Ageism in nursing homes? Voices from Casa Albergo
Is there ageism in nursing homes and what forms does it take? In Italy, several surveys have been produced to detect the incidence of mistreatment and abuse of senior residents in care homes. However, the same cannot be said about the presence and impact of ageism, although it can be argued that there is a relationship between the two phenomena in that an ageist disposition may be a precondition for maltreatment. We, therefore, decided to start investigating this phenomenon by gathering the point of view of people living and working in such places, occupying different roles and positions.
ISRAA has a long experience in caring for older citizens and over time has continued to develop services in order to best meet the needs of this composed population group. However, we know that ageism is an insidious phenomenon, which creeps into everyday practices and is, in some respects, incorporated and naturalized by individuals in the form of prejudices and stereotypes. The interviews we have started conducting are thus a search with a magnifying glass looking for evidence and clues. So far, we’ve asked questions to the coordinator of Casa Albergo, one of ISRAA’s nursing homes, two old ladies living in there, and three professionals: a psychologist, a health worker, and a reception manager responsible for the relations with the external public, relatives, and residents. We tried to find out what ageism means here, and how it materializes for these persons: if they have ever experienced it, if they recognize some signs of ageism in their disposition towards the residents, if ageism appears in everyday practices and organization of their living and working environment. We have only taken the first steps towards this pathway, but what has emerged deserves to be told: we found out that a relatively simple question like this, leads to a much more complex and nuanced answer one might think.
«Generally speaking, ISRAA is an organization that looks at the seniors quite liberally. Casa Albergo specifically because we have many self-sufficient older people, therefore they constantly bring us their self-determination, their choice, their vitality.» This is what the coordinator of the residence says when asked about the possibility that the internal organization could give rise to forms of ageism of a structural nature. However, she does not hide the fact that “routines”, such as mealtimes for non-self-sufficient seniors, can be for some aspects constraining: « (…) for organizational reasons, they eat at 11.30/11.45 and have dinner at 18.30/19.00. Probably some people would prefer a “later”, more “normal” time. We have not yet succeeded in modifying this, or rather than modifying it, in making an analysis of what the non-self-sufficient seniors really want in this regard.»
From the very outset, the themes of self-determination, desire, and choice are at the heart of her reflection as she considers them as key factors to contrast the ageism that risks embedding in the nursing home internal dynamics. That's why, she emphasizes, there is always a tension to capture the desires of older residents in organizing activities and caring for them. «What does this tension materialize in? », we ask. «It concretizes in creating activities in which older people are given the possibility to express their opinion, their desires, their projects (…) we also do many activities linked to the theme of “desires” and carry out some group initiatives in which space is given to self-expression. This self-expression creates the conditions so that, to make an example, these seniors we see in wheelchairs, who need help... we see them in another dimension, as if they had no time because emotions have no time, emotions remain in all their characteristics, even in the most fragile persons.» However, such a tension should also be reserved for routine tasks of employees, which, she argues, should be worked on more systematically: «Maybe another work that could be done to refine even more (this tension) is the issue of language in the drafting of the deliveries and work assignments. Also, in talking about the older we could do even more significant work, in particular with the figures who are in the front line on a daily basis, therefore the OSS *. First of all, describe, not judge.»
This perspective is shared by the psychologist, who believes that the guard should always be kept up in daily work, especially in those tasks belonging to habits: «Ageism is such a complex phenomenon that we run the risk of adopting attitudes and words that go towards ageism unconsciously.» She reports a concrete example: «We are all required to complete the Personalized Care Plan**. Casa Albergo has among its residents a lot of self-sufficient ones. Thinking of bypassing seniors, and not remembering that the first restitution (on the individual care plan) should be made to them… this is a form of ageism. The inclusion of the will, the determination, the autonomy of each person... this is a fundamental key to our work (...). So, the focus must always be kept high. This is why I say that ageism is there in a subtle form, perhaps dictated by the repetitive way of doing our work.»
Her words suggest that the self-determination of the older person is a major factor both in formal aspects and in the daily exchange between employees and residents. In the meantime, they suggest that there is a constant risk of forgetting this aspect and, consequently, a need to act in order to maintain, sometimes create, awareness. But, we ask: «How to work on awareness among employees? Can information and training be useful to this scope? » «If we don't know what we are talking about, training is necessary to create a common vision» she answers, however she stressed out that: «we need spaces for consolidation. Spaces dedicated to staying can be useful, spaces dedicated to thinking, a thinking that creates awareness, because if I am immersed in my routine, I don't even realize what is going on.» Such approach, she explains, should also be extended to the seniors in order to make them aware as well: «It does not mean having a training activity “let's talk about ageism”, but it means creating spaces for lateral thinking, a new mindset (...) having a space that is a repository of thoughts, and thoughts' creation creates awareness (…). So, spaces of staying, where one can afford to say without being judged, create awareness.»
A certain continuity can be found between her words and those of the coordinator, suggesting an intrinsic link between self-determination, desire, and awareness, conceived as core ingredients to discourage the spread of prejudice, stereotypes, and discriminatory behavior both among employees and residents.
This leads us to question whether and how forms of ageism among older people exist and manifest in the daily life in the residence. According to the psychologist, the spaces dedicated to staying allow thoughts and ageistic attitudes to come to the surface even among the older. As she reports: «There is a need to talk about the fact that “that old man is dead” and that old man is other than me, and that he is old and I am not.»
It is interesting to note just how in a home for seniors, a place where persons enter precisely because they are old, the subject of prejudice and discrimination it is exactly “being old”, that becomes a status to be distanced from, the "type" from which one establishes the difference between himself/herself and the other. In tackling the topic, the psychologist points out that this is a very common attitude among residents, especially when referring to non-self-sufficient persons living on the second floor of the building. «Never on the second floor, only old people go there! », is one of the most diffused statements among autonomous seniors according to her and, she continues smiling: «maybe this is said by a 93-year-old.» She goes on to note: «This tells a lot about what's inside their head, about what's inside their most authentic feeling ... “that old person is different from me”, therefore to be stigmatized, to be kept away from.» In this regard, the coordinator reports an exchange she had in the morning with an old lady, who said to her: «Listen, there are some old people who are always complaining... wait, I'm 91 years old, maybe I'm old too, but I'm a different old.»
«Well, it's true», the coordinator argues, «because there are old people who are timeless, old people who are young, old people who are old or thinking they are old.» According to her, the body seems to play a fundamental role in influencing both self-ageism and interpersonal ageism among peers. Based on her words, not only the loss of mental and physical autonomy is perceived as a step towards being (and feeling?) a “real” old person, but it is an element that allows to “create otherness”, thus a reassuring distance, to distinguish the other who is old, from myself who is not or is old in a different manner.
As she coordinator observes: «How the body ages, this influences it (the self and hetero perception). You can have a soul that remains intact or fresh, but it has to come to terms with a body that has a different age, that is a machine that wears out and reduces the possibility of enjoying life (…) and so there are these aspects that should fit together. The vitality of the spirit, of the soul, has to fit in with the body (...) Sometimes there is a kind of dystonia between how they perceive themselves and how they see the others who are old.» And then concludes stating that: «Some are more aware that they are old too, some are less aware, some are actually different! »
But what about residents' points of view on these themes? Chatting on their everyday life as residents in the home, M., one of the two old ladies we interviewed, declares: «This letting oneself go that some have made me sad. There are few who participate (in activities). Why don't they participate? They just sit there and watch people go by. And don't tell me that there's no stimulus! They also give me a bit of anger… I feel like beating them up every now and then! ». M. is strongly disturbed by what she defines as "apathy” of some of the seniors living in the home, by their negative attitude towards activities and proposals coming from the professionals. C. the other lady that we've involved in the interviews, appears to share such feelings, as she states: «Some of them complain. Why? I don't understand it well! I think there are some things that could be better, but on the whole, I think we can't do better than this! I see the girls, from the coordinator downwards, even those in the porter's lodge, each one is always ready to help, to listen to you. This is not taken into account, but (this attitude) it is also justified by their age, they must feel lonely.»
When asked if these complaints or apathy might be due to the fact that some of the residents struggle to accept they entered a care home, she replies reporting her experience: «You must give up. You've given up, you can't live alone anymore. When I was 95 years old, I started to feel that I wasn't safe … if something happens to me...I was restless and I understood that this situation had to change, it had to end there, I had reached the maximum. In short, at 95 years old I can afford it. I come back here happy, the room welcomes me, I feel at home and protected above all. I was looking for a protected refuge, and here it is (..). The light that comes from the door… passing through the floor and the door there is a line of light, and at night when I go to bed and see that light, I am happy.»
The assertions and words used by these women suggest a sort of annoyance and rejection towards those who spent time feeling sorry for themselves, adopting a renunciatory, a negative attitude, who do not accept serenely their being old. C. seems to have come to terms with her old age and some of the aging process consequences, such as feeling unsafe when at home alone. That’s why she appears surprised and disturbed by those who have not yet managed to do so. However, she underlines: «I'm lucky because my mind follows me, and so does my body.» This statement partly confirms how the synchronicity of mind and body functionality mentioned by the coordinator can make a difference in experiencing aging. Nevertheless, C. does not forget to point out that, compared to the past, her energy and possibilities for action have diminished, that she gets tired more easily, for example when embroidering and crocheting. But she goes on: «I lived my years well when I could do certain things. Then gradually I had to give up some of them. But, at that point, you have to choose: either you waste your time feeling sorry for yourself, and that's it, or you react! In short, you have to do something, you have to react!»
A certain degree of acceptance and proactiveness, what we might call the individual agentivity, sits at the hearth of her reflection. In this regard M. sustains that: «A lot of people are really negative. They think nothing is good. Food, for example, “is bad!”, they say. So, let's suggest something else, tell what you’d like to eat, react! But you can't change their ideas, you can't change them!.» A similar demotivation is shown in the participation in the many activities the professionals propose every day and during the week: «There are so many ideas and activities here. There are only six or seven of us going, but it's open to everyone! There's apathy, I don't know what it is. But you get stimulated, a bit... no, they don't even want the stimulus! It's nice, there are all these things they (the professionals) do and propose to us, and very few participate! I managed to bring one or two ladies: “come on, it's good for you!” I told them. Or, to take another example: people's names. I like to call everyone by their name, but the other ladies say: “No, no, I can't remember their names” and I say to them: “Make an effort!” and they reply: “It's my memory, that's how I am, I am old.” There is this “letting go” attitude.» According to M. words, as well as those of C., it can be assumed that ageism tends to be present as self-directed, manifesting as apathy, lack of interest, in a renunciatory attitude. What anyway seems particularly relevant, and would deserve further in-depth analysis, is this two ladies’ reaction in front of such expressions of self- ageism. At the core of C. and M. narrations, it is in fact possible to observe a desire to distance themselves from a way of being old in which they do not recognize themselves, a way of being old that, in some extent, they consider to be “wrong”. Apparently, a peculiar expression of ageism among peers that would deserve further investigation.
However, continuing our conversation on the topic, M. then poses a relevant theme: «I have my daughter, my house, my life, my things to do. But there are those who are really alone. They suffer more because they have no affection.» Her words hint at how loneliness can help create the perfect "humus" for manifestation of self-directed ageism, resulting in passivity, renunciation, and self-commiseration. In this regard, G., the health worker, tells us: «Then there are the seniors who are lonely, and if we are not there, there is no one. Loneliness is really bad (…). They are those who say: “What am I doing here? Nobody cares about me”. In most cases there is loneliness, solitude... once they are descending into loneliness... it is difficult to bring them up.» It is well known that loneliness, lack of family ties and relationships, and, more generally, social isolation play a major role in compromising physical and psychological wellbeing, and, sadly, her words sound like an additional confirmation. On this regard F., the reception manager, declares: «The Covid-19 pandemic contributes to making it (loneliness) even more visible and potent.» He states: «Residents suffered a lot the prohibition to meet their relatives during the lockdown, and they’re still suffering restrictions. A lot of them have gone into serious crisis.» These testimonies suggest that even in a collective environment, as a retirement home may appear to be, social isolation and loneliness are existing phenomena profoundly affecting self-perception on which forms of internalized ageism can take root.
Many suggestions and potential angles of investigation arose from these first few interviews. Ageism in the Casa Albergo nursing home appears to be a multifaceted and multidimensional phenomenon where elements belonging to the individual- health status, personal biography, social ties, awareness- are tightly intertwined with organizational elements, internal dynamics, relationships and the acted and introjected collective imagination of persons living and working here. That’s why, at least for now, is not yet possible to draw conclusions. Nevertheless, among the voices, the words, and thoughts collected, some concepts seem to have returned several times: self-determination, desire, choice, awareness. Others, which appeared just as often, as apathy, renunciation, self-commiseration, are for some aspect their antithesis. Therefore, it is probably around these elements that the game of ageism is played, at least here. We just have to keep investigating.
* In the Italian care and assistance contexts, the “Socio-Sanitary Operator” (OSS, Operatore Socio Sanitario) is the figure who provides basic nursing support, collaborating with other more specialized medical and nursing figures.
**The “Personalized Care Plan” (PAI, Piano Assistenziale Individualizzato) is a document that collects and describes, from a multidisciplinary perspective, the information relating to the subject with the aim of formulating and implementing a treatment and care project that can promote the best possible health and well-being for him/her.