Components: Designing Dementia Care – Self-Guided

Three green gears working togetherComponents: Designing Dementia Care  Self-Guided

Timing: 65 Minutes
Mode: In-class, Online

The video footage, audio excerpts and historical photographs and documents in this unit take learners within the walls of Ontario’s first purpose-built dementia care facility in the late twentieth century.  These self-guided resources are well suited for flipped classroom use with an in-class or online discussion or learning activity. Instructors can use the entire guided learning section or select themes and topics that are most relevant to their teaching.

Ask students to use the following themes to guide their exploration of these components:

  • The relationship between conditions of care and conditions of work
  • Ageism and stigmatizing attitudes about mental health as reflected in policy and practice
  • Impact of bureaucratic efficiencies and cost-reduction policies
  • Transinstitutionalization as an unintended consequence of deinstitutionalization
  • The need for long term care practice models which meet the requirements of residents

grand front entrace of institution with landscaping
Greenacres Home for the Aged on show: the public face of the new institution.
elderly woman walking through doorway with uniformed woman holding her arm
Greenacres resident and caregiver, 1981.

The findings of the Re-Imagining Long Term Care project, which has conducted in-depth studies of nearly two dozen institutions across Europe and North America, have repeatedly demonstrated the critical interrelationship between the conditions of care and the conditions of work at residential facilities for the aged.  As lead historian on the Re-Imagining team, Jim Struthers looked for precedents for today’s system of care homes and found a cautionary tale in the history of Greenacres Home for the Aged.  The Newmarket, Ontario institution was heralded as “unique” and “ideal” at the time of its 1956 opening, but when union officials visited the facility in 1981 they found that the high needs of residents and a lack of basic tools and training had entirely outstripped the capability of workers to offer good care. Residents were subjected to assembly-line care and were poorly fed and inadequately clothed.  Many were physically restrained for extended periods of time.

Listen to a woman who worked as a nursing attendant at Greenacres in the 1980s, describe conditions of work and care at the institution.  Compassion for the residents is evident in her narrative, but so too are the limitations to good care created by unbending institutional routines and high patient numbers.


Jim Struthers was shocked to learn of conditions at the home, which seemed to undermine the fundamental rights and dignity of the frail aged with cognitive impairments, a particularly vulnerable group in Canadian society.  Some of the factors he sees as central to the failure of Greenacres were: a poor choice of location, overcrowding, understaffing and bad institutional design. Watch this video clip where Struthers elaborates on what he discovered about life and work at Greenacres.

Download and read sections of the CUPE report that caught Struthers’ attention and which echo points raised by both Struthers and the former nursing attendant.

Eager to learn more about the origins of the CUPE report and the impact it had on residential care policy and practice, Struthers interviewed Jeff Rose, president of CUPE Local 79 in 1981 and Lynn Spink, the woman who researched and wrote the publication that served as a catalyst for institutional reform.  In the fall of 1981, Spink and Rose were working on a comprehensive study of conditions at all seven public Metro Toronto homes for the aged.  But when workers at the Newmarket facility told Spink that there weren’t enough staff assigned to care for the residents and that they lacked basic supplies such as washcloths, bedding and clothing for the residents, the two colleagues agreed that getting action on Greenacres had to be a priority.  Download and read Lynn Spink’s article about what happened next as the union moved to make the shocking story public.

Scandals are a kind of backwards policy catalyst, fuelling public fears and pushing politicians and bureaucrats into action.  Before the Committee at City Hall had finished questioning Rose about the union’s report, Metro Chairman Paul Godfrey announced that he had just stepped out of the meeting and asked Sam Ruth, President of the Baycrest Foundation, to investigate conditions at Greenacres.  Lynn Spink’s report recommended hiring additional staff, purchasing equipment, furniture and supplies, and implementing new cleaning procedures and a system for replacing absent workers.

Watch this clip of Struthers reflecting on the reoccurring phenomena of nursing home scandals in Ontario and our failure to learn from history.

Jim Struthers knew that Greenacres had been built in the 1950s, when provincial funding was available to build new 100 to 200-bed public and non-profit homes for the aged.  Tracing backward in time from the 1981 CUPE report to learn more about the original idea behind Greenacres’ creation, he came across a 1956 memo for you to download from city officials explaining why they created a facility three times the recommended size for a home for the aged and 60 kilometres distant from the City of Toronto.

map of Metro Toronto visually locating Greenacres Home for the Aged
Greenacres was part of a network of Metro Toronto eldercare facilities.

Prompted by his engagement with current ideas about meeting the complex needs of the aged with cognitive impairment, Struthers thought he might find that Greenacres, operating in an era of increasing recognition of Canada’s ageing population, was a site of research and innovation in dementia care.  But this was far from being the case.  No psychiatrist ever visited the facility, and no research was ever conducted on the premises.  Dammed by the double negative of being labelled mentally ill and aged, Greenacres residents were misfits in the post-Second World War policy world that sought to discard the mental health hospital and recreate the old age home as an attractive locale for senior citizens needing minimal assistance.  As Struthers understands it, the creation of Greenacres is an illustration of trans-institutionalization, a functionalist measure to remove a problem population from other facilities.  Watch him expand on these ideas. 

Academics and community partners from the Re-Imagining Long Term Care project stress that the 21st century residential old age home is still trying to overcome many of the problems Jim Struthers found at Greenacres three or more decades earlier.  Functionalist economies have been replaced by “charting for dollars”, which burden nurses with more administration and takes them away from the critical work of building caring relationships with residents.  Worrying reports of increased anti-psychotic drug use amongst the institutionalized elderly for media attention alongside tragic tales of institutional violence.  Residents are entering homes older and in poorer health, many with complex care needs and dementia-related concerns.  Re-Imagining researchers appreciate that medical issues are important amongst this increasingly frail population, but question whether the current Canadian system is capable of nurturing the social and the emotional lives of residents.  In every facility studied by the Re-Imagining team, residents, workers, and family have spoken of the need for empathy, dignity and respect for all who cohabit the world of the residential facility. What we need, one doctor on the team pointed out recently, is cultural change.

Jim Struthers has spent four years gathering data on current promising practices in European and North American residential care facilities but, as one of the project historians, he continues to regard the present through the rear-view mirror of history.  Watch this video clip of him sharing his vision of a future long term care facility informed by the lessons of the past.