Aging in nursing homes

Social Construction of Aging in Nursing Homes

Aging is socially constructed. Using the perspective of symbolic-interactionism, it is possible to show the precise processes whereby the social construction of aging takes place inside specific institutional contexts, like the American nursing home. The American nursing home offers insight into the culturally constrained concept of aging, for attitudes towards aging bodies and aging as a philosophical concept are informed by cultural milieu, worldview, and value construction. Biological aging is not social aging. The positive aging movement and the harmonious aging movement offer counterpoints to traditionally antagonistic and negative views of aging. Especially as the population of the United States and other industrialized nations shifts towards the older end of the age spectrum, it becomes important to reconsider the biological, psychological, and social processes and functions of aging.

The nursing home offers the opportunity to examine aging from a multidisciplinary perspective, while using the ethnography as a primary methodology. A nursing home is a community and a subculture, separated from the rest of society not because of gender or ethnicity but because of age. While economic and socio-economic status issues might impact the subculture of the nursing home, many nursing homes are government subsidized and remain one of the few domains in which the boundaries of race, class, and gender become dissolved. Age is the primary demographic factor contributing to the construction of individual identities and community identities.

Within the nursing home can also be located subgroups, based on gender but also on other factors such as support groups for specific physical or mental health conditions, hobbies, or activities. This ethnography will take into account the ways residents of a nursing home are treated by staff, illustrating power differentials in a presumably paternalistic if not outright patriarchal healthcare system. The reinforcement of aging stereotypes, and what Kaufman (1994) refers to as the social construction of frailty, will also be taken into account. Moreover, the nursing home becomes the new residential community for the individuals, who are physically removed from their families and communities of origin. They recreate new identities within the home, sometimes severing ties with the community outside. In other cases, rites of passage that would typically take place outside of the domain of the nursing home such as birthday celebrations or anniversaries, take place in the nursing home because it is the community hub. As seniors relocate to the nursing home community, a new type of population migration takes place, as nursing homes have also become a global phenomenon.

Older Bodies

The ideal body phenotype for any gender or ethnicity is young. An older body is therefore subversive and deviant. Positive aging entails an empowerment of the senior community and of the individual senior to control how images of the aging body are portrayed in the media. The positive aging movement has permeated some age-specific media, such as magazines that target the senior community and which are typically on hand in nursing homes. As Featherstone & Hepworth (1995) point out, the efforts at generating a positive aging framework have been stymied by the corporate media, which continues to deliver images of ideal aesthetics and idealized health. Youth is signified in a number of different ways, whereas aging is portrayed as monolithically negative: wrinkles, age spots, falling and yellowing teeth, flaccid muscles, and poor posture. Young adults are warned against aging in a number of ways: avoiding the sun, avoiding alcohol and smoking. In addition to the negative imagery of aging perpetrated by the media and its corporate sponsors of magical anti-aging creams and surgical techniques, the media presents an equally as demeaning view of the subjective perception of aging. Aging entails a person becoming weak. The projection of weakness and frailty upon the elderly, regardless of their actual physical health or prowess, was the subject of a study by Kaufman (1994), who observed a senior community in the United States. Results showed that frailty was presumed and projected by the medical community and by outsiders, leading to "increased dependence" and systematic use of surveillance and social control within the nursing home institution (p. 45). Nursing homes observed for this ethnography concur, substantiating what Kaufman (1994) found in the earlier observations. Nursing home staff, reflecting the words of doctors and visitors to the nursing home, frequently as the residents if they can lift things, if they are alright to move something, and other indications that they are encouraging dependence and lack of autonomy.

Using a Foucault analysis of the nursing home as a social institution, it is clear that the home has been set up for surveillance and social control. The aging body can be seen by the constant paternalistic gaze of the nursing home staff. The movements of elders are monitored and proscribed; the residents are like inmates. They have schedules, routines. Dining takes place collectively, only the sick can have their food delivered to their bed in the room, where they are sometimes monitored by the nursing home care staff. Cameras complete the surveillance system. Installed "for patient safety," as one nurse stated, the cameras ensure that the population is monitored at all time, transgressions from the norm duly recorded. Recording in bureaucratic format takes place constantly, as nurses use graphs and charts to plot everything from what a patient eats to how many times they spoke in a group counseling session.

The aging body is asexual. For women past the reproductive age, the asexualization of the aging body is particularly problematic. The link between sexuality and sexual pleasure and childbirth is a patriarchal one; the woman has lost her power of agency in sex once she moves past the age of childbirth. Bereft of her sexual power, the aging woman is portrayed in the media as "ugly," someone a young person would never want to have sex with, and even someone an older man is not supposed to want to have sex with, according to one woman who was interviewed for this report. Old men, on the other hand, are allowed to have younger partners, and are lauded for doing so. The film Harold and Maude subverted the norm, offering a positive aging framework within which to view female sexuality in particular. Another interview participant said that besides films like Harold and Maude, which is an exception to the rule, the movies and television shows that ever show older people having sex at all depict it as if it is a joke, or as something that is "disgusting." These comments are reflected in more systematic studies, such as the surveys conducted by Featherstone & Hepworth (1995).

In an attempt to take power back from the media, seniors in the nursing home need to adapt a proactive stance that situates the senior body separately from the media, and this is something that can potentially be achieved in a progressive nursing home. A positive aging framework or a "harmonious aging" framework as suggested by Liang & Luo (2012) can be used. Harmonious aging goes beyond positive aging to reverse the Cartesian duality of body/mind. Moreover harmonious aging is not culturally specific, whereas the concept of "successful" aging takes place within a Western hegemonic framework (Liang & Luo, 2012, p. 327).

Rites of Passage for the Elderly

In the nursing home environment, residents frequently go through rites of passage that might typically take place outside the community and in their communities of origin. Rites of passage take place in the nursing home, some of which may even be nursing-home specific such as anniversaries of their entry into the community. The extrication of the elder from the community of origin is a means of social control, the migration of the individual to the nursing home an exodus, and an exile of the aging body. As Saxena (2016) points out, age has become a direct cause of social inequality. Far beyond the simple biological concept of aging, the ways the media and mainstream society project negative connotations onto the aging in individual causes that individual to be exiled to the nursing home in the final rite of passage from the community of origin into what is widely believed to be a final resting place before the grave. Therefore, entering the nursing home is itself a newly socially constructed rite of passage specific to old age. This is a rite of passage that never existed before the advent of the nursing home. As life expectancy grows, the numbers of these rites of passage will also increase, until it may become as commonplace as divorce.

Within the nursing home, several social celebrations that commemorate rites of passage take place that would typically take place outside of it. This shifts the geo-spatial dimensions of that specific rite of passage. For example, birthdays and wedding anniversaries take place in the nursing home. A birthday or a wedding anniversary is itself not a rite of passage, but they commemorate the original event, the original rite of passage (birth and marriage, respectively). The death rite of passage can also take place in the nursing home, without the common fanfare of a community support system extending beyond the subculture. Without friends, family, or colleagues from outside the nursing home, each resident has come to rely on the internal support system as their new family.

Interactions with the Medical System, Paternalism and Control

The nursing home has yet to become the emblem for positive or harmonious aging, a space and place in which the elder can re-negotiate the terms of "successful" aging. Part of the problem is that the modern nursing home exists as an extension of the paternalistic healthcare system. Entrenched in a patriarchal and hegemonic cultural construct of aging, the modern medical system controls attitudes and outlooks on healthcare within the nursing home itself. Decision-making on the part of individual residents is restricted, their autonomy threatened by nurse and doctor coercion. Positive aging as a movement is based on the primacy of agency and individualism, not as they are necessarily valued in American society, but as symbols of empowerment in a more general sense (Gergen & Gergen, 2000). Individuality and agency refer to patient autonomy, which is more than just the ability of a patient to refuse a treatment or service. Patient autonomy must include assertive patient self-education, patient driven determinations of how the aging process proceeds, how the body is treated and viewed, and how much freedom the individual wants versus how much the individual actually uses. The nursing home has become a problematic space, where individuality may be constrained by the patriarchal medical system. As Katz (2005) points out, "efforts to open up new cultural spaces for older people are only too vulnerable to commercial pressures and power struggles," (Katz, 2005, p. 2). A profit-driven and paternalistic medical system generates problems for the positive aging movement. The "successful aging" model that relies too heavily on culturally-specific definitions of independence and autonomy needs to shift to one that incorporates diversity (Bengtson & Delima, 2016).