Nursing homes shouldn’t be a guilt-ridden choice for overwhelmed caregivers
Modern designs, use of technology and better understanding of the needs of seniors allow for living and leaving with dignity.
Jamie Mervyn Lim and David Ng
Ms T’s mother, battling multiple health issues, was hospitalised with a lung condition. As her condition worsened, she was given a prognosis of one to two years of life.
Despite exploring care options, Ms T felt overwhelmed by her mother’s escalating medical needs and behavioural issues. Yet, the idea of placing her in a nursing home was daunting. She feared she would be “giving up” on mum.
This dilemma is increasingly common as Singapore’s population ages. By 2026, 21 per cent of Singaporeans will be 65 or older, rising to 25 per cent by 2030. While there are efforts to promote healthier ageing and community care, some seniors cannot remain at home due to complex healthcare needs or a lack of caregivers.
As well, the nuclear family model has shrunk, and many caregivers face ageing and health issues themselves. In cases like Ms T’s, caregiving can become stressful and unmanageable.
But nursing homes in Singapore have evolved significantly, and provide a much-needed alternative when home care is not feasible. It is time to remove labels and stereotypes about nursing homes so caregivers without choice should not be made to feel guilty.
Far from having grim, dormitory-like wards, newer nursing homes have modern designs that emphasise person-centred care with a holistic focus. This approach addresses both the living and dying needs of residents, challenging old notions of nursing homes as places to “wait for death”.
Past problems about mistreatment
As at 2020, Singapore had 16,200 nursing home beds, with plans to double this number in the next decade.
By 2022, there were 83 nursing homes, with 53 public or not-for-profit and 30 private. Historically, homes were perceived as offering only basic care with little regard for residents’ dignity. Concerns about care standards were exacerbated by incidents like mistreatment at Nightingale Nursing Home in 2011. A man secretly filmed his 77-year-old mother being slapped and thrown onto a bed at the home, which was fined $15,000 for failing to ensure its care met approved standards.
To address these concerns, the Ministry of Health (MOH) introduced the Enhanced Nursing Homes Standard, followed by the 2020 Healthcare Services Act to improve governance and patient safety. The transition to this new licensing regime, which has been in place since December 2023, has significantly raised care standards.
This will go some way to assure caregivers that there will be safeguards and processes in place. Nursing homes have also invested more in staff training and developing a culture of quality improvement. Staff are now better equipped not only to manage basic care, but also specialised needs such as dementia or palliative care.
Modern, person-centred care approach
Many nursing homes even exceed the baseline standards set by the ministry. For example, our charity healthcare institution, Ren Ci Hospital – which provides a range of services such as a community hospital, nursing home and senior care centres – has adopted the “person-centred care” philosophy, with individual care plans addressing residents’ medical, psychosocial and spiritual well-being.
Note, they are called residents rather than patients. This is because they stay in the nursing home for a prolonged period, and giving them a sense of home away from home is important.
We have come a long way from the traditional idea of nursing homes comprising depressing, institutional wards. Thanks to the “households” design in newer nursing homes built by the MOH since 2017, older ward designs have been replaced with more intimate, home-like living spaces. Residents enjoy greater privacy, personalised spaces and communal areas for social activities. Outdoor spaces allow for gardening and other activities, enhancing the home-like environment.
Even in older nursing homes with a ward-like layout, much effort has been made to personalise the space and create a more homely environment. This also applies to communal areas created for shared activities.
Admission to public or not-for-profit nursing homes today is through referral with the help of a medical social worker. The cost is supported by means-tested government subsidies. Charities often supplement this with further financial support for the lowest-income tier.
The key factors that influence the choice of a nursing home, apart from the physical environment, include the location for ease of visits by family members, and specialised services such as dementia care, music therapy, art therapy or even faith-based considerations. Regular conversations with residents and next of kin also help us identify areas where we can do better to cater to the needs of different residents, making care more personalised.
Residents are encouraged to participate in their own care planning and daily activities. Care staff play a crucial role in this model, offering continuity and familiarity, managing daily routines tailored to individual needs, and building rapport with residents. Additionally, residents wear their own clothing, further reducing the feeling of institutionalisation.
Contrary to past beliefs, some residents do transition back to their own home. Improved rehabilitation and a brief respite often enable caregivers to rest, making home care feasible again. Some nursing home providers have home care teams providing regular visits for medical, nursing, therapy, or personal hygiene care. This support is crucial for successful reintegration into the community.
What about the manpower shortage?
Nursing home operations are highly manpower-intensive, often making up at least 65 percent of a budget. Adopting a person-centred care model does require more manpower such as nurses, and nursing homes compete to fill vacancies. This can be addressed to some extent by volunteers and use of technology.
Volunteers are a key feature in nursing homes. They help supplement the care team. One example is befriending, where community-dwelling seniors visit residents who share common life experience and language. Intergenerational activities with schools also allow the younger generation to better appreciate and understand seniors.
The use of technology can also increase efficiency and save on manpower. For example, autonomous mobile robots help transport laundry and food. Geofencing technology – which allows healthcare providers to set virtual boundaries to get alerts if a wearer wanders outside that zone – and facial recognition and falls detection devices help with monitoring residents.
Some nursing homes have further embarked on job redesign to upskill care associates so that they can take over some basic nursing duties.
These efforts partially relieve but not completely resolve the sector’s manpower challenges. The exponential increase in demand means nursing home providers will have to continually seek improvements to streamline operations and use technology, while not losing the human touch. Efforts must also be made to better promote eldercare jobs as attractive and meaningful employment.
End-of-life care in nursing homes
Nursing homes should also do more to integrate palliative care earlier in the course of illness, providing comprehensive support over a longer period.
It is important to incorporate palliative care principles as defined by the World Health Organisation. These focus on improving quality of life by addressing physical, psychosocial and spiritual needs.
Historically, palliative care is associated with cancer patients in hospices, limited to the last six months of life. But there is now broader recognition of its importance for conditions like frailty and organ failure, where the journey to the end of life may be longer.
Some nursing homes have started to address the emotional and spiritual needs of their residents by adopting best practices from palliative care and hospice services, such as art and music therapy, and spiritual support. Religious support is a powerful medium for peace and acceptance. Faith-based nursing homes often offer pastoral care or religious support groups.
Beyond pain relief and comfort, an important aspect of care is facilitating the patient’s last wishes. Nursing home staff can assist with a lasting power of attorney, a legal document that allows patients to appoint someone to make decisions on their behalf if they lose mental capacity. This helps in the management of personal welfare and property matters.
Many residents form close bonds with staff and fellow residents. When facing the end of life, many prefer not to return to hospitals, expressing a desire for comfort and to avoid prolonged suffering. Initiating advance care planning discussions early allows patients and families to deliberate on life priorities and have honest conversations, ensuring dignity and respect.
Through ongoing efforts and community support, care in nursing homes will continue to advance. Although we still strongly advocate ageing and care in the community, the option of admission to a nursing home is no longer as daunting and should not be guilt-ridden.
- Dr Jamie Mervyn Lim is chief executive officer of Ren Ci Hospital and Dr David Ng is the clinical director.
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