“Such Trivial Matters:” How staff account for restrictions of residents' influence in nursing homes

National policies emphasize older people's right to autonomy, yet nursing home residents often have restricted opportunities to make decisions about everyday matters. We use qualitative interview data to analyze staff members' explanations of actions that conflict with both social norms and national policies. Two types of problematic actions are discussed: restrictions of elderly residents' influence in decision making and neglect of residents' complaints. While staff members describe residents' influence as desirable, they simultaneously formulate accounts that justify their inability to live up to this ideal. Further, we demonstrate how certain complaints are “made trivial” when they are described and treated in specific ways by the staff. We argue that the accounts offered by staff members draw on an implicit folk logic, a logic in which residents are allowed to exercise influence only as long as it does not conflict with the efficient running of the institution as a whole.     

Potential for the Abuse of Medication for the Elderly in Residential and Nursing Homes in the UK

ABSTRACT

Abuse of the medication prescribed to the elderly living in long-stay care homes may be perpetrated by a minority of unscrupulous doctors, pharmacists, or home staff caring for the residents. Disorganised practices and homes, poor communications, and sloppy professional practices may create opportunities for over-dosing, errors, fraud, or theft. This article describes the circumstances leading to the potential abuse of elderly residents' medication, and the measures that may be taken to avoid or minimise such abuse from occurring.     

Seeking exemptions from nursing home routines: Residents' everyday influence attempts and institutional order

Using ethnographic data collected from a Swedish nursing home, this article analyzes residents' everyday or subtle influence attempts relative to the maintenance of institutional routines. Residents' efforts to carve out some autonomy or fulfill personal preferences in everyday matters could be categorized as (1) disruptions, (2) disturbances, or (3) “good matches” relative to ongoing and up-coming nursing home routines. Striking disruptions were often fruitless, while attempts rendered as disturbances were typically postponed or modified. In general, the outcomes of residents' maneuvers were shaped by brief and situational negotiations of whether (and how) temporary exemptions from the institutional order were deemed accountable or not by the staff. Although the staff sometimes arranged situations in which residents were given some defined or symbolic decision-making authority, the findings of this study show how an inflexible local routine culture can constitute a constraining and only occasionally porous framework for residents' self constructions and everyday life.     

The Impact of the Social Environment on Nursing Home Residents

ABSTRACT

This study contrasted the experienced quality of life of residents living on one of two nursing home units: a unit for those considered socially intact and a unit combining residents who had moderately impaired cognition or physical function with those requiring skilled nursing or therapy. Qualitative interviews were held with residents of both units. The findings indicate that the social environment of each of the units played a fundamental role in the residents' quality of life. The social environment affected the residents' conceptions of self, their interactions with other residents and their interactions with the nursing staff. The article suggests the processes behind the social environment of each floor that may have resulted in different perceptions of the quality of life.     

Coming together and pulling apart: Exploring the influence of functional status on co-resident relationships in assisted living

Social relationships can have considerable influence on physical and mental well-being in later life, particularly for those in long-term care settings such as assisted living (AL). Research set in AL suggests that other residents are among the most available social contacts and that co-resident relationships can affect life satisfaction, quality of life, and well-being. Functional status is a major factor influencing relationships, yet AL research has not studied in-depth or systematically considered the role it plays in residents' relationships. This study examines the influences of physical and mental function on co-resident relationships in AL and identifies the factors shaping the influence of functional status. We present an analysis of qualitative data collected over a one-year period in two distinct AL settings. Data collection included: participant observation, informal interviews, and formal in-depth interviews with staff, residents, administrators and visitors, as well as surveys with residents. Grounded theory methods guided our data collection and analysis. Our analysis identified the core category, “coming together and pulling apart”, which signifies that functional status is multi-directional, fluid, and operates in different ways in various situations and across time. Key facility- (e.g., admission and retention practices, staff intervention) and resident-level (e.g., personal and situational characteristics) factors shape the influence of functional status on co-resident relationships. Based on our findings, we suggest strategies for promoting positive relationships among residents in AL, including the need to educate staff, families, and residents.     

Going to the Crackhouse: Critical Space as a Form of Resistance in Total Institutions and Everyday Life

This article explores the extent to which organizational identity claims and the formal organization of social control influence how actors in a total institution conceptualize their “real” selves. The setting for this case study is Project Rehabilitate Women, a drug treatment program serving incarcerated female offenders. Using Goffman's analysis of the total institution as a guide, I explore the importance of “secondary adjustments” for self-definition. This analysis will show that the capacity of residents to distance themselves from the label of “addict” is contingent on the formal structure of social control. I will argue that, in the absence of traditional distancing strategies, residents construct “critical space” as an alternative means to subvert institutional control mechanisms and to creatively acquire the resources necessary to articulate definitions of self that are distinct from staff constructions. It is clear that resistance, whether temporary or sustained, successful or failed, is central to how subordinates maintain their sense of self in an environment committed to radical self-transformation.     

Choosing Privacy over Interaction: Restructuring Expectations and Interpretations of Community Integration in Canadian Small-House Long-Term Care Settings

In Nova Scotia, Canada, the small-house model of care has been introduced as an alternative to institutional care settings, and the province has funded and built 11 new long-term care (LTC) communities in the small-house model. Each of the new facilities was built with multiple cottages housing 12 to 15 residents; each cottage features private bedrooms and a residentially scaled kitchen and dining area. Through smaller numbers of residents living in home areas, the goal of the Provincial Department of Health was to encourage relationship building, as well as to provide opportunities for autonomy and choice in resident daily living. A qualitative case study was conducted in one of these small-house communities, focusing on the model's impact on resident interaction and community integration. Thematic analysis revealed that while resident social patterns were directly impacted by the physical environment and culture of care in the new model, interpretations of these patterns by staff and family members were influenced by preexisting expectations of community integration rooted in institutional care models of the past.     

Slaps,Punches, Pinches—But not Violence: Boundary‐Work in Nursing Homes for the Elderly

This article presents an analysis of boundary work in the context of care for the elderly, where violence appears to be widespread but is still relatively unacknowledged. Talk about aggressive patients was formulated in a particular way among workers in a nursing home. Nursing home staff described how the elderly residents sometimes slapped, pinched, or hit them. Although staff members could describe these acts as intentional, although they could hold patients responsible, and although this violence could end in injuries, demarcations were made such that aggressive acts were constructed as somehow not really “violence.” As “violent” is an inherently exclusionary label, this downplaying can be seen as an effort to avoid pushing persons outside the boundary of normalcy and of continued acceptance. Placing the elderly's violence outside the boundaries of violence means that the elderly remain “care takers,” the staff “caregivers,” and the nursing home a “caring context.”     

The Mobility of Elderly Residents Living in Suburban Territories

Abstract

Many authors have observed die elders' unanimous aspirations to age in place. Such residential aspirations echo theoretical concepts such as “environmental-fit.” Aging residents adapt to their residential environment according to their autonomy level, their financial and social resources, as well as the meanings they invest in both residential situations and lifestyle (Lord, 2004; Wagnild, 2001). Therefore, the suburbs constitute a challenge for aging residents' intentions to remain in their home for as long as possible. These low-density environments encourage car dependency for almost every daily activity. In that regard, many studies have investigated the daily mobility patterns of elders living in such areas. However, most of them have focused on aspects linked to transportation and driving security (Rosenbloom, 2003). In this context, with a socio-anthropological (in-depth interviews) method, the elders' daily mobility is explored in a complex layering of issues. Two interdisciplinary qualitative researches on the daily and residential mobility of elderly suburbanites have been used: a group living in Quebec City's Post-War suburbs in Canada (n = 56) and another in Marseille's periurban suburbs in France (n = 36). The results show that we must investigate beyond the elders' “emotional attachment”to their “home” in order to explain the everyday tensions underlying accessibility and daily mobility. Aging in a single-family house is more than a deliberate choice. Moving away from one's neighborhood is considered a last resort alternative by the majority. Instead, the elderly from both milieus will adapt their lifestyles to the environment by redesigning their daily activities and their mobility practices in order to age in place. Therefore, adapting daily mobility practices to social interactions and social representations all become a sine qua nonecondition.     

Chapter 2 Residents in Assisted Living Facilities and Visitation Patterns

Abstract

Resident visitation patterns within an assisted living facility provide insight into a resident's life satisfaction. This study investigated residents' perceptions of family and friend visitation. Thirty assisted living residents from Oklahoma participated in a comprehensive interview that included demographics, life satisfaction, visitation frequency, and perceptions of visitation patterns. A majority of the respondents (90%) perceived family and friend visitation as “important” to “very important” in their life. Visitation allows residents to reminisce with family members and friends, to fulfill the need to have outside contact, and to be reassured that they have not been forgotten. Results indicate residents do desire continued relationships with family and friends through visitation. Facilities should encourage activities involving outside members of a resident's support network and be aware of residents less visited, developing programs creating social contact and involvement.     

Are You Truly a Recovering Dope Fiend? Local Interpretive Practices at a Therapeutic Community Drug Treatment Program

Previous qualitative research on treatment programs for drug addiction/alcoholism has primarily focused on those processes whereby participants are expected to construct a new sense of self according to institutional parameters. The present article builds on that research and explores how contemporary programs attempt to resolve the problem that it is almost impossible to tell if someone has engaged in this self‐construction process. Informed by five months of ethnographic fieldwork at an adult residential drug treatment facility, the article asks: under what circumstances do program members call into doubt a client's efforts to create an institutional self, and how do they express this skepticism? The article reveals that staff and clients employ a set of local interpretive practices about community and emotions to assess whether clients are constructing the institutional self of a “recovering dope fiend.” It specifically considers how they interpret a client's emotional displays to represent that client's current self under construction. That is, a client's ability to control anger appropriately or to handle anxiety demonstrates s/he is effectively “doing the program” of self‐construction.     

Experiences of a Mass Interinstitutional Relocation for Long-Term Care Staff

This research explored long-term care (LTC) staff perceptions and experiences of working in LTC and providing care to residents following a mass interinstitutional relocation. In-depth, semistructured interviews were conducted with 63 LTC workers. Thematic analyses revealed three overarching themes related to how staff members perceived their relationships with other staff members following relocation. The first theme, post-relocation relationships between staff members, included the subthemes “Staff are segregated from each other” (physical distance) and “We were a family” to “barely say hi” (psychological distance). The second theme, post-relocation stress, has two subthemes: “Staffing is our big issue” and consequences of stress: absenteeism and leave. The third theme is recommendations for improving and managing staff relationships post-relocation. Relationships among staff members are integral to working in LTC and providing care to residents following a mass interinstitutional relocation. Recommendations for improving staff relationships and morale are suggested.     

Ensuring an Abuse-Free Environment:

Abuse and neglect of nursing home residents are recognized as a major concern in the United States. The small amount of research conducted to date concerning the extent and correlates of the problem of abuse highlights the need for specialized staff training in abuse prevention. The residents' right to be free from abuse demands that facility staff be equipped with an awareness of the types of abuse, how to recognize the potentially abusive situations, and how to appropriately defuse conflict. This paper describes the development and test implementation of an eight module abuse prevention curriculum designed specifically for nurse aides in long term care facilities.     

Anchors,Habitus, and Practices Besieged by War: Women and Gender in the Blockade of Leningrad

As war challenges survival and social relations, how do actors alter and adapt dispositions and practices? To explore this question, I investigate women's perceptions of normal relations, practices, status, and gendered self in an intense situation of wartime survival, the Blockade of Leningrad (1941–1944), an 872‐day ordeal that demographically feminized the city. Using Blockade diaries for data on everyday life, perceptions, and practices, I show how women's gendered skills and habits of breadseeking and caregiving (finding scarce resources and providing aid) were key to survival and helped elevate their sense of status. Yet this did not entice rethinking “gender.” To explore status elevation and gender entrenchment, I build on Bourdieu's theory of habitus and fields to develop anchors: field entities with valence around which actors orient identities and practices. Anchors provide support for preexisting habitus and practices, and filter perceptions from new positions vis‐à‐vis fields and concrete relations. Essentialist identities and practices were reinforced through two processes involving anchors. New status was linked to “women's work” that aided survival of anchors (close others, but also factories and the city), reinforcing acceptance of gender positions. Women perceived that challenging gender relations and statuses could risk well‐being of anchors, reconstructing gender essentialism.     

Exploring personhood in dining experiences of residents with dementia in long-term care facilities

Despite the shift toward using person-centered approaches in dementia care, the relevance and applicability of the concept “personhood” remains unclear in everyday practice and activities, such as mealtime experience for residents with dementia. Based on a qualitative study, this paper presents emergent themes at mealtimes that support or undermine personhood of twenty residents with dementia in two long-term care facilities. Methods of data collection included conversational interviews with residents with dementia, participant observations, focus groups with staff and examination of available documents. Data analysis identified eight themes: (1) outpacing/relaxed pace, (2) withholding/holding, (3) stimulation, (4) disrespect/respect, (5) invalidation/validation, (6) distancing/connecting, (7) disempowerment/empowerment, and (8) ignoring/inclusion. These findings raised questions about current practice and identified areas for improvement. Although staff approaches seemed to have the greatest impact on residents' experiences, the physical environment and organizational milieu were also responsible for hindering and facilitating staff to provide the best possible care and interaction.     

On the Margins of the Periphery: Unassisted Childbirth and the Management of Layered Stigma

This article examines an unusual practice—unassisted childbirth—and the ways in which advocates and practitioners manage the stigma they are accorded. Given their “doubly deviant” status as not only women who birth at home but also as women who choose to give birth without professional assistance, these women provide a unique case for our theoretical understanding of stigma management. As members of homebirth social networks, the women must reckon with what I term layered stigma, the broad stigma of homebirth as well as the deeper in-group stigma within their deviant community that results from their rejection of midwives as appropriate care providers. By examining the dynamics of stigma management among practitioners of unassisted childbirth, I highlight the complex, situation-dependent nature of stigma and the impact of its management on women's sense of self.     

Scandalous Care: Interpreting Public Enquiry Reports of Scandals in Residential Care

ABSTRACT

This article reviews an earlier study written for the Wagner Committee (1988) on scandals in residential care. That review was based on a study of ten enquiry reports, only two of which were about homes for older people. The main events that were described are grouped as: institutionalised practices, indifference and neglect, physical cruelty, humiliation, too authoritarian a life-style, a dull and depressing life-style, an overcrowded and run down environment, disharmony amongst the staff team, and staff misappropriating goods or money. Now, more weight should be given to: residents' abuse of residents and of staff, an improper influence on the life-style of others, and sexual abuse. Explanations proposed are: structural, environmental, and individual and worker style. Abuse is considered in the context of the nature of direct care and the acts of intimate caring of others.     

“Our Own Little Language”: Naming and the Social Construction Of Alzheimer's Disease

Social meanings and cultural definitions attached to illness, disability, and aging have a powerful influence on the development and operations of medical care as well as the social, behavioral, and therapeutic processes occurring within these settings. Specialized care environments designed to meet the needs of what some would argue is a dramatically increasing population worldwide, those with Alzheimer's disease, have been dominated by a medical model of care where treatment of disease has primacy over person. In contrast to the medical model, the Certified Nursing Assistants (CNAs) at Starrmount (pseudonym) Alzheimer's Unit have socially constructed an alternative to the medical model of care through what I argue is the use of language and a process of “naming and reframing.” In this “different world,” as the CNAs call the world of the Unit, the resident is depicted as a socially responsive actor with a surviving self that is to be treated with respect. Using a symbolic interactionist framework, this paper examines the CNAs' construction and use of a “language of openings”—that is, the language arising out of the lifeworld of the residents—as the counterpoint to the “language of limits” of the medical model. Spoken everywhere but nowhere inscribed as “official” knowledge, this “little language,” as the CNAs speak of it, is the fundamental medium for social interaction in the Alzheimer's Unit.