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Institutionalized elderly: design, community, and management effects on life quality

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Institutionalized elderly: design, community, and management effects on life quality

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Content INSTITUTIONALIZED ELDERLY; DESIGN, COMMUNITY, AND MANAGEMENT EFFECTS ON LIFE QUALITY by Robin Wallace Conerly A Thesis Presented to the SCHOOL OF URBAN AND REGIONAL PLANNING AND THE LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degrees MASTER OF PLANNING AND MASTER OF SCIENCE IN GERONTOLOGY August 1977 UMI Number: EP67032 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. O isse fta lio n UMI EP67032 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 4 8 1 0 6 - 1346 U NîVEJ^nV Of SOUTHERN CALIFORNIA LEONARV VAl/IS SCHOOL Of GERQNTOLOGV UNIl/ERSiry PARK LOS ANGELES, CALIFORNIA 90007 Tfbià u}^uXt2,n by Robin Wallace Conerly undeA the, dVizctoA. f i er T h eJ> 'i& ComïrUttzz, and app/iov2,d by a i t IXâ mmboA^, fio6 been pn.e- ^dntdd to and ac.a2.ptdd by tk d Vdan a i Tkd LdonoJid Vavtà Sakoot o {^ G2A0 lito teg y, tn poAttaZ ijal^ttùndnt 0 ^ tk d KdquÂAdmdnt^ {^ o n . ik d degree 0^ TS tOm ^ T T E E ACKNOWLEDGMENTS My special thanks goes to my two committee members and friends, Victor Regnier and Dan Fritz, for their many | hours of help and encouragement in this project. Addi- I tionally, without tireless effort by Eleanor Hudson in the i I typing and organization of this manuscript, it never would ! have come to fruition. For her reliability, patience, and ! support, I am grateful. I Lastly, many thanks go to my husband, Jim, for sharing' his many creative ideas with me and for keeping my spirits up during those late nights and early morning hours. ' TABLE OF CONTENTS ACKNOWLEDGMENTS ................. XX LIST OF DRAWINGS V INTRODUCTION.......... . , . 1 CHAPTER I PHYSICAL DESIGN IMPACT ON LIFE QUALITY.. 6 Intent and Organization ............. 6 Aging Needs and Their Relationship to The Design Process ............. 8 Design Principles ................... 15 Recommendations and Conclusions . . . 41 II COMMUNITY IMPACT ON LIFE QUALITY .... 44 Intent and Organization .......... .44 Impact of the Nursing Home on the Community 4 6 The Impact of the Community on the Nursing H o m e .................. 55 Summary 6 3 III MANAGEMENT IMPACT ON LIFE QUALITY . . . 66 Intent and Organization ............. 66 Financial Considerations .......... 70 Staff Development: Hiring Practices. 74 Safety................. 82 F o o d ................................. 82 Privacy................. 84 Program Development . . . .85 Staff Attitude Towards Residents . . 86 Resident Independence ............... 88 Problems.............................90 Criteria and Strategy ............... 91 The Multi-Dimensional Care Plan . . . 94 Community Interaction ............... 95 CONCLUSIONS AND RECOMMENDATIONS 9 8 The Planning Process 9 9 A New Focus..................... . .101 Recommendations for Future Research .103 BIBLIOGRAPHY.....................................105 XXX LIST OF DRAWINGS n DRAWING A B C D E F G H I J K The Neighborhood/Development Contact Zone ............... The Indoor/Outdoor Contact Zone . Sun Orientation ................. Responding to Vegetation and Topography ................. Plant Materials Set Against Window Elevator Lobby and Corridor Views Views to the Outside . ^ . , , , , Undesirable Configuration ^ , , Desirable Configuration , , , , "Back Yard" Security , , . , , , The Concept of Scale . , , , , ^ , 20 22 2 5 27 32 33 37 39 40 50 5 4 iyj INTRODUCTION | The phrase "Quality of Life" is an evasive one and is , often equated with the equally evasive concept of "well- ' being." Angus Campbell in his book The Quality of American; Life describes what he feels to be the American concept of | "well-being." ...'well-being* seems to take for ' granted the basic essentials of life j -- adequate food, housing, and other ; material goods — and places its em phasis on less tangible values — a sense of achievement in one's work, an appreciation of beauty in nature and the arts, a feeling of identifica tion with one's community, a sense of fulfillment of one's potential. It : is no longer enough... to aspire to material wealth; the experience of | life must be stimulating, rewarding i and secure. (Campbell, 1976, p. 1) An individual's evaluation of his own quality of life and well-being is thus influenced by a myriad of factors some of which include his racial or ethnic heritage, his resi- ; dential environment, his work experience, or in the case i of an elderly person, his retirement, experience, his I marriage, family life and friendship patterns, and his per- i i I 1 sonal resources and personal competence. I The elderly person residing in a long-term care insti-j tution is often deprived of many of the components which Campbell describes and which the individual himself may consider necessary for a positive life experience. The institutionalized person often has a chronic health problem; which diminishes his sense of personal competence. He is | I no longer able to derive a sense of worth from employment | because he can no longer work. His institutional environ- j ment may lack the privacy and personalization he is accus- j tomed to having and his circle of close, personal relation-j ships is diminishing. Traditionally, nursing care institutions have neg lected dealing with all but the health needs of their resi dents resulting in a negative perception of nursing homes by the great majority of older people. The phrase is often heard "I'll do away with myself before I let them put me in one of those places." Sheldon S. Tobin in Understanding the Elderly says. Lack of hope is probably related to ! the attitude that a nursing or re- ! tirement home is a place to die. ' Entering a home when one is old and had many physical ailments can readily evoke this attitude. Also, by the age at which most people apply for admis sion they have often lost spouse, friends, and oftentimes children. (Tobin, 19 76, p. 4) It is the contention of this paper that there are many factors which affect the quality of life experienced by | residents of a long-term care or nursing care institution, j Those factors which are felt to have the greatest impact upon life quality include : ; ° Physical Design ° Community Supports and Interaction ^ o Management j The chapter devoted to Physical Design relates aging needs to the design process and discusses several basic j design principles which take into account some of the I limitations of the institutionalized person. Optimal site design and exterior and interior design options are pre- ! sented. Recommendations are included. The basic premise upon which design criteria should be based is that the sensitive designer/planner needs to create a place where older people are treated through their, environment as well as through nursing care and rehabilita-' tion therapy. In order to accomplish this level of sensi tive design, the designer must be willing to ask himself how the physical structure he has created will impinge on | I the physiological, psychological and social well-being of the older people who consider the facility as their home. j I The second major chapter of this paper is entitled Community Impact on Life Quality. This chapter contends that the community, including its physical, social, polit ical, bureaucratic and ideological structures will have a strong impact on the quality of life experienced by its citizens residing in nursing homes. This chapter advocates| the acceptance of a "continuum of care" philosophy by planners and argues that community involvement in this continuum is crucial in making the nursing home more ac ceptable for those who have need of its services. It is essential that all available services be integrated into a total system in which, once admitted, the individual can more readily adapt to a more or less intensive degree of care as his personal requirements change. (Pima County Plan, 1975, p. 8) Chapter III, entitled Management Impact on Life Qual ity hypothesizes that the quality of resident life satis faction is directly related to the management supervisory and staffing policies of the nursing facility. Included are discussions of such issues as financial considerations, admissions policies, staff hiring and training policies, and program planning. Additional considerations including safety, food, and privacy and medication policies, are tied directly to management philosophy. A model for planning responsive nursing care facili ties is presented in the Conclusions and Recommendations chapter, in addition to comments on implications for the practicing long-term care administrators, the designer and/ or planner and the community health care professional. Recommendations for future research are included. CHAPTER I PHYSICAL DESIGN IMPACT ON LIFE QUALITY Perhaps we should think of a nursing home as not just a building but as a place of total human existence, a nursing home is a place where persons, not from choice but due to physical illness or age, spend all their time whether in the morning, at lunch, afternoon, evenings, weekdays, week ends, or holidays. A nursing home should provide, therefore, more than is found in our everyday home. It should provide in addition the street, the ter race, the park, the town; in fact, it is the place of the total human existence for the patient. The color of the wall, the shape of the rooms where they spend so much time, all of these seem to be of greater importance to the patients than they are to us in our daily lives. If we don't like our environment, we can get up and paint our own wall; if we don't like our room, providing we own our own house, we can change the shape of the room. But the patient cannot. From The New Nursing Home, 1973, p. 13 Intent and Organization Traditionally, Americans have viewed entrance into a nursing home with foreboding. When one conjures up a pic ture of a nursing home environment the words sterile, noisy, smelly, non-private, and perhaps lonely quickly leap to mind. More often then not, nursing homes are identified' as "halfway houses" between society as the non-institution- alized know it and the cemetery. It is the position of this paper that entrance into a nursing home need not be construed negatively by the prospective elderly resident or by his family. ! Students and practitioners of gerontology agree that | several elements impact on the quality of life a person j will experience in a nursing care facility. Some of the ! more important elements include; management, quality of employees, family participation in care and treatment, physical design of the facility, and design (or lack of de sign) of the overall health care system of which the nurs ing home is a part. This chapter will deal primarily with the latter two design elements and will stress the role of facility design as it impacts the quality of patient life satisfaction. i This chapter will be divided into three basic units : o Aging Needs and Their Relationships to the Design Process. | o Design Principles. j o Recommendations and Conclusions. I Aging Needs and Their Relationship to ■ The Design Process i Basic human needs are not changed by entrance into a j nursing home. Institutionalized people, like non-institu- j tionalized people have physical needs, those needs which involve using the environment to sustain acceptable phys- | ical health and comfort levels, and perceptual needs, or i those needs which involve the person's ability to process * information about the environment and other people in it. ! As people age, however, they may experience health degener-' ation including sensory loss and personal loss in terms of ' relationship termination (death of spouse, friends, rela tives) . (See Age-Loss Continuum) Many of the physical losses an older person experi- ^ ences are not dibilitating because they are gradual and be cause the human mind has a remarkable ability to compensate for losses in physical function. However, increasing loss tends to make successful navigation of and/or use of the ' environment more uncertain. For 5 percent of the elderly people in the United States, physical decay and loss reaches the point where they require extensive personal care and help in coping with even a limited life space. It is at this point that the nursing home steps in. Glenn H. Beyer in Housing the Aged in Western Coun- | I tries (1967), provides a simple overview of elderly patients in nursing homes : 8 The Age-Loss Continuum *Losses : AGE 30 40 50 60 70 80 90 Separation of children * Death of peers * Loss of spouse * Motor output deterioration * Sensory acuity losses * Age related health problems * Reduced physical mobility * *The losses for each specific individual, of course, would not happen as precisely indicated for each age category. This is an abstraction used for analytical purposes only. Source : L. Pastaian, "Privacy as an Expression of Human Territoriality." In L. Pastaian and D. Parson (Eds.), Spatial Behavior of Older People. Ann Arbor; The University of Michigan Press, p. 98. Used with permission of the author. It is characteristic of elderly patients that: I 1. They often suffer from more than j one kind of illness (multiple j pathology). 2. They often suffer from types of j illnesses that are normally found ! among elderly people only (for , example, paralytic stroke, 1 arteriosclerosis, arthritis and j senile dementia). 3. They often need a longer period I of recovery, even when suffering from types of illnesses not un- j common among other age groups. ' 4. They run the risk of increasing j incapacity when confined to bed | for longer periods. 5. They may have emotional problems j typical of old age. Because of these characteristics, ; elderly patients need types of treat- ; ment and care somewhat different from those needed by younger people and this influences the architectural pro gram and the design of the needed ac commodations. (p. 159) Few patients will be found who stay in bed the whole day. When residents are up it is important that the en vironment they find themselves in be a stimulating one. Sensitive design is an effective method of producing the desired stimulating environment. Environmental changes are relatively easy to achieve and are capable of I at least providing the sick person with some measure of comfort, some reassurance and relief from boredom. (The New Nursing Home, 1973, p. 15 ) i For general planning purposes, ! 10 J The physical surroundings should enhance the resident orientation i and increase a person's ability I to negotiate his environment be- j cause; | °Environmental competence and satisfaction are closely re lated . off people become easily con fused by the setting around them they will likely avoid ! these areas reducing the utilization and enjoyment | of the total facility. i «Not knowing where you are can i be extremely stressful. | (Gelwicks, 1974, pp. 113-114 ) Additionally, I The design, layout and architect- ! ural details of furnishing and j equipment, particularly in the j room should be planned to reduce hazards and induce a feeling of j competence on behalf of the resi dent because : oIndividuals in many ways monitor their competence by how well they perform in the environment around them. oSelf-esteem and well-being are closely related to environmental competence. °A partial feeling of independence can be maintained. (Gelwicks, 1974, pp. 113-114) Sensitive design can bolster an institutionalized per son's failing senses in numerous ways. First, it must en able the older person to "make sense" out of the place he ; I finds himself in, to recognize where he is and to relate to | I people he knows. Secondly, a nursing home should offer the potential for growth and exploration, though traditionally. 11 nursing homes have rarely done this. Design can enhance . possibilities for exploration through the use of a variety I i of physical forms, shapes, textures, and colors. Put more | simply, design should make the environment interesting, Itj should be remembered, however, that overstimulation can be-j come a burden for the semi-ambulatory patient. Brightly colored walls and surfaces may be desirable in the more public areas of the institution for orientation purposes but, they would become extremely tiresome for a person in ! a wheelchair who may be sitting in the same place for I several hours. Thirdly, it is important that institution- | alized people retain the right to make some choices about I their environment. Provision of different types of spaces i and space uses, plus the opportunity to be creative with one's personal space, small as it may be, enables the resi dent to maintain and display his individuality. ...if the potential for exploration ' is allowed to dwindle, the motivation 1 to relate to the physical environment and to other people begins to be less and less. This results in a common problem among the elderly, that of disengagement from the mainstream of life. By making sure that places make sense, offer potential for exploration (attractions), and permit role choices for users, designers can begin to create physical environments that are | responsive to human needs. (Isaac i Green, 1974, p. 49) I Not all areas in the building complex should be designed I with equal levels of supportiveness. For example, certain ..... i d common sitting areas should be located adjacent to the ! nursing station for those residents requiring or desiring : I the security of continuous nursing support. Other areas may be more private in nature for residents whose physical and psychological condition allows them a higher level of competence. There are two basic types of persons in nursing homes: 1. Ambulatory - walking unassisted, using crutches, walkers or canes. I 2. Semi-ambulatory - using a wheelchair. i Few patients are totally bedridden. Most basic in the de- | sign of a nursing home is the need to provide wheelchair j users and other handicapped persons with access and ease of ^ t movement within the facility both through exterior and common spaces (outdoor area, corridors, meal rooms, etc.) and through more private spaces (rooms) and to make pos sible the patient's use of equipment and all conveniences to allow him participation in the activities of his choice.! I Designers should be cognizant that the environment as experienced from a wheelchair is total different from that ’ experienced by a walking person. Traditionally, the design| of nursing homes has revealed a complete lack of sensitiv- ' ity to the handicaps of elderly people. This lack of sensi-| tivity clearly reduces the chances for navigation of the ' environment, thus condemning many elderly institutionalized 13 people to boring existences from which they will eventually withdraw. Additional needs and design provisions include: oMeaningful contact with family and friends — this can be accomplished through the pro vision of relatively private spaces for con versation, meals and activity. There should also be provision for guests to enter into the activities of the nursing home. °To feel a part of the larger community — the site for the home should not be in an isolated area where contact with the com munity would be further minimized. Com munity rooms should be provided which would be available for "outside" meetings. oTo feel that progress can be made, that some type of recovery is possible — the designer can increase opportunities for rehabilitation by designing varied rehabil itation facilities into the building and by providing recreational facilities which encourage independent action. oTo maintain some contact with the natural and urban scene even if it is only visual — all patients should have visual access ! 14 to a stimulating view. Landscapes should be planned to provide a seasonal change of color. Provision of a court yard with indoor and outdoor sitting areas is one way to maximize contact with the "outside." In conclusion: Next to costs, appearance and utility seem to be the prime considerations in the minds of many architects, admini strators and others who are respons ible for planning a new building. It appears that planners rarely have available studies of what patients would recommend in the construction of new facilities. Therefore, it is not surprising to go into a nursing home and find lobbies that exhibit beautiful furniture and fine wood paneling, while the patients * rooms lack convenience items and environmental necessities, such as clocks, calendars, pictures, and simply areas to paste up personal belongings. I put corkboard in the room at home where I do some work. Pretty soon I had to expand the cork board to cover the whole wall because we had so many personal items sticking on the wall. Yet I have gone into nursing homes and seen a resident's entire collection of personal items in a drawer. (The New Nursing Home, 197 3, p. 12) Design Principles As has been illustrated in the foregoing paragraphs, the physical design of nursing home has important ramifi cations for those residing (and working) in those homes. n I 15 This chapter is concerned with the physical design of the residential/health care buildings and their settings. Let's take a critical look at the physical environment that appears in some of our newly constructed nursing homes. Enthusiastic re marks are heard as visitors admire the beautiful lobbies and lounges. The staff members are gratified by the progress that has been made by specialized architects in construct ing nursing homes that are more functional. However, there appears to have been inadequate analysis of what things might give the patients the greatest comfort; what provisions might be made to relieve monotony and afford them a maximum amount of social life. (The New Nursing Home, 19 73, p. 12) Before the designer/planner can begin he must spell out the nature of a desirable product for the patient. Performance characteristics for each element of the project (i.e., the rooms, the corridors, the bathrooms, the activ ity rooms, etc.) which is required by the users (patients) must be examined emphasizing the limitations of the insti tutionalized person. The process then begins with the formulation of an effective site selection (criteria for site selection presented in a later section) and proceeds with the aggregation of dwelling units or rooms into re sponsive building configurations. The need of the long-term geriatric patient, in many ways, differs basically from those of the acutely ill patients in general hospitals. Typical considerations to 16 be taken into account when designing for long-term care patients are detailed by Glenn Beyer: 1. The duration of stay is quite different from that in a hospital or acute illness ranging from sixty days to many years. 2. Long-term geriatric patients often need considerable stimulation towards rehab ilitation. In other words, the aged sometimes have to be forced to get better in spite of themselves. With elderly patients incapacity does not disappear automatically as it is usually the case with younger patients recovering from an acute illness. Long-term and geriatric patients need ample opportunities to re learn the simple activities of daily living in order to be restored to a more independent way of living. 3. Supervision poses quite different problems in a geriatric ward -- with most patients out of bed during the day — as compared with a unit for acute patients where most of them stay in bed. 4. Nursing efficiency is of paramount importance in geriatric units. However, the ways to 17 achieve this goal, and the layouts most suitable to that end must be different than the layouts in an acute care hospital to serve the elderly patients' needs. It is not an easy task to translate the needs and re- I quitements of institutionalized persons into an architec- j tural program because often these needs can be contradic tory. For instance, the need for nursing efficiency may be in direct opposition to the privacy needs of long-term I patients. Or prolonged periods of stay as indicated in | point may lead to the conclusion that the patients' rooms should be pleasant and individualized. However, if j patients have to be forced into a rehabilitation program, it might not be wise to concentrate the design effort in rehabilitation facilities. Institutions can easily foster a dependence which is not warranted by the degenerative illness. Isaac Green (1974) offers designers a model for the i organization of activity patterns in elderly housing. Much of this information is useful in the planning of long term care institutions. Green organizes any project into ' five site and building zones which give comprehensive in- I sight into the total functioning capacity of a nursing ! home. These five zones include (from least to most pri vate) : I I 18 1. The Neighborhood/Development Contact Zone -- This is essentially the front yard of the nursing home. It provides the interface between the home and the surrounding neighborhood. Often rooms which overlook the entrance provide their residents with necessary visual contact with the "outside world." It would be possible to maximize the number of rooms with an "entrance" view by placing the entrance within a U-shaped building. (See Drawing A) 2. The Outdoor Common Area -- This is the backyard of the unit in which planned outdoor space is made available for the activities of patients. This zone should be designed to be more private than the "front yard." Areas in this zone should be planned for outside use, including physical therapy programs, by relatively feeble people. Places for specialized rehabilitation equip ment should be provided. 3. The Indoor/Outdoor Contact Zone — This zone is the interface between the exterior _19j C L ) § C s l -P ü f d -P O o -p ü 6 tn ç u C O -H <H P ( ü Q Q \ T3 O P O S en * H 0 Î3 0 £! 5 - 1 0 0 ü ü f i f i f d f d P p -P P> fi f i H H 0 f i > •H •H f d P S Q -P 0 0 P -P W C •P •H 12 -P 0 0 P -P 20 environment and the interior of the building of the nursing home. (See Drawing B) 4. The Indoor Communal Activities Zone -- This is the most public zone of the interior. Several kinds of activi ties typically occur here, including admissions, visiting, miscellaneous activities which occur in conjunction with the public, and resident communal activity. This is also a transition zone between the exterior zones and the more private residential/medical care areas and should be identifiably separate from the private spaces. This zone should feel safe and dependable from the outside. Care must be taken, however, so that those who do not wish to engage in group activity within this zone are not forced to do so nor does the space within this zone become the "property" of one person or group. 5. The Residential/Medical Care Zone — This is home base for the residents. Certain groupings of rooms may, in fact. 21 pq fi •p § P Q 0 f i O I S J -P ü f d -P f i O o u o o -p f i o u o o f i 0 Xi EH w 0 § [ S 3 m o g •p -p f d N -p f i f d u o f d u •p -p P > f d ü •p e u & 22 become miniature neighborhoods. The rooms and hallways should be of suffi ciently limited scale so that the majority of residents can relate to them and utilize them in comfort and security. Each room should be easily identifiable by its own resident(s). While the identification of these zones is useful to the planner for primary design purposes, this analysis will| concentrate on three "zones" or sections of the nursing I home environment, all of which flow into and interrelate I with each other. These include: I o The site ® The building ® The room The Site: The site a designer chooses will influence , I building form and type and thus will ultimately influence the quality of life a resident experiences. When choosing a site, a designer must be cognizant of several determin- I ants including: o Topography and soil ® Vegetative cover o Sewer and Utility system | ® Vehicle access ! I o Local zoning ' 23 o Sun orientation (See Drawing C) o View o Security o Adjacent land use | There are two basic site types, those with external influence and those with internal influence. Each has its own problems and benefits. ; 1. External influence refers to a site where I its context is so strong that its develop- i ment should be in response to external I I pressures and characteristics. Usually | I these types of sites are located in ■ highly developed population dense areas where the designer would want to take great care not to disrupt the urban con tinuity. A plan for this type of site should: ; o Respond to the texture and scale of the neighborhood. | o Maintain and enhance the I streetscape. i o Blend into surrounding I buildings. i o Relate functional components to external counterparts. ! 24 u en f i •H § U Q f i O -H 4-» f d +J § p o fi fi [ / ] 0 1 f i 0 f i O 1 —1 fi O 3 «H fi 0 0 1 0 f d -P ü +J f i m 0 0 43 MH •H 0 0 42 0 -p 0 0 0 0 -P •H -P P 43 P 42 f d 13 0 -P 42 W P> fi en +J 0 0 44 0 42 P fi f d 0 fi 0 O en-P f i O •H f d 0 13 g O 13 ( d f i f i 0 O +j m 0 42 O •H p> 0 g •H •H P> •H 42 o P -p f i1 —1 -P P> -p p 0 g 44 ü o en -p f i 0 f d O 43 < 0 0 f i• i 4 f d 13 f i p> -P -p 0 0 0 f i 13 f d r4 fi O f i ü 0 •H P f i f i a f d•H 0 f d en • f d 0 f d 0 0 -P •H M4 f i f i P 0 1 —! O 43 f d 0 tn a P •H en 0 P f i l 0 -P 0 0 f i O O 1 - 4+J •H P P p f i•H f d A 0 f i -P 0 # O P f d f i P W •H f d 0 0 f d 43 0 o 0 o 3 0 • > ü t 13 r4 P +J 1 —i13 13 0 +j f d 43 en 3 f d 0 42 f i•H g -P f i p 0 0 &13 f d•H 0 0 0 O • •H ü f i p> f i g fi p fi 0 p> fi 13 TJ *H 0 f d 0 0 O f d 0 0 0 1 —1 f d 0 >1-p 1 —143 ü f i •H 0 P P •H 13 -p f d 0 0 P> H p P f d 0 f i w 0 eu g 0 13 P> 13 a ü 13 42 ■H P 0 43 •H fi fi 1 - 4 0 0 0 •H 0 ü 3 -P 0 •H 0 fi f p 0 0 0 fi 13 f i 0 -P 0 O fi a fi f d fi 43 f i•H o •H 44 fi 0 3 43 f i a f i r4 0 E h 0 0 ü > •H 0 •H P> 0 0 f d 0 en ü 25 2. On an undeveloped or Internal Site, it is i the job of the designer not to find the | right fit but rather to create a new j residential care environment. The design ! which he chooses will often set the pat- j tern for future development of the area. ' I 1 On undeveloped land, the building can | be designed to enclose a space providing ; both inward and outward views for resi- I dents. The development of an outdoor common area is often dictated by the site. A small site is often limited to | courtyard or rooftop space while a large site suggests a i park-like organization. The area, no matter what its size, should be perceived as being "safe" by those residents wishing to use it. Additionally, it is often necessary for a staff member to accompany the resident to the out door area. Therefore, it must be conviently located to the staff member's area of operation within the facility. Most of the outdoor areas belonging to a nursing home complex will be "passive" in nature as few rigorous activi- ! ties can be expected to take place in a nursing home en- , vironment. Connecting walkways link outdoor activities and I buildings together. The outdoor areas should not be so | difficult to negotiate that they discourage use but should 26 Q Cn ■S I U Q es O, P O Of g O 4 - > C r > fi -P 43 fi O P, 0 (S -P fi I o I— I > Q ) Q 0 - t i m 0 -P •rH m tn f i •H -P 0 •p S g -r-t +J f d : -P 0 tjt > O ■P tp ■ S 43 fi O eu 0 S " O - 27 be supportive just as the interior zones contain necessary I supports. Lawn areas with shade trees should be available j where space permits. Established patio and game areas j provide variety, stimulation, and give residents contact with the outdoors. Outdoor rehabilitation areas must be , I given adequate space. : Walks should be a minimum of six feet wide so that j two wheelchairs going in opposite direction could easily ’ pass one another. Textured non-slip surfaces are mandatory; both to prevent accidents and to provide a sense of sure- ; footed well-being. There should be no gradients greater ; than 5 percent, steps should be avoided, and drains should ! be located so that water does not sheet across major circu-I i lation paths. Comfort is of prime importance when choosing outdoor furniture. It should be made of a soft material such as wood and should not be lower than a standard chair height, i i Outdoor tables should be designed with the underside of the ' top of the table a minimum of 29" above the ground to allow the arms of a wheelchair to fit underneath. Fixed tables and benches should be avoided as they discourage certain ’ i sized activity groups. The site of a nursing home should have access to physicians' services, medical facilities, and the services I of a fire department. It is also desirable that public I ! 2 8 transportation be available for staff who are employed at the institution and for occasional use by residents. ' The Building. Two basic building types are in use now; as nursing homes. The first of these is the high or medium! rise building. Several advantages are gained by designing | a building of this type. The higher density effectively j reduces land cost and usually facilitates a higher level of service delivery because of the compactness of building ■ configuration. Lastly, high rise buildings are often built in downtown areas offering physical proximity to neighborhoods frequented by older people. ; Low rise buildings, the second type of construction | I are generally perceived as being less institutional in ' nature than are the high rises. This is because they are built on a residential scale. Generally, they offer greater access to the outdoors and are located in less noisy environments found in suburban and rural settings. The choice of one or the other building type for a particular patient should depend on the kind of setting he lived in before institutionalization became necessary. For : an elderly man who had spent much of his life in the farm country, it would be a disorienting and disconcerting ex perience to be uprooted from a quiet way of life and thrust | into the fourth floor of a 12-story high rise in a noisy I polluted and fast-paced city. Conversely, a retired inner- 29 city social worker might experience intense boredom and subsequent withdrawal of interest in life if placed in a small, quiet home out in rural America removed from family relations and friends. The choice of an appropriate facil ity, therefore, must hinge on previous life-styles. Two schools of thought seem to predominate as to what constitutes the optimal size for a nursing home. In Europe, many nursing home administrators advocate designing for the smallest number of beds which would be economically feasible. This small size is felt to contribute to a home-| like atmosphere. It should be remembered though, that in I I large homes opportunities for treatment can be considerably better than in the smaller institutions simply because more income resources are available to large institutions and economics of scale can be maximized in a large operation. Through creative design it should be possible, even in a large high rise building, to retain a home-like atmosphere. It is vital that the space inside the building(s) be legible to residents. Methods of legibility include use of' color and texture to define changes in space and the use of| signs. A signing hierarchy is often recommended by nursing home planners in which the larger, more bold and brightly colored signs define the less private or common spaces and the smaller, more subdued signs give direction to private, individualized rooms. Signs should be made with simple 30 lettering which strongly contrasts with the background it is placed upon. White letters against a dark background create maximum contrast. It is essential that there be good spacing between the letters. It is extremely important to design corridors with care if they are to be utilized by elderly persons with extreme physical handicaps. Therefore, slip-resistant floors, high intensity lighting levels (though not so high as to produce glare) and hand rails on both sides of the corridor are necessary features. An institutional atmos phere in the corridor space can be softened through the use| of color, the provision of outside views and well-designed artificial lighting. (See drawing E) j Perception studies of reactions of people indicate a negative and disoriented emotional response to corridors which are long and narrow, especially when they are made up of repetitive patterns rather than individualized reference I points (such as repetitive identical doors). Ideally, cor- ! I ridor segments should not be more than 75-100 feet in length. If this is impossible, lengthy corridors can be broken up by staggering or by direction changes and by i color, texture and/or reference point variation. Again, ^ I windows not only provide natural light but reference points ; and meeting places as well. (See Drawing F) \ Lou Gelwicks (1974 ) points out that special considéra- i 31 H l T > f i •rH g U P / I § fi S -P W fi •rH en -P 0 w w H f d •p p 0 s -P g iH CM 32 Drawing F Elevator Lobby a^d Corridq# Views m Acoustic Treatment Good Indoor Plant Location Elevator Lobby with a View Out Establishing Connection with the Outdoors uAcoustic Treat ment Moduate light and color Indoor plants Corridor With a View Out and Natural Light Introduced 33J tion should be given to the design of heating, ventilation, and air conditioning systems for the entire nursing couples and particularly the resident's rooms because: o Older people are sensitive to tempera ture fluctuations. , o Patients, especially the most feeble, spend the greater part of the day in their rooms. o Patients' precarious health is safe guarded by providing a stable tempera ture and humidity rate. o In some instances, individual room temperature controls may be advisable as there is a large "comfort range" for nursing home patients as a popula tion, but a small comfort range for individual residents. Most nursing homes in existence today are hospital like in character. They are often built on a traditional "hos pital" plan. The interior consists of relatively sterile wards on long halls with central nursing stations and per haps an admissions lobby. Floor plans of the newer, more responsive nursing homes are usually based on the concept of a nursing unit. This unit may be described as the functional grouping of a 34. number of beds which can be adequately and efficiently ^ cared for by the nursing personnel. Physically, it usually I I consists of a number of patients' rooms with the necessary ; ancillary rooms such as workrooms, closets, etc. The ■ number of beds is between 20 and 45. Several kinds of spaces other than rooms should be provided in a long-term care nursing home including: ® Occupational therapy facilities 4 Physical therapy facilities o T.V. lounges o h dining room with smaller private dining rooms for small parties and guests, ° A snack bar or patients' kitchen o Beauty parlor and barber shop o Hobby rooms and facilities p A small store for personal items and gifts ® A chapel p Multipurpose activity rooms Also needed are a variety of "nooks and crannies” where people in small groups can gather together to converse or simply sit. The Room Let's look closely now. If the patient is non-ambulatory and is confined to a bed, he enters the nursing home with the memory of his past life and with some sense of isolation. The distance that the patient can see, feel or hear 35 has now become his total environment. It is for this human being that the architect must design. The architect should consider such questions as: what is there for the patient to see? Is there a view from the bed or just another wall fifty feet outside his window? Will it be possible for the patient to look out and to observe the | corridor if he wants to? This could ' easily be achieved through the use of interior windows with draperies, in case the patient wanted some privacy. (The New Nursing Home, 1973, p. 13) Planners of new facilities should also try to answer the following global questions: What are the functions of patients' rooms in a unit for geriatric patients? Should these rooms be considered primarily as bedrooms, as patients are staying in other rooms during the day, as for instance, in the rehabilitation room, common room and so forth? Or, will patients stay in their own rooms during a considerable part of the day? Obviously, the design for the latter sit uation will be quite different from that for the former. The answer may vary according to the type of patient. The planner must consider more than the number of square feet of space that a patient will have access to. Not only does amount of space play a part in the patient's conception of his personal space but also important are the dimensions and placement of the doors and windows and the variety of colors and materials used, coupled with the availability of useful furniture. The following example illustrates the importance of door and bed placement: 36 o tp fi ■H § â < D 43 ■H W ■P fi O 0 43 4J O -P 0 ■H > O Q 37 When I was in the hospital for a few weeks and couldn't get out of bed, 1 was always straining my neck to see what was going on in the corridor when someone dropped a bedpan or something; I know that it is nice to see some activity. But the bed was always in such a spot that I couldn't see anything. Maybe this was the staff's way of getting me out of bed, I don't know. But I realized people might appreciate seeing what is happen ing . (The New Nursing Home, 1973, p. 14 ) Wherever possible, patients should be given a choice of the room and/or bed in which they reside (recently it has been felt that private or semi-private two-person rooms will provide patients with the maximum amount of privacy while still retaining economic and nursing efficiency). Certain patients will prefer a bed nearer the door where they can observe activities occurring in the corridor, while others will wish to be closer to a window view. In a high rise one patient's preference may be for a good view of the surrounding cityscape while another would feel more comfortable on the first or second floor. (See drawing G) Configurations of rooms should also be considered in the primary design process. What kinds of room groupings are optimal both from the point of view of the patient and from the point of view of nursing efficiency. Two examples are seen on the following pages. The architect should provide a suitable number of toilet facilities (ratio of 1:4 recommended) so that they 38 C 0 •H 4J (d Î H 0 en œ •H MH tn C : C 0 •r-l U (d 0) u •H Q XI fd •H w (D TS C D •H -M en c • r H f d f d g Î H -p o œ o EH w p 1 O 1 • r H U U o u o -H o u u 1 o 1 ü Q ) en a ü O o N 1 —l U >i ( ü rH Q a ( ü m > -M O • r H c 1 3 < ü rH A fd u •r-l m < u Q -M o Z .39. Drawing I Desirable Configuration Nursing Stations Vertical Circulation Views Out Desirable — Floor sub-divided into reasonable zones 40 will be available to patients close to or in their rooms and throughout the building in areas frequented by patients. It has been said by the more sensitive nursing home administrators that adjacent toilets are the most effective medicine against incontinence. Recommendations and Conclusions As was emphasized in the opening remarks of this paper, basic human needs are not changed by entrance into a nursing home. It is, therefore, vitally important that the physical environment of the nursing home be designed and managed sensitively so that it will relate to the needs of the elderly resident. Though this paper has dealt primary with the design of a nursing home which houses a relatively homogeneous population in terms of dependency/frailty, there are sev eral long-term care establishments in Europe and in the United States which have been incorporated into housing/ health care systems or projects. One such example is called the "Up, Up and Away Model." This is a high rise building which houses independent elderly people on its lower floors while those requiring intermediate care are on I the middle floors and the nursing full-care units are on the upper floors. Once a person gains entry into the system, he| I is able to move throughout the various levels of care as he| needs them. For short-term illness, the nursing care ameni- 41 ties as they are housed in the building can be moved to I him. ' I The design of a nursing home as an annex to an acute < care facility or hospital has also been recommended by \ planners. The reasons for this are numerous. First, the j close proximity of the two facilities makes it easier for doctors and other medical personnel to have access to their patients. Secondly, the knowledge that hospital facilities I I are readily available increases the feeling of security and independence among both patients and staff. Thirdly, some | economies of scale may be gained as certain facilities I (occupational and physical therapy) could be shared between the hospital and the nursing home. Short term dependent living units or mini-nursing homes can actually be designed into congregate housing facilities, perhaps on floors or wings which are separate from the independent sections or areas, but which are read ily accessible to communal facilities. This arrangement has many of the same advantages as the "Up, Up, and Away Model." In summary, let me just think what is the greatest challenge. So many of us, in architecture and elsewhere, are conditioned to equate imagination with luxury and expenditure. It is doubtful that the most expensive solutions de- , serve the recognition of the magazines j in which we would all like to see our i institutions. The real challenge, in | my opinion, to both architect and sponsor, is to make greater use of the imagination. 42 This could result in a quality en vironmental solution. I think it is the duty of not only the archi tects but also the planners and the people in administration to recog nize each other's limitations and constraints. Still, within these limitations, we must tax our imagin ative thinking and work to satisfy the need for quality design and quality environments for the patient. (The New Nursing Home, 1973, p. 14) 43 CHAPTER II j I j COMMUNITY IMPACT ON LIFE QUALITY j I Intent and Organization It is a contention of this paper that the community, including its physical, social, political, bureaucratic and ideological structures will have a strong impact on the quality of life experienced by the residents of its nursing| homes. Conversely, the nursing care institution itself can, have an impact on the community which supports its exist ence. This impact will, in turn, produce a community re action which will impact on the perceived and actual life quality of its residents. This latter point is illustrated I ! by the nursing home administrator who volunteers his facil-| ities for a community meeting. Several people who attend ! j the meeting strike up a conversation with residents of the home during the coffee hours. They decide, as a result, that many residents have talents which could be utilized by the club. The contact is made and a new program is started which has the positive result of increasing the 44 activity and interest levels of those residents who parti cipate. The actions of both the community and the insti- ; ! tution then become intertwined in a spontaneous system of responses producing, hopefully, increased levels of inter- ■ action. 1 This paper is divided into two main sections -- The ! Impact of the Nursing Home on the Community and conversely , The Impact of the Community on the Nursing Home. Further, ' both sections will include discussions of physical and social impacts. As the discussion in the previous para graph indicates, many impact reinforce and stimulate each other. ' The long-term care institution or nursing home is i usually defined as a protected environment which is pro vided to enhance the health, safety and welfare of persons who are in a non-acute phase of illness or who possess a handicap requiring relatively constant care. Typically, nursing care institutions evolve in response to community need. The response to this need may be expressed in the form of enlargement of public sector nursing home facili ties, or may be an entreprenurial response to perceived market opportunities. The key point is that it is the community which first impacts upon long-term care institu- | I tions by producing the demand for them. i 45 Impact of the Nursing Home on the Community ' I Physical Impact. Winston Churchill once said, "We j I shape our buildings and afterwards our buildings shape us."I (1976, p. 1). It is certainly true that the physical de- ! sign of a nursing home and its site influences the inter- j actions of the residents in that home and the interactions | which occur between the surrounding community and the home.j Several of the influencing elements include size, shape and| openness of site, landscaping features, exterior structural! design and interior design of the building itself. , The Concept of Scale: Issac Green (1974), in his Model for the Organization of Activity Patterns in Housing Elderly Persons, designates the "Front Yard" or most public| portion of the complex as "The Neighborhood Development Contact Zone." It is an area which provides the interface and gives community residents their initial impression of the home. Numerous physical elements combine to give this ; first or exterior-oriented impression. Two of the most ' important are : o The scale of the structure, and ° Physical barriers to access the structure. I The term "scale" refers to the perceived size or bulk of a building in relation to other human experiences or per-4 ceptions. Often the term "human scale" is applied to a j I structure which seems to invite human use. _46j Another aspect of scale is the 'human ness' of a building complex. 'Human ness' is linked to one's comprehension and understanding of the building's parts. It is not purely a function of size. Although two buildings are the same size, one may be perceived as having a 'human scale' while the other may be perceived as intimidating, fore boding and inhuman. The difference is the number and quality of visual clues provided to help a person understand the building. A defined sense of entry; variations in building masses, windows; doorways and balconies; and uses of material, color and texture all play a role in defining the scale of the building. (John McRae, 1975, p. 98) This concept of "human scale" is directly related to the term "institutional." Nursing homes, like prisons, schools, hospitals and government buildings, have tradi tionally been labeled as institutions because they are not designed at a human or residential scale. The exterior of a building can give the impression that the interior is uncomfortable, boring and noisy, in a word, inhuman. A community will not relate to institutional architectures in a positive way and may see the nursing home as a place to avoid. The impact of the "institutional look" then is a negative one which creates an initial barrier to inter action between the home and the surrounding neighborhood. Scale is inextricable from the concept of "fit." Does the building or complex of building complement the adjacent land use? Has the building been designed to mesh with the 47 urban fabric of which it is a part? Design literature, which deals with elderly housing (including nursing home design) constantly admonishes the planner not to build a twenty story high rise in a neighborhood of single family dwellings or low rise apartments because this type of structure will obviously not "fit" in the neighborhood scale. A structure which does not fit into its setting often generates anger and antagonism from those living or working in the surrounding area, thus creating an initial physical barrier to communication between those on the "inside" and those on the "outside." Design Criteria; It is quite possible to design a nursing home with non-institutional look if some of the following criteria guide the design process. The building should be designed for people, those who live in it and those who live around it. The neighborhood scale should be a deciding factor in size determination of the structure. Wherever possible strive for continuity in building materials. For example, a steel and glass wall structure would interrupt an older neighborhood that was primarily of a brownstone nature. Rather, it would be better to in corporate some brick and stone work into the more modern facility so that it wouldn't detract from the continuity of the neighborhood and would blend into surrounding 48 buildings. Because the nursing home is, in fact, a resi dence , it is important for the designer/planner to select residential-like building materials such as wood, stone and brick rather than concrete and steel for the exterior and l interior of the structure. Attempt to enrich the already existing landscaping scheme. For example, if the structures to the sides of the proposed nursing home have maintained a 25-foot setback which is planted with grass and trees, the designers should attempt to maintain a similar park atmosphere in their landscaping. In this way the structure placed on the site will seem a comfortable fit with the streetscape. It is important for landscaped open air spaces as well as struc tures to maintain the scale of the neighborhood. (see following page) Barriers and Security: In addition to the problem of scale, external barriers to accessing the facility alJ^o impact on the communities' level of acceptance of the nursing home. Tall hedges or walls surrounding the front of the home are direct physical barriers to interaction. They tend to give the building a cloistered look and warn passers-by that the grounds are not for public enjoyment. Gates and guards add to this impression. It will be argued that hedges and fences are necessary for resident security. But, it is possible to retain security of the residents' 49 en ( / ] e u ( U en ü ( U 0 ) m p m ■p g o p k en g -H I —I -H 0 pq C -H S -P Q ) Q ) U -P 50 recreational and outdoor areas by enclosing them without shutting the community off from the "front yard" of the building. (see Drawing ,J) | Social Impact , As was explained in the introduction to this paper, j i nursing homes exist because the community creates a demand ; I for them. The nursing home then, once it is in place, im- | ! pacts upon the community by providing the facilities and ( I services to care for and hopefully rehabilitate aged and ! handicapped people who cannot live independently and whose j families cannot care for them at home. The services which i are provided and particularly the manner in which they have traditionally been perceived have generally been viewed | negatively. Though more recently a great amount of study and money has been concentrated on upgrading the quality of| long-term care. The American Nursing Home association summed up the general negative perception of nursing care institutions in the following quote: The nursing home profession is a | scapegoat, in part, for our society's unwillingness to face guilt feelings associated with aging and illness. (A Manual on Public Relations, 1974, p. 1) Often the nursing home administration does little or nothing to modify this perceived negative impact. Whether purposively to avoid scrutiny of questionable practices or ^ 51 simply because of ignorance of the benefits of community interaction, nursing homes become sequestered from the i I activity of the community at large. Thus, residents become| extremely isolated from the mainstream of neighborhood life and the community loses their valuable knowledge, talents j and skills. , Management Involvement : In order for the established ' long-term care institution to make a positive impact on the : community, its administrators will probably have to make j the initial vigorous contacts with key community leaders and groups. Several areas of involvement present them selves : a. Management can solicit advice from local political leaders and businessmen on issues such as employment practices, increasing knowledge of the nursing facility, involve ment of nursing home residents in community activities, and involvement of the community in nursing home programs. b. Management could initiate a "Friendly Visitor Program," which could impact the community by educating them about the needs of nursing homes, their residents, and would also provide residents with a "window" out into the community. _ . J 2 J c. The home could inform the community of its purposes and programs through "Open House" programs and lecture series. d. Residents with special talents and/ or expertise could act as consultants for community groups, businesses, or ! individuals who are in need of advice. e. A concerned administrator will insist on a treatment program which involves the resident's family and friends, I I thus impacting portions of the com- i munity by making them responsible in j some way for the welfare of that resi dent . The operationalization of the above suggestions requries a concerned and sensitive nursing home management team. j A nursing home can impact positively on its local i community by plugging itself into the network which con cerns itself with the social welfare of its citizens. The components of this system often include churches, YMCAs and| YWCAs, scouting groups. Red Cross, charitable associations, , etc. By cultivating relationships with these groups, the nursing home can become tuned into local needs and it can ' i develop appropriate responses. For instance, nursing homes i 53 en C •H g u Q Q ) I—I ( Ü ü C / a m o -p s- ü G O U (U g o 0 ^ g 54 J can often provide meeting spaces for community organiza tions or can participate in a hot meals program by utiliz ing its kitchen facilities to prepare food. Health Care System; It is vital that the long-term care institution tie itself into the local health care system so that the system can respond to the needs of the ' nursing home and vice versa. For example, the nursing home may have an excellent rehabilitation facility which j could be utilized by community residents in need of it I I while conversely the home may have need of a fast response j I emergency team in times of acute emergency. Thus, if the j i home initiates a positive response to its activities and facilities within the community, the quality of life its own residents experience may be enhanced by increased con tact with and cooperation from the surrounding community. The Impact of the Community on the Nursing Home Physical Considerations Numerous physical attributes of the community can im- ' ! pact the quality of life experienced by elderly people. ■ Yet it is impossible to assign a value judgment such as "good" or "bad" or "better" or "adequate" which will apply in all situations for all nursing home residents. Each in dividual person's life experience will shape his value ' orientation and thus his positive or negative perception of ! his surroundings. To illustrate, a person who has spent ; 55 his life in an apartment in Chicago or Detroit may not feel! the least bit uncomfortable located in a high-rise nursing home which overlooks a busy street. Conversely, a suburban or rural resident might perceive accommodations in a high- | rise as a lowering of life quality. Location: Nursing institutions have often been con- I structed in suburban or rural areas where it is relatively ' quiet and peaceful and where land costs are relatively low.; It has been asserted that elderly people living in shel tered care situations desire to be located in pastorale settings away from the mainstream of life. The reverse is I actually the case. The majority of elderly people in the i United States today are located in highly urbanized centers^ often within walking distance of the central city core. Most of these older people desire to remain in familiar surroundings "where their roots are." Proximity to rela tives and friends, shopping facilities, and other community services, especially transportation, are highly desirable. If an older person who needs the services a nursing home provides can find a facility in his residential area he will be more likely to retain community ties and friend ships, and thus experience a higher quality of life than he would be if forced to live in a nursing facility remote from his original community. Site Selection Criteria: There are certain types of 56 physical site and community factors, however, which will impact the majority of nursing home residents in the same | way (negatively or positively) though not always to the j same degree. Constant noise, such as that from heavy ! traffic or a children's playground will tend to have a negative effect on life quality. Though there are times when people enjoy the hustle and bustle of street sounds j or the sound of children's voices, nursing heme residents i need to be able to withdraw into quiet privacy when physi- ; cal strength needs rejuvenation. Additionally, heading deficiency often requires a relatively quiet environment I for older people to converse in. Hearing aids tend to i amplify sound indiscriminately so that street noise, if it j is not able to be blocked out, will inhibit conversation. Many nursing home residents spend much of their time sitting in their rooms or in the common rooms and outdoor : areas — and watching the world around them. The view should be interesting and consist of several action com ponents . For many people, especially those who are bed ridden, looking at an unchanging view day after day, whether it be a brick wall or a mountainside, diminishes ; the quality of their nursing home experience, A nursing home located in an industrial or warehousing area will be subject to relatively large amounts of noise and air pollution. Air pollution can be a detrimental 57 health hazard to older people who are often more prone to I respiratory ailments and infections than are younger per sons. Location of a nursing home in areas subject to high air pollution can diminish the quality of life experienced by residents with the above ailments. I The configuration of the site and community terrain | is an important consideration for ambulatory patients who j desire to negotiate the neighborhood. Mild slopes and flat| walkways are preferable to steep slopes without sidewalks. | The approach to the home should not be steep. ! I Once a nursing home resident is outside of the site, ' I it is important that he have somewhere to go or something to do. Otherwise, there is no incentive for him to get out ' ; into the community. Interaction with the neighborhood gives the resident a chance to experience several types of behavioral settings and thus may increase the quality of his life by staving off the boredom one must certainly ex perience when confined to a single setting. The nursing I home planner should ask the question, "Are there places such as parks, recreational centers, theaters and restau- i rants where institutionalized people may go meet non-insti-; tutionalized people?" Often a nursing home resident loses contact with friends and most certainly loses the potential; for making new "outside" friends because these people do I I not want to meet in an institutional atmosphere. It is im-I 58 portant, therefore, that the planner consider possible "neutral" meeting places when he evaluates a nursing home site. , The proximity of health services other than those j offered by the nursing home impacts upon the security ex- j perienced by residents. Residents in homes which are I located near hospitals and professional medical buildings (doctors' offices) often have a better chance that their doctors will visit them more frequently. Doctors are also i more apt to prescribe utilization of other types of medical, I services, such as physical therapy and dentistry, if the j patient can access them (or if they can access the patient) i with relative ease. Proximity to services may be, thus, directly related to quality patient care, and to the feel ings of security patients experience when they receive con- I tinuing care. Social Considerations The level of community involvement with the long-term care institution, including involvement in the initial ! planning stages, impacts the quality of life many residents' experience within a nursing home environment. It is felt that an increase in the intensity and/or comprehensiveness of community/nursing home interaction will often increase the level of nursing home resident life satisfaction. 59 Planning and the Continuum of Care If nursing homes have not been included in either the general or health planning process, the inclusion of these homes into the system will probably involve a greater phil-! osophical change than it will a physical one. The commun ity will need, if it desires to impact more strongly on I nursing homes, to view long-term care as a part of a health care continuum. In this way the institution may be ac cessed for a brief period of time. Institutionalization i should become more acceptable to older people when it is viewed by the community as part of this continuum of health care. When a community resident requires an intense level ’ of care he may enter the home on a short-term basis; when | he assumes a level of independent functioning he can then leave. The simple realization that an institution is not regarded by the community as a "holding pen" for the feeble elderly will alter an institutionalized perception of his future and this may increase the quality of life he per- I ceives himself as experiencing. An equally important impact which a community may have on a long-term care institution hinges on the system of services and supports it can offer. In order for a nursing; home to be rehabilitative, it needs to be able to access a coordinated umbrella of community services. These services j include : 1. A transportation network which is negotiable _______ 6 0 j by relatively feeble people. This may include a dial-a-ride or mini-bus system. 2. Rural services if the home is located in a rural area. 3. Mental health services, including counseling, 4. I & R services. 5. Socialization and nutrition services. 6. Companion services. 7. Health services including acute hospital care. If a person regains enough independence to move from j the nursing home into the general community, additional j services are necessary. These include : I 1. Home maintenance services. 2. Day care. 3. Home health services. 4. Health screening. 5. Podiatry, dental, eye and ear services. 6. Outpatient services. 7. Supportive congregate housing. i i If the community supports the concept of rehabilita tion and provides supportive services and housing arrange- , ments for older people, the continuity of care model will 1 not be viewed either theoretically or actually as a one-way ; street toward institutionalization: A U An aggressive long-term care admini strator can promote a full range of j services through good referral link- ; ages to other agencies. (Gilbert and ; Wing, 1975, p. 15) j Ethnic and Language Consideration ■ In larger metropolitan areas with diverse religious j and ethnic populations, the sensitivity of the community to cultural and language barriers will have a definite j I impact on the quality of life the minority people experi- I I ence within the nursing home. The experience of institu- j tionalization, coupled with a communication or cultural j barrier, severely hampers the formation of a positive life experience. A sensitive community aligned with a willing administrator could, where demand is sufficient, encourage I the provision of long-term care services within a specific language, religious, or cultural context. This may mean the construction of long-term care facilities within a cultural or ethnic minority area, or it could result in the grouping of residents within a home by culture or language.■ I I Aging Network Participation ! The community aging network may impact upon the qual ity of nursing home care if it has amassed enough political and bureucratic strength and if it assures improvement in j quality of institutional care as a goal. In order to have j an impact it will be necessary for the agencies and support groups which make up the network to plug themselves into 62 the long-term care continuum as consumer advocates fot | I nursing home residents. These groups, in the role of in- | formation gatherers, planners and policy makers^ could | collaborate in the matter of nursing home resident advocacy? their goal being to increase the quality of care provided j to the feeble elderly. ' Summary Long-term care institutions evolve in response to a community need. Their placement within the community, both physically and bureaucratically hinges on the willingness of the institution and the community to interact with one another in both the planning stages and the continuing operation of the project. It is felt that three important factors will enhance the life quality of elderly people residing in nursing care institutions. I 1. The degree to which the home is "plugged in" to the community health care system I will determine the number of health care resources open to residents of that home. 2. The degree to which the community adopts a continuum of care philosophy and con siders the nursing home to be a part of j i this continuum (not necessarily an end point) will affect the ability of the nursing home resident to move in and out of the total care environment as his needs dictate. 3. The degree to which residents are able to maintain or obtain community contact with organizations, family and friends will relate to their own concepts of worth, independence, and happiness. Physical factors warrant additional consideration. If: a community has the luxury of planning a new facility or i system of facilities, physical planning takes on added im portance. Communities which already have several long term care facilities would instead be placing much of their planning emphasis on the creation of linkages between the institutions and the health care and social services systems of the community. Long-term planning criteria should reflect the values ; and goals of the local community. These values will vary ! with the area of the country and the cultural background of the people of the community. Traditionally, nursing homes have been relatively closed communities where, ex cept for resident visiting, the community is seldom in vited. More important, therefore, than the provision of spaces for community use (a physical design solution), is | management's acceptance of a community involvement and continuum of care philosophy. This two-way involvement of the community and the long-term care institution can have « numerous positive results which have been detailed in the body of this chapter and which encourages a better quality ! I of life for elderly people residing in nursing homes. , 65 CHAPTER III MANAGEMENT IMPACT ON LIFE QUALITY ; Intent and Organization It is the contention of this chapter that the quality I of patient life satisfaction is directly related to the management and supervisory policies of the nursing facil ity, and that the management will remain the controlling | factor in creating the quality of life experienced by elderly patients housed in an institutionalized setting. While private nursing homes, non-profit homes and re tirement villages can be a better than average living situ-- ation, it is often no mistake to identify many of them as "halfway houses" between society as we know it and the cemetery. "In their shrinking away from the real world, their isolation from the normal pursuits of old people | living at home, many of these sanitariums, rest homes, and ; leisure villages are in reality, pre-funeral homes." ! \ (Garvin & Burger, 1968, p. 11) The extent of isolation in ; home for the aged is phenomenal and must be considered in 66 ' ' ~ 1 response to the quality of life questions this paper is , addressing. j I Nursing care in a home for the aged should be part of a total care system which seeks to help each individual resident maintain optimum health and maximum degrees of f self-sufficiency. Nursing care should give consideration ^ to emotional, social and spiritual, as well as physical | needs and should be integrated with other services avail- | able for the resident's well-being. A quote from How to , Choose a Nursing Home; A Shopping and Rating Guide (1974)i is .appropriate: "Entering a nursing home will require some changes in your pattern of living, but it is important to consider the positive aspects of these changes. Most im- j portant, the nursing home is a protected environment where , you can expect to receive the care your condition requires. You should receive adequate care, retain your dignity, en joy the highest degree of independence possible, retain the respect of others, retain your rights as a citizen, parti cipate as a member of the community, and participate in ^ decisions concerning yourself." (p. 8) These then are the basic necessities which should be present in a home which purports to offer high quality care. In addition, it must be emphasized that security is an important factor in the life of an elderly, chronically ill person. Without security, the institutionalized person I 67 I perceives the quality of his life as being lowered. An in-: stitution can offer security to residents in several ways, ; Elderly people should be reassured that help is always available if and when they need it. The institution should; not try to cut the person away from his previous life and security but rather, should try to link the positive I I aspects of community life with life in the institution by ^ allowing the patient personal possessions, religious prac- | tices, and visitors. The institution should aid the resi dent to form a comfortable habit pattern for daily living. Additionally, as explained in Chapter I, the atmosphere of the home should be warm, comfortable, and attempt to re- 1 duce stress and strain by being easily navigable. Freedom : of choice should be allowed and pre-determined program should be avoided or, if not avoidable, they should be flexible. In order to retain his/her dignity, the elderly resident must be treated as an adult, his privacy must be | ! respected and his pride of ownership kept alive. ; In order for residents of an institution to experience an optimal quality of life, the management must be con- , cerned with the needs of the whole patient. The admini- | stration must choose its staff members according to their ability to interact with older people. A professional bond! built between patients and employees is desirable so that | respect on both sides is the order of the day. As few per- 68 sonnel changes as possible should be made in order to mini^| mize patient stress. The members of the administrative j staff itself should attempt to make as much patient contactj as possible, both so that they can effectively evaluate ! their floor staff members and so that they are visible to j patients as being concerned with their well-being. The ' kinds of policies described above are important in main taining a high quality in total patient care in any long term care institution. ! What are the areas in which management can effect the j quality of patient life and how are these areas affected , by management philosophy and policy? The crucial areas which this paper will outline include; financial consider ations (profit and non-profit homes), advertising and ad missions, staff development (including hiring, training, and coordination), safety, food quality/quantity, privacy maintenance, and perhaps most importantly, program planning. In the area of program planning, several considerations are clear. These are, questions of independence/dependence emphasis in establishing policies of care, planning for ! individual care plans, inclusion of the family in care pro grams , inclusion of the community and its resources in the care plan, and appraisal and review of all program plans and care plans. 69 Financial Considerations In discussing the financial aspects of nursing homes as they relate to management and administrative concerns, i it is important to make the reader aware that there are j basically two types of homes in operation, the profit- j making home and the institution which is sponsored by a ' public agency or a non-profit corporation. Both have dif ferent kinds of financial pressures and considerations placed on them. The majority of homes are currently oper- ; ated by profit-making concerns. Under the terms of the ‘ J Kerr-Mills Bill, states can receive matching funds from the Federal Government for the support of the "sick-aged" ; in nursing homes which means that the state, rather than building its own homes can contract out to private homes for care of the poor elderly (those eligible for Medicaid or Medi-Cal). Relatives may be asked to make supplemental ; 1 payments for anything beyond the subsistence level. In , this way, the institution may be paid twice for certain types of services (i.e., meals, recreation, etc.), if the management of a profit-making home cares to indulge in illegal practices. However, a larger problem also exists, j federal funds slotted to be used in the upgrading of condi tions in nursing homes often are halted in state treasuries ^ because states have not set the same funding priorities as ' I the Federal Government does. "When subsidies finally 70 filter down to the homes themselves, they merely add to the] profit of the owners who will continue to operate at mini- j mum expenditure no matter how much money they receive." (Tobin, 1976, p. 2) I The owner of a nursing home is generally assured of a j break-even volume of business because of state and federal | i subsidies for welfare cases. In the better homes where ; costs are high and services more than minimal, welfare \ patients will not be as welcome as privately financed patients. However, in the homes where owners have kept costs and care to a minimum, welfare subsidies can provide ■ owners with a substantial profit. There is nothing in the ! law to indicate how much care a home must provide for the | subsidy it receives. Often the profit motive decides in stead how little, rather than how much, care the home will profide. ! Ownership and management are closely intertwined when the management is responsible to the owner for turning a profit. In a profit-making situation it is thus difficult | i to legally pin down responsibility for daily running of the homes to any one person. "The absentee landlord who creates an even more serious problem is the speculator i i whose only motive is profit and who can hide from the I public eye." (Garvin & Burger, 196 8, p. 37) From the private enterprise point of view, nursing home operation I 71 provided profit to owners often at the expense of mistreat ment and degradation of the elderly patients. Does the profit motive in the care of the aged help them or hurt them? Dr. John Wennberg of Johns Hopkins I University, School of Hygiene and Public Health, feels, | j that"in the profit-making nursing home, there is little I room for innovation. Institutional care of these people j is something about which we have a lot to learn and the freedom for innovation which exists in the non-profit ser- ; vice organizations makes them clearly more flexible." (Nursing Home Care in the United States, 1974-75, p. 21) Unfortunately, the substandard homes are utilized primarily by welfare patients who cannot afford anything better whichj forces us to the conclusion that the state is subsidizing inferior care for the poor aging person. "The American people have been paying for what they think is a free- enterprise system of care for the aged but have been get- | ( ting an inferior sort of socialized medicine. The result is a welfare state not for the benefit of society but for the welfare of the investor." (Garvin & Burger, 196 8, p. 69) I Profit-motivated managers, do not tend to provide the highest qualities of care for their residents, nor do they "waste money" on programs which offer anything but the bare; necessities of survival. Non-profit homes are infinitely I 12] more suited to provide a better quality of life for older ! institutionalized people than are their private counter parts . The basic premise on which the majority of non profit homes are initiated is that of care and concern for | a needy group rather than an opportunity to turn a profit, j This basic premise colors all actions of the management in its attempt to build a total care program for residents. Advertising and Admission The management's philosophy of care begins with its advertising and admissions policies. Often profit-making institutions advertise themselves as oases of loving care where all of the older person's needs will be satisfied. Non-profit institutions, on the other hand, tend not to feel the necessity to use false or misleading advertising to fill up their beds. The emphasis of these advertising programs often tends to be on available programs, type of nursing staff, religious affiliation, etc. Again, how nursing homes are operated and by whom depends on attitudes of administrators. "It is incumbent upon all institutions to see that their policies and practices are carefully formed and meticulously carried out in the interest of the patient." (Tobin, 19 76, p. 38) No institution should admit a patientj whose care requirements cannot be met by the resources of that institution. Institutions should only take the medi- 73 cal responsibilities for which they are properly licensed and feel comfortable with treating. Some administrators have been known to take any older person simply for the money, even when the facility can't handle the problems which the patient manifests, or more often, when the per- I son's condition doesn't warrant institutionalization. An institution should not continue to care for the patient whose condition has improved sufficiently for return to the community or who has deteriorated to the point that he re quires a higher degree of service than the institution can give. Staff Development : Hiring Practices The top administrative staff is deeply involved with setting the philosophy of care which the institution under takes. This philosophy is clearly manifested in the hiring practices the institution employs. Philosophy of care in hiring is evidenced in two major ways, the first being the choice of the kinds of skills the management feels its per sonnel need to have in order to operate an optimal nursing home program. Staff rosters, including such professionals as social workers, physical and occupational therapists, directors and assistant directors of nursing, activity directors, therapists, chaplains, dieticians, etc., often are indicative of the total care philosophy advocated earlier in this paper. Minimal staffs, including few pro 74 fessionals and many aides and housekeepers often indicate j I minimal care programs. Secondly, the number of people ' hired is an indicator of patient care, fewer numbers of staff people usually point to a minimal care program. Wages j A critical problem nursing home administrators deal with is the typically low wage scales for nursing home employees. With these low scales, it is difficult to attract quality people into the institional care field. Rather than encouraging a caring philosophy among their | i employees, low wages are liable to cause bitterness and resentment which is often taken out on the patients. Typically nursing homes cannot compete with hospitals, clinics, and private physicians for quality nurses. As a result, they must take what referral agencies send to them. Often, these people are not skilled in general nursing or care, let alone geriatric nursing. Management has great difficulties hiring skilled personnel even if it is cor rectly motivated because it often cannot pay for well- trained geriatric professional people (that is, assuming it can even find these people ). "Loving care must come from people and from people who are motivated in more than : a normal business relationship. In many non-profit insti tutions, dedicated people serve the needs of the aged as their life calling. But in the great majority of nursing 75j and rest homes, employees are simply earning a wage and a subsistence wage at that. The size of a wage can tell more about what goes on in a nursing home than the size of its advertisement." (Garvin & Burger, 1968, p. 110) Many old . age home operators actually would not prefer to have an j R.N. on their staff. Unscrupulous proprietors would rather not have someone around who might object to indiscriminate use of narcotics. Even among reputable homes there is the ■ unmistakable attitude that good will is more important than medical skill. Nursing homes tend to resist skilled help, ' placing emphasis instead on the "right attitude" rather than necessary administrative and health care skills. Because of lax regulations, the word "nurse" can mean almost anything, R.N., L.P.N., nurse aide, vocational nurse, etc. Additionally, at least one-third of all nurs ing homes in operation claim to have either registered nurses or practical nurses, but often have nurses on duty for only one shift per day leaving unskilled aides to care for patients during the majority of the time. Widespread abuses occur because of loose regulation policies. The administrator who is in the business solely for profit is actually encourage not to hire the more expensive creden- tialed nurses, as this cost takes away from his excess pro fit. Those institutions who actually value nursing skills , as a value will have credentialed members of the profession as integral members of their staffs. 76 : Hiring Criteria Few people are trained in geriatric c^re, therefore, administrators who are truly interested in hiring dedicated employees cannot rely on background training as an indica- tion of future performance. There are several guidelines j administrators can follow in choosing employees other than hiring someone for his or her basic good character. Em ployees should be dependable: dependable employees foster a sense of security in the residents. They must be physi cally able to do hard work. There should be a harmony in personality, social traits and cultural traits with the type of resident population being served (if the population is homogeneous). Employees should be able to handle them selves and their patients well in emergencies. Employers should look for supervisory ability for specific positions. What can concerned employers do to hire people who will uphold their philosophy of total care for the elderly patient? If at all possible, attractive salaries and bene fits should be provided to employees. The status of the position to be filled should be elevated (new title, etc.). Ask present employees to recruit new employees, hopefully they will choose people who have similar motivations. De- ; velop a many-sided system of referrals and sources of pos- ' sible employees (physicians, hospitals, nursing associa tions) . Advertise for applicants. Make the organization 77 worth working for. Make employees proud to work for the home. If nothing else, train new employees in skills that ' will be useful to them and to the institution. Staff Morale ; Not all administrators themselves are capable of deal-j ing with large numbers of chronically ill people with sus tained enthusiasm. This is because it is often difficult to see patient improvement. Also, critically ill patients may have some difficulty in expressing gratification to an : administrator. This lack of gratification can tend to lower an administrator's self-esteem. Administrators them selves should be aware of this tendency and should take it into consideration when evaluating both administrative pro gress and staff progress. If employees are well-trained, know what is expected of them and are properly motivated, only then will they give the resident the quality of care desired by the management. "Perhaps more than all the studies of economics and regulations by welfare agents, there is really needed a change in the motivation of oper ators. If nursing home owners had a real understanding of the problems of the aged, if they knew what it meant to be bedridden and forgetful, helpless to take care of many of the most embarrassing personal needs, easily irritated, prone to violent swings of emotion, yet human all the same, then perhaps they could attract more employees with genuine, qualifications." (Mitchell, 1973, p. 17) - 78j Training j Management, if it desires to raise the quality of lifej for its patients, must provide in-service training in order; to create an acceptance of the desired institutional phil osophy on all levels. All workers, including non-profes sional personnel and volunteers need to be included in the training sessions. A criticism of many institutions that have activity programs is that only administrators and professional level staff are invited to partici pate in in-service training programs. Excluded are the non-professionals, who have the greatest contact with the patients. Most programs, as now set up, are in the traditional pyra mid form, with administration super visory staff, and department heads at the top. This group exchanges material, attends meetings, and shares professional literature. This approach traditionally calls for bringing in an outside expert to lecture. Administra tors usually assume that this informa tion will filter down through the pyra mid to the sub-professional staff. (Winds of Change, 1971, p. 9) The suggestion is then made to schedule meetings which would be attended by staff members who have the greatest contact with, impact on, and understanding of the patients. They work closely with patients and are the actual imple mentors of policy and goals set by the administration. Additionally, their close contact with residents allows them to define the educational, social, and work needs of 79 the patients and communicate this information to the top staff members. Homes should provide a psychologically oriented sem inar-type training program for all staff to help them understand the problems of chronically ill older people and to give them some suggestions for effectively solving or mediating these problems. A project director of just such a training program writes. We never left the facilities ex actly as we found them. Changes which did occur were invariably in the positive direction as far as we could determine, that is, in the direction suggested or in- j dicated by our discussions of i issues. In most cases the changes observed were substantial, had sig nificant impact upon the life of the facility and predicted permanent change. Such changes ranged from increased decision opportunities for residents, greater environmental en- j richment via stimulation and cues, through increased attention to staff needs and sensitivities, to increased use of volunteers and to more time, ; attention, and effective procedures with families and community. Communi- | cation among all staff was consistently j noted as improved and increased by the project. (Schwartz, 1974, p. 51) Staff Coordination and Interaction ; The administrative hierarchy also influences the inter actions of staff and residents. The working relationships between the director and the associate director for example are highly perceived or felt by the residents and staff and -80J their perceptions influence their interpersonal inter actions. The new resident or staff member will usually learn the network of these staff relationships through older residents and staff. Often, the ability of the patients to discern the power hierarchy of the home is based on their ability to be mobile. Ambulatory clientele make it their business to know "who is the boss of who" and know where and when to take their complaints. Patients 1 bedridden or confined to wheelchairs tend to have a much I narrower conception of differences among staff members and j so do not know appropriate directions in which to direct | 1 complaints or compliments. If the institution is truly ' interested in making patients feel secure, it should make patients aware of available channels of communication. , Members of the staff differ in the amount of time they spend on the floor, nurses and nurses' aides spending the most time with the largest amount of patient contact. Housekeeping staff also come into close contact with resi- ' dents because of the nature of their jobs. Often these j people are the first to notice mental or physical deterior ation and can inform proper staff persons if communication ; channels are open through the entire staff hierarchial ! structure. Administration can choose to emphasize or not ! to emphasize communication with patients. If it doesn't, j patients generally revert back to a child-like way of com- | 81 municating in order to get even the simplest tasks per formed. This robs the patient of his own positive adult self-concept and causes considerable annoyance to staff members. An administration which professes to be aware of patient and staff needs will emphasize communication on all levels, management, floor staff, patients, volunteers, etc. Safety Management controls crucial aspects of the patients* lives. One of the most important areas of control is safety, especially fire safety. Nursing home fires were prevalent in the sixties and even today most states still do not require automatic sprinkler systems in nursing in stitutions. Patients are almost totally at the mercy of safety devices which either exist or do not exit (function or do not function), and staff expertise in handling emerg ency situations. Often, neither devices nor expertise ex ists. Costs are cut on safety installation devices and I often attendants are not available should emergencies ‘ arise. Even if personnel are available, it is probable that they lack training in emergency procedures or know- i ledge of building layout. ' Food Food quality is another "controlling mechanism." Often, the quality of food served in nursing home is low and the quantity, minimal. This can be a distinct problem 82 as eating is by far and away the most significant personal activity for aging patients. Food sets the whole psycho logical tone of a person's existence when there is little else to compete with it. Even the visual excitement of a well-prepared and well-served meal can be the highlight of an older person's day when the only other things he sees are walls, bedpans and attendants. In profit-making insti tutions, where good diets are needed most, economic factors I conspire to trim the food budget to the core. This is j I especially true in sub-standard mediocre homes which sub- , sist on state welfare payments. The payment remains the same no matter how good or poor the food is, so the opera- | tor of the home can skimp on good nutrition. No laws exist; dictating standards for quality or quantity of food served in nursing homes. Cheap starchy foods, such as rices, bread, pasta, 1 cereals, etc. are often substituted for needed protein and : vegetable foods, making meals unbalanced, unnutritious, and boring. Additionally, to save on labor costs, con- I venience or prepackaged foods have been used widely which j are often bland and uninteresting. Food can become a powerful weapon in the hands of staff and administration to control uncooperative patients if they wish to use it in| i this manner. , 83 Privacy I Probably the most revealing sight you will encounter in your inspec tion trip is the look of indigna tion, terror, frustration, and j helplessness in the eyes of old men : and women. Out of habitual dis respect and contempt, the nursing j home attendant or operator will forget himself and forget that you, the visitor, are perhaps more aware. ' He will ignore the anguished cries ; of human beings who do not want to be inspected, who do not want their j little privacy invaded whenever the nursing home wishes to have someone I look at them. But the patients have | lost any claim to dignity, any right ! to be treated as something more than | animals in the minds of many opera- ; tors. (Garvin & Burger, 1968, p. 21) This attitude is prevalent in many nursing homes today. Management can make arrangements to respect patient privacy] If it doesn't, it is lowering the quality of life experi enced by residents. The easiest way to break down a patient's self-respect is to make the simple activities of daily life unprivate. Simple courtesy and respect for ; human dignity is imperative. A patient may need other people to assist him in the use of a private space but i these staff members should not assume that they can use the I I space themselves. Entering private spaces without a speci fic helping purpose is an invasion of privacy. It should also be mentioned that the use of human con tact, in other words, the privilege to socialize, can also be a controlling factor of patients' lives. Isolation is a 84 feared state in the minds of most of the elderly. Deprivedj of all human contact for rule violations, many elderly slip; into states of extreme confusion, agitation, or depression.' f I Program Planning ' It is necessary for the administration of an elderly j nursing home to clearly and honestly define its goals in ^ terms of the independence they want the patient to retain. | This is the key to program planning. Programs which have j as their focus the maintenance of independence for the elderly patient will be substantially different from those which emphasize illness and dependence. One of the critical aspects of institutional living is the maximum preservation of each person's life style within a congregate setting. Physical care is not enough; the routines of daily living can be used as powerful therapuetic agents. (Winds of Change, 1971, p. u) Often management assumes that the person entering the home must be ready to give up all outside, roles and become a protected patient. For the patients themselves, however, this is not usually the case. Older people do not readily ' take upon themselves a dependent, sedate status and if forced into such a role they tend to regress and lose their| self-concepts as a living, functioning, worthy person. Un familiar surroundings may cause problems for the senior who : has established routines for dealing with life. The more ^ i similar the institution is to the residents previous livingi conditions, the less will be the degree of disorientation. { Thus, there is a need for a diversity of homes. "Recently, ! a home which was physically dilapidated was described to I me by a colleague. This woman said she was surprised she , j felt so comfortable in the old and somewhat dusty home until she realized that the residents seemed unusually I cheerful. Fortunately, the administrator of this home j screened her new residents very carefully, selecting only ' those who shared her easygoing attitude." (Tobin, 1976, ! p. 16) i Staff Attitude Towards Residents The staff of a home has the difficult task in assist- I ing the new resident in his adaptation to the home which necessitates understanding the resident through his in ternal framework. Garvin and Burger (1968) describe the attitude among many nursing home operators toward their elderly residents. i They're like children. j They're old and senile and get confused just like children. It don't pay to fix anything fancy, they'll eat it if they're hungry, just like children. I (Garvin & Burger, 1968, p. 15) ' I Often the elderly are not treated as well as children but i occupy a status akin to "housepet." Certainly, in these i 86 situations the management is making no attempt to under- | stand the resident "through his internal framework," but j rather has placed a stereotype on him which he has no way I of breaking out of. I "In some ways the elderly are like children. They | often lose their mental alertness and their physical con- j i trol to such an extent that they have to be watched over | like infants. But they struggle to retain their human dignity, their feelings, opinions, and pride, long after they have lost the outward appearances of true adulthood." ! (Winds of Change, 1971, p. 11) Residents are often afraid ' that their dependency needs will not be gratified if they allow themselves to be too competent. Under this fear thatj dependency need satisfaction will be withdrawn, many resi- , dents prefer to act somewhat childish or incompetent. Those managers who are attuned to this tendency should develop programs to make their residents feel secure with adult behavior in the institutional setting, as overpro- i tection can cause apathy in roles. Most often this over protection is a reflection of the management's "mothering" philosophy or style. If an administration so desired, and some do, it can support a philosophy which can encourage the home to be a correctional institution rather than a medical one. Patients who are old and often helpless make easy subjects | 87 I for behavior modification by the staff. Patients are labeled by doctors, nurses, and administrators as "cases" i rather than "persons," the "TB case," "the one without all ; her marbles," "the one with the sores." Staff members ! often consider themselves to be "working on" rather than j "working with" patients. In this way clients are consid- ' ered first as patients or cases, and second as rational | self-interested human beings. Alert patients typically • receive much different treatment than do confused patients. Alert patients are the recipients of much large indepen dence allowances. I Resident Independence ' Encouragement towards independence should include ex- , ercise programs, walking times, handrails, doors leading to outside, sitting and walking areas, etc. The confinement ; of people indoors is cheaper and less worrisome for manage ment, but destroys, or further adds, to the deterioration I of the capacity for independence. The ability to walk, not| I to be bedridden, is the ability to live. Unfortunately, states often pay premiums for bedridden cases, so some operators who do not have the patient's best interests at heart, attempt to keep residents immobile and in their beds as much of the time as possible. This has an extremely negative affect on the quality of life in some homes. Because some residents select certain staff members 88 for relationships while other prefer staff members with other personality traits, it seems important to have a j staff composed of a fairly wide range of personality types. A wise administrator would try to provide for his resi- | dents' relationships needs in his hiring practices. "The j tendency to obtain a staff which reflects the attitudes and personality of the administration should be counterbalanced! by this need for diversity of personality types." (Tobin, ’ 1976, p. 7) A particular patient care program may be suitable for the needs of one patient and unsuitable to fulfill the needs of the next. Programs of care should be flexible. ; The key to an effective patient care plan is individual ized services with flexibility which stems from a realiza tion that the needs of individuals do differ and change with time and circumstances. A care plan should not be a static thing. | Institutions can choose to be passive about the kinds of lives their patients lead and activities they indulge ^ i in or concern themselves with. These types of institutions! often have as their underlying philosophy the "normalizing" of all patients under their care (normal varies with de- ; finition from home to home). "The historical concept of I long-term care institutions as custodial warehouses run j deep. For a long time merely helping persons survive in I 89 long-term care institutions was considered to be enough." (Winds of Change, 19 71, p. 2) Some institutions prefer that their residents live the cloistered lives of perpetu ally cared for patients while a few encourage their staff to help and allow (sometimes "allowing" is all that is necessary) patients to live their lives as they would on the outside, insofar as is possible. Many professionals : advocate nothing short of radical change in the basic philosophy of what is expected of and for patients residing in long-term care institutions. The narrow "fun" activi- i ties (bingo, checkers, cards, T.V. , handicrafts, etc.) they; I feel, can no longer be rationalized as being "good" or "correct" things for institutionalized persons to fill ; their time with. This change in overall basic nursing home philosophy calls for helping the patient to retain, at least, a segment of his old roles, doing the things he know; he enjoys and is good at. It is necessary for both the i administration and staff to commit themselves to making ■ life full (not easy) for the persons living in the home i before an activity program can be implemented successfully.i Such a program must be integrated with every department and! accepted by all staff members as necessary in providing high quality life experiences for residents. I Problems Hindrances in setting up programs which are based on 90 - . - - j the necessity to preserve patient independence are as follows : 1. Management is unaware of patient needs; ; 2. Management lacks knowledge on how to ' set up these kinds of programs ; j 3. Management finds it easier and cheaper I I to keep patients "under wraps." ! ( The first two problems are solvable. The third must be subject to a basic change in philosophy before an activity program can be planned and implemented. Criteria and Strategy Because an activity program such as this is ongoing, ■ needs status and visibility at the outset, concrete plan- ; ning strategy needs to be formulated. Goals and policies should be placed in writing so that they may be reviewed i I and understood by all staff members. Some staff persons should be directly in charge of the program in order that the activities plan plays an important part in future I administrative decisions. Such a program takes time and | an immense amount of effort, and money (staff salaries, planning consultants, etc.). i From Winds of Change (1971) comes a definition of an i activity program: | An Activity Program in a long-term ' care institution means the conscious management of daily life through [ 91J creating, supporting, developing, and restoring the appropriate I life style of the resident in the direction of personal and socia,l i autonomy. I An Activity Program in a long-term j care institution requires: ! o A positive outlook on the part j of administration and staff | that the institution is a place where patients are helped to live, as much as possible, full and meaningful lives. . o A continuing search for crea- I tive ways to help patients lead ! meaningful lives. , o A careful scrutiny of the qual- | ity of life of patients in the j institution — a careful review j hour by hour for each patient, ■ of how he spends his time and ; of what it means for him to spend it as he does. o Provision, through administra tive action and physical imple mentation, of a wider choice of life styles for each patient. (p. 8) I Wholehearted cooperation of the staff is needed, especially ! in the initial implementation phases. Staff must be made aware of the dangers of overprotection but this awareness should also be tempered with the patient's advocacy needs. ! Knowledge of patients' lives is generally gained through four sources : 1. Patient charts; physical and mental health as charted daily by medical personnel. Basis for writing care plans. 92J 2. Information gained from observation of I patients by daily floor staff. Useful i i in writing effective activity plan. ! I 3. Information gained from particular pro- | I fessional staff members (psychologist, j occupational therapist, etc.), who ob serve the patient in particular activity ! settings. j I 4. Information gained from the patient in ' I structured interviews. i Again, it must be emphasized that the entire staff take n active part in the implementation of each patient's care .nd activity plan. Oftentimes the situation occurs in which, he top management and professionals collaborate on the drmulation of patient activity plans and then simply pass hem down in written form to the floor staff. This process nvolves two implicit assumptions : 1. That the plan will, in fact, be imple mented by the floor staff; and, 2. That patients will respond by changing their behavior. , hese two occurences do not always materialize. If patients re treated as isolated individuals and if floor staff is ot involved in planning and implementation sessions, care nd activity plans, no matter how well formulated they may I 93| be, are likely to be ignored. The Multi-Dimensional Care Plan The administrator must periodically establish, ident ify, or review what his organization is trying to achieve and to communicate these goals to all staff and employees. Elderly residents can be treated as responsible members of their health care teams if administrators don't insist on treating them "like children." The inclusion of patients in the planning of their own activity schedule would in- I crease their sense of security and self-esteem and would | greatly enhance the information base upon which care I planners have to work in order to formulate workable, posi tive care plans. i Administrators have several choices they can make in regards to setting policies designed to include outside members of the community in the resident's health and activity care plan. Institutional life, by definition, and of necessity, demands a certain amount of conformity. To counteract its nega tive effects, opportunities for learn ing can convey the message that unique and individual talent can be developed regardless of place, age and personal circumstances." (Selecting a Nursing Home or Alternative Care in California, 1974, p. 32) Opportunities for education can be provided to residents I I through the use of community resources. Work opportunities 14j can also be provided if management wishes to provide avenues through which patient's lives can be meaningful in a work-related senses For most Americans, the need for work continues throughout life. Without work a sense of uselessness, futurelessness, and dependence develops. Most Americans, in fact, never accept the myth of secure and sedate retirement. Family Participation If desired, the family can also be included in the patient care plan. "The home administrator must be all i ! things to all people. This includes the family...your , duty is to get them (the family) to put the patient first. , It is not unusual that a family may require more of the administrator's and staff's time than the actual time needed to care for the patient." (Tobin, 1976, p. 55) The institution can, if it chooses to do so, make it clear to families and relatives that they remain involved to some degree, in the life of the patient in terms of visits, calls, and opportunities for home visits. The institution ' can also inform the family of the dangers of overprotect ing the institutionalized elderly person. Community Interaction | As was discussed in the preceding chapter, it is also j up to the administration whether it will operate in an isolationist manner with its own staff providing all care | „ __95 j and activities or whether it will open up and interface with existing health care organizations and other activity facilities in the community. Wheelchair and bedridden patients can be connected to the community if the effort is to be made by administrators (stuffing enevelopes, answer ing telephone calls, giving information). If the institu tion desires to give its patients wide ranges of experi ences in which to take part, it cannot remain isolationist but must actively integrate itself into the community ac tivity framework. Institutions can remain linked to the community in several ways ; 1. Keeping a current inventory of resources; 2. Advocating for patient use of existing resources ; 3. Encouraging community use of the institution's facilities ; 4. Keeping the community informed of the institu tion 's programs. In conclusion, it is management's responsibility to guide, counsel, train, orient, and to produce, through supervision, a high quality of patient care commensurate with high health care standards. In order to do this, administrators must make conscious choices including the type of patient care philosophy they will formulate to guide their home, the attitude they will take toward patient independence (or dependence as the case may be), 96 whether the home should be a profit-making corporation or | i whether in effect, the profit motive inhibits good elderly j care, and whether the institution will operate in isolation from family and community. Any change that occurs in the facility will be because management caused its occurrence. Management is the gate through which social, political, economic, and technological change is rationally and effectively (or not rationally and effectively) spread throughout any organization, including the long-term care institution. 97. CONCLUSIONS AND RECOMMENDATIONS j As the discussion in each of the preceding chapters | indicate, the linkages of the nursing home to its commun ity, the physical design of the institutional environment including the overall site, the buildings and the land- | scaping, and the mangement philosophy of the administra tive staff all impact upon the "quality of life" residents of a nursing care institution experience. Management, how ever, seems to be the most influential member of the triad. For example, an institution lacking an informed, efficient , and concerned management team will neglect to foster opti mum bureaucratic ties and beneficial public relations with the community. Likewise, a building which has been planned and designed with a sensitivity toward the needs of a chronically ill older person can only be utilized to its full design potential by a competent administration. Ideally, several members of the administrative staff should be part of the facilities and site planning team as they | will be the initiators and coordinators of the activities | which occur within the physical facilities. 98 A good management team and competent medical staff is vital I in order to maximize the quality of care nursing home resi-; I dents receive. A change in management can transform an ex-, isting nursing home offering only the most basic custodial ' care and minimal possibilities for a positive life quality j into an environment which encourges the resident to main- : tain the highest level of independence and well being of which he is physically and mentally capable. Though exist ing institutions offer some potential for physical change i I it is in the design of new facilities that the majority of i physical planning takes place. I i The Planning Process | One extremely valuable method for assuring the avail- | ability of high quality long-term nursing care to the com munity is the initiation of a planning process for the construction of long-term care facilities. At the outset, this process should assume that the agency or firm doing the planning should be concerned with quality of life ^ I residents of the nursing home will experience and not . simply with the number of beds or other physical amenities provided. If a systematic planning policy is adopted, the plan ning criteria which are developed should promote the values| of the community, and therefore, the values of the future I residents of that community's long-term care institutions. I i _ 5 j One method of assessing community values would be to in- I elude on the planning team, community decision makers who ; are interested and knowledgable in the areas of health care and long-term care. This group might include local hospi tal administrators, doctors, members of the "aging network"i if such a network exists, other nursing home administra- | tors, nurses who have had experience working with geriatricj patients, older leaders of political, social or service- ! I oriented community groups, etc. Also, included as "con- • sultants" might be families who are carying for a chroni- I cally ill person at home. They may be able to epxress not i only their own needs, but may be able to impart valuable information about effective or non-effective care strate- i gies. The rationale for a logical planning process is that, at a minimum, it can provide the factual base which can be used to encourage or discourage the construction of nurs ing homes. The process achieves this by requiring an evaluation of the desirability and feasibility of proposed ' I long-term care services. In term, this feasibility study ' results in the formulation of recommendations to agencies with the legal authority to construct or authorize con struction of nursing care institutions. At best, the plan ning group will have the actual authority to construct facilities and mandate the bureaucratic linkages which will 100 1 make possible the integration of the institution into the community health care system. Such a planning team might eminate from the Department of Housing and Urban Develop ment, a city housing authority, a city planning department, a health systems agency, or a developer of a privately financed project. A New Focus There have been substantial changes in nursing home practices since the 1950's. Growing public concern for nursing home safety, especially fire safety, prompted ex tensive federal and state investigation into alledged nursincr home code violations. These investigations led to numerous exposes of the generally deplorable conditions nursing home patients were being forced to live in. This resulted in the reformulation of the concept of long-term care by leading social work professionals: Over the last decade an intensive national effort, sponsored by federal and state governments, as well as by the industry, has been made to upgrade the status of nursing homes in the nation's health care system. A primary objective was to change their image as way stations for the old and indigent en route to the grave. As implemented by Medicare and Medicaid legislation, the concept of the extended care facil ity exemplified a new emphasis on con valescent care and on restorative therapy and rehabilitation. (Ingram, D. and Barry, J., 19 77, p. 306) 101 ! Many of the concerns presented in this paper have been addressed by social work professionals leading the popula- | tization of new intellectual and technological disciplines. For example, students can now receive specialized training in gerontology and, more specifically, advanced degree programs are available in long-term care (University of Arizona). Additionally, the fields of architecture and planning have spawned design and consulting firms which specialize in housing for elderly persons and in nursing care institution design. Model nursing homes have evolved for themselves, over the past decade, a patient care philosophy based on re habilitation. Individual patient progress towards inde pendence has been the measure of a "good" nursing home. More recently, professionals and students of gerontology have begun to realize that increasingly, nursing homes are becoming places where older people go to die. The national statistics on nursing home mortality, which we have analyzed, appear to contradict the attempt to change the public image of these insti tutions as places where people go to die. Indeed, nursing homes are actually con fronting an increasing proportion of the nation's total mortality. (Ingram, D. & Barry, J., 1977, p. 307) The issue of life quality for the dying person must be addressed by nursing home professionals who, up to this point, have tended to emphasize rehabilitation and restora 102 tion. Orientation towards the needs of dying people by a concerned administration and staff can help to guide the institutionalized terminally-ill person through his dying process. Works by such people as Elisabeth Kub1er-Ross and Barney Glaser offer suggestions for the sensitization of staff members toward the dying person. The concept of hospice as practiced by St. Christopher's Hospice in Great Britain is also beginning to gain in acceptance in the United States. The hospice is a nursing care institution which provides an environment (physical and social) which allows terminally-ill patients to achieve a decent and "appropriate" death. It is conceivable that a hospice wing could be created in many nursing home facilities which would be staffed with people having specialized training in working with dying people. Recommendations for Future Research Published material in the general area of "Quality of Life" measurement is sparse and there have been few quanti tative studies on the qualities of "well-being," "happi ness," or "satisfaction" experience by institutionalized persons. It is recommended that general life satisfaction indicators such as the "Index of Well-being" (developed by Campbell, Converse, and Rogers) and the "Index of General Affect" be used to test nursing home populations. It is predictable that these indicators will have to be modified . 1 0 . 3 . substantially for use on this particular population. Increasing original research in the area of Changes in Domain Satisfaction (Campbell, 19 76, p. 199 ) would be particularly to quality of life issues for those elderly persons who move from an independent or semi-independent life style to a sheltered care setting. Further research in the area of quality of life re lationship to community participation in nursing home activities is also indicated. .104 BIBLIOGRAPHY 105 ; BIBLIOGRAPHY A Manual on Public Relations. Washington, B.C.: The ; American Nursing Home Association, 19 74. I Barney, J.L. "The Perogative of Choice in Long-Term Care" The Gerontologist, August 1977, 309-314. Beyer, G.H. and Neirstrasz, F.H.J. Housing the Aged in | Western Countries. Amsterdam; Elsevier Publishing Co., ; 1967. i i Byerts, T.O. "Reflecting User Requirements in Designing | City Parks." In M.P. Lawton et al. (Eds.), Community j Planning for an Aging Society, 19 76, 317-329, j Campbell, A., Converse, P. and Rogers, W. The Quality of ! American Life. New York: Russell Sage Foundation, 1976 . Carp., F. "Urban Life Style and Life Cycle Factors." ! In M.P. Lawton et al. (Eds.), Community Planning for an Aging Society, 1976, 19-40. _____ . "The Elderly and Levels of Adaptation to Changed Surroundings." In L. Pastaler et al. (Eds.), Spatial Behavior of Older People, 1970, 46-61, Churchill, Winston. As quoted in A. Campbell et al. The Quality of American Life, p. 1. Community Planning for an Aging Society. P. Lawton (Ed.) Pennsylvania : Hutchinson & Ross, Inc., 1976. Costa, Frank. "Barrier-free Environments for Older Americans." The Gerontologist, October 1976, 404-409. Greeley, M.B. -Suggested Planning Guidelines for SNF/ICF Long-Term Care Facilities. Washington, D.C.: American Health Care Association, 1974. Crooks, L.A. Long Term Care Facility Administration. Washington, D.C.: Dept, of HEW, U.S. Government Print ing Office, 106 J Directions 65 — AAHA Conference Report No. 3. Washington, D.C.: American Association of Homes for the Aging, 1964. I Ehrenrich, B. and Ehrenrich, J. "Health Care and Social Control," Social Policy, May/June 19 74, 15-25. Establishing Resident Councils. New York: Federation of Protestant Welfare Agencies, Division on Aging, 1974. , ^ I Frush, J. The Retirement Residence. Springfield, 111.: ^ C.C. Thomas, 196 8. I Garvin, R. and Burger, R. Where They Go to Die : The 1 Tragedy of America's Aged. New York : Delacorte Press, | 1968. I Gelwicks, L. and Newcomer, R. Planning Housing Environ- i ments for the Elderly. Washington, D.C.: National ! Council on Aging, 1974. Gerletti, J., Crawford, C.C. and Perkins, D. Nursing Home Administration. Los Angeles : The Attending Staff Association, 1961. Glaser, B.G. and Strauss, A.L. "The Ritual Drama of Mutual Pretense." In E.S. Shneidman (Ed.), Death : Current Perspectives. Los Angeles : Mayfield Publishing Co., 1976, 280-292. Glassman, J.J., Tell, R., Larrivee, J. and Helland, R. "Toward an Estimation of Service Need." In M. P. Lawton et al. (Eds.), Community Planning for an Aging Society, 1976, 258-265. Green, Issac. Housing for the Elderly: The Development and Design Process. New York : Van Nostrand Reinhold Co., 1974. Gubrium, J.F. Living and Dying at Murray Manor. New York : St. Martin's Press, 1975. i Housing and Environment Project: Residential Environments ^ and the Functionally Disabled. Washington, D.C.: Gerontological Society, 1975. | How to Choose a Nursing Home: A Shopping and Rating Guide. Michigan : Citizens for Better Care, The Institute of Gerontology, 1974. I 107 Ingram, D. and Barry, J- "National Statistics on Deaths in Nursing Homes: Interpretations and Implications," The Gerontologist, August 1977, 303-308. It Can't be Home : Social and Emotional Aspects of Resi dential Care. Washington, D.C.: National Institute of Mental Health, 1971. 1 Ittleson, P. "The Influence of the Physical Environment on Behavior." Environmental Psychology, 1975, 27-37. Jacobs, H.L. and Morris, W.W. Nursing and Retirement Home Administration. Ames, Iowa: Iowa State University j Press, 1966. Kart, G. "Quality of Care in Old Age Institutions." The Gerontologist, June 1976, 250-256. Kubler-Ross, E. "Coping with the Reality of Terminal Illness in the Family. In E.S. Shneidman (Ed.), Death : , Current Perspectives. Los Angeles : Mayfield Publishingi Co., 1976, 293-302. | Kurtz, R. Manual for Homes for the Aged. New York: | Federation of Protestant Welfare Agencies, 1965. ' Lawton, M.P. Planning and Managing Housing for the Elderly, New York: John Wiley & Sons, Long Term Care Facility Improvement Study. Washington, D.C.: U.S. Health Education and Welfare, July 1975. Long Term Care Handbook. Nebraska: Bureau of Comprehen sive Health Planning, Dept, of Health, March 1975. Lynch, K. Site Planning, New York : The MIT Press, 1971. McRae, J. Elderly in the Environment, Northern Europe. i Gainesville, Fla.: College of Architecture, University ; of Florida, September 1975. j McQuillan, F.L. Nursing Home Administration. Philadelphia: W.B. Saunders Co., 1968. Mendelson, M.A. Tender Loving Greed. New York : A.A. , Knopf, 197 4. i 108 Metzelaar, L. A Collection of Cartoons: A Way of Examin ing Practices in a Treatment Setting. Ann Arbor : Institute of Gerontology, University of Michigan, 19 75. MicheIson, W. (Ed.) Behavioral Research Methods in En vironmental Designs. Philadelphia: Dowden, Hutchinson arid Ross, 1975. Man and his Urban Environment. Mass.: Addison Wesley Pub. Co., 19 76. Michigan State Housing Development Authority Housing for the Elderly Development Process, MSHDA, 19 74. Miller, D.B. The Extended Care Facility: A Guide to Organization and Operation. New~Yorkl McGraw-Hill, 1969. i Mitchell, M. A Practical Guide to Long Term Care and j Health Services Administration. New York: Community i Health Administration Institute, Panel Publishers, 1973.| The New Nursing Home: A Response to the Behavior and Life Style of the Aging. Ithica, N.Y.: New York State College of Human Ecology, Cornell University, 197 3. Nursing Home Care in the U.S.: Failure in Public Policy. Subcommittee on Long-term Care of the Special Committee on Aging. U.S. Senate, Parts 1-6. Washington, D.C.: U.S. Government Printing Office, 1974-75. Ostrander, E. "The Methodology of Research Required to Analyze the Relationship of the Physical Environment and the Aging. In L. Snyder et al. (Eds.), The New Nursing Home. Ithaca, N.Y., 1973, 14-26. A Plan of Long-term Care Services for Pima County. Pima ' County, Arizona: Pima County Council on Aging, 1975. : Quality of Life : A Goal of Long Term Care Facilities. ^ St. Louis, Mo.: The Catholic Hospital Services Admini stration, 19 73. Report of the Governor's Commission on Nursing Homes. ^ Baltimore, Md., : State of 1 And Goyet'np^^ ^ a Office., 1973. 109 Saunders, C. "St. Christopher's Hospice." In E.S. Shneidman (Ed.), Death; Current Perspectives. Los | Angeles: Mayfield Publishing Co., 1976, 516-522. Selecting a Nursing Home or Alternative Care in California.' Sacramento: California Office on Aging, July, 19 74. , Schwartz, A.N. Mental Health Training in Long Term Care of the Aged. Los Angeles: Ethel Percy Andrus j Gerontology Center, University of Southern California, 1974. ! 1 Silberg, N. and Wing, S. Planning Long Term Care Services and Facilities for Older Persons. Seattle : School of Public Health and Community Medicine, University of Washington. Sponsors Guide for Nursing Homes and Intermediate Care ; Facilities : Section 2 32 of the National Housing Act. j Washington, D.C.: Department of Housing and Urban De- | velopment, March 19 72. ; Standards for Residential Care in Homes for Aged Persons. Sacramento : California Dept, of Social Welfare, May 1968. j Standards for Boarding Homes and for Aged Persons. Sacramento: California Dept, of Social Welfare, 1964. Standards, Rules and Regulations for Nursing Care Facili- ties. Wyoming: Division of Health and Medical SUCS, I 1973. ! Tobin, S.S. Understanding the Elderly. Chicago; University Press, 1964. Tobin, S.S., Lieberman, M. Last Home for the Aged. 1 San Francisco, Jossey, Bass, 1976. Winds of Change : Report of a Conference on Activity Pro grams for Long Term Care Institutions. Chicago, 111.: j American Hospital Association, 1971. Winn, S. "Characteristics of Nursing Homes Perceived to be Effective and Efficient. The Gerontologist, October 1976, 415-419. j j Zeisel, J. "Development of an Environmental Society." [ Sociology and Architectural Design. New York: Russell Sage Foundation, Social Series Frontiers, 1975, 63-75, 110,

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Asset Metadata

Creator Conerly, Robin Wallace (author)

Core Title Institutionalized elderly: design, community, and management effects on life quality

School Leonard Davis School of Gerontology

Degree Master of Planning / Master of Science in Gerontology

Degree Program Gerontology,Urban and Regional Planning

Degree Conferral Date 1977-08

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,social sciences

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c39-247388

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Legacy Identifier EP67032.pdf

Dmrecord 247388

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Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

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