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Ageing International

, Volume 43, Issue 1, pp 34–52 | Cite as

“‘Call Security’: Locks, Risk, Privacy and Autonomy in Long-term Residential Care”

  • Frances Tufford
  • Ruth LowndesEmail author
  • James Struthers
  • Sally Chivers
Article

Abstract

Locked doors and secure units are often used as a solution in long-term residential care (LTRC) for residents with moderate to severe dementia who are at risk for wandering and potentially harming themselves or others. This practice creates important quality of life implications for residents as well as for employees. In this paper we explore broader assumptions, connotations and possibilities of LTRC built environments by comparing and contrasting the use of and philosophies regarding the locking of doors and entire units in facilities that maintain this practice to those that have open doors, open units and other accessible physical spaces. This sub-study is part of a larger international, interdisciplinary study that uses rapid site-switching ethnography within a feminist political economy framework to investigate promising practices in LTRC. Field observations and interviews with management, health providers, support staff, informal care providers, union representatives, residents and family members were conducted in 27 sites, 10 of which we elected to include for the purpose of this paper, located in Nova Scotia, Ontario, Manitoba, and British Columbia (BC), Canada, as well as Norway, Germany and the United Kingdom (UK). Locked doors and units, and inaccessible physical spaces affect the balance between “home” and “institution” in LTRC facilities in numerous ways including privacy, mobility and autonomy of residents, the ability to remain socially connected within the home, possibilities of integration with the larger community and overall quality of life and care.

Keywords

Feminist political economy Ethnography Long-term care Elder care Nursing home design Homelike versus institution Locks Risk 

Introduction

The built and tangible characteristics of a physical environment have real effects on the health and quality of life of the people who inhabit those environments. An overwhelming body of research shows how, from reduced rates of depression, cardiovascular disease, and other increased indicators of an active and healthy lifestyle, the physical characteristics of a residential environment can have critical effects on a number of quality of life and health indicators (Ewing et al. 2008; Frumkin et al. 2004 and others). Mixed environments with access to public and community spaces promote inclusion and robust social networks that can be indicative of increased quality of life, longer life expectancy and increased happiness (Leyden 2003; Jacobs 1961). The range of physical health, mental health and social benefits that are possible from a physical environment relate to the experience of older adults in residential care, where the physical and environmental determinants of health intersect with the variegated unique and particular care needs that older adults have in the built environment.

Few studies explore the particular connection between the built environment and ageing in long-term care, a topic that will become increasingly relevant as the global ageing demographic trend continues and life expectancies continue to rise. A critical characteristic of the built environment in LTRC includes physical and spatial attributes that relate to security, access and exiting. All facilities have policies and mechanisms in place that govern exiting, access and security, and there is a pressing need to investigate the effects that these features have on the health and quality of life and care that residents experience. Locks and locking are valuable vehicles to examine some of the most important issues and dynamics in LTRC because they magnify key tensions and concerns, such as the friction between home and institution. Within no other part of the health and social care sector is there such an emotionally charged debate over the meaning of what constitutes a “home.” Locks and locking are similarly telling of constructions and conceptions of risk management and risk assessment in LTRC, and an examination towards this end reveals important assumptions and practices that have implications for the experience of residents and workers in these environments. Locks and locking also relate closely to measures of quality of life and the existence or absence of a “homelike atmosphere”, a topic that will be explored later in the paper.

In order to investigate the importance of locks and locking as they relate to ageing in LTRC, this paper uses interview data and field observations conducted by researchers during a multi-year, international, interdisciplinary research project entitled “Re-imagining Long-term Residential Care: An International Study of Promising Practices” led by Dr. Pat Armstrong. Researchers conducted fieldwork in a range of long-term care facilities that were selected for their potential to show promising practices in approaches and philosophies of care, accountability, financing and ownership models, work organization as well as physical and environmental structure and organization. The far-reaching and extensive nature of the project presents a unique opportunity to study locks and security practices in these settings. Along with observations, interviews were conducted with management, health providers, support staff, informal care providers, union representatives, residents and family members across 27 sites, 10 of which were elected for inclusion in this paper, located in Nova Scotia (1), Ontario (2), Manitoba (1), and BC (2), Canada, as well as Norway (2), Germany (1), and the UK (1). We selected our sites from the larger number based on the most promising or notable uses of locks and locking, from specific sites in which the authors of the paper engaged in fieldwork, since we were not all at each site studied in the larger project. In addition to 285 interviews conducted at these 10 sites, observations were carried out by researchers from different disciplines and countries, who worked in pairs covering every shift on both secure and open units. The extensive fieldnotes collected at each site are a key part of the rapid ethnographic approach used in the project that provided researchers with an in-depth ‘snapshot’ of the different LTRC facilities. This method allowed researchers to capture a comprehensive sense of the sites and jurisdictions and begin to point out promising practices in the structure and organization of each setting, while also allowing them to study a larger number of places. Field observations were then categorized thematically for ease of analysis. The fieldnotes provide rich information and descriptions of the physical and built environments, as well as how residents, care providers and visitors navigate conceptions of risk, practices of security and safety, as well as opportunities for exiting and access. The interviews and fieldnotes reveal assumptions and possibilities that exist around security, exiting, and escape and how these are navigated, evoked or challenged in the built characteristics of a LTRC home. Who is able to exit and travel, in what ways and at what times in these settings as well as the assumptions that are reflected in these possibilities reveal crucial ways that the built environment interacts with and affects those who use it.

Home and Institution

Locked and unlocked units, wings, and rooms in LTRC contribute to the complex dynamic that makes up the balance between “home” and “institution”; this balance is manifested in the physical environment and has an impact on the comfort, safety and quality of life of residents and staff. The tension between “home” and “institution” is consistently present in LTRC and issues of access, exiting and locking are central in these places where this dynamic can pivot. The dual nature of locks relates importantly to this tension because locks can either provide a sense of safety and security or can produce a sense of entrapment and exclusion. Locks and locked units in LTRC settings perpetually navigate a balance between these two poles that relates to the balance between home and institution in ways that will be explored in this paper. This dynamic appeared in a range of different ways in the observations of the various sites studied in the project. This section will explore the role that locking and locked units play in contributing to the ubiquitous tension between home and institution.

Locks and the keys or codes that can open them have a close and important relationship to localized power. Power in a LTRC facility is often contentiously and variably navigated by those individuals both receiving and providing care. Power dynamics can manifest larger, structural issues that contribute to the gendered, racialized, and precarious nature of care work, as well as the cultural and social forces that work to marginalize ageing people in our society (Armstrong and Braedley 2013). Smaller-scale and more localized, but not insignificant power dynamics are also at play in the physical environments of care facilities that are in many ways related to the tensions between home and institution. These forms of power relate closely to some of the most crucial characteristics of the concept of “home”, including control over what takes place in a residential space, comfort and privacy. Control and power are closely linked, and control over what takes place in a space, or who can enter and exit it, can be an important indication of power in a LTRC facility. The ability to move freely inside and outside of a long-term care home depends on the relationships of power around locking and accessibility, and these are negotiated in a variety of ways in the homes studied on this project. The sites presented a range of levels of accessibility and inaccessibility, from open access to outdoor spaces, wider communities, cooking facilities and medicine cabinets, to entirely closed units with no possibility of exiting, combined with various locking and inaccessibility measures such as codes, secure elevators and doors. A site with open access throughout the building is described in the following fieldnote:

[In this LTRC home] there are no locked doors anywhere. All doors are open, and residents can come and go as they wish... The door to the stairs off the dementia unit opens and closes with an arm band but the residents can still use the elevator as it is not a falling risk... The residents can go to whichever common unit they want to. It is based on an out-patient style, not an area or floor-based style. They are based on a unit but not restricted to any particular floor. They can drink whatever they want 24 hours per day. (fieldnote, Germany)

In contrast, the next reflective fieldnote was written in a LTRC home in which there was a secure unit with no ability for residents to move freely through the rest of the building or to go outside to the enclosed garden, and little space to wander or relax in the unit itself.

Looking again at the chairs lined up against the wall, facing away from the TV; seeing that the activity room is closed, along with the dining area, I can't help thinking that, although this is a much newer building by a century, this secure unit is a much less family or resident-friendly environment for socialization than its counterpart at (name of LTRC home). There is simply no place for residents to congregate in smaller groups with each other or with volunteers or family members, apart from their own rooms. Its form does not suit its function. (fieldnote, Ontario)

This inconsistency is indicative of the crucially important role that locking and access play in the possibility for LTRC homes to be safe, equitable and healthy environments that strike an appropriate balance between home and institution.

Privacy and the ability to access private spaces are key components of agency, dignity and social wellbeing for people of all ages, and constitute a pivotal nexus where conceptions of home and institution can clash. As Mary Douglas (1991) asserts, “privacy is cherished in the home”, but it is not always available in long-term care facilities (p. 305). Locks on residents’ doors that can be controlled from the inside mean that residents have access to the kind of privacy characteristic of home – this was not the case in all of the sites studied on the project. Further, privacy is not conventionally associated with many institutional settings that are organized collectively such as schools, prisons and long-term care facilities, and that are oriented towards collective outcomes such as education, reform or health. These institutional goals depend on various forms of interaction and interpersonal contact such as teaching, surveillance or care, and in this way can be incompatible with personal desires for privacy. This is one way that the ability to access privacy through locking is a central part of the divergence between home and institution in LTRC environments. Privacy is also arguably a key composing element of quality of life, as will be explored later in the paper.

Leslie Morgan (2009) examines the relationship between privacy and home in “Balancing Safety and Privacy: The Case of Room Locks in Assisted Living”. Though this study looked at assisted living as opposed to LTRC, which was the focus of our study, there are important connections made between locks, privacy and the idea of home. The article notes an explicit tension between safety and privacy, and the role that locks play in this critical interface. In differentiating themselves from LTRC facilities, assisted living frequently notes in their marketing literature the ability for residents to lock their own doors as a key indicator of a move away from the more institutional nature of long-term care. “[L]ocks were employed as a symbol that assisted living was a residential setting” (Morgan 2009, p. 188). In reality, many do not allow locked resident doors, and/or many residents in assisted living do not feel strongly about locking their doors, or many do but their family members do not. The convergence of locks, locking, care, safety and the boundaries between them is one of increased complexity as growing numbers of residents age in these places and become frailer, and more cognitively impaired.

Who holds power to determine access and exiting through doors, locks and codes is crucial to the tension between home and institution. An important dynamic of idealized, contemporary Western notions of home and comfort at home involves the ability to come and go freely, and this is frequently not compatible with the purposes, goals and realities of institutional settings. The heightened concern for privacy, which led to the demand for locked doors inside homes, was a bourgeois invention of the eighteenth century and was driven by the new middle class desire to physically segregate servants from the families they served, in order to heighten their own sense of privacy as a bourgeois domestic virtue (Rybczynksi 1986). As Rybczynksi (1986) argues, “the new sense of family privacy demanded that servants be kept at a distance. They were housed either in separate wings or in a small room between floors” (p. 87). In this way, class as well as gender were both deeply inscribed in new ideas around the stricter regulation of movement within the bourgeois project of reimagining of domestic space from the eighteenth century onwards. Within the twentieth century nursing home, however, this distinction collapsed. Care workers were given free access to move in and out of residents’ private spaces, in order to perform their work activities. Recently, this tension over control of space has re-emerged in the campaign for residents’ rights to lock their own doors.

In many of the sites studied on the project, residents benefited greatly from the ability to access the outdoors, move freely around the facilities and into the wider community and access privacy in their own rooms. And in other sites, residents were more confined and building designs created further barriers. Some were hospital settings with LTRC units within, such as in Ontario, Canada, where it was confusing to navigate through the facility, as noted in the following fieldnote:

We are told that the building design makes maneuvering difficult. There are three sets of main elevators to access the seven floors, but as we discover, some do not enable access to some floors, or certain areas on various floors, which must be accessed in a round-about way. (fieldnote, Ontario)

A participant confirmed this observation and commented on how building structure, location and low staffing levels combine to create barriers to residents’ quality of life:

I mean (name of LTRC home) looks like a hospital, right? So environmentally it’s not friendly. And we have currently a couple residents, and I have one of mine, died this last year who were just desperate to go outside but can’t go outside without somebody going with them because it’s so complicated getting in and out of that place, right? So a large part of it [is] environment. And, you know, if there were the ability to have animals around or just something nice to look at whether it’s even a big window looking out over kids playing. You know, it’s that environmental stuff that I think would be a huge contributor to quality of life and we just can’t do it. You know, the building would need to be knocked down and rebuilt. (Interview with physician, Ontario)

This interview makes clear the close, interconnected relationship between the physical layout of LTRC homes, safety, access, privacy and quality of life.

It is worthwhile to examine the concept of home in order to be able to define some of the ways that LTRC facilities relate to and contend with this conception. A recent government of Ontario report on the reformation of LTRC titled “Bringing Care Home” (Government of Ontario 2015) defines home as, “wherever [a] person resides. It can be a private residence, supportive housing, retirement home, or just about anywhere except a hospital” (p. 1). This conceptualization of home as “anywhere except a hospital” is interesting in light of a common complaint of LTRC overheard on the project: that facilities were ‘hospital-like’. If it is clear that a hospital is definitively not a home, and that hospital-like qualities often found in LTRC facilities are not desirable to residents, then who benefits from these ‘hospital-like’ features?

Looking at other conceptualizations of home – a term that is widely used and variously defined – will help to determine its substantiation in LTRC. Mary Douglas (1991) in her article “The Idea of Home: A Kind of Space,” explores the concept of home, first by foregrounding its distinctly spatial quality and the ways it is manifested materially. Although Douglas reflects only one particular cultural representation of home that is largely white and heteronormative, her insights are nonetheless useful here due to their spatial considerations of the concept of home. She states that, “home starts by bringing some space under control” (p. 289). This means having autonomy and control over some amount of space, whether through the reflection of personal tastes in a space or through the power to lock and exclude, the power to enter and exit freely, invite or exclude others or operate without surveillance or scrutiny (Douglas 1991). This spatial control is a crucial element of locks and locking in LTRC because it is that spatial control through locking and access that is frequently decidedly absent for residents living in these settings. They are in this sense unable to access what is a crucial characteristic of this conceptualization of home, adding to the tension experienced between home and institution.

The moral configuration of the home is another defining feature (Douglas 1991). Douglas insists that home “cannot use market reasoning” because it is a “virtual community” and hereby makes a distinction that says that profit and home are incompatible (p. 298). This is in part because of the emotional labour as well as the unpredictable complexity of systems of exchange that are characteristic of the home. Many LTRC homes are run on a profit model, with variances in the contracting out of services such as food to for-profit companies. The cost-benefit, profit model and its relationship to risk, locking, security and quality of life will be explored later in the paper, but it is clear that there is a level of incompatibility between this model and the idea of home, as home is explicitly not-for-profit in Douglas’s abstraction due to the complex emotional care and supportive systems involved in the functioning of the home. It is also imperative to recall the gendered implications of home, a space where the majority of the social reproductive work is done by women. This is carried over into the long-term care facility where gendered dynamics of care work are continually dominant (Armstrong and Braedley 2013).

Christine Milligan (2009) outlines some of the relationships between ageing and the ideas and materialities of home in her exploration of ageing in place. She similarly stresses the physicality of home as a critical feature, and notes how this feature particularly becomes defined as a person ages. She describes a feature of home as “a preconscious sense of setting,” which creates an intense spatial familiarity that provides safety and comfort in the ageing process (p. 68). Locking and privacy relate to this level of spatial familiarity because they provide a level of comfort and knowledge that is characteristic of home. Locking and accessibility are ways that residents obtain spatial control, comfort and familiarity, and in this way obtain a sense of home. The extent to which this is available in LTRC is variable and is dependent on a number of factors, including locking and accessibility, as this paper argues. Milligan (2009) also points to the sense of control and autonomy that can come from the ability to lock – for her, the power to exclude and to control who has access to your space is an important factor in the concept of home. In this way, it becomes apparent how locking, privacy, control and concepts of home are linked.

In the project site studies, there were high levels of variation in how residents’ bedrooms were treated as private spaces, including door positioning, how bedrooms were exited and entered, the use of locks and other barriers meant to provide safety and privacy. In one home, residents’ bedroom doors were often left open as observed in the following fieldnotes: “Sitting in the alcove under the floor plan I see that a man is sitting on a commode in his room. They have forgotten to pull the curtains. I move out of sight but he has already seen me and leans forward to pull his own curtain across. Very embarrassing” (fieldnote, Ontario). “Walking down the halls in the morning – very quiet. Most residents not yet up. But most of the doors are open (privacy seems to be a ‘spotty phenomenon’)” (fieldnote, Ontario). Also observed in this same facility was the absence of knocking prior to a staff member entering a resident’s bedroom: “A snack is brought to the room of another resident. [the staff member] does not knock but enters the room using the resident’s last name” (fieldnote, Ontario). In another Ontario site, we observed staff knocking before entering bedrooms, which was identified as a promising practice. In yet another Canadian site, residents could lock their own doors (fieldnote, BC). We also saw band barriers across residents’ bedroom doors, which are meant to keep wandering residents out and thus provide a sense of safety without locking the door. Whereas in most sites, the bands were a cautionary ‘police-like’ yellow, in Nova Scotia, the band barriers were made out of decorative fabrics, sometimes with animal prints as one might find in a nursery or daycare. While this raises questions about when and how locks are part of decor, the comparative context makes plain that these band barriers can never really be “homelike.”

Locks on doors in a home can provide security and peace of mind, but require a closer and more nuanced analysis when found in an institutional setting, particularly in a place that blends elements of both home and institution. Baer and Ravneberg (2008) explore some implications of the institutional functioning of boundaries through locks, gates and barriers between inside and outside, in the context of confinement in prisons. They employ Foucault’s (1998) concept of heterotopia in order to explore the tensions and negotiations provided by the collision of inside and outside worlds in prisons – a concept that can be fruitfully employed towards thinking about locks and locking in the juxtaposition of home and institution in LTRC. For example, Baer and Ravneberg describe the intermingling of the differing inside and outside worlds that occurs in distinct ways in a prison (including the coming and going of staff, visitors, as well as the commencement and conclusion of inmates’ sentences), ways that are shaped by confinement facilitated by locks and barriers. This intermingling and simultaneous juxtaposition of inside and outside make prisons a compelling example of heterotopia that helps to facilitate a further examination of the society that constructs the social conditions of both the inside and the outside. Foucault’s concept of heterotopia describes spaces in society that contain varying principles of difference, and, is particularly useful for thinking about LTRC facilities that include a measure of juxtaposition.

Foucault’s heterotopia is applicable to LTRC because of the distinct juxtaposition between home and institution that is often present in these environments. Heterotopia begins to reveal reflections and demonstrations of assumptions about concepts of home and institution in LTRC. A focus on locking and access shows how this works and why it is important. The juxtaposition between these two poles allows each to highlight what is present or lacking in the other – the fact that these facilities are primarily homes for ageing people, and that a key component of home revolves around power in locking and privacy, which magnifies the institutional nature that clashes with the privacy, comfort and control that is ideally found in a home. The varying degrees of accessibility and inaccessibility found in sites studied on the project produce distinct tensions and implications on residents’ quality of life, autonomy, comfort and safety. It is clear that practices of locking and access heighten the juxtaposition between home and institution, and mean that the LTRC facility emerges as heterotopia. Specifically, where locks, codes and doors punctuate the difference between LTRC settings as homes and as institutions, the facilities’ nature as heterotopia becomes clear and important questions emerge: What is home? What is the function of long-term care facilities as institutions? What happens to processes of ageing and the concomitant care work in the context of locking and security?

Locking and Risk Perception

Locks and locking have an intimate relationship with risk perception and risk assessment, as well as ideas, attitudes and policies around safety in LTRC. Examining the different ways that risk is negotiated and assessed in these environments is important because the effects often influence the quality of life and quality of workplace that residents and staff are able to access. Perceptions and assessments of risk (both formal and informal) determine many aspects of access and locking in a LTRC facility, such as resident independence, access to outdoor spaces, participation in the wider community, and access to privacy, physical exercise and kitchen spaces. The sites on the project displayed a wide range of attitudes and approaches towards risk assessment and mitigation that can be revealed by examining intersections of access and locking as they are experienced by residents and care providers. This section of the paper will explore some of the ranges of thinking about risk, cultures of risk and risk perception and assessment as it relates to security and access in LTRC, its implications for residents and care workers, as well as the ways that risk perception relates to the wide spectrum of access that was observed in the various sites.

Ortwin Renn (2008) identifies three elements of the concept of risk generally: “outcomes that have an impact upon what humans value; the likelihood of occurrence (uncertainty); and a specific context in which the risk may materialize” (p. 50). How these different elements are categorized, evaluated, placed in a hierarchy and perceived are subject to a wide range of influencing factors and are rarely based on an empirical evaluation; some scholars deny that it is possible to empirically measure and capture risk (Sjöberg 2006). Although it is clear that risk is virtually always present and that it is necessary to take steps to mitigate risk, attention should be paid to the ways that risk is variously socially and culturally constructed at a societal level, as well as shaped by personal bias on a localized level. Renn (2008) outlines some of the ways that bias operates on an individual level to influence risk perception and risk assessment. Factors that will work to increase the perceived probability of a risk event include the immediacy of events and the personal connection to them, the amount of information that is available related to an event, subjective or personal past experience with an event, and new information around an event’s compatibility with an existing belief system (Renn 2008). These factors come into play in interesting ways within the context of LTRC.

Various social and cultural constructions of risk will influence decisions around safety and access that are not necessarily based on empirical evidence. LTRC facilities engage in a series of indefinite cost-benefit analyses that result in an institutional culture of risk perception and risk acceptability that is a mix of personal biases and wider societal attitudes around risk. This means that each setting may have different policies and practices around safety and risk as it relates to both residents and staff that are at once informed by the particular style of risk assessment and mitigation (personal bias) and the wider social constructions of what are acceptable levels of risk (cultural constructions of risk) (Renn 2008).

Risk aversion in LTRC is often tied to regulations. For example, falls are frequently tracked and will impact negatively on the facility and so fall prevention is prioritized. Some of the implications of this are revealed in the fieldnotes on the project; for example, observations that found participants’ and their family members’ perceived concern that residents are placed in wheelchairs to prevent falls, and due to inadequate staffing levels or cuts they do not receive adequate care. While attending a family council meeting that was included as part of the observational process, we heard concerns from family members that residents are often left in their wheelchairs for long periods of time, and not toileted frequently enough, which quickly renders them incontinent and wheelchair dependent, another manifestation of locking and inaccessibility. In a sense, residents are “locked” into wheelchairs with an alarm that sounds if they are leaving them. This alarm is intended for fall prevention but it also prevents an otherwise ambulatory resident from leaving her chair. Staffing shortages also relate to this issue, as is demonstrated by this fieldnote that captures a family member's perspective:

John 1 brings up that physio has been cut back to five minutes per week per resident. He explains that the staff used to walk [the residents] but they don’t want to anymore because if the residents are walking there are more things to do. (fieldnote, BC)

Also overheard on the project were family members’ concerns for resident safety. This fear is exemplified in the next fieldnote taken following a care conference in one of the LTRC homes. Also noted is the observed excessive use of restraints in a particular home as part of fall prevention strategies:

I attend the care conference for two residents... I note again the use of restraints in this home. The daughter of the second resident being reviewed attends the case conference and is quite anxious that she had found her mom without her belt on in the wheelchair one day when she came in. I notice that many residents have belts on their wheelchairs. The [care aide] tells the RN [registered nurse] that they tilt the wheelchair of this same resident back to keep her in (another form of restraint). (fieldnote, BC)

This reflective fieldnote highlights the observed excessive use of restraints in this same LTRC home:

There is a heavier use of restraints here, with belt use, tables strapped to wheelchairs, reclining of wheelchairs to keep residents in them, and unsure about use of psychotropic [medications]? Why are so many people belted into their wheelchairs? Would they be walking if more staff was available? I was very surprised the first meal we observed in this home at the number of people in wheelchairs on this unit. (fieldnote, BC)

These demonstrated conceptions of safety are implicated in the risk assessment and risk management cultures and policies enacted in LTRC facilities, how locking and access relate to these, as well as what care decisions are taken and freedoms given.
Risk perception and risk assessment relates closely to locks, security and access in LTRC. Residents’ access to the outdoors, the wider community or everyday activities such as cooking, exercising, or even accessing a drink of water, will be limited if an unacceptable level of risk is perceived to be attached to these spaces or activities. For example, in one Canadian LTRC home, the decision was made to lock the unit kitchens after an incident occurred, and as a result they cannot be accessed without a key. The impact this had on residents’ everyday quality of life is captured in the following fieldnote of a male resident attempting to get a drink of water:

He walked to the kitchen door, tried to open it and discovered it was locked. Turned away, and walked out of the room. 10 minutes later he was back and did exactly the same thing, with the same result, and again left the room. He returned in another 10 minutes and did exactly the same thing. This time a care aide saw him, came into the dining room and asked ‘Roger, do you want a drink?’ He spoke up this time very clearly. ‘Yes, I would like a glass of water.’She unlocked the door and got him an ice-filled glass of water. He thanked her, took the water, and left. The care aide then relocked the door … I wonder why residents like Roger couldn't get water by themselves, when they want it?... What I saw as repetitive, compulsive wandering (entering the dining room, trying the kitchen door, and leaving again and again) turned out to be simply a quest to quench his thirst in this very dry facility. (fieldnote, Ontario)

A staff member echoed how this has affected residents’ quality of life:

We had fully functioning kitchens and they took away our stoves so, you know, I used to do baking. I’m doing baking this afternoon but I’ve got to take the people down to the fourth floor instead of doing it on the floor where we all know the smells and everything else can be enjoyed. (Interview with recreation staff, Ontario)

Residents expressing a desire to leave or to go on walks were frequently overheard requesting the ability to exit locked facilities. An observed staff response in one case was, “But what if something should happen to you?”, indicating that the risk assessment in this context of the possibility of exiting resulted in the conclusion that the risks of going outdoors were greater than the rewards. Concomitantly, the physical and mental benefits available to residents from access to the outdoors are deemed lesser than the safety accorded with remaining indoors. This assessment is a subjective combination of both personal risk bias and a reflection of cultural attitudes towards risk that cannot be based on an empirical appraisal (Renn 2008). This point is illustrated in the following fieldnote, wherein two different staff members have varying perceptions that impact resident freedom to use the outdoor garden, accessible only through a numerical key code:

11:40 a.m. I speak briefly with Alicia, the RN who gave us our tour yesterday. She has just let one of the women residents in a motorized wheelchair, go outside into the garden area on her own. She says that there are two or three residents in the same category, that she will leave on their own outside. ‘She’s cognitively quite aware and has been here for quite some time. There’s no reason why she shouldn’t be able to be outside on her own when the weather’s nice.’ I agree. Her tolerance of risk in favour of resident autonomy is another promising practice.

12 noon. I observe the lunch being served in (name of unit). Betty, in her late 40s or early 50s, comes up to chat with me. It turns out she is the Educator for the unit. She says she had seen me taking pictures in the garden area outside and points out although it is a beautiful space, it was badly designed. The concrete pathway, edged on each side by large round loose rocks, is dangerous for residents using either wheelchairs or walkers to get around, as they can easily fall off the edges. Also, the pathway itself is a nightmare to navigate when there are a lot of residents outside in their chairs. Often a real traffic jam ensues if a resident needs to get back inside in a hurry. She says the pathways need to be widened and the rocks along the edges removed. I ask if, under these circumstances, she is comfortable with any residents being outside on their own. She is much less sure than Alicia, although she says that a few are able to do this. ‘The fence is only four feet, not six feet high, so it’s possible to get over it if you’re determined. It’s amazing what a determined 95 year old can do.’ I laugh and mention the straw left outside for the deer. Do they ever jump the fence? No, she says, but woodchucks do get in and eat the plants. I ask her when spring planting will begin and compliment the new wheelchair-accessible wooden planting boxes. Betty sighs, and says ‘They are not wheelchair accessible.’ It turns out that the boxes don’t allow the wheelchairs enough clearance underneath, so residents have to lean over to do planting or weeding. It’s too dangerous. Here is another design flaw for what otherwise looks like a very nice outdoor space. (fieldnote, Manitoba)

This kind of risk assessment and mitigation that sacrifices long-term quality of life for short-term risk aversion has implications for the agency of residents who lose control of their mobility, dignity, and subjecthood in the process through experiencing a “feeling of captivity” akin to being “in a prison without bars” (Heggestad et al. 2013, p. 885, p. 887). This practice can also hinge on infantilization, and assumes a level of incompetence on the part of the resident that may not be accurate.

The segregation and isolation of older adults in the effort to mitigate the risk of an injury or accident can impinge on their quality of life. The inherent subjectivity of this risk assessment becomes clear when a contrasting scenario is considered. For example, in some of the sites, residents were allowed to come and go as they pleased, to lock their private doors or to access unit kitchens for cooking, including access to knives, stoves and kettles. These LTRC facilities may have technically been considered less safe than their more ‘secure’ counterparts; however such an evaluation does not consider the benefits gained in happiness, independence and quality of life for residents who remain physically active and socially integrated. In a Canadian LTRC facility that had no secure unit, one participant who had worked in both types of settings prefers the open units for people with dementia, explained in the next quote:

You know what? When I worked at other places I have seen that it was not mixed and I thought it was good. But after I worked here if you asked me now I don’t think it’s a big deal unless they’re really, really that bad maybe. I don’t know. But I don’t find it. It’s not as chaotic. Because I was, ‘What? They don’t have a locked. It’s going to be chaotic.’ But it’s not chaotic. I don’t find it chaotic. I find they’re just lingering there. And now I have changed my mind. I used to think yes. I used to think that way. But now I’ve changed my mind … I don’t feel they should be segregated. (Interview with receptionist, Manitoba)

In a German home the philosophy of care was to put life into days, rather than extending days of life. The residents were encouraged to use their skills to the best of their ability by participating in activities of daily living. There were no locked doors, residents were not confined to one floor, and food and drinks were out on the tables and counters, and in the fridge. All residents could access the fridge, stove, kettle, etc. in the fully equipped unit kitchens and were actively involved in food preparation (much of which is done in the common units), serving and cleaning up. They used sharp knives, poured hot liquids, and assisted other residents. Real plants and candles were also part of the everyday life in this home as described in the following fieldnote:

[T]he residents do not necessarily live on the same floor as their common shared unit is on. For example, a resident can be on third floor to sleep, but is brought to second floor to spend the day in the large communal room [for up to 12 residents]….8:46 a.m. I go into the common shared unit…There is a male resident who does a lot of the kitchen work and he is back up into the fridge, then [he] looks in the cupboard. The kitchen has a large spoon/ladle, hanging plants and real plants sitting on the countertop. There is a comfortable lounge area, burgundy colour, with a basket of treats sitting on the coffee table, and a candle, which has been used previously as is apparent with the melted wax and black wick...[The qualified worker-RN equivalent] wipes up some milk that was spilled on the floor while talking on the phone in German. The residents at the tables are quiet, little chatting every so often by a male and female at one table. 9:01 a.m. She is off the phone now, continues with a glucose reading. The male resident is up, pours coffee for all the residents. A woman at the other table pours her own coffee. Menu: coffee, water, bagels, quark and muesli (mixed), cheese and meat. 9:02 a.m. The bucket with kitchen supplies is dropped off. 9:04 a.m. The qualified worker serves one plate of meat and cheese per table while the male resident hands out bagels (one man takes two, and he serves another man two bagels). He then spreads margarine on the first man’s two bagels while the staff member sets up. A male resident tries to pass milk in the container, squeezes it and it spills out. The staff and resident both clean it up. 9:09 a.m. The man who needs assistance tries to open a package of cheese, which takes some effort but he manages and then eats it. (fieldnote, Germany)

This comparison shows how safety and risk mitigation in LTRC facilities in this way are formulated using subjective assessments that frequently rely on personal bias and social and cultural constructions of risk. In many cases, perceived risk mitigation depends on locks and locking of doors, drawers and units that have an impact on residents’ quality of life and levels of social integration, as also exemplified previously in the locking of a kitchen for safety reasons. Segregation and social isolation have significant negative effects on quality of life and risk assessment strategies that do not account for this are tenuous.

At the same time that risk perception can be exaggerated for residents, resulting in an overuse of locks and restrictive practices that impede quality of life, it is important to note that significant risk exists for workers in these environments as a result of the often dangerous nature of this work (Armstrong and Braedley 2013; Banerjee et al. 2012). Many of the sites on the project noted how risk was normalized in the work environment – it is possible that locking and restricting access is a method of attempting to gain control in a precarious work situation. As noted by residents interviewed by Heggestad et al. (2013), locking and restricting activities such as outdoor walks, exercise or cooking may be a response to inadequate, overworked and/or underpaid staffing. Reiterated at many sites, care aides and registered staff have heavy workloads and do not have time to, for example, take residents outdoors. A care aide lamented, “Sometimes I wish to do more for the residents. Sometimes I like to go help to walk and you can’t because you have so much resident and you don’t have much staff” (Interview with care aide, Ontario). This relationship between risk aversion and staff shortage is prevalent in LTRC, and has effects for the health and experience of residents.

Locking and Quality of Life

As has been touched on above, practices of locking and restricting access in LTRC have implications for residents’ quality of life. Locks, locking and restricting access have the capacity to have an effect on a range of issues, from isolation to a loss of autonomy, social exclusion and loss of dignity. Residents’ ability to have control around locking, accessibility to different spaces and an ability to exit the building as they please can lead to positive circumstances and healthy, safe environments, as was observed in many sites. Locking and access also have implications for the quality and safety of environments for care workers. The ability to restrict access and exiting may be a strategy for navigating risk in the workplace, but safe facilities that allow residents mobility, autonomy and privacy are very possible. This section of the paper will discuss the relationship between locks and locking in LTRC environments and the quality of life and quality of care experienced by residents. It will also incorporate residents’ perspectives on the subject of locking, mobility and access, in order to provide a broadening of views and voices to include individuals with the lived experience of navigating locks, locking and variances of accessibility and exclusion in long-term care.

It seems intuitive that increased levels of mobility, accessibility and spatial autonomy will mean an increase in quality of life, but it is worthwhile to outline some of the details of the ways that this relationship functions and some of the ways that it is perceived and articulated by residents. Quality of life is defined by the World Health Organization (WHOQOL Group 1995) as a measure that “assesses individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (p. 1). This definition is useful in this context because it emphasizes the subjective nature of the perception and assessment of quality of life, in relation to personal desires, value systems and expectations. This is important in LTRC not only because there is necessarily an exceptionally wide range of experiences and priorities in old age, but also because dominant cultural narratives that value youth, youthfulness and agility do not typically prioritize or reflect the voices and experiences of older adults. Employing a definition of quality of life that necessitates the subjective knowledge of older adults is a constructive strategy of returning voice and agency to them. This is consistent with the methodology of the project that used interviews to reflect residents’ and workers’ perspectives, and in this way provided a range of views and voices, locating knowledge production in people with direct experience of LTRC. There are a range of debates around definitions and methods of measuring ‘quality of life’ with a variety of advantages and disadvantages that will not be addressed here, but the concept is nonetheless an important tool to think about residents’ experiences in LTRC because it is holistic and has the capacity to capture agency and subjectivity.

Access to outdoor space is an important juncture where there is a strong link between locking and quality of life. There is bountiful evidence that links access to the outdoors and physical and mental health, and yet this opportunity is not available in all LTRC environments (Guse and Masesar 1999; Sugiyama et al. 2009; Stigsdotter et al. 2010). In some of the project sites, access to the outdoors included gardens that were open and available to residents or nearby green spaces with the option of leaving the facility, either assisted or unassisted. The following fieldnotes exemplify some such LTRC sites:

Unlike any other facility we have visited, these residents can exit through their room’s patio doors into the enclosed garden space on their own, and have a spectacular view of the gardens as well as the surrounding mountains. Their inward-facing patio doors are not locked because there is no egress from the garden area. We were told that very ill “patients’ (the term constantly used in this facility) liked to watch gardening when they couldn't do it themselves. They can even go out and collect berries! (fieldnote, Norway)

In a LTRC home in the UK the outdoor spaces were configured with residents’ input as indicated in the next fieldnote:

There are two outside spaces for residents to use, one which overlooks sea and where there are tables and chairs for residents to sit outside when the weather is good. The second area is to the side of the home and has a small greenhouse, and beds for planting some fruit and vegetables. The residents said that they wanted a children’s playground to be included in this space because when the grandchildren and great grandchildren visit, they get bored and don’t want to stay. By having the playground, the residents can spend more time with their families and also see the children playing. (fieldnote, UK)

There is evidence that points to a reduced level of aggressive behaviour in dementia patients with access to a garden (Detweiler et al. 2008). Many of the facilities on the project had such outdoor spaces, but the ability of residents to access them varied considerably. This link between the ability to go outside and resident wellbeing seems so evident that it is remarkable that there is not universal and regular access to outdoor space for residents, a practice that is commonplace in other institutional settings such as schools and correctional facilities. This disparity reveals an important fact about institutionalism and LTRC: that there is extensive opportunity to provide care for older adults that is respectful, safe and fosters autonomy and quality of life, but that this is not the case in some facilities. Frequently very simple methods and practices that improve quality of life are not enacted for different reasons. Cultural mores that devalue the social contribution of older adults in society frequently result in practices that work to isolate and marginalize residents of LTRC. Denying access to the outdoors, access to privacy, cooking and exercise facilities are all symptomatic of the persistent trivialization of older adults’ needs and quality of life. These are some of the ways that locks and locking are at the crux of indicators of quality of life and dignity in LTRC.

Social and community integration are also linked to an increased quality of life (Sherman et al. 2006). Residents who regularly experience social connections and interactions will experience increased purpose and overall health. Practices around locking and accessibility have the ability to enhance or impede this relationship, either by promoting social integration between residents and members of the wider community, in particular children, or restricting this opportunity for access. Some examples of integration from the project included facilities that incorporated several community uses into one facility such as community centres or kindergartens, or LTRC facilities that housed students as well as older residents. As the director of one such Norwegian centre told us, anyone was welcome to participate in the multifaceted cultural activities of their facility; “We don’t ask how old you are…We open the place up and invite them in” (fieldnote, Norway). This kind of integration results in a level of accessibility that amounts to an extended unlocking, and has important consequences for residents’ quality of life. Access in this sense can also mean the ability to participate in and reach community spaces outside of the immediate space of a LTRC facility, such as town centres, or nearby services. The independence and social inclusion that can accompany this nature of exit possibilities is an important indicator of quality of life.

Many residents in LTRC have dementia, which heightens the arguments for and against locks and privacy because dementia can be perceived as justifying enhanced safety and security measures. One strategy that is used for coping with wandering dementia patients is to provide no option for exiting locked units. Heggestad et al. (2013) describe residents with dementia who communicate a feeling of captivity related to a loss of dignity associated with their treatment in LTRC. From the residents’ perspectives, the inability to exit draws a direct correlation between locking and quality of life. As staff in one Norwegian home told us, moving residents with severe dementia from the first to the fifth floor impeded their quality of life by complicating access to the outdoors. The improved view of the city’s magnificent harbour was small compensation. “They think they’re on a cruise ship. It makes them anxious. They say, ‘where am I going?’” (fieldnote, Norway). Residents also cite the inability to access regular homelike activities such as making a snack or getting a glass of water as an impediment to quality of life. At the opposite end of the spectrum in Germany, we observed a home where there were “no locked doors anywhere.” When asked about residents who wander, staff informed our team that they “try to distract them rather than ‘locking them in’” (fieldnote, Germany). In this site there was an apprenticeship program that essentially doubled the staffing ratio, making this possible. In another LTRC home in the UK, snacks and liquids were available to residents in a fridge with a transparent door. Residents could also freely access alcoholic drinks from the fridge. This practice results in increased access to nutrition and hydration and by extension an increase in health and quality of life.

Conclusion

It is clear from a close look at locking and access that these barriers and possibilities reveal important facts about the tensions particular to long-term care. Locks, locking and assumptions and practices around safety, security and risk are crucial points where LTRC can provide or impede safety, comfort, social and physical health and quality of life for both residents and workers. An examination of the fieldnotes and interviews from the project, Re-imagining Long-term Residential Care: An International Study of Promising Practices, reveals observations of a wide range of practices around locking and access in these settings with varying implications and outcomes for residents and workers. The project recorded promising practices in a number of sites that related to locking and access and that promoted autonomy and security of residents while also ensuring safety, comfort and quality of life. Many of the sites allowed access to privacy, outdoor spaces, social stimulation and community integration by promoting access and progressive policies around locking and security. The findings outlined in this paper have a range of implications for LTRC generally, including the physical design and layout, the planning and organizing of activities, food distribution and programming as well as particular policies around locking and security. Incorporating principles of access and autonomy into the mission, values and philosophies of these settings will be essential moving forward, as well as the encouragement and development of more analysis and research on locking in the context of LTRC. It is clear that ageing with dignity, comfort and safety is possible within this context, and that there are a range of examples of promising practices in effect to look to as we continue to advocate for and urge the working towards health and happiness in later life. These paradoxes of privacy, safety, open and locked doors, and varying feelings of protection and independence, and more pointedly, the contradictions of trying to feel “at home” while living in an institution, are powerfully evoked in the responses of a resident of LTRC. She feels her privacy is being respected by open bedroom doors on the one hand, but that her independence is being blocked by the “locked door” to her favourite spot in her unit on the other, which is closed by security, every day “after the last person has left.”

…my bedroom door is open all the time, all night. Of course the front door is locked and all the exits are locked and secure...That’s fine to me. I feel very protected here. That’s what a lot of the people think when they come here. I know I’m protected here … I feel safe. You can tell by the doors, everyone’s door is always open. My bedroom is never closed. (Interview with resident, BC)

When asked where her favourite spot is to go in the LTRC home, she poignantly remarks, “It’s locked tonight…Security people have to open it in the morning…[at] Seven o’clock…The first guy that gets in says ‘please open the door. Call security please.’ They’ll call security and they’ll open it up for you.”

Footnotes

  1. 1.

    All participants’ names have been replaced by pseudonyms in order to maintain anonymity.

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare no conflicts of interest.

Informed Consent

All participants interviewed in this study read and signed informed consents.

Ethical Treatment of Experimental Subjects (Animal and Human)

Ethical approval was obtained for this research from York University Research Ethics Board and in all jurisdictions requiring further ethics approval.

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Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Frances Tufford
    • 1
  • Ruth Lowndes
    • 1
    Email author
  • James Struthers
    • 2
  • Sally Chivers
    • 2
  1. 1.York UniversityTorontoCanada
  2. 2.Trent UniversityPeterboroughCanada

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