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"Caring for Individuals
as a Group:
A Theological Analysis of Care of the Elderly in Nursing Homes

By Vicki Oman

Caring for the Elders in Our Society

Reflections: On caring for the “individuals” in nursing homes

Theological Analysis:  A vision of caring through mutual knowing

What is “a valuable life”?: A theological poem

References for this project

Reflections: On caring for
the “individuals” in nursing homes

In the 1970s, it became apparent that there were some problems in our long term care institutions. The institutions devoted to caring for our elders seemed to put the institution’s needs before the individual residents’ needs.  Residents had very little choice.  Many nursing home residents were being freely restrained, without real attempts to find alternative means of making them safe, and without consideration of long term effects of their methods.  It was often difficult for a nursing home resident to find an advocate if they did not have a regular family member visiting.  Residents of these facilities had little recourse;  they really didn’t know what their rights were, couldn’t identify violations, and didn’t have anyone to trust.

The National Citizens’ Coalition for Nursing Home Reform was established in 1975, and they were one of the forces which began to effect change in the landscape of long term care. (Burger et al., i)  One of the major changes occurred in 1986, when the federal government passed the Omnibus Budget Reconciliation Act of 1986 (OBRA), a set of standards for nursing home care which would be monitored by the Department of Public Health during yearly surveys.  The primary focus of this was individual residents’ rights.  They were clearly outlined, and it was required that they were posted throughout the facility, and that each resident receive a copy on admission.  Use of restraints, both physical and chemical, was closely monitored, and any restraint in use was required to be the least restrictive option, and reduced within a certain amount of time.  Each nursing home was assigned an Ombudsman, a volunteer resident advocate trained by the state and placed in homes to assist in monitoring these standards.  Each resident’s individual needs, not the convenience of the facility, was to define their care.

The quality of nursing home care improved immensely after these standards were put into place.  The focal point for each resident’s care became the resident.  I worked in nursing homes both pre- and post-OBRA, and can recount two stories which reflect the change in attitude.

Pre-OBRA:  Mary (names of story subjects have been changed) was a light hearted, smiling woman who was able to walk about the facility.  She suffered from dementia, and was unable to converse appropriately.  She also had very poor safety awareness, and often wandered into areas where she did not belong, but she was very content, interacted with other individuals, and sang happy songs without words (toot-de-toot-de-toot-de-do!).  She began to agitate other residents and to concern the staff by intruding into others’ rooms, and by picking up dangerous objects, such as a knife from another resident’s meal tray, or glass ornaments from the Christmas trees.  To keep her safe, the facility used a special vest with long ties to restrain her in a chair in her room, where she had very little social interaction.  Except for brief walks with staff, that’s where Mary spent her last days – alone in her room.

Post-OBRA:  Joan was a very restless resident who had been through a few different orthopedic surgeries, and was at high risk for a fall.  She also suffered from dementia, and had little awareness of her safety – she constantly tried to get up and walk.  The facility tried out all of their least-restrictive alternatives:  a velcro seat belt, a removable lap cushion, and a chair alarm which alerted staff that Joan’s bottom had left the seat of her chair.  She removed anything removable, and the chair alarm was so annoying she tried to get away from it by leaving her chair!  After trial and error, the staff realized that Joan needed to be on the move, and was unable to propel her wheelchair with her arms.  Her leg rests were removed, and she was suddenly able to “walk” herself wherever she wanted to go.  She stopped removing her lap cushion, and began her constant rounds of the facility.  Joan had been a head nurse before she retired, and she would check in with each of the nurse’s stations to ensure all was well, and then she would propel herself into the Director of Nurse’s or the Administrator’s office, where she would spend some time sorting through papers which were left especially for her to work with.

Joan’s quality of life improved immensely;  in the pre-OBRA period, it’s very possible that she would have been restrained in her chair with the special vest restraint, and her wheelchair locked to keep her in appropriate areas.  Mary’s quality of life deteriorated, and she became less verbal and more withdrawn as time passed.

There is more to Joan’s story than the success of the least-restrictive restraint.  Joan was known as an individual.  We all knew she was a nurse, and we all understood her need to feel useful.  She did not regularly attend the facility’s activity program, but she did enjoy the camaraderie of fellow nurses.  The approach the facility took allowed her to connect the person she had always been, and knew herself to be, with the elderly nursing home resident she was at that moment. 

Joan’s story seems like a textbook success story, but there is more to Joan’s experience than pure, documentable success.  The new, resident-focused care which nursing homes provide has indisputably been an incredible improvement over the previous model;  individuals are recognized and individual needs are prioritized more than ever before.  However, to walk in the shoes of one of these residents for a day will reveal that somehow individuals and their dignity are still not completely honored. 

Joan has some wonderful interactions with staff each day, but she also has undignified, dehumanizing interactions with well-intentioned, caring staff who believe they have her individual needs in mind.  She has been removed from a resident’s room (for the fourth or fifth time) by being pulled from the room backwards without warning, or with “warning” after she has begun to move.  She has been ignored for over 45 minutes as she tries in vain to tell a staff person, any staff person, that she needs to use the bathroom.  She has been greeted in a sing-song, kindergarten way and been called “Sweetie” for the first time in her adult life.  She has been undressed, washed, and dressed as if she were a Barbie doll by a staff person who has five more residents to care for within the next hour.  She wears “appropriate”, comfortable clothing which is nothing like the clothing she has always preferred .  She has been propelled into an entertainment program, with her wheels locked in place and other chairs on every side, to redirect her attention (although she did not want her attention “redirected” anywhere).  She has spent the day wearing her roommate’s glasses instead of her own.  All of these things can occur in the course of a day, but an individual looking at her chart and care plan, and looking at Joan, would see that the care she was receiving was a documentable, textbook success of individualized care.

Theological questions abound in the problem I have described, on the societal level and on the personal level.  In the following analysis, I will focus on some personal aspects of this frustrating struggle to care for our elders well.  Where is God for Joan?  Every day, she is surrounded by people who care, and who interact with her, yet she is very alone – where is God in her loneliness?  Where is God in the care-giving  and care-receiving relationship?  How can God be present in these relationships, which are so often focused upon bodily functions and documentable interventions?  How can caregivers relate in a way which is truly healing, instead of appropriate on paper?  What is the Good News for individuals suffering in these institutions, if they have lost all they have known?  Is it possible for human beings to care for an institutionalized group as individuals?

Theological Analysis:  A vision of caring through mutual knowing

References for this project

The information on this page is copyright 1994-2010, Wesley Wildman (basic information here), unless otherwise noted. If you want to use ideas that you find here, please be careful to acknowledge this site as your source, and remember also to credit the original author of what you use, where that is applicable. If you want to use text or stories from these pages, please contact me at the feedback address for permission.