The registered nurses serving as on-duty nurses for evening and night-shift, do this exclusively. The duties of the on-duty nurse are many and varied. Their primary functions are to assist the units in acute instances, assist with the medication for units without proper formally educated staff on shift, to make rounds at all wards and to be responsible for fire safety.
While part one of the analysis has provided a preliminary analysis of the empirical phenomenon and treatment of hospitalization, part two will concern itself with more general aspects both of our nursing homes and the doxic idea, notion and representation of «the nursing home». The gaze will be raised from the specific analysis of hospitalizations to a broader empirical object, towards understandings of what the nursing home is and should be, based on several opposing tensions (
The analysis of the nursing home is divided in two parts. In part one we will move beyond «commonsensical» representations of the nursing home, through the construction of dichotomies serving as tensions in a complex and varied institution (
Understandings of the nursing home and the resident, in combination with the forms of rules and regulations to which caring staff must relate, serve as premises from which practice is created and implemented. These elements provide a framework from which institutional autonomy can potentially thrive, allowing also for
What meaning and understanding is attributed to the notion of «the nursing home» by the respective agents and what does such a meaning and understanding entail for staff and residents?
The social fact or phenomenon of study must be constructed to avoid the illusion of immediate knowledge, readily available and alluring for the researcher. However, distancing oneself from the immediate knowledge is a daunting task:
For our purposes, in studying the nursing home,
As such, by breaking from commonsensical understanding of the nursing home, by way of constructing the object «the nursing home» (Petersen
Two aspects of the nursing home will be highlighted as particularly dominating; that of the nursing home as being
The nursing home as an idea or a notion has many elements or aspects attributed to it. Some, I believe are of particular importance, both for representations of it (as grounded in a doxa) and experiences of it (as through the everyday life of staff and residents).
Nursing homes are, primarily, where elderly go to live the remainder of their lives when other options are scarce or non-existing. Many residents, perhaps most, reside in nursing homes out of necessity, because there are no other options. Few have, on their own accord, chosen to live in nursing homes; for them the nursing home is the only alternative. From the perspective of the healthcare sector, as for many families of residents, the same also holds true: they see few, if any, realistic alternatives for the care of elderly people in need of physical and emotional support, besides nursing homes. Potential residents are cognitively or physically impaired, often both, to a degree where they cannot care for themselves or stay at home with assistance from visiting nurses. Families are seldom capable of caring properly for their elderly family members; they do not have the time or the medical competence to do so in a way deemed proper by themselves or society in general. The public discourse about nursing homes, in Norway and internationally,
The nursing home is also
As an institution the nursing home must relate to official rules, norms and expectations from the outside world. From the outside world, a nursing home has an official status, in the sense that it is publicly recognized and validated as a «nursing home», based on the fulfillment of certain characteristics. The nursing home needs to have the appearance, organizational characteristics and staff positions of a «nursing home» for it to be eligible to fill its societal function: the caretaking of the frail elderly. In other words, the nursing home is filled with content, from the eyes of the outsider; it is supposed to be a certain institution somewhere between the medicalized hospital and a home (Jacobsen
As an institution, the nursing home shares similar traits across jurisdictions, being regional and national. The specific definitions of the institution for long-term care for the elderly vary somewhat between countries, and there are varying definitions within countries, as we have seen for Norway. Nonetheless, many use the term «nursing home». The content of the term «nursing home» naturally also varies both within and between countries, especially in regard to organizational structure. Still, based on the extensive research literature on nursing homes in different jurisdictions and fieldwork at two nursing homes respectively in the United Kingdom, Canada and the United States, the general characteristics as well as the more subjectively experienced «spirit» of nursing homes are surprisingly similar. The similarities of nursing homes across jurisdictions are more striking than differences. The decisions, dilemmas and choices discussed in the following will therefore resonate outside a Norwegian and Scandinavian context.
However, I will still argue that the nursing home as an institution is particularly embedded as a collective perception in Norway: Norwegians have a distinct idea of what a nursing home is and should be, as well as the importance of the institution. Such a homology can be attributed to the high number of nursing homes, the relative homogeneity in ownership status of nursing homes compared to other countries as well as the general level of public governance in Norway. As such, the doxic notion of the nursing home is firmly established in a Norwegian context. The doxic notion of the nursing home
The relative
The nursing home as
On one level, the nursing home is in a constant and complex flux between
As such, nursing homes are simultaneously
In effect, nursing homes approach such a dichotomy in very different ways. The primary resistance to the various forms of bureaucratization in nursing homes comes from the widespread notion that
Returning to our setting, the sentiment of
How the administration and caring staff choose to present their nursing home’s appearance, and keep in mind that the staff has omnipotent power over residents when it comes to this matter, speaks not only to how the nursing homes want to be perceived, but also to how they perceive
Relating to the notion of the institution as bureaucratized is the more practically oriented notion of «professionalization»
Nursing homes are organized in particular ways, and more often than not follow the same organizational schematic. At the top are a leader and middle management primarily working with administrative and financial tasks. These positions tend to be occupied by registered nurses with some form of secondary education within «leadership» or «business». Institutional leaders do not generally work directly, perhaps not even indirectly, with residents. The size of nursing homes determines the size of the administrative corps, which in some instances also includes positions for personnel- and/or finance manager. These professional groups deal with the general aspects of the operation of the nursing home; finance, administration, commerce, and personnel, cut off from the everyday life of the units. The tasks they perform, and the specific positions defined for the performance of the tasks, are surprisingly similar from nursing home to nursing home, regardless of whether the nursing home reports to a commercial company, a non-profit organization, or a public entity.
In the units, the arena for staff-resident interaction, work is also professionalized. Not only are most positions filled by nationally or internationally recognized and validated professional groups like physicians, registered nurses and other categories of nurses (the latter more varied from country to country), but these groups, especially the positionally dominant registered nurses, serve specific functions within nursing homes. These functions, abstract (leadership, level of responsibility, level of manual labor) or specific (giving intravenous therapy, changing diapers, the administration of medicine), are largely monopolized by the respective professional groups. Registered nurses are allocated a certain domain of tasks and functions (leadership, giving intravenous therapy, the administration of medicine, for instance), primarily performed by them. The specific tasks allocated to registered nurses might, to some extent, overlap with those of assisting nurses (the administration of medicine for example), while their respective functions (primarily that of leadership and oversight, and organization and performance of resident care, respectively) are usually held separate. The tasks of assisting nurses might overlap with those of assistants, even more so than between registered nurses and assisting nurses, while their respective functions are somewhat different (primarily in the form of
The boundaries between the professional groups, spoken and unspoken, are seldom formalized in the form of written procedures. A formalized division of tasks is not necessary, as the division is known and practiced by all. In this sense, each professional group has its own methods, ideals and functions. While the division and boundaries between the respective groups are known and practiced on a daily basis, it is also presumed that other professional categories not included cannot replace those included. Other professional groups are excluded by default: residents of nursing homes
As mentioned, a significant segment of caring staff in nursing homes- categorized as assistants, have no formal education. Even though they comprise a central component of nursing homes, when considering their sheer numbers and tasks performed, they are considered less important than the professional groups in the sense that they are left with the tasks that do not fit with the ideal tasks for the professionals. This is no more evident than at morning report meetings which generally center on the tasks that have to be performed by registered nurses (and physicians, if present), and senior assisting nurses, before assistants are delegated their work. Assistant are, to be blunt, delegated whatever is left. As such, it is implied that the role of the assistants is not considered ideal; they are employed because of lack of nurses or because of a financial necessity.
Consequently, assistants are often encouraged to seek education as assisting nurses, since assisting nurses are encouraged to become registered nurses. Formal education, in other words, equals formal (position and salary
The professionalization of nursing homes is also apparent in the (perhaps increasing) amount of administrative tasks, primarily in the form of documentation procedures, both in the central administration and in the everyday life of the units. While the general division of labor is not formalized in written procedures, caring staff vehemently assert that there is no shortage of documentation tasks they have to perform themselves. While the general regimes of reporting and accountability for Norwegian nursing homes have been pointed out earlier, often described as being in the tradition of «New Public Management» (Ingstad
Professionalization is, in practice, contrasted to what can be described as an ethos of «personalized care», that is, that which opposes regimes, hierarchies and procedures created by others than those who perform them. While the idea and ideal of professionalization can be said to be connected to an anonymous demand for effectiveness, the ethos of personalized care is connected to intimate and local knowledge. The notion of the nursing home as a professionalized arena of work is, then, opposed in nuanced and complex ways in nursing homes. Elsewhere, it has been pointed out that an anti-bureaucratic sentiment arises at the level of caring staff because the work that needs to be performed is inherently anti-bureaucratic (Jacobsen
To be understood as connected to the process of professionalization, while not completely overlapping, nursing homes
Nursing homes are described in law and generally in official white papers as medical facilities offering their residents (or, in this case «patients») medical treatment when necessary. As mentioned previously, the historical development of nursing homes in Norway has seen changes in the emphasis of treatment of the elderly, which was particularly strong in the 70s and 80s, while somewhat nuanced in later decades, including also a stronger emphasis on the home and being home-like in official white papers (Hauge
Nursing homes can be said to be medicalized institutions in the sense of sharing professional roles (primarily in the form of physician, registered nurse and assisting nurse), and their respective positions in relation to each other (physician > registered nurse > assisting nurse), with the hospital. Integrated into each of these professional categories is also their respective (and thus relational) positioning towards «medical competence». In the same way as the appropriateness of the respective professional categories and their relational position, their positioning towards medical competence is taken for granted. The medical expertise and competence of both the physician and the registered nurses is widely considered, both in terms of the healthcare sector and popular opinion, to be positioned as they are and as important and integrated features of nursing homes. The question in the political and scientific discourse revolves not around their place in nursing homes, but rather about how much coverage of the respective professional groups should be considered sufficient (see for instance Hofacker et al.
The tension between medicalization and «care» unfolds on different levels: on an abstract level in the sense that staff have to position themselves according to whether the nursing home should, ultimately, be a treatment facility for the ill or a provider of a home; and on a concrete level in the sense of providing emotional and practical, or physical support. Nurses and physicians have to deal with these dilemmas on a daily basis, often also pressured by family members. The daily life of nursing homes’ staff is filled with small and large decisions, decisions that are related to questions of the cost-benefit of giving a resident a strong medicine, while at the same time being related to the larger question of what level of care should be provided in nursing homes. Such an ambivalence is constant for caring staff: there are no simple, correct solutions, no correct answer, nor does the outcome of their decisions – what happened to the resident – necessarily provide answers or prepare them for the next decision. As such, the nursing home is not medicalized to the extent of the hospital, simply because it cannot be; medical treatment of residents is not an unequivocal solution to the puzzles they have to solve.
Following on from the work of Hauge, who demonstrated an unclear relationship between the public and the private sphere (
The essence of the nursing home, its doxa, is not easily grasped, adding to the problematic endeavor of generalizing over nursing homes. A core can be identified, but when deconstructed into related layers, tensions and even contradictions are found. The nursing home is ambiguous in its very being, filled with variation and contradictions, consequently pulling its staff in contrasting and opposing directions. Specific nursing homes cannot be placed at a precise place in an abstract spectrum containing the ideas and values mentioned above, nor can caring staff choose one or the other. Rather, nursing homes are filled with lasting and constant tensions, from which there is no escape, producing changing outcomes. Life in nursing homes, more so than the general idea of the nursing home, is filled with dualities, dilemmas, ambivalences and opposing interests and ideas; for families, administration, governing bodies, and, especially caring staff.
Nor are the dichotomies presented necessarily in opposition to one another. The values of «bureaucracy» and «home», for instance, can be interpreted as omnipresent and overlapping in nursing homes, rather than strictly opposing values excluding one another. For example, based on a large workload and a feeling of being understaffed, caring staff can develop a need for
As we shall return to in part three of the analysis, the tensions, for which there are no ready-made solutions, form the basis of
Nursing home residents do, as others, socialize, form friendships, comraderies, oppose one another, and belong to groups or cliques. To a high degree, the socializing of residents at institutions can be based on affinities among residents who consider themselves equals in terms of social background or physical and cognitive skills (Bjelland
The way in which the residents are met, perceived, treated and categorized differently by staff, relates only in part to the role and position of the internal social dynamics among the residents. The perception of the caring staff towards a resident relates not as much to the social status of a resident as to how a resident fits with the caring staffs’ interpretation and definition of their tasks and duties as caring staff: «how good a resident is to work with», in other words.
Maud is a resident at Acre Woods, where she has stayed for some time. She does not suffer from dementia or, seemingly, from any other cognitive impairments, but rather gives the impression of being very clear and present. She does, however, suffer from several physical ailments, making moving around and walking independently a great strain for her. She is dependent on care, especially during the morning and evening care routines. More than any resident in the unit, Maud is outspoken, constantly seeking conversational partners from residents, staff and visitors alike, a true extrovert. She has taken a role as a leader among residents, especially for the residents who usually sit in the small common room. Her seat in the small common room is seldom empty during the day, from about 8.30 until approximately 20.00. If it is empty, it is never occupied by anyone else. Maud’s position as a prominent figure among the residents comes perhaps primarily from her energy and outspokenness, clearly surpassing that of her co-residents, who are often tired and lacking in energy. She is also extremely curious, always asking and always keeping tabs on other residents and visitors. She is seated so as to have a good overview of everyone entering the unit, usually stopping visitors and staff passing by. She has, through her constant conversations and her physical position, gathered great amounts of knowledge about residents, staff and visitors alike, which she often will refer to. In general, the staff have an ambivalent relationship to Maud; while enjoying conversing with a resident about more than the residents’ needs, the caring staff members can also find her curiosity overwhelming. After a meeting with the leaders of the unit, the physician is doing his rounds, visiting specific residents based on information from the meeting. Meanwhile, Maud is talking to one of the cleaners, a favorite conversational partner of Maud, about a television show that aired last night. When the physician is about to walk past the small common room, Maud stops him and waves him close: The next day, at breakfast time, Maud voices her dissatisfaction to me. She tells me that she is not feeling well at all and that she wishes to see the physician: Maud recovered and quickly returned to her normal self. Soon after, Maud went on a diet, with the expected effect of making her more mobile and helping her breathing. It was my understanding that the diet was planned and executed after a mutual agreement between Maud, her daughter, the physician and the assisting unit leader. After about a week on the diet, Maud addressed the issue, as she had done often in the days before. She seemed upset in part because the diet did not have the wanted effect, in part because she did not like the regimen. I listened to her, nodding in sympathy, trying not to say anything that could be understood as siding either with the caring staff or Maud. Still, Maud wanted more from me: Two days later, Maud is still discussed at the report meeting. The unit leader raises the issue by explaining that Maud, somehow, has received information about the weight of another resident (a resident who is on a similar diet to Maud’s). Maud has, in discussions with staff, been arguing for a change in her diet, referring to the other resident’s weight, according to the unit leader. The next day, the forthcoming meeting is raised again by the assisting unit leader. She asks for input from all staff members, for her to be as prepared as possible. An assisting nurse says that she found chocolate in Maud’s room, which Maud had said that she had given away. Two other assisting nurses laugh, one of them says One week later, four days after the meeting with Maud and her family, the issue of Maud and her diet resurfaced again at the report meeting, after being noticeably absent for several days. Towards the end of the report meeting, a registered nurse brought up Maud’s diet as a side note to a discussion about the day’s activities. The registered nurse said that Maud keeps asking for extra food, especially waffles in the activity center. Several other staff members concurred, mentioning examples when Maud has asked for refills of her agreed upon portion. An assisting nurse shook her head in disapproval. The assisting nurse concludes the matter by saying that they cannot use too much time babysitting Maud: Two weeks later Maud and her behavior towards the staff are raised again at the report meeting. In the preceding two weeks, both the staff and Maud have talked less about the diet. To my knowledge, the diet has gradually been phased down in the preceding weeks. The staff talk about their approach to Maud in more general terms than before. An assisting nurse says that she finds Maud difficult to deal with:
«Professionalization» will be understood as a general term relating to the processes of structure, efficiency and management, rather than as is often the case in a Norwegian context, to the traits of and relationships between specific professional groups. Professional groups are part of the concept of «professionalization», in my understanding, but not exclusive to it. In Norwegian, I am referring to the process of «profesjonalisering» rather than «profesesjoner».
The differences in salary between the professional groups (registered nurses – assisting nurses – assistants) are generally considered to be small in Norway compared to other countries, especially between registered nurses and assisting nurses. Also the difference in salary between the specialized (hospitals, for instance) and generalized (nursing homes, for instance) health sector is considered to be small in Norway.
«Act» is translated from the Norwegian «spiller», which, in this context, refers to the practice of exaggeration when presenting oneself.
An integrated part of the doxa of the nursing home is a notion of the hardship of working there, a notion which in the following will be broken down into its respective components and analyzed through empirical data from our nursing homes. It will be argued that staffing levels and challenges connected to relating to
Set against the more descriptive overview of our nursing homes given in
The hardship and toil of caring staff members influence not only the organization of work, but also how residents are perceived and, ultimately, met and treated in nursing homes. Caring staff members consider, for instance, lengthy conversations with residents a luxury they can ill afford in the hectic schedule of everyday life. Talking to residents
As such, caring staff not only have to relate to the idea of not having sufficient time to cater to all the needs of the residents, but also adapt to and, to a certain extent,
Relating to the prevalent doxa of the hardship of the caring staff is, as mentioned, the notion of the poor condition of today’s nursing home resident, as briefly presented. She (a majority are female) is presented by popular opinion, policy documents, research
These doxic representations are related; residents are frail and demand a large amount of attention, while the number of caring staff is considered disproportional measured against the amount of challenges relating to the residents. In the following, the characteristics and composition of both nursing home residents and the level of staffing for caring staff will be analyzed. The level of staffing for caring staff will be discussed in relation to the effects and consequences for the organization of the daily work routines, which ultimately affects how residents are met and cared for. The number and composition of caring staff members, in other words, are relational to the ebb and flow of everyday life in nursing homes. In a previously cited study, Kayser-Jones (et al.
While nursing home populations are typically presented (by those working with them and those analyzing them) as collective groups given certain characteristics, being «old and frail» or representing a «high level of acuity», for instance, variation between residents is easily missed. A meeting with three nursing home residents might illustrate this point, while presenting a notion of the general obstacles caring staff have to relate to, every day, in their meetings with a complex and dependent «group» of residents. Acre Woods, after dinner, on a weekday. As usual, the period right after dinner was noticeably calm in the unit, compared to any other time during the day-shift. A majority of the residents had returned to their rooms for an after-dinner nap, while others sat in chairs or wheelchairs in the common rooms dozing off. In the large common room, only three residents still sat at the large dining table, while caring staff finished with the task of cleaning up. Leif, Alexandra and Constance sat at their usual places, some distance from each other, but still within speaking range. Alexandra was still eating while Leif and Constance simply sat in peace looking out into thin air, or so it seemed. There were no caring staff present to talk to, nor did they talk amongst themselves. In total, they formed an unlikely group. Alexandra (see also Of the three residents, Leif was the only one who would usually sit at the large table, more often than not alone, often making comments to no one in particular. Alexandra usually stayed in her room, and was only seen or heard in the common room during mealtimes or shortly before and after. Constance was often in the common room, but seldom for consecutive periods of time, as she liked to move around, walking by herself. She seldom sat still for more than five minutes. I sat down with the three, after asking about how they had enjoyed dinner. Constance and Alexandra particularly gave the impression of welcoming the company, while Leif was indifferent. Sitting down and talking to the three seemed like the sensible thing to do for me, as the common room was desolate and quiet, not offering any impulses for these three who did not appear to be tired at all, as opposed to the rest of the residents in the unit. Getting a conversation started proved, however, extremely difficult, as the three responded differently, if at all. After a while, I gave up, a bit frustrated at my inability to be sociable with all three. Instead, I suggested that I could read the newspaper, which I proceeded to do. I read the highlights of some of the news bulletins and commented in between. This small exercise also proved difficult, as I did not understand how much I should explain and contextualize regarding the respective headlines. Knowing the three residents in advance only complicated it; I knew that Alexandra was well-informed on current events, and could communicate effortlessly, even though she seldom chose to do so. Constance, on the other hand, was more difficult to communicate with; she spoke fluently but did not always respond as one would expect, her mind drifting off. Leif posed different obstacles altogether; he would often make a comment on his own accord or respond when talked to, but was difficult to apprehend as his speech was slurred and mumbled. Consequently, it was hard to know what he apprehended. While I read the newspaper, the three residents’ reactions and comments mirrored my impression of them. Alexandra made few, but astute and well-informed comments. Constance paid close attention to what was being said and commented on everything, to the irritation of Leif, but was seldom to the point, while Leif did not appear to be paying attention, and made some comments which I interpreted to be about an entirely different subject (relating to fishing). It seemed to me that I had done a decent job of informing and communicating with Alexandra, while what I did and how I did it was not appropriate for Constance and Leif. Had I done it differently, by taking more time and explaining in a more detailed manner, Constance and perhaps also Leif might have benefitted more, although I am uncertain about Leif. However, Alexandra would perhaps have found it degrading, as if talking to a child.
The portrayal of the nursing home resident as old, frail and dependent is omnipotent among caring staff members. Residents are presented as utterly dependent on various forms of assistance,
A brief description of resident characteristics was given in
Comparable data were gathered for a similar sample (four large and five small nursing homes in Norway) in 1980 (Slagsvold
But is she necessarily frailer? Looking both at figures for general and specified ADL-measures, it seems that conclusions on the development of resident frailty are harder to make. The average number of residents with dementia and suffering from incontinence has risen considerably: from 21 percent to 71 percent for dementia, and from 43 percent to 79 percent for incontinence. However, when looking at average numbers for two of the activities of daily living, the tendency is contradictory: 33 percent of residents in 1980 were considered to be able to «eat individually» in contrast to 84 percent in our sample. 29 percent of residents in 1980 were considered to be able to «walk independently», in contrast to 50 percent in our sample. Other activities of daily living produced different outcomes altogether: 26 percent of residents in 1980 were considered to be able to «wash themselves independently», in contrast to only 6 percent in our sample, while 24 percent of residents in 1980 were considered to be able to «dress themselves independently», in contrast to only 8 percent in our sample.
The seemingly paradoxical variation can perhaps be explained by differences in interpretation of the respective categories. Alternatively, some of the variation can be ascribed to a change in the criteria of admission to nursing homes, signaling, perhaps, an increased emphasis on the diagnosis of dementia rather than physical ailments. Nursing home residents of today certainly have a high prevalence of dementia (higher also than yesterday´s residents), while these residents may or may not have severe physical ailments in addition to dementia. Washing and dressing independently can be interpreted as activities relatively unrelated to cognitive awareness, while eating independently might be contrary, thus perhaps explaining the confounding differences between the two samples. In an ethnographic study taking place in 1990 in a Norwegian nursing home, the relatively high number of residents dependent on wheel-chairs (62 percent) was emphasized (Jacobsen
If this hypothesis holds true, two implications can be drawn. Current caring staff seem to be more finely attuned to the
To summarize, today’s nursing home resident can be considered old and frail. The forms of frailty, however, are difficult to measure and analyze when compared to yesterday’s resident. Perhaps staff relate differently to residents today out of necessity; residents not only should but also must perform certain daily activities independently, when possible.
As illustrated by the responses to the reading of the newspaper, today’s nursing home residents should not be presented as a homogeneous group; they will vary within an institution and from institution to institution, and not only in time. The variation in residents adds to the difficulties of caring staff, not only by having a large total workload, but also residents with very different needs, adding to the effect of an already profound uncertainty among caring staff, to be discussed. Some residents, especially with diminished language and/or advanced dementia can, for instance, be difficult to understand and interpret: Acre Woods, my first day in Me: Ida: Me: Ida: Ida’s dialect is a distinguished one, her tone of voice calm and correct. She talks fluently, confidently, and does not struggle to find the words. She seems comfortable. We talk for about five minutes about the university college and about her son. Meanwhile she is pleasant company, and seems to have a good understanding of what is going on. Me: Ida: For the first time in the conversation she seems uncertain of herself. I am not sure if that is caused by confusion or by being surprised by my ignorance. Her gaze and movement indicate that something is out of place. So as not to unsettle her anymore, I politely end the conversation and thank her for the company. I leave the common room and go for a walk around the unit. About thirty minutes later, I return. The same residents are present, but they are seated differently. Ida now sits by a small coffee table in a corner of the room, together with three other residents, two of whom were seated with her earlier. They now sit closer together, within hearing range of one another. I join them. Ida nods towards me and smiles. I return the gesture, silently. Ida then leans in towards me and whispers, almost conspiratorially: Ida: As to underscore her point, Ida gently shakes her head. She leans back for about five seconds, before leaning in again and continuing: Ida: She lets out a small laugh and leans back again. When she continues, she remains like this, within hearing range of the other residents, but still directs her conversation towards me. Ida: Me: Ida: She looks at me, quizzically, obviously unsure of herself. Her uncertainty is now noticeable, and a stark contrast to her previous, confident self. I interpret her uncertainty as a fundamental one; she seems genuinely unsure of her surroundings and her place in them, and might even be scared as a consequence.
Ida, lucid, present and vigilant, appears to be in control of herself and her surroundings. At first glance there is nothing about her indicating she needs to be cared for in a long-term caring institution. But appearances can be deceiving; Ida is lost at sea, but also lost in regard to familiarity; she cannot recognize her surroundings nor her place in them. As such, Ida does not seem to fit in with the stereotype of a nursing home resident: she is neither physically impaired nor does she appear to have cognitive impairments. She is confident and assertive, far from the idea of the frail nursing home resident. Ida, then, illustrates the heterogeneity of nursing home residents, a heterogeneity not necessarily in the form of having a diagnosis or not (which Ida had), or different diagnoses (a majority are diagnosed with Alzheimer’s or dementia) but in the form of different everyday manifestations of a diagnosis or of frailty in general, implying various and different approaches from caring staff. Ida, as such, illustrates the difficulties of interpreting nursing home residents, as they adapt to their surroundings, have different needs, and express themselves in different and complex ways. Consequently,
Residents are not a homogeneous group. They vary considerably within a nursing home (or unit), in how physically dependent they are, in how they present themselves, in what they need, and in what they can or will give the impression of what they need, as seen with Ida. But does the total level of acuity of groups of residents vary considerably between nursing homes? Do some nursing homes have residents who are less frail than others? This question relates, of course, directly to institutional variations in hospitalization. If the answer is clearly «yes», we can end our investigation here.
Measuring levels of acuity, especially for a group of residents, is problematic and difficult. One aspect of nursing home life that might give some indication of how «well-functioning» residents are, is how active they are. When going from one nursing home to the next during the initial period of fieldwork, I was struck by how different the resident population of each nursing home appeared. Especially in two nursing homes, Durmstrang and Emerald Gardens, residents seemed to be far more physically mobile, more active in general and more vocal (to other residents and to staff), than in the other four nursing homes. While the level of mobility and activity of residents is difficult to measure, as are the
As for the first point, nursing home residents are admitted to a nursing home by the municipality through a specific municipal department, and not by the respective nursing homes, securing, supposedly, a relatively similar total nursing home population at each institution. It is difficult, however, to account for the accuracy of the intended even distribution among nursing homes, as neither the municipality nor the respective nursing homes grade or classify residents’ functional abilities in any systematic form that could allude to the total level of acuity for each nursing home.
In addition to a potential organizational preselecting of residents, the resident population of the respective nursing homes can hypothetically differ based on socio-economic background, and thus be considered a pre-selection of population related to area of residence. As such, nursing home populations in the respective nursing homes could be analyzed based on their cumulative capital (economic, social and cultural), in accordance with the general assumption of the association between capital and health. To make such an analysis, however, one would need extensive access to residents’ personal histories, both in the form of nursing home journals and interviews with residents and families (as many residents would not be able to provide information themselves). I did not have access to such information, nor the ethical approval for gathering it. Based on observational data, meanwhile, the composition of residents within our sample did not seem to be connected to the area in which the nursing homes were located.
As for the second point - the respective nursing homes’ focus on and ability to facilitate resident mobility and activity - the two nursing homes with apparently more functional residents, Durmstrang and Emerald Gardens, did seem to have a more explicit approach than most other nursing homes, albeit in different ways. Emerald Gardens had a well-established and widely used activity center, used collectively by all residents at the nursing home. Additionally, caring staff at this nursing home seemed to spend more time on idle conversations with residents. The latter may not in itself be directly related to activation, but certainly contributes to a general atmosphere of inclusion and staff-resident communion. Emerald Gardens, as described in
It is extremely difficult to identify a causal relationship between the approaches of the nursing homes and the functional abilities of their residents. The complex relationship between approaches and functional ability is further complicated by the fact that all nursing homes have some variant of the approaches illustrated by the two mentioned nursing homes, although not as distinct. However, Durmstrang and Emerald Gardens
A point not alluded to, but still of importance, is the level of the use of psychotropic drugs in nursing homes. It is commonly assumed that the relative widespread use of psychotropic drugs by nursing home residents, being administered to 75 percent of Norwegian nursing home residents suffering from dementia according to one source (Selbæk et al.
Small nursing home, name withheld. My first day at the nursing home had transpired relatively uneventfully. I had talked at length with the leader of the institution, been given the «tour» of the nursing home, and explained my project in short to the respective staff. I spent the last two hours of the day in the kitchen/dining area of one of the units, where I have been introduced to some of the residents, as well as to the general routines in the unit. The day-shift was about to end, and I to leave, when, in a calm moment in the unit, I was approached by two assisting nurses with whom I have had the most contact. One of them stepped close to me and said, keeping her voice down but still within the hearing range of the other assisting nurse:
Staff in nursing homes present their everyday working life as hectic and hard. The level of staffing is generally considered to be low, too low, when compared to the amount and level of care needed by residents. As we have also seen, the main tasks and assignments of caring staff can be described as basic, in the sense of primarily being directed towards medical and everyday needs, rather than psychosocial needs related to the well-being of the residents.
In the following I will discuss the consequences of the level of staffing for the organization of work and for how caring staff relate to residents.
The level of staffing for the hierarchically dominant professional groups, physicians and registered nurses, can generally be considered high when compared to the mentioned sample from 1980 (Slagsvold
Registered nurses’ hours per week, per resident are also high for our sample compared to the 1980 sample: an average of 0.26 compared to an average of 0.13
The level of assisting nurses
The current level of staffing for the groups with the highest formal competence can be attributed to the general development of the nursing home sector during this time period, previously discussed. Based on the overview of current staffing levels, nursing homes today can indeed be described as institutions with high formal competence within the medical and healthcare field. The figures also indicate that nursing homes today are considerably better staffed in total numbers. Also in an international context, the intended coverage of trained professionals in Norwegian nursing homes appears to be high (Harrington et al.
It should be noted, again, that these data (including the international comparison) are exclusively about Durmstrang, morning, weekday. I had been at the unit three times before, between two and four hours each time, and was beginning to feel familiar with the routines and «flow» there. This particular day, however, felt very different. There were only three caring staff members present, compared to the usual four, and one of them was new (she had just started her position at the nursing home). In addition to the new assisting nurse, the group leader and an experienced assisting nurse were present. As opposed to the other days I had spent at the unit, everything seemed to happen at a furious pace; there was little talking among the caring staff, except for giving instructions to the new assisting nurse, and even less talking between caring staff and residents. Breakfast, starting at about 8.30, (preparation for breakfast probably started before) lasted until approximately 9.50, much longer than usual, and was immediately followed by preparations for lunch. The caring staff, in other words, did not find time for anything besides preparing and serving the meals to the residents, during the first half of their shifts. To make matters worse, the group leader had to spend time in her office, making sure the following shifts were properly filled. For about an hour’s time during breakfast, the experienced assisting nurse tended to the administration of medicine to the residents, and was solely occupied with this. At this point, the inexperienced assisting nurse was left alone with all the residents, not quite knowing what to do.
When considering the doxic representation of levels of staffing as presented by caring staff, and discussed initially in this chapter, we are left with a paradox; why do caring staff constantly and consistently focus on the hardships and toil connected to a feeling of being understaffed in relation to their workload? The answer, I believe, is to be found in part in the frailty of today’s nursing home resident, in part in the organization and distribution of staffing (particularly at different periods of time, such as weekends, evenings, or holidays), which again must be seen in connection with financial incentives.
Levels of staffing, in the sense of number and composition of caring staff compared to number of residents, will to a high degree determine how the day at the nursing home transpires. The level of staffing relates not only to what potentially could be done during a day or a shift, but also to how residents are treated, particularly with regard to the possibility of providing for more than their most basic needs. The level of staffing not only varies in time or between institutions, as seen above, but is also considerably different from day-, to evening- and night-shifts, and from weekdays to weekends. All nursing homes have a higher level of staffing on day-shifts on weekdays than any other shifts. The priority of having better staffing during the day on weekdays can be seen as a practical one, as most of the tasks relating to resident care occur during this time. Alternatively, one could argue that most of the tasks and activities are concentrated in the beginning of the day,
Management of nursing home institutions can be said to have an incentive to prioritize day-shifts on weekdays over other shifts, as both evening-, night- and weekend-shifts (regardless of being day, evening or night) entail relatively large additions to the basic salary of the caring staff, additions that all institutions are obliged to give. All nursing home institutions, regardless of being private or public, are thus incentivized to prioritize certain shifts over others. Leadership at the nursing homes and, to a varying degree, the respective units, is pressured, from within and without, not to exceed a level of staffing considered «acceptable». The consideration of «acceptable» can be manipulated when it comes to filling short-term vacancies: Informal conversation with a unit leader, Cloud House. After discussing the general features of the unit, the discussion turns towards the role of the unit leader. I ask about challenges in her daily work: Unit leader: Me: Unit leader: Me: Unit leader:
Returning to the relative lack of public staffing regulations and the subsequent autonomy of the respective institutions, discussed earlier, nursing homes can to a large degree prioritize staffing levels of the respective shifts independently. These priorities follow a distinct pattern: nursing homes prioritize day-shifts on weekdays, because they can, because they benefit from it, and because their organization, specifically the distribution of tasks between day- and evening-shift, facilitates such a prioritization.
As such, one could argue that caring staffs’ experience of work as toil on evening-, night- and weekend-shifts, is connected to a perception of being understaffed in relation to the number and caring needs of residents, and is self-inflicted by the institutions. In my opinion, the financial incentives weigh more heavily when organizing the shifts than the needs of residents during different time periods of the day. The argument for the necessity of having more caring staff in place during day-shifts solely based on the needs of the residents is challenged by the relatively low level of staffing during weekend day-shifts. During Saturday day-shift, for instance, residents will have the same or similar needs and will constitute the same or similar total workload for caring staff, as for day-shifts during weekdays (besides the self-afflicted added burden of organizing tasks and activities on weekdays), but are staffed differently. A similar point was made by Jacobsen (
Two separate examples, one episode and one excerpt of a day, can illustrate how the ebb and flow of daily activities for caring staff are connected to the level of staffing. It should be noted that both of these examples are from the same unit at Acre Woods, about one month apart, and involve many of the same residents and some of the same staff members. Morning around 9.00, Acre Woods, weekday. Standing in the hallway observing the staff and residents during the busy morning routines, this morning struck me as particularly hectic. Most of the residents were eating breakfast already, either in the large common room or in their rooms. Maud was the only resident in the small common room, eating and trying to catch the attention of the caring staff organizing food on two large trollies just across from her. The respective staff members were quick to put whatever they needed on their trays and move on, towards the main common room or the room of a resident, not paying much attention to Maud. Shortly thereafter another staff member would replace the one that just left, to prepare her tray and then move on. Next to the two trollies, a registered nurse and an assisting nurse (with a course in medicine administration) were busy organizing the morning medicine. One of them, the registered nurse, would find the correct medicine, double check with the journals, while the assisting nurse would give it to its recipient. All the caring staff worked hard and worked swiftly, not pausing, not discussing and not deliberating about what they were supposed to do. They did not converse amongst themselves, besides the exchange of pleasantries, but sporadically took time to talk to a resident, wishing a good morning or asking what the resident would prefer to drink. At one point, an assisting nurse talked to Cate about a visit she was supposed to get later, before asking what kind of milk she would prefer. Cate did not reply to the question, as often happened, but another assisting nurse said that she prefers sour milk. The individual and collective movement of the caring staff amazed me; it seemed as if they knew exactly what to do at what time and with whom, not allowing for any spare time to be wasted. They seemed to move like an orchestra, albeit without a conductor, or perhaps working ants constructing their anthill is a better analogy; every one of the caring staff knew their respective place in the totality of work that needed to be performed, without being told, and without having any doubts. At one point, there were nine caring staff workers in the hallway or in the large common room simultaneously, all delivering breakfast or medicine, making sure everything transpired as smoothly and effortlessly as possible. It seemed as if all nine caring staff members made sure the morning routine went according to plan, although there was no plan, at least not an explicit one. The sight of so many caring staff members working diligently and – not to be forgotten – in the «public» sphere of the unit, as opposed to being inside the respective residents´ rooms, was a stark contrast to the unit at any other time, later or earlier on that particular or any other day. In fact, only one hour later, at about 10.00, the hallway was, once again, deserted Saturday, Acre Woods. My first whole Saturday spent at the nursing home. The day transpired differently compared to a normal weekday. There were five caring staff members present during the day-shift: one registered nurse, three assisting nurses and one assistant working on kitchen duty. The total level of staffing during the day-shift was slightly better than that of an evening-shift during a weekday and less than during day-shift on weekdays. During the evening-shift the five were replaced by two other assisting nurses and one assistant (it was said that one other assistant had called in sick, and was not replaced), which is one less caring staff member (including the absentee) than during evening-shift on a weekday. My general impression of the day was that it seemed like an endless evening-shift, both in atmosphere and the visibility of the staff in the «public sphere» of the unit. As a result of the relative low level of staffing compared to a normal day-shift, the caring staff had to suffice to attend to the most basic needs of the residents; making sure they were fed, visited the toilet and received their medication. The most noticeable part of the day, both during the day and evening, was the absence of the caring staff in the «public sphere» of the unit; they were hardly to be seen in the hallways or the common room. Rather, the caring staff members spent almost the entirety of their respective shifts in the rooms of residents, only seen outside when they were on their way to another resident’s room or fetching food. The entirety of the respective shifts, with the exception of the latter half of the evening-shift, transpired as such. The caring staff did not seem to find time to spend in the common rooms or the hallway (and definitely not in the nurses’ station), except for when bringing residents to and from the common rooms or the toilets. The few residents who did spent time in the common rooms, did so without the presence of caring staff for most of their time there. In addition to the absence of the caring staff, there were also noticeably fewer residents in the common rooms than during weekdays. Some of the residents walked to and from the common rooms on their own accord – influenced and perhaps somewhat unsettled by the lack of action and noise in the unit – while only two or three sat in the large common room for any length of time, as opposed to between four and eight, which was common during the weekdays. The general atmosphere of the unit that Saturday, then, was markedly different from the weekdays; it was calm, quiet and uneventful. This general feeling was accentuated by the, for me, surprising lack of visitors on a Saturday, only two in total, which would be typical also for a weekday. It should also be noted that caring staff did not find time to have extensive breaks until about 17.00. In other words, caring staff working day-shift did not find time for lunch or any other breaks during the entire shift.
These examples illustrate how and why the everyday procedures, activities and schedules are experienced as hectic and strenuous for caring staff. Everyday life for caring staff
More importantly still for our purposes is that the level of stress and bustle influences how residents are met and treated. The level of stress and bustle influences resident treatment for all shifts, though more visibly and explicitly when staffing levels are lower, as can be illustrated by the weekend-shift. During the weekend-shift the caring staff did not find time to prepare and bring the residents to the common rooms, especially residents who needed significant preparation and/or needed some form of supervision while being in the common room. In this sense, it was far more convenient for caring staff to have the residents with most needs in their rooms, where they could be controlled more easily. But it was also, in my opinion, necessary to keep them there; the few caring staff members could not keep an eye on the common room while tending to residents in their rooms; they were too few. Consequently, residents who did stay in the common rooms for shorter or longer periods of time, did so without the company of the caring staff, again, because they had to tend to residents with more pressing caring needs in their rooms. The caring staff were not in a position to solve this differently, in my opinion, given the level of staffing. The total caring needs of the residents were similar or equal to that of a weekday, while the level of staffing was significantly lower. Consequently, the caring staff had to attend to the most basic needs of the residents in their rooms.
Levels of staffing are, as seen from these examples, highly influential when considering not only the flow and development of everyday life at the nursing homes, including also, for lack of a better word, the atmosphere, but also how residents are met, treated and cared for by caring staff. Attending to the most basic needs of residents can be accomplished by relatively low levels of staffing, while attending to other needs, as seen in the difference between the two examples, implies higher levels of staffing. It is difficult to define what can be considered «low» and «high» levels of staffing, and what should be considered adequate staffing, as it is difficult to analyze todays nursing homes’ levels of staffing in relation to caring needs of residents to yesterday’s. However, Acre Woods, approximately 15.30 on a weekday. There were four caring staff members present on the evening-shift, one registered nurse, two assisting nurses, and one student. It was my impression that a vacant shift had not been filled because a student was present and considered an adequate substitute for the absentee (students were seldom part of the evening-shifts, but attended occasionally). It was a hectic evening, perhaps more so than usual, especially for the two assisting nurses. Meanwhile, the registered nurse was busy administering the medicine and tutoring the student. The registered nurse had earlier made an appointment with the student about going through the usual routines in the unit. She told an experienced assisting nurse that she and the student were on their way to the office of the unit leader. The assisting nurse replied:
This specific example is not only illustrative of the negotiation between professional groups, perhaps taking the form of a contested rather than an internalized hierarchy but is also illustrative of the generating principles of routines in nursing homes. Caring staff adapt their routines and procedures because they have to, as they perceive it, based on the relatively low level of staffing. From the perspective of caring staff, then, routines and procedures are created based on staffing levels. From the perspective of residents, such routines and procedures are not individually adjusted, can be said to be too strictly implemented, and can thus be to the disadvantage of residents. As will be discussed,
The general effects of levels of staffing on how residents are met and treated by caring staff are both systemic and specific. They are systemic in the sense of being routinized, illustrated by the predictability of the bed routines, especially for residents who do not have a say in the matter. They are specific and even mundane in the everyday incidents relating to how residents are greeted, talked to and helped. As such, caring staff adapt, explicitly and not, consciously or not, to the level of staffing in different ways, most notably by organizing the content of the shifts (primarily concerning the day-shifts), by adopting and executing a notion of primarily tending to the basic needs of residents, and by performing certain tasks based on suitability of the respective shift’s schedule, rather than the interest of the respective residents.
A major challenge when it comes to such an organization, not yet discussed, is that one does not account for unforeseen events. As illustrated by Cate in
The level of staffing, then, is not only about numbers. How the level of staffing affects residents is not only connected to the ratio between caring staff and residents. How residents are met and treated relates to an immensely important aspects touched on but not discussed in detail so far; the knowledge and experience of caring staff in relation to (the specific) residents, or
Constance was an anomaly among the fellowship of residents, in several ways. Each resident is unique in their own way, has their own way of presenting themselves, has their own physical and cognitive ailments, and poses different challenges for caring staff. Still, Constance appeared to me as being particularly set off from the rest of the residents. Constance had a form of advanced dementia, making her disoriented, forgetful and restless. Her speech, however, was perfect, and her train of thought seemingly coherent and immediate, in contrast to many other residents. This gave her the appearance, at first glance, of being more present than she was, as her conversational partner would soon find out. Physically, there seemed to be nothing wrong with Constance; she was relatively young and walked on her own, having a comparatively good and straight posture, even when sitting. Among all the residents in the unit, Constance was the most mobile, both in capability and in action; she could and did move around constantly. The most peculiar aspect of Constance, compared to the other residents, was that it seemed that her dementia did not leave her confused, uneasy or nervous. Rather, it seemed to take a form of forgetfulness rather than confusion, a forgetfulness Constance either did not comprehend herself or simply chose not to allow to affect her. Constance was always in a good mood, despite being forgetful, disoriented and restless. She always looked for companions and was always smiling and cheerful. She gave the impression, explicitly and implicitly, of being content at the nursing home. Although such a way of presenting oneself might conceal both frustration and sadness, the difference between her and other residents, the latter often displaying feelings of discomfort and displeasure explicitly, remained noticeable.
The only thing missing from Constance’s world, it would seem, were companions. She did not receive visitors, at least not on a regular basis, and found communicating with other residents difficult. It seemed to me that although Constance tried to connect with other residents constantly, she did not «match» them, as she was «too well-functioning» for the majority of residents who suffered from dementia and were lacking in language, and «not functioning enough» for the limited number of residents without dementia and language problems. When talking to the latter, as she often tried to do, she would quickly fall off the trail of the conversation, or lead it in a direction only understandable to herself, still smiling and seemingly content, to the dissatisfaction of her conversational partners. Because of Constance’s derailments, they seldom took the initiative to talk to Constance. Constance’s solitude among the residents led her to seek out staff members to talk with, relate to and connect with. Although seeing her explicit need for contact, staff seldom found time to talk to her for more than a few minutes at a time, often suggesting that she could go sit with other residents, or go to the large common room. Constance’s shy demeanor probably contributed to the ease with which the staff would dismiss her, in addition to the busy schedule of the staff. Constance was, in my opinion, the resident who was the most affected by the busy schedule of the staff and their consequential lack of tending to the residents´ psychosocial needs, often sitting alone, alert and looking for someone to connect with.
Exemplified by a caring staff member helping to feed 5-6 residents simultaneously, leaving her incapable of monitoring fluid intake, which led to a resident being hospitalized for dehydration.
Illustrated by the inability to administer intravenous therapy even when available.
The categories used (see
Naming a city far from our municipality, the name of which has been altered.
Another city far from our municipality. The name of the city has been altered.
In general, the topic of the administration of psychotropic drugs can be described as somewhat taboo in nursing homes.
This difference seems to be illustrative of a general national development, seeing an increase in physician hours per week, per resident from 0.27 in 2005 to 0.49 in 2014 when including all municipalities in Norway (
All these figures are based on intended figures for registered nurses’ working hours, as opposed to actual figures for their working hours, which may vary as we have seen, as registered nurses are generally replaced by other professional groups when ill or on leave.
Including «omsorgsarbeidere» and «helsefagsarbeidere», professional titles not yet adopted in 1980.
«Here» refers to a dementia ward, implying that dementia wards can be particularly challenging in regard to the level of staffing.
Agencies for temporary staff are used by nursing homes to varying degrees, and, in general, considered expensive.
Referring to the two caring staff members (not registered nurses) «left», and whether or not they are considered to be experienced or not.
Described elsewhere as «the great void» (translated from «det store tomrommet») (Hauge
How things are done at the nursing home, relates to three overlapping levels of influence:
Variation in practice between nursing homes
In this part, I will argue that variation is facilitated by the structure, resulting in a
Continuity and stability, viewed as aspects of other discussed factors and conditions, influence the boundaries, formation, characteristics and strength of the institutional practice. Certain elements of continuity, particularly involvement of and with family and collaboration with physicians, can contribute to understanding and explaining variations of practices on hospitalization, while, at the same time, can be symptomatic of the more general institutional practice.
Practices of caring staff are generated (by necessity) by a
I will argue that nursing homes, and even units within a nursing home,
The institutional practice is - in this book - both a premise and a result; both
But the institutional practice does not appear in a vacuum. Before the everyday practice in the nursing home, come the rules (the formal guidelines) and the routines (the quasi-official principles) organizing work. «Rules» will, in this context, include both legislation and regulations, and the specific and formalized procedures that nursing homes are obligated to implement and enforce from the respective municipalities. That means both the absolute principles which nursing homes and the agents operating within the boundaries of the nursing homes must adhere to (national legislation, for instance), and the more specific principles relating more directly to the organization of nursing homes. «Routines» will, in this context, be understood as the sets of written or unwritten principles guiding the everyday practice in nursing homes, as defined and implemented locally, by nursing homes or specific units. Routines can be similar to rules, as can their effect, but are distinct in the sense of not being created by explicit external demands. Routines are official, not always in the sense of being written, but by being shared and implemented by the practitioners; they are known by those who are responsible for their implementation.
The municipalities, although acting as the formal governing body, seldom interfere directly with the everyday operations of nursing homes. Our municipality has, for instance, suggested a maximum norm of staff per resident in nursing homes within the municipality. The specific institutions, however, can independently decide whether they want to follow this norm strictly (they will most likely not be sanctioned for deviating from the norm as long as they stay within their budget), and how they choose to interpret «staff per resident». As such, the institutions develop their own, independent systems of how many of the respective professional groups should be employed, on what shifts, and on what days, relating to but not mimicking the official regulation.
The specific institutions also create and maintain other rules, based on official guidelines but still adjusted locally. These include (though not exclusively): reporting schemes for residents (what should be documented for each resident at what time and where); workload for the staff (the structure of the shift plans, minimum coverage regulations for the respective professional groups); appearance of staff (use of uniforms, personalized items, and perfume, for instance); and visits by physicians (how and when, for private institutions). Depending on the size of the institution, the respective units may have some autonomy when it comes to these questions. Larger nursing homes usually leave it to the discretion of units when deciding how their days are organized, for instance when it comes to times for meals, report meetings, breaks for staff, delivering medication, and level and content of documentation. In sum, the organization of everyday life in nursing homes is shaped by the demands of external and internal rules, connected to a wider trend of bureaucratization within the public healthcare sector, to which nursing homes relate differently (see also Slagsvold
Many of the rules to which nursing homes must relate can be seen by practitioners as inadequate. They can be inadequate both with regard to content (degree of detail, for instance) and function (who they serve and benefit). Nursing homes as institutions, though serving as an agent of the resident, must also safeguard other interests, which in some instances might be contradictory to the best interests of residents (Freiman & Murtaugh
Many nursing homes in our municipality have outsourced the preparation of warm meals for their residents; the meals were previously made in a large kitchen serving the entire nursing home. This new arrangement is thought to be more cost-effective, and, ideally, should free up time for caring staff to spend on residents (or alternatively, wages can be moved from kitchen staff to caring staff). Most of our nursing homes had implemented this new regime; only one out of six, Acre Woods, still prepared dinner on site. These nursing homes now must order meals from a larger nursing home not included in the sample. Twice a week caring staff in the units, more often than not assisting nurses, have to spend hours ordering meals for each resident respectively, detailing personal preferences for each meal, through electronic forms, as opposed to being served warmed meals from an on-site kitchen. This is done during the caring staff’s allocated time with residents in the units; assisting nurses do not get extra time, or extra manpower, to perform these tasks, but have to find time in between other responsibilities. Consequently, assisting nurses will choose not to perform certain tasks that are not on the absolute top of the «to-do-list», more often than not spending time with residents in the common areas between meals. Meanwhile, the act of ordering food, as opposed to the «breaks» with residents, is not a responsibility that can be dropped or even postponed: Late morning, approximately 9.30-11.30, at Galactic Manor. Breakfast is finished, all residents have moved or been moved from the kitchen area. Of the ten residents in the unit, eight attended breakfast in the kitchen area, while two were served in their rooms, as they are bedridden. Four of the eight residents have retired to their rooms, while the other four have moved (two by their own accord, two with help from staff) to the adjacent common area, a spacious and nicely decorated large room with two sofa groups and a large television, which serves as the centerpiece of the room. Two of the residents sit quietly on a sofa, nodding off, while two sit in front of the television: one in a wheelchair, one in a regular chair placed there by staff. They appear to be paying attention to the television, showing local news from the public broadcaster, NRK. None of the four residents interact with each other, nor do they pay attention to my presence. In the kitchen area, partly visible from the common room (staff can pay attention to the common room from the kitchen area from one part of the kitchen, and can hear most of what goes on there) one solitary staff member, a female assisting nurse, is sitting by the large dining table. She is taking notes on a form while going to and from the kitchen cabinets and appears to be cross-referencing with another list she has. She acknowledges me and says that
The outsourcing of food, defined as within the domain of «rules» by being an obligatory (for public institutions) or voluntary (for private institutions) part of a larger municipal scheme, can, as such, produce effects which are contrary to the priorities of caring staff, and, perhaps, the best interests of residents. Based on the example, and by sentiments voiced by themselves (at the included and other nursing homes), caring staff must spend more time on administration and less time on residents because of this arrangement. While the argument that such arrangements leading to less time spent on residents than before can be debated (especially concerning difficulties in measuring such effects), the sentiments caring staff remains clear and strong; they would prefer, for their own and the residents’ sake, not to have them.
Other rules and regulations, especially concerning the multi-faceted documentation procedures concerning residents, can be construed as having the inherent function of «protecting» the institution from potential criticism, whether from family or media (Lloyd et al.
For residents and staff in nursing homes the everyday flow (who does what, at what time and with whom) is remarkably similar from day to day, as seen in the presentation of a typical day. Elsewhere, it has been demonstrated that caring staff are bound to their daily routines, always knowing what to do in a mutual and automated sense (Sandvoll Emerald Gardens, in the common area/dining area at 9.30 in the morning. Breakfast is finished for most residents, although a majority still sit at the table, finishing their coffee or talking to the caring staff, two of whom are still present. Meanwhile, the other staff members are in the rooms of bedridden residents. The activity worker has just entered, and is preparing for the daily activity of reading the newspaper and subsequent quiz. An elderly resident enters, a well-groomed «gentleman», particularly popular with both the female residents and the caring staff. He joyfully greets everyone, wishing a
Predictability and repetitiveness can be a comfort to residents; perhaps they are used to that from their former life, or perhaps it comforts residents with dementia in a constant battle to make sense of their surroundings. Similarly, predictability and repetitiveness can be a comfort for staff, trying to deal with the challenges connected to «the toil» of the nursing home.
Irrespective of whether the repetitiveness of daily life is viewed as positive or negative for residents and staff, it is still prevalent; everyday life in nursing homes is organized and structured by activities, actions and tasks that take place at the same time, every day, regardless of who performs them. In this sense,
The repetitiveness of nursing home life is influenced by more than formal and concrete guidelines and recommendations, as represented by
But not everything the staff do in nursing homes is part of their routines; not all actions are routinized. There is, I will argue, an aspect of everyday performance that is more subtle, more implicit and less instrumental. While the boundaries between them are indistinct and changing, a division between routines and
The agents, regardless of conscious deliberation, are gradually accustomed to the routines of daily life, and, from the perspective of the outsider, seem to welcome it. But whose routines are they? To what extent are routines shared in a specific nursing home, or even a unit? To what extent are routines shared among (similar) nursing homes? To what extent are routines as an abstract, theoretical phenomenon, shared and used among nursing homes, while the specific content of the routines might differ? These are important questions, as the locality and boundaries of routines can contribute to uncovering from where and how the more subtle and immeasurable everyday practice is generated. For instance: the specific incidents of hospitalization of nursing home residents can be seen either as adhering to the routines of daily life, or, in cases of meeting the unknown or unexpected, as ways in which the taken for grantedness of routines suddenly becomes a matter of active deliberation. This might be when a «new» or complicated situation arises or when inexperienced staff must relate to making quick decisions. In these exceptional cases, the routines of the institution are insufficient. In these instances, creating a space for a discussion of that which is not discussed, a local, shared and implicit institutional practice becomes explicit.
Everyday life in nursing homes is repetitive, routinized and mundane; the staff know what to do next, and residents, if in possession of the cognitive capacity to do so, know what to expect next. That is not to say that actions are not discussed or planned for, but rather that the internal framework of the staff’s practice, who does what and at what general time, is shared among the staff and implemented by the staff without much active deliberation. It is more or less taken for granted. As seen from the excerpt of daily life at a nursing home, staff have to plan certain aspects of their day, especially related to specific delegation of tasks, while
To analyze the boundaries of routines and practice, different units within the same nursing home can be a practical starting point. That being said, the organization of units, including the division between them, differs greatly between nursing homes, as within our small sample. Some nursing homes, primarily the larger ones, have units operating more or less independently from others; caring staff do not rotate between units, and do not, generally, concern themselves with the operation of the nursing home outside the boundaries of the unit. Smaller nursing homes might rotate staff between units more frequently, or even not have staff assigned to units at all; they work where needed on any given day. It is also typical in smaller nursing homes for all staff to have greater knowledge of what goes on in other units, whether it is related to residents, staff or the organization of work. Norwegian nursing homes (and keep in mind that Norwegian nursing homes on average are quite small, relatively speaking) are often somewhere between the extremes; they are typically divided into distinguishable units, while residents, unit leaders, and most of the caring staff are designated to their respective units. Caring staff usually have some form of formal flexibility (being employed at the nursing home rather than the unit, for instance), or informal flexibility (being employed in the unit, but still overlapping when needed, for instance) regarding where they «belong», thus securing some degree of overlap in knowledge and experience between units.
The organization and independence of units do not, however, only depend on nursing home size, but also on the physical space of the nursing homes. Units might be placed on different floors, or be far from each other on the same floor, not easily accessible, especially for residents. Other nursing homes have a more «open» layout; units are close to each other and connected through an open, easily accessible common area, with little delineating the boundaries of one unit from the next. Regardless of whether the physical layout of the nursing home provides clear boundaries between units, the units are usually given their distinct identity not only in name, but also in decoration, most notably different color schemes for each unit. Furthermore, the overall physical layout of nursing homes is obviously connected to when they were built, and whether they were built as a nursing home, or later refurbished as one. The physical layout of nursing homes can often be traced back to the architectural trends in the period when they were built, in other words. The autonomy of the unit, then, is connected to size and to the physical layout of the nursing home, but these do not necessarily overlap: small nursing homes can have units with relative autonomy 1: Cloud House: Cloud House can serve as an example of an ill-fitted architectural design for a nursing home. It was originally built as an apartment complex, and was recently refurbished as a nursing home, while maintaining most of the interior walls. Consequently, the hallways are far too narrow, not allowing, for example, for caring staff to support a resident on each side while walking down the hallway, a support several of the residents need. Furthermore, the units are separated clearly from each other, by floor and by a hallway not easily navigable for residents or staff. Likewise, the elevator, one of the most important features for all nursing homes, is not placed so as to directly enter the units from it. Residents are therefore not mobile, while staff have to spend a lot of time going from one place to the next during the day. Consequently, staff generally stay in their respective units. There are no easily accessible areas, common rooms for instance, where residents and staff can meet across units. There is a large common area in an adjacent part of the building, but this is difficult to access, partly because of the ineffective placement and size of the elevator, and is rarely used. 2: Emerald Gardens: The building itself is very old, and actually consists of several small buildings and add-ons, not visible before entering. The main building was not built as a nursing home, but rather a large villa. Combined, this makes for a very eclectic and varied physical layout inside the nursing home, far from the «clean» architectural designs of modern nursing homes. However, because of the way it has been refurbished, residents, staff and family members all state that it is functional and to their liking. There is a lot of open space so that residents can walk freely and easily from their rooms to the large common area, and even to other units. Staff can move quickly from their designated unit to the common area, other units, and the nurses work station. The common area also allows for a good overview of the nursing home as a whole. Perhaps as a consequence of this physical layout, the caring staff often contribute to other units than the one they are assigned to. Staff can easily access other units, and some of the more mobile residents are also, at times, in other units, a rare sight in most other nursing homes. 3: Galactic Manor: As opposed to the previous two examples, this nursing home building is new and was originally built as a nursing home. The architectural layout and the general aesthetics of the interior, therefore, are different from the two previous examples: it is neat, color coordinated, functional, and common rooms are for the most part easily accessible. When entering, the visitor immediately gets the impression of being in an «institution». One peculiar aspect of the layout, however, stands out. There are three units in the nursing home, two on one floor and one on another, the latter of which also houses the administration. The two units on the same floor are connected by hallways without doors separating them, making moving between them easy for staff and residents alike. Aside from those familiar with the nursing home, one would not get the impression of there being two separate units on the floor. Consequently, staff in the units, although formally employed in the specific units, often help in the adjacent unit; ask for help and advice, and interact socially with staff from the other unit. Residents, however, do not interact much across units, but are familiar with the staff from the adjacent unit. The third unit, on the other hand, is more secluded. It is, as mentioned, on another floor, and there is little if no mobility between the floors, at least not to the same extent as between the two other units. As opposed to the first nursing home, but similar to the second, there are no large common areas for residents outside of the units. However, as opposed to the second nursing home, the common areas inside the units are spacious and often used. 4: Acre Woods: The building is old, but has seen extensive periods of refurbishment and redecorating since it was built, and now has the interior look of a modern institution. Being significantly larger than the aforementioned institutions, the building itself and the interior create a first impression of being an «institution», in accordance with the notion previously discussed. The units are clearly separated from each other by floor, by locked doors at the points of entry, by large nameplates at the points of entry, and by different color schemes on each floor. Other units are not easily accessible as they are separated by a hallway, always locked, and not part of the units themselves. The staff can move between floors by an elevator, directly accessible through the corridors in the units, but these are off-limits to the residents, leaving staff with some level of mobility, residents with little. Given this physical layout and the size of the nursing home, units are clearly separated; staff are employed in the respective units and do not interact much with staff from other units, either to help with different tasks or socially. In addition, because of the size of the nursing home, there are two physicians employed, each responsible for their respective units, further contributing to the absence of the mobility of knowledge and experience between units (for the other three nursing homes mentioned, there is only one physician employed). Unit leaders do attend administrative meetings together, but they do not generally concern themselves with the day-to-day operation of the units.
These examples highlight the differences in physical layout and architectural design between nursing homes, and how units are organized accordingly. Although they are not randomly selected, more nursing homes could be added, which would add to the variation in physical layout and organization of units:
The significance of units in nursing homes cannot, however, be reduced to physicality; the unit is more than its appearance and the division of units is about more than the walls between them. The unit is, to varying degrees, a community (primarily) of caring staff.
As discussed, caring staff can experience alienation from the process of defining the premises of their place of work, resulting at times in opposition or even apathy. But being alienated can also have the opposite effect; it can produce strategies of ingenuity and originality, grounded in the need for defining a sense of collective identity, a sense of commonness. Such a need, the pragmatic effect of which is the coping mechanism of routines described in the previous chapter, can also result in communal sentiments among caring staff, described elsewhere as
Lindgren’s description of
Lindgren’s description of the respective cultures and the system of cultures is illustrative and, to some degree, transferable to the systems of integration and segregation within and between professional groups at our nursing homes. In my opinion, we can identify collective and cooperative cultures in our nursing homes, although in different ways than for «the clinic»
In smaller nursing homes affinity is bound to the institution. Individual and group identity is directed towards the institution as a whole rather than the units, in contrast to larger nursing homes. The community – the nursing home – is, like «the clinic», simultaneously integrated and segregated. It serves as an entity to which the respective members belong, but is simultaneously divided into professional groups (with specific tasks ascribed to them)
Depending on the nursing home, then, boundaries of collective identities
The process of collective identification is not only strongly connected to
The unit, then, is the main entity from which collective identity is defined, the degree of which will vary, depending on the organization of units at the respective nursing homes (which again depends on the size and physical layout of the nursing home). Units
To further emphasize how collective identities and a sense of community are found on the unit level, by creating informal distinctions and barriers to other units, the example can be used of a nursing home where the It is noticeable how different the two units are. I walk a lot between them during day and evening shifts, which is easy and quickly done, making the differences between them all the more apparent. An assistant nurse told me, somewhat jokingly, that their unit is much more
Units are, like nursing homes, different, adhering differently to structural frameworks and institutional conditions, having different organizational modes, different levels of staffing and, perhaps, different resident demographics. But units within the same nursing homes are generally very similar, at least at first glance. They are usually designed to be mirror images of each other with nothing else dividing them apart from different colors on the walls. Units within the same nursing home are usually built alike; having the same architectural layout, including similar number and size of resident and common rooms. They are usually staffed alike; having the same number of total staff and a similar composition of staff (from the respective professional groups). They also «recruit» residents from the same local area through the same local governing office, often evenly divided between units based on the respective nursing homes’ interpretation of the total level of caring needs in their respective units. Formally, then, units are similar, in all apparent aspects. Still, units develop distinct and different attributes, connected both to different and differing «spirits of the place» and different ways of relating to their residents.
To understand how such differences develop and are implemented, we must understand how units relate to The residents have, as mentioned earlier, their own and independent rhythms of everyday life, from which they rarely deviate. They usually sit at the same places, at the same time, with the same co-residents, regardless of whether it is mealtime or not The staff working specifically in
This brief description of some of the most notable features of An interview with the assisting unit leader of The assisting unit leader:
While the assisting unit leader highlighted the role of the physician in how
To caring staff in
Specifically, what the assisting unit leader points to as a defining characteristic – an approach of less medical treatment of severely ill or dying residents – not only points to this; the shared practice in
Practice in nursing homes has a strong local component, through sentiments of community and collectivity shared at the nursing home or in the unit. However,
The practices of caring staff are not given. There are few ready-made solutions. Many of the actions and decisions during a day, especially concerning the deteriorating health of a resident are filled with
As such, detachment and powerlessness relate to the need for what I argue manifests itself as
When applied to the specific decisions caring staff make, such an uncertainty is similar to what has elsewhere been described as the professional uncertainty principle: when «standard treatment procedures» are not widely established and followed, decisions and judgment may be «highly discretionary» (Wennberg, Barnes & Zubkoff (
The diffuse and unclear development of residents’ illness, for instance, makes the understanding, evaluation and decisions regarding residents’ well-being complicated and ambiguous. Many residents are in a more or less constant state of being eligible for hospitalization, making the decision process for the staff unclear, while being, in many cases, constant. How to relate to «the resident» is not provided those who must relate to her, and decisions concerning her are highly discretionary.
Such an understanding of the dynamics of practice in nursing homes, is contrasted not only to how practice is presented in a majority of the research literature, but also to the understanding of practice undertaken by those who train the practitioners in practice in nursing homes - nursing schools and equivalent institutions. To be brief, practice in nursing homes is presented to nursing students as abilities and techniques that are a priori (they are an inherent part of the «nursing profession», regardless of the respective nurses) and generic (they are universal), which the practitioner either has or not. Thus, it is seen to be achieved through training. Practice in nursing homes is presented and understood, therefore, as an absolute entity, similar or identical (ideally) between institutions. Neither variation nor the possibility of variation is problematized within such a perspective. Students can, if diligent, achieve mastery of such practice, and thus be a part of what is understood as the shared practice in the nursing home. Of course, such an understanding of practice has the effect of legitimizing the education at the same time. Based on such an understanding of practice, and the specific training it implies, the nursing student (registered nurse or assisting nurse) is met with a different reality in the nursing home. Against such a dominant view, Wærness argues for the importance of
For Davies’ nurse, codified knowledge and skills are not sufficient; they are not adequate to the practice which they must perform, and, consequently, need to be supplemented by other forms of knowledge and skills. Other forms of knowledge and skills relate, for the nurse, to experience and familiarity with the patient; they must be acquired. Armstrong makes a similar argument stressing that the skills required within work environments predominantly employed by women, such as care work, are not, as is often presented, inherent in those who perform them (Armstrong
The skills required for caring staff must, in other words, be acquired through experience directly related to the precise area of their work, rather than simply through formal training or being a «good care provider». Relating to the need of acquirement, I will argue, is that such skills can only be attained with and through
Acre Woods, two episodes related to the same resident. In the large common room on a Tuesday late morning, everything is as it usually is in
Three weeks later: Pauline had fallen and broken her arm while in her room one evening. I was not present in the ward at the time, but was told by the assisting ward leader that they had
Continuity, in the form of experience and stability of staff and familiarity between staff and residents, is essential when relating to the nursing home resident. Understanding, attending and evaluating the nursing home resident is characterized by uncertainty for the caring staff. Combined, the premises of practice for caring staff result in a need to attain a set of skills that, I will argue,
The importance of knowledge and experience extends beyond the specific residents and units, including also knowledge about and experience with the healthcare sector in general and the specific context of the respective nursing homes. Regarding decisions on hospitalization, experience in communicating with hospitals, emergency wards (in interpreting physicians´ orders, for instance), and the healthcare sector in general, proved greatly advantageous at our nursing homes. Caring staff without former experience, either with the reporting systems Conversation with on-duty registered nurse after the evening-shift described in
An on-duty nurse without intimate knowledge of a unit or a resident can benefit from detailed knowledge of «the system»; knowing who to contact and, more importantly, how to convey her message. Continuity can also be made relevant on an institutional level; through the communication and collaboration between institutional entities (between a nursing home and the municipality or a hospital, for instance). As seen, nursing homes from within our sample vary considerably in the form and frequency of contact with municipal representatives, while communication with hospitals has been underscored as problematic because of lack of continuity in persons of contact for nursing home staff.
In general, continuity can be seen as a significant aspect of the respective professional groups’ practices, the collaboration between caring staff, and between caring staff and other professional groups. Still, most important is the caring staff’s knowledge of specific residents and their experience from within their respective units.
Knowledge of and experience with Emerald Gardens. An activity worker is preparing for the activity of the day, bingo, while several caring staff members help out getting it started. Getting started proves difficult, as residents from other units are brought in, several of whom are in wheelchairs, which are difficult to maneuver in the relatively small room. The residents, most of whom are anxious to get started, wait patiently for the last remaining two residents, while the bingo equipment is set up. I sit down beside a familiar resident, ready to help her fill out the numbers on her board. The last resident arrives from another unit, brought in by an assistant, who is unfamiliar to me. The assisting nurse wheels the immobile resident towards our table, and places her close to the table so that the resident can reach the table with both hands. The assistant gets a board for the resident from another table. When she has finished, the activity worker notices the resident, walks over to her and readjusts her position, so that the resident now sits with her right side towards the table, enabling her to reach her board with her right arm. I later learn that the resident has suffered from a severe stroke, leaving her entire left side paralyzed.
This small incident could be supplemented with almost endless others; caring staff in nursing homes act and relate to residents based on residents’ individual needs and preferences, not simply based on the habits of residents (cooking the egg just right), but also related to the individual somatic and cognitive needs of residents. As seen, residents are generally in a poor state, while also varying in how poor. Understanding them (literally and figuratively) and attending to their respective needs, then, implies actual knowledge and experience with
The caring staff’s knowledge and experience of residents facilitates not only the physical well-being of residents, but also how they generally experience everyday life. The opposite, the lack of knowledge of and experience with residents, can lead to misunderstandings between staff and residents (overcooking the egg), and can produce more profound effects, as in the case of Pauline’s fall.
Knowledge of and familiarity with residents can be said to be particularly significant for caring staff in nursing homes because of the danger of falls for residents and because of dementia among residents. Falls are not simply dangerous for residents because they can result in serious injuries, but also because of the anxiety many frail elderly experience towards the possibility of falling, or after a fall (Rubenstein et al.
Returning to our nursing homes, explicit attention to the prevention of falls varies somewhat between nursing homes; some addressed the issue often at report meetings, especially regarding specific residents, while others did not. An even greater variation is found in the mundane, everyday and often implicit attention to preventing falls. How caring staff act towards the potential dangers of falling, especially for «high-risk residents», varies greatly, not only between nursing homes, or different professional categories, but also between individual caring staff members, as seen in the excerpt with Pauline. Such variation is related to level of experience and knowledge of residents. Less experience and knowledge of residents will lead, I will argue, to a higher occurrence of falls and/or to higher use of restraints, either in the form of physical restraints, including hindering movement, and restraints through medication.
The experience and knowledge of caring staff at Acre Woods led to particular attention to the danger of falling for two residents: Rita (see
Similar to dealing with potential falls, experience and knowledge is, I will argue, a prerequisite for understanding and generally dealing with residents suffering from dementia. Residents suffering from dementia are demanding and complicated; experience and knowledge not only of dementia but also of the specific residents suffering from dementia are vital for their well-being in nursing homes.
Residents suffering from dementia pose significant challenges for caring staff, especially in somatic units. These challenges are primarily, but not solely, connected to difficulties in communication and language, consequently also in
I will argue that experience with and knowledge of
A generic understanding of the disease, I will argue, does not suffice in dealing with its various forms. Facilitating the activities of Leif and Constance demands specific knowledge of and experience with them, rather than dementia in general. Understanding Ida’s challenges, similarly, presupposes former experience with
Knowledge of and experience from within the unit is, as seen, an important aspect of nursing home life. The unit, rather than the entire nursing home, can be the entity towards which the identification of caring staff is directed. Units are also, albeit to a varying degree, the premise for organizing everyday life. Knowledge of and experience with the respective units of work, therefore, might be more significant than experience in nursing homes in general or even other units at the same nursing home: Conversation with an assisting nurse on an evening-shift during the weekday at a medium sized private nursing home, the United States. At about 20.00, a female assisting nurse is cleaning the kitchen area, alone in the unit. All but two residents, who are sitting quietly in front of the television, have retired to their rooms, while no other staff members are in sight. After some «light» conversation, I ask her about the work schedule for the unit. She explains that she only works late shifts, from 14 to 22. What days she works and the number of days per week differ from week to week. When asked about how common such arrangement are, she replies that it varies a lot from staff member to staff member, but that this is the best solution for her, because of studies she has to attend during the day. Although this poses problems for her, having two small children, she has no other choice, she explains. When asked if she works in the unit exclusively, she responds that she primarily works on this floor, the dementia unit, but that she sometimes is told to work in other places as well:
Working sporadically in other units had led the assisting nurse to appreciate not only her work in her primary unit, but also the significance of experience from within the unit. Perhaps her sporadic meeting with other units left her more capable of appreciating such importance. Still, I will argue, the significance of the unit, of experience from within it, does not merely arise from the need to «belong to a place», but also from the need to master complex and multifaceted everyday life: A casual conversation with three assisting nurses during their lunch break, Durmstrang. After a while, the conversation drifts towards levels of staffing in the unit:
Knowledge of and experience from within the respective units is not simply significant because that happens to be the place where residents are, but also because of the general organizational centrality of the unit in nursing. As seen from a typical day at the nursing home: caring staff
Continuity is significant for small and large matters: for the ability to adjust to the everyday routines of nursing home life, and to help a resident get the preferred spread on a piece of bread just right. Continuity
Continuity is influential for what can be described as universal dynamics at play at all nursing homes. As seen, informal recognition and position for caring staff in the units can be gained by experience; by being knowledgeable about routines and of residents, or simply by knowing what to do. Such traits can, on occasion, surpass that of formal authority; an assisting nurse intimately familiar with the unit can influence others, implicitly and explicitly, in ways that the formal authority of the inexperienced registered nurse cannot. Inexperienced caring staff might be inclined to follow the lead of the experienced assisting nurse, consciously or not, by being shown, deliberately or not, how to perform.
Continuity is also universally relevant for nursing homes because of
While such a dynamic is universal for all nursing homes in the sense of providing premises to which all nursing homes must relate, the outcome of the dynamic is not given by the premises. The need for experience and knowledge to cope with the perceived «hardship and toil» and an uncertainty is shared, while
Nursing homes, and even units within a nursing home,
How can this be? I argue that regimes of practices are generated in nursing homes and nursing home units because it must; because the premises caring staff must relate to necessitate the creation of local and informal regimes of practices. These premises, most notably the rules that govern nursing homes, the state of «the nursing home resident» and the workload and content of work for caring staff, create a fundamental uncertainty for caring staff pertaining to large and small tasks and decisions alike. Such uncertainty further contributes to local rather than generic understandings and actions; they are not provided from «the outside». Thus arises the need for an institutional practice.
Let us trace back and elaborate on this argument, starting with the premises for caring staff: the rules and routines. «Rules» work, it has been argued, when they are respected and deemed adequate for the area they are intended to cover (Goffman
For the rules of the nursing home, agents do resist and oppose them, not necessarily with intent or deliberation, but because they are not experienced as being adequate or sufficient for everyday practice. Rules, then, can contribute to a sense of detachment and powerlessness for the caring staff. Consequently, rules at the nursing home will be manipulated, opposed, altered or ignored. Primarily, however, they will be altered and supplemented locally, because they can be inadequate for those who are supposed to implement them. Rules provide
The form of rules and regulations contributes to uncertainty for caring staff. This uncertainty is accentuated by the variation of residents´ needs and capabilities, and experiences of toil for caring staff. Combined, these elements constitute a
Nursing home units have been used in this chapter to illustrate both the need for and the formative mechanics of an institutional practice. Units can differ within the same nursing home because collective identity and sense of community is placed on the level of units, generating different and differing institutional practices. Nursing homes with a clear division of units, such as Acre Woods, can and will produce different and unique institutional practices in their respective units.
However, caring staff do not come unequipped when facing this fundamental uncertainty. The uncertainty can, in part, be tamed by experience and familiarity, most notably by detailed and intimate knowledge about residents. In the ongoing process of creating and recreating practices, experience and knowledge - among caring staff, with residents, with the nursing homes and with the unit - is essential not only as a coping mechanism, but also for developing and implementing that which is not explicit.
In conclusion, nursing homes, and even units within a nursing home,
While most incidents concerning acute illness and the potential of hospitalization can be analyzed in connection to various forms of interrelated factors, some incidents seem unrelated to factors such as staffing level, treatment options and competence in the unit. Perhaps their occurrence is not to be explained by underlying factors. However, I will argue that
Pauline was anxious and uneasy, not finding peace with «nursing home life» or in her unit (see also excerpt with Pauline in the introduction to this chapter). She was bound to a wheelchair, but could move swiftly around in her wheelchair, and did so, often to the annoyance of caring staff members. On one occasion, Pauline was nowhere to be found when she was supposed to receive her medication, later to be discovered in the activity center on a different floor, alone. Apparently, she had taken the staff elevator by herself, although no one could understand how she had managed.
The end came swiftly for Pauline, and when it came, the caring staff, despite their strained relationship, tried their best to comfort and take care of Pauline. Two assisting nurses and I are enjoying a short break in the nurses’ station shortly after breakfast on a Friday when the assisting unit leader arrives, more flustered than her usual stoic self. She explains that Pauline has still not got out of bed (Pauline was usually an early riser, and her sleeping in had already been mentioned at the morning report meeting): About forty minutes later the physician has already been to see Pauline. The assisting nurse informs me: The following Monday morning a table stands in the corridor outside what used to be Pauline´s room. A picture of Pauline stands on it next to a burning candle. Pauline died Sunday night, her family present. The assisting unit leader is already planning for the arrival of the next resident.
«
It should also be noted that the three levels of hierarchy within «the clinic»: «flickor», «systrar» and «doctorer» (physicians), do not fit, formally, with my definition of «caring staff» (consisting of assistants, assisting nurses and registered nurses, leaving out physicians), but are still translated as such, since physicians have a smaller part (in numbers and influence) in nursing homes than in hospitals.
The predictability of seating arrangements for residents at mealtimes has been described elsewhere as resembling that of the parking lot at a place of work: workers park in their designated places, automatically and without deliberation (Hauge
Refers to a neighboring unit discussed previously in the conversation.
Elsewhere, it has been argued that documentation relating to transfers of residents is unnecessarily time consuming, and that the information can be of little use for sender and receiver alike as the information can be perceived to be «
Translated from the Norwegian «kvinnelist».
«
Nursing homes and/or units develop institutional practices, meanwhile all sharing a dynamic of how and why they are generated. But how does an institutional practice relate to practices of hospitalization? And more importantly in this context: how can we explain differences in practices of hospitalization?
In this concluding chapter, I will argue that practices of hospitalization to a large degree are
This argument will be elaborated on in three parts in this chapter. First, I will revisit the discussion about influencing factors for hospitalization given in
To what do decisions on hospitalizations in nursing homes relate? What are the influencing factors, and
I will argue, in a continuation of the discussion given in
A model does not sufficiently capture the complexity of the potential variation of influence, unfortunately. The relationship between certain institutional conditions (such as size of nursing home) and outcomes (such as rates of hospitalization) can, for instance, be
«Spurious effects» are understood as connections that are seemingly strong and direct, and might be presented as such in research literature where the connection between an isolated factor or a set of factors and the outcome appears determinant, but proves coincidental and/or weaker than previously assumed when the onion is further peeled. Spurious effects are, in other words, connections between factors or between conditions and outcome that are not, strictly speaking, causal (A does not determine B, but A may influence B, given C, D, E and F).
Similarly to the McGregor argument for the potential effect of the intermediary variable of ownership on the relationship between size and rates of hospitalizations, I will argue that the general effect of size on hospitalizations is spurious in the sense that other factors,
For the analysis of practice, if only the more or less direct effect of separate factors is included, effect can be exaggerated. Spurious effects, such as in the example presented, might cover an effectual relationship that is sporadic and varied, as evident when analyzing a broader spectrum of relevant, interrelated factors.
Size, in itself, produces spurious effects on practice in nursing homes; the influence is dependent on additional factors, employment of physicians, among others. I will further argue that even when including physician employment, the influence (size → physician employment → practice) is varied and non-determinant. Larger nursing homes do, generally speaking, offer closer to full-time positions to physicians than smaller nursing homes, often exceeding the minimum requirement given by the municipality. Larger and medium-sized nursing homes are also more inclined to employ physicians directly, rather than through the municipality. Private nursing homes, meanwhile, are also more inclined to employ physicians independently, as opposed to public ones, but not necessarily in larger positions, making a potential connection between
How the physical layout of nursing homes influences practice, can serve as another example of potential sporadic influences. Physical layout, understood as the physical environment of nursing homes, consists both of the interior physical appearance of nursing homes and to the subtler atmosphere. The physical layout of nursing homes might relate to ownership, in the sense that private nursing homes have more autonomy over their physical space than public nursing homes. Physical layout, in combination with ownership, also relates strongly to size of nursing homes, as we have seen, for obvious and less obvious reasons. Of particular importance is the relationship between physical layout, size and ownership on the one hand, and the organization of units in nursing homes, including level and form of unit autonomy, on the other. Physical layout, ownership and size, combined and respectively, also influence staffing patterns. Nursing homes might have to adjust staffing patterns based on physical layout, private nursing homes have, overall, a different composition of caring staff than public ones, while staffing patterns - particularly for registered nurses and physicians - are strongly influenced by size of nursing home.
These are but a few of the potential connections between physical layout, differing conditions and practice that could be drawn. These will still suffice to illustrate the dynamics of influence: physical layout does influence practice in nursing homes more or less directly, but its primary influence on practice depends on other factors, which are different for each nursing home. It is through and in combination with other factors, most notably ownership, size and staffing patterns, that physical layout influences practice. This connection,
The influence of physical layout on practice seems to be significant, primarily in the form of the organization and integration of units, which again relates to
Staffing patterns can be said to be more directly influential on practice, than other influential factors mentioned, such as size and physical layout. That being said, analyzing the more or less direct influence of staffing patterns on practice is, though alluring, problematic for two reasons. First, the staffing pattern is not created from a vacuum; it is affected by other factors in addition to being effectual. Second, the more or less direct effect of staffing pattern on practice cannot be understood simply by describing its general qualities or, as is the case for treatment options, simply by occurrence (how many and at what time, for instance). It must also incorporate informal traits of caring staff, most notably experience and continuity of care between staff and residents. To understand the difference in influence and effect between the mentioned factors and practice, we need to move beyond the formal qualities of the object of study and ask: what is it
The effect of potentially relevant factors on practice can be spurious and sporadic, difficult to grasp. Giving credence to trends and tendencies, for the researcher, can, however alluring, be problematic and even misleading. The problem of measuring effect is also connected to scale. Larger studies, seen in detail, tend only to include a few relevant factors and only seldom analyze how factors are interrelated, thus producing findings that exaggerate the effects of one or a few factors. A study of our sample, meanwhile, is also problematic especially for purposes of generalizations and universality (as discussed in
Physicians’ individualized approach to treatment of residents can serve as an example. Physicians in nursing homes can have very different approaches to their role in nursing homes, sometimes to the point of physicians going well beyond the tasks they are obliged to perform. Medium sized, private non-profit nursing home, Canada, evening-shift. A physician exits the room of a resident, entering directly into the large common room. He has blood splatters all over his shirt and appears to be somewhat agitated. He approaches us He has just completed his rounds, being scheduled for an afternoon shift in the unit. The resident he attended to had a blood clot in the knee, which he, alone, proceeded to drain while in the room of the resident, he explains. He did so, he says, even though He gives the impression of being very dedicated, of going out of his way to take care of elders in need, and points out several times that the tasks he performs are beyond what he is obliged to do. Since he has no social life, as he explains it, his visits have become his social life, and he Later, he explains that he sees the bureaucracy connected to his work as too demanding and hindering his work. If he were to do what he
Practices of hospitalization at a nursing home (or unit) are strongly connected to the preferences of physicians, either in the form of explicit preferences and approaches (such as the above example) or by not taking an explicit stance, and thus elevating the potential influence of caring staff and/or families. While the significance of physicians’ preferences on variation of practice of hospitalization will be revisited shortly, for now the example can illustrate how physicians’ approaches can be influential within a small sample such as ours.
Within such a small sample, the potential influence of a single resident on institutional rates of hospitalization also becomes evident. At two of the smaller nursing homes within the sample,
The examples mentioned speak to a point often missing from research literature (again, related to the relatively large samples of most studies); the relationship between variables, for specific institutions, might be confounding and non-generalizable. That is not to say that they are coincidental - there are reasons behind the relationship - but rather that complex relationships discussed cannot be easily generalized for all nursing homes within a sample. The influence of the irregularities mentioned could, I will argue, contribute to understanding
Long-term bed nursing homes within a small geographical area with similar patient groups exhibit varied practices. Practices vary formally and informally, for specific, measurable practices (such as the occurrence of hospitalization) and for more general, unmeasurable practices (such as the collaboration between caring staff and physicians, and interaction with family, for instance). This variation is rooted in an institutional practice. The variation in institutional practice, leads to, I will argue shortly, variations in practices of hospitalization. But from where is that which in the first place is varied, the institutional practice, generated?
To understand variation of practice, so we can understand variation of practices of hospitalizations, we must revisit our general understanding of practice, theoretically and how it can be applied specifically to the nursing home context.
Revising a theoretical understanding, based on Bourdieu’s theory of practice, including the interdependency between practice, habitus and structure, we can start with the more general aspects of how practice can be understood, briefly dwell on how practice relates to structure and agency, ending up with how the theory of practice can contribute to an analysis of variation.
First, and on a fundamental level, man lives his life according to rhythms. To do one’s job as a man, according to Bourdieu, implies a degree of conformity to a social order. Man must respect rhythms, to keep on track and not fall out of line:
Implicitly we can surmise that practice, by a Bourdieuan understanding, somehow relates to «rules» (in the sense of «that which governs beyond the contemplations of individuals or groups», rather than «rules» as specific schemes of management, as discussed earlier). This relationship, as Bourdieu presents it, is complex and imprecise. Practice, in itself, is not absolutely governed or determined by rules, nor do they follow distinct patterns, as exemplified in an early study of marriage patterns in Kabyle. Bourdieu found, to summarize, that the logic of marriage was more complex than what a structuralistic analysis would convey (Bourdieu
The practice of the agent, then, cannot be reduced to his rational and strategic expectations of the outcome of an act (such as he presents it). Practice is only determined by expected future outcomes
This quote illustrates the complexity of Bourdieu’s agent’s liminality between agency and structural influences (on which there is not sufficient space to elaborate): his practice can be seen to be organized as strategies, without being the product of a genuine strategic intention, while at the same time reproducing the objective structures, structuring his practice.
Based on these premises we can outline Bourdieu´s theory of practice. The theory of practice can be described as a theory of
The agent’s detachment from the principles that structure his action does not imply, however, that the agent does not find meaning in his action, or that his practice can be said to be without meaning. The agent and his actions are more
Habitus, as seen by this definition, are dispositions that guide practice without «being used» deliberately by agents (more possessed than in possession of the habitus (Bourdieu
Practice is thus neither mechanical nor completely rational. Still, practice has more meaning and function than the agent alludes to. To understand why agents, through practice, «do» more than they «know they do», we must understand habitus as being
With this, we see that it is the very mechanism that makes practice meaningful to the agent that simultaneously makes such meaning difficult to reach for the agent. Perhaps paradoxically, practice is simultaneously
In this light, employees in a nursing home unit can be seen as performing their daily tasks as a collective without the conscious choice of a collective performance. Furthermore, the collective practice is taken for granted, it is a
In a perhaps naïve attempt to convey the dynamic of the practical sense of caring staff members in nursing homes - how the practical sense is practiced by them - an analogy of a «pathway» or «trail» can be constructed. When we act, we act based on those who have acted before us and those who act with us, like walking on a trail in the forest. The trail is not particularly distinct nor is it straightforward (as opposed to a road), yet something about our intuition makes us walk it. In an interplay between the body and mind that is almost automatic, we follow the trail, without making explicit deliberations about our choices. We follow the trail without expressing a desire to follow it. Furthermore, the trail is not random or coincidental, people have walked it before, with some kind of purpose or at least meaning; it is there for a reason. Yet the reason is not explicit or even known to us. The trail is most likely a sensible route to where one is going; those who have walked before us did not choose it randomly. One can diverge from the trail, intentionally (if the trail or a part of the trail is clear and easy to see) or unintentionally. Yet something about the landscape surrounding the trail leads us, more often than not, back on the trail. Over time, as we walk it, the trail changes, gradually and perhaps unnoticeably, not necessarily as the result of an intent to change, but because a more sensible path was walked, over time. The trail exists and «works» only because of those who walk it and those who have walked it. Others do/did not create it, being either a divine entity or officials (either God or a representative from the municipality). Such an analogy is far from an adequate depiction of Bourdieu’s theoretical framework, or of its applicability to caring staff in our nursing homes, but it does share some common traits. The trail might illustrate that walking is not determined exclusively by explicit intent or by external influence. Nor is the trail walked exclusively based on old habits. Practice is found somewhere in between these influencing bodies. For caring staff in nursing homes the trail is walked, more often than not,
For Bourdieu, practice is both dynamic and relational, and at the same time, structured. For agents in the nursing home, decisions concerning residents are at the same time based on interactional aspects occurring continuously and on aspects outside the reach of the reflections and negotiations of the agents involved. In this way habitus points to something shared
Such is the understanding of the institutional practices in nursing homes: caring staff share taken for granted practice, which makes sense without stating sensibility. Rather than stating the universal applicability of the theory of practice on man, it will suffice for me to state
Before further elaborating on how the theoretical perspectives of the theory of practice can be transferred to our setting, the structuring mechanisms for practice in the nursing homes – the premises of practice - will be revisited. The relationships between practice and structure are not tangible; they are constantly in flux for the practitioner, serendipitous and deceiving for the researcher. Even so, structural mechanisms
The structural mechanisms relate to practice in nursing homes differently: both in form and degree of influence. The relationship between the structural mechanisms and practice differs both in time and space; differently within a nursing home or units within a nursing home at different times, and differently between nursing homes. The absence of specific directives and protocols connected to decisions of hospitalization can serve as an example; there are no formal guidelines addressing the issues of hospitalization for caring staff. For the incidents described in the preceding chapters, there were no protocols for those dealing with the situation, no instructions and no textbooks; the «solution» had to be found on the spot. As such, the complex and ambiguous decisions were left to the discretion of the nursing home staff. Thus, variation
The uncertainty for caring staff resulting from structural mechanisms is further accentuated by the variation and complexity of the nursing home resident, making continuity vital on several levels. Continuity is, as seen, a prerequisite for understanding the nursing home resident; she is old, frail, dependent and in need of a broad array of assistance and supervision. To make matters more challenging for caring staff, there are many of her, all different, all frail, and all dependent. The skills needed to deal with her, at least to deal with her in a manner by which her varied needs are met, are not easily attainable. They are certainly not passed on to caring staff when entering the nursing home for the first time, nor are they attained through their education. The skills needed to deal with the multitude of residents’ challenges, including communication, are not fixed entities one either possesses or not; rather they are inherently ambiguous in the sense of being shifting, varied and non-specific. Caring staff, then, have to acquire skills and practices that have to be interpreted and adjusted continually, both for the neophyte and the experienced.
The uncertainty of the caring staff member is not simply an uncertainty of meeting the unknown, but a
To be specific: sets of practices for the caring staff need to be created, constantly re-created and implemented
As such, caring staff in nursing homes develop and implement sets or regimes of practices that can vary between institutions. Although caring staff in nursing homes share the fundamental uncertainty functioning as a premise for the development of the institutional practice, they do not necessarily share the specific traits, forms or «strengths» of the institutional practice. While
An improvised conversation with a physician in the corridor, Durmstrang. The physician, a consultant working exclusively within geriatric care (as opposed to other physicians at other small nursing homes who only worked part time exclusively with elderly patients), emphasized the importance of knowing the particular and peculiar challenges that are relevant when working in nursing homes:
As seen, communicating with family members of residents, both on admission and later, is important for when severe or acute illness occurs and for the general preparation for such incidents. In a majority of the qualitative studies described,
This particular nursing home in the included excerpt above for instance, had a more explicit and systematized approach towards involving family members in discussions about treatment and palliative care, on admission and later. Consequentially, the nursing home was better equipped to deal with pressure from family, even from what could be considered demanding family members, than other nursing homes. As illustrated by this nursing home, continuity in relationships in the form of familiarity between the respective agents, can breed
Relatedly, physicians’ involvement with family vary considerably within our sample. Some have virtually no contact, some have formalized contact in the form of meetings with next of kin on the resident’s arrival at the nursing home, while some have extensive and continual contact. Consequently, the
Similarly to the few research articles addressing the issue (Dreyer et al.
Different forms of physician employment lead to different forms of integration and collaboration between physicians and caring staff, and between physicians, caring staff and family. Continuity of physicians, in the form of size of position and tenure at the nursing home (in part also general experience with elderly patients), is influential for how well equipped physicians are at evaluating, understanding and treating nursing home residents, in other words. Continuity of physicians relates not solely to technical knowledge, but also to how integrated they are within the institutional practice. This influence also works in reverse: the physician with experience and knowledge of the unit and the residents in it, will influence the respective institutional practices, as will be elaborated on shortly. In general, physicians vary, within and outside our sample, significantly in experience and knowledge of the units. My first meeting with the only physician at a small nursing home (name withheld) led to a short conversation leaving a lasting impression. The physician, employed through the municipality and performing his duty-work one day a week at the nursing home, expressed, after getting a brief overview of my project, a grave dissatisfaction with the working conditions. He conveyed a feeling of being pressured, that there was too much to do in too little time (which he explained frantically, as he needed to hurry on):
Physician collaboration and family interaction can explain variation in practices (and rates) of hospitalization. These aspects are also components of the institutional practice; how caring staff (or caring staff and physician) interact with family is – in effect – not part of the formalized set of guidelines or even routines; they are rather part of the implicit, taken for granted practices, shared among practitioners locally. Caring staff act towards family as they do as a part of their practical sense.
The differences between nursing homes regarding these (and other) aspects of everyday practices in nursing homes can also be found between units within the same nursing home. Two units at Acre Woods will be revisited.
In
The excerpt, alludes to the understanding of caring staff (and physician) in
How this particular unit, the main unit of fieldwork, is presented as being different with regard to positioning towards hospitalizations, is connected not only to other units at the nursing home or other nursing homes, but also specifically to one other unit in the nursing home. This
At the
The differences, more often than not in the form of nuances and degrees, were conveyed collectively at report meetings, during physician visitations, and during interviews with unit leadership. The unit leader of
Collaboration with the physician in The weekly meeting between unit leadership and the physician takes place in the office of the unit leader. The unit leader, another registered nurse and the physician are present. After some initial conversation and small talk, they prepare for the weekly review of residents: the registered nurse by reading from journals/charts in paper form, the physician by placing himself in front of the computer to get access to the electronic journals if needed, while the unit leader sits behind her desk. The registered nurse is «running the show»: she initiates the topics of conversation and presents the residents one by one, sometimes informing the others, sometimes asking questions. The physician and the unit leader occasionally respond to the presentation of the registered nurse, sometimes adding a detail to the presentation, sometimes answering a question. All three demonstrate detailed knowledge of the residents, their current state and their regimens of medicine. In general, the tone is informal and relaxed: they seem comfortable with each other and appear to value the insight and opinions of one another. On several occasions, the registered nurse would correct the physician, regarding the day of an event for instance, to which the physician would smile and thank the registered nurse. They alter between discussing the general condition of residents and their specific regimens of medicine, both in terms of developments in the last week. The registered nurse informs the others of significant changes in general health for four of the residents, warranting an increase or decrease in medical treatment. Together they discuss how the residents in question should be approached, both in terms of their «psychosocial» and medical well-being. An increase in or an excessive use of medication is stressed several times as unwanted. Such an emphasis was, to my understanding, primarily implicit among the three: they attempted to find other solutions than medical treatment when they could (without stating the need to), and resorted to medical treatment when they deemed they had to. One resident, who suffered from back pain after a recent fall, was given an increase in current medication, after a rather long deliberation, while another resident, gradually becoming more tired in recent weeks according to the registered nurse, was taken off her medication. Together they decided that increased attention towards activities and movement was the right path for the resident, while monitoring possible changes in restlessness and «wandering». Collaboration with the physician in The weekly meeting between unit leadership and the physician takes place in the office of the unit leader. The assisting unit leader (in the absence of the unit leader) is alone with the physician, while another registered nurse joins them towards the end. More familiar with the collaboration and atmosphere between the physician and caring staff in
During physician visits in
As such, the positioning of caring staff in
In conclusion, two particularly important features of the broader concepts of continuity – family and physician interaction - can simultaneously illustrate how an institutional practice affects the everyday life of nursing homes and how it can generate variation for specific decisions of hospitalizations. Even though caring staff in nursing homes share a fundamental uncertainty that functions as a premise for an institutional practice, they do not share the specific traits or forms of it. The need to develop regimes of practice are universal for caring staff, while the specific forms these take are unique and shared locally. The result is different practices of hospitalization between nursing homes and even units within a nursing home.
Following the argumentation, practices of hospitalizations are, as an integrated part of the institutional practice, a) shared, b) local and c) discretionary. Furthermore, practices of hospitalizations can vary between (and sometimes within) institutions. That is not to say that practices of hospitalizations are coincidental, or that the development of sets of practices of hospitalizations appears from a vacuum, independently from the micro and macro context of the nursing homes. Rather, I will argue that sets of practices of hospitalizations are conditional, in the sense that they do relate to a wide range of structural mechanisms, of various importance in time and space, and generally non-determinant in effect. The analysis has shown that we do need to look at each individual nursing home, in depth, and not simply at their formal characteristics. By the sheer virtue of being nursing homes, the institutions are inexplicably influenced by a structural framework and institutional conditions to which they must adhere. These structuring mechanisms do not, however,
Where does this conclusion leave us? First and foremost, generalizations of nursing homes’ practices based on formal characteristics must be avoided. There is no typical nursing home with high rates of hospitalization, or a typical nursing home with low rates, at least within the sample of nursing homes in this study. In other words, and returning to the sample, there are no defining characteristics shared within the two respective samples that would explain why they hospitalize more or less than the average nursing home; there is no clear and obvious connection between shared characteristics of the two respective samples and our defined outcome, rates of hospitalization.
As such, we cannot isolate what makes a nursing home hospitalize more or less than others,
Again: where does that leave us? Can we, instead, isolate traits or qualities of nursing homes more ideal for practices of hospitalization than others? I believe we can speak, at least, of
Continuity, as an
Continuity, I believe, is a prerequisite for dealing more or less soundly with ambiguous decisions that are typical for instances where hospitalizations are considered. Continuity, then, in its many forms, can be seen as an ideal, often underappreciated by decision-makers and researchers alike. The significance of continuity should not, though, be understood simply as dependent on length of tenure, but rather as connected to the stability of staff/resident interaction on several interrelated levels. Staff should know (and should be allowed to know) their residents, while residents should have familiar and knowledgeable staff members tending to them.
As for traits of nursing homes, isolating «correct» practices of hospitalizations are problematic. As previously discussed, high (or low) rates of hospitalization,
Alice was never one to make a huge impression on those around her. Her small physical frame and the fact that she would usually sit in a faraway corner of the large common room, almost as if hiding, mirrored that of her presence in the unit in general. She did not interact much with other residents, she did not ask much of the staff - she did not make much of a fuss. Alice has lost most of her hearing, some of her sight, and is generally physically frail, hardly able to walk on her own. However, she appears to have a clear mind, giving coherent responses when asked, although seldom raising issues herself. My impression of her is of someone who struggles with her loss of hearing, leading both to anxiety and modesty, further reinforcing an already introvert demeanor. The staff, in my opinion, seemed to have developed a liking for her, but at the same time did not spend a lot of time with her, perhaps because they could afford not to, perhaps they felt Alice did not want them to. For the caring staff, Alice was «easy to care for», both in the sense of not needing or demanding much care and attention and in the sense of being «easy to read»; the caring staff seemed to have figured out what and when Alice needed assistance. When seen or heard outside her seat in the common room, Alice was usually on her way to or from the toilet, either alone, cautiously walking with her walking frame, or together with a staff member. I too did not spend much time with Alice; she seemed to blend in with her surroundings while my attention was drawn towards other, more «visible» residents. In the latter part of my fieldwork, I wanted to remedy my lack of attention towards her. I had talked to her before, or rather exchanged pleasantries that seldom developed into more. When approaching Alice, I, as I have seen some of the caring staff do, crouched down close to her, to get onto her «level». Talking loudly, a conversation of sort transpired. Her story, mostly a monologue as a consequence of lack of hearing, was a sad one: she said that she realized she was getting old, and did not have much time left. Still, she said, she was glad for each day. Her biggest regret was not having a close relationship with her family. Alice said with a slight tremor in her voice: The next time I approached Alice, shortly after the above conversation, she was noticeably more welcoming towards me. She smiled on my approach, and, as opposed to before, took the initiative of starting a conversation: During the next couple of weeks, I got the impression of Alice becoming increasingly uneasy. She did not seem at ease when seated, as she usually did, and, perhaps more strikingly, rose and walked aimlessly around many times every day, obviously discomforted. Her walks to the toilet, though frequent before, became an hourly event, to the point of being viewed by some staff members as compulsive. These frequently and sudden walks to the toilet became a concern for many caring staff members, as they were afraid that Alice would fall. As discussed in several report meetings, the caring staff paid close attention to Alice in this period, at least when they could. One evening in particular displayed Alice´s growing anxiety and the staff’s attempts to calm her. Alice said that she expected a visitor later that evening, before continuing, visibly stressed and shaken up: Two days later, Alice´s mood and behavior were still uneasy, still displaying apparent anxiety. After seeing her like this and talking to her, struck by the remarkable similarity to two days before, I asked the assisting nurse who had calmed Alice, what had happened regarding the visit. She explained, while not concealing her displeasure, that the daughter had not arrived at all. Alice had
Emergency department.
On fieldwork in the nursing homes from our international sample, researchers worked in pairs.
This general point has been illustrated both by the mentioned analysis of marriage practices in Kabyle and in Bourdieu’s criticism of Marcell Mauss´ interpretation of «the gift». The reciprocity of the gift-exchange, argues Bourdieu, is presented as adhering to rigid models:
Described elsewhere as
Referring to the visitation of residents.
Referring to family members.
Referring to palliative treatment.