Moving From How To Why

Over wine with some friends, who happen to be physicians, we were talking about nursing homes. I know. Occupational hazard. By the way, it is much to my husband’s chagrin that this topic is a frequent visitor to our happy hours. These friends are great, caring physicians who are hospital- and private practice-based, and have fairly regular interactions with nursing homes. They also see the need to do things better for elders, and we are talking about how nursing homes have been trying to change – to true communities in which the people who live there can live with choice, dignity, respect, self-determination, and purpose. Communities where people live according to what matters to them. The pace and depth of change is not what we have hoped to see. We know that the people working in nursing homes are good people. And we are all so exasperated. Grrrrr. As we are sharing frustrations, another non-healthcare-employed wine drinker in our group innocently asks, “So, why haven’t they changed?”

Hmm. That’s a question! Why. Where do you start?

I was in a nursing home the other day. The person with whom I was working was showing me around and introducing me to people. He made this comment: “The thing is, when you are working with residents, you have to have sympathy, not empathy.” I was somewhat perplexed and asked what he meant by that. He told me that you can’t get too personal with residents. That this was a medical environment and it was most important to follow the doctors’ orders. That residents really didn’t know what they needed so you couldn’t give in to them, no matter how much they wanted something. He used the example of a resident with diabetes, who wanted a soda. “You just can’t give it to them – you can’t have empathy for them and give in.”


I flashed back to the first nursing home I worked in 22 years ago. And I am pretty sure I had the exact same conversation. How can that be? How can we not have changed in 22 years? Why haven’t we changed?

yield-98939_1280I will insert my caveat here. I know that there are nursing homes that are working so hard to do better. They are changing the way they do things, for the people who live and work in these homes. I work with these people.  It is incredibly hard work. And it is possible. Thank you to these brave people. But as a “field”, there is still not enough change.

There are many reasons that make it difficult for nursing homes to change. And yet, I don’t think these reasons adequately answer this important question of “Why haven’t we changed?” How can it be that 22 years later, I am still hearing conversations about how people living in nursing homes do not know what they need or want, and that we have to manage their needs and wants for them. These reasons make change difficult, but do they explain WHY we haven’t changed?

Let’s take a peek at these reasons. Regulation is a common reason given to explain why change in nursing homes is hard. But how would regulation really explain “why” this resident with diabetes is not allowed to have soda? The regulations actually support residents’ rights and their right to choose. Medicare/Medicaid reimbursement (or lack thereof) is given as a reason. How does reimbursement play into a resident wanting a soda and not getting it? I’m not sure. Lack of staff education? I don’t know about that. I am guessing that when a person starts working in a nursing home they actually begin with the premise that if someone wants a Coke, we should get them a Coke. And somewhere along the line, this becomes replaced with a paradigm that says no, we can’t give them that Coke.  I know, because that was what happened to me. By the way, we are talking about giving a person a Coke, and we are talking about more than just giving a person a Coke, know what I mean?


I hear the “yeah, but’s” in my head. Regulation IS a reason, the voices are saying. Because if we are always giving people with diabetes sodas, we are going to get cited for neglect, or not providing an appropriate diet….. Reimbursement, yeah, definitely, the voices say. We barely get enough to meet everyone’s needs. We don’t have the staff to be running around getting Cokes for people …… Do you hear the voices too? Nevertheless, are these really the reasons why nursing homes have not changed?

Why, why, why. Why haven’t we changed? I don’t have a good answer for my wine buddies. In Peter Block’s book, The Answer to How is Yes, he says:

“We often avoid the question of whether something is worth doing by going straight to the question ‘How do we do it?’”

Have we been avoiding the question of why we haven’t changed by focusing too much on how we can or can’t change?  I think we need to spend more time on this question of “why” – why we haven’t changed, but maybe even more importantly, why DO we need to change? Do we think this matters? I think it does. I can’t speak for everyone, but I do know that it matters to the resident who can’t have her soda when she really just wants a soda. I think it matters to the millions of people living and working in nursing homes, who know we can do better. They deserve better. We deserve better.

2 thoughts on “Moving From How To Why

  1. Why?
    Change is hard
    Lack of leadership
    Lack of urgency
    Lack of enforcement
    No one is leading the revolution.

    We are not going to get there through education alone. Incremental change is s l o w. very slow.
    We need to re-activate the revolutionary prong.


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