This article focuses on the function of Norwegian nursing homes. A brief history of institutionalisation of older people in Norway is presented. An expressed task for Norwegian nursing homes is active treatment, and even though the “Guarantee of dignity” was implemented from January 2011, there are proofs that the rights of the residents are constantly violated. Another task for Norwegian nursing homes is to be home for the residents. This double function of the nursing home, being both a care facility and a home is discussed, and whether the nursing homes succeed in fulfilling these tasks or not is questioned. It is also questioned if Goffman’s descriptions of total institutions are applicable on nursing homes of today.
Nursing Home Total Institutions Older PersonsAbstract
This article focuses on the function of Norwegian nursing homes. A brief history of institutionalisation of older people in Norway is presented. An expressed task for Norwegian nursing homes is active treatment, and even though the “Guarantee of dignity” was implemented from January 2011, there are proofs that the rights of the residents are constantly violated. Another task for Norwegian nursing homes is to be home for the residents. This double function of the nursing home, being both a care facility and a home is discussed, and whether the nursing homes succeed in fulfilling these tasks or not is questioned. It is also questioned if Goffman’s descriptions of total institutions are applicable on nursing homes of today.
Keywords
Nursing Home, Total Institutions, Older Persons
1. Introduction
The rapid move towards an ageing population is a world-wide phenomenon. Norway is no exception from the global trend. The number of inhabitants in Norway is constantly increasing. In 2011, we passed the 5 million mark, and Statistic Norway estimates that there will be just fewer than 7 million inhabitants in Norway by 2060. High birth rate after Second World War gives a tremendous growth of the elderly population in the next decades. This ageing population will challenge our health care and social system. The higher age the more need for help due to increased risk of sickness. About 11% of the population between 80 - 89 years are residents in institutions for older persons. Among the eldest (more than 90 years), about 32% are in the need for help in institutions. The growth of the older population in the years to come will increase the need for 24-hour skilled nursing facilities, like nursing homes. The double function of the nursing home, being both a care facility and a home, and whether the nursing homes succeed in fulfilling these tasks or not, are discussed in this paper. It is also questioned if Goffman’s descriptions of total institutions are applicable on nursing homes of today.
2. The Purpose of Nursing Homes
In order to understand the nature of nursing homes today one has to take into consideration the history of institutionalisation of older persons in Norway. In the second half of the 1900s, institutions for older persons who could not take care of themselves were built; the main purpose of those institutions were neither as a home nor a place for treatment, it was purely meant as a place for storing the older people [1] . A hundred years after the first institution was built, this “storing” of older adults was criticised, mainly by physicians. Reforms were needed and a new area began where focus was put on nursing homes as an arena for active treatment; the idea of nursing homes as “homes” was not yet on the agenda. The transformation of nursing homes into arenas for active treatment did not succeed, and as the nursing homes neither had qualities of a home nor an institution for treatment, new steps were taken to try to help nursing homes succeed. The responsibility for nursing homes was moved from the municipalities into the counties in 1969. Economical incitements led to many new nursing homes, but the idea of active treatment in nursing homes was not reached. In addition, the nursing homes proved to be very expensive and beginning in 1980 the focus was shifted to home care services. However, the problems in the nursing homes did not decrease. On the contrary, due to pressure from the municipalities who lacked proper housing for frail older persons, and the hospitals who claimed to be filled to capacity by older persons who needed a lot of care (but not treatment), and the problems of recruiting qualified staff, the nursing homes again were criticised for being a storing place for older adults [2] . Thus, in 1988 the responsibility for nursing homes was given back to the municipalities [3] and it seemed that the idea of nursing homes as institutions for active treatment was lost [4] . The “entrance ticket” to nursing homes is usually a disease that demands long-term treatment or comprehensive and permanent need for care [5] . Beginning in 1985 the expressed policy has been that nursing homes are to function as homes and institutions for treatment. The question regarding whether or not this has been a success continues to be discussed by numerous stakeholders.
3. Nursing Home as a Care Facility
An expressed task for Norwegian nursing homes is active treatment. The Municipalities Health Services Act [6] outlines nursing homes’ responsibility for, amongst other things: diagnosing and treatment of illnesses, rehabilitation and care to the municipalities. This may be done within the organisation of a nursing home. Provision of care in nursing homes is regulated by “Regulation of quality of care” [7] . Amongst other issues, the regulation should ensure that the basic needs of the residents’ are satisfied. These include psychological needs, preservation of dignity and self-respect, the degree of choice within the daily routine, physical needs (including nutrition), and social needs. Safe and secure services are a primary goal and quality services means that the probability for errors and adverse events to occur is reduced to a minimum. The Norwegian government has also introduced a plan that aims to increase the quality of care by 2015 [8] . Beginning in January 2011, a new regulation was implemented “The guarantee of dignity” (“Verdighetsgarantien”). The purpose of the regulation is to ensure that care for older persons, whether it is home or institutional care based, is organised in a way that contributes to dignified, secure and meaningful ageing. This guarantee is designed to clarify the rights of the older persons and demonstrates how care should be adjusted to the individual person [9] .
The rights of residents in Norwegian nursing homes are constantly violated. A Norwegian nationwide survey from 2003 shows that, according to staff, 10% of the residents in nursing homes (n = 3866) did not receive sufficient help during meals, 15% did not receive sufficient help regarding personal care and personal hygiene, and 60% did not have sufficient activities and psychosocial care [10] . Other studies of quality of care in Norwegian nursing homes show that the care is not sufficient, especially regarding psychosocial care [11] [12] and the need for treatment and assistance regarding physical activities, psychiatric problems and dementia diseases are not adequately addressed [12] Seventy seven per cent of registered nurses in 125 Norwegian nursing homes reported that residents in their ward sometimes were treated in an irresponsible way [12] . Another study of quality of care in Norwegian nursing homes confirms that even though most residents receive good basic care, there is a practice of using pads instead of following residents to the toilet [13] . The same study describes neglect of residents need for leisure activities and going for walks outside the building. A Norwegian study of constraint in nursing homes shows that 37% of residents in regular nursing home wards are subjected to some kind of constraint each week [14] .
A study of drug utilisation quality amongst more than 1500 residents in Norwegian nursing homes revealed that the majority of the residents were at risk of side effects, insufficient use, or they were under medicated [15] . The findings are further supported by a study of psychiatric symptoms and behavioural disturbances and the use of psychotropic drugs in Norwegian nursing homes showing that the prevalence of inadequate use of antipsychotic medicine amongst residents with a dementia disease and aggressive behaviour was particularly high [16] . A survey study (n = 616) of inadequate care, abuse and neglect in Norwegian nursing homes [17] revealed that nursing home residents to a great extent are exposed to abuse and neglect from staff.
Norwegian health authorities are aware of the risk that deficiencies in provision of municipal nursing and care services may occur. The Norwegian Board of Health Supervision has summarized the experience gained from supervision of municipal nursing and care services in all the counties in Norway [18] . Deviations from the regulations were identified in 80 per cent of the 373 supervision visits. Regulatory deficiencies were mainly related to inadequate help with basic needs, inadequate administrative procedures when allocating services, and inadequate routines for internal control. The Norwegian Board of Health Supervision also questions whether there is enough staff with the necessary competencies to meet the needs of the residents. A new supervision visit was arranged in 2010, and for institutional care the deviations from the regulations were found in different areas; there was a lack of knowledge, practice and routines to detect undernourished older persons, and thus to prevent and treat under nourishment. In addition, supervision found that residents in nursing homes were not given the correct treatment regarding rehabilitation, and that the residents freedom of movement were violated (through locked door) as a collective restriction, something that is against the regulations [19] . A recently published report from The Norwegian Board of Health Supervision [20] about compulsory health care in nursing homes concludes that: “The breaches of the regulations that we detected indicate that there is a great risk that service provision is inadequate” (p. 9).
4. Nursing Home as a Home
Norwegians general are particularly concerned about their homes and the environment [21] , and due to the cold climate during winter, Norwegians spend a significant amount of time in their own homes. A home is associated with security, connection, continuity, relationships, a place for different types of activities, and serves as a symbol of status and materiel values [22] . Home is a place for identity building and identity preserving, a place where you can “be yourself” [23] . Thorsen [23] also emphasize the meaning of home as a storyteller; until the very end of life the home tells the unique history of the person living there. The history will help the person to recognize him/herself, as well as helping others to know the person behind the “patient”. Jacobsen [24] discusses whether there is room for home-likeness in nursing homes, and asks if our ideas of homes also should be our ideas of nursing homes. He argues that even though the nursing homes have developed more home like environments, the patients rooms remain the only area that can be seen as an exclusive room for the residents, since this room is the only room they, to a certain extent, can control and make their mark on. Studies of the meaning of home amongst older persons have shown that older persons are specially connected to their homes [25] [26] . A Norwegian study about older persons expectations for their own aging, showed that the majority wanted to live in their own homes, even if they became in need of care [27] , while only a few saw nursing homes as desirable alternatives.
It is reasonable to question whether the Norwegian nursing homes have succeeded in fulfilling their tasks as homes for older people. Only a few Norwegian studies have focused on nursing homes as a home [4] [28] -[30] . A field study in Norwegian nursing homes [4] [30] showed that even though the residents’ private rooms were furnished with some of their own furniture and with family portraits and decorations, the bed and the bedside table were hospital like. Indicators of non-privacy were that staff often went into the room when the resident was not present, the room had no doorbell, and the door between the room and the corridor were open quite often, and gives anyone who passes the door, insight into a private room. According to the study, the residents who were mobile spent more time in their rooms and had more opportunities for privacy than did those residents who were more dependent on the staff for moving. The diffuse boundaries between the public area and the private room, and the residents’ lack of control, distinguish the nursing home from “real” home.
5. Nursing Home—A Total Institution?
Half a decade ago, Goffman [31] introduced the term total institutions and referred to institutional settings which were self-encompassing environments isolated from the outside world. This landmark study of total institutions had a powerful influence on the early studies of nursing homes. The phrases that Goffman used to describe the process of institutionalisation, such as “mortification on the self”, “curtailment of the self” and “territories of the self” have been seen as relevant to describe life in nursing homes. Townsend [32] studied institutions for old persons in England and Wales and discussed what effect institutionalisation had upon the old people living there. In his book “The Last Refuge”, Townsend concluded that these institutions did not adequately meet the physical, psychological and social needs of the old people living in them and alternative services and living arrangements should quickly take their place. Some of the effects of institutionalisation as he describes it are depressingly familiar even today; lack of occupation, isolation from family, friends and community, loneliness, loss of privacy and identity, and the collapse of power and self-determination. In each decade since this early work of Townsend, other researchers have shown the same effect of institutionalisation. In the 70’s Gottesman & Bourestrom [33] showed that nursing home residents were vulnerable to loneliness, boredom, and negative self-esteem. They found that residents spent more than half of their time doing little or nothing. During this same period, Norwegian nursing homes were described as storage places for old people [34] , and the loupe was directed towards need off improvement [35] . A study of institutions for older persons in one county in Norway showed that the residents were to a very little extent free to make decisions of their daily routine, and the medical practice seemed to be insufficient [36] . The regulations at that time demanded that the institutions provide varied and meaningful activities for the residents; however, this seemed to be very limited, and the conclusion of the study was that the institutions, to a certain extent, could be characterized as total institutions, according to Goffman’s definition [31] .
Studies in the 80’s and 90’s show improvement in the institutional care for older persons, but still Goffman’s model of total institutions is applicable to nursing homes, either partially or as a whole [37] [38] .
The results from a Welsh study, where nursing home residents spent approximately 70% of their time engaged in passive activities [39] , are supported by a study of 27 nursing home residents in USA which showed that the residents spent the majority of their time in passive activities, such as doing nothing, sleeping and waiting [40] . In his article titled “Flying towards Neverland”, Casson [41] uses the metaphor “being at a departure lounge”, as a reference to the fact that the residents in nursing homes are waiting for their last journey, death.
6. Conclusion
It seems that even though the facilities are making great efforts to improve quality of care, life in nursing homes is still characterised by the lack of social interaction and meaningful activities, and, even today, nursing homes may, to some extent, be described as total institutions.
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