Sot. Sri. Med. Vol. 30. No. II. pp. 1201-1210. 1990 0277-9536 90 $3.00 + 0.00 Printed in Great Britain. All nghts reserved Copyright C 1990 Pergamon Press plc

QUALITY OF EVERYDAY LIFE IN LONG STAY INSTITUTIONS FOR THE ELDERLY.

AN OBSERVATIONAL STUDY OF LONG STAY HOSPITAL AND NURSING HOME CARE

PATRICIA CLARK and ANN BOWLING

Health Services Research Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WCIE 7HT, England

Abstract-The observational study reported here was part of a wider evaluation of long stay care for elderly people. The observational study showed that it was essential not to rely on interview material alone. Qualitative techniques provided insights into behaviours, moods and interactions which would have been difficult to measure using traditional survey techniques. The data collected was analysed in relation to the theory of the total institution and disengagement theory. Although the survey data presented evidence of block treatment of individuals in both long stay hospital wards and smaller nursing homes for the elderly, the observational study showed that only the ward setting conformed closely to Goffrnan’s concept of the total institution. In addition, the study indicated that involvement in activities and interaction with others promotes positive feelings among elderly people, and questions the validity of disengagment theory.

Key words-elderly, ageing, institutions, disengagement

INTRODUCTION

The use of obsercarion as a method of sociological research

An extensive search of the literature has revealed few reports of studies in which observation methods have been used to investigate the quality of every- day life in long stay care settings for the elderly. Observational methods are particularly appropriate when the study requires an examination of complex social relationships or intricate patterns of inter- action. Institutions are ideal settings within which participant or non-particpant observation can take place in an unobtrusive manner. Observational methods are essential in evaluation studies of long stay care where the dynamics of the caring process and the content of everday life are either unknown or difficult to measure using other techniques (e.g. survey methods). Survey techniques, in particular, inevitably suffer from the problems of respondent bias or reluctance to disclose information in sensitive areas of research. Some of the difficulties arising out of interviewing in sociological research can be over- come by combining observation with interviewing. The rationale behind the use of observational tech- niques in sociological research is that the sociologist should become party to a set of social actions suficiently to assess directly the social relationships and interactions involved.

Observational techniques are not simple to employ or to introduce to those being observed. The researcher must be seen to be unthreatening, and good relationships must be maintained if the research is also seen as potentially leading to suggestions for change within an organisation. A relationship between observer and observed can easily be jeopardised if people feel that their activities are under critical scrutiny. There are also many ethical

questions to address. What constitutes informed con- sent? To what extent is observation of behaviour in a public or semi-public place an intrusion of privacy? How can more qualitative research findings be pre- sented without revealing clues about the identity of those being observed? [l].

Textbooks on observational methods seldom simplify the task, which probably explains why it is a method which is little used and perhaps mystified. While there are a few excellent texts on observational methods in anthropological research [2,3], few help the investigator with issues such as how to draw up an observational schedule, reliability or questions such as how many observations to carry out (sampling). Most researchers carrying out observ- ation have found it necessary to carry out extensive pilot studies of observational schedules in attempts to decide what behaviour is codable and analysable. Largely because of variability between settings, such piloting is essential in any case: rarely is a schedule designed for use in one situation transferrable to another.

Participant observation [e.g. where the observer takes on a role such as nursing assistant or domestic) was judged to be too difficult for the present study, which aimed to collect both structured and unstruc- tured data. Participant observation is limiting in that the observer has to make frequent exits from the research situation to write up notes, which are then from memory, and is then absent from the situation being observed.

Non-participant observation was the technique used, which permitted the continuous recording of activities and moods. Undoubtedly the presence of the observer in a comer of the room must inevitably have some effect on those observed. However, it was the view of the researchers that both staff and patients soon became used to the observer’s presence and

1201

I202 PATRICIA CLARK and ANN BOWLING

carried out their routines, activities and interactions as usual. Although subjective, this assumption was based on familiarity with the wards, staff and patients throughout the year due to the interview study.

The dynamics of everyday activities and the quality of interactions were largely unknown in the care settings prior to the study. Structured and unstructured observational schedules were used for the data collection, after extensive piloting in order to ascertain what behaviours were codable and what required full qualitative recording. No coding frame was designed before this testing period. This was partly because the researchers were uncertain about the content of daily activities and interactions in the settings observed, and partly to avoid the accusation of distorting social reality. Details of the observational schedule are provided later.

The framework of analysis

In the tradition of ‘grounded theory’ [4], the observations were analysed post hoc in relation to current theories of institutions [5] and ageing (disengagement) [6].

An institution can be defined as a social unit devoted primarily to the attainment of specific goals [7]. Goffman (1961) defined a total institution as a place where inmates are segregated from wider society and where life is carried on in the company of a large batch of others, all of whom are treated alike and required to do the same thing together, with one activity leading at a prearranged time into the next (‘batch living’). Goffman drew attention to the way in which old fashioned institutions, with a custodial function (either hospitals or prisons) resemble other segregated communities in which inmates are isolated from general social life. In such total institutions the staff and residents have different points of view and may come to perceive each other in ‘narrow, hostile stereotypes’; staff often feel ‘superior and righteous’; inmates tend to feel ‘inferior, weak, blameworthy, and guilty’ (‘binary management’). Goffman iden- tified ‘batch living’ and ‘binary management’ as two of the main characteristics of a total institution.

Goffman also identified ‘stripping’ of self identity as one of the mechanisms which are used to facilitate the uniform management of inmates. Stripping includes not only the loss of personal posessions and clothing, but also intrusions of privacy and sub- mission to demeaning practices, for example, being required to eat all one’s food, force feeding, being forced to eat with a spoon or a cup; having to ask for little things such as a drink of water or to go to the toilet; or: ‘Often he is considered to be of insufficient ritual status to be given even minor greetings, let alone listened to’ [S].

The philosophy of institutional care for elderly people has attempted to move away from this custodial model, and towards a rehabilitative model, with an emphasis on individual needs, flexibility and staff interaction with inmates. A few investigators have explicitly adopted Goffman’s model as a method of analysis of care for people with chronic mental and physical illness [8-l 11. These investigators have con- firmed that in large hospitals the characteristics of the total institution remain, although its features are less in evidence in smaller homes and hostels for the care

of dependent groups [8-l 11. Most research on elderly people in institutional care has implicitly collected data which is pertinent to Goffman’s model. These studies. through data on patient satisfaction, level of daily activity, amount of privacy and flexibility of routines appear to confirm that the features of total institutions are difficult to overcome, except in very small hostels and homes [ 12-171.

The second analytical framework adopted, post hoc, for this study was disengagement theory [6]. Several studies of life in institutions for the elderly note the lack of activity, or engagement, among residents [ 12-171. Disengagement theory is a socio- logical theory which hypothesises that this inactivity is the manifestation of the natural process of ‘dis- engagement’ in old age, and that this withdrawal is necessary for the psychological health of the elderly [6]. However, this theory is now being questioned [ 181.

THE EVALUATION

The observational study reported here is part of a wider evaluation of traditional health authority funded geriatric ward and nursing home care. There are two health authority funded nursing homes in the district under study. Both were included in the study. The philosophy of the homes is that a smaller environment will lead to flexibility in care practices, and that this will lead to a better quality of life [19].

This wider evaluation is based on a randomised controlled trial of nursing home care in comparison with geriatric ward care. Patients entering long stay geriatric care, who do not need acute or psychiatric nursing care, are randomised to either one of the two nursing homes or to a geriatric ward bed. The patients are initially assessed before the staff, patient or interviewer know the outcome of the random- isation, and then quarterly for 12 months. There are several survey methods available for the evaluation of long stay care in the positivist tradition (20-231. The assessments used include well tested measures of functional ability, mental orientation and confusion, life satisfaction and morale and patients’ assessments of their quality of life in terms of feelings about their environment, meals, degree of choice and privacy, relationships with other patients and the staff, level and type of activity [21-231. This part of the evalu- ation is ongoing. To date, over 100 patients have been assessed for 12 months, the study will terminate when 200 patients have been referred to the study (in order to give the hypotheses underlying the study a reasonable chance of being accepted) [24].

THE OBSERVATIONAL STUDY

Aims of the study

The observational study aimed to document the activities and quality of everyday life in an NHS long stay geriatric ward and in two NHS nursing homes for the elderly within the same health district.

One of the post hoc aims of the analysis was to analyse (1) the extent to which the concept of a total institution, derived from Goffman’s work in the 195Os, is applicable to long stay wards for the elderly

Quality of life in institutions for the elderly 1203

and small nursing homes for the elderly in the late 1980s; and (2) the extent to which disengagement theory could be supported by the data.

The settings for the study were the two nursing homes and the female geriatric ward which contained most of the patients randomised to hospital beds. Observations on the ward were supplemented by observation of the patient’s club in the basement of the hospital, where less confused patients (and patients randomised to the study) sometimes spent about an hour a day. The club was run by the occupational therapy department, and staffed by an occupational therapy (O.T.) aide. The opportunity for patients visiting the club was dependent on the O.T.‘s aide’s availability, and the availability of porters to escort the patients.

METHODS OF THE OBSERVATIONAL STUDY

The obsen9ational schedule

The observational schedule used was developed and piloted by PC and tested for inter observer reliability by PC and AB. Reliability checks con- tinued until the two observers achieved consistent ratings. The piloting was essential in order to assess the type of data which could be itemised in a struc- tured fashion, and which type of data would need to be recorded qualitatively.

The observation schedule consisted of a structured section which involved logging activities, interactions and moods in 1.5-min blocks. The log was restricted to general activity, personal relationships and inter- action between patients and patients and staff. This structured log was supplemented by a qualitative observational log, where the observer wrote an account of what she had witnessed, using the above criteria, over each 15 min period. At the end of each day the observer also wrote an overview of the observational period. In addition, a table based on visual analogue rating scales was used in order to document each patient’s moods and changes in mood throughout the observational period. All observations after the pilot study were carried out by one observer (PC). They were all conducted at different times of the day, ensuring comparable periods in each setting were observed. The observ- ations took place in that part of the home/ward where most residents/patients were seated and where activity was most likely to take place (day/dining rooms).

The numbers of patients observed at each session ranged between 3 and 10 in the club, 5 and 18 in Home A, 7 and 19 in Home B and 6-20 in the ward. The average numbers present in each setting respectively were: 6, 13, 12, 15. A total of 232 15-min observation sessions spread over the four settings were recorded over a 3-month period.

The proportions of observed activities, interactions and moods have been calculated out of the numbers of 15-min logging periods in each setting (not out of the duration of the observational sessions which ranged from 2 to 4 hr).

The observer continuously wrote up her subjective impressions of each setting. Synopses of these serve as useful introductions to each.

The settings

Two nursing homes for the elderly were opened during 1986 and 1987 in an inner London health district. They were planned to serve elderly people living in the district, who required long term, non- psychiatric, nursing care, of a type that could not be provided in the community. The homes were small (22-24 places each). Although one of the homes was situated in the grounds of an out-patients’ hospital, it was close to the street and both were situated in residential areas. The homes were managed by a nursing sister, responsible to nursing officers in the same way as ward sisters in the hospital. Medical care in the homes was provided by a designated general practitioner, although the consultant geriatricians from the hospital still held overall responsibility for clinical care and visited the homes regularly. The sisters in charge of the homes had the authority to participate in staff recruitment, purchase materials, arrange for replacement or repair of items (e.g. glasses, hearing aids) and, with the other staff and the residents, decide on menus. Staff were not trans- ferred between units to compensate for any staffing shortages. As they were situated in a deprived work- ing class district, with a poor public transport system, the homes shared the same problems of staff recruit- ment as the hospitals in the district, and frequently had to rely on agency staff. The elderly people were known as residents in the homes, and patients in the ward and club settings of the hospital.

Nursing Home A

This nursing home is situated in the grounds of a local out-patient hospital. Like Nursing Home B, the atmosphere was generally pleasant, and patients had a great deal of control over their lives within the institutional setting. They moved freely between their own rooms and the sitting, dining and quiet rooms.

Residents’ requests were answered promptly and in a pleasant, friendly manner by staff. Requests were generally taken seriously and acted upon (e.g. requests to go to be taken to the toilet, to be given a drink or to be made comfortable). However, as will be discussed later, 18% of patients’ requests were totally ignored in Home A. This was usually because no staff member was present at the time of the request. Unlike Nursing Home B, staff and residents did not appear to share a communal area, and staff in Home A were often busy in other parts of the home. As in the other settings, sister played an important personal role in the patients’ lives. She was well liked, and she made a point of interacting with patients. Sister and the staff nurses interacted with patients, while the nursing aides were generally more busy with their chores and were less likely to involve themselves in patients’ activities. The domestic staff were observed to be friendly with the residents, often talking to them as they carried out their work. Unlike Home B, patients were not taken out by the staff.

Frequent interaction between residents was ob- served, although, in contrast to Nursing Home B, this was frequently negative. This was partly due to one aggressive female resident who caused argu- ments, and partly due to the large numbers of residents with walking frames and wheelchairs who got in each other’s way. This was a problem at

1204 PATRICIA CLARK and ANN BOWLING

mealtimes when they all tried to enter the dining room together (the space was only big enough for one person at a time to move through easily). Despite some friction, the residents tried to help and support each other and generally expressed concern if someone was distressed, confused or unwell.

Nursing Home B

This nursing home is situated in the community in the extreme north of the district. It gives an impres- sion of being bright and pleasant, and the genera1 atmosphere generally seems to be calm and relaxed. The dining room contained large windows, stretching from floor to ceiling, wall to wall. This seemed to attract the residents as most chose to spend their days in this setting, despite having to sit on hard dining chairs, rather than one of the other two rooms with softer arm chairs (the television room and the ‘quiet’ room). An additional feature of the dining room was that residents could sit in groups around small tables, rather than around the walls. The residents could, and did, however, move around between the rooms at will. The staff also often sat at the dining tables, another factor which might have attracted patients to sit there.

In this home, the nurses were observed to show affection for the patients, and most patients greeted each other in the mornings and afternoons, asking after each other’s health. They showed support and sympathy if someone was unwell or unhappy. Con- versations frequently took place between patients, several patients read regularly. Nurses were observed to set and style patients hair and to put facial make up on for the female patients. The nurses were liked by patients and most seemed to regard them as friends. Frequent activities included beer making, pub nights, gardening and painting. Patients were also taken out occasionally by staff.

Geriatric hospital: Ward X

Ward X is a female geriatric ward, situated on an upper floor of an old district hospital. Most of the patients randomised to the study were on this ward, and!most were lucid, or no more than moderately mentally confused. The ward sister was observed to work extremely hard throughout the day, and was well liked by the patients. She participated in the general care of patients: bathing and dressing them and patients turned to her for help and comfort. In contrast, the staff nurses and nursing aides were less attentive to patients’ demands and appeared less patient. Two staff nurses in particular were regularly recorded as being bad tempered with patients. Most patients appeared to be afraid of these two nurses. The domestic staff were also recorded as being insen- sitive to patient’s needs. At meal times, patients were rarely asked what they wanted: drinks and meals were simply handed out. Patients never asked staff for second helpings of food. Domestic staff rarely waited until patients had finished their meals before remov- ing their plates when they wanted to clear up. They were even observed taking spoons out of patients hands while they were eating. In the afternoons, when patients were given drinks, domestics were observed taking cups of tea from patients before they had finished because of their inflexible work schedules.

There was no recreation available on the ward for patients, although those who were lucid or no more than moderately confused were sometimes able to go to the patient’s club (when it was open and when porters were available to take them). The television was usually turned on in the mornings, without asking patients if they wanted it on, althought it was not usually on loud enough for them to be able to hear it. In general, morale among the ward staff and patients appeared low.

The hospital patients’ club

Occupational therapy took place in the patients’ club, situated in the basement of the hospital. The patients were involved in decision making in the club. They chose the name of the club and decided what sort of recreational activites they wanted to do. If anyone objected to the activity a vote was carried out. Quizes were popular, and were also used as a focus for reminiscence therapy.

Most observation sessions witnessed music being played, and patients appeared to enjoy this and often sang in tune to it. The observer felt that the happiest atmosphere of all settings observed in was in the club. This overall impression was confirmed by the structured observational recordings of moods 125).

Patients had good rapport with the occupational therapy aide who ran the club. Most patients were observed telling her about their worries and prob- lems. One effect of the free and easy atmosphere in the club was that a large number of patients asked the O.T. aide to take them to the toilet. The observer felt this was because the O.T. aide never regarded this request as a nuisance, unlike some of the nursing staff on the ward. Patients appeared to delay going to the toilet until they visited the club.

Patients appeared free to express a range of emotions in the club: anger and distress were often expressed by the patients due to the loss of control over their lives, loss of their homes and possessions, and over pets being ‘put down’ or given away without being able to say a ‘last goodbye’ to them. Although the mood scales showed that some negative feelings were expressed by patients in the club, these always related to their lives in general or their experience on the ward-never to the club [25].

The saddest moods relating to the club were observed when patients had to return to the geriatric wards. Many were recorded seeking reassurances that they would be allowed to return. Some patients expressed fears about returning to the wards because of the poor relationships with some staff and the other patients.

RESULTS

The Survey Data

Batch treatment

Analyses to date on the patients who have been assessed and interviewed for 12 months in both geriatric wards and nursing homes showed no differ- ences between settings in terms of functional and mental ability, or with life satisfaction. There were no differences between settings in the times at which the majority of patients got up in the mornings or

Quality of life in institutions for the elderly 1205

went to bed (this was largely due to most of them needing some help, and having to wait until staff had finished helping other patients before they too could be helped). Nor were there any differences between settings with meal times, although patients in the homes were given meals if they arrived late for them. Patients were uncritical of lack of privacy: 90% of patients in both the homes and the wards said they had enough privacy (this was despite no private space available to them on the wards, except a curtain around their beds if it was required).

The lack of any significant differences between settings indicated that the characteristics of the total institution, in terms of ‘batch treatment’, were evident in large and small institutions.

A methodological problem imposed on the assess- ments of life satisfaction and feelings about environ- ment during the interviews was the reluctance which elderly people resident in institutions expressed towards revealing their feelings, probably due to low expectations and fears of repercussion if they expressed criticism. This difficulty has been docu- mented by previous researchers [14]. Typical expres- sions by elderly people when asked to comment on their environment were: “I don’t have any likes. I just take what I get. If people do things for you, you can’t grumble”; “I don’t know, I just don’t want to know. I’ve got no interest in things anymore”; “No, I’m alright. I don’t grumble”; “I take it as it comes”. This methodological problem of acceptance and fear of criticism among elderly people [ 141, led to the researchers’ decision of adopting observational techniques.

The Observational Data

The main results have been reported elsewhere 125); this paper is limited to the analyses in relation to the theory of institutions and disengagement theory.

Disengagement theor]

The level of activity and interaction with others is partly dependent on the presence of staff and visitors in each care setting.

Professionals present. The following comparisons of professionals present during each observational session are restricted to the ward and the homes. The club was excluded from these analyses because of the continuous presence of the O.T. aide, and was frequently assisted by a professional visitor (e.g. community artist).

The ward and Home A were both least likely to have non-professional visitors (e.g. relatives or volun- teers) present during the observational sessions: in 18% of sessions in the ward, and 20% in Home A, a visitor was present, in comparison with 32% in Home B (x’ test; P c 0.0001).

Professional visitors other than nurses (e.g. occu- pational therapists, physiotherapists etc.) were also least likely to be recorded in the ward: present in 11% of sessions, in comparison with 37% in Home A and 21% in Home B (I? test; P < 0.0001).

Nurses were present in 83% of sessions in the ward and in Home B. Fewer nursing staff were present in Home A (69%) because of the layout of the home, with staff being less likely to be carrying out their routine tasks in the day area. In contrast, in Home B,

staff were often working in the dining area where patients preferred to sit. Similarly, while the sister was present in only 17% of sessions on the ward, and 20% of sessions in Home A, she was present in 50% of sessions in Home B. Domestic staff were also more likely to be present in Home B: on 52% of recorded sessions, in comparison with 33% in the ward and 43% in Home A (x’ tests; P < 0.0001).

Recreation and activity. In 31% of the sessions some residents were involved in some form of recreational activity. This included reading. groups recreation (e.g. singing) and individual recreation (e.g. tending potted plants).

Recreation among one or more patients per setting was observed in only 6% of observation sessions on the ward, in contrast to 27% in Home B and 38% in Home A (1’ tests; P < 0.0001). Recreation among a quarter or more of patients and residents in the ward and in the homes was never observed. Recreation was always observed in the club, by its nature.

In 25% of sessions some patients were observed reading. There was no reading at all in the ward: in contrast reading was observed by at least one patient on 58% of occasions in Home B and 32% in Home A. In no setting were a quarter or more of the residents observed reading. The patients’ club was excluded from this analysis as the O.T. aide would always have newspapers available for patients to read but she would generally read out news items to them.

In almost 100% of observational sessions in each setting, there was evidence of other activity among at least one patient, but this was usually going to the toilet, going to bed or other activity of daily living. These daily activities were observed among a quarter or more patients and residents in 74% of observation sessions in the club, 59% on the ward. 55% in Home A and 82% in Home B (x2 tests; P c 0.0001). The increased activity in Home B and in the club is explained by greater staff presence and their response to patients’ requests for help (e.g. with going to the toilet).

Although in about a quarter of the sessions ob- served in the homes and in the club, tea or coffee was served to the patients, this was only observed in 9% of the sessions in the ward (;c’ test; P -C 0.0001). No tea or coffee was ever served in the morning observation sessions in the ward-although the homes and the club gave patients and residents a morning coffee break, the ward did not.

In 32% of the sessions in the ward and Home A the television was turned on. In Home B the residents tended not to watch it during the day, as they preferred to sit in the dining room, rather than the television room, partly because it was sunnier and the staff carried out their work in there. There was no television in the club.

In the ward the television was turned on by staff without asking patients if they wanted to watch it, and it was usually turned on too low for them to hear it. Patients in the homes were always asked if they wanted the television on first.

In 20% of the sessions in the ward a radio was turned on or music was playing, in contrast to 97% of sessions in the club, 40% in Home B and 34% in Home A.

1206 PATRFXA CLARK and ANN E~OWLINC

Differences in patient’s moods were evident from the observational data when music was playing and when professionals were involved with recreation with patients: moods were more positive and happi- ness more likely to be displayed. When music was playing there was evidence of happiness in at least one patient on 49% of sessions, in comparison with 24% when no music was playing (x2 test; P c 0.0001). When professionals were involved with recreation with patients and residents, there was evidence of happiness among at least one patient on 59% of occasions observed, in comparison with 27% when there was no interaction (x2 test; P < 0.0001). These differences were statistically sig- nificant in each setting, but they were most apparent in the ward.

Each setting, apart from the club, had at least one patient observed to be showing signs of detachment during 81-96% of observation sessions (defined as showing no bias or involvement; lack of interest; unemotional or disconnected) on most observation sessions. The ward had the most patients who dis- played detached moods. A quarter or more elderly people showed signs of detachment during 74% of observational sessions in the ward, during 20% of sessions in Home A and 3% of sessions in Home B. The proportion of detached patients never exceeded a quarter in the club (x2 test; P < 0.0001).

The implication is that hospital patients who went to the patient’s club had much higher levels of engagement and activity than the nursing home patients. Thus, although they lacked activity back in the ward setting, this was compensated for on those occasions when they could visit the club.

Apart from the club. where during 59% of the sessions more than a quarter of the patients were actively involved in recreation, the proportion of patients recorded as being engaged in activity rarely rose above 25% in the ward or in the homes during the observation sessions.

Although disengagement theory argues that general inactivity is a normal feature of ageing and part of the process of withdrawing from society, the associations reported earlier between happiness and music and happiness and recreation with staff questions this. Also, comments passing between patients in the ward and residents in the home sometimes indicated that some form of diversion was needed to prevent boredom. For example:

(Observer goes to check on patient’s names): “they all respond with great joy as if anticipating I’m going to chat to them. They give me their hands and Jane and Daisy hold my hand tightly and seem grateful for the little attention I am giving them.” (Hospital ward)

An optician has visited the home and Fran and Rose are telling each other in detail about how their eyes were tested . . . They become involved in a jolly conversation about this. They seem quite bright and Kate joins them.. She has also just been to see the optician. She is laughing heartily with them. (Observer’s comment: The visit meant a lot to them and illustrates how new input can stimulate them and help them to relate to each other.) (Nursing home B)

As the patients leave the club they are saying “goodbye” to each other, some of them hold hands and then wave to each other.. . As the O.T. aide helped Nancy to the lift she

asked her if she enjoyed herself. Nancy replies “Yes and I’m looking forward to coming again”. . (Patients club)

Observer’s comment of patients’ club: “this afternoon shows how important it is for them go get out of the ward. They see their visit to the club as a reason to make themselves ‘look nice’ and put on clothes they like and wear make up: e.g. The radio is playing soft music in the background. Patients begin to arrive in the club with the porter. Edith, Diane and Millie are the first. Edith and Maud are both complaining that they did not have time to make themselves look nice before they come down. The O.T. aide tells them they ‘look nice” and Maud tells the O.T. aide that she also “looks nice”. Edith adds “You look like a holiday Monday, and thanks for inviting us down”. They sound very grateful for being there. . . The aide goes to make tea for them and Edith says to her: “You’re a good person, God will bless you for it.” She continues *.. . People don’t have time for old people nowadays. There is just a handful of people who care for old people and love ‘em. That’s why it’s nice to be down here (in the club)“. . (Patients club)

Observer’s comment: “An ILEA teacher came into the club and taught the patients how to paint and make collages. They are making tablecloths and napkins for their tables in the club. . . all the patients are participating and seem to be enjoying it, Edith is applying wax to her tablecloth, the others are painting their’s, There is a great deal of concentration going on, and most appear to be totally engrossed in their work. Catherine is smiling and beaming on and off while doing her work.” (Patients’ club)

Binary management

Interactions. The proportion of staff and visitors present in each session, by setting, was reported in the previous section.

In around a third of the observation sessions (35%), professional visitors were present. Interaction between them and the patients was recorded in 29% of all sessions.

Table 1 shows the proportions of sessions in which interactions were observed in each setting. The table also shows the proportion of sessions in which com- ments were exchanged and in which conversations took place. Conversations were generally brief, but were defined as more than two sentences (other- wise they were classified as comments). Most verbal interaction was single comment instruction.

Table 1 shows that there were no significant differences between settings in the verbal interactions (comments or conversations) between nurses and patients or between patients themselves.

On average there were two comments per session between nurses and patients in Nursing Home A, 2.25 in Nursing Home B, 1.71 in the ward (not statistically significant).

The recorded qualitative data reveals that the proportion of comments exchanged between patients in the ward was composed largely of negative comments.

Patients in the homes and in the club were less likely than patients in the ward to have their requests ignored by staff. In 32% of sessions observed in the ward, lucid patients’ requests were totally ignored, in comparison with 18% in Nursing Home A, 8% in Nursing Home B and none were ignored in the club (x2 test; P < 0.0004). The staff in the homes and in the club were also quicker to respond to them than staff in the wards. This was not explained by number of staff on duty. The average length of time staff took

Quality of life in institutions for the elderly 1207

Table I. Interactions by setting

Interaction between:

Patients and professional visitors* 25 Patients and domestic stafft 20

Comments exchanged between patients and domestic stafft 20 Conversations between patients and domestic staff: 0 Comments exchanged between patientst 37 Comments instructions between nurses and patients 41 Conversations between nurses and patients? 3 No. of observation sessions 65

Nursing

Home A

Wo)

Home e

(O/O)

18

15

II

39

52

II

62

Hospital Hospital

ward club

(“/a) W)

8 92

12 -

II -

0 -

48 32 53 -

4 -

57 37

‘Chi-square test: P <O.Ol to 0.00001.

tNot statistically significant.

$Not tested due to small numbers in cells.

-Not applicable.

to respond to lucid patients’ requests (e.g. for a drink of water; to go to the toilet) was 21 min in the ward; 9 min in Nursing Home A, 4 min in Nursing Home B and 2 set in the patients’ club (x’ test; P < 0.01).

The observer classified the type of interactions between staff/visitors and patients and patients them- selves as positive, neutral or negative. These were classified according to dictionary definitions:

Positive: emphasis on what is good, constructive, beneficial.

Neutral: neither positive nor negative; no distinctive quality or characteristics; indifferent.

Negative: expression of a refusal or denial; lacking positive qualities; showing opposition or resistance.

While 34% of the observation sessions in the club had recorded instances of positive interactions be- tween patients or between patients and professionals/ visitors, the proportions were slightly less for the ward, 28%, and the homes (both 29%). There were larger differences in the proporition of interactions recorded as neutral and negative, with the ward scoring worst.

While 44-50% of sessions in the homes had recordings of neutral interactions, and 56% in the club, the proportion was 24% in the ward. While just 8% of the sessions in the club showed evidence of negative interactions, more, 48% of sessions in the ward did so, as did 30% in Home A and 22% in Home B (x’ test; P < 0.0001). The larger proportion of negative interactions in Home A was accounted for by one aggressive resident.

The following examples provide evidence of the hostile reactions to patients on the part of some members of staff in the ward:

The nurse comes back from helping Ada and goes to Jane’s string bag (uninvited) and says “What have you got in there?” She looks and says “They’re only mother’s day cards”. She reads them and throws them back into the bag. Jane looks upset. (Hospital ward)

As the nurse passes Rose she wakes her up and shouts “sit up”. Rose is confused but the nurse pushes her with her fingers on her shoulder: “Come on sit up. don’t lie there like that, sit up.” Rose can’t sit up without help. The nurse walks away without helping her. (Hospital ward)

Fran is soundly asleep, and is sharply awakened by a firm shake by the staff nurse. This frightens her (she is confused). The nurse shouts “Come on, you can’t just sleep all day”. Fran replies “I know but give me a chance”. The nurse then

SSM M I I--E

roughly puts a plastic beaker in her hand. Fran raises it to her mouth but misses and spills the contents. The nurse leaves her to cope on her own. (Hospital ward)

These negative interactions between staff and residents and patients were rarely witnessed in the club or the homes. Negative interactions in these settings were usually between the elderly people themselves, or involved the staff scolding them for deliberately anti-social behaviour. The following example shows how attitudes were quite different in the homes and the club:

Nellie asks to go to the toilet, the O.T. helper answers her straight away and says “OK love”. The O.T. aide helped her to the toilet. Henry says “Can I have a cigarette? The O.T. aide says “You’ve just had one”, but he says he wants another so she gives him one. Nellie is calling for help from the toilet but the O.T. aide does not hear her. When she eventually does hear her she goes into the toilet and apologises to her for leaving her. (Patients’ club)

A nurse helps Sara into the room and says “Coffee is over, you’ve missed it. Would you like a cup of coffee?“. Sara says “Yes”. The nurse goes to the kitchen and returns with a cup of coffee for her. . . Sara smiles and says “thank you”. . Harriet is reading. The nurse notices and asks “Would you like the light on? It’s a bit dark because of the bad weather”. Harriet says “Yes” and the nurse turns on the light.. . Another nurse helps in Maud. Edith and Ada say “hello” to her; Edith aks her if she has had breakfast. Maud says “Yes”. Catherine sees me and says “Good morning. I’ve just had a bath. I like having a bath”. She has a broad smile on her face.. . (Nursing Home B)

Stripping: demeaning practices

Some examples of demeaning practices were given in the previous section (negative interactions; the ignoring of patients’ requests for help). Other examples were evident from the qualitative observ- ational recordings of mealtimes in the ward. These included forgetting patients’ names, ignoring need for help, restraining patients, force feeding, supplying patients with spoons, plastic beakers with spouts or plastic cups at meal times, rather than normal domestic crockery, and the removal of cutlery and food from patients before they had finished their meals:

The domestic arrives and hands out tea to the patients. Nancy, Mary and Jane return from the Patients’ club. The domestic asks the nurse “Who usually gets the dough- nuts?‘. The nurse says “Nancy and Mary, but they are not back yet”. However, Nancy is sitting right in front of her. (Hospital ward)

1208 PATRICIA CLARK and ANN BOWLING

(I 5 min later) Lunch is served . . Mary and Nancy ask the staff nurse not to seat them with Jane saying they “can’t stand it-we’ve got enough to contend with siting with Daisy who can’t feed herself”. But the nurse still seats Jane with-them. (5 min later) Daisy then pulls the tablecloth and nearly pulls everything off. Nancy tries to help her but calls the nurse as she can’t manage. The nurse scolds her for calling her, and Mary replies “Daisy can? feed herself”. The nurse goes over and straightens the tablecloth but does not attempt to feed Daisy. (Hospital ward)

Two nurses are feeding the patients. Sweet is served. Everything has been served by the nurses in relative silence (15 min later) Rose tries to get up from her wheelchair. The nurses see her and persuade her to walk over to the armchairs to sit down--this is her restraining chair (a chair with a tray fastened to the front). She goes over and sits, but when she realises they are going to fasten her in she starts screaming and becomes hysterical. She fights and kicks the nurses. (30 min later) . . Rose is still crying and banging on her table which is restraining her. She calls out “You bloody bastards to do this to me”. Rose’s banging is getting on the other patients’ nerves. They shout “Pack it in”. She bangs with more force. . . (Hospital ward)

The domestic comes in and hands tea out. . Clara does not want her tea so the nurse forces her to drink it. Clara is fighting against this. The nurse then holds her hands and forces her head up threatening “I’ll throw you out of the window if you don’t drink it”. . The nurse goes out and returns with milk in a beaker and tells Clara she has brought her a cold drink as she doesn’t want tea. Clara, who is always reluctant to eat or drink and used to be fed with a syringe, does not look happy about this. She is forced to drink it while the nurse holds her hands down. The main problem was that she did not appear able to breathe. The feeding took 9 min and in that time she was given only three breaks for breath. (Hospital ward)

Another patient begins to bang a spoon on the table. Tapping or banging seems to be a way of attracting attention. (I5 min later) Soup is served. All patients are given their soup in a cup or in a plastic beaker with a spout. Jane is pulling terrible faces as she drinks it, but nevertheless she finishes it. (Hospital ward)

The abrupt nurse is feeding Sara very quickly. Sara hardly has time to swallow her food. . Vera has not eaten any- thing at all, no-one has noticed. . . Daisy is trying to feed herself but not getting very much into her mouth. Jane has not eaten her main course, she had a couple of mouthfulls and did not seem 10 like it.. . (Hospital ward)

(Lunch time) Mary is watching one of the patients who does not eat being force fed with a beaker of complan. She says angrily to Jane “It’s no good them force feeding them because it doesn’t do them any good. It gives them indiges- tion and makes them unhappy. It’s no good at all!“. (30 min later) The domestic is in a hurry to clear up the dishes, she says “I’m on my own” She removes Daisy’s and Jane’s sweets before they have finished. She actually removed the spoon from Daisy’s hand, and Jane had not even started on her sweet. (Hospital ward)

Again, this demeaning behaviour did not occur in the other settings, where mealtimes were quite different events:

Twenty one patients are seated round the dining tables for lunch. The nurse wheels in Clare in her wheelchair. Clare says “hello” to everyone and nearly all of them answer.. . Clare calls the nurse and asks for a drink of water. The nurse acknowledges her immediately and asks her to “wait a minute”. . . a few minutes later Clare calls the nurse again. The nurse answers immediately and goes lo get the water. (I5 min later). . An occupational therapist

walks past and Henry asks her for a jug of water.. Clare hears this and also asks for a jug of water. The occupational therapist goes to get two jugs of water and gives them to Henry and Clare (Nursing Home B)

Sara is not looking happy at the sight of her lunch in front of her. She calls for the nurse and is mumbling. The nurse is beside her cutting up Jane’s food. She turns to Sara to see what she wants. Sara aggressively pushes her plate away, so hard that she almost spills it. The nurse says “Would you like me to cut it up for you?” Sara looks upset and says “No, I don’t want it. I don’t want meat. I want potatoes and greens”. The problem is that the home has run out of vegetables (frequently not enough are delivered). The sister enters the room and the nurse tells her about Sara. Sister talks to Sara and says “Would you like scrambed eggs and potatoes?” Sara says “Yes”, so sister orders Sara’s lunch from the cook. Sister says she is upset by the lack of green vegetables sent in for the residents. The domestic is going round the patients asking them if they would like orange or lemon squash. (15 min later) Everyone is eating their lunch except Sara who is watching the serving hatch expectantly. The nurses are feeding Henry and Maud. A nurse goes round the patients offering them extra chicken. Fran and Jane accept. Sara is served with her scrambled eggs and potatoes.. . (Nursing Home B)

There were also positive interactions between staff and patients in the ward, as in the other settings, usually when the ward sister was on duty:

Sister comes in and tries to stimulate some interest in the patients. She goes over to Jane and sits with her. She asks her if she wants a cigarette. Jane says “I’ve already had one”. Sister asks her if she would like another, and Jane says “Yes”. Sister gives her a cigarette. Sister then goes over to Mary, and asks her if she can play an organ. Nellie says she can play a piano, so sister gives her a small organ to play. She practises a few notes but cannot play it. (Hospital ward)

The staff nurse wheels in a patient in a wheelchair. As she sits her next to another patient she introduces them and says “Sav hello” . . . Sister wheels in Vera in a wheelchair (Vera hasno legs). Sister asks her if she would like her hair hone. Vera says “Yes please, if it isn’t any bother”. (Hospital ward)

DISCL’SSION

The preliminary analyses of the survey data provided support for the argument that ‘batch treatment’ of individuals occurs regardless of the size or type of the total institution. It appeared that the nursing homes were little different from the traditional geriatric ward.

The data from the observational study presented here also gave several examples of binary manage- ment and demeaning practices. Evidence of detach- ment was provided, and the value of elderly people’s engagement in everyday activities and interactions emphasised, in contradiction to disengagement theory.

More positive moods were observed when patients were involved in recreation with staff, and when they were able to listen to music. Several examples were given of the positive effects of activity.

Unlike the survey techniques, the observational methods were sufficiently sensitive to be able to discriminate between the ward and the homes. The more positive environment evident in the homes, and also in the hospital patients’ club, indicated that

Quality of life in institutions for the elderly 1209

the characteristics of the total institution are not inevitable features of long stay care.

The higher proportion of instances in the ward of patients’ requests being ignored, and of responses being delayed, and the higher proportion of negative interactions illustrated the demeaning characteristics of institutions, and their binary management, described by Goffman. However, the contrasting findings in the homes and in the hospital patients’ club indicates that these settings do not entirely fit Goffman’s concept of the characteristics of institu- tions. although all settings clearly had room for improvement. particularly in relation to verbal inter- action. Moreover, neither the homes nor the ward achieved positive interactions between patients, or patients and staff/visitors in excess of 30%. Although the proportion of positive interactions was highest in the patients’ club, at 36%. this was still a minority of the interactions observed. Apart from the patients’ club, less than a quarter of patients were involved in recreation at any one time.

The common features of residential institutions may be so dominant in their effects that they mask any differences in the social environment between settings. Despite the block treatment of individuals, in terms of getting up and bed times, and meal times, which is inevitable when staff have a work routine to adhere to and not all patients can be helped at once, there appeared to be more flexibility in the homes than in the ward setting: patients in the homes were observed being offered tea or coffee or meals if they missed these for some reason. They were also observed to be offered a choice. This was not observed in the wards. Although examples of these differences were recorded qualitatively, no structured (pre-coded) data was collected on this and therefore the impression remains merely subjective. Given that patients were observed exercising choice in terms of activities in the patients’ club, this indicates that more flexibility and choice is possible within a large institution if the atmophere to foster this can be generated. The club’s success was due to uniquely motivated occupational therapy staff. Poor morale on the ward was probably due to the poor image of geriatric nursing, which was reflected in difficulties in recruiting staff. Such an atmosphere makes internal change difficult. However, change was achieved by the 0.T.s in the hospital patients’ club. This indicates that Goffman’s concepts of a total institution are not inevitable features of long stay care.

This study, using multiple methods, has shown how essential it is not to rely solely on interview material and assessments of mental and physical functioning, and to view quality of life more broadly than simply in terms of outcome. Whereas no differ- ences in outcome were found between settings relying on the survey data, the observational data support the conclusion that a different quality of life was apparent between settings.

It was apparent from the literature review that most research on the institutional care of the elderly is positivist in approach, largely based on survey techniques or extraction of information from records (e.g. deaths) and assumes that the circumstances of the elderly can be measured using such scientific approaches. It is, however, difficult to identify objec-

tive parameters and measurable criteria with which to evaluate care of the elderly in institutional settings. The positivist scales of mental and physical impair- ment and of life satisfaction used in the present evaluation were inadequate in terms of discriminating between the hospital and nursing home settings. It is in this situation, where survey methods were clearly limited, that observational techniques can clearly give insights into the behaviours, moods, interactions and atmospheres between settings.

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