Nursing Care – The truth About What is Required

Maximum Dependence is Normal for all Residents of Long-Term Care Facilities

Long-term care, nursing care, skilled care, nursing home, personal care home – the terminology is varied depending on your jurisdiction, but the concept is similar. Nursing care seems to be a little more universal and generic, so we will use that terminology here.

The landscape for nursing care has evolved over the years. At one time, residents in a nursing care facility were varied in their capabilities to perform activities of daily living. Residents ranged from minimal to maximum dependence, with many requiring intermediate to maximum attention. Today, maximum dependence is normal for all residents of long-term care facilities. Independence is normally evaluated in six categories:

  • Bathing and dressing
  • Assistance with meals including feeding
  • Ambulation / mobility / transfers
  • Elimination
  • Professional intervention (such as oxygen therapy, skin care, recording of vital signs, and treatments / medications
  • Behaviour management / support and supervision required. 1

Of course, maximum dependence has a significant impact on operations and facility design. Operationally, the demand on staffing time is very high. Residents have high needs and require focused attention to meet daily requirements, the majority of which are non-medical. Nursing care, as a medical model, is high in regulatory requirements, including minimum medical staffing and procedures. This is a significant issue in rural facilities with modest populations and limited medical professional resources.

Facility design is also driven by resident needs, compounded by operational and medical regulatory requirements. As examples:

  • Resident with mobility issues:
    – Staff need to assist with getting in and out of bed, chairs, using the toilet
    – Staff experience injury due to physical requirements
    – Facilities add patient lifts and tracks to minimize workplace injury and assist in resident dignity
    – Resident room design is modified to allow for tracks to be continuous into resident washrooms, doorway widths are increased in size, structure is added, power requirements are increased, washrooms are expanded to allow for two staff members to assist, etc.
  • Resident with dementia and behavioural issues:
    – Resident is confused and frustrated by unfamiliar routines and environment
    – Staff use sedatives to manage disruptive behaviour of frustrated residents
    – Quality of life of resident diminishes, including overall health dimensioning due to lesser physical and mental stimulation as a result of sedative use
    – Smaller household design with nine resident rooms, living room, dining room and kitchen attempts to create familiar routines and living environment
    – Staff specialization is reduced in favour of familiarity between staff and resident – building relationships to reduce frustration and anxiety
  • Infection control:
    – Residents with weakened immune systems, particularly in larger facilities, are susceptible to viruses
    – Precautionary measures are taken to reduce the spread ofviruses, including increased hand sanitation, enhanced facility cleaning techniques and quarantine procedures
    – Facility design introduces additional strategically placed hand wash sinks (differentiated from resident washroom sinks and kitchen or activity sinks), requires building materials to readily cleanable and layouts are reviewed for quarantine procedures

Assisted Living – Slowing Physical Deterioration by Introducing Meaningful Activity

Assisted Living, Supportive Housing, there are many jurisdictional variations on the definition of these terms. Simplistically, these are housing models that provide support to residents in their apartment style homes, which are grouped together for efficiencies.

Assisted living environments were created as a means to bridge the gap between the independence of the family home or independent living style condominiums or apartments, and the need for nursing care. Typically, a resident in an assisted living complex needs some assistance with daily household activities:

  • Housecleaning and laundry
  • Preparing healthy, well balanced meals
  • Remembering to turn off the stove or sink
  • Remembering to take medications
  • Shopping
  • Bathing
  • Mobility is diminished

It is important to note that memory care is significantly different than caring for a resident with physical mobility challenges.

Many seniors are fiercely independent and insist on remaining in their single family home as long as possible. Home care services assist with enabling this outcome, providing services as needed to maintain physical health. We should, however, be equally concerned about a seniors' social and psychological health. Assisted living communities, as with other seniors' communities, reduce incidents of isolation particularly with group dining and programmed activities. This is critical in reducing physical deterioration as well as providing opportunity for meaningful social interaction and activity.

The design of assisted living facilities is typically a housing model. Suites are residential in style and material choices, with bedrooms, living rooms and small kitchens / kitchenettes and modest dining facilities. Washrooms are sized for the use of wheelchairs and walkers but assume residents are capable of functioning independently. The suites are usually modest in size to reduce costs to the resident with more emphasis placed on common areas such as dining rooms and lounge and activity areas. Many complexes have chapels,, exercise, theater, craft and workshop, wine making, library and / or game rooms to suit the lifestyle choices of the residents. The desired outcome is to encourage a community of social interaction.

Can Nursing Care and Assisted Living Coexist and Should They?

Many providers of independent and assisted living have aspirations of extending services to include nursing care. Similarly, many nursing care organizations are expanding into assisted living, taking advantage of existing kitchen and laundry infrastructure and an established nursing program to grow their operations.

There are implications to crossing over or 'blurring the edges' of the medical and housing models.

For organizations that are established in the housing model, the challenge is regulatory. It is a significant shift in operations and facility design to provide nursing care. Costs are higher and protocols are demanding.

For established nursing facilities, the challenge is more relational – allowing residents to function as independently as possible, resisting the temptation to intervene with solutions. Furthermore, it will require some amount of courage to not over-manage the residents' schedule or significantly limit the program of activities out of an 'abundance of caution'.

From the perspective of the resident, a variety of options would seem ideal. In the past two decades there has been a focus on developing defined models to suit a segment of population and their specific needs. These individuals are then grouped together and asked to live with others who are similar, primarily to improve support staff efficiencies and to allow specialists to work in one location. Current thinking on integration would suggest that groupings based on needs should be de-clustered, allowing residents to continue to live in the broader community, in appropriate accommodation, with the appropriate service delivered to the home. This is not to say that every individual should 'age-in-place', remaining in the family home. A wholehearted acceptance of the 'aging-in-place' model inevitably leads to isolation, removing seniors from a community of social interaction and support while their world becomes smaller and smaller.

A concerted focus is needed to integrate our seniors into community. The goal is to develop healthy intergenerational communities with blurred edges between family housing, seniors housing of any type and nursing care. For this reason we should be pleased when medical model and the housing model merge together and providing options based on need and preference is pursued. These models will continue to merge as universal design principles are more fully implemented in market housing, commercial and community buildings. Similarly, the medical model will continue to be de-institutionalized from a design and aesthetic perspective – and we need to encourage our care giving staff to modify regulatory requirements to provide pleasing, homelike communities for our most dependent residents.

Assisted living, in all its varieties, and nursing care, deinstitutionalized, should not only co-exist with each other – they should be fully integrated into communities.

1. Manitoba Centre for Health Policy, University of Manitoba.


by Jerald D. Peters, Architect, AAA, AIBC,, MAA, OAA, SAA, MRAIC, LEED® AP, Principal at ft3

Jerald Peters brings more than 18 years of experience creating vibrant, functional spaces, and has provided leadership and technical expertise on an extensive array of projects in healthcare, institutional, housing,, commercial, and religious environments.