the family metaphor applied to nursing home life

Pergamon tnr J.Nuru. Stud.,Vol. 33,No. 3,pp. 237-248, 1996

Copynght 8 1996 Elsevier Scmce Ltd All rights reserved Pmted m Great Britam

0020m-7489196 $15.00+0.00

0020-7489(95)00053-4

The family metaphor applied to nursing home life

ANNE E. M. NYSTROM, R.N., Dipl. Nurs. Ed., Cand. Phil. KERSTIN M. SEGESTEN, R.N., Dipl. Nurs. Ed., M.S.N., Ph.D. Depurtmmt of’ Primary Health Care, Vasa sjukhus, 41133, Gothmburg, Sweden

Abstract-The family metaphor was applied to data from participant observations of 18 lucid nursing home patients in order to highlight how nursing home life influenced their experience of health. The instrumental activities in the nursing home were more routinised and specialised than in a family, but usually care was observed to be tender, loving and diligent. Further analysis revealed many factors, which may combine to disturb self-esteem and prevent efforts towards further maturation: loss of continuity to earlier self, collectivisation of activities, extreme dependence, embarrassing situations, child role, and constantly mild behaviour from staff. Copyright 0 1996 Elsevier Science Ltd.

Introduction

Good health of citizens is the goal of society’s health care. The nursing home is also supposed to function as the last home of the elderly, dependent patients. The care periods are long lasting and the interactions often very intimate, and many similarities to family life can be recognised. Thus, it was decided to use the concept of family as a metaphor and adapt terms from family research to data from participant observations in a nursing home unit to elucidate how interactions and conditions in nursing homes might influence the experience of health in lucid, elderly nursing home patients.

231

238 A. E. M. NYSTROM and K. M. SEGESTEN

Frame of reference

Health

In nursing, the concept of health is multidimensional, including clinical, functional, adaptive and eudaimonistic dimensions (Smith, 1981). In a study by Nystrom and And- ersson-Segesten (1990), elderly nursing home patients were asked what it meant to them to live in a healthy way. The answers were organised in three hierarchical levels: (a) acceptable function in daily life, a nice environment, and relief from pain and worries; (b) positive self- esteem: identity and integrity; and (c) experience of peace of mind. Patients describing all three levels, presented the inner, private state of peace of mind as the most crucial factor influencing their total life experience. These patients were expressing and radiating peace, satisfaction and confidence, leading to a calm acceptance of whatever may come and an appreciative memory of the past. Activity and aspirations were diminished, but the patients retained old interests, were affectionate towards family and friends, and associated with some of the people around. Experiences were valued in a very thoughtful, balanced way. Peace of mind was not a stable state, it had to be repeatedly fought for, but when existent it could compensate for shortcomings on the preceding levels (Nystriim and Andersson- Segesten, 1990).

Health can also be related to individual, harmonious growth and development. Erikson (1982) and Erikson et al. (1986) have described syntonic human development in the last stage of life: the maturing towards integrity and wisdom reached by philosophising, similar to the state of ‘peace of mind’ as described by Nystrdm and Andersson-Segesten (1990). Also Tornstam (1994) has described a unique developmental stage in old age: gerotranscendence, having many traits in common with wisdom and peace of mind.

Kayser-Jones (1991) Clark and Bowling (1990) and others have studied environmental factors in nursing homes, and found them crucial for the quality of life of the residents. Interactions between staff and patients will decide much of the conditions and experiences of the elderly patients. Nystriim and Segesten (1994) described feelings of powerlessness reported by elderly nursing home patients and derived the origins both from power dis- tribution in the nursing homes and from existential experiences. But even in nursing homes where considerable efforts have been made in organisational change and staff education programmes, and where the staff consciously strive to offer high quality care, still all patients do not experience health. Thus it is very important to further clarify the way in which interactions and conditions in nursing homes influence patients’ experiences.

The family metaphor

In this paper ‘family’ has been used as a structural metaphor in order to give new perspectives on nursing home life. The “essence of a metaphor is understanding and experiencing one kind of thing or experience in terms of another” (Lakoff and Johnson, 1980, p. 455). A structural metaphor involves using concepts from one domain to lead thoughts to many other entailments, which may highlight important features. The nursing home unit is not a family, but using terms from family nursing could help in pointing out mechanisms also active in the nursing home.

The family is a genuine human institution, intended to protect the members and help them to mature and to live a good, healthy life. A family has been defined as a primary group of people, living in a household, in consistent proximity and intimate relationships (Helvie, 1981). The family is a unit with outward and inward functions, interactions, roles,

THE FAMILY METAPHOR APPLIED TO NURSING HOME LIFE 239

exchange and power (Wright and Leahey, 1984). In the ecological approach (Mercer, 1989) developmental, systems, and situational perspectives are mixed, and family members are studied individually, interactions and roles in the family are charted, and the effects on the family of factors in local environment and society are discussed. Specific factors have been described as crucial for family functioning: instrumental/expressive functions; individuation/enmeshment; mutuality/isolation; flexibility/rigidity; stability/disorganisation; clear/unclear, distorted perception and communication; clear/unclear roles; role reciprocity/role conflict; and a full spectrum of feelings (Wright and Leahey, 1984; Barnhill, 1979; Gershwin and Nilsen, 1989). Thus, many different factors have been found to influence the well-being of the members of a family, and some of these may be used to clarify mechanisms in nursing home life.

Method

Our own valuing of the events in familiar situations are easily ascribed to others par- ticipating in the same situation. If one really wants to understand what impact an event may have for someone else, it is necessary to share this person’s reactions and comments on daily life during a longer period. Being accepted as an interested visitor gradually gives access to patients’ reactions and valuations of their life situations (Leininger, 1985).

Participant observations were made by the first author in one of the six units of a nursing home. There were 35 somatically disabled and/or mentally impaired patients on the unit (mean age 86 years; oldest patient 101 years; 26 females/9 men). The regular daytime staff consisted of the head nurse, two staff nurses, 11 licensed practical nurses, and 12 nursing aides. The physician, one of the staff nurses and some night and temporary staff were men, the others women. The premises were modern but built in hospital fashion, and safe for disabled persons: five rooms with four beds, six rooms with two beds and three single rooms, service facilities in the centre as well as some common living and dining rooms. The observations were directed toward 18 patients over 65 years old, who were able to communicate, were medically stable, and mentally well-organised and judged by the nurses as lucid and aware of their identity and total situation. Daily life was observed over a 6- month period for approximately 120 hours, covering mornings, daytime, and evenings. Most of the time was spent initially in informal, daily conversations with the patients. Events, signs of patients’ reactions, and patients’ spontaneous comments on daily life were registered. Gradually a closer relationship was established with seven of the patients-the key informants-and these patients described their life histories and recent feelings, reactions, and expectations to the researcher in private conversations on several occasions. Unstructured interviews were conducted with groups of three to six nursing aides and licensed practical nurses regarding their view of the life in the unit.

Attention was paid to events and interactions, which resulted in obvious reactions in the patients, or which seemed to cause some reaction. Interpretations of the non-verbal expressions were later verified by discrete questions to the patient. The knowledge of the social and historical backgrounds of the subjects, sensitivity to verbal and facial expressions, body language and related behaviours, and knowledge of organisation and routines of nursing homes helped understanding of what was happening. Great care has been devoted to facilitation of expressions of feelings and opinions without imposing personally-held meanings. During the observation period, themes found in the data were discussed with the key informants, verified and further illustrated by them. As many of the classifications

240 A. E. M. NYSTRBM and K. M. SEGESTEN

and themes were connected to family terms, a special analysis was made comparing these to family concepts.

Findings

Spending time together with the patients and observing life in a nursing home unit from a patient perspective revealed a picture, sometimes very different from that experienced from the perspective of a registered nurse working in a nursing home. Having no overview of what was going on and a different pre-conception, patients often interpreted events in a different way to nursing personnel. The researcher recognised many elements of affection- caring-support-intimacy-presence-cohesion between staff and patients: patients and personnel joking, hugging, having long and meaningful conversations, personnel comforting sad patients, and patients listening to personal troubles of a member of staff. Also observed on some occasions were rigid, bullying manners toward patients and a disregard of their needs. The atmosphere was usually open and relaxed, and patients were often seen chatting round a table, and exchanging easy, spontaneous comments about daily life with one another and staff.

Primary group of people, living in a household

This group was very large, consisting of patients and staff. Regular visitors to the patients became well acquainted with most of the patients and staff, and were invited to participate in the unit activities, and were also expected to do laundry and other services. The cultural background was largely shared, but the age gap between patients and staff was considerable (ages ranging between 20 and 101 years). The use of spoken and body language could be misinterpreted. The humble behaviour of an elderly woman was seen as incongruent with her expectations of respect and help from the young, and the staff commented th,at this did not make sense to them. The patients had few contacts with patients from othei units and usually also with the world outside, except for two alternating care patients. The cohesion in the unit was strong: patients and staff were co-operating in the activities of daily life, sharing the worries about new cuts in the budget, interested in the other members, sometimes building friendships (patients/patients or patients/staff).

The patients shared living accommodations and daily activities. Each patient had a hospital bed, bedtable and wardrobe. A private chair or small chest of drawers might be kept in the smaller rooms. There were few spaces for private conversation or thinking. Mentally disturbed patients were seen by the lucid patients as frightening examples of what might happen, and patients often commented on this. These patients could also sometimes intrude into other patients’ beds and drawers, etc. Some were very disturbing, perhaps constantly screaming, untidy or disruptive, and one of them was physically threatening to the female patients. Many efforts were made to create ‘cosiness’: domestic textiles, pot plants, old furniture and decorations in the common areas. The instrumental activities of the unit were well attended to, both daily activities and medical supervision, but the timetable was fixed and sometimes pressed for time. Most of the instrumental activities were of the same kind as in a family: eating, getting dressed and bathing. The performance of the activities was adapted to the state of the patients, which the patients saw as adequate but sometimes not very enjoyable. Two old ladies described the delight a bath had been in earlier life and compared that to the “being flushed with a hose” that it meant today. The


staff put hair on rollers for the female patients and also helped polish nails and put on make-up for patients who wanted that. For some patients this meant extreme well-being. For a few patients their interest concentrated around bodily symptoms, and their anxiety was attended to with respect.

Constant proximity and intimacy

Very intimate help was given and embarrassing situations were usually managed by warm loving acceptance from the staff. Informal behaviours were accepted: patients using the toilet with the door wide-open, walking in the corridor undressed, or fighting across the breakfast table. Close interaction during long-lasting periods made both patients and staff reveal personal traits and adapt to each other. Some patients sitting together were heard commenting to one another about a member of staff being rude and supercilious, and discussing how to handle this person. The patients also knew many of the other patients very well: present state, earlier life, family situation, and they empathised with each other, but also sometimes commented on unsuccessful or rude individual patterns of reaction.

Family roles

The functional roles in the unit may be compared to family roles. The registered nurses were supposed to take the role of the ‘good mother’: expected to be experienced, skilled, affectionate, comforting, impartial, balanced and organising. Problems of all kinds were referred to the registered nurses to be solved. They were also expected to be able to perform medical treatments and to make adequate observations for the prevention of unnecessary suffering from symptoms or disease episodes. The ‘father’ role could be attributed to the physician: (medical) expert, ultimate decision maker in delicate matters, for example when nurses knew that the patient would not accept their decisions. He was absent to a great extent, but important. To be visited and recognised by the doctor seemed to be a treat to some patients. The patients were the centre around which everything circulated, like children in a family, and were usually treated with diligence and affection. Patients with obvious identity, integrity and disciplined behaviour were treated as almost grown-up children. They were engaged in discussions about unit issues and consulted about different matters, had influence over their own situation and could autonomously also make their own arrangements for activities and excursions, as long as this did not disturb unit routines. Some patients needed as much help with basic needs as a baby, and were properly attended to. The patients were looked upon as unique people and individual choices were allowed when possible. However, the patients were also expected to subordinate to the routines, and there were some staff with very rigid, insensitive work routines, who were feared by the patients. Sometimes sad and upset patients were comforted with warm acceptance. Sometimes patients of grandparent age behaved like and were treated like children: fighting with each other, being jealous, wanting to be helped first, trying to outdo each other. Children in a family are expected to become efficacious and autonomous, but not the patients. The personnel were always ready to take over the responsibility: when the patient forgot, when something was difficult, or when the patient did not want to. Patients sometimes said that they felt not responsible, not dependable, not capable to or allowed to decide for themselves, but that they were also confident that they would get the help they might eventually need. They also pointed out that the staff tried to be beneficent.

242 A. E. M. N YSTRdM and K. M. SEGESTEN

Continuity

Continuity to earlier self was damaged by the deterioration of abilities, the lack of their own environment and belongings, and the sometimes missing relationships with relatives and friends (dead, very ill, lost contacts). The fatigue, resulting from the effects of disease and from the laborious life of a disabled person, also contributed to giving up earlier interests.

The work was organised to provide continuity between patients and staff. Staff were assigned to the same patients during the day shift for several months, and then changed to the other group. As the average stay in the unit was almost I year and the patients needed so much help, there were good opportunities to get well acquainted with one another. The daily routines were mostly very stable, even if there were conscious efforts to allow flexibiIity. However the stability earlier experienced in nursing home care had given rise to some worries for the patients. Some patients expressed fear that they should be moved out through reorganisations without having anywhere to go, since they had split their homes.

Relationships

Patient/staff contacts were usually open, affective and supportive. The weak, dependent patients seemed to awake warm compassion and commiseration and also interest for another human being, and it seemed natural to be very close to each other. Hugs and friendly joking were common. The patients shared their thoughts and anxieties concerning somatic symptoms, threats of reorganisation, and existential threats with members of staff. Normally, the work routines also allowed someone in the staff to devote extra time to a patient who needed that. There was always time for a sad or crying patient.

Contacts between patients were following normal social life patterns: first polite respect, then compassion, slowly building deeper relations with a few people, when energy was sufficient, and some suitable person was found. One patient complained angrily that it was hard even to find someone to talk to in this environment. Staff believed that patients preferred them to co-patients, but when no staff were present, there were pleasant conversations, sharing opinions on staff, and support and help among patients. The patients also revealed good knowledge of each other. They knew of acute illness episodes and somatic problems, of strengths and weaknesses in the person, of family relations and sometimes also of earlier history (as they might have lived in the same neighbourhood).

Most of the patients and staff had easy relationships with others around. Openness to relationships could be demonstrated as: expressing appreciation of others; taking initiatives to emotional contact or gratefully accepting invitations; offering services; keeping contacts with few/many, with staff, co-patients, relatives. The contacts could be close or more formal, emotional and/or intellectual, intimate or public. Some of the patients demonstrated a more destructive and unsuccessful way for searching of contacts: whining, clinging, nagging, jealousy, presentation of symptoms or problems, clear requirements of attention, or sometimes submission. For some patients it seemed much harder to be so dependent and in such close, intimate contact. The staff tried to respect adequate distance, by politely offering services and asking for preferences, but at the same time offering assurance of support by being very observant. One patient handled this dependence by pointing out that being cared for was a human right and something that was earned in advance during her lifetime. There were also patients rejecting relationships by very conventional behaviour, politeness and distance, sometimes even conscious withdrawal. Also objectification of the staff and depre-


ciating of others were observed. One elderly woman angrily told a young slender nursing aide, that she was there to help and had better help her immediately, and alone, despite the requirement of several people to move her because of her weight and inability to participate. A few staff members were distanced, not wanting to, daring to, or knowing how to show emotional engagement. One of them was very fixed by her working routines, and thought that patients ought to be grateful. Another one was fairly young and convinced that she knew what was best for the patients.

Also the attitudes towards influence over the situation differed. Some patients seemed easily to accept getting infantilised, feeling dependent, irresponsible and taken care of, surrendering to staff. Others tried to get influence over themselves, their relatives and over the environment by presenting preferences adequately, searching for relevant information, keeping good relationships, defending their private zone, exercising influence when possible, sometimes using all available means to manipulate the environment by crying, nagging, reporting symptoms, scenes, subordination or flattery. For some patients the search for influence was not very successful: not adequately understanding the situations, how to get relevant information, how/when/on whom to act; using aggressiveness; even trying to get influence by reports to authorities.

Atmosphere

The climate changed from time to time, from happy, friendly and sometimes expectant to tedious and soporific or to boiling and aggressive. Patients often became exhausted and had to rest after physical efforts like getting out of bed, bathing and physical therapy. They were also very tired in the evening, but sometimes the whole unit breathed tiredness or aggression. The communication tone could change from nice, open and accepting to aggressive and ironic.

The standard behaviour was mild and loving--even when patients were very rude and demanding. The mild behaviour did not necessarily lead to adaptation to their wishes. Once a very mild answer was observed to make an angry male patient still more furious than before. A very mild discussion with many explanations to a female patient concerning a smaller conflict, seemed to make her very sad and defenceless, not wanting to comment on what had happened. This mild behaviour was seen as professional by the staff. They reported deep repentance at home after some angry reaction to a patient’s behaviour. This repentance sometimes was severe enough to cause their family to question their choice of vocation. Co-operation with ‘difficult’ patients was discussed in reports and sometimes with the physician. When relationships had deteriorated between patients and staff, a change of patients was arranged.

Collectivisation

Efforts were made to individualise life for the patients, but the workload, the crowded area, and the patients’ extensive needs for basic care were limiting. Collective leisure activities of different kinds were organised: entertainment, song groups, parties, newspaper reading, trips to the city centre, to stores or to McDonald’s The striving to find something that could interest everybody was governing, but also sometimes staff had priorities. The patients wished to participate with the others and hence participated in activities which they did not enjoy very much. Patients also commented on the choice of activities. One male patient said that he used to participate in the weekly prayers, not because he was

244 A. E. M. NYSTROM and K. M. SEGESTEN

religious, but because he saw this as a break in monotony. There were few areas available to retire from life in the unit by oneself or together with visitors.

Individuation

In a good family the individuals receive needed protection and care, love and support, and stimulation to continuing growth and maturation. For the nursing home patients the progressive deterioration, dependence and fatigue lead to lost responsibilities and lost autonomy. Protection, care, love and support were well attended to, but there were no staff discussions of what continuing growth might mean when you are very old. The staff recognised that patients’ preferences and reactions differed widely, and tried to adapt to this and offer individualised care as far as possible. The patients were very individualistic, not only in their relationships with others as mentioned earlier, but also in attitudes towards themselves. Some were very self-centred, excessively looking after themselves and active in getting others to support or help. Others demonstrated quite unreasonable expectations of staff, relatives, co-patients and environment to centre around just them; were very dis- contented with other’s injustice and neglect; and tried to get unreasonable advantages in the unit, creating competition and jealousy. Some of the patients had a very realistic self- image, built stable contacts with environment, attained respect, affection and support, and could successfully obtain necessary help and contacts. For the lucid patients the observations of the mentally deteriorated patients involved perceptions of possible threats also to their own future. The negative factors in the unit influenced some patients to a higher degree, for instance to become infantilised through the mild and ‘mothering’ attitudes of the staff. In some patients this might even be considered as self-effacement: levelling to the common denominator was frequent, submission to staff or even idealising the environment existed. What seemed to be the worst reactions were: shame and dissatisfaction over disabilities and dependency, feelings of inferiority, objectifying of self, and sometimes withdrawal, apathy and depression.

The staff were worried about the way some patients handled their experiences, and also tried to make life easier for them. Some patients commented on other patients as “not having come to terms with their lives”. They stated that it was necessary to withdraw from others to realistically and honestly think through their experiences. This cogitation was seen as a personal responsibility, which led to a balanced view of life, to peace of mind, which seemed to be what the patients saw as the mature state, adequate for this high age. After the analysis patients’ observed attitudes towards life in the nursing home were classified as (1) thoughts characterised by balanced perspectives on self and situation: based on cogitation or on religious explanations and confidence; (2) thoughts stuck in one track: blaming others, brooding and feelings of guilt, dwelling on experienced injustice; (3) thoughts stuck in one track because of overwhelming experiences: acute disease episodes, pain or other disturbing symptoms, signs of severe deterioration, worries about oneself or about relatives; and (4) escape from troublesome thinking: need for constant diversion, withdrawal or idealising nursing home life.

Discussion

Making observations of nursing home life during visits to the unit, mainly spending time together with the patients in common areas and in patient rooms, resulted in fieldnotes


describing very varying situations. There might be a suspicion that no negative interactions would be demonstrated when an observer was present, but in fact there were many kinds of situations observed. The long observation period, the growing familiarity of having someone observing, and the stressed work-schedule, seemed to generate normality and the maintenance of ordinary behaviours. Also the responses from patients to the personnel, and the statements from the patients to the researcher indicated that the observed behaviour did not very much deviate from standard routines.

Using family concepts as a metaphor revealed both similarities and differences between life in the nursing home and a family. Both the family and the nursing home are created to provide protection and care for weak individuals not able to appropriately take care of themselves in a way worthy of the members of the society. The goals encompass, among others, to be adequately fed, to be clean and comfortable, to be supervised and prevented from suffering (for the nursing home patient from falls, unnecessary symptoms or acute illness). But the Swedish legislation, SOSFS 1993: 17, also recognises that when someone is institutionalised for a longer period, attention has to be paid to all kinds of human needs, also social and spiritual ones. The need to encourage ongoing personal development has not been discussed.

The instrumental and expressive functions in the nursing home and in a family are very similar, but the size and hospital style of the home, the age of the dependants, the need for medical supervision and treatment, and for special measures and equipment differ greatly from family life. The necessary extreme direction of activities towards the instrumental functions might also be seen as deviant from normal life. As the patients were so weak and handicapped, the losses of home comfort in the nursing home seemed easily accepted. Selling one’s home caused great grief, but was sometimes seen as absolutely necessary. Living together with mentally disturbed people was seen as shameful by some patients, and seemed to make all patients fear that this was what might happen to them.

The persons in the unit-both staff and patients--exhibited a manifold variety of personal traits and patterns of reactions and actions. The atmosphere of this unit was generally open, friendly and considerate. Interactions, relationships and attachments with others influenced self-esteem. Close relationships with relatives or old friends seemed to fill the need for intimacy and for continuity for some patients. Those without such connections did not always search for new friends. Life in the home with its physical closeness might have destroyed the desire for friendship, or the efforts to develop new friendships might not be seen as worthwhile given so many people were transient. For a more introvert person, having spent a lifetime alone or in a well-known environment, it may also be hard to renew the skills to develop new friendships (Bould et al., 1989; Powers, 1991). Opportunities to find new friends are also found to be related to how many persons you meet (ROSOW, 1967) as you do not make friends with everybody. However, there were warm friendship between some patients, and also between some patients and staff, providing intimacy and companionship, while others just talked about the others as superficial acquaintances. The staff observation that patients prefer to communicate with staff rather than other patients, may be interpreted as similar to the attention to a guest in the home. When staff were present patients talked to them, but when no staff were around there were pleasant conversations, helping situations, or joint commenting on personnel behaviour.

In a family the continuity over a long time can bridge misunderstandings between the generations. The large age gap between the elderly patients and some very young personnel now and then resulted in misinterpretations. Also the world-view differed between the

246 A. E. M. NYSTRBM and K. M. SEGESTEN

residents and the younger staff. The residents were very individualistic, but expected a joint responsibility for work to be done. This corresponds to the findings of Dowd (1986), who described the changes in rules and grammar of the culture that has taken place during this century. He emphasised the alterations in the moral system (older people rooted in the Protestant sanctification of work) and in ideology.

The character of dependency differs when comparing a nursing home to a family. Interpersonal reciprocity is the basis for help in the family, but for the nursing home patient it may be harder to find something to offer back in the give-and-take relationship (Bould et al., 1989). In a family the most dependent, the baby, gives great joy to the family, and the children are expected to grow more skilled and wiser as years go by, eventually reaching autonomy and efficacy. And just as development and growth are expected during the first years of life, most of the patients accepted deterioration and diminishing strengths. Also the staff accepted the gradual loss and demonstrated readiness to take over. Somatic disturbances were individually and professionally dealt with, perhaps better than in a family. Severe pain that was hard to manage and other serious symptoms, dominated the experience totally, influencing all care and contact. Some patients rejected awareness of changes, and became very upset when symptoms intruded, and when help was needed. This may be compared to Leder’s (1990) discussion about the “dysappearing body parts”. We are totally dependent on our body for participation in the environment. If we have taken this for granted and have never thought about it, as long as the body did function well (disappearing body), then signals from inside (dysappearing body parts) may be experienced as an unexpected and dangerous threat. Beside this experience of threat, it was also very shameful for some patients to be so dependent.

There were many similarities between the child role in the family and the patient role in the nursing home. The patients were dependent on help, and for those of the patients who were not lucid it was also necessary to take over total responsibility. The patients were usually cared for in a very conscientious way, but the mildness in staff behaviour towards patients and their readiness to take over responsibility gave an impression of reduced accountability to the lucid patients, to which they reacted. For elderly people, used to being autonomous and perhaps influential, and having fought for liberation during their teenage years, this was very insulting, as the mildness did not lead to any influence. The reflection that the mildness might be an effect of having an observer in the room, was contradicted by the spontaneous discussion in staff interviews of remorse reactions after ‘non-professional’ behaviours. Also patient statements of the benevolence of the staff supports the authenticity of the observation. In family terms the ability to “express a full spectrum of feelings” is seen as a good sign (Wright and Leahey, 1984) but here just one kind of behaviour was allowed. The incongruence between the reality of dependence and lack of influence and the very mild behaviour may also cause dysfunctional communication (Hoffer, 1989). Unfortunately, the extreme mildness towards patients sometimes might be suspected to be a cover of disregard of the proper respect of the human worth of a the patient.

In a ‘good’ family there are strivings to support the development and maturation of children, and development and maturation may be regarded as continuing all life through- out (Erikson, 1982; Erikson et al., 1986; Jung, 1960). Cummin’s theory (Cummin and Henry, 1961) presenting disengagement as natural in old age, has been questioned by several authors. Tornstam (1994) has described a theory of gerotranscendence, giving new meaning to the old observations of withdrawal. Ageing is at best accompanied by a shift in metaperspective towards gerotranscendence. Gerotranscendence includes more time spent


in ‘meditation’, and is followed by redefinition of the perceptions of time, space, objects, life and death, affinity to past and coming generations and to the universe. A state of gerotranscendence is normally followed by an increase in life satisfaction, and a decrease in interest in superfluous social interaction and in material things. Thus there seems to be agreement that there is a special kind of development/maturation to be expected even in the last period of life. What actually happens in this process and how to stimulate it, seems not to have been sufficiently studied (Atchley, 1991).

For elderly people moving into a nursing home, there are several factors combining to disturb further maturation. The change from being a member of society to being a nursing home patient, loss of home and belongings, diminished contacts with earlier friends and family, diminishing ability and opportunity to maintain earlier interests may be very disturbing to the identity. Even if staff were interested in knowing who the patient had been, the adaptation to the new situation left little room for individuality; leisure activities in the home were chosen to fit as many as possible, and the attachment and cohesion to the new group seemed to lead to refraining from old interests. The extreme dependence on help, the child role and the accompanying mild behaviour from the personnel also combined to weaken self-esteem. When the mild behaviour was executed as a professional obligation, it seemed to achieve the opposite effect to the one intended, leaving the patient feeling as though they were not seen to be adult or accountable. Thus, good self-esteem-the basis for further maturation-was very threatened.

A ‘cogitation’ process was reported by some of the patients as being successful for reaching balance and peace of mind. The process described had several traits in common with the ‘philosophising’ described by Erikson (1982) Jung (1960) and Tornstam (1994). The characteristics of this process will be described in another paper.

Conclusion

Applying the family metaphor to nursing home life has revealed that the goals and activities have many traits in common. Comparing interactional traits has pointed to the conflict between the increasing dependence leading to a child role for the patient, and the naturally ongoing maturation, which was hampered by deteriorating abilities, discontinuity to earlier self, collectivisation, deindividualisation, and ‘antiliberation’. Attention ought to be directed towards the interaction between patients and staff (1) the opportunities to stimulate ongoing maturation in elderly nursing home patients through varying nursing measures ought to be further elucidated, also considering the perceptions of the elderly; and (2) effects of communication patterns between patients and staff need further clarification. Concerning the mildness observed there is also an ethical dilemma: we do not want the mildness changed to rudeness. It is necessary to find a balance between insulting mildness and realistic answers, which at the same time preserve self-esteem.

Acknowlledgements-This investigation has been supported by a grant from the Swedish Council for Social Research. The authors want to thank patients and personnel in the unit studied for their friendly and active contribution and co-operation in the study. Thanks are also due to the registered nurses in the nursing home and to the colleagues in the college who reviewed and commented on the results,

References

Atchley, R. C. (1991). The influence of aging or frailty on perceptions and expressions of the self: theoretical and methodological issues. In The Concept and Measurement of Quality of Life in the Frail Elderly (Birren, J. E., Lubben, J. E. Rowe, J. C. and Deutchman, D. E., Eds). Academic Press, San Diego.

248 A. E. M. NYSTRiiM and K. M. SEGESTEN

Barnhill, L. (1979). Healthy family systems. Family Coordinator 29,941OO. Bould, S., Sanborn, B. and Reif, L. (1989). Eighty-five Plus: The Oldest Old. Wadsworth, Belmont, CA. Clark, P. and Bowling, A. (1990). Quality of everyday life in long stay institutions for the elderly. An observational

study of long stay hospital and nursing home care. Social Sci. Med. 30, 1201-1210. Cummin, E. and Henry, W. E. (1961). Growing Old: The Process of Disengagement. Basic Books, New York. Dowd, J. J. (1986). The old person as a stranger. In Later Life: The Social Psychology ofAging (Marshall, V. W.,

Ed.), pp. 147-189. Sage Publications, Beverly Hills, CA. Erikson, E. H. (1982). The Life Cycle Completed. A Review. W. W. Norton, New York. Erikson, E. H., Erikson, J. M. and Kivnick, H. Q, (1986). Vital Involvement in Old Age: The Experience of Old

Age in Our Time. W. W. Norton, New York. Gershwin, M. W. and Nilsen, J. M. (1989). Healthy families: forms and processes. In Toward a Science of Family

Nursing (Gilliss, C. L., Highley, B. L., Roberts, B. M. and Martinson, I. M., Eds), pp. 77-91. Addison-Wesley, Menlo Park, CA.

Helvie, C. (1981). Community Health Nursing-Theory and Process. Harper and Row, New York. Hoffer, J. (1989). Family communication. In Nurses and Family Health Promotion: Concepts, Assessment, and

Interventions (Bomar, P. J., Ed.), pp. 78-89. Williams and Wilkins, Baltimore, MD. Jung, C. G. (1960). iiber die Psychologie des Unbewussten. Rascher and Cie, Zurich. Kayser-Jones, J. S. (1991). The impact of the environment on the quality of care in nursing homes: a social-

psychological perspective. Holist. Nurs. Pratt. 5, 29-38. Lakoff, G. and Johnson, M. (1980). Conceptual metaphor in everyday language. J. Philosophy 77,453486. Leder, D. (1990). The Absent Body. University of Chicago Press, Chicago, IL. Leininger, M. M. (1985). Qualitative Research Methods in Nursing. Grune and Stratton, Orlando, FL. Mercer, R. T. (1989). Theoretical perspectives on the family. In Toward a Science of Family Nursing (Gilliss, C.

L., Highley, B. L., Roberts, B. M. and Martinson, I. M., Eds), pp. 9-36. Addison-Wesley, Menlo Park, CA. NystrBm, A. and Andersson-Segesten, K. (1990). Peace of mind as an important aspect of old people’s health.

Stand. J. Caring Sci. 4, 55-62. Nystrom, A.E. M. and Segesten, K. M. (1994). On sources of powerlessness in nursing home life. J. Adv. Nurs.

19, 124-133. Powers, B. A. (1991). The meaning of nursing home friendships. Adv. Nurs. Sci. 14,42-58. Rosow, I. (1967). Social Integration of the Aged. Free Press, New York. Smith, J. A. (1981). The idea of health: a philosophical inquiry. Adv. Nurs. Sci. 3, 43-50. Tomstam, L. (1994). Gerotranscendence-a theoretical and empirical exploration. In Aging and the Religious

Dimension (Thomas, L. E. and Eisenhandler, S. A., Eds). Greenwood, Westport. Wright, L. M. and Leaky, M. (1984). Nurses and Families: a Guide to Family Assessment and Intervention. F. A.

Davis, Philadelphia.

(Received 17 January 1994; in revisedform 5 June 1995; acceptedfor publication 28 July 1995)

the family metaphor applied to nursing home life

Documents