Nursing Homes – Places of Care versus Places of Living

Over recent decades, residential and care institutions have undergone a profound transformation – evolving from strictly regulated facilities into places that increasingly accommodate individual needs and personal lifestyles. In his column, Prof. Dr. phil. François Höpflinger traces this shift from institutional care to a living environment and examines how residents’ rights, freedoms, and expectations have changed.

François Höpflinger, Prof. Dr. phil., is a renowned social scientist, emeritus titular professor and member of the steering committee of the Centre for Gerontology at the University of Zurich. With his many years of expertise, he is probably the most sought-after expert on ageing in Switzerland and a key voice in the debate on the challenges and opportunities of an ageing society.

Retrospective

Until the mid-20th century, Bürgergemeinden (local citizens’ communities) were responsible for providing care for poor, sick, and elderly people. Accordingly, local citizens’, poor, and old people’s homes were established. These were often located on the outskirts of towns, with large plots of land and gardens for self-sufficiency, where residents – regardless of age – were required to work in agriculture or gardening. In the poor and old people’s homes of the 19th and early 20th centuries, strict house rules applied (including bans on visiting inns, attending dances, or consuming alcoholic beverages within the home) (see Brändli 2022). The institutional character of many municipal homes for the elderly remained dominant until the 1950s and, in some cases, even longer. Modernization (including professionalization) of municipal elderly care only took place in the second half of the 20th century.

Between 1970 and the mid-1990s, residential elderly care expanded in many regions of Switzerland, both through modernization of municipal institutions and through the construction of new elderly and nursing homes based on new care concepts. Increasing consideration was given to residents’ lifestyles and life histories. In recent decades, multi-bed rooms have largely been replaced by single rooms, and house rules have become more flexible, including extended visiting hours. Homes have also opened up more to the outside world – for example, by allowing external visitors into their cafés, letting local associations use community rooms, or organizing intergenerational activities such as kindergarten children baking cakes together with elderly residents.

Expansion of Rights and Freedoms

Over time, the rights and freedoms of nursing home residents have gradually been expanded – for example, the right to have a beer at the local pub or to order a pizza for delivery. Participation in organized events has become voluntary, whereas attending church services was once obligatory.

The Swiss Civil Code (CC) and cantonal regulations enshrine, in principle, the right of residents (that are capable of judgement) to participate in decision-making. This includes involvement in care-related decisions, the ability to file complaints, and the assurance of autonomy and self-determination. Many homes have introduced residents’ councils or committees as participatory bodies. However, developments in recent decades – such as the growing number of residents with dementia and shorter stays – have limited the scope for active participation by many residents.

Today’s main principle is that elderly residents in nursing homes retain, as far as possible, all the rights enjoyed by people living in their own homes. This applies, however, only insofar as the rights of other residents are not disturbed. Thus, homes – like all other public facilities – generally have smoking bans, although many still allow the smoking of cigarettes, cigars, pipes, and sometimes even cannabis products in designated smoking rooms.

Certain issues remain controversial or are handled differently in practice. For instance, political activities in nursing homes raise questions: residents with the capacity of judgement are entitled to vote in elections and referenda, and this is ensured through on-site ballot boxes. However, it remains disputed – since it can cause considerable disturbance – whether political parties should be permitted to hold campaign events or collect signatures for petitions and referenda within nursing homes. As far as can be judged, there are no clear legal regulations or landmark Federal Supreme Court rulings in Switzerland regarding political activities in nursing homes.

Controversy also persists concerning assisted suicide within nursing homes. An increasing number of institutions now allow assisted suicide to take place on the premises, if requested by residents, avoiding the need to transfer to another location. The most successful practice has proven to be one in which the organization and responsibility lie entirely with the assisted dying organization. The home itself is not directly involved, but merely provides the space where the dying process occurs.

Homes as Places of Living

In recent decades, greater attention has been given to the biographical and domestic aspects of residents’ lives – for example, allowing them to furnish their rooms with personal furniture and meaningful objects. In general, the homeliness of nursing homes has been intentionally enhanced in recent years, including through warm color schemes and stimulating outdoor areas.

However, the notion of the home as a “normal place of living” always exists in tension with other aspects such as safety and care standards. Some homes still feature architectural elements from earlier periods, such as long corridors and hospital-like layouts, that detract from a sense of homeliness. Safety and fire regulations also restrict design possibilities, for instance by requiring visually unappealing security doors. Even personal room design is subject to care-related limitations, such as the need for standardized nursing beds rather than personally chosen ones.

The modernization of nursing homes in terms of their living environment often receives too little public attention, partly because many older people still hold outdated images of care homes from the past. Negative individual cases receive media attention, while good examples often go unreported. At the same time, there has been an increase in elderly nursing home residents who, due to psychological and cognitive impairments, generally find major changes difficult to handle.

For most people, the move from a privately arranged, often “unsystematic” home environment to a facility structured by safety and care standards represents a major upheaval – much of one’s former surroundings are lost, and the living environment is different. This transition can be particularly painful for those who have shaped their own home over many years. A nursing home can certainly become a new – initially unfamiliar, later familiar – place of living, but it can hardly replace the previous home.

Therefore, it is crucial that, as far as possible, the transition before and after moving into a nursing home is carefully supported. This includes communicating both the changes that will occur and the new benefits that may arise. It is not helpful to mislead prospective residents and their families into believing that “nothing will fundamentally change” upon entering a home simply because it defines itself as a “normal place of living”.

Reference:

Brändli, Otto (2022) Aufgewachsen im Altersheim. Alters- und Pflegeheim Böndler in Bauma, Mönchaltdorf: Bubu AG.