Looking behind the curtains

Facts not fiction in Germany’s nursing homes

Aileen, Damaris, Franzi

Everybody believes in good old German accuracy, right? Germany is one of the few countries in which civil servants investigate fast, accurately and properly. Hence, when it comes to grandparents, parked in nursing homes, we have the medical inspection service „Medizinischer Prüfdienst“ (MDK) to ensure that all of them are in good hands. So, what has it found out so far? What are the results? Are those results reliable? Most importantly, are our grandparents well looked after?

Public perception

If you enter the “quality of nursing homes in Germany” into the Google search machine, you will notice that their overall quality has evolved over the past years. At least this is what the “3. Pflegequalitätsbericht” of the MDK reported in 2012. Thisinspection service regularly investigates the quality of nursing homes in Germany since 2008. In their opinion, especially the fields of nutrition, liquid supply and the caregiving of people with dementia have shown a positive development. Reasons for this trend are the quality efforts of the nursing homes, the effect of the examinations of the MDK, and nursing transparency. But even though most homes achieved decent results, there are still fields which need reconstruction, like dealing with bedsores from too much lying (“decubitus”).

The MDK inspections between 07/01/09 and 12/31/10 form the basis of the 2012 report. This includes quality checks in 8,101 nursing homes with roundabout 62,000 nursing home residents. The results from these inspections are representative for the quality of care in Germany. 62,000 residents sounds like a large sum, but given the fact that they are spread over 8,000 nursing homes, leaves quality checks of only seven to eight residents per home! This is not a proportionately high number, considering that in 2009, the number of people living in nursing homes was as high as 717,490. That makes an average of 64 residents per home. So how can an inspection of only seven to eight in each home be representative for the whole care in Germany?

If a quality inspector surveys a nursing home, it is either an unannounced regular check, a repeated visit, or because he was called by either a staff member, a resident or family member. On a regular inspection the main focus lies in the care situation and care actions of 10% of randomly chosen residents. A good example is the nutrition situation. In 95% of all inspected cases the nutrition was appropriate. About two thirds of the residents were in need of help with eating and drinking. Four out of five (79.5%) of the residents in need of support did get this assistance. In 2007 it was only 64%, which is a positive development. What happened to every fifth person (20.5%), who did not get this support? We do not know.

As one can see, there is a positive trend in the quality of the caregiving, however, there are still enough fields worthy of improvement, including the range of inspections.

Foto

The naked truth

It is a common fact that the German medical inspection service has established an extensive criteria catalogue, which should ensure that proper conditions exist for seniors in nursing homes. It is also a common fact that, in the opinion of the MDK, most nursing homes already fulfill the majority of those criteria. Nevertheless, a great number of insiders claim that conditions are not as satisfactory as the inspection service pretends, due to invalid criteria. Hence, for the benefit of our grandparents, don’t we feel the urge to look behind the dusty curtains and to raise awareness for these grievances? How do those affect the living circumstances of the residents? Where are the major problems rooted in? And, lastly, who is to blame? In order to reveal the crux of the problem, let’s face the figures. We can find about 13,000 nursing homes in Germany. There are over 2 million care-dependent people. According to the MDK, approximately every third care- dependent person is not being taken care of adequately. In addition, about a fifth of all nursing home residents, who have been checked, are not fed or moved properly. And not enough, the dramatically growing demand in the nursing care sector makes the federal association of private operators (Bundesverband Privater Anbieter) predict that about 220,000 more care workers will be needed in the following nine years. While reading this mass of information, I asked myself why people have to suffer although they live in a home with care workers surrounding them. The truth looks a little different. One vital reason for the lack of sufficient care is the lack of care workers- particularly well-trained ones. There are simply not enough people who are able -or willing- to work in the care sector, which is not especially prominent for offering attractive wages. This shortage of skilled workers has the effect that the care workers have to cope with a heavy workload. A second major reason for the existing shortcomings is that statutory safety regulations hinder proper care treatment. This reason is simple, yet disastrous. If, for instance, a resident needed bed barriers due to his physical or mental constitution, this could not be enforced as German law forbids it. Many care workers decry these conditions as injury prevention is barely possible. Nevertheless, we cannot solely blame the external circumstances or point our fingers exclusively at the state or nursing homes. We also have to face the fact that a number of problems are rooted in the nature of age and therewith the feeling of being abandoned. This problem is rather difficult to solve by the nursing homes, as the need for communication and social interaction seems too massive for the home’s capacities. All in all, the figures are sobering. Certainly, the influence of the inspection service has improved the overall situation in German nursing homes over the past few years, and yet, the gap between the results of the MDK report and the actual situation is still unsettling. Although there is a great deal of research in terms of the care situation in Germany, this has not translated into policy. Surely, the financial burden hinders progressive approaches. Most of us are stingy when it comes to tax paying and, across the board, this is understandable. However, it is elusive why we attempt to cut in areas that are already underresourced. If we spent more money, time and effort on the matters of care, we would sooner or later have more humane conditions in German nursing homes.

Think twice

There is this unuttered, yet very prominent view that people in old age are lonely. Society equates being old with being alone and, therewith, being lonely. It is the so to speak myth of loneliness in seniority. But what does being alone and being lonely really mean? And are people in old age significantly lonelier than other age groups? The term “alone” refers to the actual time in minutes and hours a person spends alone. “Aloneness” can be interpreted individually, either positively or negatively. “Loneliness”, however, describes the negative aloneness and, very importantly,also the feeling of being lonely, even though a person is not actually alone but is integrated in a social network. Hence, a person who is alone does not necessarily have to feel lonely, yet a person who is not alone still can. Accordingly, the quality of social contacts is the key determinant whether a person feels lonely but not so much the availability or frequency of social contacts. If loneliness depends on the quality of social contacts and not so much on the quantity of possible social contacts, all age groups are equally vulnerable to loneliness. Yet, there is this self-fulfilling prophecy of loneliness in old age, this image that old age equals loneliness. Scientifically, there are divided opinions whether old age is a risk determinant for loneliness, yet most of the other determinants or circumstances have something to do with age: absence of a marriage partner, bad health status, dissatisfying relationship to own children, lack of close friends and the entry into a nursing home. Therefore it can be said that people in old age have higher chances of becoming lonely. Nevertheless, as already mentioned, it is a highly subjective feeling which means that there can be people in old age, who are still perfectly happy and integrated in society.

However, one social group is even more likely to become lonely: residents of nursing homes. As Wenger states: “Loneliness has been identified as a significant correlate with entry to residential care.” (Wenger et al. 1996, in: Hanisch- Berndt/Göritz 2005). But why is the risk for residents of nursing homes even higher than for old people in general? The reason is that most of the people that need residential care not only fulfil all the other crucial determinants for loneliness but also basically lose all of their self-determination. As soon as a person enters a nursing home, that person is viewed as being incapable of caring for him- or herself. All decisions, whether it is what to eat for dinner or when to eat, when to take a shower or where to go, are very limited in a nursing home. Even privacy is highly restricted due to double rooms or the like. These limitations are, on the one hand, due to the fact that the residents are not capable of making these decisions anymore, and on the other hand, caused by the home’s strictly organized schedule, which should guarantee a smooth and efficient process. The lack of self-government and autonomy combined with the dependency on the staff can lead to the feeling of loneliness even though there is no lack of possible social contacts. Also the limited choice of social contacts can lead to loneliness. Residents are not able to choose their social contacts freely like people outside of nursing homes. The choice is restricted to the residents, whether one likes the others or not. They are not only the nearest social contacts available but also the people one lives together with. So even if a resident, for example, really wishes to talk about his or her problems with a staff member, there still is, however, the problem of time. The staff members have to, as already mentioned, guarantee that everyone is taken care of in the same manner which does not leave much time for the social aspects. All in all, it can be stated that people in old age have a higher risk of being lonely, especially if they enter residential care. This problem, however, is not the fault of the staff. More time for the social aspects would probably help the residents to feel more comfortable but the staff members are not able to replace real friendships, simply because they are getting paid to take care of and communicate with the residents. Only people that socialize with the residents out of free will, just like it happens in the “real world outside” can help to tackle loneliness.

In the end, loneliness in old age is not only a matter of the nursing homes, the insurance companies, politics or the inspection service, but a matter that should concern our society in general. We will all be old someday and we all might need help at some point and then how do we want to be treated? Therefore, we have to ask ourselves how we want to and can participate in this tough task.

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