Can Older Women Residing in Nursing Homes Feel Empowered?
Nursing homes have often been viewed unfavourably, both as a location for employment and residency. Frontline workers often have low status, and residents are assumed to be dependent and have little control over their lives. As a consequence there has been little research on this group of people in connection with empowerment. This paper draws upon the narratives of older women residing in two Ontario nursing homes and the frontline workers providing their care. It will illustrate how practices of managers influence the attitudes of health care workers, who in turn influence the personal empowerment of older women. After considering the relationships present within nursing home environments, positive practices will be suggested.
‘Empowerment’ is a key word that is prevalent in the literature. Many researchers in North America have highlighted the importance of delivering empowering policies. However, only a handful of studies have explored the theme of empowerment in connection with nursing homes (Nelson, 2000, Meddaugh and Peterson, 1997, Kari and Michels, 1991, Katan, 1991). This could be a result of the negative image nursing homes have or, the view that nursing home residents cannot be empowered because many of them have cognitive impairments (Meddaugh and Peterson, 1997). In addition, some older people do not have a choice in the move to nursing homes (Peace et al., 1997) and as a consequence they are not viewed as ideal settings for empowerment.
Empowerment is difficult to define (Meddaugh and Peterson, 1997, Hagner and Marrone, 1995). It has a variety of meanings and can be applied to many different experiences. Although there is little consensus in the literature on what empowerment is, many professionals can identify what it is not. Absence of empowerment is evident when there is a feeling of “powerlessness, helplessness, hopelessness, alienation, victimisation, subordination, oppression, paternalism, loss of a sense of control and dependency” (Meddaugh and Peterson, 1997, 32). These words all have negative connotations, and are the same words that are often used in conjunction with nursing home residents. Many of these characteristics can be encouraged or hindered through various relationships. Therefore this paper will explore some of the relationships present in the nursing home environment.
The Empowerment of Frontline Staff
Research has found that the empowerment and attitudes of staff in the nursing home are a good indicator of the quality of care and empowerment of the residents (Eaton, 2000, Nelson, 2000). If staff do not feel empowered by their managers, there is a greater chance they will not empower others around them, such as the residents. Some studies present reasons why staff may not feel empowered. Eaton (2000) explains that frontline staff members often receive low wages. This could be a result of care work being socially undervalued (Eaton, 2000, Ungerson, 2000, Lee-Treweek, 1997). In addition, those who work with basic bodywork such as emptying bedpans are often viewed as the lowest on the hierarchy of health care workers (Twigg, 2000). Low salaries and low status positions may contribute to disempowerment. This is concerning as front-line staff provide the majority of direct care to the residents (Eaton, 2000).
The Empowerment of Residents
Ryan and Heaven (1988) studied the attitudes of adults toward the elderly. They found that older people were considered kinder, but less competent than younger people were. Unfortunately, this public stereotype is prevalent in nursing homes as well. There is “evidence to suggest that professionals who work with older people often hold some of the most negative and ageist attitudes of all” (Bernard and Phillips, 2000, 44). Bernard and Phillips (2000) suggest this may be a result of staff wanting to distance themselves from what they could be like in the future.
While empowering care is often encouraged in nursing homes, unfortunately disempowerment frequently occurs (Clark and Bowling, 1990). With a focus on residents with dementia, Kitwood (1990) indicates that disempowerment is practiced when things are done for a resident even though they can do it for themselves, although slowly. This leads to the resident losing confidence in his or her abilities. Additional insight comes from Sharpe (1995), who noted that staff might impose childlike qualities onto the residents by being overprotective or trying to speed up tasks. Kari and Michels (1991) have also pointed out that if caregivers view residents as victims, who are unable to change their situation, they will take on paternalistic attitudes. However, all these actions lead to learned helplessness, a term coined by Seligman (1975) to describe situations in which people feel their actions will not influence their environment. Learned helplessness can cause depression, loss and stress, and does not solely effect residents suffering from dementia (Niven, 2000). Any resident who is disempowered can develop learned helplessness, and this in turn can encourage dependence (Meddaugh and Peterson, 1997).
Negative structures of ‘dominance and dependence’ are predominately mentioned throughout the literature (Nelson, 2000). However, the following research sought to discover whether women residing in nursing homes could feel empowered. The following research will consider 1) whether frontline staff members and female residents feel empowered and 2) how various relationships influence the empowerment of older women.
A semi-structured questionnaire was developed and piloted in December 2000 in one Ontario nursing home. After appropriate changes were made to the interview schedule, the main study was carried out in a separate Ontario nursing home (operated by the same company for consistency), in July 2001. The main study involved interviews with two frontline staff members and two older women.
All interviews were taped, transcribed and analysed. There were separate interview schedules for staff and residents that related to personal histories, relationships, activities and practices within the nursing home. Scenarios were also utilised to obtain information. They had the advantage of aiding staff and residents to recall related experiences without directly asking about practices.
This study focused solely on mentally aware women. This decision was made because female perspectives regarding empowerment may be different than males (Yoder and Kahn, 1992). In addition, due to their gender, some women may have ‘internalised oppression’ during their lives and this could influence their present feelings of empowerment (Rowlands, 1995). Therefore, findings may not apply to other groups of people.
This paper is based upon the narratives of the participants in the main study. All participants have received pseudonyms. The residents include 78 year old Ingrid who has lived at the nursing home for 22 years, and 76 year old Mary who has lived there for a year and a half. The two frontline staff members are Erin, who has worked at the present home for 13 years, and Celene who has worked there for 20 years. Both women have worked in various frontline roles during their time at the nursing home.
The building has been run as a nursing home for 22 years; however, the present owners have been operating it for 5 years. There are beds for 45 nursing residents and in total there are 65 full, part time and on call staff members.
Relationships Between Staff Members
Both staff members admitted they began working at the nursing home because it was “just a job” and they needed employment. However, both women did feel control in their present positions. Although the current management team is empowering, it was found that some supervisors do look down upon the frontline staff. Celene suggested that newer staff members were not as aware of the residents’ needs, indicating some friction between older and recently hired staff.
Staff Relationships with Residents
The staff members both regard the residents as part of their family. However, Celene later mentions “a lot of the residents do not have family, we are all the family they have got.” As true as this sentence may be, it depicts the residents as victims.
Scenarios were presented in the interview to gain some insight into how frontline staff and residents interact. One of the scenarios presented in the interview concerned answering a call bell that ‘Mrs. Jones’ pulled. The question asked if the frontline worker would check on her even though she was not one of the residents they normally cared for. Celene replied “Well I would check on Mrs. Jones because obviously she is ringing the bell for a reason. So if it only takes a moment and I am able to help her, I will.” In the second part of the question, the staff member answered the bell and discovered that Mrs. Jones had been waiting twenty minutes to use the toilet. It asks what the staff member would do in this situation. Erin replied “if I couldn’t get her nurse because her nurse was busy, then I would have to take time out of my busyness and take her to the bathroom.” These answers promote empowerment because they listen to the resident and try to solve her problem. However, how accurate are these answers in practice? This same scenario was posed to the residents and Ingrid offered some insight into the answer. She stated “I couldn’t get my dress off last night, I told one of the nurses, and she told me to wait for my own nurse.” Although the staff members interviewed state they would help the resident; this illustrates how in practice this is not always done.
Relationships with Family
Residents and staff had different perspectives on family involvement. Although Ingrid does not have any close family members, Mary described her family as very empowering and supportive. However, an interesting finding came out when questioning staff members about family involvement. Celene mentioned that some family members complain a lot. She felt they should not do this because “They don’t see the whole picture.” Therefore some staff may view family as interfering.
Relationships Between Residents
Ingrid has been living at the nursing home for many years. She says she does not feel a sense of community, and states “There is not really anyone I can talk to, they are so out of it.” She does have one roommate she converses with, but Ingrid does get frustrated because her roommate is not at the same cognitive level as herself. Mary is in a similar situation, however she does feel a sense of community. She is happy living in the nursing home and spends much time helping others.
Staff members in this study began working at the nursing home because it was “just a job”, confirming the lower status of their positions. However, this study has found that empowerment can take place irrespective of the position one holds in an organisation. In opposition to Meddaugh and Peterson’s (1997) hypothesis that lower status positions may lead to feelings of powerlessness, this study found that both frontline workers did feel a sense of control in their jobs. This may be a result their empowering management team. In addition, both staff members approached various scenarios in positive ways indicating empowering practice with the residents. This supports the literature of Eaton (2000) and Nelson (2000) which states that the empowerment of staff in the nursing home is a good indicator of the empowerment of the residents.
When focusing on the residents, this study found that Mary felt empowered while Ingrid did not. This conclusion was made after applying the words Meddaugh and Peterson (1997) used to describe disempowerment to each of the women. Ingrid displayed many of these characteristics; feeling alienated from others, dependent on the staff for care, and the absence of close family relationships may have caused staff to regard her as a ‘victim’. In contrast, Mary displayed many qualities of an empowered individual. She had a sense of control over her activities, felt part of the community and tried to empower others around her. Therefore the strongest conclusion that can be made in this study is that it is possible for older women to feel empowered while living in a nursing home.
It is important to consider why Mary felt empowered and Ingrid did not. Although many reasons exist that are outside of the scope of this paper, it is crucial to reflect on the relationships mentioned. Regarding staff members, those interviewed admitted that some of their colleagues did participate in disempowering practices. This included both supervisors and other frontline staff. Staff need to realise that empowering practices can have multiple benefits, for it not only improves the quality of life for the resident but it may also make their job easier. If learned helplessness is prevented it may decrease the workload for the staff. One step toward positive practice is therefore educating the staff on all the benefits of empowerment.
If we consider the presence of family, Mary has children who come to visit her and Ingrid does not. It is recognised that family involvement is complex and the support provided can vary. Therefore all that will be suggested is that relationships with others residing outside of the nursing home can influence the empowerment of residents. This influence can be positive (as in Mary’s case) or negative depending on whether the family consults the older person about their wishes. Just as staff members can encourage learned helplessness by making all the decisions for the women, so can family. It was found in the study that some family members complain a lot, encouraging the staff to feel defensive. Therefore another aim for positive practice would be for staff and family members to work toward collaboration instead of criticism. After all, both parties have the same aim of acting in the best interest of the older person.
The final relationship mentioned was between residents. Although Ingrid felt isolated from others, Mary actively engaged with her neighbours. This demonstrates how empowerment does not just come from staff and family, but older women themselves can be a great support to each other. Providing help to others has empowered Mary. It has also illustrated the value of resident’s contributions to the nursing home environment.
Although relationships are just one factor involved in empowerment, it has been illustrated how Mary (who has various empowering relationships), feels more empowered than Ingrid (who does not have as many positive relationships). In light of this research, the following suggestions for positive practice have emerged:
- strengthening teamwork between staff members of various positions.
- educating frontline workers of the benefits of empowering practice.
- encouraging collaboration between staff and family members.
- recognising the role residents have in empowerment.
These practices are possible, as evidence has been provided of these relationships existing within the nursing home. The challenge will be to encourage more individuals to follow them.
Bernard, M and Phillips, J. (2000) ‘The Challenge of Ageing in Tomorrow’s Britain’, Ageing and Society, vol. 20, p. 33-54.
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 Science and Medicine, vol. 30, no. 11, p. 1201-1210.
Eaton, S.C. (2000) ‘Beyond ‘Unloving Care’: Linking Human Resource Management and Patient Care Quality in Nursing Homes’, International Journal of Human Resource Management, vol. 11, no. 3, p. 591- 616.
Goldsmith, M. (1996) Hearing the Voice of People With Dementia: Opportunities And Obstacles, Jessica Kingsley Publishers, London. Chapter 6.
Hagner, D. and Marrone, J. (1995) ‘Empowerment Issues in Services to Individuals With Disabilities’, Journal of Disability Policy Studies, vol. 6, no.2. (http://www.empowermentzone.com)
Kari, N. and Michels, P. (1991) ‘The Lazarus Project: The Politics of Empowerment’, The American Journal of Occupational Therapy, vol. 45, no. 8, p. 719-725.
Katan, J. (1991) ‘Democratic Processes in Old Age Homes: Supporting and Hindering Factors’, Journal of Gerontological Social Work, Vol. 17(1/2), p. 163-181.
Kitwood, T. (1990) ‘The Dialectics of Dementia: With Particular Reference to Alzheimer’s Disease’, Ageing and Society, vol. 10 p. 177-196.
Lee-Treweek, G. (1997) 'Women, Resistance and Care: An Ethnographic Study of Nursing Auxiliary Work’, Work, Employment and Society, vol. 11, no. 1, p. 47-63.
Meddaugh, D.I. and Peterson, B. (1997) ‘Removing Powerlessness From The Nursing Home’, Nursing Homes Long Term Care Management, vol. 46, no. 8, p. 32-35.
Nelson, H.W. (2000) ‘Injustice and Conflict in Nursing Homes: Toward Advocacy And Exchange’, Journal of Aging Studies, vol. 14, no.1, p. 39-61.
Niven, N. (2000) Health Psychology For Health Care Professionals Third Edition, Harcourt Publishers Limited, London.
Peace, S., Kellaher, L. and Willcocks, D. (1997) Rethinking Ageing: Re-Evaluating Residential Care, Open University Press, Buckingham. Chapter 4.
Rowlands, J. (1995) ‘Empowerment Examined’, Development in Practice, vol. 5, No. 2, p. 101-106.
Ryan, E.B. and Heaven, R.K.B. (1988) ‘The Impact of Situational Context on Age- Based Attitudes’, Social Behaviour, vol. 3, p. 105-118.
Seligman, M.E.P. (1975) Helplessness, Freeman, San Francisco.
Sharpe, P.A. (1995) ‘Older Women and Health Services: Moving from Ageism Toward Empowerment’, Women and Health, vol. 22, no. 3, p. 9-23.
Twigg, J. (2000) 'Carework as a form of bodywork’, Ageing and Society, vol. 20, p. 389-411.
Ungerson, C. (2000) 'Thinking About the Production and Consumption of Long-Term Care in Britain: Does Gender Still Matter?’, Journal of Social Policy, vol. 29, No. 4, p. 623-643.
Yoder, J.D. and Kahn, A.S. (1992) ‘Toward a Feminist Understanding of Women and Power’, Psychology of Women Quarterly, vol. 16, p. 381-388.