CHAPTER 13

The Undignified Body:

Excremental Assault in
Canadian Nursing Homes
Donna Lynn Smith, Megan Aiken, Amy Gerlock, and
john Church

LEARNING OBJECTIVES

1. To present conceptual and analytic perspectives that explain why being forced into

inescapable contact with one's own excrement is a fundamental. and perhaps the

most egregious, violation of human dignity

2. To highlight disparities between the rhetoric and reality of bodily care in profes­

sional. industry, policy, and media discourse and to illustrate how alarmist rhetoric

contributes to the problem of policy-induced incontinence

3. To encourage critical reflection about the ideas and interests that enable. rational­

ize. and perpetuate the dehumanizing practice of excremental assault in so-called

caring organizations and the wider prevalence of ageism in public policy and media

discourse

The shock of physical defilement causes spiritual concussion. and simply to

judge from the reports of those who suffer it, subjection to filth seems often to

cause greater anguish than hunger or fear of death. (Des Pres 1976:66-67)

INTRODUCTION

In the early stages of the COVID-19 pandemie in 2020, panieked citizens rushed
to supermarkets to huy toilet paper. This crowd behaviour provides insight into
a deeper reality: the thought of being forced into prolonged, inescapable con­
tact with one's own excrement is universally feared. As the pandemie continued,
 CHAPTER 13 The Undignified Body 225

it became obvious through media reports from journalists like Robert Green,
Dennis Gruending, and Christina Spencer that incapacitated residents in Can­
adian nursing homes were particularly endangered-not only by the new virus,
but also by the pre-existing conditions of neglect in which they had been living
(Green 2020; Gruending 2020; Spencer 2020).
The Criminal Code of Canada names indignity to a dead body as a crime,
and sorne indignities to living bodies, such as child abuse or sexual assault, are
also crimes. But as media reports and public inquiries reveal, neglect of basic
hygienic care of vulnerable people in hospitals and nursing homes has been nor­
malized through administrative and policy decisions in recent decades. In this
chapter, we define this issue as policy-induced incontinence. lt causes affected
persons to literally become "human remains," lacking entitlement to dignities
historically afforded the dead (see box 13.1).
We begin the discussion of this disturbing reality by reviewing reasons that
people at various stages of the life cycle might need bodily care. The fundamental
connection between cleanliness and human dignity is explained in practical and
theoretical terms. The silence and complicity about policy-induced incontinence
extend from the bedside to the boardroom. We point to several theoretical per­
spectives that are helpful in understanding how and why it can occur in so-called
caring institutions and why, for the most part, individual caregivers should not
be held responsible for failings in care that result from corporate and administra­
tive decisions beyond their control.
We wish to emphasize the role of paradoxical rhetoric and structural fac­
tors in perpetuating policy-induced incontinence. Concerned family members,
nursing professionals, and unions had attempted to draw attention to physical
neglect in nursing homes for many years before it was widely exposed during

Box 13.1: Policy-lnduced Incontinence

This is a specifie form of neglect in hospitals and nursing homes in which basic

hygienic care is not provided to people who are unable to go to the toilet in­

dependently and who typically require incontinence products such as commer­

cial diapers. This practice is normalized by the policies and cultures of the health

care organizations in which it takes place, and it has been rationalized by appeals

to efficiency and unaffordability due to inadequate staffing or for other reasons

having to do with administrative policies, Leadership, or political priorities. Mali­

cious intent by individual caregivers who make personal choices to harm per­

sans in their care through humiliation. torture, or other unprofessional and illegal

practices is excluded from this definition.

226 PART Ill POLITICAL BODYWORK

the COVlD-19 pandemie. Such neglect has continued due to, in part, alarmist
daims that increasing numbers of older people will bank.rupt the health sys­
tem and ageist marketing rhetoric that denies bodily realities. Canada's system
of government, in which health service delivery and regulation is a provincial
responsibility, helps to explain the patchwork of rudimentary standards and in­
effectuai enforcement in the provinces, �here powerful corporate actors have
successfully resisted attempts at more robust regulation.
We argue that policy-induced incontinence is a form of "excremental as­
sault," a practice historically associated with crimes against humanity. Presently
in Canada, there are no substantial legal protections for helpless nursing home
residents subjected to indignities as they wait for their diapers to be changed as
per institutional schedules. ln the UK, government has responded to this prob­
lem by passing legislation that names and punishes corporate crimes. Based on
our research, we conclude that the Criminal Code of Canada should be amended
to follow and expand on the UK example.
Neglect of incapacitated persons in hospitals and nursing homes has been
documented through public inquiries, media reports, and research in many
Western countries and Canadian provinces prior to 2020 (Pedersen, Mancini,
and Ouellet 2018). However, it took the pandemie to expose what a former
minister of health for Canada called "the shame of Canada's nursing homes"
(Ambrose 2020).
The conditions of neglect that arise from the policies and institutional rou­
tines in nursing homes are a specifie form of abuse that occurs because of admin­
istrative decisions to ration staff and supplies. ln one example, reported in 2019,
investigative journalists Katie Pedersen and Melissa Mancini of the Canadian
Broadcasting Corporation (CBC) witnessed a wheelchair-bound resident of a
long-term care home repeatedly cry for help as she waited for over an hour to use
the washroom. When confronted about this, an employee explained that the resi­
dent could not go out of turn: "There is a schedule for washroom," the employee
said. "The Personal Support Workers [PSW] know their schedule" (Pederson
and Mancini 2019). A similar case was reported after being investigated under
the auspices of Alberta's Protection of Persons in Care Act (Government of
Alberta 2019b). Erica Johnson of the CBC writes that in late 2018, while receiv­
ing care from Extendicare in Viking, Alberta, Josephine Ewashko experienced
severe dehydration and died. Her son stated that when staff were asked to "help
their mother get to the bathroom, or change her foul-smelling diaper, it would
often be hours before a nurse or aide responded" (Johnson 2020b). The final
report, from the acting director for protection of persons in care, concluded that
 CHAPTER 13 The Undignified Body 227

the circumstances leading to her death were abuse; "staff failed to consistently
assess, monitor, and respond to the client's changing condition" and "acts and/
or omissions of staff" resulted in "failing to provide adequate nutrition, adequate
medical attention or another necessity of life without a valid consent causing
serious bodily harm" (Government of Alberta 2019a:8).
A few months after this incident report, media coverage of another nursing
home owned by the same operator described nurses' concerns that "senior staff
did not deliver proper care and hygiene to 50 residents, that the facility was con­
stantly understaffed," and diapers were locked away and limited "to three during
the day and one at night" Uohnson 2020a). Citing statistics from the Canadian
Institute for Health Information, the article indicated that from 2017 to 2018
the home had a reported urinary tract infection rate of 7.5 per cent, much higher
than the national average of 4.3 per cent; however, the operator had stated that
the home was "'fully compliant' with provincial standards in the last audit of
March 2019" Qohnson 2020a). These and similar cases demonstrate that neg­
lect of bodily care and basic hygiene has become a social norm-embedded in
institutional policy and condoned or ignored by provincial regulators in Canada.
Although the experience of incontinence may seem distant to younger readers
of this book, it can be experienced at any age if a person becomes immobile or
incapacitated and needs assistance with bodily care.

HYGIENE, DIGNITY, AND THE HUMAN EXPERIENCE

OF INCONTINENCE

Hygiene is fundamental, not only to human dignity, but also to basic survival.
Valerie Curtis (2007:11) writes that its origins can be seen "as the set of behav­
iours that serves to avoid infection and that is exhibited by most animais, and re­
mains partly instinctive in humans, driven by an innate sense of the need to avoid
that which disgusts." Abundant scientific evidence reinforces the commonsens­
ical view that dirt causes disease. Legal requirements to provide the necessities
of life to dependent persons reflect the widely held public view that cleanliness is
necessary to maintain human dignity.
Dignity is ascribed to all people. The concept of Menschenwürde refers to
the inalienable value of human beings regardless of social, mental, or physical
properties, and it is reflected in human rights codes and international conven­
tions. More specifi.cally, as Winifred Tadd, Linus Vanlaera, and Chris Wastmans
write, it relates to self-respect and one's identity as a person; it can be violated
by exogenous factors such as physical or emotional assault and humiliation, as
228 PART Ill POLITICAL BODYWORK

well as frailty, disability, and old age (Tadd et al. 2010:256-257). The products
of elimination, urine and feces, are odorous and considered dirty and disgusting.
They contain chemicals that can cause stains and damage the skin, and they can
contain bacteria. The ethical codes and practice standards of professional colleges
reflect public expectations that (1) human beings are entitled to dignity and re­
spect and (2) privacy and cleanliness are necessary to prevent infection and the
spread of disease. Conditions of filth are associated with indignity.
Across cultures and generations, there has been clarity and broad agreement
about how to manage the naturally occurring phenomenon of incontinence in
infants and children. Dirt is associated with neglect, and parents whose children
are discovered in conditions of uncleanliness can be prosecuted for failing to pro­
vide the necessities of life to their dependents. New parents are instructed on the
importance of promptly detecting and changing soiled diapers and how to care
for infants' skin to prevent rashes or other problems. Before 1942, when dispos­
able diapers were developed, mothers were taught how to wash soiled cloth dia­
pers for repeated use (Diaper Jungle 2020). As with other products marketed to
make women's work in the home easier or less time consuming, disposable dia­
pers are claimed to have superior cleanliness. Katie Engelhart and June Rogers
note that, in Western societies, convention and professional advice prompt par­
ents to "train" children to use the toilet and dean themselves properly (Engelhart
2014; Rogers 2002).
In older children, bedwetting was historically considered a shameful prob­
lem; as Dan Eshet (2015) explained, it was severely punished in residential
schools. More recently, products designed to prevent older children's embarrass­
ment by containing urine for the duration of the night have become available.
The National Kidney Foundation (2020) emphasizes that "absorbent underpants
should only be used with the approval of the child and should never be forced on
a child or otherwise used in a fashion that the child might interpret as a punish­
ment." The foundation also cautions that wearing an absorbent brief or pad for
prolonged periods makes the skin prone to damage that can cause soreness, pain,
burning, or itching; this can occur within just a few days if there is prolonged
exposure to urine and feces.
Adults can become incontinent because of acute or chronic illness, mental
incapacity, or injury. It may prove to be a reversible problem or may be man­
aged over time by means of individualized care plans in which caregivers help
incontinent persons to anticipate the need to go to the toilet and assist them at
regular intervals. Incontinent adults who are able to express their wishes and
preferences may maintain sorne persona! control over their care and appearance.
 CHAPTER 13 The Undignified Body 229

If incontinence becomes a chronic condition combined with physical or mental

incapacity, then adults, like infants, become completely dependent upon others
for bodily care. At this point, many leave their homes to become nursing home
residents. A friend of one older person1 described the descent into the indignity
of policy-induced incontinence:

I had the privilege of being the friend and caregiver to an elegant elderly
woman. Everything crumbled in her late eighties, when she fell and fractured
her hip. While in hospital she acquired one of those nasty bugs that required
isolation, and developed delirium. Even through the veil of confusion, the dia­
pers were an embarrassment to her. She at least had a commode at her b edside
for times when there were staff that responded to her needs. That ali changed
when she was transferred to longterm care.
At first, there was an effort to "toilet" her every shift, but it was made clear
that this was the most they could offer with available staff. She was reassured
that they had the best in incontinence products, justifying the once per shift
contact. As she experienced long waits with no response, she gave up trying
to use the call bell. When a mechanical lift was needed to assist her to the

bathroom, she waited even longer periods of time without attention. I would
tend to her saturated diaper during my visits but wondered, in retrospect, if this
presented more humiliation to her than the staff doing the chore. When she

had a cardiac arrest during one of my visits, I did not bother using the cali bell.

Any immobile body will become undignified if caregivers do not have the time
and resources to provide fundamental care to prevent exposure, keep the skin
dean and dry, and provide prompt, tactful cleansing when incontinence has oc­
curred. Although discrimination on the basis of age, disability, and gender vio­
lates basic human rights, elderly people and a disproportionate number of elderly,
incapacitated women are at risk for institutionalized indignity. Having cared for
the basic needs of children, aging family members and husbands, they suffer
embarrassment and adverse health consequences while waiting for their diapers
to be changed as institutional schedules dictate.

INTERSECTIONS OF THEORY AND PRACTICE

The theoretical concepts advanced by Erving Goffman (1956) are foundational

to our discussion and are cited by Drew Leder (1990, 2016), a medical doctor,
philosopher, and phenomenologist who has advocated for renewed attention to
230 PART Ill POLITICAL BODYWORK

the visceral body. Highlighting an obvious but widely ignored reality, he stated,
"my skin is susceptible to the most exquisite and differentiated tortures if it is eut,
burned, pricked, tickled, stretched, struck, pinched" and, further, that subjective
choices do not "assert a final autonorny over the biological requirernents of the
body to drink, eat, sleep, and excrete at certain times" (Leder 1990:41). This fact
accounts for the dys-appearance of the body in concepts such as "dysfunctional,"
in which the body "may emerge as an alien thing . . . a painful prison or tornb in
which one is entrapped" (1990:87 ). Extending the metaphor of irnprisonrnent,
he re-ernphasized Goffrnan's earlier parallel between admission into a medical
institution and incarceration, explaining that "this powerless state results from
both internai and external forces: one's own body has rendered one vulnerable to
coercion" (Leder 2016:175).
Objectification theory originated in the late 1990s and continues to be elabor­
ated by scholars like. Barbara L. Fredrickson, Lee MeyerhoffHendler, Stephanie
Nilsen, Jean Fox O'Barr, and Torni-Ann Roberts (Fredrickson et al. 2011). The
bodies of older or disabled people are objectified in the extrerne, as the needs of
the visceral body assert thernselves. No other group of people receiving health or
personal services has been so extensively categorized in objective and quantita­
tive terrns, for the purpose of assigning them to-or, more frequently, restricting
their use of-services. Case rnix rneasurernent systems and classification tools
now deconstruct the bodies of older and disabled persons into physical charac­
teristics and behaviours that are used to allocate funds and thus generate incorne
for nursing horne operators. Ironically, as Steven B. Clauser and BrantE. Fries
(1992) as well as Simon Akinsulie (2016) notice in such systems, the more phys­
ically and rnentally incapacitated a person becornes, the more their body is worth
to a nursing horne operator. As we illustrate in this chapter, physical incapacity
deprives the person of autonorny and liberty, leading to their irnprisonrnent in
unchanged diapers.
In a reprise of the developrnent of cultural gerontology, Julia Twigg and
Wendy Martin (2015) explain that the body and ernbodirnent have been central
to this theoretical domain, which ernphasizes the politics of everyday life. It also
addresses the dichotorny often described as the medical versus social rnodel of
care-a paradoxical effort of gerontologists and policy decision makers to rnove
beyond dated knowledge and custodial care, but which has had the effect of de­
valuing and obscuring necessary bodily care.
One contribution of cultural gerontology has been to integrate studies and
literatures in the hurnanities with other studies of aging. Of central importance
to this chapter are Terrence Des Pres's (1976) highly respected studies of the
 CHAPTER 13 The Undignified Body 231

writings of people who lived in but survived the death camps. These provide a
conceptual and evidential benchmark against which to discuss excremental as­
sault in so-called caring institutions within the broader context of human rights
legislation and international law governing the treatment of prisoners.
These perspectives share a common concern about the disparities between
rhetoric and reality. Analyzing the moral reform that occurred in Canada through
a combination of religious and public health ideas, Mariana Valverde (1991:14)
commented that "moral panics are multidimensional and the social anxiety as­
sociated with them is probably rooted in the unconscious coming together or
condensation of different discourses, different fears, in a single image. " A sim­
ilar argument was advanced by Stephen Katz (1992:204), who showed that the
popular media, lobbying organizations, and gerontology textbooks engage in
discourses characterized by alarmism and inappropriately accentuate the demo­
graphie features of an aging population. Katz presciently focused on historical
constructions of the elderly population as an object of power/knowledge rela­
tions, and more recent media coverage has proven him correct. Apocalyptic
demography remains a popular theme of Canadian opinion writers such as Keith
Gerein (2019) and John lbbitson (2020), who use statistics in misleading ways
to exaggerate the impact of the growing number of older and very old people in
society. ln fact, research confirms that such alarmism is unfounded (Canadian
Health Services Research Foundation 2000, 2003, 2007 ).
If applied to other identifiable populations, this pejorative rhetoric would
be called out. Discrimination on the basis of disability, gender, and age vio­
lates human rights and puts elderly, incapacitated women at a disproportion­
ately high risk of institutionalized neglect, which causes them embarrassment
and humiliation and risks medical complications. As the COVID-19 pandemie
intensified, the high numbers of nursing home residents who died of the virus
were dismissed by many opinion writers as a reasonable priee to pay for allowing
the economy to remain open. As one satirical commentator wrote, "we can save
billions of taxpayer dollars if people didn't live as long . . . a lifespan set at 70
would help balance the books . . . after the age of 70, you're not much use to our
oil and gas overlords . . . but seniors will be thankful that they're helping Al­
berta by becoming a hydrocarbon " (Beaverton 2020). The term "dictatorship of
vocabulary" was coined by John Ralston Saul (1995:105 ) to describe a process in
which words such as choice, independence, and successfulaging are co-opted to serve
the ideological and political purposes of special interests. This is apparent in our
subsequent discussion of how supportive housing and nursing homes are mar­
keted and how policies to constrain expenditures on staff time and incontinence
232 PART Ill POLITICAL BODYWORK

supplies are justified in public policy discourse. Ethical issues associated with
marketing rhetoric in health care systems have been identified by scholars like
Thomas Foreman (2015 ).
Our own stance as researchers is pragmatic, rooted in the study of public
and health policy, with a particular focus on administrative accountability. ln
keeping with François-Pierre Gauvin's (2014) approach, we analyze the interests
and ideas of political actors who, through their leadership (including political
advocacy and administrative decisions), create the context and organizational
routines that have normalized indignity in nursing home care in Canada and
elsewhere. As an intergenerational team, ranging in age from 28 to 75, our
practical experience has included clinical care and health care administration
at institutional and public policy levels, as well as direct experience in Canadian
intergovernmental affairs and in evaluating local, national, and international
health care programs.
As academies and teachers, our insights are informed by the experience of
having made and lived with administrative decisions that affect the lives and
well-being of other people. We fully understand that this is hard work and de­
serving of respect. But unlike regulated clinical or other professions, business
and health care executives in Canada are not required to hold licences that can
be revoked by third-party regulators if professional standards are violated. The
private and public organizations that deliver nursing home services in Canada
are not governed by national standards and in general have opposed provin­
cial government regulation, which is perceived to interfere with administrative
flexibility.
Our emphasis on structural analysis acknowledges that individuals who
work in systems and organizations can be dominated and imprisoned by what
Gareth Morgan (1997:216) called "favoured ways of thinking." Institutions, par­
ticularly those described by Goffman (1961:xiii) as "total institutions," do not
have conscience, but they exercise power. As described in this chapter, the exer­
cise of institutional power determines the experience and fosters neglect of the
bodies of vulnerable nursing home residents.

AÇCOUNTABILITY FAILUR E IN THE MANAGEMENT

OF NURSING HOMES

In 2002, as scientific research into patient safety was developing, a report by

Canada's National Steering Committee on Patient Safety (2002) explained that
errors are rarely the result of individual clinical decisions or incompetence (called
 CHAPTER 13 The Undignified Body 233

sharp-end factors). More often, hazards and harm occur at the blunt end, where
the factors include people and forces in the many layers of the health system
who are not in direct contact with patients but who set policy, manage health
care institutions, and design medical deviees that affect how care is delivered.
The antecedents of patient neglect are described in a systematic research review
conducted by Tom W. Reader and Alex Gillespie (2013). These blunt-end root
causes most often involve high workloads and under-resourcing of personnel and
materials. Conditions causing staff burnout and the failure of leaders to set and
monitor standards are also causative factors. More distant causes include organ­
izational prioritizing of financial targets and inadequate systems for reporting
neglect. In the context of this growing body of research, the treatment of incapa­
citated, incontinent persons in Canadian nursing homes-which shocked people
as it came to light during the COVID-19 pandemic-was, like the pandemie
itself, entirely predictable.
In our own research Qohn Church, Amy Gerlock, and Donna Lynn Smith
[2018]), we examined 18 health care catastrophes that were documented in re­
ports of public inquiries over a 30-year period in the UK and Canada and con­
cluded that all were examples of accountability failure (see box 13.2).
As we were completing the initial phase of our work, additional cases were
being reported in the United Kingdom, Canada, Australia, and other countries,
confirming that leaders, organizations, and governments had not learned and
were repeating mistakes. In sorne instances, individuals with malicious or crim­
inal intent were found to have slipped through regulatory processes. However,

Box 13.2: Accountability Failure

Accountability failure occurs when the stated vision. mission. objectives. struc­
tures. governance. and leadership behaviour of systems and organizations fail
to achieve desired results and instead produce outcomes that are negative to

the point of being fatal and catastrophic. Such failure includes the behaviours

of individuals and organizations but also encompasses broader. systemic fac­

tors. including decisions and policies that fail to provide the necessary checks.

balances. and oversight required to recognize and prevent needless suffering

or death. Accountability failure can result in one death or serious injury. many

deaths or injuries. or circumstances that place individuals or the public at un­

necessary risk (Church et al. 2018).

234 PART Ill POLITICAL BODYWORK

in the majority of cases, the policies and decisions of governments and organ­
izational leaders were the root causes of neglect, including the specifie type of
accountability failure we have termed policy-induced incontinence.
A growing body of research and anecdotal examples confirm that health
outcomes, whether positive or negative, can rarely be attributed to the inten­
tional or malicious actions of individual care workers, most of whorn are salaried
employees with little or no influence over the policies of the organizations in
which they work or the broader context in which these organizations operate.
As Erving Goffman (1961), Rosabeth Moss Kanter and Barry Stein (1979), and
Gareth Morgan (1997) have all emphasized, inmates and keepers may be more
similar than different in a mechanistic organization.

DREAMS FOR SALE: THE MODERNIZATION OF

CANADA'S NURSING HOME INDUS TRY

Long-term care in Canada is not a national system; it is, rather, a patchwork

of provincially regulated services including two major elements-housing and
care-each with different funding and regulatory frameworks. In the Canadian
parliamentary system, provinces are responsible for health care delivery. This
accounts for inconsistent definitions of services, regulation, and reporting across
the country. Therefore, in this chapter, we describe the two major elements gen­
erically and cite selective case examples from several provinces.
Supportive housing (more recently called assisted living in sorne provinces)
is a form of congregate accommodation in which individuals or couples typically
live in independent suites and are provided with a meal plan and basic house­
keeping services. Citizens pay directly to live in supportive housing facilities.
Sorne provinces have rudimentary standards, and licensing requirements differ.
Supportive housing residences are owned by for-profit or voluntary organizations
that expect to be able to finance their operations through residents' fees.
Competition is unlimited in the supportive housing sector. The appealing
illusions of choice, independence, and autonomy characterize intense market­
ing rhetoric that reveals subtle ageism (Smith et al. 2002). The supp�rtive hous­
ing and assisted living industry has been promoted as a substitute for nursing
homes. In advertisements for this "lifestyle choice," sentimental images of smil­
ing, attractive, well-dressed people, often heterosexual white couples, are re­
inforced by narrative implying a "normal" and carefree life. With no cooking or
cleaning to do, older people can spend their time socializing, go!ng on outings,
and participating in structured activities, surrounded by similar people who have
 CHAPTER 13 The Undignified Body 23 5

made the decision to move into assisted living to free their families from the "bu­
rden" of worrying about and caring for them. These discours es rely upon the age­
ist concept of the dependency ratio, which de scribes the ratio of older to younger
people in the population, and incorporate the assumption that older people will
become financially burdensome to society (Statistics Canada n.d.). But they also
acknowledge the concept of compression of morbidity, first defined in the 1980s
and the subject of continuons research (Fries, Bruce, and Chakavarty 2011).1his
reveals that the onset of illness and dependency is, on average, compressed into
the last months or years of life, giving truth to expressions such as "70 is the new
50" and the fact that older people are a profitable market.
The ability to "age in place" is advertised to governments and families as a
by-product of this lifestyle choice, implying that people will be able to live in
their safe and often luxurious new suites for the rest of their lives. Rosemary
Ziemba, Tarn E. Perry, Beverly Takahashi, and Donna Algase have shown that
about one third of nursing home residents in the United States, where the madel
originated, only lived in them for about three years before dying of chronic and
progressive conditions (Ziemba et al. 2008).
Assisted living facilities have various profitable ways to maintain the illusion
that residents are healthy and normal and to compensate for the absence of pro­
fessionally trained nursing staff. As residents become more frail, they can pur­
chase additional "care" that they might need, one activity at a time. For example,
residents who can no longer walk or operate their own wheelchairs can pay to
be portered to the dining room for meals. Paying in this way for baths and other
services enables sorne residents to remain in their suites. When health issues
arise, the residents are sent to hospital by ambulance at public or persona! cost.
For decades, administrative insiders and public servants have used the term
nursing home industry to describe institutional or facility-based care for older
people. Owners and operators of nursing homes include multinational corpor­
ations, smaller businesses, and in sorne provinces, family-owned businesses.
Unlike supportive housing, nursing home capacity is limited by provincial gov­
ernments through contracts to specifie operators, who are paid a per diem rate
for every occupied "bed." ln addition to the government funding they receive,
nursing homes charge residents directly for accommodation services: lodging,
meals, and housekeeping. Provincial governments set a rate for these charges
based on economie indicators. The capital construction of private nursing homes
is usually a public cost. These highly predictable business arrangements guar­
antee profitability and remove any need for nursing homes to compete with one
another by offering better service.
236 PART Ill POLITICAL BODYWORK

In spite of the fact that their existence and level of funding depend upon
the qualities of physical and psychological incapacity of those who occupy their
"beds," nursing home operators perpetuate stigmatization of the incapacitated
body in advertising and programming. Happy older people are depicted in styl­
ish leisure clothing or street clothes as they socialize and participate in pleasur­
able activities. It is doubtful that the people portrayed in these images are, or ever
were, typical of nursing home residents. In fact, evidence has been accumulating
for years that nursing home residents are increasingly frail, dependent, and have
multiple morbidities, and nursing home operators use this to lobby for additional
funding (Wilson and Woytowich 2004).
The forced move from the advertised carefree life in supportive housing or
assisted living to a "care-free" life in a nursing home is commonly referred to as
a transition, when, in fact, it is a major upheaval in the lives of people and their
families. It cornes about when someone is no longer independently able to move
in bed, from bed to a commode, or from a wheelchair or stretcher on which they
might be transported to the toilet or for a bath. If a single family member or
staff member can provide such assistance, residents can continue to age in place.
However, if they require two-person transfers, they and their families are noti­
fied that they will have to rnove out of their "home" to a nursing home, where, it
is implied, the needed additional care is available. This moment in the life cycle
marks a loss of self-determination, liberty, and dignity for incapacitated persons.
The illusion of a carefree life is enacted on the front stage of nursing homes
in design and programming. In the early 1980s, gerontologists adopted models of
care that de-emphasized physical care in a well-intentioned effort to enrich pro­
gramming. ln this shift to what is called a social model, physical-care activities
were de-emphasized in an attempt to dissociate nursing homes from earlier no­
tions of institutionalization. lnterdisciplinary programming, with an emphasis on
recreational and social activities, overshadows the requirements for bodily care,
which are dismissed as needlessly regimented, hospital-like processes that prevent
residents from living "normally." As older nursing home infrastructure was reno­
vated or replaced, operators added additional communal spaces and "homelike"
furniture and features. ln many newer buildings, the practical need for storage
space to accommodate wheelchairs, bedside commodes, mechanical lifts, extra
linen, and supplies to meet physical-care needs was not considered, and residents'
bathroom sinks are the only remaining place for staff to wash their hands.
Various fashionable program models flourish, all emphasizing highly visible
social and recreational activities. One popular proprietary model is the Eden Al­
ternative, based on the premise that the "plagues of long-term care are loneliness 1
 CHAPTER 13 The Undignified Body 237

helplessness and boredom, [which] will be mitigated by the presence of plants,

animais and children, and the opportunity for the resident to 'give back'" (Steiner,
Eppelheimer, and De Vries 2004). Appealing as these models might be to the
imaginations and motivations of the healthy younger professionals who promote
them, it seems obvious that people who are imprisoned in wet or dirty diapers are
likely to be more concerned about this physical indignity and discomfort than
with boredom.
Bodily care moves backstage, where people in wet or dirty diapers are likely
to be excluded, or to exclude themselves, from social and recreational activities.
In the nursing home environment, bathing is no longer a private process but,
like diaper changing, has become a scheduled, public, task-specific routine. In
table 13.1, a generic description of a bed bath, composed from a review of several
nursing textbooks, is compared to a generic description of a bath routine derived
from the media and reports of public inquiries.
Although it challenges the imagination to think about how the bath routine
can be considered less institutional than a bed bath, the type of task special­
ization it represents has become the norm in nursing home care, where staff
shortages are endemie and effi.ciency is pre-eminent. While resident and family
perspectives align with nursing education and standards that emphasize individ­
ualized care in the context of a caring relationship, task-specific routines are ad­
ministratively prescribed in the so-called "nursing" home. A disconnect between
language and reality characterizes the rationalizations for excremental assault
and extends to the workers who provide care.

DENIAL, DISSIMULATION, AND DIAPERS

The realities of bodil y care are enacted away from the arrangement of silk plants
and stylish accoutrements in the foyer and the fashionably decorated public and
recreational spaces. The immediate world of incapacitated nursing home residents
contains their bed and, if suffi.cient space is available, a wheelchair or commode
chair. There being limited storage space for physical care supplies in the "home­
like" design, public evidence of their incontinent state might be in obvious view
on window sills or the bedside table in the form of the discarded wrappers of dis­
posable products or even dirty linen or diapers. In the nursing home, the "us" of
idealized, sentimentalized, and physically functioning bodies displaces relational
awareness and caring attention to "them"-that is, persons whose incapacitated
bodies have ceased to be attractive and who reinforce inescapable but frightening
biological realities of human existence. Heavily marketed incontinence products
 Table 13.1: Comparison of Baths

N
Bed Bath Bath Routine w
00

Preparation Before the bath begins. the persan is greeted politely and On assigned bath day, two bath team attendants
�
offered the opportunity to use the toilet. commode, or a bedpan if remove the persan from bed using a mechanical ::0
-l
necessary. Lift and transport them in the sling of the Lift (or in -

a commode chair or wheelchair) through a public "0

0
r
hallway to a tub room. =i
0
)>
Process Modesty is protected as a curtain is drawn around the bed and one The tub is prefilled. r
OJ
Limb or body area at a time is exposed, washed, and dried, then Standards require that water temperature be 0
0
-<
covered before another is exposed. tested.
�
0
Bony prominences of heels. elbows. shoulders. and sacrum are The persan is Lowered. naked. into the prefilled ::0
:A
inspected for early signs of pressure injuries and massaged to tub.
increase circulation. The whirlpool motor is turned on.
Bed Linen is removed and refreshed in a prescribed sequence and Attendants are to remain with the resident.
manner, designed to minimize transmission of airborne particles,
which are known to transmit diseases Like TB. polio, influenza. and,
more recently, SARS and COVID-19.

Conclusion Caregiver tidies the bedside area, properly disposing of soi led Linen The persan is raised from the tub in the
or ether supplies. mechanical sling and dried by the two attendants.
May assist the persan into a chair or to sit up in bed. May be transported back to the bedside and
Offers a drink and places drinking water within reach. dressed there or dressed in the tub room.

-- - Places nurse call bell within reach. Returned to bed. bedside chair. or wheelchair.

Personnel 1 persan 2 persans throughout

required Temporary assistance by a second persan would be needed to
position an obese or very Large persan.

1 ����--�
L_ -·-

15-30 min 15-30 min

a
.----- - ' - ' 1
,.,...
_� ... ..
 CHAPTER 13 The Undignified Body 239

that minimize odours and protect bedding and furniture are the substitute for
respectful attention, without concern for sk.in damage, infection, or damage to
the fundamental dignity of persons who are left unattended for hours at a time
and told to "go in your diaper" or "wait your turn" for cleansing.
Rationing of caregiver time and supplies now determines residents' daily
routine. One nurse in a rural facility described concern and frustration with the
dilemma faced by direct caregivers:

We are running with the same number of staff as we did 20 years ago yet
the complexity of the residents has drastically changed. Most residents require
2 people for morning care, getting up, toileting, changing Attends (diapers)
etc.... Patients are having to soil themselves after calling out multiple times
for help because the 2 aides assigned to the unit are busy toileting, bathing
or attending other residents. Morning care is being rushed because the next
patient is waiting.
Then you add complex patients with extensive wounds that take an hour to
dress. The lack of staff places residents at risk for falls, and skin breakdown af­
ter having to sit in soiled Attends. There is no time to change wound dressings

regularly. Staff are burnt out: we know it's not acceptable care.

Policy-induced incontinence is operationalized at the point of care through

administrative rationing of staff time and diapers. If diapers are kept under lock
and key and a minimum number is made available for each resident on each shift,
there is no obvious expectation that the staff will promptly attend to an incontin­
ent person. Diaper rationing is not confined to one care setting or province-it
was the subject of a pre-COVID-19 advertisement that workers represented by
their union (the Service Employees International Union or SEIU) placed in a na­
tional newspaper, naming the chief executive officers of the for-profit long-term
care organizations Chartwell, Extendicare, Revera, and Sienna.

It doesn't take a wizard to generate profits from a captive market by cutting

costs relentlessly.... A CEO ... might :find better ways to make money than by
rationing diapers, seriously understaffing homes, and leaving workers strug­
gling to provide basic levels of care. (Globe and Mai/2019)

During the COVID-19 pandemie, these statements proved prophetie in that one
newspaper report after another, such as those from Tonda MacCharles (2020)
and Ryan Flanagan (2020), confirmed physical neglect, diaper rationing, and
uncleanliness in facilities operated by these same companies.
240 PART Ill POLITICAL BODYWORK

LI FE AT THE BOT TOM: NURSING HOMES AS

ORGANIZATIONAL PRISONS

Employees of nursing homes carry the stigma of the incapacitated residents

whose lives they directly control. Necessary to efficient operation, they are re­
warded for obedience and compliance with organizational rules. As Kanter and
Stein (1979:177) have explained, the real sign of being at the bottom is the extent
to which a worker is controlled and how little discretion or autonomy they have
over their work processes: "By subdividing tasks into minute parts that can be
performed repetitively by workers with relatively little skill . . . the organization
makes workers expendable and interchangeable."
During the COVID-19 pandemie, they were treated as equally dispensable,
as it was widely reported that the persona! protective equipment (PPE) needed
for their safety was being rationed just as staff time and diapers for residents are
rationed. Legal proceedings have documented that in Ontario, nursing home
operators failed to comply with the Directive of the Medical Officer of Health
(MOH) to cohort or isolate symptomatic individuals and to allow staff who pro­
vide direct care to use their own professional judgment in deciding what level of
PPE was appropriate to protect themselves. Speci:fi.cally, N95 masks were kept in
a locked room or cart, where direct caregivers could not access them. The judge
considered this fact in granting an injunction against four operators (Ontario
Nurses Association v. Eatonville/Henley Place 2020) and commented on the privil­
ege that managers and owners demonstrated as they wore PPE themselves while
denying it to those who were providing direct care.
In a second proceeding (Participating Nursing Homes v. Ontario Nurses'Asso­
ciation 2020), the judge noted that the operators had failed to comply with legally
mandated occupational health and safety requirements-placing bath residents
and staff at risk-and confirmed the employer's legal duty to employ the pre­
cautionary principle. The operators named in the 2019 SEIU advertisement were
among those named in this action and several are members of the board of the
Ontario Long Term Care Association, an interest group of operators and admin­
istrators that has successfully lobbied to limit regulation.
These and similar cases graphically demonstrate the action of more powerful
able-bodied people against stigmatized and less powerful others (in this case,
residents and staff). Acknowledging this power differentiai in the nursing home
workplace, the judge stated:

The nurses who exercise their right to access :fitted N95 facial respirators and

other appropriate PPE . . . shall not be intimidated, threatened, or coerced in

 CHAPTER 13 The Undignified Body 241

any way, including but not limited to threatening to impose a penalty or disci­

pline, because the nurse acted in accordance with herlhis rights under this

award. (Ontario Nurses Association v. Eatonville/Henley Place 2020: 14)

ln these decisions, the judges confirmed the realities being widely reported
across the country: that residents and the nursing staff attempting to care for
them were imperilled in the closed world of nursing homes. As in the death
camps and other total institutions, persons at the bottom-whose labour is es­
sential to keep nursing homes running-are treated as if they are disposable,
like their charges.

ADRIFT IN A LIFEB OAT: FOR SALE AT BARGAIN PRICES

ln the clandestine and dissimulating world of many nursing homes, physically

incapacitated residents and their direct caregivers share a gendered, racialized,
and class-structured experience of indignity and neglect in which daily and re­
petitive bodily realities are denied. Their dehumanizing existence as victims and
as shamed, sharp-end perpetrators of crimes against humanity was widely ex­
posed during the COVID-19 pandemie but was previously well documented.
Dismissed in discriminatory language that would be unacceptable if applied to
other populations, they are described as a problem and a threat, and the legitim­
ate costs of their care and labour are belittled. Apocalyptie demography and ideas
of scarcity have been the persuasive tools of interest groups and governments.
These ideas serve identifiable economie interests (Evans et al. 2010), and so far
in Canada, the interests of industry owners and operators have easily overruled
those of citizens directly affected by the conditions of life and work in Canadian
long-term care facilities.
The rationing of staff time and supplies, in addition to segmented institu­
tional routines that are administratively imposed, negate the possibilities for
individualized and caring responses that experts advocate in the care of older
people. Individualized, relational care is taught in nursing education programs
and reinforced and required by professional nursing standards. Over many
years, unions have been accused of self-interest when advocating for improved
standards, public reporting, and increased accountability in Canadian nursing
homes. However, recommendations from unions are closely aligned with those
of interest groups who advocate on behalf of residents and families. Both groups
have lobbied for higher ratios of regulated to non-regulated staff, for increased
staff, and for public reporting of staffing levels and other key indieators. Reports
from impartial third parties such as the Auditor General of Alberta (2014) and
242 PART Ill POLITICAL BODYWORK

independent researchers or commissions like Yuting Song, Matthias Hoben,

Peter Norton, and Carole A. Estabrooks (Song et al. 2020) have recommended
similar measures.
Media and inquiry reports have revealed the distress of family members
who have been unable to prevent indignities to their loved ones, as well as the
shame and guilt of direct caregivers whose labour in long-term care workplaces is
the medium through which policy-induced incontinence is perpetrated. Family
members are sometimes subjected to trespass orders as they have attempted to
observe, assist, and advocate for their relatives. ln rigorous studies, unlicensed
caregivers have self-reported their inability to complete tasks (Song et al. 2020)
and the phenomenon of moral distress has been extensively documented in the
profession of registered nursing, particularly by Wendy Austin (Austin 2012;
Austin et al. 2009). Registered nurses and unlicensed workers who realize that
excremental assault is a violation of professional and community standards are
powerless as individuals to prevent it in workpiaces where segmented routines,
rationing, and efficiencies are prioritized and speaking up is often punished.
Degradation through forced contact with human waste was named and pun­
ished as a crime against humanity when it was proven to have occurred in the
death camps of the 20th century. ln his analysis of written testimony of people
who survived to document the horrors of this experience, Terrence Des Pres
(1976) demonstrated that it is the most fundamental and egregious violation of
human dignity. As with policy-induced incontinence, the conditions that gave
rise to this physical and psychoiogicai torture were "determined by deliberate
policy" and the environment "organized" (Des Pres 1976:59, 62) to make clean­
liness impossible. Although it is a crime to commit indignity to a dead body, the
normalized conditions of excrementai assault in Canadian nursing homes are be­
ing rationalized as an economie necessity by interest groups that enjoy elite pol­
iticai access through industry associations and have successfully Iobbied against
reguiatory measures that might detect and limit institutionalized negiect.
Accountability for excremental assault in Canadian nursing homes presents
a classic example of what has been called the problem of many hands by Mary
Dixon-Woods and Peter Pronovost (2016) and Dennis F. Thompson (1980, 2014,
2017). Whereas direct caregivers can be punished with Ioss of empioyment or,
if they are reguiated professionais, the Ioss of their licence to practice, corporate
executives and officiais are not required to be licensed. Nevertheiess, as senior
officiais in the industry, they are eligible to serve as surveyors for Accreditation
Canada (2020a, 2020b), a national voluntary accreditation program financed by
payment for accreditation based on surveys by industry peers and organizationai
self-reports. Thus, in the minimally regulated provincial contexts of Iong-term
 CHAPTER 13 The Undignified Body 243

care, operators called upon to account for publicized instances of normalized

neglect in the nursing homes they own and manage are able to boast truthfully
that they are "fully compliant" with ail applicable standards.
As Mohammad Farhad Peerally, Susan Carr, Justin Waring, and Mary
Dixon-Woods (2017) write, health care workers, mainly women, face significant
moral distress as the culturally transmitted values of caring and cleanliness collide
with the relentless neoliberal drive for "efficiencies" in their workplaces. Licensed
professionals who recognize that neglectful practices are at odds with their clin­
ica! and ethical training can face discipline from their professional colleges if they
do not report violations of accepted standards. Emotional numbing is the predict­
able consequence of witnessing cruelty and being personally powerless to prevent
it, precipitating a vicious circle in which people who know better and might like
to do better are unable to enact caring behaviour (Austin 2013). In these circum­
stances, mistreated residents in nursing homes become "human remains" but lack
the entitlement to dignity that would be their legal right if they were dead.
The COVID-19 pandemie broadened awareness of the need for better ac­
countability in the Canadian long-term care industry. In the context of federal
and provincial responsibilities in Canada, it will not be easy to achieve policy
consensus or quickly implement measures to hold corporations and senior organ­
izational officiais accountable for their crimes. Having researched the problem
of what can and should be clone, we conclude that the necessary first step to re­
storing human status and dignity to the victims of policy-induced incontinence
is an immediate amendment to the Criminal Code of Canada. In the code, an
indignity to a dead body is already named as a crime. Canadian legislators should
follow and learn from recent legislative changes in the United Kingdom, where a
new offence of corporate manslaughter was named and is now being prosecuted
in response to health care scandais and overwhelming evidence that individ­
ual caregivers cannot act individually to prevent harms (BBC News 2016; Care
Qyality Commission 2020; Crown Prosecution Service 2018; Lexology 2007;
Robertson 2016; Shafiq 2016).
There is strong evidence and expert consensus that blunt-end or proximal
decisions are the root causes of most safety violations. Organizational policies
and routines associated with what we have termed policy-induced incontinence
violate clinical, professional, and ethical standards and are generally beyond the
power of individual employed workers to prevent. As Emma-Louise Aveling,
Michael Parker, and Mary Dixon-Woods (2016:230) pointed out:

The opportunities for workers to "be good" are made logistically possible and
cultivated culturally, both by the organisations they work in, and by wider
244 PART Ill POLITICAL BODYWORK

institutional structures .... An important element of organisation and account­

ability systems is the cultivation and enabling of individuals' moral agency and
the fostering of the conditions of moral community.

The actions of individual leaders at various levels of the long-term care hier­
archy can influence caregivers' practiees and sometimes prevent neglect and
harm. But if hygiene and human dignity are not prioritized and dictated from
the top, the individual efforts of well-intentioned caregivers will remain random
acts of kindness in a system organized, like the death camps, for bureaucratie
effi.ciency.
During the COVID-19 pandemie, the closed world of long-term care was
exposed as professionally independent public health officiais identified the dan­
gers it presented to the wider community. All Canadians now know that long­
term care residents and their direct caregivers have been sinking in a leaky ship
for years. Legislative changes are needed to name and end discriminatory prac­
tiees that deprive older, incapacitated people of basic human dignity. We will
ali eventually grow older, and as fellow human beings, we are all adrift in the
lifeboat. The horizon is not presently in sight.

NOTE

1. Personal communication; used with permission.

CRITICAL THINKING QUESTIONS

1. The authors of the systematic review of neglect to whom we have referred in this

chapter used a social-psychology perspective to formulate their conceptual madel.

Are there other concepts or analytic tools that would help to explain policy-induced

incontinence?

2. lnstitutional mechanisms such as accreditation regulation. inspection. and legis­

lation have sometimes been proposed as means of correcting substandard care

and improving quality. Why have these mechanisms not prevented the problem of

policy-induced incontinence in Canada?

3.. A "patient-rights" group has formed in your community to advocate for victims of

policy-induced incontinence and to bring it forward as a public policy and elec­

tion issue. What advice would you give as a consultant to this group to help it

succeed?
 CHAPTER 13 The Undignified Body 24 5

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GLOSSARY

ableism: 1. beliefs, processes, and practices that discrirninate against people

with disabilities in favour of able-bodied people (Carnpbel12001:44). 2. the
discursive assurnption that the able body is normal and a superior rneasure
against which ali other bodies should be cornpared. Ableisrn generates so­
cial structures that create invisible and visible barriers that span institutions,
public spaces, the internet, and countless aspects of life. These barriers ex­
elude people with diverse disabilities so that they may not participate equit­
ably in society. See chapter 5.
adolescents (teenagers): a demographie age group cornrnonly identi:fied as the
life stage of puberty, prior to formai adulthood, especially teenagers aged 13
to 19 years. See chapter 3.
ageism: "the ultirnate prejudice" (Bennett and Gaines 2010:435) against a class
of people because they are old. Ageisrn endorses an extrernely negative set of
attitudes and behaviours toward aging and older adults. See chapter 5.
agentic body: the body as an active agent in resisting social norrns.
See chapter 8.
alternative masculinities: culturally prorninent non-hegemonie forrns of rnas­
culinity that are aspirational ideals for sorne males, such as rnetrosexuality
(which incorporates elements that are ty pically associated with fernininity,
such as an interest in groorning and fashion). See chapter 11.
Anishinaabe: refers to Ojibwe peoples who reside in what is now Canada and
the United States. See chapter 2.
Anishinaabek.we: used to describe an Ojibwe wornan/wornen. Kwe rneans "fe­
male." See chapter 2.
apocalyptic demography: 1. an ideology whereby population aging is argued to
negatively impact social resources, thus depicting older adults as a burden to
society. 2. the use of demographie information about older people to raise
alarrnist and unjusti:fied concerns about their impact on the costs of health
or social services. See chapter 8.
assisted living: also known as supportive housing; residential accommodation
designed to provide an alternative to independent housing for older people
or persons with disabilities who may wish to live in congregate settings that
provide services such as rneals and housekeeping. See chapter 13.