Long-term health care in the United States is a system in trouble. In late July 2001, a report of the House of Representatives Committee on Government Reform, based on an annual inspection of the nation's 17,000 nursing homes, revealed that more than 30 percent of U.S. facilities were cited for physical, sexual, or verbal abuse of patients over a two-year span.¹ Alarming findings like these document only the most obvious problems. The General Accounting Office, the investigative arm of Congress, believes that the committee's report understates the deficiencies because nursing homes are often warned that inspectors are coming. Existing programs designed to address the problems have been only marginally effective. Clearly the moral environment of long-term care facilities is in need of better protection than it has so far received.

Two events in central Kentucky in the past two years provide context for these reflections on addressing this crisis.

In early October 2000 a resident in a small-town nursing home wrote a letter to a board member of our Nursing Home Ombudsman Agency of the Bluegrass (NHOA), whose mission is to improve the quality of care for residents of long-term care facilities in seventeen Kentucky counties. In response to the board member's column in the Lexington Herald-Leader about nursing home staffing, the resident wrote:

I live in a small nursing home, and I agree with everthing you said in your column . . . In my home there are five nursing assistants in the daytime, four in the afternoon, and three at nighttime to cover sixty patients. The only opportunity I have to talk to them is during mealtime or when going to the toilet. With regard to the latter, on occasion I have had to wait forty-five minutes after having requested my trip to the bathroom. I am very competent and know what I want. Yet often I'm treated like I'm stupid . . . I do not wish to lodge any formal complaint at this point. I merely want to express my appreciation to your agency for its ongoing work, and to speak on behalf of those who cannot. For every person like me, who is trapped—but knows it, there are two dozen who float in a nether limbo of knowing, and not knowing. Regardless of all the smiles at the entrances, it's hell for all of us.

This testimony underlines the problem of inadequate staffing in many nursing homes—now a rallying point in nursing home reform; it recognizes the part that an active ombudsman program can play; and it gives voice to a resident who is among a tiny minority of the inhabitants of nursing homes who are capable of effectively articulating their plight and their plea for respect.

The second example of the crisis in long-term care occurred the following spring in another small central Kentucky town. A 106-bed nursing home, where my 96-year-old aunt has been a resident for two years, was diagnosed as having major problems in complying with long-term care regulations. These problems were linked, at least indirectly, to two deaths. An insider had tipped off NHOA. Among the problems uncovered at this facility, owned by a national nursing home corporation that had declared bankruptcy, were failures to follow doctors' orders and give treatments, falsification of records, and inadequate staffing. Investigators from the Office of the Kentucky Inspector General's Division of Long-Term Care, the Office of the Kentucky Attorney General, and the state police invaded the nursing home; and some of the monitors stayed for weeks.

With a new administrator in place, our county ombudsman, herself a former registered nurse (RN), visited the facility on Easter weekend to find no RN on duty. Short staffing, treatments not given, a medical doctor who had not practiced in nine months, and the absence of an RN were all excused by the administrator because it was a holiday weekend. Again the scrutiny picked up until the situation was righted.

This example points to problems of insufficient staffing, to the potential role of nursing home ombudsmen, and to the competence and commitment of whistleblowers. Taken together the two cases raise the deeper question of what can be done to assure that nursing homes provide high-quality care and respect residents. Put another way: What can be done to make the nursing home truly "home" for those who feel they have left their real homes to live there?

Any constructive answer will be both political and ethical. It will depend, at least in part, on political and ethical understandings of the problems and potential solutions, as well as an analysis of the daily realities of nursing home care. Insufficient staffing, low pay, inadequate training, and high staff turnover only begin a litany of problems that in turn fuel other problems, including the resident abuse that has been documented in as many as a third of the nation's nursing homes.

The ombudsman program has the potential to ameliorate these problems. But ombudsmen and their programs face additional, substantial, and often structurally enshrined moral challenges. These include multiple conflicts of interest and competing loyalties; the challenge of addressing power disparities and exercising power appropriately; and contrasting interpretations of what is good, right, or virtuous. What truly is the common good, and who determines it? Who has what rights, and what constitutes genuine justice? What sorts of persons should the various players in the nursing home context aim to be, and what virtues should they cultivate? The last sections of this discussion will address these political and ethical questions most directly. An underlying assumption of that discussion, and of this article as a whole, is that each person—including each nursing home resident—is God's human creature and thus deserves to be treated with respect.

THE PUSH FOR STAFFING RATIOS
It is important to set the scene, by identifying the players, the programs, and the possibilities and pitfalls they may face and create. To address staffing shortages, resident advocates believe that setting minimum staffing ratios, meaning appropriate ratios of nurses and nursing assistants to residents, would give consumers and advocates a clear standard for measuring quality of care and serve as a brake on the pursuit of profit at the expense of quality care. In a report to Congress in July 2000, the U.S. Department of Health and Human Services's (HHS's) Health Care Financing Administration—now the Centers for Medicare and Medicaid Services (CMS)—reported on the appropriateness of minimum nurse staffing ratios in nursing homes.² This study, based on eight years of research, found that residents need 2.9 hours of nurse aide assistance and one hour of care by licensed nursing staff—RNs and licensed practical nurses (LPNs)—each day for optimal care. The report also found that 92 percent of nursing homes fail to meet that standard and that nearly half would have to increase their staffs by 50 percent to reach it.

The report finally recommended two hours of care per day per resident as a minimum and found that 54 percent of nursing homes fall below that recommendation. Nonprofit homes, the report found, do have much higher staffing levels than for-profit homes. Great Britain, Sweden, and Spain have better ratios than the United States; and Delaware, Maine, Alaska, and Hawaii rank highest among our states, with Oklahoma, Kansas, and Iowa among the lowest. The report also found federal law and regulations "too vague" to guarantee an adequate number of employees since current regulations only require enough staff to achieve "the highest practicable physical, mental and psychosocial well-being" of residents. There is no indication of what would constitute minimum or appropriate levels of staffing.

Findings like these help to explain why the National Citizens' Coalition for Nursing Home Reform (NCCNHR) has been conducting a petition drive to get Congress to support "mandatory staffing patterns" in nursing homes. The petition form cites the 2000 HHS report to Congress in estimating that more than one million Americans live in nursing homes that lack enough nurses and nursing assistants to give good care. In addition, we are told, "Forty percent of nursing home residents are malnourished or dehydrated because no one helps them eat and drink regularly."

Advocates suggest that Medicaid reimbursements be frozen for facilities that fail to meet staffing ratio standards and that future increases be made contingent on meeting them. The Clinton administration had proposed that detailed staff information for different times of the day be posted for public review at each facility and on a web site maintained by the government.

The response of the nursing home industry to the ratio push has been frosty. Many owners believe that current regulations are already too burdensome and object to another imposition of "one size fits all" standards without regard to the differences in resident needs. From their perspective, the people in the trenches are best able to ascertain what level of staffing is required to assure high-quality care. One industry representative at a meeting of Kentucky's Task Force on Quality Long-Term Care in June 2001 called minimum ratios "an artificial standard." Another stated, "We do not need mandates that redirect resources that were being directed well. This would result in lower quality. My best facility has the least staff and my worst the most."³ They often argue in addition that low unemployment levels and cuts in Medicare (as part of the Prospective Payment System, which places caps on what Medicare will pay) are making it unaffordable to meet such standards.

When the industry cited Medicare cuts as the reason staffing could not be increased, advocates had several rejoinders. Based on earlier statistics revealing excessive restraints, overmedication, unmet care plans, and pressure sores—all traced to inadequate staffing—the staffing levels were too low before the Medicare cuts. In addition, Medicare pays only 12 percent of the costs of residents in nursing homes. ⁴ Furthermore, Congress has reinstated nearly all of the cuts, if not all of them.

An important aspect of this staffing crisis is the plight of the certified nursing assistants (CNAs) who give the lion's share, more than 70 percent, of the care in these facilities. The median pay for these assistants in Kentucky is reported at $7.72 an hour, 50 percent over the minimum wage.⁵ In 1999, it was $6.70. At the same time that nursing assistants are making $7.72, state prison guards average $9.36 an hour and sanitation workers in Lexington, the largest city in the area served by NHOA, make $11.53 an hour. It's no wonder that these labor-intensive and stressful positions are hard to fill and that many nursing homes have turnover rates of 100 percent and more during a year. The U.S. Government Accounting Office cites national turnover rates for nursing assistants at 94.3 percent in 1992, 80.1 percent in 1993, 100.4 percent in 1994, 106 percent in 1995, 96.8 percent in 1996, and 93.9 percent in 1997.⁶ According to Ingrid McDonald, senior policy analyst with the Service Employees International Union (SEIU), a large percentage of the CNAs quit within the first six months because of the heavy workload and the low wages. An SEIU publication, "Caring Till It Hurts," indicates that nursing assistants have higher injury rates than coal miners and construction workers.⁷

One further sobering note is that nursing assistants get seventy-five hours of training before they begin work, while cosmetologists and hairdressers get 3,555 hours of training before certification. Simply adding to the number of CNAs in a facility will not be sufficient to improve quality of care if training is questionable and the number and quality of RNs and LPNs to supervise them is inadequate. Taken together, however, these staffing issues are as crucial to protecting the moral environment and ensuring quality care as any ingredient in the mix.

Congress has tried to ameliorate the staffing crisis. In 2000 Representative Paul Ryan (R-WI) introduced the Medicare and Medicaid Nursing Services Quality Improvement Act (H.R. 4547). It proposed greater use of "single task workers" (STWs), who would work part-time and be equipped with only two hours of training, to perform carefully restricted functions, such as feeding and transporting residents, helping them get dressed and groomed, and helping them in and out of bed. The industry hailed this proposal, but resident advocates denounced it. Proponents saw CNAs being freed to handle tougher problems, but critics saw an excuse to give CNAs a heavier case load and a proponderance of the heaviest and most repetitive tasks. CNAs would then be even harder to retain. Advocates feared that quality of care would be further compromised because the STWs would inevitably be asked to take on additional tasks for which they were not adequately trained and they would be too broadly embraced as a way to reduce wages and training for staff. The legislation died in committee.

Since September 11, the nursing home staffing crisis has been on the back burner in Congress. There has been debate between CMS Administrator Thomas A. Scully and members of Congress regarding news reports that CMS planned to reduce oversight of nursing homes. CMS called these reports inaccurate.⁸

Whether or not minimum staffing ratios are an idea whose time has come remains to be seen. The growing demand for them reveals, however, that past reliance on government-mandated ombudsman programs to assure quality of care has been unrealistic. What is the ombudsman program, and why has it been a disappointment?

THE POTENTIALITY OF OMBUDSMEN
The nursing home ombudsman program was first proposed for experimentation in the Older Americans Act (OAA) of 1965, and then mandated by the OAA of 1978 and its regular reauthorizations, most recently in August 2000, and also by the Nursing Home Reform Act of 1987. As spelled out by the OAA, the duties of an ombudsman are (1) to identify (versions before 1992 say "receive"), investigate, and resolve complaints; (2) to provide services to protect the health, safety, welfare, and rights of residents; (3) to provide information to residents, families, and the general public about services and facilitate public comment; (4) to assure residents and families access to ombudsmen and timely responses from them; (5) to represent residents to government agencies and seek remedies to protect health, safety, welfare, and rights; (6) to analyze, comment on, and monitor regulations and policies; (7) to support the development of resident and family councils; and (8) to promote development of citizen organizations to participate in the ombudsman program. The legislation thus mandated advocacy on both individual and institutional levels.⁹

The federal allocations to the states under this program fund the offices of state ombudsmen, but the state unit on aging may or may not implement the mandate fully. Allocations are made as block grants, and the form of implementation is left to the states. How much happens in each state or area within a state depends on initiatives of both public and private actors. All of the money can remain in the state office, or it can be used to stimulate matching funds from bidding agencies.

Much has been happening in this program. In the United States during 1998, more than 900 paid ombudsmen and seven thousand certified volunteers working in 587 localities received 200,000 complaints by 121,000 individuals, and provided information to 200,000 inquirers.¹⁰ Nevertheless, to read the state-by-state breakdown is to be overwhelmed by the unevenness of the programs. The National Academy of Science's Institute of Medicine evaluated the Long-Term Care Ombudsman Program in 1995¹¹ and found that the Institute's standard of one ombudsman for every 2000 residents was far from being met. In Memphis, for example, the ratio was one to 4,667 residents. In general they found across the nation an unevenly organized, underfunded, understaffed, and overextended system compromised by conflicts of interest and provider resistance. The evaluation found as many different approaches as there were states. The system suffered from lack of legal counsel, lack of frequent visits to facilities, and reliance on telephone inquiries only. Nearly all local ombudsmen, it turns out, are unpaid, that is, are volunteers.

Despite this discouraging picture, there are notable examples of effective implementation. Local people of good will from faith communities and labor organizations have volunteered. For example, Jewish Family Services in Boston, Lutheran Social Services in Cleveland, Catholic Social Services in Louisville, Catholic Charities in New Orleans, and Legal Services in West Virginia have bid on contracts to deliver a large measure of the needed advocacy.

In the seventeen-county Bluegrass Area Development District (ADD) in central Kentucky, a freestanding, independent, nonprofit model program has been developed that celebrated its twentieth birthday in October. It apparently has the only paid local-facility ombudsmen in the country, and it has achieved the remarkable ratio of ombudsmen to residents of one to 160. (Recall the recommendation of one to 2000 above and the widespread failure to meet it.) These ombudsmen work forty to fifty hours a month. In this instance, the ADD's Planner on Aging took the initiative to generate matching funds, and the urban county government in Lexington gives space and funding because of mayoral support. Of the $456,000 annual budget of this private, nonprofit Nursing Home Ombudsman Agency, only $45,127 comes from the ADD—less than 10 percent. United Way gives $181,049; city and county governments, $78,500.¹² Kathleen Gannoe, NHOA's director for seventeen years, is in demand nationally to provide training and to explain the program's success.

In the twelve months beginning May 1, 1999, NHOA took 2,259 complaints; verified and worked on 1,759; resolved or partially resolved 1,498; and handled 255 information and assistance calls. Its complaint load constituted 29 percent of all Kentucky complaints. Only twenty-six of the complaints were of abuse and neglect. The largest numbers concerned resident care, staffing, dietary problems, and environmental problems, such as room temperature, dirty linens, and dirty floors. The ombudsmen focus on prevention of problems and abuse. In the cited time period, ombudsmen visited 5,600 residents in sixty-four homes and eighty-five family care facilities. They held 165 meetings with resident councils and sixty-seven with family councils. They also provided training and consultation to nursing home staffs.

The program has been a catalyst for systemic change. Board members were instrumental in getting the governor of Kentucky to sign a bill establishing the task force, mentioned earlier, on long-term care in the state.¹³ The agency provides publications regarding rights and placement, such as "Your Rights and Responsibilities as a Medicaid Recipient," "A Handbook for Nursing Home Litigation" for attorneys, and "What You Need to Know Before You Enter a Nursing Home." It has explored ways to enhance the pool of nurse's aides, and it has worked with other organizations and agencies that deal with the needs of the elderly.

The fact is, however, that NHOA's intense implementation of the ombudsman program is the exception, not the rule. Statistics about the aging population, about nursing homes, and about complaints tell us that ombudsman programs seek to address an acute need and often do; but these statistics also reveal that the overall effectiveness is uneven and that the general state of long-term care reflects the long-time tilt of our healthcare system toward attempted cure—and the resulting neglect of sustained care. Aggressive marketing of long-term care insurance, proposals for Medicare coverage of prescription drugs, and proposals to give tax credits for home care of the elderly are all evidence of growing concern about long-term care; but a full-blown, systematic response to the challenge has gotten no further than talk.

Ombudsmen know full well that institutional safeguards, such as minimum staffing ratios, are needed to keep nursing home reform from being a primarily reactive response to specific abuses rather than an anticipatory prevention of poor quality care. Implementation of long-term care ombudsman programs can be seen as either a glass that is half empty or one that is half full, but it is still a half-way implementation of an institutional necessity for improving the moral environment surrounding a growing segment of the population that is least able to defend itself. Even a ratio of ombudsmen to residents as small as NHOA's one to 168 is not going to address adequately situations where a nursing assistant is, in many instances, caring for fifteen people on a shift. Both mandated staffing ratios and a full implementation of the ombudsman program at the local level are needed to improve care of residents in long-term facilities. It is noteworthy that the investigation of the home where my aunt resides came about because an insider notified the ombudsman program. It takes a very perceptive ombudsman to unearth things that vigilant family members and staff members see on a regular basis.

MORAL AGENCY IN NURSING HOMES
Given the realities of nursing home life, much change is needed. But obstacles, both contextual and individual, make "protecting the moral environment" in the nursing home a continuous challenge. One of the factors that pollutes the environment in which both staff members and ombudsmen function, even when numbers of staff and ombudsmen are both at satisfactory levels, is the competing loyalties that claim their attention. It would seem that loyalty to persons in need of long-term care would be the engine driving all players in the long-term care arena, but the realities reveal no such single purpose.

In its 1995 evaluation of ombudsman programs, the Institute of Medicine gives major attention to conflicts of interest.¹⁴ For starters, the structural location of many of the state offices is a problem. Most often the state ombudsman is a state employee in a governmental chain of command. Every executive branch of government places some limits on its employees' contacts with legislatures and the media. By law, the ombudsman is supposed to speak out against laws, regulations, policies, and actions that work to the disadvantage of recipients or potential recipients of long-term care, but taking such steps can place them at cross-purposes with the administrations that they serve. The Institute found the OAA's regulations on conflicts of interest outdated in their limitation to financial interests and nursing home facility settings. The report recommended that no ombudsman program be located in an entity of state or local government or an agency outside of government whose head is responsible for licensure, certification, or accreditation of facilities; provision of long-term care services; long-term care case management; reimbursement rate setting; adult protective services; Medicaid eligibility determination; preadmission screening for long-term care residential placement; or decisions regarding admission to facilities. It recommended exclusion of parties who provide, purchase, or regulate services within the purview of ombudsman programs from membership on policy boards exercising governance over long-term care ombudsman programs. It further recommended establishing procedures and resources to identify and address conflicts of interest and to ensure availability of legal counsel without conflict of interest—such as employment by a government agency that could conceivably have a conflict of interest.

The report did not provide an exhaustive list of the quicksands of conflict. Employees with state survey and certification agencies, which ombudsmen rely on to monitor problem facilities, may be offered lucrative positions with the nursing home industry when they leave government service. Both staff members and ombudsmen may feel an inner conflict because they want to please the facility management, the residents, and their families. Ombudsmen and staff may encounter conflicts between a family and a resident and conflicts within families over the expenditure and even exhaustion of a resident's resources that otherwise might end up in the pockets of family members. Staff members may face competing loyalties if families want them to moonlight by giving supplemental care to family members. This inducement can skew the attention of the employee and the workloads of other employees. One resident's family may also have a conflict with other residents if those residents are bothering or abusing the family member. The facility may blame a resident for abuse to escape responsibility for inadequate staffing and supervision, with the result that the facility abandons a troublesome resident. Staff members may compete against each other because they want to please their supervisors and also the residents and families that they serve; yet they need to look out for themselves in terms of pay and working conditions. Sometimes the only way to get better pay is to change jobs, which means abandoning residents.

These many competing loyalties that chill the environment in which staff members and ombudsmen operate can compromise the quality of care that residents receive. In this context, the loyalty of staff members and the ombudsman to residents' welfare, both individually and collectively, should be undiluted and unwavering. The professional ethics of staff members and the structure of the ombudsman program should protect that independence and that commitment, but keeping resident welfare the top priority can be a huge challenge.

Conflicts of interest and loyalty occur in the context of power realities. If we cannot rely simply on the goodness of people's hearts and consistently compassionate care, we will have to acknowledge that the exercise of power is often required to assure quality care of our healthcare system—or healthcare disorganization. As long as we regard the provision of long-term care to the vulnerable elderly as an act of charity apart from the realities of power, we will ignore many of the dynamics of long-term care and render ourselves inept in addressing the crisis we face. Either to acquiesce naively before the economic and political power of providers or to trust solely in the paternalistic power of healthcare professionals is to consign the recipients of services to powerlessness. The possession of power then becomes a zero-sum game in which the acquisition of more power by residents and their advocates is viewed as a subtraction from the power of facility management and health professionals.

From another perspective, power is the only factor in play; compassion has nothing to do with the address of problems in long-term care. The dynamics of the situation are thus limited to the entrepreneurial power of the nursing home corporation, the regulatory power of the government, the professional power of physicians and nurses, and the buying power of the consumer. In the power struggle, the contending players keep each other honest. In the marketplace, these contenders make it unnecessary for the government to protect the common good or provide long-term care. In the courts, litigation will protect long-term care residents by making the provider pay for its failure to give good care.

The advocate perspective that prompts NCCNHR's push for legislated staffing ratios and the ombudsman program assumes that the use of power is required to assure quality care. This power involves the power of law and the power of expertise, but it also espouses the power of persuasion. It assumes that the exercise of power is not antithetical to the expression of compassion. It views the aim of love to be the empowerment of the resident and of the resident's family and friends. It aims at "power with" and not simply "power over" or "power for."¹⁵ It works to enable the most vulnerable of the elderly and their families to be treated with the respect owed every member of the human community—the respect owed a child of God. It believes that absolute powerlessness dehumanizes absolutely as surely as absolute power corrupts absolutely. The advocacy of the ombudsman programs suffers from insufficient funding, uneven administration, and a more reactive than anticipatory mode of operation; but its heart is in the right place. The current push for staffing ratios recognizes that the power of government and the concerns of ombudsmen coincide.

Advocacy for better quality of long-term care not only labors amid the pulls of competing interests and conflicting perspectives on the location and use of power in relation to compassion; it also contends with competing ethical stances—with contrasting views of the good, the right, and the virtuous. An ethic of the good seeks a desired end, but contends with disagreement about the nature of the good and suspicion of the imposition of someone's version of the good on someone else. If the end is only what is deemed best for one's corporation, institution, family, or interest group, then corporate egoism rules—even if it parades as concern for better long-term care. If the good is the greatest good for the greatest number, understood as aggregate economic well-being, it may amount to a utilitarian trust in market forces to lift all or most boats and a libertarian fear of allowing a majority or a governmental agency to impose some version of the common good, applied in this case to long-term care.

On the other hand, if an ethic of the good envisions a common good in which everyone has a stake and aims at giving everyone the opportunity to be a full participant in the society, adequate long-term care for all takes on a different ranking. We have Social Security because our society decided at some point that we all have a stake in it. As it dawns increasingly on us that we all have a stake in good quality long-term care, the welfare of the 24 million who will need it in 2060 (up from 9 million in 2000) will become a higher priority than it has been so far. Unless we are willing to write off nursing home residents as people who have unfortunately outlived their usefulness and to forget that we may well turn out to be those people, the health of the long-term care facility resident is destined to become a common concern.

According to the National Long-Term Care Survey done by Duke's Center for Demographic Studies, "the vast majority of caregiving is done by relatives for no pay."¹⁶ Nevertheless, even now, 43 percent of people over sixty-five will spend some time in nursing homes, and soon people over sixty will have an even chance of being at some point a resident. Most of these people will not have family members who can maintain them at home or monitor their care closely in a facility. Most in fact will have no personal visitors in the nursing home. We as a society are left then with deciding whether there is a common good that includes a growing and often vulnerable cohort in our citizenry.

An ethic of the right may deal in competing rights or claims—the rights of nursing home residents not to be restrained against their will; the right to regular, warm meals to their liking, to baths, to clean clothes and sheets, to appropriate medication, etc.; their rights of nursing assistants to better pay and working conditions; the right of a nursing home corporation to make a profit and to decide its own staffing ratios; the rights of families to full and accurate information about nursing homes. These rights obviously conflict sometimes. Which rights have legal protection, and which rate moral priority in cases of conflict? There's the rub.

Instead, or in addition, an ethic of the right can explore the meaning of distributive justice. Is it intergenerational justice for the elderly to get more than their proportional slice of our health care resources? Is it fair for them to be denied fair compensation for their years of contributing to our common life? Or one can talk about the "preferential option for the poor"¹⁷—including those who have spent all of their resources and now qualify for Medicaid support in a nursing home—and protection of the least advantaged. It is estimated that about 70 percent of nursing home residents are poor, and we have already noted that nursing assistants are often so poorly paid that they live on the margin of poverty. Justice in this case means liberation of the poor, giving voice to the voiceless, and protection of the most vulnerable.

Concerns for equal justice raise questions of insurance or Medicare coverage for long-term care as well as hospital care and skilled care in nursing homes. In Canada, for example, all citizens are eligible for long-term nursing home care. Under a co-pay system, residents pay about $19 of a typical $67 per day, which makes this long-term care affordable. In the United States, the cost of living in a nursing home ranges from $40,000 to $100,000 per year. Medicare only pays for skilled care—100 percent for the first 20 days and a co-pay for the next 80, with a 100-day limit. Medicaid only pays when a resident has spent himself down to a state of poverty.

Advocates for empowerment stress justice as solidarity with the poor, vulnerable, and deprived. For example, the ombudsman's vocation is to be an advocate for the residents' needs, especially the need for respect. The common fate of the long-term care resident is to be "dissed"—disregarded, dislocated, disoriented, discounted, dismissed, and, above all, disrespected. As partial and piecemeal as the ombudsman's role is, she at least demands that people be given respect, whether they be residents or their families or nursing assistants. "Respect" is hard to elaborate in a list of residents' rights, and "no respect" can be hard to explain on a complaint form. True respect comes down to the kind of people who care for residents and the kind of environment that they inhabit, to the way supervisors regard staff members and the culture they foster in the facility. The quality of care that people give, however, depends in considerable measure on having a sufficient quantity of people there to give it.

H. Richard Niebuhr in The Responsible Self argues for an ethic of the fitting, not in refutation of an ethic of the good or an ethic of the right, but as a more inclusive understanding of the moral life.¹⁸ This ethic focuses on the self who reflects and acts as a member of various communities more than on the ends to be sought or the laws or principles to be obeyed. This emphasis focuses on what James Gustafson terms "the sort of person" one is and attends above all to the moral agent; it is a virtue ethic.¹⁹ In underlining the importance of the agency of able and sufficient staff and of able and sufficient ombudsmen in protecting the moral environment in nursing homes, I am tilting toward such an ethic of responsible agency. What will it take to attract, train, and retain the sort of people who are needed to insure a respectful environment in nursing homes? The American Health Care Association, the largest trade group of nursing homes, is asking Congress for funds to do this very thing; and it will take more money than anyone is spending now.

For starters, we need to be clear about the virtues that should be embodied by the individual and institutional agents in long-term care. Organizations are agents too, so virtue is not only individual, but also institutional. Efficiency on behalf of the bottom line has too often been the primary virtue fostered by the industry although quality of care has been given ample lip service and often actual emphasis. The contractarian virtues of meeting minimum terms need to be surpassed by the more covenantal virtues of care and fidelity. If these are to be the cardinal virtues of both the individuals and the institutions that provide long-term care, staff training and pay will need substantial improvement, and retention of staff will need radical reassessment. Fidelity suffers when the staff turnover percentage approaches triple digits, and care is compromised when a staff member is stretched too thin, trained too little, worked too hard, and paid too poorly.

Ombudsmen do function as friendly visitors, but their occasional visits are not enough to assure high-quality care, even where the ratio of ombudsmen to residents is ideal. Even if the ombudsmen care deeply, their time spent with residents, families, and staffs cannot, in itself, meet resident needs. What is more, dealing with complaints after problems arise does not address the transformation of the institutional environment. However, because ombudsmen are advocates at the institutional level as well as the personal level, they are attempting preventive health care and promoting institutional virtue. The very fact that ombudsmen are in the picture, that they lobby for staffing ratios and better staff pay, that they direct information about facilities to consumers seeking placement, and that they help to educate staffs, families, residents, lawyers, and other concerned people about quality of care issues, means that they keep providers on their toes and help build virtue into the system. In the best of situations, they can head off problems before they happen instead of merely exposing violations. Just knowing that the ombudsmen are on call affects the culture of a facility and the standards of an industry. Faithful care is not just a quality of one-on-one relationships; it is a condition of a moral environment. Care and the prudent exertion of pressure need not be antithethical in the work of advocates; the two should complement and educate each other. The best of facilities see ombudsmen as their friends rather than their enemies.

CONCLUSION
An ad poster for nursing home reform shows an elderly man. It reads: "What does he miss most? Regular meals, baths, medication, clean clothes and sheets, respect. Give him what he misses most—quality care." The two examples cited at the beginning of this discussion highlight failures to provide quality care and underline potential roles of both staff members and ombudsmen in recovering and maintaining quality. Lest we look largely to litigation to right the wrongs in the system, we need such legislative safeguards as minimal staffing ratios and such regular monitoring as ombudsmen provide. Charity alone will not suffice. Only an alliance of political clout and compassionate concern will salvage a system in trouble.

To get beyond the most obvious and heinous abuses to the deeper and less glaring deficiencies caused by insufficient staff, insufficient training, and staff instability requires both staff and resident advocates—family members, ombudsmen, and others—who are willing to flag problems before they become dire and who can even anticipate them before they occur. The enactment of mandated staffing ratios would give ombudsman programs and other monitoring agencies and groups a way of measuring care quality that, while admittedly imperfect, would set institutional standards that encourage a more compassionate culture of long-term care. It is one step toward a moral environment that incorporates those in need of long-term care into the community's common good, extends justice to the poor and the vulnerable, and makes the virtue of faithful care an institutional reality. Residents of long-term care facilities should not have to leave home without it.

NOTES
1. House Committee on Government Reform, Special Investigations Division, Minority Staff, Abuse of Residents is a Major Problem in U.S. Nursing Homes. U.S. House of Representatives, Committee on Government Reform, Minority Office web site. Prepared for Rep. Henry Waxman. Released July 30, 2001. Accessed December 10, 2001. (http://www.house.gov/reform/min/inves_nursing/index.htm#anch_abuse).