NURSING'S ROLE.

Once upon a time (in the early 1900s), compassionate nurses, deeply concerned about the health and care of the nation's elderly, began to care for those elderly individuals who could not care for themselves and who had no one to care for them. These nurses--the first gerontological nurses--opened their homes and their hearts at a time when the elderly had no other alternative but to accept that loving care. Indeed, nurses were the first professionals to begin research and study in the area of gerontological health, as evidenced in an early issue of the American Journal of Nursing, 1904, in an article by by L.F. Bishop. The article, The Relation of Old Age to Disease, with illustrative Cases, clearly demonstrates the interest of the nursing community at that early date. It was unique--the first such study of its type.

Thus, "nursing homes" were just that--homes for the sick elderly. These were homes where nurses provided excellent care, without government subsidy or involvement. The basis for their care was concern and compassion. The homes were accepted in the community and were respected.

The Great Depression drew attention to the plight of many of our nation's citizens, including the elderly. In 1935, the Social Security Act was enacted and thus provided some funds, on a regular basis, for the elderly. Boarding homes for the elderly came into the picture and these also were overseen by retired and older nurses. The care continued to be patient-centered and compassionate.

By the early 1950s, under the Hill-Burton Hospital Survey and Construction Act, funding became available for the construction of nursing homes, and the number of these homes grew. Some were religious, some public and some for-profit. Nursing homes became an interesting source of revenue. "Nursing homes," as once known, were becoming a thing of the past and were fast becoming a big business. Entrepreneurs were titillated by the revenue potential of these homes.

After 1965, the long-term care industry grew rapidly when the federal government became more involved in the care of the nation's elderly. Contributing factors, of course, were the establishment of Medicare and Medicaid. Medicare provided reimbursement for skilled care in an "extended care facility," and Medicaid provided for care of the indigent. While regulatory guidelines were established for these programs, much was left up to each individual state for the regulation of its nursing homes. This later proved to be somewhat ineffective. There was, in many cases, more concern for revenue than for care. The public's negative impression of the nursing home industry grew during this period. Claims of abuse and neglect were reported and investigated.

From the 1960s to the present time, exposes involving "profiteers" and "abusers" in nursing homes have continued. The media brought a sense of "panic" to the public as the number of exposes increased. The public outcry was heard throughout the nation. It became more and more difficult to recruit professional nurses to work in nursing homes. Indeed that problem continues to this day, and poses a very serious problem to the nursing home industry.

Some of the scenarios portrayed by the media were accurate, some were not. Unethical legal experts latched on to and took advantage of the public outcry. Legal actions involving the industry proliferated. With increased litigation involving nursing homes, nursing administrators (directors of nursing) and their professional staff (registered nurses and licensed practical nurses) have become acutely aware of their professional liability in nursing homes. This has caused an exodus of many of these professionals and has fostered an atmosphere of paranoia in their work setting.

Many experts in the long-term care industry said that if the industry had properly regulated itself throughout its formative years, it would not have become the second-largest regulated industry in the nation.

With heavy governmental and public pressures on the long-term care industry, the industry has spent millions (possibly billions) in dealing and negotiating with regulatory and other agencies in an attempt to bring more reasonable expectations and reimbursement to the table. In addition, millions more have been spent fighting litigation related to neglect and abuse. Some speculate that these monies are being "taken" from the long-term care industry and thus from patient care. This is an "ostrich-type" opinion. They fail to see or understand that the monies spent or penalties incurred are for the welfare of the long-term care patient. Hopefully, these penalties will drive the industry to more carefully scrutinize itself, to regulate itself, to instill newer philosophies in its operations and to initiate models of good care. Perhaps the industry will come to realize once again that "nursing homes" are for the "nursing" of their residents. Then, as with any healthy industry, the revenues will actualize and incre ase.

At the end of this century, as we scrutinize current "happenings" in our industry, we must admire the stamina of an industry that is beset by many challenges. We must recognize the efforts of thousands of nursing homes and caregivers who, in spite of pressures and poor public recognition, have endured and continue to provide excellent care for most of our nation's sick elderly. These homes--nonprofit, public and for-profit--have met the demands of stiff governmental regulations, increased oversight inspections, unreasonable reimbursement policies, and more, and yet still provide excellent care. It is our hope, at NADONA, that they are sustained and supported throughout the next 100 years, and that they will receive the recognition that they deserve. Godspeed to those facilities and caregivers who have endured!

Joan Warden-Saunders is executive director of the National Association of Directors of Nursing Administration in Long Term Care (NADONA).

Factoids from Nursing Homes, 1962

Just in case you think things haven't changed much in the past 35 years or so, take a look at these tidbits, reprinted from an article in the August 1962 issue of Nursing Homes, Common questions About Nursing Homes...and Their Answers."

Question What will it [a nursing home] cost to build? How much should land cost?

Answer: Most authorities agree building and land costs should run between $6,000 and $7,000 per bed. The American Nursing Home Association says land costs should not exceed 20% of the total But builder Warren Wittman, of Columbus, Ohio says he can pay more if a top-drawer location demands it Furnishings will average $500 per bed, but this includes items like furniture and TV for public areas. Builders Sander Field and Edwin Ducat, who have built four nursing homes (321 beds) and two general hospitals (226 beds) in the Philadelphia area, contend the safe limit for mortgage debt is $3,00 per bed.

Question: What does it cost to operate a modern nursing home?

Answer: A recent Public Health Service survey shows costs vary from $3.38 to $13.85 per day per bed. Acceptable nursing service would require a minimum of $7 per day, according to the American Nursing Home Association. This is more than most states will pay for welfare-aided patients (in 14 states, payments range from $65 to $225 per month), so unless state laws let relatives make up the difference, few new nursing homes can take public-aided cases.