Citation
Chronic life

Material Information

Title:
Chronic life an anthropological view of an American nursing home
Creator:
Henderson, Jospeh Neil
Place of Publication:
[S.l.]
Publisher:
University of Florida
Publication Date:
Language:
English
Physical Description:
xi, 122 leaves : ill. ; 28 cm.

Subjects

Subjects / Keywords:
Anthropology ( jstor )
Cultural anthropology ( jstor )
Death ( jstor )
Diseases ( jstor )
Hospitals ( jstor )
Housekeeping ( jstor )
Nurses ( jstor )
Nursing ( jstor )
Nursing homes ( jstor )
Older adults ( jstor )
Anthropology thesis Ph. D ( lcsh )
Dissertations, Academic -- Anthropology -- UF ( lcsh )
Nursing homes -- United States ( lcsh )
City of Orlando ( local )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis--University of Florida.
Bibliography:
Includes bibliographical references (leaves 114-121).
Additional Physical Form:
Also available online.
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Joseph Neil Henderson.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright Joseph Neil Henderson. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Resource Identifier:
06169965 ( OCLC )
0023232841 ( ALEPH )

Downloads

This item has the following downloads:


Full Text











CHRONIC LIFE: AN ANTHROPOLOGICAL VIEW OF AN
AMERICAN NURSING HOME







BY

JOSEPH NEIL HENDERSON














A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY






UNIVERSITY OF FLORIDA 1979































Copyright 1979

by

Joseph Neil Henderson









This dissertation is dedicated to the patients and staff of Pecan Grove Manor -- past, present, and future.









ACKNOWLEDGEMENTS


The acknowledgements made below are indications of my sincere debt to the numerous people who encouraged, assisted, and nurtured me throughout the duration of this fieldwork project. Prerequisites for successful anthropological fieldwork are many and varied. Often obscured is the value of the anthropologist's spouse. In this research project, my wife, Jan, figures prominently. She willingly worked and traveled with me throughout the rigors of university training and fieldwork, thereby delaying the realization of some of her personal ambitions. Jan also helped me in gathering data to which I otherwise would not have been privy and charmed those who were at first reluctant to be a part of this study. Besides technical talent, she exudes warmth, personality and love for those around her.

My parents, Ike and Patti, have been a continual

source of inspiration and sustenance for this part of my life experience. In so doing, they continue to build on an atmosphere of unconditional love and respect which they engendered at my beginning.

My brother, Greg, contributes to this project and my life daily. I learned from him discipline, perseverance, humor, and a multitude of other things in the dearest way possible. He is my friend. Greg's wife, Mariquita, contributes to my dissertation by her love for Greg and for Jan and me.
iv









My uncle, Phil Stumpff, his wife 'berta, and their
four children, Kurt, Erik, Stacia, and Stephanie, all have a part in this research. Phil provided me with complete access not only to a research site, but to a part of his livelihood. I hope that his trust has been well-placed. His family has repeatedly placed their home and selves at our disposal.

My grandmother, Mother Polly, and grandfather, Gang, remain lifelong sources of love and inspiration. Their home was made available to Jan and me, providing not only physical shelter, but an experience that speaks well for extended family kinship systems.

Those who suggest that kinship declines in importance in industrialized societies may want to review the above acknowledgements. However, many non-kin deserve mention. Among them are Phyllis Maines, Sally Watkins, Wilma Davis, and Dorothy Harrison,who all diligently work at Pecan Grove Manor. Some figure-drawing and rough-draft typing was done by Bobbie Bryant, Ruth Kagen, and Anita Morris.

Members of my committee have expended great efforts on my behalf in training me in anthropology over the past several years. I will continue to develop my anthropological knowledge and skills because, if I have learned anything, I know that the endeavor of understanding is a lifelong process of wondering, investigating, and learning. I particularly thank Professor Otto von Mering for sharing his novel insights, Dr. J. Anthony Paredes whom I have

v









known the longest of all the committee members, for his continued interest in me and his extensive and expert influence on me, and Dr. Leslie S. Lieberman for her watchful supervision and tremendously useful discussions with me. Dr. Carol Taylor and Dr. Walter Cunningham have provided significant comments on this project, making it a more solid effort. Overall, however, I am responsible for those deficiencies present.

It is my sincere hope that this dissertation contains some information benefiting even a small segment of humanity. If this is the case, my debt to those instrumental in this research may be partially repaid.






























vi












TABLE OF CONTENTS


CHAPTER PAGE ONE BACKGROUND . . . . 1


TWO METHODOLOGY ................ 10


THREE DEMOGRAPHICS AND EPIDEMIOLOGY. . . 17 FOUR ENVIRONMENTAL SETTING . . . 25
Note ... . . . ... 42
FIVE THE DAILY CYCLE: RITUALS OF
FABRICATED LIFE . . . 43


SIX THE PATIENT EXPERIENCE: THE NEXT
BEST THING TO HOME . . . 75


SEVEN CHRONIC LIFE AND AGE SEGREGATION ...... 94 APPENDICES

1 SELECTED NURSING HOME INDICES 1977 ..... 103


2 PECAN GROVE MANOR TOTAL DISEASE
ROSTER (FROM PHYSICAN LISTINGS
IN PATIENTS' CHARTS) .... ........ 104


3 PECAN GROVE MANOR
TEN MOST PREVALENT DISEASES . . 110


DISEASE PREVALENCE
PECAN GROVE MANOR . . . 111






vii









5 POPULATION PYRAMID:
PECAN GROVE MANOR. . . . 112


6 WING ASSIGNMENT BY DEBILITY FACTOR . 113 REFERENCES CITED . . . . .... 114



BIOGRAPHICAL SKETCH. .. ......... ..... ... 121










































viii















Abstract of Dissertation Presented to
the Graduate Council of the University of Florida in Partial Fulfillment of the Requirements for
the Degree of Doctor of Philosophy


CHRONIC LIFE:
AN ANTHROPOLOGICAL VIEW OF AN
AMERICAN NURSING HOME

By

Joseph Neil Henderson

December 1979


Chairman: Otto Von Mering Major Department: Anthropology

This research project examines the experience of chronically ill geriatric patients and the care-giving response patterns of unlicensed nursing personnel in a ninety-bed proprietary nursing home in southern Oklahoma.

The study of the residents and staff of Pecan Grove

Manor (pseudonym) is based on an anthropological community study approach, with theoretical orientations derived from functionalist and social systems models. It extended over a period of thirteen months of participant-observation. Pertinent data were also collected by personal interview, scheduled interview, patient diaries, still photography and cinematography.

Overall, Pecan Grove Manor is revealed as a standard American example of a specialized age-segregated community ix








which has become a commonplace sociocultural and brick-andmortar invention in response to biomedically induced longevity, prolonged debilitating disease, and the ethical proscription against senilicide. The nursing home, therefore, is the setting for observing the uniquely debilitating phenomenon of leading a "half-life of disease" within a "half-existence of social functioning."

The research also documents salient features of a

resident population with a significant capacity to mobilize adaptive behavioral responses to physical limitations and the formal institutional environment. A further important finding shows unlicensed nursing personnel serving as "folk healers" and surrogate mothers to the patients and non-nursing personnel (i.e., housekeepers) to be the key staff group whose normal or "proper" task performance promotes transactions rather than ritualistic contact with patients. In spite of patients' adaptive resilience, the nursing staff perceives patients as adult children whose physical and intellectual resources are exhausted. This belief, generally coupled with medical-model-induced nursing neglect of psychosocial aspects of well-being, contributes to a web of fabricated life rituals that veil the underlying efforts at palliative care.

A concurrent intensive study of a special sub-group or cohort of twenty-three mentally-intact residents provides evidence that, in the main, they experience nursing home life not as ideal, but "the next best thing to home,"

x









given their situation of unemployment and illness. This perception is partly based in fact, and in part a derivative of a need to counter-balance the inescapable stress of life under imminent, compounded health threats and the related institutional confinement.

The significance of the role of the housekeepers as agents of psychosocial support is not formally recognized by either the nursing or administrative staffs. Unlike nurses' aides, proper job performance for housekeepers involves lengthy in-room tasks during which meaningful interaction can and does occur with individual residents. Housekeepers serve too as brokers between groups of residents and the nursing staff.

These findings as a whole suggest that institutionalized elderly can remain adaptively resourceful for an extended period in personal body care, and do respond positively to informal or unplanned psychosocial care. It is argued that psychological care can be promoted within an existing standard program by actively rewarding the spontaneous social-support role of non-nursing staff members, like the housekeepers. The cost-benefit ratio of such a strategy is seen as potentially attractive to proprietary nursing home owners for the improvement of the quality of institutional life.







xi









CHAPTER ONE
BACKGROUND


The regeneration of time, according to Mircea Elaide (1963), is a driving concern of all people throughout the world. Concepts of heirophanic eternities may represent the products of attempts to teleologically demonstrate regenerated time. In any case, the occupants of some eternity have in common the passage from mundane existence to supernatural existence; for many, from secular old age to unencumbered old age.

Also observed worldwide is some form of peculiar

segregation of the aged. Age-grading may be explicit as with the Karimojong of Uganda (Dyson-Hudson 1966) or implicit as with the Americans of North America. The segregation of aged people may be physical, as among the Ainu of Hokkaido, Japan, who isolate the very old in small huts (Simmons 1946:90) or conceptual, thus allowing for physical proximity of young and old but retaining distance socially and conceptually as found among the Chiricahua Apache of the southwestern United States (Beals and Hoijer 1971:360). Perhaps special perspectives regarding the aged are ultimately functions of an awareness of the elderly approaching the mysterious phenomenon of death. Thus, people who have lived many years are viewed positively or negatively, as functional or non-functional, but always recognized and distinctively engaged by others as aged.



1






2


Throughout time, the concept or label of "aged" has been assigned to people in accordance with prevailing beliefs regarding the chronological age at which someone "becomes" old. Assignment to the category of aged, then, is a combination of belief and time. In extremes, the six year old progeric patient is considered old while the Russian Abkhasians or Ecuadorian Hunza are considered old only after reaching a purported (cf. Butler 1978b and Mazess and Forman- 1979) 100 years of age.

During the middle Paleolithic, Neandertal burials at Mount Carmel disclose that of a male about 50 years of age (Clark 1969:45) although most Neandertal burials are of individuals less than 30 years of age (Stern 1969:98). Mellaart's (1967:225) excavations in Turkey show that very few of the Neolithic inhabitants of Catel HuyUk lived over 40 years of age. During the Iron Age (c. 100 B.C.), the average life span was 18 years although some rare individuals survived as septugenerians (Birren and Clayton 1975:15). By 50 B.C., the life span has increased to 25 years until the 1600s A.D. when the life span edged ahead to 32 years of age (Birren and Clayton 1975:24).

During the year 1776 A.D. in America, only 20% of neonates lived to the age of 70 and only 4% of American families were comprised of three generations (Butler 1978b: 15). By 1900, the human life span was 47 years and in 1970 it was 71 years of age (Cutler and Harootyan 1975:32-34).






3


Butler (1978b:15) projects that the maximum limits of human longevity range between 100 and 120 years.

Given the rapid acceleration of human longevity and

its recency, "old" is new in America and the world. It is as if a new sub-species of Homo sapiens has evolved as a product of machine-age industry and antibiotic medicine. While the subspecies designation is facitious, it can be recognized that elderly people are in some ways physiologically and intellectually distinctive. These distinctive features (e.g., change of bone density, change of arterial elasticity, digestive changes, cognitive and sensory capacity change) relate to special needs of the elderly and finally to demands placed on society pursuant to meeting those needs.

The importance of addressing the needs of the elderly in America becomes clear when demographic trends are examined. The total population aged 65 and over in 1900 was 3.1 million but in 1970 was 20.2 million. The proportion of people 65 and older has increased almost 2.5 times from 1900 to 1970: 4.1% to 9.9%. However, the percent of the total population 65 and older will be 11% in 1990, decline slightly until 2020 when it will rise to 13.1%. Projections for the next five decades show that the absolute number of people 65 and older will increase from about 20 to about 40 million (Cutler and Harootyan 1975:33-35).

The rapid increase in the number of aged Americans has produced a series of attempted societal adjustments aimed at






4


adapting modern American life to a new element of the social and cultural system. In this sense, sociocultural evolution is proceeding under the guise of federal and local governmental programs providing services for needy elderly while also functioning to shift responsibility away from individual elderly persons and their families to the general public. Monetary assistance for the aged, treatment and storage facilities for the aged, separate communities for the aged, and simple ostracism appear to be the American ways of dealing with the growing aged population. Thus, the American aged population has been identified, categorized, and stigmatized as a "problem" with which the "un-old" must cope.

Throughout the United States, the vast majority of aged people (hereafter meaning those persons 65 years of age and older) live in community settings with 72.7% of aged males heading a household. Relatively few aged people live alone (14.7% male; 36.2% female) and even fewer live in institutional settings (3.6% male; 4.6% female) (Cutler and Harootyan 1975:63). This minority of institutionalized aged, however, currently total 1.2 million people (Brody 1977a:85) and projections indicate that by the year 2000, there may be 11 million aged people residing in institutional facilities (Brody 1977b:15).

The institutional setting likely to be encountered is a privately-owned, profit-operated business selling various degrees and types of care to the elderly sick. According






5


to Butler (1975:251), 79% of all institutions providing care for the aged sick are proprietary in nature. Nonprofit institutions for the aged provide care for 14% of the institutionalized aged and 7% of the institutionalized aged are in government-funded facilities.

Characteristics of institutionalized aged populations are varied, but even so, certain clusterings of traits are apparent. The median age of institutionalized people is 82 with 43% age 85 and older. There are three times as many women as men. Most institutionalized people are white and poor and are maintained by public funds. The institutionalized aged population is likely to have a variety of chronic physical impairments including circulatory disorders, arthritis, digestive disorders and mental impairment such as senility and depression (Brody 1977a:85-89).

Additionally, most institutionalized aged people have no spouse, no close relatives and the majority have no visitors. They stay in the institution almost 2.5 years with only 20% returning home, the remainder dying in the institution or at a hospital. Few can walk, 33% are incontinent and there is an average of more than four drugs taken per person each day :Moss and Halamandaris (1977:8).

The above description projects a dismal existence for the participants of geriatric institutions. If it is unpleasant to be poor or sick or lonely, then the combination of these three elements can only constitute a compounded sense of demoralizing desolation. Yet, in this






6


investigation in a proprietary nursing home, the harsh reality of the participants' situation is tempered by the human ability to adjust and adapt to prevailing circumstances. The circumstances to which these aged people must adjust and adapt center about the entity known as the "nursing home."

Care for the sick elderly is known in all societies regardless of the level of technological proficiency or sociopolitical organization. The existence of senilicide among band and tribal societies is not uncommon, but exists only when necessary. The usual motivating factors are related to vital components of band and tribal subsistence: mobility and productivity. Those who interfere with these basic requirements are killed or allowed to die (see Simmons 1946 and 1960). Among some state level societies, such as the Inca of Peru and the Aztec of Mexico, tribute from the productive citizens was redistributed to the needy including the infirm elderly (Simmons 1960:70).

Another element of aging recognized cross-culturally is a distinction between productive old age and nonfunctional old age. The nonfunctional and often sick elderly are referred to as "overaged," "useless," in the "sleeping period," in the "age-grade of dying," and "already dead" (Simmons 1960:87). Among the Hopi of Arizona, for example, when people are in the "helpless stage" their death is assisted by purposeful neglect (Simmons 1945:89).






7


The occupants of an American nursing home are often very old and very sick. Their membership in a geriatric institution is a symbol of their inability to negotiate even the simplest aspects of life unassisted. In response, the geriatric institution has evolved as a cultural product of technological society's ability to maintain biological life for an extremely long duration but with uneven functional capacity. Thus, nursing home patients find themselves the victims of a peculiar American pathology-chronic life.

The nursing home in America has a lengthy evolutionary history. Cohen (1974) reviews the development of institutionalized care for the aged in six phases. The first is labeled the "colonial phase" referring to the 17th and 18th centuries. Those in need (aged, orphans, sick, prisoners) all had recourse to state relief programs. Overall, however, "outdoor relief" (i.e., noninstitutional care) was more common prior to the Revolution than after it when the almshouse became the popular mode of dealing with the needy.

Second, from 1800 to 1920, America was heavily influenced by England's Poor Law of 1834. The Poor Law firmly established the almshouse as the primary institution responsible for the care of all needy, including the aged, The starkness of life in the almshouse was a matter of policy so that it would not be attractive to the undeserving. It was not until the 19th century that humanitarian reforms






8


fueled the development of institutions specifically designed for long-term care of the aged.

During Cohen's third phase, 1929 marks the date by which nonprofit institutions were primarily responsible for care of the elderly. The programs of the Social Security Act subsequently provided assistance for the aged. Privately-owned boarding homes began to house the elderly and when nurses were added, the boarding home became a nursing home. By 1939, Cohen's fourth phase, there were 1200 long-term care institutions with a 25,000-bed capacity nationally.

By 1954, Cohen's fifth phase, there was a noticeable increase in the number of proprietary nursing homes. The number had risen to 25,000 institutions with a 450,000-bed capacity. Cohen suggests that this increase reflected a backlog of potential patients.

After 1965, Cohen's sixth phase, long-term care became institutionalized into the fabric of government policy, medicine, and business. In 1965, legislation allocated funds to nursing home patients and passed the Older Americans Act. The number of facilities expanded and in 1977 there were 1.2 million nursing home beds.

It was during the phase of rapid expansion of nursing

homes in the U.S. that Pecan Grove Manor (pseudonym) nursing home was built in southern Oklahoma. Pecan Grove Manor was built in 1963 as a 30-bed proprietary facility. Within two years, it was expanded to a 60-bed facility and within






9


another three years, 30 more beds were added to fix its present patient load at 90. Seldom does the patient load drop below its maximum capacity.









CHAPTER TWO
METHODOLOGY


Pecan Grove Manor was initially reviewed as a potential research site because the administrator is the author's mother's brother and,thus, a close kinsman. The timeconsuming negotiations and development of rapport that would accompany commencement of fieldwork among strangers was consequently reduced. Advantage could be taken of the researcher's kin network only if such a relationship would not attenuate objectivity and access to data. Secondly, permission to engage in research was needed from the administrator as well as the cooperation of staff and patients. All of these criterion were met, leading to field entry in June 1977.

A research effort affording complete access to all

components of a proprietary nursing home is unusual. This project thus represents a departure from many studies regarding the phenomenon of aging. In fact, research among the institutionalized aged has been relatively neglected based on a review, for example, of the Journal of Gerontology from 1946-1979 (i.e., Volume 1 through the present) and the Index Medicus from 1967-1979. This is particularly conspicuous when compared to the relatively voluminous literature on other gerontologic topics.

Anthropologists have virtually ignored the institutionalized aged (see Clark 1973; Holmes 1976) and only a few gerontologists have used anthropological methodologies 10






11


(Gubrium 1975). None have used anthropological perspectives. Of the research activities reported by any social science discipline among the institutionalized aged, it is my distinct impression that the overwhelming majority are based on data gathered in nonprofit nursing homes affiliated with some organized religious group. This is particularly noteworthy in view of the fact that 79% of the institutionalized aged live in proprietary nursing homes (Butler 1975: 261). The few reports of research in proprietary nursing homes are generally not recent and are superficial treatments of a very complex social setting (e.g., Scott 1955; Solon 1957; Bennett and Nahemow 1965).

Anthropological investigation in a proprietary nursing home is particularly appropriate. Not only does such an effort fill a gap in studies on aging, but the anthropologist brings powerful perspectives and methodologies as analytical tools that are seldom found in other human sciences. The concept of holism coupled with participantobservation data collection provides comprehensive, in-depth reification of conceptual themes (Opler 1945) and experiences of cultural systems.

Furthermore, the methodology of participant-observation has proven utility in a variety of institutional health-care settings. Carol Taylor (1970; 1977) provides insight into the experience of nurse/patient interactions by underscoring the array of nonmedical manipulative behaviors exchanged among health care personnel and patients and their






12

attendant consequences. Buckingham et al. (1976) explored the lives of dying patients on a palliative-care ward in an acute-care hospital. Rosenhan (1973) gained otherwise unobtainable data on the effect of labeling and institutional treatment of not-so-mentally-ill volunteers. The closest precedent for this study is by Gubrium (1975) who engaged in participant-observation studies in a nonprofit, sectarian nursing home.

Participant-observation is not new nor does it possess the seductive glamour of statistically-fortified questionnaires coded for key-punching and resulting in reams of computer-tallied data. Before computers (or anthropology) existed, Frederic LePlery studied French peasant families by living in their homes with them (Timasheff 1967). With the formalization of anthropology as a distinct field of inquiry, intensive coexistence with the subjects of study has been modeled after anthropologists such as Franz Boas and Bromslan Malinowski of the early twentieth century. Thus, the "art and science" (Pelto 1970) of participantobservation fieldwork has established a firm basis for its use (Babbie 1979; LeVine 1970; Simon 1978).

Participant-observation was selected as the primary data collection technique at Pecan Grove Manor because of its personal, experiential nature. Suspicions generally felt about the ulterior goals of proprietary nursing homes would cause data collected by government statistical compilations, questionnaires, mail surveys or other techniques






13


characterized by negligible encounter with the subject population to be questionable.. Conversely, participantobservation allows for first-hand data collection, in-depth experience, and observance of formally-stated ideals of behavior compared to actual expressions of behavior.

My personal use of participant-observation at Pecan Grove Manor ran the entire gamut of possibilities except being actually institutionalized. Although the fieldworker may be admonished to totally immerse himself in the culture of the study population, there actually exists daily situational fluctuations of degrees of participation and observation (Gold 1969). My research site allowed for the total access to all participants: administrative, support staff, patients, and families. However, because proprietary nursing homes seem to expect negative assessments and in fact are continually under the scrutiny of government inspectors (not to mention families), observing and writing notes in public areas presented some difficulty. In anticipation, I had written nothing in public and carried no notebook for the first few weeks after my arrival. As the scene began to make more sense to me, the need to preserve my increasingly numerous meaningful observations required the immediate jotting of notes in a field notebook.

On the day that I first began to write notebook

entries, I contrived a scene which would allow patients and staff to see me taking notes and with the potential for them to actually read what I had written. I selected a table






14


in the center of the lobby under a ceiling spotlight. Using a large notebook and opening it, I began to conspicuously look about and then record my observations. I purposely avoided any entry of a potentially sensitive nature, such as "nurses' aide Wheeler is goofing off," etc. As I suspected, the "natives" became immensely.curious. The curious "natives" were all employees of the nursing home who first walked nearby, barely glancing at me and then later returned to loudly speak in an overly endearing tone to some "sweet" patient. After all, I was the boss's nephew who had been sent to "spy" on them.

Within fifteen minutes of my act, the assistant

administrator and the R.N. very quietly came from behind me and peered over my shoulder. When I noticed them, I moved my arms away from my notebook, leaving it totally exposed and undefended. They immediately asked me in a friendly, shy way what I was writing. I handed over the notebook explaining that the two pages of notes were just a beginning and that I would surely require their assistance in the future. The mundane jottings were handed back to me and business went on as usual with several more months of a "marginal native" (cf. Freilich 1970) exhibiting uninterrupted "note taking behavior" (cf. Rosenhan 1973).

My extent of participation included helping as a janitor, taking patients to the physician, going to the home of a prospective patient and experiencing the trip from their community home to the nursing home, being in a play to






15


celebrate the Fourth of July, and working as a paid employee (nurses' aide). Thus, I was able to observe and experience much of nursing home life during my thirteenmonth stay. Although it is obvious, I never personally experienced being an old, sick, nursing home patient.

Because I could not experience age beyond my years or

experience the length of a hallway for an arthritic patient, other data collection techniques were used. Notable is a scheduled interview given to staff, families, and selected patients. The interview schedule contained questions specific to the respondent's role classification, but each also contained a common core of questions for intergroup comparison. Personal open-ended interviews were collected, patient diaries collected, with still-photography and sound cinematography completing the data-collection strategies. The intent here was to maximize the quality of data collected by using a multi-instrument research design revolving about personal participation and observation.

In the larger view, the analytical framework used is based on the model for community study (Arensberg and Kimball 1965; Steward 1950). Conceptually, I approach Pecan Grove Manor as I would any other society regardless of geography. Pecan Grove Manor is thus viewed as a small community with its peculiar beliefs, behaviors, boundaries, rituals for incorporation and expulsion, etc., existing not as a remote, untouched bit of flotsam, but as a part of a network of other social groups of variable influence.






16


While Arensberg and Kimball (1965) emphasize that a

community is a microcosm of the cultural system of which it is a part, Steward (1950) states that a single community cannot be absolutely representative of its cultural system (Crane and Angrosino 1974). Much the same consideration must be made here. Pecan Grove Manor, as a community of institutionalized elderly, cannot be absolutely representative of all other nursing homes. However, there exist certain parameters that cause the methods used here and the subsequent findings to be useful in the investigation of other age-segregated, institutionalized settings. For example, Pecan Grove Manor is included in the following attributes of contemporary American nursing homes: the typical nursing home is a privately-owned business, the physical plant is most often a system of rail-lined corridors covering large distances, the patients are generally very old (80s) and there is a three-to-one femaleto-male ratio, most patients are widowed, most employees are untrained nurses' aides, patients have few visitors and seldom leave the nursing home grounds, and of those who are admitted to a nursing home and do not electively move to another long-term care facility, most die there or die shortly after transfer to a hospital. In these important factors, Pecan Grove Manor is strikingly similar to the profile of other American nursing homes (Moss and Halamandaris 1977).








CHAPTER THREE
DEMOGRAPHICS AND EPIDEMIOLOGY


The patients of Pecan Grove Manor are institutionalized because of some physical or mental debility. The degree of debility among the patients is variable but must be serious enough to warrant fulltime care as judged by physician assessment. As a nursing home, Pecan Grove Manor is essentially a living environment designed to support a population of aged, debilitated people suffering the extended effects and acute exacerbations of chronic diseases. The purpose of this chapter is to develop a demographic and epidemiologic profile of Pecan Grove Manor's health and disease environment. These data will be seen to significantly influence the sociocultural environment of this geriatric community. Thus, chronic disease and sociocultural systems mutually influence each other.

Eventually all states in America must address the needs of the expanding aged population. Those states which currently have large aged populations may serve as prototypes while other states observe and analyze their strategies for adaptation. Oklahoma is one such "pioneer state" with regard to aged populations. Demographically, Oklahoma ranks seventh nationally with 12.3% of the total population 65 years of age and older (See Figure 1).

In reflection of Oklahoma's sizeable aged population, 9% of the $458 per capita health care expenditures in 1976 went to pay for nursing home services (Oklahoma Health


17






18



1. Florida 16.4% 2. Arkansas 13.2% 3. Iowa 12.8% 4. Missouri 12.7% 5. Nebraska 12.6% 5. South Dakota 12.6% 6. Kansas 12.5% 6. Rhode Island 12.5% 7. Oklahoma 12.3% 8. Maine 11.9% 9. Pennsylvania 11.8% 9. West Virginia 11.8% 10. Massachusetts 11.7%



Compiled from: The Elderly Population: Estimates
by County, 1976. DHEW #(OHDS)
78-20248.



RANK BY % OF TOTAL STATE POPULATION 65+, 1976


Figure 1






19


Systems Agency 1978:46). Also, Oklahoma's availability of nursing home beds is high. In 1977, Oklahoma had 80 beds per 1,000 population 65 and over, compared to the national figure of 62 beds per 1,000 population 65 and over (See Appendix 1).

The geographic distribution of Oklahoma's aged population is associated with urban and rural areas (Oklahoma Health Systems Agency 1978:25a). The two large urban areas of Oklahoma are Oklahoma City (Oklahoma County) and Tulsa (Tulsa County). Other rural counties in the state have significantly higher populations of people aged 65 and over (See Figure 2). Of all the 66 counties in Oklahoma, Marshall County has one of the highest aged populations. It is in Marshall County that Pecan Grove Manor is situated (See Figure 2).

As a population ages, the prevalence of chronic noninfectious disease increases. The epidemiologic profile of Pecan Grove Manor patients is characterized by a high prevalence of such diseases (See Appendix 2). Of all the disease entries in Appendix 2, arthritis has the highest prevalence rate (See Appendix 3). When the diseases at Pecan Grove Manor are collapsed into categories used by the Merck Manual, cardiovascular, neurologic, psychiatric, and musculoskeletal/connective tissue diseases are by far the most prevalent (See Appendix 4).

The patient population at Pecan Grove Manor is primarily female (70% female, 30% male) and the average age is















State of Oklahoma


Tulsa County
9.9%


Oklahoma County
9.9%











Marshall County 20.6% PERCENT OF POPULATION 65+ BY SELECTED COUNTY
Figure 2






21


70. A population pyramid of the patients shows the greater percentage of female patients to male patients begins in the seventh decade and persists through the ninth decade (See Appendix 5). The predominance of women is still preserved when staff is included in a Pecan Grove Manor patient/staff population pyramid. Thus, when considering the patient and staff populations, Pecan Grove Manor nursing home is predominantly female and middle-aged (average age of patients and staff is 51.7 years).

The patient population is divided into three physically and conceptually distinct units based on degree of debility. Pecan Grove Manor is essentially three nursing homes in one. The configuration of the physical plant is based on "wings" radiating from a core containing the lobby, dining room, nurses' station, and administrative office (See Figure 3). Assignment to a wing is based on one's level of debility and thus the type of nursing care required.

General observations give the impression that each wing is characterized by distinctly different disease entities. The level of care required on each wing would appear to be a function of progressively more serious disease types. However, disease distribution throughout the nursing home is even. Wing assignment is not related to the roster of diseases found on the patients' charts.

Four factors are related to wing assignment and do not require physician assessment or orders in patient charts. At admission, the prospective patient is assessed by the






















SOUTH WING LOBBY NORTH WING Intermediate Care Heavy Care







PECAN GROVE MANOR Figure 3

,~
<% /'. A ov \,






23


R.N. and/or assistant administrator according to continence, ambulation, location of meal-taking, and ability to feed one's self. These four patient-management factors determine wing assignment.

The wings at Pecan Grove Manor are called by the

cardinal direction with which they most closely.align (See Figure 3). The North Wing is closest to the nurses' station, personnel, medications and medical equipment. Those patients on the North Wing are most likely incontinent, nonambulatory, eat meals in their rooms and must be fed. The diseases found on this wing are the same found throughout the nursing home but the degree of debility is greatest here. The efficiency of care delivery is enhanced by the proximity of the nurses' station to the wing requiring the most patient care.

At the other extreme, the East Wing houses people who are most likely to be continent, ambulatory, dining room users, and self-feeders. This wing is furthest from the main nurses' station. Seldom are call lights used on this wing. In fact, patients desiring "prn" (i.e., as often as needed) medications typically walk from their rooms to the nurses' station to make such a request.

The South Wing represents an intermediate transition between the "heavy care" and "light care" wings. Here the ambulatory, dining room users who feed themselves are moderately represented relative to the other wings.






24


However, incontinence is highest on this wing. This is due to ambulatory patients with urinary incontinence and nocturnal-only urinary incontinence.

In summary, patient-management strategies are less

related to specific disease categories and more related to level of debility as indirectly reflected by degree of continence, ambulation, ability to feed one's self and location of meal-taking (See Appendix 6). In this way, Pecan Grove Manor becomes three nursing homes in one. The patients, staff, and visitors learn and are affected by the design of patient-management and the physical environment.









CHAPTER FOUR
ENVIRONMENTAL SETTING


The physical plant of Pecan Grove Manor comprises a

setting in which patients and nonpatients engage in activities for significant parts of their lives. For patients particularly, the physical plant represents the environment which they must negotiate in order to interact with others, get medicines, eat, and otherwise live their lives. The staff, too, must perform within the confines of the building. Staff activities often center about getting from one patient to another which actually means one location to another. Thus, the configuration of the physical plant has the potential to "coerce" certain behaviors from its inhabitants (Sommer 1969).

Consideration for the environment as an influential

component of human societal existence has a lengthy tradition in anthropology. Perhaps the cataloging of "exotic" food items, shelters, medicines, rituals, etc.,required at least a superficial treatment of the environment as the matrix from which these "goods" were extracted. As environment became a more central issue in social science, human ecology emerged as the descriptive study of the adjustment of human populations to the conditions of their respective physical environments" (Hawley 1944:404). Later, anthropology took account of environment from the cultural ecological perspective of the interactive physical and cultural environments (Steward 1955).


25






26

Of specific importance here is a special type of environment known as an institution. Goffman's (1960) analysis of "total institutions" underscores the oppressive nature of the "inmates'" lives in a heavily controlled habitat. While prisons or mental hospitals may be characteristic of total institutions, many nursing homes, and particularly Pecan Grove Manor, are not.

Bennett and Nahemow (1965) have developed a system of ranking an institutional facility according to its degree of institutional totality. Their perspective maintains that a nursing home represents a significantly different living environment compared to independent community life and that while a nursing home may approach the total institution, it often falls short of this extreme.

To assess Pecan Grove Manor along a continuum of institutional totality requires a review of the environmental setting encountered by patients and staff. The building is comprised of three corridors attached to an open square room (See Figure 3). Corridor architecture seems to characterize the physical plant of many institutional facilities (Beckman 1971; Bennett and Eisdorfer 1975; Gubrium 1975; Koncelik 1976). Butler (1975) even refers to the "motel-like" appearance of many nursing homes.1

The corridor design of Pecan Grove Manor departs from the motel image in that all corridors are lined with handrails. The rail-lined corridor is the distinctive feature of many nursing home environments. Acute-care hospitals may






27

have handrails, but usually only in physical therapy areas, and residential homes are devoid of such devices. While hospitals share with nursing homes items such as bedrails, bedpans, stethescopes, and white uniforms, and private residences share with nursing homes things such as personal furniture, patios, and bathrooms, the continuous rail-lined corridor is to be found not in the hospital or private residence, but only in the nursing home.

The handrail is both a metaphor and artifact of geriatric institutional life. As the banister- of a staircase implies that use of the stairs is a risk, handrails in a nursing home are prominent visual symbols of people whose lives are at risk. Still, the handrail remains a needed prosthesis and is thus a medical artifact supportive of those people with diminished strength or poor balance.

The rail-lined corridor is public space. Activity in the corridor is always simple locomotion from point A to point B. Use of the corridor as a public pathway places one on display to all those within seeing distance. Thus, one's abilities or disabilities become community knowledge.

Each of Pecan Grove Manor's three corridors lead to the main lobby area. The lobby is intended to serve as a central location for patient interaction and activities. Here are found vending machines, a color television, magazines, a piano, and numerous chairs, couches and rockers. In spite of these various attractions, the lobby at Pecan Grove Manor is an area of little person-to-person interaction.





28


Observations in other nursing homes disclose a similar lack of use:

In the current state of the art of building of nursing homes, lounges
must be regarded as the single greatest failure as a concept. Typical
lounges are the result of regulations
which specify that so many square feet must be devoted to lounge space on the basis of number of beds. This device
usually results in one or more very
large areas devoted to socialization,
relaxation, and contemplation, but not
really accomodating any of these
activities. (Koncelik 1976)

In one corner of the main lobby is the color television set. The television area is marked by sectional vinylcovered couches facing the television and situated about 4 to 10 feet from the screen. While it is common to see patients sitting on these couches, seldom is anyone actually engaged in watching some program. Often patients fall asleep sitting up or seem to welcome any distraction (such as conversation with the researcher, an aide, a phone call, etc.). In one instance, the volume control on the color television broke, leaving video without audio. The office personnel placed a small black-and-white portable television next to the color set to use for the audio portion of programs. After a few minutes a patient changed channels on the soundless color set. The picture on the color television never matched the sound on the black-andwhite set for the remainder of the day. Still, patients came to the television area, sat or slept, and then left, never noticing the video/audio mismatch.






29

Several factors relate to the television area's inability to actually engage the potential viewer. Sensory deficiencies may make seeing the screen and hearing the sound difficult, particularly in a heavy-traffic area such as the lobby (cf. Koncelik 1976:53). At times, when the television sound is loud, nurses' aides lower the volume or as soon as no one is in the television area, turn the set off.

Also, many patients have personal televisions in their rooms complete with cable service. The television area serves, too, as a brief rest-stop on the way to the dining room. When food trays are served, the television area is immediately vacated.

Interaction among patients in the lobby is further inhibited by the arrangement of chairs and couches. The chairs and couches represent long lines of seating which occasionally meet at right angles. For persons with decreased sensory sensation and physical mobility, sitting in lines of seats facing directly ahead requires difficult bodily contortions to enable each person to twist to see and hear the other. The degree of difficulty posed by these communication obstacles is such that little interaction takes place while seated in the lobby (cf. Koncelik 1976:53; Sommer 1970:26-29).

The vending machines (soft drinks, potato chips, nuts, candy, cigarettes) are located along a wall away from activity areas. In contemporary American culture, the






30

media promote snack-type foods as vehicles which fuel social interaction and cement social ties. Nonetheless, the vending machines do not have chairs or tables clustered nearby to take advantage of the Madison Avenue promotion for food/love--love/food orientations.

Thus, the main lobby fails as an arena of lively

patient interaction in daily use. The only times at which the main lobby becomes the location of significant interaction are those of cyclical ritual events staged by the nursing home staff and/or community. These events include weekly religious services, civil/religious ceremonies (Independence Day, Mothers' Day, Memorial Day), and JudeoChristian celebrations (Christmas, Easter).

The main lobby does, however, produce an impression of a spacious "homey" atmosphere. The institutional nature of Pecan Grove Manor is masked by residential-type furniture, carpeted areas, and soft pastel wall colors. There also are planters with green plants and decorative wooden support posts with wood-shake shingles fronting the nurses' station. Lighting is primarily by recessed neon bulbs, but even so, table lamps are present in the lobby. Overall, the lobby generates in the observer a positive feeling about the nursing home as a whole.

Certain areas of public space seem to be conducive to interaction due to some accidental configuration of design elements. Adjacent to the main lobby is a zone which serves as the main entrance to the nursing home. The entrance area is a natural, unplanned interaction zone.






31

The main-entrance area promotes patient interaction by its position as a vantage point for observing the daily events within the nursing home. Other observers likewise cite entrance areas as natural vantage points (Gubrium 1975:10; Koncelik 1976:52; Sommer 1970:34). Sitting in the chairs or area near the chairs facing the entrance doors, one can see through the glass doors and adjacent glass panels to the parking area and the nearby highway. This view allows for monitoring the travels of patients, visitors, and staff. Also within sight is the nursing home business office with its attendant activities. Looking to one side offers the view of the entire ambulatory corridor. Patients move within in the corridor frequently for visiting, medicines, food, and exercise. Looking to the other side affords a comprehensive view of the main lobby, dining room and nurses' station. For those patients whose mental abilities permit, the entrance area provides a good allaround location for gathering information about the daily events of nursing home life.

The entrance area is also marked by its function as a communication center. Here is found a phone for patients to use, a large monthly-activities and events calendar, and a major-event bulletin board. This area also is marked by many color photographs of past parties. Live plants are also here along with craft displays.

The entrance also attracts interaction due to its midpoint location between the ambulatory corridor and the






32

lobby/dining room/nurses' station cluster. Traffic in either direction can, for convenience or necessity, stop here to rest, observe and talk.

Social interaction is thus promoted in the entrance area by numerous coincidental features. Seating in this area is limited, however, and most users are those who have retained higher levels of functioning. This part of the nursing home physical environment serves as a central location for patients to learn of various activities occurring in "their" building and to exchange information which is then diffused to the other corridors of the physical plant.

Floor space area, whether lobby, entrance, or patient rooms, is determined by formulas based on the number of patients housed. The main lobby fulfilled the space requirements for the first thirty-bed unit and the second addition of another thirty beds. When continued construction added an additional thirty beds, however, additional lobby space had to be built. This new lobby area is at the end of the ambulatory corridor. In this new lobby, about one-third the size of the main lobby, most intrainstitutional activities occur.

Intrainstitutional activities include weekly bingo games, activities such as singing and craft work, daily domino games, and other patient/family activities such as private parties. The new lobby area also serves as a place for large groups of visitors to see their relatives.






33

One final area of public space to consider is the

dining room. While most other biological needs can be met in the patient rooms, eating in the dining room is considered- indicative of a relatively high level of functioning. The administrative and nursing staffs encourage dining room use for the change of scenery and social interaction. Even so, seating placement is fixed so that forgetful patients will not be so easily confused.

The dining room, like the lobby, is a place of very

little social interaction. Meals are brought to the tables by the kitchen staff on large fiberglass trays. In an effort to serve the food hot or cold, and to satisfy hungry patients, great haste is made in getting food trays to the tables. One result is that the kitchen staff has little time to exchange pleasantries with the patients at the tables.

Other obstacles to interaction at mealtime are related' to sensory deficiencies in the patients. The hearingimpaired patient has difficulty understanding another from across the table. Impaired vision may further hamper communication by disallowing lip-reading. Additionally, the kitchen is adjacent to the dining room where a very loud dishwasher operates during meals (cf. Koncelik 1976:54). Thus, food service responsibilities, sensory deficiencies, and environmental noise function to inhibit mealtime interaction.






34

While the lobbies and entrance area are zones of

public space, there are zones of private space. The private space areas are those controlled by the nursing and administrative staffs. At the nurses' station can be found the R.N. (i.e., registered nurse), L.P.N.s (i.e., licensed practical nurses), patient charts, and medications. The area behind the nurses' station marks the private space for staff only. Here the nursing staff can work on charts or medications with minimal patient contact. The privacy of this zone enables the nursing staff to exchange medical information as well as gossip about patients, other staff members, or their community lives.

The nursing staff also converts part of the public

dining area to private space for breaks and staff mealtime. The "break table" functions to channel news throughout the corridors to the nurses' aides. Thus, aides assigned elsewhere can review important interactions to which they were not witness.

While all staff members spend many hours of each day

within Pecan Grove Manor, only the patients live the entirety of their remaining lives in the institutional environment. Most of this time is spent inside their rooms. An empty room would look much the same as any other throughout the nursing home. However, each wing has its own distinc-. tive atmosphere when filled with patients and their belongings.






35

The three-winged configuration of Pecan Grove Manor has been used to assign patients to a particular wing not based on specific disease entities but rather on a subjective assessment of individual debility. Assignment protocol has led to describing the wings by level of care needed and has resulted in clustering of physical capacities (See Appendix 6). Likewise, the artifacts in patient rooms reflect the level of debility of those living there.

The North Wing, or "heavy care" wing, houses those

patients with the greatest physical and mental difficulty. An artifactual inventory of these rooms discloses a general paucity of personal belongings, residential furniture, photographs, wall decorations and personal televisions. It is here that the greatest number of restraining "halfdoors" are found (See Figure 4). These patient rooms most closely fit expectations of an institutional environment (See Figure 5).

The South Wing, of "intermediate care" wing, is characterized by a mid-range level of debility relative to other patients at Pecan Grove Manor. The patient rooms are relatively well-adorned with personal memorabilia but residential furniture and personal linens and appliances are scarce. Televisions are in greater evidence but not universal.

The East Wing, or "light care" wing (also "ambulatory wing"), reflects the relatively high level of functioning retained by these patients. In this wing, the greatest







36

































I jl




r4
.I-
~ k~S En












































FIGURE 5

PATIENT ROOM--HEAVY CARE CORRIDOR





38


number of personal belongings, residential furniture, hand crafts, and television sets are found. A television set is present in every patient's room and occasionally one room has two televisions (See Figure 6).

Those patients with high levels of functioning are fully aware of the wing--debility relationship. The nursing staff on occasion may "threaten" an ambulatory-wing patient into some behavior (typically some type of self health-care action) by simply mentioning the likelihood of being moved to the intermediate care wing. Other similar coercions exist, always with the power of the "threat" directed at movement toward the least desirable wing. There is very little voluntary contact with the heavy-care wing patients by members of the other wings, and the heavycare wing is referred to as "over on North where those pitiful people are" (cf. Gubrium 1975: 16, 26). Thus, wing assignment is a metaphor of one's functional capacity and proximity to death.

Establishment of one's position within the wing--debility system is decided at admission by the R.N. and/or the assistant administrator. Room availability may also influence the initial wing assignment. Regardless of actual placement, the cognitive map of relating to the entire experience of living and dying at Pecan Grove Manor is one of initial admission to the ambulatory wing with a highlevel functional capacity, followed by physical and mental decline resulting in a move to the intermediate wing. From











































FIGURE 6

PATIENT ROOM--AMBULATORY WING






40


here, further decline is experienced necessitating a move to the heavy-care wing with the other "pitiful people," "poor things," and "crazy ones." Even within this wing, a final move through space signals impending death. The dying are moved to Room #1 North due to its proximity to the nurses' station. From here, the final move is final. The patient, then, learns to use this "cosmology" as a grid upon which to maintain a constant fix on his or her date with death.

The experience of Pecan Grove Manor seems to be characteristic of American institutional settings for the aged. Pecan Grove Manor as an institution conforms generally to Bennett's medium level of institutional totality (Bennett and Nahemow 1965:47). However, Pecan Grove Manor's three sections have certain institutional characteristics in common but also each wing requires its own special treatment. Institutional characteristics common to all wings range from high to low levels of institutional totality. For example, the nursing home as a whole is a permanent residence (high level), socialization of new members is informal (medium level), and there exists no objective sanction system (low level).

Again, using Bennett and Nahemow's (1965:47) scheme, the heavy-care wing has seven of ten criteria commensurate with a high level of institutional totality. The mediumcare wing has only three of ten high-level characteristics, while the light-care wing has only one, that of permanence. With regard to a medium level of institutional totality, the






41

heavy-care wing has only one matching item, the intermediate-care wing has seven out of ten matches. The low totality category has all three wings assigned to just one item--- no objective sanctions. Overall, Pecan Grove Manor can be characterized as an institution with a medium level of totality. In this setting, patients play out their daily life cycles in association with sets of employees hired to assist and monitor this final phase of existence.






42


Note


. In fact, on the 11 PM to 7 IAM shift one night several
years ago, the aides and myself were surprised to
see a car drive from the highway into the nursing home parking lot. A man came into the nursing home, walked
across the lobby to the nurses' station and asked
for a room for the night.









CHAPTER FIVE
THE DAILY CYCLE: RITUALS OF FABRICATED LIFE


Pecan Grove Manor is a society of elders experiencing life at imminent risk of death while their progress toward this end is monitored by paid attendants. However, the American propensity for denial of death demands illusion to mask the cultural apparatus of lingering death. This stance is like the mesmerizing qualities of the magician's slight-of-hand that allows transcendence beyond the plane of mundane experience into the mystifying realm of reality denied. Thus, the functional reality of the nursing home is obscured by a daily series of rituals fabricating the illusion of meaningfully transacted life.

The critical elements of nursing home life involve

a triad of patients, nurses' aides, and care-giving patterns associated with chronic debilitating disease necessitating long-term care. Interactional exchanges between nurses' aides and patients are characterized by daily, intensive contact with each other. In this environment of long-term exposure to patients, the nurses' aides, though generally untrained, become highly sensitized to patients' typical behavioral patterns and ultimately become diviners of exacerbated illness episodes who may treat or report their findings to licensed nursing personnel who then carry out a treatment protocol. Also, patients are able to manipulate their hosts by exploiting informal mechanisms of social control and identifying resources within the nursing home 43






44


community to assist them in negotiating institutional life and chronic disease.

The inner workings of nursing homes have been examined from a variety of perspectives, each with its own version of reality and degree of quality. Social critics have long accused the nursing home industry of being charlatans. Consider these titles: Tender Loving Greed (Mendelson 1974), Old Age: The Last Segregation (Townsend 1971), Where They Go to Die: The Tragedy of America's Aged (Garvin and Burger 1968), and Too Old, Too Sick, Too Bad (Moss and Halamandaris 1977).

Another category of nursing home speculators involves the experienced administrator teaching others to be administrators. These works are characterized by manipulative marketing techniques designed to promote a nursing home (Bachner 1974) and "how to" instructions detailing how to do to patients and families (Rogers 1971; Miller 1969). Other administratively oriented volumes attempt to be more therapeutically oriented (McQullan 1974; Kramer and Kramer 1976).

A shift in orientation of perspective is observed as the authors of works examining nursing homes are identifiable as social scientists. The content of such volumes tends to be oriented toward an analytical view of the inner workings of nursing home living and ideas regarding the quality of life of the inmates. Some comprehensive volumes include Long-Term Care (Sherwood 1975), Long-Term Care of Older People (Brody 1977), Last Home for the Aged (Tobin






45


Lieberman 1976), and Better Homes for the Old (Manard, Woehle, and Heilman 1977).

An irony of expositions regarding aging and particularly aging in an institutional environment is that these research efforts are done by young and middle-aged people. It would seem especially uncommon for a nursing home patient to do and publish research on his or her own setting. It is here that the benefit of the anthropological data-gathering method of participation coupled with systematic observations and recording are highlighted. While one may never become a member of another reality, participant-observation enhances the depth of understanding and communication between the researcher and the community of study. In this research project, I was able to not only observe and record daily events, but also participate to the extent of being a confidant of patients, a part-time paid employee of the nursing home, a participant of civil/religious in-house events, a cultural broker for new patients and families, and a paid speaker for the state-wide nursing home association. Thus, not only did I observe the daily cycle, but was actually an agent in the fabrication of life.

The participants in communities undergo communityspecific socialization processes known as rituals of incorporation which are further reinforced on occasion by rituals of solidarity. The objects of this socialization process are the people of the community. In order to properly fabricate life in Pecan Grove Manor, the daily






46

participants must be identified, their roles defined and assigned, and then this system put into action.

The members of this community can be classed into two general categories: managerial and target populations. The managerial group consists of the hierarchy of all paid staff groups and the target group consists of patients and their families. Implicit in this scheme is an interactional orientation characterized by managerial groups acting on target groups. The components of primary importance here are the nurses' aides as a managerial subgroup and the patients as a target subgroup, due to the enormous amount of time these two groups of people spend together engaged in fabricating rituals of life.

The incorporation of nurses' aides into the ethics of

the nursing home staff involves formal and informal socialization. Formally, the new aide is taught how to ideally behave in a meeting with the R.N. during which the patient is identified as most important and the administrator (i.e., boss) as least important. Even a document indicating the assimilation of this scheme is signed by the new nurses' aide and filed in her employment folder.

The informal socialization of the new nurses' aide filters down from the administrator and is based on the perceived expectations of patients, their families, and government inspectors. A common phrase which circulates among the administration at Pecan Grove Manor characterizes the perception of the typical nurses' aide: "fat, white,






47


and forty." In fact, this phrase is fairly accurate. Most of the nurses' aides have not graduated from high school, are married or divorced, have children, have a history of working at a variety of semiskilled jobs, and are overweight, white and middle-aged. Two other local industries predominate in the same town as Pecan Grove Manor. These industries, the manufacture of horse trailers and the assembly of trousers, hire at minimum wage and offer assembly-line type tasks. Employment at Pecan Grove Manor is perceived by many as a coup because one works in a higher-status setting with humanitarian goals and still is paid the federal minimum wage.

The administration, however, is confronted with a

special task. While local women may aspire to employment at Pecan Grove Manor, once there, a transformation from a view of job goals as repetitive, quick action on inanimate objects to a view of job goals as repetitive, quick action on animate objects is required. The value of assembly line efficiency is retained, but there is a shift from machine to human as the task target.

The administrator of Pecan Grove Manor fosters a pseudo mother/child interactional orientation between nurses' aides and patients. The effort is to anthropomorphize the targets of the aides' responsibilities. The mother/child perspective also makes use of roles familiar to the new nurses' aide employee who typically has no professional training and a meager repertoire of roles on which






48

to base her behavior in a nursing home setting. There exist many symbols to excite the mother role or "mothering": helplessness, toddling, incontinence, beds with bars, diapers, etc. By focusing on the mother/child interactional pattern, a maximum level of care behavior is extracted from the untrained, low-level nurses' aide.

The mother/child role relationship is expressed in a variety of ways. The infantilization of the adult patient can be observed in child-like words for excrement ("shooshoo," "wee-wee") and diapers ("didees"). One instance I observed demonstrated the nursing staff need to persist in infantilizing the patient. A nurse was examining a male patient with a distended lower abdomen. The man had a history of prostatitis. The nurse used "pee" and "make water" while the patient used "urinate" and "catch a specimen. "

Other expressions of infantilization are more completely explicit than referring to patients as "baby," "little one," or "little people." Consider these phrases:

.. just wash them like I would
one of my own children, 'cause that's
just what they are."

"I've got twelve kids and so I'm well
suited to this job."

"Like babies, they get good and warm
and they pee up a storm."

"I think of these people as my babies,
especially the ones on North Wing
because they are so helpless."

"They're like children. They are there
for us to spoil."






49


"They are like children and that's
the way I treat them."

While promotion of the mother/child role behavior may function to enhance care-giving and to animate the patients conceptually, there are also costs that accrue. For example, acting as a mother toward a patient will elicit the appropriate dyadic response of a child. Adult-to-adult interaction is thus retarded.

Particularly lacking is adult/adult interaction among

male patients and the female nursing staff. I found the men thirsty for "man" talk. Male patients were the most animated in their conversations when I sought advice about proper carburetion on a lawn mower, inquired about hunting, fishing, and trapping exploits, asked about farming or ranching and other "male domains." Conversational topics of this nature were absent during nurse/male patient interactions. Self-generated conversation of this nature was not common among the men due to daily familiarity of the members and possible exhaustion of topics. My presence and questions produced high-energy conversations due to my newness to the nursing home, and my continual contact with the non-nursing home community, and a perception of selfworth in that they were being asked to share a part of their past role experiences with a younger man.

Administrative influence on nurses' aides is seen

again in the distribution of the nursing staff in task and wing assignment. Staffing of each wing varies according to






50


the level of care needed and shift time. For instance, federal regulations require one nursing staff member per each ten patients on day shift (6 AM to 2:30 PM), one nursing staff member per each twenty patients on evening shift (2:30 PM to 11 PM) and one nursing staff member per each twenty-five patients on night shift (11 PM to 6:30 AM). Since Pecan Grove Manor is designed to accomodate ninety patients, the day shift has eight nurses' aides and one L.P.N., the evening shift has five aides and one L.P.N., and the night shift has three aides and one L.P.N.

The distribution of aides by shift is based on level of care needed on each wing. Patients, visitors, office staff, and thus nurses' aides are the most active during the day shift. Day shift nursing staff is the most differentiated. The heavy-care wing has four aides, the intermediatecare wing has three aides, and the ambulatory wing has one aide who, during part of the day shift, helps with baths and food delivery. The majority of the day shift she spends dividing her time between the other wings.

The day shift begins officially at 6:00 AM, but day

shift aides have informally assembled in the lobby near the nurses' station for casual socializing ranging from 5:15 AM until shift report. Pre-shift conversations are typically about personal community life. Only if something unusual regarding a patient has occurred is the topic of the nursing home related.






51

Shift report begins about 5:50-5:55 AM. The day shift aides move to the nurses' station, having been summoned by the charge nurse (an L.P.N.) to review as listeners the events of the night seen as significant. The content of the shift report includes three topics: medications given, assessments made (e.g., vital signs), and unusual illness or mood changes.

Most shift-report information is useless to the nurses' aide. Medications given are read by name of drug, amount given and to whom it was given. After report, none of the aides were ever able to tell me what the medications were for or why they were given, with the exception of two tranquilizers, Thorazine and Sparine ("to keep them quiet"), Valium ("nerve pills"), and nitroglycerin ("heart pills"). Vital signs were seen as significant only if unusually exaggerated and emphasized by the charge nurse reading the report.

Shift-report information that elicited response from the nurses' aides was the mention of laxatives (often read as "milk of mag"), falls, escapes, and rowdiness. Laxatives and behavior problems mean work for the aides. Reports of laxatives being given were met with such remarks as "Oh, no!," "We'll be busy today!," and "They don't need any laxatives!"

In spite of the selective use of shift-report information, the entire previous-shift nursing activities were always reported. Rather than functionless ritualism,






52


however, shift-report serves an important purpose. It marks a transition from mundane conversations and concerns current moments before, toward inspiring awe and respect for the medical and humanitarian tasks ahead. As one aide put it while making a bed, "I've always wanted to be in the world of medicine."

The duties of the nurses' aides are seen in the most complete form on the day shift on the heavy-care wing. A typical routine for four nurses' aides is presented in Figure 7. This daily shift routine collapses into seven main task categories plus miscellaneous ones (See Figure 8).

The tasks requiring the most time per shift are feeding, bed check, and showers. Feeding is time-consuming in that on the heavy-care wing, 88% of the patients eat in their rooms and of these, 24% require feeding by an aide.

At lunchtime, for example, there are four nurses'

aides who pour milk and tea for each patient, place them on the trays, and take the trays to the patients. After all trays have been distributed, the four aides feed the eight patients who cannot otherwise eat. For the nurses' aides there are "feeders" (i.e., a patient requiring feeding) who are more desirable than others. Desirable features include a room furniture arrangement allowing (read: requiring) the aide to sit while feeding, a patient who does not choke, drool or otherwise "cause problems," and a patient who eats rapidly. Thus, following tray distribution, a silent race ensues among the aides to acquire the most desirable feeders.






53



ACTIVITY TIME .. .... Lights on 05:57 AM Linens 05:58 06:06 AM Get patients up 06:06 06:28 AM Make beds 06:28 06:54 AM Breakfast 06:54 08:07 AM Bed Check (2 aides) 08:07 10:10 AM Showers (2 aides) 08:07 10:55 AM Shaving 10:10 10:33 AM Break 10:35 10:50 AM Shaving 10:50 11:37 AM Lunch 11:37 12:58 PM Put patients to bed 01:00 01:40 PM Rinse dirty linens 01:40 01:47 PM Aides' lunch 01:47 02:17 PM Shaving 02:17 02:25 PM Talk, fix sink 02:25 02:30 PM





NURSES' AIDE TASK-TIME ACTIVITY

5 May 1978

(FOUR AIDES EXCEPT WHERE NOTED) Figure 7






54



ACTIVITY TIME DURATION

Patients up, down, or cleaning 1 hour 02 minutes Food service 2 hours 22 minutes Bed check, make beds, clean beds 2 hours 29 minutes Shaving 1 hour 18 minutes Break, Lunch 45 minutes Linen 08 minutes Showers 2 hours 48 minutes Miscellaneous (rinse dirty linen,
fix the sink) 12 minutes



8 hours 16 minutes*


*For those nurses' aides who don't give the showers.








NURSES' AIDE TASK-TIME CATEGORIES

5 May 1978


Figure 8






55


When I began working as a paid nurses' aide, the first striking discovery I made was that each aide has memorized a large array of personal habits of each patient that rendered their service to the patient more personal and timeefficient (cf. Taylor 1970). For instance, the placement of a juice glass on the left side of a breakfast tray for one person renders the glass more visible and accessible, two packages of sugar for one person, three for another, no napkin for that person because they eat paper, etc., is required for proper job performance. The catalog of individual patient wants is enormous and generally fulfilled. Only lengthy, daily contact would make such a feat possible.

This same intimate knowledge of patients is observed in noting behavioral change that may be of medical consequence. Actual hands-on contact with patients such as feeding, bathing, clothing, changing diapers and bed linens, provides the nurses' aide with another set of information. The nurses' aide becomes aware by sheer repetition of patient-specific behavior patterns and potentials. Deviation from an expected set of behaviors warrants mention to a higher authority.

For example, Mr. Robert Henry (pseudonym) is a white male, 72 years old, bed-fast, diabetic, paralyzed on his right side as a result of a cerebral vascular accident, incontinent and requires feeding. The position of Mr. Henry's bed is such that the nurses' aides continually feed him from one side of the bed. For weeks this was satisfactory until one morning a nurses' aide reported to the






56


other aides that Mr. Henry seemed to be drooling very slightly from the left corner of his mouth. I later fed Mr. Henry and found the report accurate. The loss of food from his mouth was slight enough so that only the staff who worked with this patient routinely day-in-and-day-out would recognize this as a potentially significant behavioral change. Without extensive awareness of Mr. Henry's behavior patterns, the drooling may have been attributed to his position in bed, soft diet, dislike of the menu, or as just another patient who drools. This change was reported to the R.N. as evidence of a minor stroke. The aide who reported the change later told the group that the R.N. attributed the change not to stroke, but to his medications which included large quantities of Thorazine. However, Mr. Henry's chart recorded no change in medications before or after the aide's report.

The nurses' aides, in spite of no medical training, are the most important health-care agents in Pecan Grove Manor. Their significance exists in their extensive contact with the patients. They may be able to identify an important change in a patient that the R.N. would be unable to do. The aide who notices some relevant change recounts her coup for several days until virtually all the staff is aware of it. Thus, the lack of training and low status of the nurses' aide is not necessarily a detriment to patient well-being.






57

Noticing slight changes in patients leads the nurses'

aides to engage in a variety of folk-diagnoses and prescriptions, for they"know what that patient needs." A frequent diagnosis is constipation. This does not require notification of the R.N. or laxatives unless symptoms persist. The symptoms are subtle ones such as patients who look like they are straining when they should be relaxed in bed, a patient exploring his anus with a somewhat determined facial expression, general foul mood, and deviation from expected time intervals of bowel movements.

If it is determined that the patient suffers from constipation, the cure is to remove a suspected lower rectal impaction. This involves a trip to the nurses' station (otherwise off-limits to the average aide) to get a surgical glove and some "K-Y" jelly. The patient is often positioned in front of a toilet in expectation of successful therapy. If an impaction is present and removed and the dilatage action promotes a bowel movement, or even if the blockage is up higher and not immediately relieved, the diagnosis and therapy still allows the nurses' aides a brief foray into "medicine" and some assurance for themselves that it will be some time before they have to change that patient's underwear or diaper.

Other folk-diagnoses made by nurses' aides revolve

about observed changes in the integument. Tasks assigned to the nurses' aides require seeing and touching the patients' skin. Feeding, bathing, cleaning incontinence and clothing






58

a patient provide ample opportunity for close, sustained contact with individual patients. This "hands-on" contact promotes situations in which the nurses' aides are the initial agents of health-care providing.

Abnormal body temperature is susceptible to nurses' aide detection. However, since all thermometers are kept at the nurses' station, the nurses' aide in a patient's room uses her bank of past experience with a patient to determine abnormal temperature. The ability to perceive fever by a nurses' aide requires long-term contact with each patient. Several reasons exist for this prerequisite. Each person has individual responses for body temperature adjustment, air temperature in each room is variable, blankets and clothing alter skin temperatures, and rubber draw sheets, plastic-covered mattresses, or plastic air-mattresses may be present which cause skin temperature increases. Thus, one person may typically sweat enough to thoroughly dampen bed linens while showing a normal temperature.

If a patient is suspected of having an abnormal body temperature, the nurses' aide goes to the nurses' station to get a sterile thermometer and "K-Y" jelly if rectal temperature is taken. Not only does this allow the nurses' aide to engage in "medical therapy" for a brief time, but it is a legitimate time-consumer away from the more mundane, "dirty work" which is the common lot of nurses' aides.

Integument changes are also noted for acute hypertension. Redness of the face is a primary symptom nurses'






59

aides use to diagnose hypertension. An aide who is trained to measure blood pressure goes to the nurses' station for a stethescope and syphgmomanometer. If hypertension is indicated, the nurses' aide will report it to the nurses' station with no report if the charge nurse is away or casually mentioned as a negative result to the charge nurse if present.

Perhaps the most important skin signs observed by the nurses' aides is the precondition leading to decubitus ulcers. Reddened skin, particularly in regions of bony prominences, is a signal of impending bedsores. Bedsores are particular problems for long-term care bed-patients and those who sit in wheelchairs or even lounge chairs for lengthy periods of time.

When reddened skin is noticed, it is desirable to

massage the local area with lotion. However, this simple preventive measure is infrequently used. The technique of simple massage lacks the paraphenalia which signals highlevel medical therapy. Also, lotions that are frequently used are purchased by the patient or the patient's family and are thus generally unavailable for even distribution throughout the patient population. As a result, decubitus ulcers are present.

The presence of decubitus ulcers is an embarrassment to the nursing staff. The nursing staff often blame the existence of decubitus ulcers on mismanagement of patients while they were away at a hospital. These hospital-genera-






60

ted bedsores are then transferred to the nursing home. While this may be true to some extent, bedsores likewise originate in the nursing home. Yet, the nursing dictum that "bedsores are totally preventable" seems to be overly optimistic. People who are kept alive for so long that they can't be handled because deep tears in the skin occur can hardly be expected to remain free of decubitus ulcers. Likewise, the comatose geriatric patient who is incontinent and fed by a naso-gastric tube represents another nearly impossible task in decubitus ulcer management. It remains true, however, that more effort is expended in bedsore management than prevention.

Also involved in the primacy of physical care is that it is expressed in physical activity. The busy aide is one who is moving. The charge nurse can look down the corridor and tell if the aides are actually working by the movement in and out of rooms. The aides assimilate this dogma rather completely and probably by transfer from other jobs. For instance, I noticed one nurses' aide leaning on a patient's bedrail and talking to the patient for about five minutes. Later, in response to my question of what she had been doing, I was told, "just foolin' around."

Physical orientation to patient care is further promoted by its observability, immediacy of results, and amenability to rapid dispensing. Thus, the nurses' aide can project the good-worker image not only by activity, but by the physical proof of duty performance within the time constraints of her shift.






61

Perhaps the task most associated with nurses' aides'

duties is "bed check." By federal regulation, all nonambulatory patients must be routinely checked for incontinence. Bed check thus consists of visual or physical inspection of incontinent patients. Soiled clothing, bed linens, bed frames and patients must be changed or cleaned.

Gubrium (1975) refers to this part of nurses' aides' duties as "bed and body" work. It is this task category that most undermines the patients' and nurses' aides' sense of propriety. Bed and body work peels away the cosmetics of one's daily "act" to reveal the "underside" of a lifetime of culturally appropriate impression management. The locked door that screens the toilet habits occurring in the American bathroom (cf. Miner 1956) is ripped from its hinges for both the patients and nurses' aides.

Bed check is considered the most mentally and physically taxing job task. One's performance here leads to peer ranking along a continuum of good to bad. The stresses involved for aides and patients in bed check are immense and are expressed in the following vignette from my participation and observation:

"Now you're really gonna get broken in,"
the female nurses' aide told me as I
approached Mr. Joe Green's (pseudonym)
room. Mr. Green lay in his nursing home
bed in a near-visible order of incontinence. He is a diabetic, an alcoholic,
an amputee, a hemiplegic from an old
cardiovascular accident, is non-ambulatory and generally considered to be illtempered. As he lies in bed, Mr. Green
often hollers as if sharp pains momen-






62


tarily seize him.
Mr. Green lay on his back, his head on pillows and the stump of his left leg (amputated at the distal end of the femur) supported on pillows. A plastic urinal is left between his legs with his penis positioned inside. The first task of the aide is to empty the urinal. Sometimes the glans rests on the side of the dry urinal, other times it is submerged in urine. In either case, the urinal is removed by moving it away from the body. As the penis exits the urinal, it drags along the inside surface of the urinal eliciting a pained cry or a stream of expletives. Only once was it observed that an aide positioned Mr. Green's penis so that it didn't scrape against the surface of the urinal.
As Mr. Green is rolled toward the side of the bed, a liquid pool of feces becomes visible and is filled with recognizable bits of food. The aide nearly vomits. The aide "lovingly" chastises Mr. Green and begins to clean him.
The buttocks are spread and the corner of a Chux protective panel is used to begin cleaning. After the majority of fecal matter is removed, washcloths are used to finish the job. Invariably, Mr. Green screams at the aides that they are hurting him as they clean the scrotum. Seldom does an aide attempt to touch the scrotum in an effort to expedite the ease and thoroughness of cleaning.
Occasionally, a shower is required
to clean Mr. Green from incontinence. In this instance, he may be wrapped in the bed sheets and placed in a shower chair to be rolled to the shower. At other times, when the floor and aides' shoes are not in such jeopardy, he is placed on the shower chair nude and then covered with a sheet preparatory to transport. At these times, he is apt to loudly complain that "you sat me on my nuts!" The aides generally scold him and try to reposition him.
Interaction with Mr. Green typically requires the services of three aides: two to lift and clean and one to hold Mr. Green's hands to prevent him from striking






63

those in reach. While Mr. Green is mentally alert, conversational, and
likes to talk about his former fishing days, conversation is directed toward Ir. Green's roommate who cannot speak at all. The roommate is 54 years old, mentally retarded, behaves in a childlike manner including delight with toys
and stuffed animals.

A number of stresses between patients and nurses' aides are expressed in the above interaction. Observing the procedures for cleaning incontinence or reading about it does little to reify the actual, hourly, daily experience.

At Pecan Grove Manor, the nurses' aide "must," from official administrative and nursing dictum, "love" all of the "little old people," do their jobs with great efficiency and above all, never, ever mistreat a patient. From a managerial perspective, expecting these superhuman qualities will not insure perfection of job performance, but will enhance the likelihood of good patient care. Acting out these exhortations with patients like Mr. Green is difficult.

In spite of admonishments and reports of "loving all these little old people," occasionally more honest statements emerged: "We love all of these little old people, but we love some more than others." Thus, the good patient/bad patient distinction commonly observed in other health care settings is found here, too (cf. Lorber, 1975; von Mering and Earley, 1966).

Mr. Green is considered a "bad" patient. Incontinence or other debility alone is not enough to warrant bad-patient status. These traits, however, can produce bad-patient






64

status in some combination with the following attributes: some degree of mental intactness, physical strength, speech, and vocal complaints.

Another obstacle to care results from sexual tabus. Only once did a nurses' aide touch Mr. Green's penis to facilitate exit from the urinal. Mr. Green's scrotum often was left with some fecal material on it due to imcomplete cleaning. Other male patients who were not circumcised never, in my observations, had the foreskin retracted for thorough cleaning of the glans. On the other hand, I was allowed to assist in toileting habits with a twenty-five year old, mentally retarded female except when she was menstruating.

Lastly, the nurses' aides minimized interaction with

Mr. Green by avoiding all but essential communications. Mr. Green's roommate, even though he was aphasic, was the recipient of generous amounts of conversation to which he would laugh, act shy, and make "goo-goo" noises, delighting the nurses' aides.

Is Mr. Green's case one of a difficult patient or a

difficult staff? I personally experienced working with Mr. Green very distasteful. He did smell, look, and act badly. However, when I had the time to ask him about his life, he was responsive and I was surprised to find a rather complete, intact personality. This did not elicit in me a missionary zeal of saving this man's integrity. My willingness to talk with Mr. Green not only produced conversa-






65

tion but identified me as a resource (perhaps "easy mark" should be read) for him. Mr. Green would shout from his bed for me by name to give him a cigarette. A patient smoking in bed requires the aide to stay in the room and thus interferes with the work schedule. At times I would comply and at other times I was unable to do so due to work demands.

Actions other than physical care directed at patient involve efforts at promoting psychosocial support for the patient population. The psychosocial environment is expected to be fueled by that part of the nursing home life known as "activities." Activities at Pecan Grove Manor are frequent and of variable quality (See Figure 9). Three features of the ritual calendar deserve mention: (1) nurses' aides' interference, (2) lack of response measurement, and

(3) advertising.

The nurses' aides represent interference to effective activity programs, primarily with regard to the weekly secular in-house activities. For example, the "band" activity consists of the activities director assembling several patients in the east wing lobby to play various percussive instruments. She complained often that by the time she walked a few patients to the east lobby and went down the corridors to get others and walk them back to the lobby, the early arrivals had become bored and wandered off to different parts of the building. Efforts to enlist the assistance of nurses' aides were futile due to the aides'






66




CATEGORY OF PUBLIC INTRAINSTIEVENTS INVOLVEMENT TUTIONAL CYCLE Religious
Services X WEEKLY Special
Religious
Celebrations:

1. Christmas X ANNUAL 2. Easter X ANNUAL Civil/Religious
Celebrations:

1. Valentines Day X X ANNUAL 2. St. Patrick's Day X X ANNUAL 3. Mother's Day X ANNUAL 4. Father's Day X ANNUAL 5. 4th of July X ANNUAL 6. Halloween X ANNUAL 7. Thanksgiving X ANNUAL Secular Activities:

1. Birthdays X MONTHLY 2. Bingo X WEEKLY 3. Beauty Shop X WEEKLY 4. Crafts X WEEKLY 5. Remotivation X WEEKLY 6. Band ..... ...X .. WEEKLY


ACTIVITIES

Figure 9






67

insistence that they did not have time, or could not leave "the lights" unattended.

The beauty shop is an activity that sometimes becomes a spontaneous party, even attracting male patients and office workers to the door. One L.P.N. disliked the laughing and commotion in the beauty shop because it disrupted the sanctuary-like environment she considered proper. As she told me one day, she preferred to work on shifts in the evening and night hours because families were less present, most patients were asleep, and she could engage in "puredee quality nursing care." One of those involved in activities suggested that the nurses' aides disliked patients in the beauty shop in the afternoon hours because it prevented the aides from putting the patients to bed so the aides "wouldn't have anything to do."

Activities as therapy are suspect, too, because there are no assessments of improvements in patients attributable to the activity program. Benefits to patients may be slight subtle, or nonexistent, but no one knows for certain. The visibility of physical care benefits overshadows the relative invisibility of psychosocial improvement.

Activities in the religious and civil/religious categories are highly visible and receive great attention from the administrative, nursing, and activities staffs. Most important is Christmas and Mother's Day. For example, the Mother's Day celebration becomes a community competitive potlatch in which conspicuous consumption brings status to the nursing home from the community.






68

Mother's Day 1978 lasted about three hours. It cost

Pecan Grove Manor $897.30. Newspaper ads accounted for over $200. One nearly full-page ad outlined a "roaring '20's theme with a skit, play, snow-cone stand, and antique cars parked near the highway." A competing nursing home seven miles away countered with a smaller ad announcing a new gerontologist on staff and a "peaceful visitation on Mother's Day."

Pecan Grove Manor spent $85.50 on radio spots, $100

on a band, $94.90 on flowers, $137 on costumes, and $66.74 on photographs, and more on miscellaneous items. Relatives of patients, employees and townspeople totaled between 100 and 150 spectators. Patients, staff and visitors all appeared to enjoy themselves. Within a few weeks, reminiscing about the party had ceased.

One month before the Mother's Day event, a group of

patients were involved in an activity that they still mention over one year later. Nearby Pecan Grove Manor is a large lake with many recreational potentials. The activities director decided to arrange a fishing trip to a floating, enclosed fishing dock. The interior of the float is arranged so people can sit and fish in any type of weather. Complete services are available, ranging from a bait store and equipment rental, to a cafe.

Seven male patients were selected to go on this trip. Selection was based on level of debility, behavior, and an expressed desire to go. Three men from the community were






69

asked to help at the fishing site. They were expected to assist in baiting hooks, netting fish, and any other fishing-related tasks. They were invited to fish, too. The remainder of the party consisted of the activities director and myself.

Twelve people participated in the outing for a cost to the nursing home of $71.71. The five-hour event took place on a Tuesday from 9 AM to 2 PM. The activities director sent a small write-up to the local weekly newspaper as is commonly done with patient birthdays. Other than this, the community-at-large was uninvolved and unaware of the fishing trip.

The effect of the trip on the patients and the activities director was quite noticeable. Patients were ready to go and positioned at the entrance doors 30 to 40 minutes in advance. Although everyone was ready for a rest at the end of the trip, the patients asked when they could go again. The activities director considered possible ways to continue such trips by buying some small Zebco rods-and-reels and some fishing tackle. A member of the administrative staff cautioned that the group of people wanting to go would increase in size. Overall, I had never seen these particular men so animated prior to the trip or known of a special activity that engendered such a sustained level of excitement and anticipation of another trip.

Mother's Day and the fishing trip were both entered on government forms as activities. Nonetheless, each event






70

served different purposes which led to the retention or loss of the event. The Mother's Day events and other major productions are opportunities to symbolically, though indirectly, communicate to the public Pecan Grove Manor's solid concern for the welfare of their patients. The more visible and lavish this public event is, the more status is given to the nursing home, and its reputation is sustained or improved. Conversely, the fishing trip was a low visibility, inexpensive event affecting seven patients. There is great opportunity for quality psychosocial improvement (judging by change in their affective mood) and maintenance but little chance for status accruementto the nursing home. Mother's Day will continue to be celebrated annually as part of the major public potlatches. Over a year later, the fishing trip has not been repeated although the men participants still reminisce about it.

The overall orientation toward patients in Pecan Grove Manor is one of palliative care. The presence of the medical model is expressed in ritualistic monitoring of patient decline. No physical or occupational therapist is present. Although a fulltime R.N. is not required, Pecan Grove Manor boasts one who is present during part of the day shift, five to six days per week (however, on-call twenty-four hours daily), and functions primarily as a nursing staff administrator and token representative of "high level" medical status to attract and assuage patients and families. Other personnel involved in activities for patients supportive of






71


psychosocial maintenance report difficulty getting assistance from nurses' aides and a perceived low status with the hierarchy of service providers.

This milieu is not conducive to maximizing the remaining potentials of the patients. Unlike palliative care units in acute-care hospitals (cf. Buckingham, et al. 1976), this nursing home and likely most others, masks the nontherapeutic environment with a battery of rituals designed to create illusions of life for the patients, families, and staff.

It is clear that the patient career (cf. Roth 1963) is most directly influenced by that segment of the nursing staff known as the nurses' aides. The style of care-giving is one in which physical care is emphasized to the neglect of psychosocial care. Several reasons exist for this skewing. The nursing staff supervisors are trained in the traditional medical model as L.P.N.s or R.N.s. Their training emphasizes physical therapy with only a slight orientation toward psychosocial parameters. Federal inspection by Title 19 requirements clearly promotes and rewards medical action. For example, Pecan Grove Manor prides itself on having patient charts up-to-date meaning that all entries had been made on a daily basis, particularly daily remarks regarding each patient. "Charting" consumes the vast majority of the L.P.N.'s time. This practice becomes so perfunctory, however, that patients who are away visiting or in the hospital have been unintentionally charted as not only pre-






72


sent, but the recipient of "usual a.m. care" or "up and about; cheerful" (cf. Gubrium 1975). Still, the nursing home must meet the demands of federal government regulations.

The nurses' aide/patient/long-term care institutional environment operates collectively to produce a community of daily forced- interaction. The longevity of patient/nurses' aide interaction coupled with a mother-child interactional pattern leads to in-depth knowledge of patient behaviors. The nurses' aides being generally untrained, make use of their own physical senses and beliefs about health and disease to make decisions regarding therapeutic actions.

Psychosocial care is de-emphasized due to the pressures of fulfilling physical care needs. Most important, however, is the relative invisibility of psychosocial care procedures and benefits. Additionally, benefits that accrue are likely to be relatively gradual in appearance. Lastly, there is no staff member who is trained to be perceptive of the psychosocial environment, while conversely there are plenty of staff members who have received formal education in business management and medical-model nursing. These factors are reflected in the topics for in-service training (See Figure

10).

The foregoing material describes a social system oriented toward long-term palliative health care performed by unskilled nurses' aides on institutionalized aged patients. A number of tensions between aides and patients have been identified with resolution couched in an ambience of strategies particular to long-term care environment.










PHYSICAL CARE
SESSION GIVEN & PATIENT PSYCHOSOCIAL EVACUATION AND STAFF
BY MANAGEMENT ENVIRONMENT FIRE PROCEDURES SALARY TOTAL R.N. or L.P.N. 19 4 6 0 29




ANTHROPOLOGIST 0 4 0 0 4





ADMINISTRATORS 0 0 0 1 1





TOTALS 19 8 6 1 34



IN-SERVICE TRAINING TOPICS

March 1977 July 1978

Figure 10






74


Nurses' aides and patients alike have an enormously

difficult task. The patient career consists of pretending

to be socially functional while being totally expendable.

One is the victim of chronic disease and social circumstance. The nurses' aide, dressed in white, pretends to be

therapeutically functional while dispensing palliative care.

One is the victim of therapeutic expectation and incurable

disease. Thus, aides and patients engage in a variety of

rituals to fabricate a facsimile of life. In this way the

stark reality of chronic disease and old age can be partly

veiled.

Orientation toward patients at Pecan Grove Manor is

remarkably similar to Jules Henry's (1963:474) summary of

the humane Tower Nursing Home:

An effort to formulate a "national
character" for Tower yields the following: the staff, though animated by
solicitude and kindliness seems to
maintain an attitude of indulgent
superiority to the patients whom they
consider disoriented children, in need
of care, but whose confusion is to be brushed off, while their bodily needs
are assiduously looked after. Tower is
oriented toward body and not toward mind. The mind of the patients gets
in the way of the real business of the
institution, which is medical care, feeding, and asepsis. Anything rational
that the patient wants is given him as
quickly as possible in the brisk discharge of duty, and harsh words are rare.
At the same time the staff seems to have
minimal understanding of the mental
characteristics of an aged person.








CHAPTER SIX
THE PATIENT EXPERIENCE: THE NEXT BEST THING TO HOME


Perhaps the most direct route to the experiential

reality of patienthood in Pecan Grove Manor involves elicited response from the patients themselves. On a daily basis, the patients must negotiate the entire social system of Pecan Grove Manor. The exigencies of nursing home life that seemingly are "non-problems" to the staff, families, and researcher, in fact are real problems to the patients who must as resourcefully as possible manage their lives in this environment. Self-management in an institution becomes an exercise not in futility but in the identification and maximization of situationally-specific behavioral resources from a meager resource pool.

Nursing home life involves institutionally-imposed constraints. Nonetheless, there exists sufficient tolerance or "slack" in the formal normative system for behavioral flexibility or creativity to emerge. Thus, the patient population can be seen to experience oppressive external controls while simultaneously engaging in the creative extraction of self-benefiting behavioral procedures.

The capacity for ingenuity within a geriatric population is apparently a point of dispute. In one recent treatise on aging (Woodruff and Birren 1975), diametrically opposed statements are found:

The impression one gets from .
environments in which aged persons live as well as from that which is written to 75






76


describe such environments suggests
the existence of a simplistic notion
that man is infinitely adaptable. This
is surely an erroneous view of man.
Both common sense and empirical
data demonstrate that human adaptability is finite. (Schwartz 1975:289)

Old people are extremely adaptable.
Birren tells a story about an experience
he had while doing research on visual perception One of the volunteers for the project was a man of around 85
years old who was active in the home and
a leader in the activities there
He was well known by most of the residents
and well liked. When Birren tested this man for visual acuity he found that the old man was functionally blind. Birren
went to the nursing-home administrator
and asked if the administrator knew that
Mr. X was blind. The administrator
couldn't believe Birren. Observing the
old man's behavior very carefully,
Birren found that the man was always
accompanied by his wife, and she very subtly guided him and gave him cues so
that, although this man was functionally
blind, not even the nursing-home staff
were aware of it. This remarkable example
stresses the adaptability of old people.
(Woodruff 1975:190)

The assessment of patient resourcefulness involves direct

observation and questioning of the patient population.

Recently, assessments of personal nursing home living

experiences have found salient data not in sociodemographic

variables or in elaborate physiological workups but in

subjective perceptions of the inmates about their membership

in an institution (Noelker and Harel 1978). Therefore,

much important data about the sociocultural system comes

directly from the patients themselves.

Twenty-three patients at Pecan Grove Manor were

identified as mentally intact by my personal assessment and






77

their scoring on the Mental Status Questionnaire (Kahn, et al. 1960) at the time of interview. All but one were ambulatory. The term "resident" is often used in gerontological literature when referring to institutionalized people with the greatest amount of ability. However, in this community of elderly people, all of the non-staff are considered and called "patients." They are simply patients with a lesser dependence on help from the nurses' aides. Still, they are medicated, monitored, required to see a physician monthly, have call-lights in their rooms, and their bowel movements are daily charted. Their distinction from others lies within themselves. The fortuitous combination of relatively intact mental and locomotor function provides them with the ability to mobilize their resourceful capacities.

In anthropological terms, these people are best able to undergo the psychological, behavioral, and sometimes physical contortions of adjustment to a new environment. Over time, these adjustments become routinized as adaptive responses enabling the patient to maximize their chances of a successful "fit" within the community of which they are a part.

The purpose here is to examine the consequences of

adaptation to a nursing home environment by a subgroup of the patient population. All twenty-three patients responded to a structured interview. The average age of this sample is 82 years and 8 months with an average educational experi-





78


ence lasting seven-and-a-half years. Seven are males and sixteen are females. All of their respective spouses are dead. Prior to institutionalization, 74% lived alone, 22% lived with a relative, and 4% lived with a spouse. Members of this sample had an average of ten-and-a-half visitors per month (mostly by relatives) with the last visit fourand-a-half days before the time of interview. Room changes had occurred for 83% of them. Of these, the average number of changes approached two. They had lived at Pecan Grove Manor for an average of three years (upper range: eleven years; lower range: one month; mode: one year).

In all societies, environmental adaptations involve food procurement. In Pecan Grove Manor, prospective patients and their families are given information about dining that conveys a feeling of the greatest simplicity of getting food. There is a consultant dietician and a fulltime kitchen staff to provide complete food service three times daily. All the patient has to do is show up.

The patient, however, discovers otherwise. As with any new environment, there are certain ways to move efficiently to negotiate the system to maximize one's level of satisfaction. So it is with food procurement at Pecan Grove Manor.

The ambulatory dining-room patients have developed food procurement strategies. The kitchen staff's view is that they put the food out and all the patient has to do is come eat. However, the patients' plane of existence






79


differs from the kitchen staff in terms of corridor life and concepts of time and space. Thus, for the patient, nutrition requires special planning.

Meals are never served at exactly the same time. The variance ranges from fifteen to thirty minutes and is due to mundane human factors and differing preparation times for various foods. Meals are usually served between 11:30 A.M. and 12:00 Noon. Also, patient trays are distributed by rotating the starting place of distribution. If at breakfast the first trays were placed at the west end of the dining room, at lunch they will begin at the east end. Distribution time from one end to the other is about thirty minutes.

The patient's goal is to coincide his or her time of arrival at the assigned table with the arrival of the food tray. If timing is correct, hot food will be hot and cold food will be cold. Patients begin leaving their rooms from 11:15 A.M. to 11:30 A.M. to walk or roll to the lobby or entrance area. Here they sit, rest and sometimes talk with those nearby. At this "way station" patients continually glance toward the dining room which they can now see to notice the earliest activity from the kitchen. One signal used by many people is the appearance of a kitchen staff member who turns on the dining room light. Tray distribution begins at one end of the dining room. Those who sit at that end walk the now short distance to their






80


tray immediately. Those who sit at the opposite end typically wait until it is closer to the time their own tray arrives.

Thus, the necessity of eating is experienced differently by the staff and the patients. The administrative and kitchen staffs experience feeding as "food service." The patient population experiences feeding as "food procurement" with a battery of strategic behaviors necessary to adapt their physical capacities to the physical environment.

The community of Pecan Grove Manor comes to acquire

personal meaning beyond the brick-and-mortar ediface. The most common and consistently elicited report was that living at Pecan Grove Manor is neither ideal nor desirable but it is "the next best thing to home" given their circumstance. Nursing home life is viewed by the patient as the only reasonable solution to their predicament of unemployment and chronic illness. The typical patient also suggests that no other supportive resource system is available to meet essential needs for physical well-being. For those having children who represent potential caretakers, the children are reported as willing to take them but the patient will not "burden" their children or "get in the way." Thus, the patient sees the nursing home as a resource rather than a place of confinement.





81


I'd rather be here than with my kids to eliminate potential conflict with
them (paraphrased, 77 year old female).

If they can't get up and get around, tell 'em to come on (to Pecan Grove
Manor). (77 year old male)

It's a good place to live, but there's no place like home. (88 year old male)

Next thing to home, but it ain't home.
(91 year old male)

If you can't live at home, this is
tops. (78 year old male)

It's more like home than if I was with
my children. I'd feel in the way if
I was with my children and I don't feel
in the way here. (94 year old female)

They (her grandchildren) have no use for old people. Don't you know that?
(88 year old female)


Responses to "What do you like most about living

here at Pecan Grove Manor?" centered about patient/staff dependency. The primary benefit is the security of having one's needs consistently met within a cognitive set of perceived personal risks at simply being alive. The needs were clearly biosocial: companionship of staff and other patients, food service, and perceived medical-care availability. Responses to "What do you like least about living here at Pecan Grove Manor?" were oriented toward situationspecific items rather than the nursing home itself: separation from family and friends and disvalued behavior of other patients (eg., noisy, messy).

References to what these patients missed most about their life prior to being institutionalized were






82


independent of the institution. The predominant response was a loss of personal independence coupled with the loss of their spouse. On the other hand, these patients experienced improvements as a result of institutionalization. The presence of nurses' aides as helpers and being around other people for socializing were likewise reported as improvements in their lives.

The experience of being a nursing home patient actually begins before one enters the front door (Tobin and Lieberman, 1976). The patient brings with him previously developed' beliefs regarding nursing home life. Little is done to better precondition the prospective patient for admission to Pecan Grove Manor while in the hospital or at home prior to admission. Thus, early experiences in the nursing home can be unnecessarily traumatic. Consider the report

(edited) of Mrs. Nancy Pipkin (pseudonym), a 75 year old, white female:

JNH: What kind of adjustments did you
make? When you think back about when
you first came here.

NP: Well, when I first came I was
unhappy a little while. I didn't hardly
know see I just come out of the hospital here and I had had a nervous
breakdown. And I had a lot of adjusting to do anyway, wherever I had been.
And then I just come out of it and I
can just walk and do anything I want to
do. And I'm happy here.

JNH: What do you miss most about living
in the community?






83


NP: Well, anybody misses home, but outside of that But I miss home and friends. But the friends come to see me and I see them, so. I just know that this is going to be my home from now on and I just accept it and try to make myself be happy. I don't have any complaints as far as myself is concerned. They are just as sweet to me as they can be. Everytime I've ever needed anything, why, they're right here to help me. I'm just I'm just thrilled I've got a place like this to stay.

JNH: About how long do you remember it taking until you felt comfortable here? From the time you were first here.

NP: Oh, I guess it was six months maybe before I really could just turn loose and feel at home, but after that I was Now I was never miserable understand. I when I come I knew that this was going to be my home and I was going to make it pleasant as I could. So, I haven't let myself worry and think, "Why did I have to come here?" and "Why did this have to happen to me?" I've just accepted it and I've enjoyed it. I just wish every old person that has to stay alone and be in danger of not being cared for you know that couldn't take care of themselves. It's bad to have that feelin' that you might .

JNH: OK, how about some more on this. You were saying that you wished other people that needed to have these kinds of services could have them. Could you kinda repeat that?

NP: Yeah, well I do. I wish that other people could see and know how happy we are in here. I don't think that it'll be seemed like it ... that I did, I had a fear of coming down here. Before I come here, I'd heard things, you know, remarks made. And I haven't found any of that to be true in my case of what I'd heard or was afraid of.






84


JNH: What kind of things were those?

NP: Well, they just didn't take care
of 'em and they'd let 'em lay in the
bed and not take, go see about 'em or they couldn't get nobody to come when
they wanted 'em. Things like that,
well, I've never had that.

Well, I wish more people understood how we feel out here. And that
we do have care out here. Not do like I had, such a horror of coming. I just
really, I did have a horror of coming
out here, but after I got sick and Dr. P. came in and told me I'd have
to come down here and stay while, well I didn't say a word. I just thought, "Well this I have to do."

It's the best place outside of
your own home that you could have to
come to.

Also, consider the report (edited) of Mr. Frank Miller

(pseudonym), a 78 year old, white male:

FM: Well, for the last 30 or 40 years
there's been a great improvement. A great one. I can remember my father and I went over to a certain nursing
home in Texas; were thinkin' about puttin' my mother in there, and we
changed our mind when we visited the
nursing home.

JNH: Why is that?

FM: Well, They wadn't run like they
are now. So many old people think of a nursing home as a horrible place to
go. They think it's just a dumpin'
ground for Now, that the state
and federals (unintelligible), it's
run like a business more than it's ever been before. They've got to run right
or else! close the door.

JH: How does this one fit for that?

FM: It's a I'd say number one.






85


JNH: Number one?

FM: It's the tops.

course Joe (JNH), I'll say that you
can make up your mind to be satisfied
with anything. Now people come here that's dissatisfied and don't want to
come here. And people puts 'em in here
and it takes 'em a long time to get, get satisfied. We've had one or two to come here that's just, oh, hated
this place. Now, they like it, after they learn what it is. Because those
old people, they thought about them
old nursing homes years ago. I still
think about 'em myself.


These comments regarding Pecan Grove Manor should not be taken as actual evidence of a utopian nursing home community. Underlying the positive aspects of life at this nursing home are the expected and typical conflicts inherent among any group of people living in the community or an institution. What is significant, however, are the patients' denials of conflict and reluctance to talk about conflicts.

There exists an ethos of risk among the patients. Their lives are, in fact, daily at risk of worsening by having to leave the nursing home if they become too healthy, dealing with interpersonal conflict in a small environment, and deteriorating physically and mentally with death always on the horizon. Of the twenty-three elite patients interviewed, twenty-two referred to the possibility of being dead in one year and all respondents said that they would be dead in five years.






86


Although leaving the nursing home to re-enter the community is rare (one mild stroke patient and one burn patient in the thirteen months of fieldwork), all patients receiving public funds must have a monthly physical examination by a physician. Most patients consider the physical to be a necessary nuisance to keep receiving their funds. The patients report the physical to be superficial and a means for the physician to make money. Still, residence at public expense requires disability. The physical represents. a monthly potential for discharge.

Of more daily importance is the avoidance of open intragroup and intergroup conflict among patients and staff. The mechanisms which are conflict-obtrusive are partly related to features of long-term care and partly related to characteristics of institutional living.

Membership in the institution is forced. There are no other viable options. The process of adjustment and incorporation into the institution develops a sense of personal investment in this community. Patients away on visits with relatives or during hospital stays speak of their desire to "get back home" to "sleep in my own bed." Thus, there is a desire to preserve their position in the nursing home.

Institutional characteristics that generate conflictavoidance center about reduced private space. Open conflict in communities with a very limited territorial range is likely to be expressed beyond necessity. Those in






87


conflict will constantly be near each other and have little option to retreat to quell hostilities due to reduced private space. Also in operation is institutional public life expressed in the feeling that "everyone will know my problems."

One patient (86 year old female) stopped me in the

hall one day finding it difficult to maintain eye contact and select her words. She eventually began with, "I know you know this already, ." I didn't. She related in a halting voice that she suspected her roommate of conspiring with one of the cleaning women to put aluminum foil on the top part of the room windows. Her roommate is consistently too warm and she is consistently too cold. She said she didn't know whether or not this should be included in her diary which she wanted to give me. They had earlier agreed to divide ownership of the window by the two panels of glass. Even in the winter, her roommate would exercise her ownership perogative over her panel of glass by opening it, even though the window unit was not on "her side of the room."

This woman was convinced that the magnitude of this conflict was such that it was surely public knowledge. She also felt quite helpless in that two people (roommate and a staff member) had conspired against her. The perceived and real lack of physical and social resources caused a minor incident to have major implications for this patient.






88


Another male patient agreed to keep a diary to give to me but then rescinded. Before he returned the unused diary to me, another patient told me that this man had bragged that he was "going to be a spy for Joe." When he returned it, he very obliquely stated that he was afraid that keeping the diary might cause trouble. In an environment that houses only a small pool of people, friendships are resources with which one should not tamper.

Other aspects of avoidance of open conflict exist in relation to long-term care. Not only would open conflict cause life to be difficult in close quarters, but one would experience a sustained level of tension because they will live there the rest of their lives. In acute-care hospitals, personal risk stemming from angered roommates or hospital staff would not endure indefinitely. The experience of nursing home life is very much different.

At times,when complaints (though relatively innocuous) were voiced to me, I was typically told not to divulge the complaintant's name to anyone. For example, comments about unsatisfactory menus were ended with "don't tell 'em I said that." A man told me that some folding chairs borrowed from a men's club had unintentionally been kept at the nursing home. His statement was almost totally shrouded in disclaimers and caveats. The man's primary intent was to preserve a good relationship between the club and the nursing home. It was evident, however, that he didn't want to be perceived as a "trouble maker" for






89


the administration. Returning the chairs to the club would be more work for an already busy staff. Another instance involved a female patient who called me to a quiet corner and asked me to move some lawn chairs back to their previous location so that they could be used as before. I was then told not to tell anyone that she had made the request.

The caution exercised by the patients regarding what seemed to me to be reasonable and minor items is produced by the knowledge that one will quite literally have to live with the not-totally-predictable consequences of one's actions. The public nature of life in an institution coupled with long-term membership makes the otherwise inconsequential momentous.

The administrative staff also participates in conflict obtrusion. The nurses' aides are told never to gossip or argue in the presence of patients. The patients are not to be bothered by personal staff problems. The administrative staff believe that families and patients expect an idllyic paradise and the nursing home will produce what the customer wants.

It was my experience, however, that the patients thirsted for information of any type. To overhear a nurses' aide's actual personal problems was at the least better than the fiction of television soap operas. Often patients interjected comments expected to be helpful in solving some dilemma. The patients felt more alive through




Full Text
CHAPTER FOUR
ENVIRONMENTAL SETTING
The physical plant of Pecan Grove Manor comprises a
setting in which patients and nonpatients engage in activi
ties for significant parts of their lives. For patients
particularly, the physical plant represents the environment
which they must negotiate in order to interact with others,
get medicines, eat, and otherwise live their lives. The
staff, too, must perform within the confines of the build
ing. Staff activities often center about getting from one
patient to another which actually means one location to
another. Thus, the configuration of the physical plant has
the potential to "coerce" certain behaviors from its inhabi
tants (Sommer 1969).
Consideration for the environment as an influential
component of human societal existence has a lengthy tradi
tion in anthropology. Perhaps the cataloging of "exotic"
food items, shelters, medicines, rituals, etc., required at
least a superficial treatment of the environment as the
matrix from which these "goods" were extracted. As environ
ment became a more central issue in social science, human
ecology emerged as . the descriptive study of the
adjustment of human populations to the conditions of their
respective physical environments" (Hawley 1944:404). Later,
anthropology took account of environment from the cultural
ecological perspective of the interactive physical and
cultural environments (Steward 1955) .
25


31
The main-entrance area promotes patient interaction by
its position as a vantage point for observing the daily
events within the nursing home. Other observers likewise
cite entrance areas as natural vantage points (Gubrium
1975:10; Koncelik 1976:52; Sommer 1970:34). Sitting in the
chairs or area near the chairs facing the entrance doors,
one can see through the glass doors and adjacent glass
panels to the parking area and the nearby highway. This
view allows for monitoring the travels of patients,
visitors, and staff. Also within sight is the nursing home
business office with its attendant activities. Looking to
one side offers the view of the entire ambulatory corridor.
Patients move within in the corridor frequently for visit
ing, medicines, food, and exercise. Looking to the other
side affords a comprehensive view of the main lobby, dining
room and nurses' station. For those patients whose mental
abilities permit, the entrance area provides a good all-
around location for gathering information about the daily
events of nursing home life.
The entrance area is also marked by its function as a
communication center. Here is found a phone for patients
to use, a large monthly-activities and events calendar, and
a major-event bulletin board. This area also is marked by
many color photographs of past parties. Live plants are
also here along with craft displays.
The entrance also attracts interaction due to its mid
point location between the ambulatory corridor and the


24
However, incontinence is highest on this wing. This is due
to ambulatory patients with urinary incontinence and noc
turnal-only urinary incontinence.
In summary, patient-management strategies are less
related to specific disease categories and more related to
level of debility as indirectly reflected by degree of
continence, ambulation, ability to feed one's self and
location of meal-taking (See Appendix 6). In this way,
Pecan Grove Manor becomes three nursing homes in one. The
patients, staff, and visitors learn and are affected by the
design of patient-management and the physical environment.


113
APPENDIX 6
WING ASSIGNMENT BY DEBILITY FACTOR
WINGS
North
South
East
All
All
Wings
FACTOR
"Heavy
"Intermediate
"Light
Wings
Care"
Care"
Care"
Male
Female
Continent
45.5%
41.4%
100.0%
62.0%
65.4%
60.6%
Incontinent
54.5%
58.6%
0%
38.0%
34.6%
39.4%
Ambulatory
51.5%
58.6%
100.0%
68.5%
73.1%
66.7%
Non-ambulatory
48.5%
41.4%
0%
31.5%
26.9%
33.3%
Meals in Dining Area
12.1%
24.1%
73.3%
35.9%
42.3%
33.3%
Meals in Patient Area
87.9%
75.9%
26.7%
64.1%
57.7%
66.7%
Feeds Self
75.8%
93.1%
96.7%
88.0%
7 6.9%
92.4%
Requires Feeding
24.2%
6.9%
3.3%
12.0%
23.1%
7.6%


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Walter CunninghaiyT7
Associate Professor of Psychology
This dissertation was submitted to the Graduate Faculty of
the Department of English in the College of Liberal Arts and
Sciences and to the Graduate Council, and was accepted as
partial fulfillment of the requirements for the degree of
Doctor of Philosophy.
December, 1979
Dean, Graduate School


SESSION GIVEN
BY
PHYSICAL CARE
& PATIENT
MANAGEMENT
PSYCHOSOCIAL
ENVIRONMENT
EVACUATION AND
FIRE PROCEDURES
STAFF
SALARY
TOTAL
R.N. or L.P.N.
1.9
4
6
0
29
ANTHROPOLOGIST
0
4
0
0
4
ADMINISTRATORS
0
0
0
1
1
TOTALS
19
8
6
1
34
IN-SERVICE TRAINING TOPICS
March 1977 July 1978
Figure 10


95
Clark and Anderson (1967:11) state, "The elderly have
problems in our society because it takes them so long to
die these days." The affliction of chronic life, then,
is iatrogenic in origin.
The cultural apparatus for dealing with chronic life
takes various forms. Acute-care hospitals sometimes
designate a section of the patient floors as palliative-
care wards. The hospice is typically an institution for
the terminally ill that is separate from the hospital.
However, nursing homes loom most prominent as the standard
American agency dealing with the biosocial penalties of
longevity and incapacitating incurable disease.
The ethnomedical perspective was used in the study
of Pecan Grove Manor nursing home. Special emphasis was
directed toward patients and paid care agents as signifi
cant role categories within the nursing home community.
The ethnomedical view identified patients, nurses' aides,
and housekeepers as the interactional network most mean
ingfully associated with long-term care quality.
Within any community of people, differing points of
view exist analytically as multiple realities (Gubrium
1974). This research has disclosed realities specific to
various categories of people within the nursing home com
munity. These realities characterize a category-specific
ethos.
The patient ethos is marked by a pervasive sense of
life at risk. The patients risk becoming too well or


40
here, further decline is experienced necessitating a move to
the heavy-care wing with the other "pitiful people," "poor
things," and "crazy ones." Even within this wing, a final
move through space signals impending death. The dying are
moved to Room #1 North due to its proximity to the nurses'
station. From here, the final move is final. The patient,
then, learns to use this "cosmology" as a grid upon which to
maintain a constant fix on his or her date with death.
The experience of Pecan Grove Manor seems to be charac
teristic of American institutional settings for the aged.
Pecan Grove Manor as an institution conforms generally to
Bennett's medium level of institutional totality (Bennett
and Nahemow 1965:47). However, Pecan Grove Manor's three
sections have certain institutional characteristics in
common but also each wing requires its own special treatment.
Institutional characteristics common to all wings range from
high to low levels of institutional totality. For example,
the nursing home as a whole is a permanent residence (high
level), socialization of new members is informal (medium
level), and there exists no objective sanction system (low
level).
Again, using Bennett and Nahemow1s (1965:47) scheme,
the heavy-care wing has seven of ten criteria commensurate
with a high level of institutional totality. The medium-
care wing has only three of ten high-level characteristics,
while the light-care wing has only one, that of permanence.
With regard to a medium level of institutional totality, the


14
in the center of the lobby under a ceiling spotlight.
Using a large notebook and opening it, I began to conspicu
ously look about and then record my observations. I pur
posely avoided any entry of a potentially sensitive nature,
such as "nurses' aide Wheeler is goofing off," etc. As I
suspected, the "natives" became immensely.curious. The
curious "natives" were all employees of the nursing home who
first walked nearby, barely glancing at me and then later
returned to loudly speak in an overly endearing tone to some
"sweet" patient. After all, I was the boss's nephew who had
been sent to "spy" on them.
Within fifteen minutes of my act, the assistant
administrator and the R.N. very quietly came from behind me
and peered over my shoulder. When I noticed them, I moved
my arms away from my notebook, leaving it totally exposed
and undefended. They immediately asked me in a friendly,
shy way what I was writing. I handed over the notebook
explaining that the two pages of notes were just a beginning
and that I would surely require their assistance in the
future. The mundane jottings were handed back to me and
business went on as usual with several more months of a
"marginal native" (cf. Freilich 1970) exhibiting uninterrup
ted "note taking behavior" (cf. Rosenhan 1973).
My extent of participation included helping as a jani
tor, taking patients to the physician, going to the home of
a prospective patient and experiencing the trip from their
community home to the nursing home, being in a play to


7
The occupants of an American nursing home are often
very old and very sick. Their membership in a geriatric
institution is a symbol of their inability to negotiate
even the simplest aspects of life unassisted. In response,
the geriatric institution has evolved as a cultural product
of technological society's ability to maintain biological
life for an extremely long duration but with uneven func
tional capacity. Thus, nursing home patients find them
selves the victims of a peculiar American pathology--
chronic life.
The nursing home in America has a lengthy evolutionary
history. Cohen (1974) reviews the development of institu
tionalized care for the aged in six phases. The first is
labeled the "colonial phase" referring to the 17th and 18th
centuries. Those in need (aged, orphans, sick, prisoners)
all had recourse to state relief programs. Overall, how
ever, "outdoor relief" (i.e,, noninstitutional care) was
more common prior to the Revolution than after it when the
almshouse became the popular mode of dealing with the needy.
Second, from 1800 to 1920, America was heavily influ
enced by England's Poor Law of 1834. The Poor Law firmly
established the almshouse as the primary institution
responsible for the care of all needy, including the aged.
The starkness of life in the almshouse was a matter of
policy so that it would not be attractive to the undeserving.
It was not until the 19th century that humanitarian reforms


19
Systems Agency 1978:46). Also, Oklahoma's availability of
nursing home beds is high. In 1977, Oklahoma had 80 beds
per 1,000 population 65 and over, compared to the national
figure of 62 beds per 1,000 population 65 and over (See
Appendix 1).
The geographic distribution of Oklahoma's aged popula
tion is associated with urban and rural areas (Oklahoma
Health Systems Agency 1978:25a). The two large urban areas
of Oklahoma are Oklahoma City (Oklahoma County) and Tulsa
(Tulsa County). Other rural counties in the state have
significantly higher populations of people aged 65 and over
(See Figure 2). Of all the 66 counties in Oklahoma,
Marshall County has one of the highest aged populations.
It is in Marshall County that Pecan Grove Manor is situated
(See Figure 2).
As a population ages, the prevalence of chronic non-
infectious disease increases. The epidemiologic profile
of Pecan Grove Manor patients is characterized by a high
prevalence of such diseases (See Appendix 2). Of all the
disease entries in Appendix 2, arthritis has the highest
prevalence rate (See Appendix 3). When the diseases at
Pecan Grove Manor are collapsed into categories used by the
Merck Manual, cardiovascular, neurologic, psychiatric, and
musculoskeletal/connective tissue diseases are by far the
most prevalent (See Appendix 4).
The patient population at Pecan Grove Manor is pri
marily female (70% female, 307, male) and the average age is


119
Roth, Juluis
1963 Timetables: Structuring the Passage of Time in
Hospital Treatment and Other Careers. Indianapolis:
Bobbs-Merrill.
Schulman, Sam
1958 Basic Functional Roles in Nursing: Mother Surro
gate and Healer, In Patients, Physicians, and
Illness. E. Gartly Jaco, ed. New York: Free Press.
1972 Mother Surrogate--After a Decade. In Patients,
Physicians, and Illness. E. Gartly Jaco, ed. New
York: Free Press.
Schwartz, Arthur N.
1975 Planning Micro-Environments for the Aged. In
Aging: Scientific Perspectives and Social Issues.
Diana S. Woodruff and James E. Birren, eds. New
York: Van Nostrand.
Scott, F. G.
1955 Factors in the Personal Adjustment of Institu
tionalized and Non-Institutionalized Aged. American
Sociological Review 20:538-546.
Sherwood, Sylvia, ed.
1975 Long-term Care: A Handbook for Researchers, Plan
ners, and Providers. New York: Spectrum.
Siegler, Mirian and Humphry Osmond
1976 Models of Madness, Models of Medicine. New York:
Harper Colophon Books.
Simmons, Leo W.
1945 The Role of the Aged in Primitive Society. New
York: Yale University Press.
1946 Attitudes Toward Aging and the Aged: Primitive
Societies. Journal of Gerontology 1: 72-95.
1960 Aging in Preindustrial Societies. In Handbook
of Social Gerontology. C. Tibbits, ed. Chicago:
University of Chicago Press.
Simon, Julian L.
1978 Basic Research Methods in Social Sciences, Second
Edition. New York: Random House.
Solon, J.
1957 Nursing Homes, Their Patients, and Their Care.
Public Health Monograph, Number 46.


66
CATEGORY OF
EVENTS
PUBLIC
INVOLVEMENT
INTRAINSTI-
TUTIONAL
CYCLE
Religious
WEEKLY
Services
X
Special
Religious
Celebrations:
1. Christmas
X
ANNUAL
2. Easter
X
ANNUAL
Civil/Religious
Celebrations:
1. Valentines Day
X
V
ANNUAL
2. St. Patrick's Day
X
X
ANNUAL
3. Mother's Day
X
ANNUAL
4. Father's Day
X
ANNUAL
5. 4th of July
X
ANNUAL
6. Halloween
X
ANNUAL
7. Thanksgiving
X
ANNUAL
Secular Activities:
1. Birthdays
X
MONTHLY
2. Bingo
X
WEEKLY
3. Beauty Shop
X
WEEKLY
4. Crafts
X
WEEKLY
5. Remotivation
X
WEEKLY
6. Band
X
. WEEKLY
ACTIVITIES
Figure 9


known the longest of all the committee members, for his
continued interest in me and his extensive and expert
influence on me, and Dr. Leslie S. Lieberman for her
watchful supervision and tremendously useful discussions
with me. Dr. Carol Taylor and Dr. Walter Cunningham have
provided significant comments on this project, making it a
more solid effort. Overall, however, I am responsible for
those deficiencies present.
It is my sincere hope that this dissertation contains
some information benefiting even a small segment of
humanity. If this is the case, my debt to those instru
mental in this research may be partially repaid.
vr


9
another three years, 30 more beds were added to fix its
present patient load at 90. Seldom does the patient load
drop below its maximum capacity,


117
Holmes, Lowell D.
1976 Trends in Anthropological Gerontology: From
Simmons to the Seventies. International Journal of
Aging and Human Development 7: 211-220.
Illich, Ivan
1976 Medical Nemesis: The Expropriation of Health.
New York: Bantam Books.
Jacobs, Jerry
1974 Fun City: An Ethnographic Study of a Retirement
Community. New York: Holt, Rhinehart, and Winston.
Kahn, R. L., A. I. Goldfarb, M. Pollack, and I. E. Gerber
1960 The Relationship of Mental and Physical Status
in Institutionalized Aged Persons. American Journal
of Psychiatry 117: 120-124.
Koncelik, J. A.
1976 Designing the Open Nursing Home. Stroudsburg,
Pennsylvania: Dowden, Hutchinson, and B.oss.
Kramer, Charles J. and Jeanette R. Kramer
1976 Basic Principles of Long-Term Patient Care:
Developing a Therapeutic Community. Springfield:
Thomas.
Landy, David
1974 Role Adaptation: Traditional Curers Under the
Impact of Western Medicine. American Ethnologist 1:
103-128.
LeVine, Robert A.
1970 Research Design in Anthropological Fieldwork.
In A Handbook of Method in Cultural Anthropology.
Raoul Naroll and Ronald Cohen, eds. New York:
Columbia.
Lorber, Judith
1975 Good Patients and Problem Patients: Conformity
and Deviance in a General Hospital. Journal of Health
and Social Behavior 16: 213-225.
Manard, Barbara, R.alph Woehle, and James Heilman
1977 Better Homes for the Old. Lexington, Massachu
setts : Lexington Books.
Mazess, Richard B. and Sylvia Forman
1979 Longevity and Age by Exaggeration in Vilcabamba,
Ecuador. Journal of Gerontology 34: 94-98.
McQuillan, Florence L.
1974 Fundamentals of Nursing Home Administration.
Second edition. Philadelphia: Saunders.


64
status in some combination with the following attributes:
some degree of mental intactness, physical strength, speech,
and vocal complaints.
Another obstacle to care results from sexual tabus.
Only once did a nurses aide touch Mr. Green's penis to
facilitate exit from the urinal. Mr. Green's scrotum often
was left with some fecal material on it due to imcomplete
cleaning. Other male patients who were not circumcised
never, in my observations, had the foreskin retracted for
thorough cleaning of the glans. On the other hand, I was
allowed to assist in toileting habits with a twenty-five
year old, mentally retarded female except when she was
menstruating.
Lastly, the nurses' aides minimized interaction with
Mr. Green by avoiding all but essential communications. Mr.
Green'sroommate, even though he was aphasic, was the recipi
ent of generous amounts of conversation to which he would
laugh, act shy, and make "goo-goo" noises, delighting the
nurses' aides.
Is Mr. Green's case one of a difficult patient or a
difficult staff? I personally experienced working with Mr.
Green very distasteful. He did smell, look, and act badly.
However, when I had the time to ask him about his life, he
was responsive and I was surprised to find a rather com
plete, intact personality. This did not elicit in me a
missionary zeal of saving this man's integrity. My will
ingness to talk with Mr. Green not only produced conversa-


72
sent, but the recipient of "usual a.m. care" or "up and
about; cheerful" (cf. Gubrium 1975). Still, the nursing
home must meet the demands of federal government regulations.
The nurses' aide/patient/long-term care institutional
environment operates collectively to produce a community of
daily forced-interaction. The longevity of patient/nurses'
aide interaction coupled with a mother-child interactional
pattern leads to in-depth knowledge of patient behaviors.
The nurses' aides being generally untrained, make use of
their own physical senses and beliefs about health and
disease to make decisions regarding therapeutic actions.
Psychosocial care is de-emphasized due to the pressures
of fulfilling physical care needs. Most important, however,
is the relative invisibility of psychosocial care procedures
and benefits. Additionally, benefits that accrue are likely
to be relatively gradual in appearance. Lastly, there is
no staff member who is trained to be perceptive of the psy
chosocial environment, while conversely there are plenty of
staff members who have received formal education in business
management and medical-model nursing. These factors are
reflected in the topics for in-service training (See Figure
10).
The foregoing material describes a social system orien
ted toward long-term palliative health care performed by
unskilled nurses' aides on institutionalized aged patients.
A number of tensions between aides and patients have been
identified with resolution couched in an ambience of strate
gies particular to long-term care environment.


41
heavy-care wing has only one matching item, the intermedi
ate-care wing has seven out of ten matches. The low
totality category has all three wings assigned to just one
item no objective sanctions. Overall, Pecan Grove Manor
can be characterized as an institution with a medium level
of totality. In this setting, patients play out their
daily life cycles in association with sets of employees
hired to assist and monitor this final phase of existence.


ACKNOWLEDGEMENTS
The acknowledgements made below are indications of
my sincere debt to the numerous people who encouraged,
assisted, and nurtured me throughout the duration of this
fieldwork project. Prerequisites for successful anthropo
logical fieldwork are many and varied. Often obscured is
the value of the anthropologist's spouse. In this research
project, my wife, Jan, figures prominently. She willingly
worked and traveled with me throughout the rigors of uni
versity training and fieldwork, thereby delaying the
realization of some of her personal ambitions. Jan also
helped me in gathering data to which I otherwise would not
have been privy and charmed those who were at first
reluctant to be a part of this study. Besides technical
talent, she exudes warmth, personality and love for those
around her.
My parents, Ike and Patti, have been a continual
source of inspiration and sustenance for this part of my
life experience. In so doing, they continue to build on
an atmosphere of unconditional love and respect which they
engendered at my beginning.
My brother, Greg, contributes to this project and my
life daily. I learned from him discipline, perseverance,
humor, and a multitude of other things in the dearest way
possible. He is my friend. Greg's wife, Mariquita,
contributes to my dissertation by her love for Greg and
for Jan and me.
iv


102
The future is likely to see a proliferation of nursing
homes as we know them today. Given this projection,
research efforts may best be directed at maximum extraction
and enhancement of naturally evolved beneficial behaviors
and roles within a nursing home community. The cost-
benefit ratio of the enhancement of pre-existing behavioral
systems is seen as potentially attractive to proprietary
nursing home owners for the improvement of the quality
of institutional life.


CHRONIC LIFE:
AN ANTHROPOLOGICAL VIEW OF AN
AMERICAN NURSING HOME
BY
JOSEPH NEIL HENDERSON
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1979

Copyright 1979
by
Joseph Neil Henderson

This dissertation is dedicated to the patients and
staff of Pecan Grove Manor -- past, present, and future.

ACKNOWLEDGEMENTS
The acknowledgements made below are indications of
my sincere debt to the numerous people who encouraged,
assisted, and nurtured me throughout the duration of this
fieldwork project. Prerequisites for successful anthropo
logical fieldwork are many and varied. Often obscured is
the value of the anthropologist's spouse. In this research
project, my wife, Jan, figures prominently. She willingly
worked and traveled with me throughout the rigors of uni
versity training and fieldwork, thereby delaying the
realization of some of her personal ambitions. Jan also
helped me in gathering data to which I otherwise would not
have been privy and charmed those who were at first
reluctant to be a part of this study. Besides technical
talent, she exudes warmth, personality and love for those
around her.
My parents, Ike and Patti, have been a continual
source of inspiration and sustenance for this part of my
life experience. In so doing, they continue to build on
an atmosphere of unconditional love and respect which they
engendered at my beginning.
My brother, Greg, contributes to this project and my
life daily. I learned from him discipline, perseverance,
humor, and a multitude of other things in the dearest way
possible. He is my friend. Greg's wife, Mariquita,
contributes to my dissertation by her love for Greg and
for Jan and me.
iv

My uncle, Phil Sturapff, his wife 'berta, and their
four children, Kurt, Erik, Stacia, and Stephanie, all have
a part in this research. Phil provided me with complete
access not only to a research site, but to a part of his
livelihood. I hope that his trust has been well-placed.
His family has repeatedly placed their home and selves at
our disposal.
My grandmother, Mother Polly, and grandfather, Gang,
remain lifelong sources of love and inspiration. Their
home was made available to Jan and me, providing not only
physical shelter, but an experience that speaks well for
extended family kinship systems.
Those who suggest that kinship declines in importance
in industrialized societies may want to review the above
acknowledgements. However, many non-kin deserve mention.
Among them are Phyllis Maines, Sally Watkins, Wilma Davis,
and Dorothy Harrison,who all diligently work at Pecan Grove
Manor. Some figure-drawing and rough-draft typing was done
by Bobbie Bryant, Ruth Kagen, and Anita Morris.
Members of my committee have expended great efforts
on my behalf in training me in anthropology over the past
several years. I will continue to develop my anthropo
logical knowledge and skills because, if I have learned
anything, I know that the endeavor of understanding is a
lifelong process of wondering, investigating, and learning.
I particularly thank Professor Otto von Mering for sharing
his novel insights, Dr. J. Anthony Paredes whom I have
v

known the longest of all the committee members, for his
continued interest in me and his extensive and expert
influence on me, and Dr. Leslie S. Lieberman for her
watchful supervision and tremendously useful discussions
with me. Dr. Carol Taylor and Dr. Walter Cunningham have
provided significant comments on this project, making it a
more solid effort. Overall, however, I am responsible for
those deficiencies present.
It is my sincere hope that this dissertation contains
some information benefiting even a small segment of
humanity. If this is the case, my debt to those instru
mental in this research may be partially repaid.
vr

TABLE OF CONTENTS
CHAPTER PAGE
ONE BACKGROUND 1
TWO METHODOLOGY 10
THREE DEMOGRAPHICS AND EPIDEMIOLOGY 17
FOUR ENVIRONMENTAL SETTING 25
Note 42
FIVE THE DAILY CYCLE: RITUALS OF
FABRICATED LIFE 43
SIX THE PATIENT EXPERIENCE: THE NEXT
BEST THING TO HOME 75
SEVEN CHRONIC LIFE AND AGE SEGREGATION 94
APPENDICES
1 SELECTED NURSING HOME INDICES 1977 103
2 PECAN GROVE MANOR TOTAL DISEASE
ROSTER (FROM PHYSICAL1 LISTINGS
IN PATIENTS' CHARTS) 104
3 PECAN GROVE MANOR
TEN MOST PREVALENT DISEASES 110
DISEASE PREVALENCE
PECAN GROVE MANOR Ill
Vll

5
POPULATION PYRAMID:
PECAN GROVE MANOR.
112
6 WING ASSIGNMENT BY DEBILITY FACTOR . .
REFERENCES CITED
BIOGRAPHICAL SKETCH
113
114
121
viii

Abstract of Dissertation Presented to
the Graduate Council of the University of Florida
in Partial Fulfillment of the Requirements for
the Degree of Doctor of Philosophy
CHRONIC LIFE:
AN ANTHROPOLOGICAL VIEW OF AN
AMERICAN NURSING HOME
By
Joseph Neil Henderson
December 1979
Chairman: Otto Von Mering
Major Department: Anthropology
This research project examines the experience of
chronically ill geriatric patients and the care-giving
response patterns of unlicensed nursing personnel in a
ninety-bed proprietary nursing home in southern Oklahoma.
The study of the residents and staff of Pecan Grove
Manor (pseudonym) is based on an anthropological community
study approach, with theoretical orientations derived from
functionalist and social systems models. It extended over
a period of thirteen months of participant-observation.
Pertinent data were also collected by personal interview,
scheduled interview, patient diaries, still photography
and cinematography.
Overall, Pecan Grove Manor is revealed as a standard
American example of a specialized age-segregated community
IX

which has become a commonplace sociocultural and brick-and-
mortar invention in response to biomedically induced
longevity, prolonged debilitating disease, and the ethical
proscription against senilicide. The nursing home,
therefore, is the setting for observing the uniquely
debilitating phenomenon of leading a "half-life of disease"
within a "half-existence of social functioning."
The research also documents salient features of a
resident population with a significant capacity to mobilize
adaptive behavioral responses to physical limitations and
the formal institutional environment. A further important
finding shows unlicensed nursing personnel serving as
"folk healers" and surrogate mothers to the patients and
non-nursing personnel (i.e., housekeepers) to be the key
staff group whose normal or "proper" task performance
promotes transactions rather than ritualistic contact with
patients. In spite of patients' adaptive resilience, the
nursing staff perceives patients as adult children whose
physical and intellectual resources are exhausted. This
belief, generally coupled with medical-model-induced
nursing neglect of psychosocial aspects of well-being,
contributes to a web of fabricated life rituals that veil
the underlying efforts at palliative care.
A concurrent intensive study of a special sub-group
or cohort of twenty-three mentally-intact residents pro
vides evidence that, in the main, they experience nursing
home life not as ideal, but "the next best thing to home,"
x

given their situation of unemployment and illness. This
perception is partly based in fact, and in part a deriva
tive of a need to counter-balance the inescapable stress
of life under imminent, compounded health threats and the
related institutional confinement.
The significance of the role of the housekeepers as
agents of psychosocial support is not formally recognized
by either the nursing or administrative staffs. Unlike
nurses' aides, proper job performance for housekeepers
involves lengthy in-room tasks during which meaningful
interaction can and does occur with individual residents.
Housekeepers serve too as brokers between groups of resi
dents and the nursing staff.
These findings as a whole suggest that institutional
ized elderly can remain adaptively resourceful for an
extended period in personal body care, and do respond
positively to informal or unplanned psychosocial care.
It is argued that psychological care can be promoted within
an existing standard program by actively rewarding the
spontaneous social-support role of non-nursing staff mem
bers, like the housekeepers. The cost-benefit ratio of
such a strategy is seen as potentially attractive to pro
prietary nursing home owners for the improvement of the
quality of institutional life.
xi

CHAPTER ONE
BACKGROUND
The regeneration of time, according to Mircea Elaide
(1963), is a driving concern of all people throughout the
world. Concepts of heirophanic eternities may represent
the products of attempts to teleologically demonstrate
regenerated time. In any case, the occupants of some
eternity have in common the passage from mundane existence
to supernatural existence; for many, from secular old age
to unencumbered old age.
Also observed worldwide is some form of peculiar
segregation of the aged. Age-grading may be explicit as
with the Karimojong of Uganda (Dyson-Hudson 1966) or
implicit as with the Americans of North America. The
segregation of aged people may be physical, as among the
Ainu of Hokkaido, Japan, who isolate the very old in small
huts (Simmons 1946:90) or conceptual, thus allowing for
physical proximity of young and old but retaining distance
socially and conceptually as found among the Chiricahua
Apache of the southwestern United States (Beals and Hoijer
1971:360). Perhaps special perspectives regarding the aged
are ultimately functions of an awareness of the elderly
approaching the mysterious phenomenon of death. Thus,
people who have lived many years are viewed positively or
negatively, as functional or non-functional, but always
recognized and distinctively engaged by others as aged.
1

2
Throughout time, the concept or label of "aged" has
been assigned to people in accordance with prevailing
beliefs regarding the chronological age at which someone
"becomes" old. Assignment to the category of aged, then,
is a combination of belief and time. In extremes, the six
year old progeric patient is considered old while the
Russian Abkhasians or Ecuadorian Hunza are considered old
only after reaching a purported (cf. Butler 1978b and Mazess
and Forman. 1979) 100 years of age.
During the middle Paleolithic, Neandertal burials at
Mount Carmel disclose that of a male about 50 years of age
(Clark 1969:45) although most Neandertal burials are of
individuals less than 30 years of age (Stern 1969:98).
Mellaart's (1967:225) excavations in Turkey show that very
few of the Neolithic inhabitants of Catel Hyk lived over
40 years of age. During the Iron Age (c. 100 B.C.), the
average life span was 18 years although some rare indi
viduals survived as septugenerians (Birren and Clayton
1975:15). By 50 B.C., the life span has increased to 25
years until the 1600s A.D. when the life span edged ahead
to 32 years of age (Birren and Clayton 1975:24).
During the year 1776 A.D. in America, only 207o of
neonates lived to the age of 70 and only 4% of American
families were comprised of three generations (Butler 1978b:
15). By 1900, the human life span was 47 years and in 1970
it was 71 years of age (Cutler and Harootyan 1975:32-34).

3
Butler (1978b:15) projects that the maximum limits of
human longevity range between 100 and 120 years.
Given the rapid acceleration of human longevity and
its recency, "old" is new in America and the world. It is
as if a new sub-species of Homo sapiens has evolved as a
product of machine-age industry and antibiotic medicine.
While the subspecies designation is facitious, it can be
recognized that elderly people are in some ways physio
logically and intellectually distinctive. These distinctive
features (e.g., change of bone density, change of arterial
elasticity, digestive changes, cognitive and sensory
capacity change) relate to special needs of the elderly and
finally to demands placed on society pursuant to meeting
those needs.
The importance of addressing the needs of the elderly
in America becomes clear when demographic trends are
examined. The total population aged 65 and over in 1900
was 3.1 million but in 1970 was 20.2 million. The propor
tion of people 65 and older has increased almost 2.5 times
from 1900 to 1970: 4.1%, to 9.9%. However, the percent of
the total population 65 and older will be 11% in 1990,
decline slightly until 2020 when it will rise to 13.1%.
Projections for the next five decades show that the abso
lute number of people 65 and older will increase from about
20 to about 40 million (Cutler and Harootyan 1975:33-35).
The rapid increase in the number of aged Americans has
produced a series of attempted societal adjustments aimed at

4
adapting modern American life to a new element of the social
and cultural system. In this sense, sociocultural evolution
is proceeding under the guise of federal and local govern
mental programs providing services for needy elderly while
also functioning to shift responsibility away from indi
vidual elderly persons and their families to the general
public. Monetary assistance for the aged, treatment and
storage facilities for the aged, separate communities for
the aged, and simple ostracism appear to be the American
ways of dealing with the growing aged population. Thus,
the American aged population has been identified, cate
gorized, and stigmatized as a "problem" with which the
"un-old" must cope.
Throughout the United States, the vast majority of
aged people (hereafter meaning those persons 65 years of
age and older) live in community settings with 72.7%, of
aged males heading a household. Relatively few aged people
live alone (14.7%, male; 36.2% female) and even fewer live
in institutional settings (3.6%, male; 4.6%, female) (Cutler
and Harootyan 1975:63). This minority of institutionalized
aged, however, currently total 1.2 million people (Brody
1977a:85) and projections indicate that by the year 2000,
there may be 11 million aged people residing in institu
tional facilities (Brody 1977b: 15).
The institutional setting likely to be encountered is a
privately-owned, profit-operated business selling various
degrees and types of care to the elderly sick. According

5
to Butler (1975:251), 797 of all institutions providing
care for the aged sick are proprietary in nature. Nonprofit
institutions for the aged provide care for 147 of the insti
tutionalized aged and 77 of the institutionalized aged are
in government-funded facilities.
Characteristics of institutionalized aged populations
are varied, but even so, certain clusterings of traits are
apparent. The median age of institutionalized people is
82 with 437 age 85 and older. There are three times as
many women as men. Most institutionalized people are white
and poor and are maintained by public funds. The institu
tionalized aged population is likely to have a variety of
chronic physical impairments including circulatory dis
orders, arthritis, digestive disorders and mental impair
ment such as senility and depression (Brody 1977a:85-89).
Additionally, most institutionalized aged people have
no spouse, no close relatives and the majority have no
visitors. They stay in the institution almost 2.5 years
with only 207, returning home, the remainder dying in the
institution or at a hospital. Few can walk, 337 are
incontinent and there is an average of more than four drugs
taken per person each day Moss and Halamandaris (1977:8).
The above description projects a dismal existence for
the participants of geriatric institutions. If it is
unpleasant to be poor or sick or lonely, then the combina
tion of these three elements can only constitute a com
pounded sense of demoralizing desolation. Yet, in this

6
investigation in a proprietary nursing home, the harsh
reality of the participants' situation is tempered by the
human ability to adjust and adapt to prevailing circum
stances. The circumstances to which these aged people must
adjust and adapt center about the entity known as the
"nursing home.
Care for the sick elderly is known in all societies
regardless of the level of technological proficiency or
sociopolitical organization. The existence of senilicide
among band and tribal societies is not uncommon, but
exists only when necessary. The usual motivating factors
are related to vital components of band and tribal subsis
tence: mobility and productivity. Those who interfere with
these basic requirements are killed or allowed to die (see
Simmons 1946 and 1960). Among some state level societies,
such as the Inca of Peru and the Aztec of Mexico, tribute
from the productive citizens was redistributed to the needy
including the infirm elderly (Simmons 1960:70).
Another element of aging recognized cross-culturally
is a distinction between productive old age and nonfunc
tional old age. The nonfunctional and often sick elderly
are referred to as "overaged," "useless," in the "sleeping
period," in the "age-grade of dying," and "already dead"
(Simmons 1960:87). Among the Hopi of Arizona, for example,
when people are in the "helpless stage" their death is
assisted by purposeful neglect (Simmons 1945:89).

7
The occupants of an American nursing home are often
very old and very sick. Their membership in a geriatric
institution is a symbol of their inability to negotiate
even the simplest aspects of life unassisted. In response,
the geriatric institution has evolved as a cultural product
of technological society's ability to maintain biological
life for an extremely long duration but with uneven func
tional capacity. Thus, nursing home patients find them
selves the victims of a peculiar American pathology--
chronic life.
The nursing home in America has a lengthy evolutionary
history. Cohen (1974) reviews the development of institu
tionalized care for the aged in six phases. The first is
labeled the "colonial phase" referring to the 17th and 18th
centuries. Those in need (aged, orphans, sick, prisoners)
all had recourse to state relief programs. Overall, how
ever, "outdoor relief" (i.e,, noninstitutional care) was
more common prior to the Revolution than after it when the
almshouse became the popular mode of dealing with the needy.
Second, from 1800 to 1920, America was heavily influ
enced by England's Poor Law of 1834. The Poor Law firmly
established the almshouse as the primary institution
responsible for the care of all needy, including the aged.
The starkness of life in the almshouse was a matter of
policy so that it would not be attractive to the undeserving.
It was not until the 19th century that humanitarian reforms

8
fueled the development of institutions specifically designed
for long-term care of the aged.
During Cohens third phase, 1929 marks the date by
which nonprofit institutions were primarily responsible
for care of the elderly. The programs of the Social Secur
ity Act subsequently provided assistance for the aged.
Privately-owned boarding homes began to house the elderly
and when nurses were added, the boarding home became a
nursing home. By 1939, Cohens fourth phase, there were
1200 long-term care institutions with a 25,000-bed capacity
nationally.
By 1954, Cohen's fifth phase, there was a noticeable
increase in the number of proprietary nursing homes. The
number had risen to 25,000 institutions with a 450,000-bed
capacity. Cohen suggests that this increase reflected a
backlog of potential patients.
After 1965, Cohen's sixth phase, long-term care became
institutionalized into the fabric of government policy,
medicine, and business. In 1965, legislation allocated
funds to nursing home patients and passed the Older Ameri
cans Act. The number of facilities expanded and in 1977
there were 1.2 million nursing home beds.
It was during the phase of rapid expansion of nursing
homes in the U.S. that Pecan Grove Manor (pseudonym) nursing
home was built in southern Oklahoma. Pecan Grove Manor was
built in 1963 as a 30-bed proprietary facility. Within two
years, it was expanded to a 60-bed facility and within

9
another three years, 30 more beds were added to fix its
present patient load at 90. Seldom does the patient load
drop below its maximum capacity,

CHAPTER TWO
METHODOLOGY
Pecan Grove Manor was initially reviewed as a poten
tial research site because the administrator is the author's
mother's brother and .thus, a close kinsman. The time-
consuming negotiations and development of rapport that
would accompany commencement of fieldwork among strangers
was consequently reduced. Advantage could be taken of the
researcher's kin network only if such a relationship would
not attenuate objectivity and access to data. Secondly,
permission to engage in research was needed from the admin
istrator as well as the cooperation of staff and patients.
All of these criterion were met, leading to field entry in
June 1977.
A research effort affording complete access to all
components of a proprietary nursing home is unusual. This
project thus represents a departure from many studies
regarding the phenomenon of aging. In fact, research among
the institutionalized aged has been relatively neglected
based on a review, for example, of the Journal of Gerontol
ogy from 1946-1979 (i.e., Volume 1 through the present) and
the Index Medicus from 1967-1979. This is particularly
conspicuous when compared to the relatively voluminous lit
erature on other gerontologic topics.
Anthropologists have virtually ignored the institu
tionalized aged (see Clark 1973; Holmes 1976) and only a
few gerontologists have used anthropological methodologies
10

11
(Gubrium 1975). None have used anthropological perspec
tives. Of the research activities reported by any social
science discipline among the institutionalized aged, it is
my distinct impression that the overwhelming majority are
based on data gathered in nonprofit nursing homes affiliated
with some organized religious group. This is particularly
noteworthy in view of the fact that 79% of the institution
alized aged live in proprietary nursing homes (Butler 1975:
261). The few reports of research in proprietary nursing
homes are generally not recent and are superficial treat
ments of a very complex social setting (e.g., Scott 1955;
Solon 1957; Bennett and Nahemow 1965).
Anthropological investigation in a proprietary nursing
home is particularly appropriate. Not only does such an
effort fill a gap in studies on aging, but the anthro
pologist brings powerful perspectives and methodologies as
analytical tools that are seldom found in other human
sciences. The concept of holism coupled with participant-
observation data collection provides comprehensive, in-depth
reification of conceptual themes (Opler 1945) and experi
ences of cultural systems.
Furthermore, the methodology of participant-observation
has proven utility in a variety of institutional health-care
settings. Carol Taylor (1970; 1977) provides insight into
the experience of nurse/patient interactions by underscoring
the array of nonmedical manipulative behaviors exchanged
among health care personnel and patients and their

12
attendant consequences. Buckingham et al. (1976) explored
the lives of dying patients on a palliative-care ward in an
acute-care hospital. Rosenhan (1973) gained otherwise
unobtainable data on the effect of labeling and institu
tional treatment of not-so-mentally-ill volunteers. The
closest precedent for this study is by Gubrium (1975) who
engaged in participant-observation studies in a nonprofit,
sectarian nursing home.
Participant-observation is not new nor does it possess
the seductive glamour of statistically-fortified ques
tionnaires coded for key-punching and resulting in reams of
computer-tallied data. Before computers (or anthropology)
existed, Frederic LePlery studied French peasant families
by living in their homes with them (Timasheff 1967). With
the formalization of anthropology as a distinct field of
inquiry, intensive coexistence with the subjects of study
has been modeled after anthropologists such as Franz Boas
and Bromslan Malinowski of the early twentieth century.
Thus, the "art and science" (Pelto 1970) of participant-
observation fieldwork has established a firm basis for its
use (Babbie 1979; LeVine 1970; Simon 1978).
Participant-observation was selected as the primary
data collection technique at Pecan Grove Manor because of
its personal, experiential nature. Suspicions generally
felt about the ulterior goals of proprietary nursing homes
would cause data collected by government statistical compi
lations, questionnaires, mail surveys or other techniques

13
characterized by negligible encounter with the subject
population to be questionable.. Conversely, participant-
observation allows for first-hand data collection, in-depth
experience, and observance of formally-stated ideals of
behavior compared to actual expressions of behavior.
My personal use of participant-observation at Pecan
Grove Manor ran the entire gamut of possibilities except
being actually institutionalized. Although the fieldworker
may be admonished to totally immerse himself in the culture
of the study population, there actually exists daily
situational fluctuations of degrees of participation and
observation (Gold 1969) My research site allowed for the
total access to all participants: administrative, support
staff, patients, and families. However, because proprietary
nursing homes seem to expect negative assessments and in
fact are continually under the scrutiny of government in
spectors (not to mention families), observing and writing
notes in public areas presented some difficulty. In
anticipation, I had written nothing in public and carried
no notebook for the first few weeks after my arrival. As
the scene began to make more sense to me, the need to pre
serve my increasingly numerous meaningful observations
required the immediate jotting of notes in a field notebook.
On the day that I first began to write notebook
entries, I contrived a scene which would allow patients and
staff to see me taking notes and with the potential for them
to actually read what I had written. I selected a table

14
in the center of the lobby under a ceiling spotlight.
Using a large notebook and opening it, I began to conspicu
ously look about and then record my observations. I pur
posely avoided any entry of a potentially sensitive nature,
such as "nurses' aide Wheeler is goofing off," etc. As I
suspected, the "natives" became immensely.curious. The
curious "natives" were all employees of the nursing home who
first walked nearby, barely glancing at me and then later
returned to loudly speak in an overly endearing tone to some
"sweet" patient. After all, I was the boss's nephew who had
been sent to "spy" on them.
Within fifteen minutes of my act, the assistant
administrator and the R.N. very quietly came from behind me
and peered over my shoulder. When I noticed them, I moved
my arms away from my notebook, leaving it totally exposed
and undefended. They immediately asked me in a friendly,
shy way what I was writing. I handed over the notebook
explaining that the two pages of notes were just a beginning
and that I would surely require their assistance in the
future. The mundane jottings were handed back to me and
business went on as usual with several more months of a
"marginal native" (cf. Freilich 1970) exhibiting uninterrup
ted "note taking behavior" (cf. Rosenhan 1973).
My extent of participation included helping as a jani
tor, taking patients to the physician, going to the home of
a prospective patient and experiencing the trip from their
community home to the nursing home, being in a play to

15
celebrate the Fourth of July, and working as a paid
employee (nurses' aide). Thus, I was able to observe and
experience much of nursing home life during my thirteen-
month stay. Although it is obvious, I never personally
experienced being an old, sick, nursing home patient.
Because I could not experience age beyond my years or
experience the length of a hallway for an arthritic patient,
other data collection techniques were used. Notable is a
scheduled interview given to staff, families, and selected
patients. The interview schedule contained questions
specific to the respondent's role classification, but each
also contained a common core of questions for intergroup
comparison. Personal open-ended interviews were collected,
patient diaries collected, with still-photography and
sound cinematography completing the data-collection
strategies. The intent here was to maximize the quality of
data collected by using a multi-instrument research design
revolving about personal participation and observation.
In the larger view, the analytical framework used is
based on the model for community study (Arensberg and
Kimball 1965; Steward 1950). Conceptually, I approach
Pecan Grove Manor as I would any other society regardless
of geography. Pecan Grove Manor is thus viewed as a small
community with its peculiar beliefs, behaviors, boundaries,
rituals for incorporation and expulsion, etc., existing not
as a remote, untouched bit of flotsam, but as a part of a
network of other social groups of variable influence.

16
While Arensberg and Kimball (1965) emphasize that a
community is a microcosm of the cultural system of which it
is a part, Steward (1950) states that a single community
cannot be absolutely representative of its cultural system
(Crane and Angrosino 1974). Much the same consideration
must be made here. Pecan Grove Manor, as a community of
institutionalized elderly, cannot be absolutely representa
tive of all other nursing homes. However, there exist
certain parameters that cause the methods used here and the
subsequent findings to be useful in the investigation of
other age-segregated, institutionalized settings. For
example, Pecan Grove Manor is included in the following
attributes of contemporary American nursing homes: the
typical nursing home is a privately-owned business, the
physical plant is most often a system of rail-lined
corridors covering large distances, the patients are
generally very old (80s) and there is a three-to-one female-
to-male ratio, most patients are widowed, most employees
are untrained nurses' aides, patients have few visitors and
seldom leave the nursing home grounds, and of those who are
admitted to a nursing home and do not electively move to
another long-term care facility, most die there or die
shortly after transfer to a hospital. In these important
factors, Pecan Grove Manor is strikingly similar to the
profile of other American nursing homes (Moss and Halaman-
daris 1977) .

CHAPTER THREE
DEMOGRAPHICS AND EPIDEMIOLOGY
The patients of Pecan Grove Manor are institutionalized
because of some physical or mental debility. The degree
of debility among the patients is variable but must be
serious enough to warrant fulltime care as judged by
physician assessment. As a nursing home, Pecan Grove Manor
is essentially a living environment designed to support a
population of aged, debilitated people suffering the
extended effects and acute exacerbations of chronic dis
eases. The purpose of this chapter is to develop a demo
graphic and epidemiologic profile of Pecan Grove Manor's
health and disease environment. These data will be seen
to significantly influence the sociocultural environment
of this geriatric community. Thus, chronic disease and
sociocultural systems mutually influence each other.
Eventually all states in America must address the needs
of the expanding aged population. Those states which
currently have large aged populations may serve as proto
types while other states observe and analyze their strate
gies for adaptation. Oklahoma is one such "pioneer state"
with regard to aged populations. Demographically, Oklahoma
ranks seventh nationally with 12.37, of the total population
65 years of age and older (See Figure 1).
In reflection of Oklahoma's sizeable aged population,
97 of the $458 per capita health care expenditures in 1976
went to pay for nursing home services (Oklahoma Health
17

18
1.
Florida
16.4%
2.
Arkansas
13.2%
3.
Iowa
12.8%
4.
Missouri
12.7%
5.
Nebraska
12.6%
5.
South Dakota
12.6%
6.
Kansas
12.5%
6.
Rhode Island
12.5%
7.
Oklahoma
12.3%
8.
Maine
11.9%
9.
Pennsylvania
11.8%
9.
West Virginia
11.8%
10.
Massachusetts
11.7%
Compiled from: The Elderly Population: Estimates
by County, 1976. DHEW #(OHDS)
78-20248.
RANK BY % OF TOTAL STATE POPULATION 65+, 1976
Figure 1

19
Systems Agency 1978:46). Also, Oklahoma's availability of
nursing home beds is high. In 1977, Oklahoma had 80 beds
per 1,000 population 65 and over, compared to the national
figure of 62 beds per 1,000 population 65 and over (See
Appendix 1).
The geographic distribution of Oklahoma's aged popula
tion is associated with urban and rural areas (Oklahoma
Health Systems Agency 1978:25a). The two large urban areas
of Oklahoma are Oklahoma City (Oklahoma County) and Tulsa
(Tulsa County). Other rural counties in the state have
significantly higher populations of people aged 65 and over
(See Figure 2). Of all the 66 counties in Oklahoma,
Marshall County has one of the highest aged populations.
It is in Marshall County that Pecan Grove Manor is situated
(See Figure 2).
As a population ages, the prevalence of chronic non-
infectious disease increases. The epidemiologic profile
of Pecan Grove Manor patients is characterized by a high
prevalence of such diseases (See Appendix 2). Of all the
disease entries in Appendix 2, arthritis has the highest
prevalence rate (See Appendix 3). When the diseases at
Pecan Grove Manor are collapsed into categories used by the
Merck Manual, cardiovascular, neurologic, psychiatric, and
musculoskeletal/connective tissue diseases are by far the
most prevalent (See Appendix 4).
The patient population at Pecan Grove Manor is pri
marily female (70% female, 307, male) and the average age is

State of Oklahoma
Tulsa County
9.9%
Oklahoma County
9.9%
Marshall County
20.6%
PERCENT OF POPULATION 65+ BY SELECTED COUNTY
Figure 2

21
70. A population pyramid of the patients shows the greater
percentage of female patients to male patients begins in
the seventh decade and persists through the ninth decade
(See Appendix 5). The predominance of women is still
preserved when staff is included in a Pecan Grove Manor
patient/staff population pyramid. Thus, when considering
the patient and staff populations, Pecan Grove Manor nursing
home is predominantly female and middle-aged (average age
of patients and staff is 51.7 years).
The patient population is divided into three physically
and conceptually distinct units based on degree of debility.
Pecan Grove Manor is essentially three nursing homes in one.
The configuration of the physical plant is based on "wings"
radiating from a core containing the lobby, dining room,
nurses' station, and administrative office (See Figure 3).
Assignment to a wing is based on one's level of debility and
thus the type of nursing care required.
General observations give the impression that each wing
is characterized by distinctly different disease entities.
The level of care required on each wing would appear to be
a function of progressively more serious disease types.
However, disease distribution throughout the nursing home is
even. Wing assignment is not related to the roster of
diseases found on the patients' charts.
Four factors are related to wing assignment and do not
require physician assessment or orders in patient charts.
At admission, the prospective patient is assessed by the

SOUTH WING
Intermediate Care
PECAN GROVE MANOR
Figure 3
NORTH WING
Heavy Care

23
R.N. and/or assistant administrator according to continence,
ambulation, location of meal-taking, and ability to feed
one's self. These four patient-management factors determine
wing as signment.
The wings at Pecan Grove Manor are called by the
cardinal direction with which they most closely .align (See
Figure 3). The North Wing is closest to the nurses' sta
tion, personnel, medications and medical equipment. Those
patients on the North Wing are most likely incontinent, non
ambulatory, eat meals in their rooms and must be fed. The
diseases found on this wing are the same found throughout
the nursing home but the degree of debility is greatest
here. The efficiency of care delivery is enhanced by the
proximity of the nurses' station to the wing requiring the
most patient care.
At the other extreme, the East Wing houses people who
are most likely to be continent, ambulatory, dining room
users, and self-feeders. This wing is furthest from the
main nurses' station. Seldom are call lights used on this
wing. In fact, patients desiring "prn" (i.e., as often as
needed) medications typically walk from their rooms to the
nurses' station to make such a request.
The South Wing represents an intermediate transition
between the "heavy care" and "light care" wings. Here the
ambulatory, dining room users who feed themselves are
moderately represented relative to the other wings.

24
However, incontinence is highest on this wing. This is due
to ambulatory patients with urinary incontinence and noc
turnal-only urinary incontinence.
In summary, patient-management strategies are less
related to specific disease categories and more related to
level of debility as indirectly reflected by degree of
continence, ambulation, ability to feed one's self and
location of meal-taking (See Appendix 6). In this way,
Pecan Grove Manor becomes three nursing homes in one. The
patients, staff, and visitors learn and are affected by the
design of patient-management and the physical environment.

CHAPTER FOUR
ENVIRONMENTAL SETTING
The physical plant of Pecan Grove Manor comprises a
setting in which patients and nonpatients engage in activi
ties for significant parts of their lives. For patients
particularly, the physical plant represents the environment
which they must negotiate in order to interact with others,
get medicines, eat, and otherwise live their lives. The
staff, too, must perform within the confines of the build
ing. Staff activities often center about getting from one
patient to another which actually means one location to
another. Thus, the configuration of the physical plant has
the potential to "coerce" certain behaviors from its inhabi
tants (Sommer 1969).
Consideration for the environment as an influential
component of human societal existence has a lengthy tradi
tion in anthropology. Perhaps the cataloging of "exotic"
food items, shelters, medicines, rituals, etc., required at
least a superficial treatment of the environment as the
matrix from which these "goods" were extracted. As environ
ment became a more central issue in social science, human
ecology emerged as . the descriptive study of the
adjustment of human populations to the conditions of their
respective physical environments" (Hawley 1944:404). Later,
anthropology took account of environment from the cultural
ecological perspective of the interactive physical and
cultural environments (Steward 1955) .
25

26
Of specific importance here is a special type of envi
ronment known as an institution. Goffman's (1960) analysis
of "total institutions" underscores the oppressive nature
of the "inmates'" lives in a heavily controlled habitat.
While prisons or mental hospitals may be characteristic of
total institutions, many nursing homes, and particularly
Pecan Grove Manor, are not.
Bennett and Nahemow (1965) have developed a system of
ranking an institutional facility according to its degree
of institutional totality. Their perspective maintains that
a nursing home represents a significantly different living
environment compared to independent community life and that
while a nursing home may approach the total institution,
it often falls short of this extreme.
To assess Pecan Grove Manor along a continuum of insti
tutional totality requires a review of the environmental
setting encountered by patients and staff. The building is
comprised of three corridors attached to an open square room
(See Figure 3). Corridor architecture seems to characterize
the physical plant of many institutional facilities (Beckman
1971; Bennett and Eisdorfer 1975; Gubrium 1975; Koncelik
1976). Butler (1975) even refers to the "motel-like"
appearance of many nursing homes.
The corridor design of Pecan Grove Manor departs from
the motel image in that all corridors are lined with hand
rails. The rail-lined corridor is the distinctive feature
of many nursing home environments. Acute-care hospitals may

27
have handrails, but usually only in physical therapy areas,
and residential homes are devoid of such devices. While
hospitals share with nursing homes items such as bedrails,
bedpans, stethescopes, and white uniforms, and private
residences share with nursing homes things such as personal
furniture, patios, and bathrooms, the continuous rail-lined
corridor is to be found not in the hospital or private
residence, but only in the nursing home.
The handrail is both a metaphor and artifact of geri
atric institutional life. As the banister of a staircase
implies that use of the stairs is a risk, handrails in a
nursing home are prominent visual symbols of people whose
lives are at risk. Still, the handrail remains a needed
prosthesis and is thus a medical artifact supportive of
those people with diminished strength or poor balance.
The rail-lined corridor is public space. Activity in
the corridor is always simple locomotion from point A to
point B. Use of the corridor as a public pathway places
one on display to all those within seeing distance. Thus,
one's abilities or disabilities become community knowledge.
Each of Pecan Grove Manor's three corridors lead to
the main lobby area. The lobby is intended to serve as a
central location for patient interaction and activities.
Here are found vending machines, a color television, maga
zines, a piano, and numerous chairs, couches and rockers.
In spite of these various attractions, the lobby at Pecan
Grove Manor is an area of little person-to-person interaction.

28
Observations in other nursing homes disclose a similar
lack of use:
In the current state of the art of
building of nursing homes, lounges
must be regarded as the single great
est failure as a concept. Typical
lounges are the result of regulations
which specify that so many square feet
must be devoted to lounge space on the
basis of number of beds. This device
usually results in one or more very
large areas devoted to socialization,
relaxation, and contemplation, but not
really accomodating any of these
activities. (Koncelik 1976)
In one corner of the main lobby is the color television
set. The television area is marked by sectional vinyl-
covered couches facing the television and situated about
4 to 10 feet from the screen. While it is common to see
patients sitting on these couches, seldom is anyone actually
engaged in watching some program. Often patients fall
asleep sitting up or seem to welcome any distraction
(such as conversation with the researcher, an aide, a
phone call, etc.). In one instance, the volume control on
the color television broke, leaving video without audio.
The office personnel placed a small black-and-white portable
television next to the color set to use for the audio por
tion of programs. After a few minutes a patient changed
channels on the soundless color set. The picture on the
color television never matched the sound on the black-and-
white set for the remainder of the day. Still, patients
came to the television area, sat or slept, and then left,
never noticing the video/audio mismatch.

29
Several factors relate to the television area's in
ability to actually engage the potential viewer. Sensory
deficiencies may make seeing the screen and hearing the
sound difficult, particularly in a heavy-traffic area such
as the lobby (cf. Koncelik 1976:53). At times, when the
television sound is loud, nurses' aides lower the volume or
as soon as no one is in the television area, turn the set
off.
Also, many patients have personal televisions in their
rooms complete with cable service. The television area
serves, too, as a brief rest-stop on the way to the dining
room. When food trays are served, the television area is
immediately vacated.
Interaction among patients in the lobby is further
inhibited by the arrangement of chairs and couches. The
chairs and couches represent long lines of seating which
occasionally meet at right angles. For persons with de
creased sensory sensation and physical mobility, sitting in
lines of seats facing directly ahead requires difficult
bodily contortions to enable each person to twist to see and
hear the other. The degree of difficulty posed by these
communication obstacles is such that little interaction
takes place while seated in the lobby (cf. Koncelik 1976:53;
Sommer 1970:26-29).
The vending machines (soft drinks, potato chips, nuts,
candy, cigarettes) are located along a wall away from
activity areas. In contemporary American culture, the

30
media promote snack-type foods as vehicles which fuel
social interaction and cement social ties. Nonetheless,
the vending machines do not have chairs or tables clustered
nearby to take advantage of the Madison Avenue promotion
for food/love--love/food orientations.
Thus, the main lobby fails as an arena of lively
patient interaction in daily use. The only times at which
the main lobby becomes the location of significant inter
action are those of cyclical ritual events staged by the
nursing home staff and/or community. These events include
weekly religious services, civil/religious ceremonies
(Independence Day, Mothers' Day, Memorial Day), and Judeo-
Christian celebrations (Christmas, Easter).
The main lobby does, however, produce an impression of
a spacious "homey" atmosphere. The institutional nature of
Pecan Grove Manor is masked by residential-type furniture,
carpeted areas, and soft pastel wall colors. There also
are planters with green plants and decorative wooden support
posts with wood-shake shingles fronting the nurses' station.
Lighting is primarily by recessed neon bulbs, but even so,
table lamps are present in the lobby. Overall, the lobby
generates in the observer a positive feeling about the
nursing home as a whole.
Certain areas of public space seem to be conducive to
interaction due to some accidental configuration of design
elements. Adjacent to the main lobby is a zone which serves
as the main entrance to the nursing home. The entrance area
is a natural, unplanned interaction zone.

31
The main-entrance area promotes patient interaction by
its position as a vantage point for observing the daily
events within the nursing home. Other observers likewise
cite entrance areas as natural vantage points (Gubrium
1975:10; Koncelik 1976:52; Sommer 1970:34). Sitting in the
chairs or area near the chairs facing the entrance doors,
one can see through the glass doors and adjacent glass
panels to the parking area and the nearby highway. This
view allows for monitoring the travels of patients,
visitors, and staff. Also within sight is the nursing home
business office with its attendant activities. Looking to
one side offers the view of the entire ambulatory corridor.
Patients move within in the corridor frequently for visit
ing, medicines, food, and exercise. Looking to the other
side affords a comprehensive view of the main lobby, dining
room and nurses' station. For those patients whose mental
abilities permit, the entrance area provides a good all-
around location for gathering information about the daily
events of nursing home life.
The entrance area is also marked by its function as a
communication center. Here is found a phone for patients
to use, a large monthly-activities and events calendar, and
a major-event bulletin board. This area also is marked by
many color photographs of past parties. Live plants are
also here along with craft displays.
The entrance also attracts interaction due to its mid
point location between the ambulatory corridor and the

32
lobby/dining room/nurses' station cluster. Traffic in
either direction can, for convenience or necessity, stop
here to rest, observe and talk.
Social interaction is thus promoted in the entrance
area by numerous coincidental features. Seating in this
area is limited, however, and most users are those who have
retained higher levels of functioning. This part of the
nursing home physical environment serves as a central loca
tion for patients to learn of various activities occurring
in "their" building and to exchange information which is
then diffused to the other corridors of the physical plant.
Floor space area, whether lobby, entrance, or patient
rooms, is determined by formulas based on the number of
patients housed. The main lobby fulfilled the space re
quirements for the first thirty-bed unit and the second
addition of another thirty beds. When continued construc
tion added an additional thirty beds, however, additional
lobby space had to be built. This new lobby area is at the
end of the ambulatory corridor. In this new lobby, about
one-third the size of the main lobby, most intrainstitu-
tional activities occur.
Intrainstitutional activities include weekly bingo
games, activities such as singing and craft work, daily
domino games, and other patient/family activities such as
private parties. The new lobby area also serves as a place
for large groups of visitors to see their relatives.

33
One final area of public space to consider is the
dining room. While most other biological needs can be met
in the patient rooms, eating in the dining room is consid
ered. indicative of a relatively high level of functioning.
The administrative and nursing staffs encourage dining room
use for the change of scenery and social interaction. Even
so, seating placement is fixed so that forgetful patients
will not be so easily confused.
The dining room, like the lobby, is a place of very
little social interaction. Meals are brought to the tables
by the kitchen staff on large fiberglass trays. In an
effort to serve the food hot or cold, and to satisfy hungry
patients, great haste is made in getting food trays to the
tables. One result is that the kitchen staff has little
time to exchange pleasantries with the patients at the
tables.
Other obstacles to interaction at mealtime are related
to sensory deficiencies in the patients. The hearing-
impaired patient has difficulty understanding another from
across the table. Impaired vision may further hamper
communication by disallowing lip-reading. Additionally,
the kitchen is adjacent to the dining room where a very
loud dishwasher operates during meals (cf. Koncelik 1976:54).
Thus, food service responsibilities, sensory deficiencies,
and environmental noise function to inhibit mealtime inter
action.

34
While the lobbies and entrance area are zones of
public space, there are zones of private space. The pri
vate space areas are those controlled by the nursing and
administrative staffs. At the nurses' station can be found
the R.N. (i.e., registered nurse), L.P.N.s (i.e., licensed
practical nurses), patient charts, and medications. The
area behind the nurses' station marks the private space for
staff only. Here the nursing staff can work on charts or
medications with minimal patient contact. The privacy of
this zone enables the nursing staff to exchange medical
information as well as gossip about patients, other staff
members, or their community lives.
The nursing staff also converts part of the public
dining area to private space for breaks and staff mealtime.
The "break table" functions to channel news throughout the
corridors to the nurses' aides. Thus, aides assigned else
where can review important interactions to which they were
not witness.
While all staff members spend many hours of each day
within Pecan Grove Manor, only the patients live the entire
ty of their remaining lives in the institutional environ
ment. Most of this time is spent inside their rooms. An
empty room would look much the same as any other throughout
the nursing home. However, each wing has its own distinc-:.
tive atmosphere when filled with patients and their belong
ings.

35
The three-winged configuration of Pecan Grove Manor has
been used to assign patients to a particular wing not based
on specific disease entities but rather on a subjective
assessment of individual debility. Assignment protocol has
led to describing the wings by level of care needed and
has resulted in clustering of physical capacities (See
Appendix 6). Likewise, the artifacts in patient rooms
reflect the level of debility of those living there.
The North Wing, or "heavy care" wing, houses those
patients with the greatest physical and mental difficulty.
An artifactual inventory of these rooms discloses a general
paucity of personal belongings, residential furniture,
photographs, wall decorations and personal televisions.
It is here that the greatest number of restraining "half
doors" are found (See Figure 4). These patient rooms most
closely fit expectations of an institutional environment
(See Figure 5).
The South Wing, o:r "intermediate care" wing, is charac
terized by a mid-range level of debility relative to other
patients at Pecan Grove Manor. The patient rooms are
relatively well-adorned with personal memorabilia but resi
dential furniture and personal linens and appliances are
scarce. Televisions are in greater evidence but not uni
versal.
The East Wing, or "light care" wing (also "ambulatory
wing"), reflects the relatively high level of functioning
retained by these patients. In this wing, the greatest

FIGURE 4
HEAVY CARE CORRIDOR

LO
FIGURE
PATIENT ROOM--HEAVY CARE CORRIDOR

38
number of personal belongings, residential furniture, hand
crafts, and television sets are found. A television set is
present in every patient's room and occasionally one room
has two televisions (See Figure 6).
Those patients with high levels of functioning are
fully aware of the wing--debility relationship. The
nursing staff on occasion may "threaten" an ambulatory-wing
patient into some behavior (typically some type of self
health-care action) by simply mentioning the likelihood of
being moved to the intermediate care wing. Other similar
coercions exist, always with the power of the "threat"
directed at movement toward the least desirable wing.
There is very little voluntary contact with the heavy-care
wing patients by members of the other wings, and the heavy-
care wing is referred to as "over on North where those
pitiful people are" (cf. Gubrium 1975: 16, 26). Thus, wing
assignment is a metaphor of one's functional capacity and
proximity to death.
Establishment of one's position within the wing--debil-
ity system is decided at admission by the R.N. and/or the
assistant administrator. Room availability may also influ
ence the initial wing assignment. Regardless of actual
placement, the cognitive map of relating to the entire
experience of living and dying at Pecan Grove Manor is one
of initial admission to the ambulatory wing with a high-
level functional capacity, followed by physical and mental
decline resulting in a move to the intermediate wing. From

FIGURE 6
PATIENT ROOM--AMBULATORY WING

40
here, further decline is experienced necessitating a move to
the heavy-care wing with the other "pitiful people," "poor
things," and "crazy ones." Even within this wing, a final
move through space signals impending death. The dying are
moved to Room #1 North due to its proximity to the nurses'
station. From here, the final move is final. The patient,
then, learns to use this "cosmology" as a grid upon which to
maintain a constant fix on his or her date with death.
The experience of Pecan Grove Manor seems to be charac
teristic of American institutional settings for the aged.
Pecan Grove Manor as an institution conforms generally to
Bennett's medium level of institutional totality (Bennett
and Nahemow 1965:47). However, Pecan Grove Manor's three
sections have certain institutional characteristics in
common but also each wing requires its own special treatment.
Institutional characteristics common to all wings range from
high to low levels of institutional totality. For example,
the nursing home as a whole is a permanent residence (high
level), socialization of new members is informal (medium
level), and there exists no objective sanction system (low
level).
Again, using Bennett and Nahemow1s (1965:47) scheme,
the heavy-care wing has seven of ten criteria commensurate
with a high level of institutional totality. The medium-
care wing has only three of ten high-level characteristics,
while the light-care wing has only one, that of permanence.
With regard to a medium level of institutional totality, the

41
heavy-care wing has only one matching item, the intermedi
ate-care wing has seven out of ten matches. The low
totality category has all three wings assigned to just one
item no objective sanctions. Overall, Pecan Grove Manor
can be characterized as an institution with a medium level
of totality. In this setting, patients play out their
daily life cycles in association with sets of employees
hired to assist and monitor this final phase of existence.

42
Note
1. In fact, on the 11 PM to 7 AM shift one night several
years ago, the aides and myself were surprised to
see a car drive from the highway into the nursing home
parking lot. A man came into the nursing home, walked
across the lobby to the nurses' station and asked
for a room for the night.

CHAPTER FIVE
THE DAILY CYCLE: RITUALS OF FABRICATED LIFE
Pecan Grove Manor is a society of elders experiencing
life at imminent risk of death while their progress toward
this end is monitored by paid attendants. However, the
American propensity for denial of death demands illusion to
mask the cultural apparatus of lingering death. This
stance is like the mesmerizing qualities of the magician's
slight-of-hand that allows transcendence beyond the plane
of mundane experience into the mystifying realm of reality
denied. Thus, the functional reality of the nursing home
is obscured by a daily series of rituals fabricating the
illusion of meaningfully transacted life.
The critical elements of nursing home life involve
a triad of patients, nurses' aides, and care-giving patterns
associated with chronic debilitating disease necessitating
long-term care. Interactional exchanges between nurses'
aides and patients are characterized by daily, intensive
contact with each other. In this environment of long-term
exposure to patients, the nurses' aides, though generally
untrained, become highly sensitized to patients' typical
behavioral patterns and ultimately become diviners of
exacerbated illness episodes who may treat or report their
findings to licensed nursing personnel who then carry out a
treatment protocol. Also, patients are able to manipulate
their hosts by exploiting informal mechanisms of social
control and identifying resources within the nursing home
43

44
community to assist them in negotiating institutional life
and chronic disease.
The inner workings of nursing homes have been examined
from a variety of perspectives, each with its own version of
reality and degree of quality. Social critics have long
accused the nursing home industry of being charlatans.
Consider these titles: Tender Loving Greed (Mendelson 1974),
Old Age: The Last Segregation (Townsend 1971), Where They
Go to Die: The Tragedy of America's Aged (Garvin and Burger
1968), and Too Old, Too Sick, Too Bad (Moss and Halamandaris
1977).
Another category of nursing home speculators involves
the experienced administrator teaching others to be admin
istrators. These works are characterized by manipulative
marketing techniques designed to promote a nursing home
(Bachner 1974) and "how to" instructions detailing how to do
to patients and families (Rogers 1971; Miller 1969). Other
administratively oriented volumes attempt to be more thera
peutically oriented (McQullan 1974; Kramer and Kramer 1976).
A shift in orientation of perspective is observed as
the authors of works examining nursing homes are identi
fiable as social scientists. The content of such volumes
tends to be oriented toward an analytical view of the inner
workings of nursing home living and ideas regarding the
quality of life of the inmates. Some comprehensive volumes
include Long-Term Care (Sherwood 1975), Long-Term Care of
Older People (Brody 1977), Last Home for the Aged (Tobin

45
Lieberman 1976), and Better Homes for the Old (Manard,
Woehle, and Heilman 1977).
An irony of expositions regarding aging and particu
larly aging in an institutional environment is that these
research efforts are done by young and middle-aged people.
It would seem especially uncommon for a nursing home patient
to do and publish research on his or her own setting. It is
here that the benefit of the anthropological data-gathering
method of participation coupled with systematic observations
and recording are highlighted. While one may never become
a member of another reality, participant-observation en
hances the depth of understanding and communication between
the researcher and the community of study. In this research
project, I was able to not only observe and record daily
events, but also participate to the extent of being a con
fidant of patients, a part-time paid employee of the nursing
home, a participant of civil/religious in-house events, a
cultural broker for new patients and families, and a paid
speaker for the state-wide nursing home association. Thus,
not only did I observe the daily cycle, but was actually an
agent in the fabrication of life.
The participants in communities undergo community-
specific socialization processes known as rituals of incor
poration which are further reinforced on occasion by
rituals of solidarity. The objects of this socialization
process are the people of the community. In order to
properly fabricate life in Pecan Grove Manor, the daily

46
participants must be identified, their roles defined and
assigned, and then this system put into action.
The members of this community can be classed into two
general categories: managerial and target populations.
The managerial group consists of the hierarchy of all paid
staff groups and the target group consists of patients and
their families. Implicit in this scheme is an interactional
orientation characterized by managerial groups acting on
target groups. The components of primary importance here
are the nurses' aides as a managerial subgroup and the
patients as a target subgroup, due to the enormous amount
of time these two groups of people spend together engaged in
fabricating rituals of life.
The incorporation of nurses1 aides into the ethics of
the nursing home staff involves formal and informal sociali
zation. Formally, the new aide is taught how to ideally
behave in a meeting with the R.N. during which the patient
is identified as most important and the administrator (i.e.,
boss) as least important. Even a document indicating the
assimilation of this scheme is signed by the new nurses
aide and filed in her employment folder.
The informal socialization of the new nurses' aide
filters down from the administrator and is based on the
perceived expectations of patients, their families, and
government inspectors. A common phrase which circulates
among the administration at Pecan Grove Manor characterizes
the perception of the typical nurses' aide: "fat, white,

47
and forty." In fact, this phrase is fairly accurate. Most
of the nurses' aides have not graduated from high school,
are married or divorced, have children, have a history of
working at a variety of semiskilled jobs, and are over
weight, white and middle-aged. Two other local industries
predominate in the same town as Pecan Grove Manor. These
industries, the manufacture of horse trailers and the
assembly of trousers, hire at minimum wage and offer
assembly-line type tasks. Employment at Pecan Grove Manor
is perceived by many as a coup because one works in a
higher-status setting with humanitarian goals and still is
paid the federal minimum wage.
The administration, however, is confronted with a
special task. While local women may aspire to employment
at Pecan Grove Manor, once there, a transformation from a
view of job goals as repetitive, quick action on inanimate
objects to a view of job goals as repetitive, quick action
on animate objects is required. The value of assembly line
efficiency is retained, but there is a shift from machine to
human as the task target.
The administrator of Pecan Grove Manor fosters a
pseudo mother/child interactional orientation between
nurses' aides and patients. The effort is to anthropomor
phize the targets of the aides' responsibilities. The
mother/child perspective also makes use of roles familiar
to the new nurses' aide employee who typically has no pro
fessional training and a meager repertoire of roles on which

48
to base her behavior in a nursing home setting. There
exist many symbols to excite the mother role or "mothering":
helplessness, toddling, incontinence, beds with bars,
diapers, etc. By focusing on the mother/child interactional
pattern, a maximum level of care behavior is extracted from
the untrained, low-level nurses' aide.
The mother/child role relationship is expressed in a
variety of ways. The infantilization of the adult patient
can be observed in child-like words for excrement ("shoo-
shoo," "wee-wee") and diapers ("didees"). One instance I
observed demonstrated the nursing staff need to persist in
infantilizing the patient. A nurse was examining a male
patient with a distended lower abdomen. The man had a
history of prostatitis. The nurse used "pee" and "make
water" while the patient used "urinate" and "catch a speci
men. "
Other expressions of infantilization are more com
pletely explicit than referring to patients as "baby,"
"little one," or "little people." Consider these phrases:
"... just wash them like I would
one of my own children, 'cause that's
just what they are."
"Ive got twelve kids and so I'm well
suited to this job."
"Like babies, they get good and warm
and they pee up a storm."
"I think of these people as my babies,
especially the ones on North Wing
because they are so helpless."
"They're like children. They are there
for us to spoil."

49
"They are like children and thats
the way I treat them."
While promotion of the mother/child role behavior may
function to enhance care-giving and to animate the patients
conceptually, there are also costs that accrue. For
example, acting as a mother toward a patient will elicit
the appropriate dyadic response of a child. Adult-to-adult
interaction is thus retarded.
Particularly lacking is adult/adult interaction among
male patients and the female nursing staff. I found the men
thirsty for "man" talk. Male patients were the most anima
ted in their conversations when I sought advice about
proper carburetion on a lawn mower, inquired about hunting,
fishing, and trapping exploits, asked about farming or
ranching and other "male domains." Conversational topics
of this nature were absent during nurse/male patient
interactions. Self-generated conversation of this nature
was not common among the men due to daily familiarity of the
members and possible exhaustion of topics. My presence and
questions produced high-energy conversations due to my
newness to the nursing home, and my continual contact with
the non-nursing home community, and a perception of self-
worth in that they were being asked to share a part of their
past role experiences with a younger man.
Administrative influence on nurses' aides is seen
again in the distribution of the nursing staff in task and
wing assignment. Staffing of each wing varies according to

50
the level of care needed and shift time. For instance,
federal regulations require one nursing staff member per
each ten patients on day shift (6 AM to 2:30 PM), one
nursing staff member per each twenty patients on evening
shift (2:30 PM to 11 PM) and one nursing staff member per
each twenty-five patients on night shift (11 PM to 6:30 AM).
Since Pecan Grove Manor is designed to accomodate ninety
patients, the day shift has eight nurses' aides and one
L.P.N., the evening shift has five aides and one L.P.N.,
and the night shift has three aides and one L.P.N.
The distribution of aides by shift is based on level
of care needed on each wing. Patients, visitors, office
staff, and thus nurses' aides are the most active during the
day shift. Day shift nursing staff is the most differentia
ted. The heavy-care wing has four aides, the intermediate-
care wing has three aides, and the ambulatory wing has one
aide who, during part of the day shift, helps with baths
and food delivery. The majority of the day shift she spends
dividing her time between the other wings.
The day shift begins officially at 6:00 AM, but day
shift aides have informally assembled in the lobby near the
nurses' station for casual socializing ranging from 5:15 AM
until shift report. Pre-shift conversations are typically
about personal community life. Only if something unusual
regarding a patient has occurred is the topic of the
nursing home related.

51
Shift report begins about 5:50-5:55 AM. The day shift
aides move to the nurses' station, having been summoned by
the charge nurse (an L.P.N.) to review as listeners the
events of the night seen as significant. The content of
the shift report includes three topics: medications given,
assessments made (e.g., vital signs), and unusual illness or
mood changes.
Most shift-report information is useless to the nurses'
aide. Medications given are read by name of drug, amount
given and to whom it was given. After report, none of the
aides were ever able to tell me what the medications were
for or why they were given, with the exception of two
tranquilizers, Thorazine and Sparine ("to keep them quiet"),
Valium ("nerve pills"), and nitroglycerin ("heart pills").
Vital signs were seen as significant only if unusually
exaggerated and emphasized by the charge nurse reading the
report.
Shift-report information that elicited response from
the nurses' aides was the mention of laxatives (often read
as "milk of mag"), falls, escapes, and rowdiness. Laxa
tives and behavior problems mean work for the aides.
Reports of laxatives being given were met with such remarks
as "Oh, no!," "We'll be busy today!," and "They don't need
any laxatives!"
In spite of the selective use of shift-report informa
tion, the entire previous-shift nursing activities were
always reported. Prather than functionless ritualism,

52
however, shift-report serves an important purpose. It
marks a transition from mundane conversations and concerns
current moments before, toward inspiring awe and respect
for the medical and humanitarian tasks ahead. As one aide
put it while making a bed, "I've always wanted to be in the
world of medicine."
The duties of the nurses' aides are seen in the most
complete form on the day shift on the heavy-care wing. A
typical routine for four nurses' aides is presented in
Figure 7. This daily shift routine collapses into seven
main task categories plus miscellaneous ones (See Figure 8).
The tasks requiring the most time per shift are feed
ing, bed check, and showers. Feeding is time-consuming in
that on the heavy-care wing, 887 of the patients eat in
their rooms and of these, 247. require feeding by an aide.
At lunchtime, for example, there are four nurses'
aides who pour milk and tea for each patient, place them
on the trays, and take the trays to the patients. After all
trays have been distributed, the four aides feed the eight
patients who cannot otherwise eat. For the nurses' aides
there are "feeders" (i.e., a patient requiring feeding)
who are more desirable than others. Desirable features
include a room furniture arrangement allowing (read: requir
ing) the aide to sit while feeding, a patient who does not
choke, drool or otherwise "cause problems," and a patient
who eats rapidly. Thus, following tray distribution, a
silent race ensues among the aides to acquire the most de
sirable feeders.

53
ACTIVITY
TIME
Lights on
05:57 AM
Linens
05:58 06:06 AM
Get patients up
06:06 06:28 AM
Make beds
06:28 06:54 AM
Breakfast
06:54 08:07 AM
Bed Check (2 aides)
08:07 10:10 AM
Showers (2 aides)
08:07 10:55 AM
Shaving
10:10 10:33 AM
Break
10:35 10:50 AM
Shaving
10:50 11:37 AM
Lunch
11:37 12:58 PM
Put patients to bed
01:00 01:40 PM
Rinse dirty linens
01:40 01:47 PM
Aides' lunch
01:47 02:17 PM
Shaving
02:17 02:25 PM
Talk, f ix s ink
02:25 02:30 PM
NURSES' AIDE TASK-TIME ACTIVITY
5 May 1978
(FOUR AIDES EXCEPT WHERE NOTED)
Figure 7

54
ACTIVITY
TIME DURATION
Patients up, down, or cleaning
1 hour 02 minutes
Food service
2 hours 22 minutes
Bed check, make beds, clean beds
2 hours 29 minutes
Shaving
1 hour 18 minutes
Break, Lunch
45 minutes
Linen
08 minutes
Showers
2 hours 48 minutes
Miscellaneous (rinse dirty linen,
fix the sink)
12 minutes
8 hours 16 minutes*
*For those nurses' aides who don't give the showers.
NURSES' AIDE TASK-TIME CATEGORIES
5 May 1978
Figure 8

55
When I began working as a paid nurses' aide, the first
striking discovery I made was that each aide has memorized
a large array of personal habits of each patient that ren
dered their service to the patient more personal and time-
efficient (cf. Taylor 1970). For instance, the placement of
a juice glass on the left side of a breakfast tray for one
person renders the glass more visible and accessible, two
packages of sugar for one person, three for another, no
napkin for that person because they eat paper, etc., is
required for proper job performance. The catalog of indi
vidual patient wants is enormous and generally fulfilled.
Only lengthy, daily contact would make such a feat possible.
This same intimate knowledge of patients is observed
in noting behavioral change that may be of medical conse
quence. Actual hands-on contact with patients such as
feeding, bathing, clothing, changing diapers and bed linens,
provides the nurses' aide with another set of information.
The nurses' aide becomes aware by sheer repetition of
patient-specific behavior patterns and potentials. Devia
tion from an expected set of behaviors warrants mention to
a higher authority.
For example, Mr. Robert Henry (pseudonym) is a white
male, 72 years old, bed-fast, diabetic, paralyzed on his
right side as a result of a cerebral vascular accident,
incontinent and requires feeding. The position of Mr.
Henry's bed is such that the nurses' aides continually feed
him from one side of the bed. For weeks this was satis
factory until one morning a nurses' aide reported to the

56
other aides that Mr. Henry seemed to be drooling very
slightly from the left corner of his mouth. I later fed
Mr. Henry and found the report accurate. The loss of food
from his mouth was slight enough so that only the staff who
worked with this patient routinely day-in-and-day-out would
recognize this as a potentially significant behavioral
change. Without extensive awareness of Mr. Henry's behavior
patterns, the drooling may have been attributed to his posi
tion in bed, soft diet, dislike of the menu, or as just
another patient who drools. This change was reported to the
R.N. as evidence of a minor stroke. The aide who reported
the change later told the group that the R.N. attributed
the change not to stroke, but to his medications which
included large quantities of Thorazine. However, Mr. Henry's
chart recorded no change in medications before or after
the aide's report.
The nurses' aides, in spite of no medical training,
are the most important health-care agents in Pecan Grove
Manor. Their significance exists in their extensive contact
with the patients. They may be able to identify an importart
change in a patient that the R.N. would be unable to do.
The aide who notices some relevant change recounts her coup
for several days until virtually all the staff is aware of
it. Thus, the lack of training and low status of the nurses'
aide is not necessarily a detriment to patient well-being.

57
Noticing slight changes in patients leads the nurses'
aides to engage in a variety of folk-diagnoses and prescrip
tions, for they "know what that patient needs." A frequent
diagnosis is constipation. This does not require notifica
tion of the R.N. or laxatives unless symptoms persist. The
symptoms are subtle ones such as patients who look like they
are straining when they should be relaxed in bed, a patient
exploring his anus with a somewhat determined facial expres
sion, general foul mood, and deviation from expected time
intervals of bowel movements.
If it is determined that the patient suffers from con
stipation, the cure is to remove a suspected lower rectal
impaction. This involves a trip to the nurses' station
(otherwise off-limits to the average aide) to get a surgical
glove and some "K-Y" jelly. The patient is often positioned
in front of a toilet in expectation of successful therapy.
If an impaction is present and removed and the dilatage
action promotes a bowel movement, or even if the blockage
is up higher and not immediately relieved, the diagnosis
and therapy still allows the nurses' aides a brief foray into
"medicine" and some assurance for themselves that it will be
some time before they have to change that patient's under
wear or diaper.
Other folk-diagnoses made by nurses' aides revolve
about observed changes in the integument. Tasks assigned to
the nurses' aides require seeing and touching the patients'
skin. Feeding, bathing, cleaning incontinence and clothing

58
a patient provide ample opportunity for close, sustained
contact with individual patients. This "hands-on" contact
promotes situations in which the nurses' aides are the
initial agents of health-care providing.
Abnormal body temperature is susceptible to nurses'
aide detection. However, since all thermometers are kept
at the nurses' station, the nurses' aide in a patient's
room uses her bank of past experience with a patient to
determine abnormal temperature. The ability to perceive
fever by a nurses' aide requires long-term contact with each
patient. Several reasons exist for this prerequisite. Each
person has individual responses for body temperature adjust
ment, air temperature in each room is variable, blankets
and clothing alter skin temperatures, and rubber draw
sheets, plastic-covered mattresses, or plastic air-mattress
es may be present which cause skin temperature increases.
Thus, one person may typically sweat enough to thoroughly
dampen bed linens while showing a normal temperature.
If a patient is suspected of having an abnormal body
temperature, the nurses' aide goes to the nurses' station
to get a sterile thermometer and "K-Y" jelly if rectal
temperature is taken. Not only does this allow the nurses'
aide to engage in "medical therapy" for a brief time, but
it is a legitimate time-consumer away from the more mundane,
"dirty work" which is the common lot of nurses' aides.
Integument changes are also noted for acute hyperten
sion. Redness of the face is a primary symptom nurses'

59
aides use to diagnose hypertension. An aide who is trained
to measure blood pressure goes to the nurses' station for a
stethescope and syphgmomanometer. If hypertension is indi
cated, the nurses' aide will report it to the nurses' sta
tion with no report if the charge nurse is away or casually
mentioned as a negative result to the charge nurse if pre
sent .
Perhaps the most important skin signs observed by the
nurses' aides is the precondition leading to decubitus
ulcers. R-eddened skin, particularly in regions of bony
prominences, is a signal of impending bedsores. Bedsores
are particular problems for long-term care bed-patients and
those who sit in wheelchairs or even lounge chairs for
lengthy periods of time.
When reddened skin is noticed, it is desirable to
massage the local area with lotion. However, this simple
preventive measure is infrequently used. The technique of
simple massage lacks the paraphenalia which signals high-
level medical therapy. Also, lotions that are frequently
used are purchased by the patient or the patient's family
and are thus generally unavailable for even distribution
throughout the patient population. As a result, decubitus
ulcers are present.
The presence of decubitus ulcers is an embarrassment
to the nursing staff. The nursing staff often blame the
existence of decubitus ulcers on mismanagement of patients
while they were away at a hospital. These hospital-genera-

60
ted bedsores are then transferred to the nursing home.
While this may be true to some extent, bedsores likewise
originate in the nursing home. Yet, the nursing dictum
that "bedsores are totally preventable" seems to be overly
optimistic. People who are kept alive for so long that they
can't be handled because deep tears in the skin occur can
hardly be expected to remain free of decubitus ulcers.
Likewise, the comatose geriatric patient who is incontinent
and fed by a naso-gastric tube represents another nearly
impossible task in decubitus ulcer management. It remains
true, however, that more effort is expended in bedsore
management than prevention.
Also involved in the primacy of physical care is that
it is expressed in physical activity. The busy aide is one
who is moving. The charge nurse can look down the corridor
and tell if the aides are actually working by the movement
in and out of rooms. The aides assimilate this dogma
rather completely and probably by transfer from other jobs.
For instance, I noticed one nurses' aide leaning on a
patient's bedrail and talking to the patient for about five
minutes. Later, in response to my question of what she had
been doing, I was told, "just foolin' around."
Physical orientation to patient care is further promo
ted by its observability, immediacy of results, and amena
bility to rapid dispensing. Thus, the nurses' aide can pro
ject the good-worker image not only by activity, but by the
physical proof of duty performance within the time con
straints of her shift.

61
Perhaps the task most associated with nurses' aides'
duties is "bed check. By federal regulation, all nonambu
latory patients must be routinely checked for incontinence.
Bed check thus consists of visual or physical inspection of
incontinent patients. Soiled clothing, bed linens, bed
frames and patients must be changed or cleaned.
Gubrium (1975) refers to this part of nurses' aides'
duties as "bed and body" work. It is this task category
that most undermines the patients' and nurses' aides' sense
of propriety. Bed and body work peels away the cosmetics of
one's daily "act" to reveal the "underside" of a lifetime of
culturally appropriate impression management. The locked
door that screens the toilet habits occurring in the Ameri
can bathroom (cf. Miner 1956) is ripped from its hinges for
both the patients and nurses' aides.
Bed check is considered the most mentally and physi
cally taxing job task. One's performance here leads to peer
ranking along a continuum of good to bad. The stresses in
volved for aides and patients in bed check are immense and
are expressed in the following vignette from my participa
tion and observation:
"Now you're really gonna get broken in,"
the female nurses' aide told me as I
approached Mr. Joe Green's (pseudonym)
room. Mr. Green lay in his nursing home
bed in a near-visible order of inconti
nence. He is a diabetic, an alcoholic,
an amputee, a hemiplegic from an old
cardiovascular accident, is non-ambula
tory and generally considered to be ill-
tempered. As he lies in bed, Mr. Green
often hollers as if sharp pains momen-

62
tarily seize him.
Mr. Green lay on his back, his
head on pillows and the stump of his
left leg (amputated at the distal end
of the femur) supported on pillows.
A plastic urinal is left between his
legs with his penis positioned inside.
The first task of the aide is to empty
the urinal. Sometimes the glans rests
on the side of the dry urinal, other
times it is submerged in urine. In
either case, the urinal is removed
by moving it away from the body. As
the penis exits the urinal, it drags
along the inside surface of the urinal
eliciting a pained cry or a stream of
expletives. Only once was it observed
that an aide positioned Mr. Green's
penis so that it didn't scrape against
the surface of the urinal.
As Mr. Green is rolled toward the
side of the bed, a liquid pool of feces
becomes visible and is filled with
recognizable bits of food. The aide
nearly vomits. The aide "lovingly"
chastises Mr. Green and begins to clean
him.
The buttocks are spread and the
corner of a Chux protective panel is
used to begin cleaning. After the majori
ty of fecal matter is removed, washcloths
are used to finish the job. Invariably,
Mr. Green screams at the aides that they
are hurting him as they clean the scrotum.
Seldom does an aide attempt to touch the
scrotum in an effort to expedite the ease
and thoroughness of cleaning.
Occasionally, a shower is required
to clean Mr. Green from incontinence. In
this instance, he may be wrapped in the
bed sheets and placed in a shower chair
to be rolled to the shower. At other times,
when the floor and aides' shoes are not in
such jeopardy, he is placed on the shower
chair nude and then covered with a sheet
preparatory to transport. At these times,
he is apt to loudly complain that "you sat
me on my nuts!" The aides generally scold
him and try to reposition him.
Interaction with Mr. Green typically
requires the services of three aides: two
to lift and clean and one to hold Mr.
Green's hands to prevent him from striking

63
those in reach. While Mr. Green is
mentally alert, conversational, and
likes to talk about his former fishing
days, conversation is directed toward
Mr. Green's roommate who cannot speak
at all. The roommate is 54 years old,
mentally retarded, behaves in a child
like manner including delight with toys
and stuffed animals.
A number of stresses between patients and nurses' aides
are expressed in the above interaction. Observing the pro
cedures for cleaning incontinence or reading about it does
little to reify the actual, hourly, daily experience.
At Pecan Grove Manor, the nurses' aide "must," from
official administrative and nursing dictum, "love" all of
the "little old people," do their jobs with great efficiency
and above all, never, ever mistreat a patient. From a
managerial perspective, expecting these superhuman qualities
will not insure perfection of job performance, but will en
hance the likelihood of good patient care. Acting out these
exhortations with patients like Mr. Green is difficult.
In spite of admonishments and reports of "loving all
these little old people," occasionally more honest state
ments emerged: "We love all of these little old people, but
we love some more than others." Thus, the good patient/bad
patient distinction commonly observed in other health care
settings is found here, too (cf. Lorber, 1975; von Mering
and Earley, 1966).
Mr. Green is considered a "bad" patient. Incontinence
or other debility alone is not enough to warrant bad-patient
status. These traits, however, can produce bad-patient

64
status in some combination with the following attributes:
some degree of mental intactness, physical strength, speech,
and vocal complaints.
Another obstacle to care results from sexual tabus.
Only once did a nurses aide touch Mr. Green's penis to
facilitate exit from the urinal. Mr. Green's scrotum often
was left with some fecal material on it due to imcomplete
cleaning. Other male patients who were not circumcised
never, in my observations, had the foreskin retracted for
thorough cleaning of the glans. On the other hand, I was
allowed to assist in toileting habits with a twenty-five
year old, mentally retarded female except when she was
menstruating.
Lastly, the nurses' aides minimized interaction with
Mr. Green by avoiding all but essential communications. Mr.
Green'sroommate, even though he was aphasic, was the recipi
ent of generous amounts of conversation to which he would
laugh, act shy, and make "goo-goo" noises, delighting the
nurses' aides.
Is Mr. Green's case one of a difficult patient or a
difficult staff? I personally experienced working with Mr.
Green very distasteful. He did smell, look, and act badly.
However, when I had the time to ask him about his life, he
was responsive and I was surprised to find a rather com
plete, intact personality. This did not elicit in me a
missionary zeal of saving this man's integrity. My will
ingness to talk with Mr. Green not only produced conversa-

65
tion but identified me as a resource (perhaps "easy mark"
should be read) for him. Mr. Green would shout from his
bed for me by name to give him a cigarette. A patient
smoking in bed requires the aide to stay in the room and
thus interferes with the work schedule. At times I would
comply and at other times I was unable to do so due to work
demands.
Actions other than physical care directed at patient
involve efforts at promoting psychosocial support for the
patient population. The psychosocial environment is expec
ted to be fueled by that part of the nursing home life known
as "activities." Activities at Pecan Grove Manor are fre
quent and of variable quality (See Figure 9). Three fea
tures of the ritual calendar deserve mention: (1) nurses'
aides' interference, (2) lack of response measurement, and
(3) advertising.
The nurses' aides represent interference to effective
activity programs, primarily with regard to the weekly
secular in-house activities. For example, the "band"
activity consists of the activities director assembling
several patients in the east wing lobby to play various
percussive instruments. She complained often that by the
time she walked a few patients to the east lobby and went
down the corridors to get others and walk them back to the
lobby, the early arrivals had become bored and wandered off
to different parts of the building. Efforts to enlist the
assistance of nurses' aides were futile due to the aides'

66
CATEGORY OF
EVENTS
PUBLIC
INVOLVEMENT
INTRAINSTI-
TUTIONAL
CYCLE
Religious
WEEKLY
Services
X
Special
Religious
Celebrations:
1. Christmas
X
ANNUAL
2. Easter
X
ANNUAL
Civil/Religious
Celebrations:
1. Valentines Day
X
V
ANNUAL
2. St. Patrick's Day
X
X
ANNUAL
3. Mother's Day
X
ANNUAL
4. Father's Day
X
ANNUAL
5. 4th of July
X
ANNUAL
6. Halloween
X
ANNUAL
7. Thanksgiving
X
ANNUAL
Secular Activities:
1. Birthdays
X
MONTHLY
2. Bingo
X
WEEKLY
3. Beauty Shop
X
WEEKLY
4. Crafts
X
WEEKLY
5. Remotivation
X
WEEKLY
6. Band
X
. WEEKLY
ACTIVITIES
Figure 9

67
insistence that they did not have time, or could not leave
"the lights" unattended.
The beauty shop is an activity that sometimes becomes
a spontaneous party, even attracting male patients and
office workers to the door. One L.P.N. disliked the laugh
ing and commotion in the beauty shop because it disrupted
the sanctuary-like environment she considered proper. As
she told me one day, she preferred to work on shifts in the
evening and night hours because families were less present,
most patients were asleep, and she could engage in "pure-
dee quality nursing care." One of those involved in activi
ties suggested that the nurses' aides disliked patients in
the beauty shop in the afternoon hours because it prevented
the aides from putting the patients to bed so the aides
"wouldn't have anything to do."
Activities as therapy are suspect, too, because there
are no assessments of improvements in patients attributable
to the activity program. Benefits to patients may be slight,
subtle, or nonexistent, but no one knows for certain. The
visibility of physical care benefits overshadows the rela
tive invisibility of psychosocial improvement.
Activities in the religious and civil/religious cate
gories are highly visible and receive great attention from
the administrative, nursing, and activities staffs. Most
important is Christmas and Mother's Day. For example, the
Mother's Day celebration becomes a community competitive
potlatch in which conspicuous consumption brings status to
the nursing home from the community.

68
Mother's Day 1978 lasted about three hours. It cost
Pecan Grove Manor $897.30. Newspaper ads accounted for over
$200. One nearly full-page ad outlined a "roaring '20's
theme with a skit, play, snow-cone stand, and antique cars
parked near the highway." A competing nursing home seven
miles away countered with a smaller ad announcing a new
gerontologist on staff and a "peaceful visitation on
Mother's Day."
Pecan Grove Manor spent $85.50 on radio spots, $100
on a band, $94.90 on flowers, $137 on costumes, and $66.74
on photographs, and more on miscellaneous items. P.elatives
of patients, employees and townspeople totaled between 100
and 150 spectators. Patients, staff and visitors all
appeared to enjoy themselves. Within a few weeks, reminis
cing about the party had ceased.
One month before the Mother's Day event, a group of
patients were involved in an activity that they still men
tion over one year later. Nearby Pecan Grove Manor is a
large lake with many recreational potentials. The activi
ties director decided to arrange a fishing trip to a float
ing, enclosed fishing dock. The interior of the float is
arranged so people can sit and fish in any type of weather.
Complete services are available, ranging from a bait store
and equipment rental, to a cafe.
Seven male patients were selected to go on this trip.
Selection was based on level of debility, behavior, and an
expressed desire to go. Three men from the community were

69
asked to help at the fishing site. They were expected to
assist in baiting hooks, netting fish, and any other fish
ing-related tasks. They were invited to fish, too. The
remainder of the party consisted of the activities director
and myself.
Twelve people participated in the outing for a cost to
the nursing home of $71.71. The five-hour event took place
on a Tuesday from 9 AM to 2 PM. The activities director
sent a small write-up to the local weekly newspaper as is
commonly done with patient birthdays. Other than this, the
community-at-large was uninvolved and unaware of the fishing
trip.
The effect of the trip on the patients and the activi
ties director was quite noticeable. Patients were ready to
go and positioned at the entrance doors 30 to 40 minutes in
advance. Although everyone was ready for a rest at the end
of the trip, the patients asked when they could go again.
The activities director considered possible ways to continue
such trips by buying some small Zebco rods-and-reels and
some fishing tackle. A member of the administrative staff
cautioned that the group of people wanting to go would in
crease in size. Overall, I had never seen these particular
men so animated prior to the trip or known of a special
activity that engendered such a sustained level of excite
ment and anticipation of another trip.
Mother's Day and the fishing trip were both entered on
government forms as activities. Nonetheless, each event

70
served different purposes which led to the retention or loss
of the event. The Mother's Day events and other major pro
ductions are opportunities to symbolically, though indirect
ly, communicate to the public Pecan Grove Manor's solid
concern for the welfare of their patients. The more visible
and lavish this public event is, the more status is given
to the nursing home, and its reputation is sustained or im
proved. Conversely, the fishing trip was a low visibility,
inexpensive event affecting seven patients. There is great
opportunity for quality psychosocial improvement (judging by
change in their affective mood) and maintenance but little
chance for status accruement to the nursing home. Mother's
Day will continue to be celebrated annually as part of the
major public potlatches. Over a year later, the fishing
trip has not been repeated although the men participants
still reminisce about it.
The overall orientation toward patients in Pecan Grove
Manor is one of palliative care. The presence of the medi
cal model is expressed in ritualistic monitoring of patient
decline. No physical or occupational therapist is present.
Although a fulltime R.N. is not required, Pecan Grove Manor
boasts one who is present during part of the day shift, five
to six days per week (however, on-call twenty-four hours
daily), and functions primarily as a nursing staff adminis
trator and token representative of "high level" medical
status to attract and assuage patients and families. Other
personnel involved in activities for patients supportive of

71
psychosocial maintenance report difficulty getting assist
ance from nurses aides and a perceived low status with the
hierarchy of service providers.
This milieu is not conducive to maximizing the remain
ing potentials of the patients. Unlike palliative care
units in acute-care hospitals (cf. Buckingham, et al. 1976),
this nursing home and likely most others, masks the nonther-
apeutic environment with a battery of rituals designed to
create illusions of life for the patients, families, and
staff.
It is clear that the patient career (cf. Roth 1963) is
most directly influenced by that segment of the nursing
staff known as the nurses' aides. The style of care-giving
is one in which physical care is emphasized to the neglect
of psychosocial care. Several reasons exist for this skew
ing. The nursing staff supervisors are trained in the tra
ditional medical model as L.P.N.s or R.N.s. Their training
emphasizes physical therapy with only a slight orientation
toward psychosocial parameters. Federal inspection by
Title 19 requirements clearly promotes and rewards medical
action. For example, Pecan Grove Manor prides itself on
having patient charts up-to-date meaning that all entries
had been made on a daily basis, particularly daily remarks
regarding each patient. "Charting" consumes the vast major
ity of the L.P.N.s time. This practice becomes so perfunc
tory, however, that patients who are away visiting or in the
hospital have been unintentionally charted as not only pre-

72
sent, but the recipient of "usual a.m. care" or "up and
about; cheerful" (cf. Gubrium 1975). Still, the nursing
home must meet the demands of federal government regulations.
The nurses' aide/patient/long-term care institutional
environment operates collectively to produce a community of
daily forced-interaction. The longevity of patient/nurses'
aide interaction coupled with a mother-child interactional
pattern leads to in-depth knowledge of patient behaviors.
The nurses' aides being generally untrained, make use of
their own physical senses and beliefs about health and
disease to make decisions regarding therapeutic actions.
Psychosocial care is de-emphasized due to the pressures
of fulfilling physical care needs. Most important, however,
is the relative invisibility of psychosocial care procedures
and benefits. Additionally, benefits that accrue are likely
to be relatively gradual in appearance. Lastly, there is
no staff member who is trained to be perceptive of the psy
chosocial environment, while conversely there are plenty of
staff members who have received formal education in business
management and medical-model nursing. These factors are
reflected in the topics for in-service training (See Figure
10).
The foregoing material describes a social system orien
ted toward long-term palliative health care performed by
unskilled nurses' aides on institutionalized aged patients.
A number of tensions between aides and patients have been
identified with resolution couched in an ambience of strate
gies particular to long-term care environment.

SESSION GIVEN
BY
PHYSICAL CARE
& PATIENT
MANAGEMENT
PSYCHOSOCIAL
ENVIRONMENT
EVACUATION AND
FIRE PROCEDURES
STAFF
SALARY
TOTAL
R.N. or L.P.N.
1.9
4
6
0
29
ANTHROPOLOGIST
0
4
0
0
4
ADMINISTRATORS
0
0
0
1
1
TOTALS
19
8
6
1
34
IN-SERVICE TRAINING TOPICS
March 1977 July 1978
Figure 10

74
Nurses' aides and patients alike have an enormously
difficult task. The patient career consists of pretending
to be socially functional while being totally expendable.
One is the victim of chronic disease and social circum
stance. The nurses' aide, dressed in white, pretends to be
therapeutically functional while dispensing palliative care.
One is the victim of therapeutic expectation and incurable
disease. Thus, aides and patients engage in a variety of
rituals to fabricate a facsimile of life. In this way the
stark reality of chronic disease and old age can be partly
veiled.
Orientation toward patients at Pecan Grove Manor is
remarkably similar to Jules Henry's (1963:474) summary of
the humane Tower Nursing Home:
An effort to formulate a "national
character" for Tower yields the follow
ing: the staff, though animated by
solicitude and kindliness seems to
maintain an attitude of indulgent
superiority to the patients whom they
consider disoriented children, in need
of care, but whose confusion is to be
brushed off, while their bodily needs
are assiduously looked after. Tower is
oriented toward body and not toward
mind. The mind of the patients gets
in the way of the real business of the
institution, which is medical care, feed
ing, and asepsis. Anything rational
that the patient wants is given him as
quickly as possible in the brisk dis
charge of duty, and harsh words are rare.
At the same time the staff seems to have
minimal understanding of the mental
characteristics of an aged persor

CHAPTER SIX
THE PATIENT EXPERIENCE: THE NEXT BEST THING TO HOME
Perhaps the most direct route to the experiential
reality of patienthood in Pecan Grove Manor involves elici
ted response from the patients themselves. On a daily basis,
the patients must negotiate the entire social system of
Pecan Grove Manor. The exigencies of nursing home life that
seemingly are "non-problems" to the staff, families, and
researcher, in fact are real problems to the patients who
must as resourcefully as possible manage their lives in this
environment. Self-management in an institution becomes an
exercise not in futility but in the identification and maxi
mization of situationally-specific behavioral resources from
a meager resource pool.
Nursing home life involves institutionally-imposed con
straints. Nonetheless, there exists sufficient tolerance or
"slack" in the formal normative system for behavioral flexi
bility or creativity to emerge. Thus, the patient popula
tion can be seen to experience oppressive external controls
while simultaneously engaging in the creative extraction of
self-benefiting behavioral procedures.
The capacity for ingenuity within a geriatric popula
tion is apparently a point of dispute. In one recent trea
tise on aging (Woodruff and Birren 1975), diametrically
opposed statements are found:
The impression one gets from . .
environments in which aged persons live
as well as from that which is written to
75

76
describe such environments suggests
the existence of a simplistic notion
that man is infinitely adaptable. This
is surely an erroneous view of man.
Both common sense and . empirical
data . demonstrate that human adapt
ability is finite. (Schwartz 1975:289)
Old people are extremely adaptable.
Birren tells a story about an experience
he had while doing research on visual
perception . One of the volunteers
for the project was a man of around 85
years old who was active in the home and
a leader in the activities there . .
He was well known by most of the residents
and well liked. When Birren tested this
man for visual acuity he found that the
old man was functionally blind. Birren
went to the nursing-home administrator
and asked if the administrator knew that
Mr. X was blind. The administrator
couldn't believe Birren. Observing the
old man's behavior very carefully,
Birren found that the man was always
accompanied by his wife, and she very
subtly guided him and gave him cues so
that, although this man was functionally
blind, not even the nursing-home staff
were aware of it. This remarkable example
stresses the adaptability of old people.
(Woodruff 1975:190)
The assessment of patient resourcefulness involves direct
observation and questioning of the patient population.
Recently, assessments of personal nursing home living
experiences have found salient data not in sociodemographic
variables or in elaborate physiological workups but in
subjective perceptions of the inmates about their membership
in an institution (Noelker and Harel 1978). Therefore,
much important data about the sociocultural system comes
directly from the patients themselves.
Twenty-three patients at Pecan Grove Manor were
identified as mentally intact by my personal assessment and

77
their scoring on the Mental Status Questionnaire (Kahn,
et al. 1960) at the time of interview. All but one were
ambulatory. The term "resident" is often used in geronto
logical literature when referring to institutionalized
people with the greatest amount of ability. However, in
this community of elderly people, all of the non-staff are
considered and called "patients." They are simply patients
with a lesser dependence on help from the nurses' aides.
Still, they are medicated, monitored, required to see a
physician monthly, have call-lights in their rooms, and
their bowel movements are daily charted. Their distinction
from others lies within themselves. The fortuitous combin
ation of relatively intact mental and locomotor function
provides them with the ability to mobilize their resourceful
capacities.
In anthropological terms, these people are best able to
undergo the psychological, behavioral, and sometimes physi
cal contortions of adjustment to a new environment. Over
time, these adjustments become routinized as adaptive
responses enabling the patient to maximize their chances of
a successful "fit" within the community of which they are
a part.
The purpose here is to examine the consequences of
adaptation to a nursing home environment by a subgroup of
the patient population. All twenty-three patients responded
to a structured interview. The average age of this sample
is 82 years and 8 months with an average educational experi-

78
ence lasting seven-and-a-half years. Seven are males and
sixteen are females. All of their respective spouses are
dead. Prior to institutionalization, 747, lived alone, 227
lived with a relative, and 47, lived with a spouse. Members
of this sample had an average of ten-and-a-half visitors
per month (mostly by relatives) with the last visit four-
and-a-half days before the time of interview. Room changes
had occurred for 837, of them. Of these, the average number
of changes approached two. They had lived at Pecan Grove
Manor for an average of three years (upper range: eleven
years; lower range: one month; mode: one year).
In all societies, environmental adaptations involve
food procurement. In Pecan Grove Manor, prospective
patients and their families are given information about
dining that conveys a feeling of the greatest simplicity
of getting food. There is a consultant dietician and a
fulltime kitchen staff to provide complete food service
three times daily. All the patient has to do is show up.
The patient, however, discovers otherwise. As with
any new environment, there are certain ways to move effi
ciently to negotiate the system to maximize one's level of
satisfaction. So it is with food procurement at Pecan
Grove Manor.
The ambulatory dining-room patients have developed
food procurement strategies. The kitchen staff's view
is that they put the food out and all the patient has to
do is come eat. However, the patients' plane of existence

79
differs from the kitchen staff in terms of corridor life
and concepts of time and space. Thus, for the patient,
nutrition requires special planning.
Meals are never served at exactly the same time. The
variance ranges from fifteen to thirty minutes and is due
to mundane human factors and differing preparation times
for various foods. Meals are usually served between 11:30
A.M. and 12:00 Noon. Also, patient trays are distributed
by rotating the starting place of distribution. If at
breakfast the first trays were placed at the west end of
the dining room, at lunch they will begin at the east end.
Distribution time from one end to the other is about thirty
minutes.
The patient's goal is to coincide his or her time of
arrival at the assigned table with the arrival of the food
tray. If timing is correct, hot food will be hot and cold
food will be cold. Patients begin leaving their rooms
from 11:15 A.M. to 11:30 A.M. to walk or roll to the lobby
or entrance area. Here they sit, rest and sometimes talk
with those nearby. At this "way station" patients conti
nually glance toward the dining room which they can now
see to notice the earliest activity from the kitchen. One
signal used by many people is the appearance of a kitchen
staff member who turns on the dining room light. Tray
distribution begins at one end of the dining room. Those
who sit at that end walk the now short distance to their

80
tray immediately. Those who sit at the opposite end typi
cally wait until it is closer to the time their own tray
arrives.
Thus, the necessity of eating is experienced differ
ently by the staff and the patients. The administrative
and kitchen staffs experience feeding as "food service."
The patient population experiences feeding as "food pro
curement" with a battery of strategic behaviors necessary
to adapt their physical capacities to the physical environ
ment .
The community of Pecan Grove Manor comes to acquire
personal meaning beyond the brick-and-mortar ediface. The
most common and consistently elicited report was that
living at Pecan Grove Manor is neither ideal nor desirable
but it is "the next best thing to home" given their circum
stance. Nursing home life is viewed by the patient as the
only reasonable solution to their predicament of unemploy
ment and chronic illness. The typical patient also sug
gests that no other supportive resource system is avail
able to meet essential needs for physical well-being. For
those having children who represent potential caretakers,
the children are reported as willing to take them but the
patient will not "burden" their children or "get in the
way." Thus, the patient sees the nursing home as a re
source rather than a place of confinement.

81
I'd rather be here than with my kids
to eliminate potential conflict with
them (paraphrased, 77 year old female).
If they can't get up and get around,
tell 'em to come on (to Pecan Grove
Manor). (77 year old male)
It's a good place to live, but there's
no place like home. (88 year old male)
Next thing to home, but it ain't home.
(91 year old male)
If you can't live at home, this is
tops. (78 year old male)
It's more like home than if I was with
my children. I'd feel in the way if
I was with my children and I don't feel
in the way here. (94 year old female)
They (her grandchildren) have no use
for old people. Don't you know that?
(88 year old female)
Responses to "What do you like most about living
here at Pecan Grove Manor?" centered about patient/staff
dependency. The primary benefit is the security of having
one's needs consistently met within a cognitive set of
perceived personal risks at simply being alive. The needs
were clearly biosocial: companionship of staff and other
patients, food service, and perceived medical-care avail
ability. Responses to "What do you like least about living
here at Pecan Grove Manor?" were oriented toward situation-
specific items rather than the nursing home itself: sepa
ration from family and friends and disvalued behavior of
other patients (eg., noisy, messy).
References to what these patients missed most about
their life prior to being institutionalized were

82
independent of the institution. The predominant response
was a loss of personal independence coupled with the loss
of their spouse. On the other hand, these patients expe
rienced improvements as a result of institutionalization.
The presence of nurses' aides as helpers and being around
other people for socializing were likewise reported as
improvements in their lives.
The experience of being a nursing home patient actually
begins before one enters the front door (Tobin and Lieber-
man, 1976). The patient brings with him previously devel
oped beliefs regarding nursing home life. Little is done
to better precondition the prospective patient for admis
sion to Pecan Grove Manor while in the hospital or at home
prior to admission. Thus, early experiences in the nursing
home can be unnecessarily traumatic. Consider the report
(edited) of Mrs. Nancy Pipkin (pseudonym), a 75 year old,
white female:
JNH: What kind of adjustments did you
make? When you think back about when
you first came here.
NP: Well, when I first came I was
unhappy a little while. I didn't hardly
know . see I just come out of the
hospital here and I had had a nervous
breakdown. And I had a lot of adjust
ing to do anyway, wherever I had been.
And then I just come out of it and I
can just walk and do anything I want to
do. And I'm happy here.
JNH: What do you miss most about living
in the community?

83
NP: Well, anybody misses home, but
outside of that . But I miss home
and friends. But the friends come to
see me and I see them, so. I just know
that this is going to be my home from
now on and I just accept it and try to
make myself be happy. I don't have any
complaints as far as myself is con
cerned. They are just as sweet to me
as they can be. Everytime I've ever
needed anything, why, they're right
here to help me. I'm just . I'm
just thrilled I've got a place like
this to stay.
JNH: About how long do you remember it
taking until you felt comfortable here?
From the time you were first here.
NP: Oh, I guess it was six months
maybe before I really could just turn
loose and feel at home, but after that
I was . Now I was never miserable
understand. I . when I come I knew
that this was going to be my home and
I was going to make it pleasant as I
could. So, I haven't let myself worry
and think, "Why did I have to come here?"
and "Why did this have to happen to me?"
I've just accepted it and I've enjoyed it.
I just wish every old person that has to
stay alone and be in danger of not
being cared for you know . that
couldn't take care of themselves. It's
bad to have that feelin' that you might .
JNH: OK, how about some more on this.
You were saying that you wished other
people that needed to have these kinds
of services could have them. Could you
kinda repeat that?
NP: Yeah, well I do. I wish that other
people could see and know how happy we
are in here. I don't think that it'll
be . seemed like it ... that I
did, I had a fear of coming down here.
Before I come here, I'd heard things,
you know, remarks made. And I haven't
found any of that to be true in my
case of what I'd heard or was afraid of.

84
JNH: What kind of things were those?
NP: Well, they just didn't take care
of 'em and they'd let 'em lay in the
bed and not take, go see about 'em or
they couldn't get nobody to come when
they wanted 'em. Things like that,
well, I've never had that.
. . Well, I wish more people under
stood how we feel out here. And that
we do have care out here. Not do like
I had, such a horror of coming. I just
really, I did have a horror of coming
out here, but after I got sick and
Dr. P. came in and told me I'd have
to come down here and stay while,
well I didn't say a word. I just
thought, "Well this I have to do."
. . It's the best place outside of
your own home that you could have to
come to.
Also, consider the report (edited) of Mr. Frank Miller
(pseudonym), a 78 year old, white male:
FM: Well, for the last 30 or 40 years
there's been a great improvement. A
great one. I can remember my father
and I went over to a certain nursing
home in Texas; were thinkin' about
puttin' my mother in there, and we
changed our mind when we visited the
nursing home.
JNH: Why is that?
FM: Well, They wadn't run like they
are now. So many old people think of
a nursing home as a horrible place to
go. They think it's just a dumpin'
ground for . Now, that the state
and federis (unintelligible), it's
run like a business more than it's- ever
been before. They've got to run right
or else! . close the door.
JNH: How does this one fit for that?
FM: It's a . I'd say number one.

85
JNH: Number one?
FM: It's the tops.
. . 'course Joe (JNH), I'll say that you
can make up your mind to be satisfied
with anything. Now people come here
that's dissatisfied and don't want to
come here. And people puts 'em in here
and it takes 'em a long time to get,
get satisfied. We've had one or two
to come here that's just, oh, hated
this place. Now, they like it, after
they learn what it is. Because those
old people, they thought about them
old nursing homes years ago. I still
think about 'em myself.
These comments regarding Pecan Grove Manor should not
be taken as actual evidence of a utopian nursing home
community. Underlying the positive aspects of life at
this nursing home are the expected and typical conflicts
inherent among any group of people living in the community
or an institution. What is significant, however, are the
patients' denials of conflict and reluctance to talk
about conflicts.
There exists an ethos of risk among the patients.
Their lives are, in fact, daily at risk of worsening by
having to leave the nursing home if they become too
healthy, dealing with interpersonal conflict in a small
environment, and deteriorating physically and mentally
with death always on the horizon. Of the twenty-three
elite patients interviewed, twenty-two referred to the
possibility of being dead in one year and all respondents
said that they would be dead in five years.

86
Although leaving the nursing home to re-enter the
community is rare (one mild stroke patient and one burn
patient in the thirteen months of fieldwork), all patients
receiving public funds must have a monthly physical exami
nation by a physician. Most patients consider the physical
to be a necessary nuisance to keep receiving their funds.
The patients report the physical to be superficial and a
means for the physician to make money. Still, residence
at public expense requires disability. The physical rep
resents, a monthly potential for discharge.
Of more daily importance is the avoidance of open
intragroup and intergroup conflict among patients and
staff. The mechanisms which are conflict-obtrusive are
partly related to features of long-term care and partly
related to characteristics of institutional living.
Membership in the institution is forced. There are
no other viable options. The process of adjustment and
incorporation into the institution develops a sense of
personal investment in this community. Patients away on
visits with relatives or during hospital stays speak of
their desire to "get back home" to "sleep in my own bed."
Thus, there is a desire to preserve their position in
the nursing home.
Institutional characteristics that generate conflict-
avoidance center about reduced private space. Open con
flict in communities with a very limited territorial
range is likely to be expressed beyond necessity. Those in

87
conflict will constantly be near each other and have
little option to retreat to quell hostilities due to
reduced private space. Also in operation is institutional
public life expressed in the feeling that "everyone will
know my problems."
One patient (86 year old female) stopped me in the
hall one day finding it difficult to maintain eye contact
and select her words. She eventually began with, "I know
you know this already, ..." I didn't. She related in
a halting voice that she suspected her roommate of con
spiring with one of the cleaning women to put aluminum
foil on the top part of the room windows. Her roommate
is consistently too warm and she is consistently too cold.
She said she didn't know whether or not this should be
included in her diary which she wanted to give me. They
had earlier agreed to divide ownership of the window by
the two panels of glass. Even in the winter, her roommate
would exercise her ownership perogative over her panel of
glass by opening it, even though the window unit was not
on "her side of the room."
This woman was convinced that the magnitude of this
conflict was such that it was surely public knowledge.
She also felt quite helpless in that two people (roommate
and a staff member) had conspired against her. The per
ceived and real lack of physical and social resources
caused a minor incident to have major implications for
this patient.

88
Another male patient agreed to keep a diary to give
to me but then rescinded. Before he returned the unused
diary to me, another patient told me that this man had
bragged that he was "going to be a spy for Joe." When he
returned it, he very obliquely stated that he was afraid
that keeping the diary might cause trouble. In an environ
ment that houses only a small pool of people, friendships
are resources with which one should not tamper.
Other aspects of avoidance of open conflict exist in
relation to long-term care. Not only would open conflict
cause life to be difficult in close quarters, but one would
experience a sustained level of tension because they will
live there the rest of their lives. In acute-care hospi
tals, personal risk stemming from angered roommates or
hospital staff would not endure indefinitely. The experi
ence of nursing home life is very much different.
At times, when complaints (though relatively innocuous)
were voiced to me, I was typically told not to divulge the
complaintant's name to anyone. For example, comments
about unsatisfactory menus were ended with "dont tell 'em
I said that." A man told me that some folding chairs
borrowed from a mens club had unintentionally been kept
at the nursing home. His statement was almost totally
shrouded in disclaimers and caveats. The man's primary
intent was to preserve a good relationship between the
club and the nursing home. It was evident, however, that
he didn't want to be perceived as a "trouble maker" for

89
the administration. Returning the chairs to the club
would be more work for an already busy staff. Another
instance involved a female patient who called me to a
quiet corner and asked me to move some lawn chairs back
to their previous location so that they could be used as
before. I was then told not to tell anyone that she had
made the request.
The caution exercised by the patients regarding what
seemed to me to be reasonable and minor items is produced
by the knowledge that one will quite literally have to
live with the not-totally-predictable consequences of one's
actions. The public nature of life in an institution
coupled with long-term membership makes the otherwise
inconsequential momentous.
The administrative staff also participates in conflict
obtrusion. The nurses' aides are told never to gossip or
argue in the presence of patients. The patients are not
to be bothered by personal staff problems. The administra
tive staff believe that families and patients expect an
idllyic paradise and the nursing home will produce what
the customer wants.
It was my experience, however, that the patients
thirsted for information of any type. To overhear a
nurses' aide's actual personal problems was at the least
better than the fiction of television soap operas. Often
patients interjected comments expected to be helpful in
solving some dilemma. The patients felt more alive through

90
vicariously dealing with someone else's problem when their
own environment minimized them.
In fact, the nurses' aides are a virtual data bank
for the patients to learn of community life and internal
nursing home events. In spite of supervisory attempts to
restrain nurses' aides' conversational topics, the aides
are in intimate contact with patients for too great a
time to totally prevent exchange of personal information.
Patients at Pecan Grove Manor nursing home have also
seized upon a naturally evolved element of their institu
tional setting as a personal resource: the housekeepers.
The housekeepers at Pecan Grove Manor are two women who
were nurses' aides at this nursing home prior to their
employment as housekeepers. They routinely move through
the hallways in separate, systematic routes. Each house
keeper pushes a janitorial cart containing a mop, mop
bucket with "squeegee," trash bag, and numerous cleaners'
and disinfectants. The thoroughness of their work is
attested to by the universal report from visitors and
patients that Pecan Grove Manor is "the cleanest nursing
home I've ever seen."
In addition to their function as housekeepers, they
represent an important resource to the patient population.
They are brokers bridging the patients and the nursing
staff especially with regard to sensitive issues and they
are more available for conversational interaction than
any other staff group.

91
Several factors are involved in the development of
the dual role of the housekeepers. First, the potential
for engaging interaction is greater with the housekeepers
than with the nurses' aides because in-room task assign
ments typically require longer periods of time for house
keepers. Whereas rapid in-and-out activity signals appro
priate work modes for aides, the opposite is true for
housekeepers.
Proper cleaning requires lengthy task performance per
room. Thus, informal job-related normative pressures pro
mote in-depth interaction between the patients and the
housekeepers.
Babby Heath (pseudonym), one of the housekeepers,
spoke of her dual role (edited):
JNH: We'd be wondering why . why
they (patients) seem to visit with you
all (housekeepers) so much.
BH: I think probably it's because
maybe we're in the rooms longer and
we don't wear white and they, they seem
closer to us. Because they'll tell us
things maybe that they won't tell
someone else.
JNH: . because they talk to you
and Doris (pseudonym; housekeeper) and
they wouldn't talk to an aide?
BH: Well, ok, another reason, Joe. See,
I've been here now for quite awhile,
you know. And I worked as an aide on
the mornings and I worked on the evenings.
And they, really, they feel like they
know me better than they do some of the
other girls. And I think the same way on
Doris because Doris has been out here a
long time too, and a lot of these old

92
people were here when we came here, you
know. And ... I don't know, I really
don't know why, but they will, and Doris
will probably tell you the same thing.
They tell her things that they won't tell
the nurses or even Miss Brown (pseudonym;
R.N.), you know.
JNH: That sounds like in a way you all
are more reliable ways to get to . .
information to Miss Brown or Maureen
(pseudonym; medications aide).
BH: And maybe another thing, I thought,
well maybe they (patients) don't want to
tell 'em (aides), theirself, and they
(patients) know if they tell me then I
will go tell if I think they (R.N. or
L.P.N.) should know these things then I
do go tell 'em, you know.
Well, sometime, you know, now, I know,
I never did feel like this: but some of
the aides think the housekeepers are just
the housekeepers, you know. But, sometimes
we understand the old people more than the
nurses do.
Several subsidiary factors can be identified as
enhancers of patient/housekeeper interaction. These seem
to revolve about personal characteristics of the house
keepers: employment at Pecan Grove Manor for a long time,
previous work as an aide, wearing street clothes, and they
are viewed as adults due to their middle-age status. These
personal and job-related characteristics combine to produce
a job and role category of great importance to institution
alized patients. The patients have identified and used
the housekeeping staff category as an intrainstitutional
resource in an unintended and unexpected way. While the
nurses tend to the body, the housekeepers tend to the mind.

93
The patient population of Pecan Grove Manor, and
particularly those most able patients, actively engage
themselves in their community's environment. Their efforts
are aimed at resource identification and exploitation.
These adaptive tasks are in constant motion due to the
changing social environment and changes in their own per
sonal capacity for negotiating shifts in physical and
cognitive states. Thus, life in this nursing home is a
physical and emotional challenge as was life in the non-
institutional community.
Given chronic illness, unemployment, loss of spouse,
and other common facts of the American "old age experience,
membership in a nursing home does not necessarily involve
life without sensation or challenge. The very nature of
the American proprietary nursing home generates physical
and emotional challenges to the patient population on a
daily basis. This is not an argument against improvements
in nursing homes but just the opposite. Recognition of
the naturally-existing resource pool allows for enhancement
of patient life with little economic cost to the manage
ment. Observation and discussion among the patients will
provide the routes to pre-established patient resources
which can then be monitored, preserved, and enhanced.

CHAPTER SEVEN
CHRONIC LIFE AND AGE SEGREGATION
Palliative-care settings, whether in hospitals or
nursing homes, typically house people with chronic
disease(s) and without expected recovery. The diseased
state gradually usurps the psychosocial essence of human
ness until the host's life, in the fullest interactive
sociocultural sense, is overshadowed by disease and debil
ity. Disease becomes established as the prominent mode of
existence and life now becomes the factor of chronicity.
Disease is not the target of treatment; physical existence
is. Thus, a condition of chronic life exists in the pres
ence of debilitating disease which is permanent and para
mount, rendering the diseased state more prominent than
wellness and life, not disease, as the target of therapy.
Globally, modernization as a societal process occurs
with numerous attendant changes especially in technology
and health technology (Cowgill and Holmes 1972; Cowgill
1974:129). One result is increased longevity. For the
very old, this is a dubious benefit (cf. Illich 1976:73).
Many societies distinguish between functional old age
and nonfunctional old age (Simmons 1945; Simmons 1960;
Clark and Anderson 1967). Functional old age can be con
sidered extended life while nonfunctional old age can be
considered chronic life. Improvements in health care
technology resulting in increased longevity also increase
the risk of inducing chronic life in the aged population.
94

95
Clark and Anderson (1967:11) state, "The elderly have
problems in our society because it takes them so long to
die these days." The affliction of chronic life, then,
is iatrogenic in origin.
The cultural apparatus for dealing with chronic life
takes various forms. Acute-care hospitals sometimes
designate a section of the patient floors as palliative-
care wards. The hospice is typically an institution for
the terminally ill that is separate from the hospital.
However, nursing homes loom most prominent as the standard
American agency dealing with the biosocial penalties of
longevity and incapacitating incurable disease.
The ethnomedical perspective was used in the study
of Pecan Grove Manor nursing home. Special emphasis was
directed toward patients and paid care agents as signifi
cant role categories within the nursing home community.
The ethnomedical view identified patients, nurses' aides,
and housekeepers as the interactional network most mean
ingfully associated with long-term care quality.
Within any community of people, differing points of
view exist analytically as multiple realities (Gubrium
1974). This research has disclosed realities specific to
various categories of people within the nursing home com
munity. These realities characterize a category-specific
ethos.
The patient ethos is marked by a pervasive sense of
life at risk. The patients risk becoming too well or

96
too sick. Expulsion from the institution and life is
the ultimate outcome. Patients adopt a fatalistic outlook
regarding their membership in a nursing home population.
Their control over their own destinies has been undermined
by chronic disease, unemployment, and institutionalization.
Therefore, they accept their lot not having capacities to
retaliate.
One form of adaptation is to selectively attend to
the positive virtues of their current life and institution
al home. Given the lack of better possibilities, patients
report "their" nursing home as the best possible setting
other than self-sufficient community life.
Conflict-avoidance serves to maintain the belief in
the high quality of their situation by minimizing disrup
tive events. This pressure is exacerbated by long-term
institutional living. Additional pressure is leveled by
the nursing and administrative staffs to convey an aura
of serenity in order to reduce family complaints and
inquiries. Although staff groups exert efforts to deny
conflict, the patients likewise construct perspectives
ultimately useful in psychological adaptation to the long
term institutional environment.
Patients also engage in resource identification and
exploitation within their community. The physical and
psychosocial environments have been met as surmountable
challenges rather than insurmountable obstacles. Thus,
food procurement strategies, role invention, and

97
non-medical use of care agents market the resourcefulness
of the geriatric nursing home patient.
Direct primary care from the "native" experience
is the province of nurses' aides and housekeepers. Nurses'
aides constitute 4370 of all staff categories in nursing
homes nationwide (Subcommittee on Long-Term Care 1975:361)
and 417o at Pecan Grove Manor. From 1960-1976, the number
of nurses' aides employed has increased by 5507, (Moss and
Halamandaris 1977:21). The rapid rise in the number of
nurses' aides is a product of the relatively recent bio
medical culture contacting the American cultural value
system proscribing senilicide and thus generating "spinoffs"
such as nursing homes and the emergent (cf. Landy 1974)
therapeutic role of the nurses' aides.
While biomedicine has charmed the medical and public
sector alike, the increase in chronic incurable disease
has created a therapy and therapist vacuum. This vacuum
is currently being filled by middle-aged women with little
or no training engaging in therapy modeled after mother/
child interactive patterns which are considered to be
physically and emotionally nurturant. The response pattern
of directing victims of chronic, incurable disease to folk
medical practitioners rather than biomedical specialists
was also found by Gould (1965) in rural North India.
Over the past two decades, the role of licensed
nursing personnel has shifted from patient-contact to

98
paper-contact as efforts at increased education and pro
fessionalism have been pursued. The licensed nurse as
mother-surrogate has declined (Schulman 1958; 1972) to
be replaced by the nurses' aide, particularly in nursing
homes. The maternal approach to patient care in nursing
by nonlicensed personnel is not unique to the American
long-term health care culture. Caudill (1961), for example,
describes the Japanese tsukisoi as an untrained female
providing long-term basic care to psychiatric patients.
The benefit of the t sukis oi is found in the use of the
mother/child interactive pattern and long-term patient
contact. As among the American nurses aide, lack of
formal training is compensated by surrogate kinship roles,
a thorough familiarity of the patient (often consanguineal
and affinal kin, Befu 1971), and use of folk therapies.
Thus, the white uniform, hospital-like environment, and
other symbols of biomedicine serve only as a thin veil
over the "modern" geriatric folk therapist.
In summary, the nursing staff ethos is characterized
by adult nursery nursing. Unlicensed and untrained nurses'
aides play mother roles in the discharge of their duties
with patients who are conceptually seen as children. Their
work consists of bed-and-body-worlc to the near exclusion
of psychosocial support of the patients. Pragmatically,
mother/child interactional patterns extract useable be
haviors from pre-existing role repertoires of the generally
untrained nurses' aides.

99
The nurses' aides through all of the reports of love
for the patients essentially monitor patient decline.
Their activities are viewed as necessary to make patients
as comfortable as possible until they die. This view is
consistent with a medical-model oriented toward cures as
success and lack of cures as failures. In order not to
fail, there will be no attempt at therapy, only palliative
care.
In Pecan Grove Manor care agents were found to include
an unexpected category of providers: housekeepers. The
biomedical view of health care organization excludes
housekeepers as therapeutic agents. The ethnomedical
view, however, identifies the housekeeper as a naturally
evolved, unplanned agent of psychosocial support for
patients.
Characteristics of the housekeepers' tasks, values
regarding employment, and personal demeanor provide a field
for engaging interaction rather than brief, ritualistic
interaction typical of nurses' aides. These characteris
tics include lengthy in-room task performance (by necessity
and demonstration to supervisors of thoroughness of clean
ing) wearing street clothing, previous work as nurses'
aide, and middle age status. Thus, the housekeeper is
seen by the patient as an expected, daily visitor who can
converse at length, carry information throughout the
nursing home, and report on local community matters on a
routine basis. Also patients use the housekeeper as a

100
broker in the transmittal of sensitive messages (e.g.,
complaints regarding the nursing staff) thereby distancing
and insulating the patient from potential reprisals.
Collectively, these findings provide an example of
the utility of the ethnomedical orientation in examining
"health care cultures," the unplanned existence of agents
of psychosocial support in a nursing home in the form of
housekeepers, and the persistent depth of capacity for
human resource identification and use among institution
alized geriatric patients.
Overall, elderly Americans live a life of paradox.
Millions fall victim to the iatrogenically-induced disease
of chronic life. The technological milieu of moderniza
tion has increased longevity in the absence of cultural
milieu concommitantly generating respect for long-term
survivors. The penchant for the compartmentalization of
life is a breeding ground for reservation systems to
contain certain segments of society.
Age-segregated communities are contained segments
of society (Jacobs 1974; Angrosino 1976). Within one
such community, the nursing home, the chronically-ill
elderly are housed. At one level of abstraction, the
culture of which they have been participants negotiates
their lives by paid ritual-custodians. Within the cere
monial chambers, the curators perform rituals fabricating
signals of life which are designed to be in opposition to

101
culturally relevant negative sanctions proscribing senil-
icide while actually inducing the fatal course of chronic
life.
The medical model is elevated to such a lofty spiri
tual plane (Siegler and Osmond 1976; Szasz 1977) that a
cure for the chronically-aged sick is not only impossible,
but unimaginable. Since health is culturally signaled
by freedom from acute physiological pathogenicity and
cure by medical-model intervention, those who are chroni
cally ill and not physiologically responsive to such
"appropriate" intervention are housed in palliative-care
institutions to await death. Their minds are numbed by
the anesthetic of psychosocial starvation while their
bodies are carefully tended, reducing the odor of pro
longed death.
Thus, nursing homes are cultural products. They are
part of the machinery of living and dying in industrialized
societies. Most likely, nursing homes are commonly viewed
as edifices to humanitarian ideals. Nonetheless, the
ominous workings of ecological, cultural, and social
forces exert pressures on human groups to deal with illness
and death in culturally relevant and behaviorally expedient
ways.

102
The future is likely to see a proliferation of nursing
homes as we know them today. Given this projection,
research efforts may best be directed at maximum extraction
and enhancement of naturally evolved beneficial behaviors
and roles within a nursing home community. The cost-
benefit ratio of the enhancement of pre-existing behavioral
systems is seen as potentially attractive to proprietary
nursing home owners for the improvement of the quality
of institutional life.

APPENDIX I
SELECTED NURSING HOME INDICES 1977
Oklahoma
United States
Resident Patients
23,500
1,150,000
Licensed Beds
27,036
1,277,000
Number of beds per
1000: population
aged 65 and over
80.1
62.3
Occupancy Rate
87.2
88.2
Employees Per Patient
.507
.657
Source: Oklahoma Health Systems Agency, page 44
103

APPENDIX 2
PECAN GROVE MANOR TOTAL DISEASE ROSTER
(From physican listings in patients' charts)
Number
in
of Times Entered
Patient Charts
1.
Advanced Age
1
2.
Alcoholism
1
3.
Amputee
1
4.
Anal Fixation
1
5.
Anemia
1
6.
Aneurysm
1
7.
Angina Pectoris
7
8.
Aortic Systolic Murmurs
1
9.
Aphasia
2
10.
Arteriosclerosis
7
11.
Arteriosclerotic Brain Syndrome
1
12.
Arthralgia
3
13.
Arthritis
37
14.
Arteriosclerotic Cerebral
Insufficiency ASCI
16
15.
Arteriosclerotic Coronary
Insufficiency ASCI
29
16.
Arteriosclerotic Cardio-Vascular
Disease ASCVD
29
17.
Arteriosclerotic Hypertensive
Disease ASHD
10
18.
Asthma
3
19.
Atrial Fibulation
2
20.
Back Pain
1
104

105
P.G.M. TOTAL DISEASE ROSTER, cont.
Number of Times Entered
in Patient Charts
21. Bedfast/Chairfast 2
22. Blindness 5
23. Blood Sugar Unstable 1
24. Brain Deterioration 1
25. Cancer 5
26. Cardiac Arrythmia 4
27. Cardiomegaly 1
28. Cataracts 2
29. Cerebral Ischemeia &
Transient Cl 9
30. Cerebral palsy 2
31. Cholecystectomy 1
32. Cholecystitis 4
33. Chronic Brain Syndrome 6
34. Chronic Obstructive Pulmonary
Disease COPD 3
35. Cerebral Insufficiency (Cl) 9
36. Coronary Insufficiency (Cl) 18
37. Club Foot 1
38. Colitis 3
39. Colostomy 1
40. Congestive Heart Failure (CHF) 4
41. Convulsive Disorder 1
42. Coronary Artery Disease (CAD) 1
43. Coronary Heart Disease (CHD) 7

106
P.G.M. TOTAL DISEASE ROSTER, cont.
Number of Times Entered
in Patient Charts
44. Cerebral Vascular Accident
(CVA)
45. Cystitis
46. Degenerative Disc Disease
47. Degenerative Joint Disease
(DJD)
48. Deafness
49. Debility
50. Deformity
51. Dehydration
52. Depression
53. Dermatitis
54. Diabetes Mellitus
55. Diarrhea
56. Disorientation
57. Diverticulitis
58. Sysphagia
59. Emphysema
60. Epilepsy, Petit Mai
61. Fractures
62. Gastric Neurosa
63. Gastritis
64. Gastro-enteritis
65. Hallucinations
66. Hypertensive Cardio-Vascular
Disease HCVD
17
4
1
4
7
3
2
1
1
13
2
1
10
1
3
1
15
1
3
1
1
23

107
P.G.M. TOTAL DISEASE ROSTER, cont.
Number of Times Entered
in Patient Charts
67. Hemiplegia 1
68. Hemmorrhoid 1
69. Hernia 9
70. Hypertension 12
71. Hypoglycemia 1
72. Hypokalemia 5
73. Hypothyroidism 2
74. Hysterectomy 1
75. Indigestion 1
76. Labyrinthitis 1
77. Lumbar 1
78. Malnutrition 1
79. Mastectomy 3
80. Meningitis 1
81. Mental Abberations 1
82. Mental confusion 24
83. Mental deterioration 5
84. Mental retardation 5
85. Migraine headaches 1
86. Multiple Sclerosis 1
87. Myocardial Infarction 2
88. Neurological deficit of
obstructive hydrocephalus 1
89. Obesity 7
90. Organic brain syndrome
4

108
P.G.M. TOTAL DISEASE ROSTER, cont.
Number of Times Entered
in Patient Charts
91. Osteoarthritis 13
92. Osteoparesis 2
93. Osteporosis 26
94. Osteosclerosis 1
95. Paralysis 8
96. Parkinsonism 6
97. Paroxysmal artial tachycardia
(PAT) 1
98. Pedal edema 1
99. Peripheral Vascular Disease
(PVD) 6
100. Phlebitis 1
101. Pleural effusion 2
102. Pneumonia 2
103. Polio 1
104. Prostatitis 1
105. Prostectomy 1
106. Prosthesis 1
107. Psychoneurosis 1
108. Pyelonephritis 3
109. Radiculitis 2
110. Renal disease 1
111. Rheumatoid 1
112. Sciatica Neuritis 1
113. Seizures 1
114. Senility/Senile Psychosis
14

109
P.G.l
1. TOTAL DISEASE ROSTER, cont.
Number
in
of Times Entered
Patient Charts
115.
Shoulder. Injury
1
116.
Sinusitis
5
117.
Speech difficulty
1
118.
Stroke Syndrome
2
119.
Syncope
2
120.
Synonitis
2
121.
Tachycardia
1
122.
Teeth absent
1
123.
Thr omb ophlebitis
1
124.
Transient Ischemic Attack (TIA)
1
125.
Ulcer
3
126.
Urinary Tract Infection (UTI)
1
127.
Visions
1

APPENDIX 3
PECAN GROVE MANOR
TEN MOST PREVALENT DISEASES
Disease
Number
of cases
Prevalence
Rate
1. Arthritis
37
39.47c
2. Arteriosclerotic
Cardiovascular
Disease
29
30.87=
3. Arteriosclerotic
Coronary
Insufficiency
29
30.87o
4. Osteoporosis
26
27.67=
5. Mental Confusion
24
25.57=
6. Hypertensive
Cardiovascular
Disease
23
24.57=
7. Coronary Insufficiency
18
19.1%
8. Arteriosclerotic
Cerebral
Insufficiency
16
17.0%
9. Cardiovascular Accident
17
18.0%
10. Fractures
15
15.9%
110

APPENDIX 4
DISEASE PREVALENCE
PECAN GROVE MANOR
PR
Cardiovascular Disorders .2340
Neurologic Disorders .2127
Psychiatric Disorders .1914
Musculoskeletal and Connective
Tissue Disorders .1489
Gastrointestinal Disorders .1063
Genitourinary Disorders .0744
Miscellaneous .0744
Nutritional and Metabolis Disorders .0638
Respiratory Disorders .0531
Ear, Nose and Throat Disorders .0319
Endocrine Disorders .0319
Opthalmic Disorders .0212
Hepatic and Biliary Disorders .0212
Gynecology and Obstetrics and
Breast Diseases .0212
Infectious and Parasitic Diseases .0106
Hematologic Disorders .0106
Dermatologic Disorders .0106
Cancer Disorders .0106
111

112
100
90
80
70
60
50
40
30
20
10
APPENDIX 5
POPULATION PYRAMID:
PECAN GROVE MANOR
10% 5% 0%
5% 10% 15% 20% 25% 30%
MALES
FEMALES

113
APPENDIX 6
WING ASSIGNMENT BY DEBILITY FACTOR
WINGS
North
South
East
All
All
Wings
FACTOR
"Heavy
"Intermediate
"Light
Wings
Care"
Care"
Care"
Male
Female
Continent
45.5%
41.4%
100.0%
62.0%
65.4%
60.6%
Incontinent
54.5%
58.6%
0%
38.0%
34.6%
39.4%
Ambulatory
51.5%
58.6%
100.0%
68.5%
73.1%
66.7%
Non-ambulatory
48.5%
41.4%
0%
31.5%
26.9%
33.3%
Meals in Dining Area
12.1%
24.1%
73.3%
35.9%
42.3%
33.3%
Meals in Patient Area
87.9%
75.9%
26.7%
64.1%
57.7%
66.7%
Feeds Self
75.8%
93.1%
96.7%
88.0%
7 6.9%
92.4%
Requires Feeding
24.2%
6.9%
3.3%
12.0%
23.1%
7.6%

REFERENCES CITED
Angrosino, Michael V.
1976 Anthropology and the Aged: a Preliminary Community
Study. Geronotologist 16:174-180.
Arensberg, Conrad M. and Solon T. Kimball
1965 Culture and Community. New York: Harcourt,
Brace, and World.
Babbie, Earl R.
1979 The Practice of Social Research. Second edition.
Belmont, California: Wadsworth.
Befu, Harumi
1971 Japan: an Anthropological Introduction. San
Francisco: Chandler.
Bachner, John P.
1974 Public Relations for Nursing Homes. Springfield:
Thomas.
Beals, Ralph and Harry Hoijer
1971 An Introduction to Anthropology. Fourth edition.
New York: MacMillian.
Beckman, Ronald
1971 The Therapeutic Corridor. Hospitals 45:71-80.
Bennett, Ruth and Carl Eisdorfer
1975 The Institutional Environment and Behavior Change.
In Long-term Care: a Handbook for Researchers, Planners,
and Providers. Sylvia Sherwood, ed. New York:
Spectrum.
Bennett, Ruth and Lucille Nahemow
1965 Institutional Totality and Criteria of Social
Adjustment in Residences for the Aged. Journal of
Social Issues 21:44-78.
Birren, James E. and Vivian Clayton
1975 History of Gerontology. In Aging: Scientific
Perspectives and Social Issues. Diana S. Woodruff and
James E. Birren, eds. New York: Van Nostrand.
Buckingham III, R.W., S. A. Lack, B. M. Mount, L. 0. MacLean,
and J. T. Collins
1976 Living with the Dying: Use of the Technique of
Participant-observation. Canadian Medical Association
Journal 115:1211-1215.
114

115
Butler, Robert N.
1975 Why Survive?: Being Old in America. New York:
Harper & Row.
1978a Unravelling the Secrets of Aging. Aging (July-
August): Numbers 285-286. Pps. 5-8.
1978b Thoughts on Aging. American Journal of Psychiatry
135: Supplement: 14-16.
Brody, Elaine M.
1977a Number of Elderly in Institutions to Rise Says
Expert in Field. Aging (November-December), Numbers
277-278. Washington: DHEW Office of Human Develop
ment, Administration on Aging.
1977b Number of Elderly. Aging (November-December),
Numbers 277-278. Washington: DHEW Office of Human
Development, Administration on Aging. Page 15.
1977c Long-term Care of Older People. New York: Human
Sciences Press.
Caudill, William
1961 Around the clock patient care in Japanese psychiatric
hospitals: the role of the tsukisoi. American
Sociological Review 26:204-214.
Clark, Grahame
1969 World Prehistory. Cambridge: Cambridge University
Press.
Clark, Margaret
1973 Contributions of Cultural Anthropology to the
Study of Aging. In Cultural Illness and Health.
L. Nader and T. W. Maretzki, eds. American Anthro
pological Association, Anthropological Studies,
Number 9. Washington, D.C.
Clark, Margaret and Barbara G. Anderson
1967 Culture and Aging: An Anthropological Study of
Older Americans. Springfield: Thomas.
Cohen, E. S.
1974 An Overview of Long-Term Care Facilities. In
A Social-Work Guide for Long-Term Care Facilities.
Brody, E. M. and contributors. Washington: DHEW
Publication Number (HSM) 73-9106, U. S. GPO.
Cowgill, Donald 0. and Lowell Holmes, Editors.
1972 Aging and Modernization. New York: Appleton-
Century-Crofts.
Cowgill, Donald 0.
1974 Aging and Modernization: A Revision of the Theory.
In Late Life. Jaber F. Gubrium, ed. Springfield:
Thomas.

116
Crane, Julia G. and Michael V. Angrosino
1974 Field Projects in Anthropology. Morristown:
General Learning Press.
Cutler, Neal E. and Robert A. Karootyan
1975 Demography of the Aged. In Aging: Scientific
and Social Perspectives. Diana S. Woodruff and
James E. Birren, eds. New York: Van Nostrand.
Dyson-Hudson, N.
1963 The Karimojong Age System. Ethnology 2: 353-401.
Eliade, Mircea
1963 Patterns in Comparative Religion. New York:
New American Library.
Freilech, Morris
1970 Marginal Natives. New York: Harper & Row.
Garvin, Richard M. and Robert E. Burger
1968 Where They Go to Die: The Tragedy of America's
Aged. New York: Delacorte Press.
Goffman, Erving
1960 Characteristics of Total Institutions. In Identity
and Anxiety: Survival of a Person in Mass Society.
Glencoe, Illinois: Free Press.
Gold, Raymond L.
1969 Roles in Sociological Field Observations. In
Issues in Participant Observation. George J. McCall
and J. L. Simmons, eds. Reading, Massachusetts:
Addison-Wesley.
Gould, Harold A.
1965 Modern Medicine and Folk Cognition in Rural
India. Human Organization 24: 201-208.
Gubrium, Jaber F.
1973 The Myth of the Golden Years. Springfield: Thomas.
1974 On Multiple Realities in a Nursing Home. In
Late Life. Jaber F. Gubrium, ed. Springfield: Thomas.
1975 Living and Dying at Murray Manor. New York:
Martin's Press.
Hawley, Amos H.
1944 Ecology and Human Ecology. Social Forces 22:
400-405.
Henry, Jules
1963 Culture Against Man. New York: Random House.

117
Holmes, Lowell D.
1976 Trends in Anthropological Gerontology: From
Simmons to the Seventies. International Journal of
Aging and Human Development 7: 211-220.
Illich, Ivan
1976 Medical Nemesis: The Expropriation of Health.
New York: Bantam Books.
Jacobs, Jerry
1974 Fun City: An Ethnographic Study of a Retirement
Community. New York: Holt, Rhinehart, and Winston.
Kahn, R. L., A. I. Goldfarb, M. Pollack, and I. E. Gerber
1960 The Relationship of Mental and Physical Status
in Institutionalized Aged Persons. American Journal
of Psychiatry 117: 120-124.
Koncelik, J. A.
1976 Designing the Open Nursing Home. Stroudsburg,
Pennsylvania: Dowden, Hutchinson, and B.oss.
Kramer, Charles J. and Jeanette R. Kramer
1976 Basic Principles of Long-Term Patient Care:
Developing a Therapeutic Community. Springfield:
Thomas.
Landy, David
1974 Role Adaptation: Traditional Curers Under the
Impact of Western Medicine. American Ethnologist 1:
103-128.
LeVine, Robert A.
1970 Research Design in Anthropological Fieldwork.
In A Handbook of Method in Cultural Anthropology.
Raoul Naroll and Ronald Cohen, eds. New York:
Columbia.
Lorber, Judith
1975 Good Patients and Problem Patients: Conformity
and Deviance in a General Hospital. Journal of Health
and Social Behavior 16: 213-225.
Manard, Barbara, R.alph Woehle, and James Heilman
1977 Better Homes for the Old. Lexington, Massachu
setts : Lexington Books.
Mazess, Richard B. and Sylvia Forman
1979 Longevity and Age by Exaggeration in Vilcabamba,
Ecuador. Journal of Gerontology 34: 94-98.
McQuillan, Florence L.
1974 Fundamentals of Nursing Home Administration.
Second edition. Philadelphia: Saunders.

118
Mendelson, Mary
1974 Tender Loving Greed. New York: Knopf.
Mellaart, James,, ,,
1967 Catal Huyuk: A Neolithic Town in Anatolia.
New York: McGraw-Hill.
Miller, Dulcy B.
1969 The Extended Care Facility: A Guide to Organiza
tion and Operation. New York: McGraw-Hill.
Miner, Horace
1956 Body Ritual among the Nacirema. American
Anthropologist 58: 503-507.
Moss, Frank E. and Val J. Halamandaris
1977 Too Old, Too Sick, Too Bad. Germantown, Maryland
Aspen Systems Corporation.
Noelker, Linda and Zev Harel
1978 Predictors of Well-Being and Survival among
Institutionalized Aged. The Gerontologist 18:
562-567.
Oklahoma Health Systems Agency
1978 A Plan for Health in Oklahoma. Oklahoma City:
Oklahoma Health Systems Agency.
Opler, Morris E.
1945 Themes as Dynamic Forces in Culture. American
Journal of Sociology 51: 198-206.
Palmore, Erdman
1975 The Honorable Elders: A Cross-Cultural Analysis
of Aging in Japan. Durham: Duke University Press.
Pelto, Pertti J.
1970 Anthropological Research: The Structure of
Inquiry. New York: Harper & Row.
Rogers, Wesley W.
1971 General Administration in the Nursing Home.
Boston: Cahners Books.
Ro s enhan, D. C.
1973 On Being Sane in Insane Places. Science 179:
250-258.
Ross. Jennie-Keith
19~4 Life Goes On: Social Organization in a French
Bletirement Residence. In Late Life. Jaber F.
Bubrium, ed. Springfield: Thomas.

119
Roth, Juluis
1963 Timetables: Structuring the Passage of Time in
Hospital Treatment and Other Careers. Indianapolis:
Bobbs-Merrill.
Schulman, Sam
1958 Basic Functional Roles in Nursing: Mother Surro
gate and Healer, In Patients, Physicians, and
Illness. E. Gartly Jaco, ed. New York: Free Press.
1972 Mother Surrogate--After a Decade. In Patients,
Physicians, and Illness. E. Gartly Jaco, ed. New
York: Free Press.
Schwartz, Arthur N.
1975 Planning Micro-Environments for the Aged. In
Aging: Scientific Perspectives and Social Issues.
Diana S. Woodruff and James E. Birren, eds. New
York: Van Nostrand.
Scott, F. G.
1955 Factors in the Personal Adjustment of Institu
tionalized and Non-Institutionalized Aged. American
Sociological Review 20:538-546.
Sherwood, Sylvia, ed.
1975 Long-term Care: A Handbook for Researchers, Plan
ners, and Providers. New York: Spectrum.
Siegler, Mirian and Humphry Osmond
1976 Models of Madness, Models of Medicine. New York:
Harper Colophon Books.
Simmons, Leo W.
1945 The Role of the Aged in Primitive Society. New
York: Yale University Press.
1946 Attitudes Toward Aging and the Aged: Primitive
Societies. Journal of Gerontology 1: 72-95.
1960 Aging in Preindustrial Societies. In Handbook
of Social Gerontology. C. Tibbits, ed. Chicago:
University of Chicago Press.
Simon, Julian L.
1978 Basic Research Methods in Social Sciences, Second
Edition. New York: Random House.
Solon, J.
1957 Nursing Homes, Their Patients, and Their Care.
Public Health Monograph, Number 46.

120
Sommer, Robert
1969 Personal Space. Englewood-Cliffs, New Jersey:
Prentice-Hall.
1970 Small Group Ecology in Institutions for the
Elderly. In Spatial Behavior of Older People.
Leon A. Pastalan and Daniel H. Carson, eds. Ann
Arbor, Michigan: University of Michigan.
Spindler, George and Louise Spindler
1974 Forward. In Fun City. Jerry Jacobs. New York:
Holt, Rhinehart, Winston.
Stern, Phillip Van Doren
1969 Prehistoric Europe: From Stone Age Man to the
Early Greeks. New York: Norton.
Steward, Julian
1950 Area Research: Theory and Practice. Social
Science Research Council Bulletin, 63.
1955 Theory of Culture Change. Urbana: University of
Illinois.
Subcommittee on Long-Term Care of the Special Committee
on Aging, U. S. Senate
1975 Nurses in Nursing Homes: The Heavy Burden (The
Reliance on Untrained and Unlicensed Personnel).
Nursing Home Care in the U.S.; Failures in Public
Policy, supporting paper No. 4 Report No. 94-00,
94th Congress, First Session.
Szasz, Thomas
1977 The Theology of Medicine. New York: Harper Colo
phon Books.
Taylor, Carol
1970 In Horizontal Orbit: Hospitals and the Cult of
Efficiency. New York: Holt, Rhinehart, and Winston.
1977 Death, American Style. Death Education 1: 177-
185.
Timasheff, Nicholas S.
1967 Sociological Theory. New York: Random House.
Tobin, Sheldon S. and Morton A. Lieberman
1976 Last Home for the Aged. San Francisco: Jossey-
Bass.
Townsend, Claire
1971 Old Age: The Last Segregation. New York: Gross
man.

121
von Mering, Otto and 0. William Earley
1966 The Diagnosis of Problem Patients. Human Organiza
tion 25: 20-23.
Woodruff, Diana S.
1975 A Physiological Perspective of the Psychology
of Aging. In Aging: Scientific Perspectives and
Social Issues. Diana S. Woodruff and James E.
Birren, eds. New York: Van Nostrand.
Woodruff, Diana S. and James E. Birren, eds.
1975 Aging: Scientific Perspectives and Social Issues.
New York: Van Nostrand.

122
BIOGRAPHICAL SKETCH
Joseph Neil Henderson was bom February 11, 1951 in
Sulphur, Oklahoma. In 1959 He moved with his family to
Orlando, Florida. Educational experience includes gradua
tion from William R. Boone High School in Orlando, Florida
in 1969; a B.A. in sociology from the University of Central
Florida in Orlando in 1973; a M.S. in anthropology from
Florida State University in Tallahassee in 1975; and
doctoral work in anthropology at the University of Florida
beginning in 1975.
Mr. Henderson is married to Janet Elizabeth Moran
Henderson of Orlando, Florida. They now reside in Ada,
Oklahoma where Mr. Henderson is an Assistant Professor of
Anthropology in the Sociology Department at East Central
Oklahoma State University.

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Ot'td'voh Merihg, Ghefirmah"
Professor of Anthropology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
(/
Anthony Faredes
Professor 0f Anthropology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
J Leslie S. Lieoerman
Assistant Professor of Anthropology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.

I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Walter CunninghaiyT7
Associate Professor of Psychology
This dissertation was submitted to the Graduate Faculty of
the Department of English in the College of Liberal Arts and
Sciences and to the Graduate Council, and was accepted as
partial fulfillment of the requirements for the degree of
Doctor of Philosophy.
December, 1979
Dean, Graduate School



58
a patient provide ample opportunity for close, sustained
contact with individual patients. This "hands-on" contact
promotes situations in which the nurses' aides are the
initial agents of health-care providing.
Abnormal body temperature is susceptible to nurses'
aide detection. However, since all thermometers are kept
at the nurses' station, the nurses' aide in a patient's
room uses her bank of past experience with a patient to
determine abnormal temperature. The ability to perceive
fever by a nurses' aide requires long-term contact with each
patient. Several reasons exist for this prerequisite. Each
person has individual responses for body temperature adjust
ment, air temperature in each room is variable, blankets
and clothing alter skin temperatures, and rubber draw
sheets, plastic-covered mattresses, or plastic air-mattress
es may be present which cause skin temperature increases.
Thus, one person may typically sweat enough to thoroughly
dampen bed linens while showing a normal temperature.
If a patient is suspected of having an abnormal body
temperature, the nurses' aide goes to the nurses' station
to get a sterile thermometer and "K-Y" jelly if rectal
temperature is taken. Not only does this allow the nurses'
aide to engage in "medical therapy" for a brief time, but
it is a legitimate time-consumer away from the more mundane,
"dirty work" which is the common lot of nurses' aides.
Integument changes are also noted for acute hyperten
sion. Redness of the face is a primary symptom nurses'


This dissertation is dedicated to the patients and
staff of Pecan Grove Manor -- past, present, and future.


105
P.G.M. TOTAL DISEASE ROSTER, cont.
Number of Times Entered
in Patient Charts
21. Bedfast/Chairfast 2
22. Blindness 5
23. Blood Sugar Unstable 1
24. Brain Deterioration 1
25. Cancer 5
26. Cardiac Arrythmia 4
27. Cardiomegaly 1
28. Cataracts 2
29. Cerebral Ischemeia &
Transient Cl 9
30. Cerebral palsy 2
31. Cholecystectomy 1
32. Cholecystitis 4
33. Chronic Brain Syndrome 6
34. Chronic Obstructive Pulmonary
Disease COPD 3
35. Cerebral Insufficiency (Cl) 9
36. Coronary Insufficiency (Cl) 18
37. Club Foot 1
38. Colitis 3
39. Colostomy 1
40. Congestive Heart Failure (CHF) 4
41. Convulsive Disorder 1
42. Coronary Artery Disease (CAD) 1
43. Coronary Heart Disease (CHD) 7


68
Mother's Day 1978 lasted about three hours. It cost
Pecan Grove Manor $897.30. Newspaper ads accounted for over
$200. One nearly full-page ad outlined a "roaring '20's
theme with a skit, play, snow-cone stand, and antique cars
parked near the highway." A competing nursing home seven
miles away countered with a smaller ad announcing a new
gerontologist on staff and a "peaceful visitation on
Mother's Day."
Pecan Grove Manor spent $85.50 on radio spots, $100
on a band, $94.90 on flowers, $137 on costumes, and $66.74
on photographs, and more on miscellaneous items. P.elatives
of patients, employees and townspeople totaled between 100
and 150 spectators. Patients, staff and visitors all
appeared to enjoy themselves. Within a few weeks, reminis
cing about the party had ceased.
One month before the Mother's Day event, a group of
patients were involved in an activity that they still men
tion over one year later. Nearby Pecan Grove Manor is a
large lake with many recreational potentials. The activi
ties director decided to arrange a fishing trip to a float
ing, enclosed fishing dock. The interior of the float is
arranged so people can sit and fish in any type of weather.
Complete services are available, ranging from a bait store
and equipment rental, to a cafe.
Seven male patients were selected to go on this trip.
Selection was based on level of debility, behavior, and an
expressed desire to go. Three men from the community were


48
to base her behavior in a nursing home setting. There
exist many symbols to excite the mother role or "mothering":
helplessness, toddling, incontinence, beds with bars,
diapers, etc. By focusing on the mother/child interactional
pattern, a maximum level of care behavior is extracted from
the untrained, low-level nurses' aide.
The mother/child role relationship is expressed in a
variety of ways. The infantilization of the adult patient
can be observed in child-like words for excrement ("shoo-
shoo," "wee-wee") and diapers ("didees"). One instance I
observed demonstrated the nursing staff need to persist in
infantilizing the patient. A nurse was examining a male
patient with a distended lower abdomen. The man had a
history of prostatitis. The nurse used "pee" and "make
water" while the patient used "urinate" and "catch a speci
men. "
Other expressions of infantilization are more com
pletely explicit than referring to patients as "baby,"
"little one," or "little people." Consider these phrases:
"... just wash them like I would
one of my own children, 'cause that's
just what they are."
"Ive got twelve kids and so I'm well
suited to this job."
"Like babies, they get good and warm
and they pee up a storm."
"I think of these people as my babies,
especially the ones on North Wing
because they are so helpless."
"They're like children. They are there
for us to spoil."


60
ted bedsores are then transferred to the nursing home.
While this may be true to some extent, bedsores likewise
originate in the nursing home. Yet, the nursing dictum
that "bedsores are totally preventable" seems to be overly
optimistic. People who are kept alive for so long that they
can't be handled because deep tears in the skin occur can
hardly be expected to remain free of decubitus ulcers.
Likewise, the comatose geriatric patient who is incontinent
and fed by a naso-gastric tube represents another nearly
impossible task in decubitus ulcer management. It remains
true, however, that more effort is expended in bedsore
management than prevention.
Also involved in the primacy of physical care is that
it is expressed in physical activity. The busy aide is one
who is moving. The charge nurse can look down the corridor
and tell if the aides are actually working by the movement
in and out of rooms. The aides assimilate this dogma
rather completely and probably by transfer from other jobs.
For instance, I noticed one nurses' aide leaning on a
patient's bedrail and talking to the patient for about five
minutes. Later, in response to my question of what she had
been doing, I was told, "just foolin' around."
Physical orientation to patient care is further promo
ted by its observability, immediacy of results, and amena
bility to rapid dispensing. Thus, the nurses' aide can pro
ject the good-worker image not only by activity, but by the
physical proof of duty performance within the time con
straints of her shift.


81
I'd rather be here than with my kids
to eliminate potential conflict with
them (paraphrased, 77 year old female).
If they can't get up and get around,
tell 'em to come on (to Pecan Grove
Manor). (77 year old male)
It's a good place to live, but there's
no place like home. (88 year old male)
Next thing to home, but it ain't home.
(91 year old male)
If you can't live at home, this is
tops. (78 year old male)
It's more like home than if I was with
my children. I'd feel in the way if
I was with my children and I don't feel
in the way here. (94 year old female)
They (her grandchildren) have no use
for old people. Don't you know that?
(88 year old female)
Responses to "What do you like most about living
here at Pecan Grove Manor?" centered about patient/staff
dependency. The primary benefit is the security of having
one's needs consistently met within a cognitive set of
perceived personal risks at simply being alive. The needs
were clearly biosocial: companionship of staff and other
patients, food service, and perceived medical-care avail
ability. Responses to "What do you like least about living
here at Pecan Grove Manor?" were oriented toward situation-
specific items rather than the nursing home itself: sepa
ration from family and friends and disvalued behavior of
other patients (eg., noisy, messy).
References to what these patients missed most about
their life prior to being institutionalized were


33
One final area of public space to consider is the
dining room. While most other biological needs can be met
in the patient rooms, eating in the dining room is consid
ered. indicative of a relatively high level of functioning.
The administrative and nursing staffs encourage dining room
use for the change of scenery and social interaction. Even
so, seating placement is fixed so that forgetful patients
will not be so easily confused.
The dining room, like the lobby, is a place of very
little social interaction. Meals are brought to the tables
by the kitchen staff on large fiberglass trays. In an
effort to serve the food hot or cold, and to satisfy hungry
patients, great haste is made in getting food trays to the
tables. One result is that the kitchen staff has little
time to exchange pleasantries with the patients at the
tables.
Other obstacles to interaction at mealtime are related
to sensory deficiencies in the patients. The hearing-
impaired patient has difficulty understanding another from
across the table. Impaired vision may further hamper
communication by disallowing lip-reading. Additionally,
the kitchen is adjacent to the dining room where a very
loud dishwasher operates during meals (cf. Koncelik 1976:54).
Thus, food service responsibilities, sensory deficiencies,
and environmental noise function to inhibit mealtime inter
action.


79
differs from the kitchen staff in terms of corridor life
and concepts of time and space. Thus, for the patient,
nutrition requires special planning.
Meals are never served at exactly the same time. The
variance ranges from fifteen to thirty minutes and is due
to mundane human factors and differing preparation times
for various foods. Meals are usually served between 11:30
A.M. and 12:00 Noon. Also, patient trays are distributed
by rotating the starting place of distribution. If at
breakfast the first trays were placed at the west end of
the dining room, at lunch they will begin at the east end.
Distribution time from one end to the other is about thirty
minutes.
The patient's goal is to coincide his or her time of
arrival at the assigned table with the arrival of the food
tray. If timing is correct, hot food will be hot and cold
food will be cold. Patients begin leaving their rooms
from 11:15 A.M. to 11:30 A.M. to walk or roll to the lobby
or entrance area. Here they sit, rest and sometimes talk
with those nearby. At this "way station" patients conti
nually glance toward the dining room which they can now
see to notice the earliest activity from the kitchen. One
signal used by many people is the appearance of a kitchen
staff member who turns on the dining room light. Tray
distribution begins at one end of the dining room. Those
who sit at that end walk the now short distance to their


82
independent of the institution. The predominant response
was a loss of personal independence coupled with the loss
of their spouse. On the other hand, these patients expe
rienced improvements as a result of institutionalization.
The presence of nurses' aides as helpers and being around
other people for socializing were likewise reported as
improvements in their lives.
The experience of being a nursing home patient actually
begins before one enters the front door (Tobin and Lieber-
man, 1976). The patient brings with him previously devel
oped beliefs regarding nursing home life. Little is done
to better precondition the prospective patient for admis
sion to Pecan Grove Manor while in the hospital or at home
prior to admission. Thus, early experiences in the nursing
home can be unnecessarily traumatic. Consider the report
(edited) of Mrs. Nancy Pipkin (pseudonym), a 75 year old,
white female:
JNH: What kind of adjustments did you
make? When you think back about when
you first came here.
NP: Well, when I first came I was
unhappy a little while. I didn't hardly
know . see I just come out of the
hospital here and I had had a nervous
breakdown. And I had a lot of adjust
ing to do anyway, wherever I had been.
And then I just come out of it and I
can just walk and do anything I want to
do. And I'm happy here.
JNH: What do you miss most about living
in the community?


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Ot'td'voh Merihg, Ghefirmah"
Professor of Anthropology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
(/
Anthony Faredes
Professor 0f Anthropology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
J Leslie S. Lieoerman
Assistant Professor of Anthropology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.


55
When I began working as a paid nurses' aide, the first
striking discovery I made was that each aide has memorized
a large array of personal habits of each patient that ren
dered their service to the patient more personal and time-
efficient (cf. Taylor 1970). For instance, the placement of
a juice glass on the left side of a breakfast tray for one
person renders the glass more visible and accessible, two
packages of sugar for one person, three for another, no
napkin for that person because they eat paper, etc., is
required for proper job performance. The catalog of indi
vidual patient wants is enormous and generally fulfilled.
Only lengthy, daily contact would make such a feat possible.
This same intimate knowledge of patients is observed
in noting behavioral change that may be of medical conse
quence. Actual hands-on contact with patients such as
feeding, bathing, clothing, changing diapers and bed linens,
provides the nurses' aide with another set of information.
The nurses' aide becomes aware by sheer repetition of
patient-specific behavior patterns and potentials. Devia
tion from an expected set of behaviors warrants mention to
a higher authority.
For example, Mr. Robert Henry (pseudonym) is a white
male, 72 years old, bed-fast, diabetic, paralyzed on his
right side as a result of a cerebral vascular accident,
incontinent and requires feeding. The position of Mr.
Henry's bed is such that the nurses' aides continually feed
him from one side of the bed. For weeks this was satis
factory until one morning a nurses' aide reported to the


2
Throughout time, the concept or label of "aged" has
been assigned to people in accordance with prevailing
beliefs regarding the chronological age at which someone
"becomes" old. Assignment to the category of aged, then,
is a combination of belief and time. In extremes, the six
year old progeric patient is considered old while the
Russian Abkhasians or Ecuadorian Hunza are considered old
only after reaching a purported (cf. Butler 1978b and Mazess
and Forman. 1979) 100 years of age.
During the middle Paleolithic, Neandertal burials at
Mount Carmel disclose that of a male about 50 years of age
(Clark 1969:45) although most Neandertal burials are of
individuals less than 30 years of age (Stern 1969:98).
Mellaart's (1967:225) excavations in Turkey show that very
few of the Neolithic inhabitants of Catel Hyk lived over
40 years of age. During the Iron Age (c. 100 B.C.), the
average life span was 18 years although some rare indi
viduals survived as septugenerians (Birren and Clayton
1975:15). By 50 B.C., the life span has increased to 25
years until the 1600s A.D. when the life span edged ahead
to 32 years of age (Birren and Clayton 1975:24).
During the year 1776 A.D. in America, only 207o of
neonates lived to the age of 70 and only 4% of American
families were comprised of three generations (Butler 1978b:
15). By 1900, the human life span was 47 years and in 1970
it was 71 years of age (Cutler and Harootyan 1975:32-34).


93
The patient population of Pecan Grove Manor, and
particularly those most able patients, actively engage
themselves in their community's environment. Their efforts
are aimed at resource identification and exploitation.
These adaptive tasks are in constant motion due to the
changing social environment and changes in their own per
sonal capacity for negotiating shifts in physical and
cognitive states. Thus, life in this nursing home is a
physical and emotional challenge as was life in the non-
institutional community.
Given chronic illness, unemployment, loss of spouse,
and other common facts of the American "old age experience,
membership in a nursing home does not necessarily involve
life without sensation or challenge. The very nature of
the American proprietary nursing home generates physical
and emotional challenges to the patient population on a
daily basis. This is not an argument against improvements
in nursing homes but just the opposite. Recognition of
the naturally-existing resource pool allows for enhancement
of patient life with little economic cost to the manage
ment. Observation and discussion among the patients will
provide the routes to pre-established patient resources
which can then be monitored, preserved, and enhanced.


57
Noticing slight changes in patients leads the nurses'
aides to engage in a variety of folk-diagnoses and prescrip
tions, for they "know what that patient needs." A frequent
diagnosis is constipation. This does not require notifica
tion of the R.N. or laxatives unless symptoms persist. The
symptoms are subtle ones such as patients who look like they
are straining when they should be relaxed in bed, a patient
exploring his anus with a somewhat determined facial expres
sion, general foul mood, and deviation from expected time
intervals of bowel movements.
If it is determined that the patient suffers from con
stipation, the cure is to remove a suspected lower rectal
impaction. This involves a trip to the nurses' station
(otherwise off-limits to the average aide) to get a surgical
glove and some "K-Y" jelly. The patient is often positioned
in front of a toilet in expectation of successful therapy.
If an impaction is present and removed and the dilatage
action promotes a bowel movement, or even if the blockage
is up higher and not immediately relieved, the diagnosis
and therapy still allows the nurses' aides a brief foray into
"medicine" and some assurance for themselves that it will be
some time before they have to change that patient's under
wear or diaper.
Other folk-diagnoses made by nurses' aides revolve
about observed changes in the integument. Tasks assigned to
the nurses' aides require seeing and touching the patients'
skin. Feeding, bathing, cleaning incontinence and clothing


90
vicariously dealing with someone else's problem when their
own environment minimized them.
In fact, the nurses' aides are a virtual data bank
for the patients to learn of community life and internal
nursing home events. In spite of supervisory attempts to
restrain nurses' aides' conversational topics, the aides
are in intimate contact with patients for too great a
time to totally prevent exchange of personal information.
Patients at Pecan Grove Manor nursing home have also
seized upon a naturally evolved element of their institu
tional setting as a personal resource: the housekeepers.
The housekeepers at Pecan Grove Manor are two women who
were nurses' aides at this nursing home prior to their
employment as housekeepers. They routinely move through
the hallways in separate, systematic routes. Each house
keeper pushes a janitorial cart containing a mop, mop
bucket with "squeegee," trash bag, and numerous cleaners'
and disinfectants. The thoroughness of their work is
attested to by the universal report from visitors and
patients that Pecan Grove Manor is "the cleanest nursing
home I've ever seen."
In addition to their function as housekeepers, they
represent an important resource to the patient population.
They are brokers bridging the patients and the nursing
staff especially with regard to sensitive issues and they
are more available for conversational interaction than
any other staff group.


CHAPTER SIX
THE PATIENT EXPERIENCE: THE NEXT BEST THING TO HOME
Perhaps the most direct route to the experiential
reality of patienthood in Pecan Grove Manor involves elici
ted response from the patients themselves. On a daily basis,
the patients must negotiate the entire social system of
Pecan Grove Manor. The exigencies of nursing home life that
seemingly are "non-problems" to the staff, families, and
researcher, in fact are real problems to the patients who
must as resourcefully as possible manage their lives in this
environment. Self-management in an institution becomes an
exercise not in futility but in the identification and maxi
mization of situationally-specific behavioral resources from
a meager resource pool.
Nursing home life involves institutionally-imposed con
straints. Nonetheless, there exists sufficient tolerance or
"slack" in the formal normative system for behavioral flexi
bility or creativity to emerge. Thus, the patient popula
tion can be seen to experience oppressive external controls
while simultaneously engaging in the creative extraction of
self-benefiting behavioral procedures.
The capacity for ingenuity within a geriatric popula
tion is apparently a point of dispute. In one recent trea
tise on aging (Woodruff and Birren 1975), diametrically
opposed statements are found:
The impression one gets from . .
environments in which aged persons live
as well as from that which is written to
75


APPENDIX 4
DISEASE PREVALENCE
PECAN GROVE MANOR
PR
Cardiovascular Disorders .2340
Neurologic Disorders .2127
Psychiatric Disorders .1914
Musculoskeletal and Connective
Tissue Disorders .1489
Gastrointestinal Disorders .1063
Genitourinary Disorders .0744
Miscellaneous .0744
Nutritional and Metabolis Disorders .0638
Respiratory Disorders .0531
Ear, Nose and Throat Disorders .0319
Endocrine Disorders .0319
Opthalmic Disorders .0212
Hepatic and Biliary Disorders .0212
Gynecology and Obstetrics and
Breast Diseases .0212
Infectious and Parasitic Diseases .0106
Hematologic Disorders .0106
Dermatologic Disorders .0106
Cancer Disorders .0106
111


67
insistence that they did not have time, or could not leave
"the lights" unattended.
The beauty shop is an activity that sometimes becomes
a spontaneous party, even attracting male patients and
office workers to the door. One L.P.N. disliked the laugh
ing and commotion in the beauty shop because it disrupted
the sanctuary-like environment she considered proper. As
she told me one day, she preferred to work on shifts in the
evening and night hours because families were less present,
most patients were asleep, and she could engage in "pure-
dee quality nursing care." One of those involved in activi
ties suggested that the nurses' aides disliked patients in
the beauty shop in the afternoon hours because it prevented
the aides from putting the patients to bed so the aides
"wouldn't have anything to do."
Activities as therapy are suspect, too, because there
are no assessments of improvements in patients attributable
to the activity program. Benefits to patients may be slight,
subtle, or nonexistent, but no one knows for certain. The
visibility of physical care benefits overshadows the rela
tive invisibility of psychosocial improvement.
Activities in the religious and civil/religious cate
gories are highly visible and receive great attention from
the administrative, nursing, and activities staffs. Most
important is Christmas and Mother's Day. For example, the
Mother's Day celebration becomes a community competitive
potlatch in which conspicuous consumption brings status to
the nursing home from the community.


TABLE OF CONTENTS
CHAPTER PAGE
ONE BACKGROUND 1
TWO METHODOLOGY 10
THREE DEMOGRAPHICS AND EPIDEMIOLOGY 17
FOUR ENVIRONMENTAL SETTING 25
Note 42
FIVE THE DAILY CYCLE: RITUALS OF
FABRICATED LIFE 43
SIX THE PATIENT EXPERIENCE: THE NEXT
BEST THING TO HOME 75
SEVEN CHRONIC LIFE AND AGE SEGREGATION 94
APPENDICES
1 SELECTED NURSING HOME INDICES 1977 103
2 PECAN GROVE MANOR TOTAL DISEASE
ROSTER (FROM PHYSICAL1 LISTINGS
IN PATIENTS' CHARTS) 104
3 PECAN GROVE MANOR
TEN MOST PREVALENT DISEASES 110
DISEASE PREVALENCE
PECAN GROVE MANOR Ill
Vll


116
Crane, Julia G. and Michael V. Angrosino
1974 Field Projects in Anthropology. Morristown:
General Learning Press.
Cutler, Neal E. and Robert A. Karootyan
1975 Demography of the Aged. In Aging: Scientific
and Social Perspectives. Diana S. Woodruff and
James E. Birren, eds. New York: Van Nostrand.
Dyson-Hudson, N.
1963 The Karimojong Age System. Ethnology 2: 353-401.
Eliade, Mircea
1963 Patterns in Comparative Religion. New York:
New American Library.
Freilech, Morris
1970 Marginal Natives. New York: Harper & Row.
Garvin, Richard M. and Robert E. Burger
1968 Where They Go to Die: The Tragedy of America's
Aged. New York: Delacorte Press.
Goffman, Erving
1960 Characteristics of Total Institutions. In Identity
and Anxiety: Survival of a Person in Mass Society.
Glencoe, Illinois: Free Press.
Gold, Raymond L.
1969 Roles in Sociological Field Observations. In
Issues in Participant Observation. George J. McCall
and J. L. Simmons, eds. Reading, Massachusetts:
Addison-Wesley.
Gould, Harold A.
1965 Modern Medicine and Folk Cognition in Rural
India. Human Organization 24: 201-208.
Gubrium, Jaber F.
1973 The Myth of the Golden Years. Springfield: Thomas.
1974 On Multiple Realities in a Nursing Home. In
Late Life. Jaber F. Gubrium, ed. Springfield: Thomas.
1975 Living and Dying at Murray Manor. New York:
Martin's Press.
Hawley, Amos H.
1944 Ecology and Human Ecology. Social Forces 22:
400-405.
Henry, Jules
1963 Culture Against Man. New York: Random House.


APPENDIX 3
PECAN GROVE MANOR
TEN MOST PREVALENT DISEASES
Disease
Number
of cases
Prevalence
Rate
1. Arthritis
37
39.47c
2. Arteriosclerotic
Cardiovascular
Disease
29
30.87=
3. Arteriosclerotic
Coronary
Insufficiency
29
30.87o
4. Osteoporosis
26
27.67=
5. Mental Confusion
24
25.57=
6. Hypertensive
Cardiovascular
Disease
23
24.57=
7. Coronary Insufficiency
18
19.1%
8. Arteriosclerotic
Cerebral
Insufficiency
16
17.0%
9. Cardiovascular Accident
17
18.0%
10. Fractures
15
15.9%
110


97
non-medical use of care agents market the resourcefulness
of the geriatric nursing home patient.
Direct primary care from the "native" experience
is the province of nurses' aides and housekeepers. Nurses'
aides constitute 4370 of all staff categories in nursing
homes nationwide (Subcommittee on Long-Term Care 1975:361)
and 417o at Pecan Grove Manor. From 1960-1976, the number
of nurses' aides employed has increased by 5507, (Moss and
Halamandaris 1977:21). The rapid rise in the number of
nurses' aides is a product of the relatively recent bio
medical culture contacting the American cultural value
system proscribing senilicide and thus generating "spinoffs"
such as nursing homes and the emergent (cf. Landy 1974)
therapeutic role of the nurses' aides.
While biomedicine has charmed the medical and public
sector alike, the increase in chronic incurable disease
has created a therapy and therapist vacuum. This vacuum
is currently being filled by middle-aged women with little
or no training engaging in therapy modeled after mother/
child interactive patterns which are considered to be
physically and emotionally nurturant. The response pattern
of directing victims of chronic, incurable disease to folk
medical practitioners rather than biomedical specialists
was also found by Gould (1965) in rural North India.
Over the past two decades, the role of licensed
nursing personnel has shifted from patient-contact to


30
media promote snack-type foods as vehicles which fuel
social interaction and cement social ties. Nonetheless,
the vending machines do not have chairs or tables clustered
nearby to take advantage of the Madison Avenue promotion
for food/love--love/food orientations.
Thus, the main lobby fails as an arena of lively
patient interaction in daily use. The only times at which
the main lobby becomes the location of significant inter
action are those of cyclical ritual events staged by the
nursing home staff and/or community. These events include
weekly religious services, civil/religious ceremonies
(Independence Day, Mothers' Day, Memorial Day), and Judeo-
Christian celebrations (Christmas, Easter).
The main lobby does, however, produce an impression of
a spacious "homey" atmosphere. The institutional nature of
Pecan Grove Manor is masked by residential-type furniture,
carpeted areas, and soft pastel wall colors. There also
are planters with green plants and decorative wooden support
posts with wood-shake shingles fronting the nurses' station.
Lighting is primarily by recessed neon bulbs, but even so,
table lamps are present in the lobby. Overall, the lobby
generates in the observer a positive feeling about the
nursing home as a whole.
Certain areas of public space seem to be conducive to
interaction due to some accidental configuration of design
elements. Adjacent to the main lobby is a zone which serves
as the main entrance to the nursing home. The entrance area
is a natural, unplanned interaction zone.


26
Of specific importance here is a special type of envi
ronment known as an institution. Goffman's (1960) analysis
of "total institutions" underscores the oppressive nature
of the "inmates'" lives in a heavily controlled habitat.
While prisons or mental hospitals may be characteristic of
total institutions, many nursing homes, and particularly
Pecan Grove Manor, are not.
Bennett and Nahemow (1965) have developed a system of
ranking an institutional facility according to its degree
of institutional totality. Their perspective maintains that
a nursing home represents a significantly different living
environment compared to independent community life and that
while a nursing home may approach the total institution,
it often falls short of this extreme.
To assess Pecan Grove Manor along a continuum of insti
tutional totality requires a review of the environmental
setting encountered by patients and staff. The building is
comprised of three corridors attached to an open square room
(See Figure 3). Corridor architecture seems to characterize
the physical plant of many institutional facilities (Beckman
1971; Bennett and Eisdorfer 1975; Gubrium 1975; Koncelik
1976). Butler (1975) even refers to the "motel-like"
appearance of many nursing homes.
The corridor design of Pecan Grove Manor departs from
the motel image in that all corridors are lined with hand
rails. The rail-lined corridor is the distinctive feature
of many nursing home environments. Acute-care hospitals may


54
ACTIVITY
TIME DURATION
Patients up, down, or cleaning
1 hour 02 minutes
Food service
2 hours 22 minutes
Bed check, make beds, clean beds
2 hours 29 minutes
Shaving
1 hour 18 minutes
Break, Lunch
45 minutes
Linen
08 minutes
Showers
2 hours 48 minutes
Miscellaneous (rinse dirty linen,
fix the sink)
12 minutes
8 hours 16 minutes*
*For those nurses' aides who don't give the showers.
NURSES' AIDE TASK-TIME CATEGORIES
5 May 1978
Figure 8


69
asked to help at the fishing site. They were expected to
assist in baiting hooks, netting fish, and any other fish
ing-related tasks. They were invited to fish, too. The
remainder of the party consisted of the activities director
and myself.
Twelve people participated in the outing for a cost to
the nursing home of $71.71. The five-hour event took place
on a Tuesday from 9 AM to 2 PM. The activities director
sent a small write-up to the local weekly newspaper as is
commonly done with patient birthdays. Other than this, the
community-at-large was uninvolved and unaware of the fishing
trip.
The effect of the trip on the patients and the activi
ties director was quite noticeable. Patients were ready to
go and positioned at the entrance doors 30 to 40 minutes in
advance. Although everyone was ready for a rest at the end
of the trip, the patients asked when they could go again.
The activities director considered possible ways to continue
such trips by buying some small Zebco rods-and-reels and
some fishing tackle. A member of the administrative staff
cautioned that the group of people wanting to go would in
crease in size. Overall, I had never seen these particular
men so animated prior to the trip or known of a special
activity that engendered such a sustained level of excite
ment and anticipation of another trip.
Mother's Day and the fishing trip were both entered on
government forms as activities. Nonetheless, each event


FIGURE 6
PATIENT ROOM--AMBULATORY WING


21
70. A population pyramid of the patients shows the greater
percentage of female patients to male patients begins in
the seventh decade and persists through the ninth decade
(See Appendix 5). The predominance of women is still
preserved when staff is included in a Pecan Grove Manor
patient/staff population pyramid. Thus, when considering
the patient and staff populations, Pecan Grove Manor nursing
home is predominantly female and middle-aged (average age
of patients and staff is 51.7 years).
The patient population is divided into three physically
and conceptually distinct units based on degree of debility.
Pecan Grove Manor is essentially three nursing homes in one.
The configuration of the physical plant is based on "wings"
radiating from a core containing the lobby, dining room,
nurses' station, and administrative office (See Figure 3).
Assignment to a wing is based on one's level of debility and
thus the type of nursing care required.
General observations give the impression that each wing
is characterized by distinctly different disease entities.
The level of care required on each wing would appear to be
a function of progressively more serious disease types.
However, disease distribution throughout the nursing home is
even. Wing assignment is not related to the roster of
diseases found on the patients' charts.
Four factors are related to wing assignment and do not
require physician assessment or orders in patient charts.
At admission, the prospective patient is assessed by the


5
POPULATION PYRAMID:
PECAN GROVE MANOR.
112
6 WING ASSIGNMENT BY DEBILITY FACTOR . .
REFERENCES CITED
BIOGRAPHICAL SKETCH
113
114
121
viii


4
adapting modern American life to a new element of the social
and cultural system. In this sense, sociocultural evolution
is proceeding under the guise of federal and local govern
mental programs providing services for needy elderly while
also functioning to shift responsibility away from indi
vidual elderly persons and their families to the general
public. Monetary assistance for the aged, treatment and
storage facilities for the aged, separate communities for
the aged, and simple ostracism appear to be the American
ways of dealing with the growing aged population. Thus,
the American aged population has been identified, cate
gorized, and stigmatized as a "problem" with which the
"un-old" must cope.
Throughout the United States, the vast majority of
aged people (hereafter meaning those persons 65 years of
age and older) live in community settings with 72.7%, of
aged males heading a household. Relatively few aged people
live alone (14.7%, male; 36.2% female) and even fewer live
in institutional settings (3.6%, male; 4.6%, female) (Cutler
and Harootyan 1975:63). This minority of institutionalized
aged, however, currently total 1.2 million people (Brody
1977a:85) and projections indicate that by the year 2000,
there may be 11 million aged people residing in institu
tional facilities (Brody 1977b: 15).
The institutional setting likely to be encountered is a
privately-owned, profit-operated business selling various
degrees and types of care to the elderly sick. According


99
The nurses' aides through all of the reports of love
for the patients essentially monitor patient decline.
Their activities are viewed as necessary to make patients
as comfortable as possible until they die. This view is
consistent with a medical-model oriented toward cures as
success and lack of cures as failures. In order not to
fail, there will be no attempt at therapy, only palliative
care.
In Pecan Grove Manor care agents were found to include
an unexpected category of providers: housekeepers. The
biomedical view of health care organization excludes
housekeepers as therapeutic agents. The ethnomedical
view, however, identifies the housekeeper as a naturally
evolved, unplanned agent of psychosocial support for
patients.
Characteristics of the housekeepers' tasks, values
regarding employment, and personal demeanor provide a field
for engaging interaction rather than brief, ritualistic
interaction typical of nurses' aides. These characteris
tics include lengthy in-room task performance (by necessity
and demonstration to supervisors of thoroughness of clean
ing) wearing street clothing, previous work as nurses'
aide, and middle age status. Thus, the housekeeper is
seen by the patient as an expected, daily visitor who can
converse at length, carry information throughout the
nursing home, and report on local community matters on a
routine basis. Also patients use the housekeeper as a


CHRONIC LIFE:
AN ANTHROPOLOGICAL VIEW OF AN
AMERICAN NURSING HOME
BY
JOSEPH NEIL HENDERSON
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1979


29
Several factors relate to the television area's in
ability to actually engage the potential viewer. Sensory
deficiencies may make seeing the screen and hearing the
sound difficult, particularly in a heavy-traffic area such
as the lobby (cf. Koncelik 1976:53). At times, when the
television sound is loud, nurses' aides lower the volume or
as soon as no one is in the television area, turn the set
off.
Also, many patients have personal televisions in their
rooms complete with cable service. The television area
serves, too, as a brief rest-stop on the way to the dining
room. When food trays are served, the television area is
immediately vacated.
Interaction among patients in the lobby is further
inhibited by the arrangement of chairs and couches. The
chairs and couches represent long lines of seating which
occasionally meet at right angles. For persons with de
creased sensory sensation and physical mobility, sitting in
lines of seats facing directly ahead requires difficult
bodily contortions to enable each person to twist to see and
hear the other. The degree of difficulty posed by these
communication obstacles is such that little interaction
takes place while seated in the lobby (cf. Koncelik 1976:53;
Sommer 1970:26-29).
The vending machines (soft drinks, potato chips, nuts,
candy, cigarettes) are located along a wall away from
activity areas. In contemporary American culture, the


44
community to assist them in negotiating institutional life
and chronic disease.
The inner workings of nursing homes have been examined
from a variety of perspectives, each with its own version of
reality and degree of quality. Social critics have long
accused the nursing home industry of being charlatans.
Consider these titles: Tender Loving Greed (Mendelson 1974),
Old Age: The Last Segregation (Townsend 1971), Where They
Go to Die: The Tragedy of America's Aged (Garvin and Burger
1968), and Too Old, Too Sick, Too Bad (Moss and Halamandaris
1977).
Another category of nursing home speculators involves
the experienced administrator teaching others to be admin
istrators. These works are characterized by manipulative
marketing techniques designed to promote a nursing home
(Bachner 1974) and "how to" instructions detailing how to do
to patients and families (Rogers 1971; Miller 1969). Other
administratively oriented volumes attempt to be more thera
peutically oriented (McQullan 1974; Kramer and Kramer 1976).
A shift in orientation of perspective is observed as
the authors of works examining nursing homes are identi
fiable as social scientists. The content of such volumes
tends to be oriented toward an analytical view of the inner
workings of nursing home living and ideas regarding the
quality of life of the inmates. Some comprehensive volumes
include Long-Term Care (Sherwood 1975), Long-Term Care of
Older People (Brody 1977), Last Home for the Aged (Tobin


83
NP: Well, anybody misses home, but
outside of that . But I miss home
and friends. But the friends come to
see me and I see them, so. I just know
that this is going to be my home from
now on and I just accept it and try to
make myself be happy. I don't have any
complaints as far as myself is con
cerned. They are just as sweet to me
as they can be. Everytime I've ever
needed anything, why, they're right
here to help me. I'm just . I'm
just thrilled I've got a place like
this to stay.
JNH: About how long do you remember it
taking until you felt comfortable here?
From the time you were first here.
NP: Oh, I guess it was six months
maybe before I really could just turn
loose and feel at home, but after that
I was . Now I was never miserable
understand. I . when I come I knew
that this was going to be my home and
I was going to make it pleasant as I
could. So, I haven't let myself worry
and think, "Why did I have to come here?"
and "Why did this have to happen to me?"
I've just accepted it and I've enjoyed it.
I just wish every old person that has to
stay alone and be in danger of not
being cared for you know . that
couldn't take care of themselves. It's
bad to have that feelin' that you might .
JNH: OK, how about some more on this.
You were saying that you wished other
people that needed to have these kinds
of services could have them. Could you
kinda repeat that?
NP: Yeah, well I do. I wish that other
people could see and know how happy we
are in here. I don't think that it'll
be . seemed like it ... that I
did, I had a fear of coming down here.
Before I come here, I'd heard things,
you know, remarks made. And I haven't
found any of that to be true in my
case of what I'd heard or was afraid of.


50
the level of care needed and shift time. For instance,
federal regulations require one nursing staff member per
each ten patients on day shift (6 AM to 2:30 PM), one
nursing staff member per each twenty patients on evening
shift (2:30 PM to 11 PM) and one nursing staff member per
each twenty-five patients on night shift (11 PM to 6:30 AM).
Since Pecan Grove Manor is designed to accomodate ninety
patients, the day shift has eight nurses' aides and one
L.P.N., the evening shift has five aides and one L.P.N.,
and the night shift has three aides and one L.P.N.
The distribution of aides by shift is based on level
of care needed on each wing. Patients, visitors, office
staff, and thus nurses' aides are the most active during the
day shift. Day shift nursing staff is the most differentia
ted. The heavy-care wing has four aides, the intermediate-
care wing has three aides, and the ambulatory wing has one
aide who, during part of the day shift, helps with baths
and food delivery. The majority of the day shift she spends
dividing her time between the other wings.
The day shift begins officially at 6:00 AM, but day
shift aides have informally assembled in the lobby near the
nurses' station for casual socializing ranging from 5:15 AM
until shift report. Pre-shift conversations are typically
about personal community life. Only if something unusual
regarding a patient has occurred is the topic of the
nursing home related.


87
conflict will constantly be near each other and have
little option to retreat to quell hostilities due to
reduced private space. Also in operation is institutional
public life expressed in the feeling that "everyone will
know my problems."
One patient (86 year old female) stopped me in the
hall one day finding it difficult to maintain eye contact
and select her words. She eventually began with, "I know
you know this already, ..." I didn't. She related in
a halting voice that she suspected her roommate of con
spiring with one of the cleaning women to put aluminum
foil on the top part of the room windows. Her roommate
is consistently too warm and she is consistently too cold.
She said she didn't know whether or not this should be
included in her diary which she wanted to give me. They
had earlier agreed to divide ownership of the window by
the two panels of glass. Even in the winter, her roommate
would exercise her ownership perogative over her panel of
glass by opening it, even though the window unit was not
on "her side of the room."
This woman was convinced that the magnitude of this
conflict was such that it was surely public knowledge.
She also felt quite helpless in that two people (roommate
and a staff member) had conspired against her. The per
ceived and real lack of physical and social resources
caused a minor incident to have major implications for
this patient.


32
lobby/dining room/nurses' station cluster. Traffic in
either direction can, for convenience or necessity, stop
here to rest, observe and talk.
Social interaction is thus promoted in the entrance
area by numerous coincidental features. Seating in this
area is limited, however, and most users are those who have
retained higher levels of functioning. This part of the
nursing home physical environment serves as a central loca
tion for patients to learn of various activities occurring
in "their" building and to exchange information which is
then diffused to the other corridors of the physical plant.
Floor space area, whether lobby, entrance, or patient
rooms, is determined by formulas based on the number of
patients housed. The main lobby fulfilled the space re
quirements for the first thirty-bed unit and the second
addition of another thirty beds. When continued construc
tion added an additional thirty beds, however, additional
lobby space had to be built. This new lobby area is at the
end of the ambulatory corridor. In this new lobby, about
one-third the size of the main lobby, most intrainstitu-
tional activities occur.
Intrainstitutional activities include weekly bingo
games, activities such as singing and craft work, daily
domino games, and other patient/family activities such as
private parties. The new lobby area also serves as a place
for large groups of visitors to see their relatives.


121
von Mering, Otto and 0. William Earley
1966 The Diagnosis of Problem Patients. Human Organiza
tion 25: 20-23.
Woodruff, Diana S.
1975 A Physiological Perspective of the Psychology
of Aging. In Aging: Scientific Perspectives and
Social Issues. Diana S. Woodruff and James E.
Birren, eds. New York: Van Nostrand.
Woodruff, Diana S. and James E. Birren, eds.
1975 Aging: Scientific Perspectives and Social Issues.
New York: Van Nostrand.


23
R.N. and/or assistant administrator according to continence,
ambulation, location of meal-taking, and ability to feed
one's self. These four patient-management factors determine
wing as signment.
The wings at Pecan Grove Manor are called by the
cardinal direction with which they most closely .align (See
Figure 3). The North Wing is closest to the nurses' sta
tion, personnel, medications and medical equipment. Those
patients on the North Wing are most likely incontinent, non
ambulatory, eat meals in their rooms and must be fed. The
diseases found on this wing are the same found throughout
the nursing home but the degree of debility is greatest
here. The efficiency of care delivery is enhanced by the
proximity of the nurses' station to the wing requiring the
most patient care.
At the other extreme, the East Wing houses people who
are most likely to be continent, ambulatory, dining room
users, and self-feeders. This wing is furthest from the
main nurses' station. Seldom are call lights used on this
wing. In fact, patients desiring "prn" (i.e., as often as
needed) medications typically walk from their rooms to the
nurses' station to make such a request.
The South Wing represents an intermediate transition
between the "heavy care" and "light care" wings. Here the
ambulatory, dining room users who feed themselves are
moderately represented relative to the other wings.


101
culturally relevant negative sanctions proscribing senil-
icide while actually inducing the fatal course of chronic
life.
The medical model is elevated to such a lofty spiri
tual plane (Siegler and Osmond 1976; Szasz 1977) that a
cure for the chronically-aged sick is not only impossible,
but unimaginable. Since health is culturally signaled
by freedom from acute physiological pathogenicity and
cure by medical-model intervention, those who are chroni
cally ill and not physiologically responsive to such
"appropriate" intervention are housed in palliative-care
institutions to await death. Their minds are numbed by
the anesthetic of psychosocial starvation while their
bodies are carefully tended, reducing the odor of pro
longed death.
Thus, nursing homes are cultural products. They are
part of the machinery of living and dying in industrialized
societies. Most likely, nursing homes are commonly viewed
as edifices to humanitarian ideals. Nonetheless, the
ominous workings of ecological, cultural, and social
forces exert pressures on human groups to deal with illness
and death in culturally relevant and behaviorally expedient
ways.


106
P.G.M. TOTAL DISEASE ROSTER, cont.
Number of Times Entered
in Patient Charts
44. Cerebral Vascular Accident
(CVA)
45. Cystitis
46. Degenerative Disc Disease
47. Degenerative Joint Disease
(DJD)
48. Deafness
49. Debility
50. Deformity
51. Dehydration
52. Depression
53. Dermatitis
54. Diabetes Mellitus
55. Diarrhea
56. Disorientation
57. Diverticulitis
58. Sysphagia
59. Emphysema
60. Epilepsy, Petit Mai
61. Fractures
62. Gastric Neurosa
63. Gastritis
64. Gastro-enteritis
65. Hallucinations
66. Hypertensive Cardio-Vascular
Disease HCVD
17
4
1
4
7
3
2
1
1
13
2
1
10
1
3
1
15
1
3
1
1
23


98
paper-contact as efforts at increased education and pro
fessionalism have been pursued. The licensed nurse as
mother-surrogate has declined (Schulman 1958; 1972) to
be replaced by the nurses' aide, particularly in nursing
homes. The maternal approach to patient care in nursing
by nonlicensed personnel is not unique to the American
long-term health care culture. Caudill (1961), for example,
describes the Japanese tsukisoi as an untrained female
providing long-term basic care to psychiatric patients.
The benefit of the t sukis oi is found in the use of the
mother/child interactive pattern and long-term patient
contact. As among the American nurses aide, lack of
formal training is compensated by surrogate kinship roles,
a thorough familiarity of the patient (often consanguineal
and affinal kin, Befu 1971), and use of folk therapies.
Thus, the white uniform, hospital-like environment, and
other symbols of biomedicine serve only as a thin veil
over the "modern" geriatric folk therapist.
In summary, the nursing staff ethos is characterized
by adult nursery nursing. Unlicensed and untrained nurses'
aides play mother roles in the discharge of their duties
with patients who are conceptually seen as children. Their
work consists of bed-and-body-worlc to the near exclusion
of psychosocial support of the patients. Pragmatically,
mother/child interactional patterns extract useable be
haviors from pre-existing role repertoires of the generally
untrained nurses' aides.


70
served different purposes which led to the retention or loss
of the event. The Mother's Day events and other major pro
ductions are opportunities to symbolically, though indirect
ly, communicate to the public Pecan Grove Manor's solid
concern for the welfare of their patients. The more visible
and lavish this public event is, the more status is given
to the nursing home, and its reputation is sustained or im
proved. Conversely, the fishing trip was a low visibility,
inexpensive event affecting seven patients. There is great
opportunity for quality psychosocial improvement (judging by
change in their affective mood) and maintenance but little
chance for status accruement to the nursing home. Mother's
Day will continue to be celebrated annually as part of the
major public potlatches. Over a year later, the fishing
trip has not been repeated although the men participants
still reminisce about it.
The overall orientation toward patients in Pecan Grove
Manor is one of palliative care. The presence of the medi
cal model is expressed in ritualistic monitoring of patient
decline. No physical or occupational therapist is present.
Although a fulltime R.N. is not required, Pecan Grove Manor
boasts one who is present during part of the day shift, five
to six days per week (however, on-call twenty-four hours
daily), and functions primarily as a nursing staff adminis
trator and token representative of "high level" medical
status to attract and assuage patients and families. Other
personnel involved in activities for patients supportive of


51
Shift report begins about 5:50-5:55 AM. The day shift
aides move to the nurses' station, having been summoned by
the charge nurse (an L.P.N.) to review as listeners the
events of the night seen as significant. The content of
the shift report includes three topics: medications given,
assessments made (e.g., vital signs), and unusual illness or
mood changes.
Most shift-report information is useless to the nurses'
aide. Medications given are read by name of drug, amount
given and to whom it was given. After report, none of the
aides were ever able to tell me what the medications were
for or why they were given, with the exception of two
tranquilizers, Thorazine and Sparine ("to keep them quiet"),
Valium ("nerve pills"), and nitroglycerin ("heart pills").
Vital signs were seen as significant only if unusually
exaggerated and emphasized by the charge nurse reading the
report.
Shift-report information that elicited response from
the nurses' aides was the mention of laxatives (often read
as "milk of mag"), falls, escapes, and rowdiness. Laxa
tives and behavior problems mean work for the aides.
Reports of laxatives being given were met with such remarks
as "Oh, no!," "We'll be busy today!," and "They don't need
any laxatives!"
In spite of the selective use of shift-report informa
tion, the entire previous-shift nursing activities were
always reported. Prather than functionless ritualism,


53
ACTIVITY
TIME
Lights on
05:57 AM
Linens
05:58 06:06 AM
Get patients up
06:06 06:28 AM
Make beds
06:28 06:54 AM
Breakfast
06:54 08:07 AM
Bed Check (2 aides)
08:07 10:10 AM
Showers (2 aides)
08:07 10:55 AM
Shaving
10:10 10:33 AM
Break
10:35 10:50 AM
Shaving
10:50 11:37 AM
Lunch
11:37 12:58 PM
Put patients to bed
01:00 01:40 PM
Rinse dirty linens
01:40 01:47 PM
Aides' lunch
01:47 02:17 PM
Shaving
02:17 02:25 PM
Talk, f ix s ink
02:25 02:30 PM
NURSES' AIDE TASK-TIME ACTIVITY
5 May 1978
(FOUR AIDES EXCEPT WHERE NOTED)
Figure 7


76
describe such environments suggests
the existence of a simplistic notion
that man is infinitely adaptable. This
is surely an erroneous view of man.
Both common sense and . empirical
data . demonstrate that human adapt
ability is finite. (Schwartz 1975:289)
Old people are extremely adaptable.
Birren tells a story about an experience
he had while doing research on visual
perception . One of the volunteers
for the project was a man of around 85
years old who was active in the home and
a leader in the activities there . .
He was well known by most of the residents
and well liked. When Birren tested this
man for visual acuity he found that the
old man was functionally blind. Birren
went to the nursing-home administrator
and asked if the administrator knew that
Mr. X was blind. The administrator
couldn't believe Birren. Observing the
old man's behavior very carefully,
Birren found that the man was always
accompanied by his wife, and she very
subtly guided him and gave him cues so
that, although this man was functionally
blind, not even the nursing-home staff
were aware of it. This remarkable example
stresses the adaptability of old people.
(Woodruff 1975:190)
The assessment of patient resourcefulness involves direct
observation and questioning of the patient population.
Recently, assessments of personal nursing home living
experiences have found salient data not in sociodemographic
variables or in elaborate physiological workups but in
subjective perceptions of the inmates about their membership
in an institution (Noelker and Harel 1978). Therefore,
much important data about the sociocultural system comes
directly from the patients themselves.
Twenty-three patients at Pecan Grove Manor were
identified as mentally intact by my personal assessment and


given their situation of unemployment and illness. This
perception is partly based in fact, and in part a deriva
tive of a need to counter-balance the inescapable stress
of life under imminent, compounded health threats and the
related institutional confinement.
The significance of the role of the housekeepers as
agents of psychosocial support is not formally recognized
by either the nursing or administrative staffs. Unlike
nurses' aides, proper job performance for housekeepers
involves lengthy in-room tasks during which meaningful
interaction can and does occur with individual residents.
Housekeepers serve too as brokers between groups of resi
dents and the nursing staff.
These findings as a whole suggest that institutional
ized elderly can remain adaptively resourceful for an
extended period in personal body care, and do respond
positively to informal or unplanned psychosocial care.
It is argued that psychological care can be promoted within
an existing standard program by actively rewarding the
spontaneous social-support role of non-nursing staff mem
bers, like the housekeepers. The cost-benefit ratio of
such a strategy is seen as potentially attractive to pro
prietary nursing home owners for the improvement of the
quality of institutional life.
xi


Copyright 1979
by
Joseph Neil Henderson


59
aides use to diagnose hypertension. An aide who is trained
to measure blood pressure goes to the nurses' station for a
stethescope and syphgmomanometer. If hypertension is indi
cated, the nurses' aide will report it to the nurses' sta
tion with no report if the charge nurse is away or casually
mentioned as a negative result to the charge nurse if pre
sent .
Perhaps the most important skin signs observed by the
nurses' aides is the precondition leading to decubitus
ulcers. R-eddened skin, particularly in regions of bony
prominences, is a signal of impending bedsores. Bedsores
are particular problems for long-term care bed-patients and
those who sit in wheelchairs or even lounge chairs for
lengthy periods of time.
When reddened skin is noticed, it is desirable to
massage the local area with lotion. However, this simple
preventive measure is infrequently used. The technique of
simple massage lacks the paraphenalia which signals high-
level medical therapy. Also, lotions that are frequently
used are purchased by the patient or the patient's family
and are thus generally unavailable for even distribution
throughout the patient population. As a result, decubitus
ulcers are present.
The presence of decubitus ulcers is an embarrassment
to the nursing staff. The nursing staff often blame the
existence of decubitus ulcers on mismanagement of patients
while they were away at a hospital. These hospital-genera-


71
psychosocial maintenance report difficulty getting assist
ance from nurses aides and a perceived low status with the
hierarchy of service providers.
This milieu is not conducive to maximizing the remain
ing potentials of the patients. Unlike palliative care
units in acute-care hospitals (cf. Buckingham, et al. 1976),
this nursing home and likely most others, masks the nonther-
apeutic environment with a battery of rituals designed to
create illusions of life for the patients, families, and
staff.
It is clear that the patient career (cf. Roth 1963) is
most directly influenced by that segment of the nursing
staff known as the nurses' aides. The style of care-giving
is one in which physical care is emphasized to the neglect
of psychosocial care. Several reasons exist for this skew
ing. The nursing staff supervisors are trained in the tra
ditional medical model as L.P.N.s or R.N.s. Their training
emphasizes physical therapy with only a slight orientation
toward psychosocial parameters. Federal inspection by
Title 19 requirements clearly promotes and rewards medical
action. For example, Pecan Grove Manor prides itself on
having patient charts up-to-date meaning that all entries
had been made on a daily basis, particularly daily remarks
regarding each patient. "Charting" consumes the vast major
ity of the L.P.N.s time. This practice becomes so perfunc
tory, however, that patients who are away visiting or in the
hospital have been unintentionally charted as not only pre-


38
number of personal belongings, residential furniture, hand
crafts, and television sets are found. A television set is
present in every patient's room and occasionally one room
has two televisions (See Figure 6).
Those patients with high levels of functioning are
fully aware of the wing--debility relationship. The
nursing staff on occasion may "threaten" an ambulatory-wing
patient into some behavior (typically some type of self
health-care action) by simply mentioning the likelihood of
being moved to the intermediate care wing. Other similar
coercions exist, always with the power of the "threat"
directed at movement toward the least desirable wing.
There is very little voluntary contact with the heavy-care
wing patients by members of the other wings, and the heavy-
care wing is referred to as "over on North where those
pitiful people are" (cf. Gubrium 1975: 16, 26). Thus, wing
assignment is a metaphor of one's functional capacity and
proximity to death.
Establishment of one's position within the wing--debil-
ity system is decided at admission by the R.N. and/or the
assistant administrator. Room availability may also influ
ence the initial wing assignment. Regardless of actual
placement, the cognitive map of relating to the entire
experience of living and dying at Pecan Grove Manor is one
of initial admission to the ambulatory wing with a high-
level functional capacity, followed by physical and mental
decline resulting in a move to the intermediate wing. From


APPENDIX 2
PECAN GROVE MANOR TOTAL DISEASE ROSTER
(From physican listings in patients' charts)
Number
in
of Times Entered
Patient Charts
1.
Advanced Age
1
2.
Alcoholism
1
3.
Amputee
1
4.
Anal Fixation
1
5.
Anemia
1
6.
Aneurysm
1
7.
Angina Pectoris
7
8.
Aortic Systolic Murmurs
1
9.
Aphasia
2
10.
Arteriosclerosis
7
11.
Arteriosclerotic Brain Syndrome
1
12.
Arthralgia
3
13.
Arthritis
37
14.
Arteriosclerotic Cerebral
Insufficiency ASCI
16
15.
Arteriosclerotic Coronary
Insufficiency ASCI
29
16.
Arteriosclerotic Cardio-Vascular
Disease ASCVD
29
17.
Arteriosclerotic Hypertensive
Disease ASHD
10
18.
Asthma
3
19.
Atrial Fibulation
2
20.
Back Pain
1
104


5
to Butler (1975:251), 797 of all institutions providing
care for the aged sick are proprietary in nature. Nonprofit
institutions for the aged provide care for 147 of the insti
tutionalized aged and 77 of the institutionalized aged are
in government-funded facilities.
Characteristics of institutionalized aged populations
are varied, but even so, certain clusterings of traits are
apparent. The median age of institutionalized people is
82 with 437 age 85 and older. There are three times as
many women as men. Most institutionalized people are white
and poor and are maintained by public funds. The institu
tionalized aged population is likely to have a variety of
chronic physical impairments including circulatory dis
orders, arthritis, digestive disorders and mental impair
ment such as senility and depression (Brody 1977a:85-89).
Additionally, most institutionalized aged people have
no spouse, no close relatives and the majority have no
visitors. They stay in the institution almost 2.5 years
with only 207, returning home, the remainder dying in the
institution or at a hospital. Few can walk, 337 are
incontinent and there is an average of more than four drugs
taken per person each day Moss and Halamandaris (1977:8).
The above description projects a dismal existence for
the participants of geriatric institutions. If it is
unpleasant to be poor or sick or lonely, then the combina
tion of these three elements can only constitute a com
pounded sense of demoralizing desolation. Yet, in this


13
characterized by negligible encounter with the subject
population to be questionable.. Conversely, participant-
observation allows for first-hand data collection, in-depth
experience, and observance of formally-stated ideals of
behavior compared to actual expressions of behavior.
My personal use of participant-observation at Pecan
Grove Manor ran the entire gamut of possibilities except
being actually institutionalized. Although the fieldworker
may be admonished to totally immerse himself in the culture
of the study population, there actually exists daily
situational fluctuations of degrees of participation and
observation (Gold 1969) My research site allowed for the
total access to all participants: administrative, support
staff, patients, and families. However, because proprietary
nursing homes seem to expect negative assessments and in
fact are continually under the scrutiny of government in
spectors (not to mention families), observing and writing
notes in public areas presented some difficulty. In
anticipation, I had written nothing in public and carried
no notebook for the first few weeks after my arrival. As
the scene began to make more sense to me, the need to pre
serve my increasingly numerous meaningful observations
required the immediate jotting of notes in a field notebook.
On the day that I first began to write notebook
entries, I contrived a scene which would allow patients and
staff to see me taking notes and with the potential for them
to actually read what I had written. I selected a table


77
their scoring on the Mental Status Questionnaire (Kahn,
et al. 1960) at the time of interview. All but one were
ambulatory. The term "resident" is often used in geronto
logical literature when referring to institutionalized
people with the greatest amount of ability. However, in
this community of elderly people, all of the non-staff are
considered and called "patients." They are simply patients
with a lesser dependence on help from the nurses' aides.
Still, they are medicated, monitored, required to see a
physician monthly, have call-lights in their rooms, and
their bowel movements are daily charted. Their distinction
from others lies within themselves. The fortuitous combin
ation of relatively intact mental and locomotor function
provides them with the ability to mobilize their resourceful
capacities.
In anthropological terms, these people are best able to
undergo the psychological, behavioral, and sometimes physi
cal contortions of adjustment to a new environment. Over
time, these adjustments become routinized as adaptive
responses enabling the patient to maximize their chances of
a successful "fit" within the community of which they are
a part.
The purpose here is to examine the consequences of
adaptation to a nursing home environment by a subgroup of
the patient population. All twenty-three patients responded
to a structured interview. The average age of this sample
is 82 years and 8 months with an average educational experi-


CHAPTER TWO
METHODOLOGY
Pecan Grove Manor was initially reviewed as a poten
tial research site because the administrator is the author's
mother's brother and .thus, a close kinsman. The time-
consuming negotiations and development of rapport that
would accompany commencement of fieldwork among strangers
was consequently reduced. Advantage could be taken of the
researcher's kin network only if such a relationship would
not attenuate objectivity and access to data. Secondly,
permission to engage in research was needed from the admin
istrator as well as the cooperation of staff and patients.
All of these criterion were met, leading to field entry in
June 1977.
A research effort affording complete access to all
components of a proprietary nursing home is unusual. This
project thus represents a departure from many studies
regarding the phenomenon of aging. In fact, research among
the institutionalized aged has been relatively neglected
based on a review, for example, of the Journal of Gerontol
ogy from 1946-1979 (i.e., Volume 1 through the present) and
the Index Medicus from 1967-1979. This is particularly
conspicuous when compared to the relatively voluminous lit
erature on other gerontologic topics.
Anthropologists have virtually ignored the institu
tionalized aged (see Clark 1973; Holmes 1976) and only a
few gerontologists have used anthropological methodologies
10


88
Another male patient agreed to keep a diary to give
to me but then rescinded. Before he returned the unused
diary to me, another patient told me that this man had
bragged that he was "going to be a spy for Joe." When he
returned it, he very obliquely stated that he was afraid
that keeping the diary might cause trouble. In an environ
ment that houses only a small pool of people, friendships
are resources with which one should not tamper.
Other aspects of avoidance of open conflict exist in
relation to long-term care. Not only would open conflict
cause life to be difficult in close quarters, but one would
experience a sustained level of tension because they will
live there the rest of their lives. In acute-care hospi
tals, personal risk stemming from angered roommates or
hospital staff would not endure indefinitely. The experi
ence of nursing home life is very much different.
At times, when complaints (though relatively innocuous)
were voiced to me, I was typically told not to divulge the
complaintant's name to anyone. For example, comments
about unsatisfactory menus were ended with "dont tell 'em
I said that." A man told me that some folding chairs
borrowed from a mens club had unintentionally been kept
at the nursing home. His statement was almost totally
shrouded in disclaimers and caveats. The man's primary
intent was to preserve a good relationship between the
club and the nursing home. It was evident, however, that
he didn't want to be perceived as a "trouble maker" for


CHAPTER SEVEN
CHRONIC LIFE AND AGE SEGREGATION
Palliative-care settings, whether in hospitals or
nursing homes, typically house people with chronic
disease(s) and without expected recovery. The diseased
state gradually usurps the psychosocial essence of human
ness until the host's life, in the fullest interactive
sociocultural sense, is overshadowed by disease and debil
ity. Disease becomes established as the prominent mode of
existence and life now becomes the factor of chronicity.
Disease is not the target of treatment; physical existence
is. Thus, a condition of chronic life exists in the pres
ence of debilitating disease which is permanent and para
mount, rendering the diseased state more prominent than
wellness and life, not disease, as the target of therapy.
Globally, modernization as a societal process occurs
with numerous attendant changes especially in technology
and health technology (Cowgill and Holmes 1972; Cowgill
1974:129). One result is increased longevity. For the
very old, this is a dubious benefit (cf. Illich 1976:73).
Many societies distinguish between functional old age
and nonfunctional old age (Simmons 1945; Simmons 1960;
Clark and Anderson 1967). Functional old age can be con
sidered extended life while nonfunctional old age can be
considered chronic life. Improvements in health care
technology resulting in increased longevity also increase
the risk of inducing chronic life in the aged population.
94


56
other aides that Mr. Henry seemed to be drooling very
slightly from the left corner of his mouth. I later fed
Mr. Henry and found the report accurate. The loss of food
from his mouth was slight enough so that only the staff who
worked with this patient routinely day-in-and-day-out would
recognize this as a potentially significant behavioral
change. Without extensive awareness of Mr. Henry's behavior
patterns, the drooling may have been attributed to his posi
tion in bed, soft diet, dislike of the menu, or as just
another patient who drools. This change was reported to the
R.N. as evidence of a minor stroke. The aide who reported
the change later told the group that the R.N. attributed
the change not to stroke, but to his medications which
included large quantities of Thorazine. However, Mr. Henry's
chart recorded no change in medications before or after
the aide's report.
The nurses' aides, in spite of no medical training,
are the most important health-care agents in Pecan Grove
Manor. Their significance exists in their extensive contact
with the patients. They may be able to identify an importart
change in a patient that the R.N. would be unable to do.
The aide who notices some relevant change recounts her coup
for several days until virtually all the staff is aware of
it. Thus, the lack of training and low status of the nurses'
aide is not necessarily a detriment to patient well-being.


74
Nurses' aides and patients alike have an enormously
difficult task. The patient career consists of pretending
to be socially functional while being totally expendable.
One is the victim of chronic disease and social circum
stance. The nurses' aide, dressed in white, pretends to be
therapeutically functional while dispensing palliative care.
One is the victim of therapeutic expectation and incurable
disease. Thus, aides and patients engage in a variety of
rituals to fabricate a facsimile of life. In this way the
stark reality of chronic disease and old age can be partly
veiled.
Orientation toward patients at Pecan Grove Manor is
remarkably similar to Jules Henry's (1963:474) summary of
the humane Tower Nursing Home:
An effort to formulate a "national
character" for Tower yields the follow
ing: the staff, though animated by
solicitude and kindliness seems to
maintain an attitude of indulgent
superiority to the patients whom they
consider disoriented children, in need
of care, but whose confusion is to be
brushed off, while their bodily needs
are assiduously looked after. Tower is
oriented toward body and not toward
mind. The mind of the patients gets
in the way of the real business of the
institution, which is medical care, feed
ing, and asepsis. Anything rational
that the patient wants is given him as
quickly as possible in the brisk dis
charge of duty, and harsh words are rare.
At the same time the staff seems to have
minimal understanding of the mental
characteristics of an aged persor


108
P.G.M. TOTAL DISEASE ROSTER, cont.
Number of Times Entered
in Patient Charts
91. Osteoarthritis 13
92. Osteoparesis 2
93. Osteporosis 26
94. Osteosclerosis 1
95. Paralysis 8
96. Parkinsonism 6
97. Paroxysmal artial tachycardia
(PAT) 1
98. Pedal edema 1
99. Peripheral Vascular Disease
(PVD) 6
100. Phlebitis 1
101. Pleural effusion 2
102. Pneumonia 2
103. Polio 1
104. Prostatitis 1
105. Prostectomy 1
106. Prosthesis 1
107. Psychoneurosis 1
108. Pyelonephritis 3
109. Radiculitis 2
110. Renal disease 1
111. Rheumatoid 1
112. Sciatica Neuritis 1
113. Seizures 1
114. Senility/Senile Psychosis
14


107
P.G.M. TOTAL DISEASE ROSTER, cont.
Number of Times Entered
in Patient Charts
67. Hemiplegia 1
68. Hemmorrhoid 1
69. Hernia 9
70. Hypertension 12
71. Hypoglycemia 1
72. Hypokalemia 5
73. Hypothyroidism 2
74. Hysterectomy 1
75. Indigestion 1
76. Labyrinthitis 1
77. Lumbar 1
78. Malnutrition 1
79. Mastectomy 3
80. Meningitis 1
81. Mental Abberations 1
82. Mental confusion 24
83. Mental deterioration 5
84. Mental retardation 5
85. Migraine headaches 1
86. Multiple Sclerosis 1
87. Myocardial Infarction 2
88. Neurological deficit of
obstructive hydrocephalus 1
89. Obesity 7
90. Organic brain syndrome
4


REFERENCES CITED
Angrosino, Michael V.
1976 Anthropology and the Aged: a Preliminary Community
Study. Geronotologist 16:174-180.
Arensberg, Conrad M. and Solon T. Kimball
1965 Culture and Community. New York: Harcourt,
Brace, and World.
Babbie, Earl R.
1979 The Practice of Social Research. Second edition.
Belmont, California: Wadsworth.
Befu, Harumi
1971 Japan: an Anthropological Introduction. San
Francisco: Chandler.
Bachner, John P.
1974 Public Relations for Nursing Homes. Springfield:
Thomas.
Beals, Ralph and Harry Hoijer
1971 An Introduction to Anthropology. Fourth edition.
New York: MacMillian.
Beckman, Ronald
1971 The Therapeutic Corridor. Hospitals 45:71-80.
Bennett, Ruth and Carl Eisdorfer
1975 The Institutional Environment and Behavior Change.
In Long-term Care: a Handbook for Researchers, Planners,
and Providers. Sylvia Sherwood, ed. New York:
Spectrum.
Bennett, Ruth and Lucille Nahemow
1965 Institutional Totality and Criteria of Social
Adjustment in Residences for the Aged. Journal of
Social Issues 21:44-78.
Birren, James E. and Vivian Clayton
1975 History of Gerontology. In Aging: Scientific
Perspectives and Social Issues. Diana S. Woodruff and
James E. Birren, eds. New York: Van Nostrand.
Buckingham III, R.W., S. A. Lack, B. M. Mount, L. 0. MacLean,
and J. T. Collins
1976 Living with the Dying: Use of the Technique of
Participant-observation. Canadian Medical Association
Journal 115:1211-1215.
114


LO
FIGURE
PATIENT ROOM--HEAVY CARE CORRIDOR


42
Note
1. In fact, on the 11 PM to 7 AM shift one night several
years ago, the aides and myself were surprised to
see a car drive from the highway into the nursing home
parking lot. A man came into the nursing home, walked
across the lobby to the nurses' station and asked
for a room for the night.


SOUTH WING
Intermediate Care
PECAN GROVE MANOR
Figure 3
NORTH WING
Heavy Care


which has become a commonplace sociocultural and brick-and-
mortar invention in response to biomedically induced
longevity, prolonged debilitating disease, and the ethical
proscription against senilicide. The nursing home,
therefore, is the setting for observing the uniquely
debilitating phenomenon of leading a "half-life of disease"
within a "half-existence of social functioning."
The research also documents salient features of a
resident population with a significant capacity to mobilize
adaptive behavioral responses to physical limitations and
the formal institutional environment. A further important
finding shows unlicensed nursing personnel serving as
"folk healers" and surrogate mothers to the patients and
non-nursing personnel (i.e., housekeepers) to be the key
staff group whose normal or "proper" task performance
promotes transactions rather than ritualistic contact with
patients. In spite of patients' adaptive resilience, the
nursing staff perceives patients as adult children whose
physical and intellectual resources are exhausted. This
belief, generally coupled with medical-model-induced
nursing neglect of psychosocial aspects of well-being,
contributes to a web of fabricated life rituals that veil
the underlying efforts at palliative care.
A concurrent intensive study of a special sub-group
or cohort of twenty-three mentally-intact residents pro
vides evidence that, in the main, they experience nursing
home life not as ideal, but "the next best thing to home,"
x


80
tray immediately. Those who sit at the opposite end typi
cally wait until it is closer to the time their own tray
arrives.
Thus, the necessity of eating is experienced differ
ently by the staff and the patients. The administrative
and kitchen staffs experience feeding as "food service."
The patient population experiences feeding as "food pro
curement" with a battery of strategic behaviors necessary
to adapt their physical capacities to the physical environ
ment .
The community of Pecan Grove Manor comes to acquire
personal meaning beyond the brick-and-mortar ediface. The
most common and consistently elicited report was that
living at Pecan Grove Manor is neither ideal nor desirable
but it is "the next best thing to home" given their circum
stance. Nursing home life is viewed by the patient as the
only reasonable solution to their predicament of unemploy
ment and chronic illness. The typical patient also sug
gests that no other supportive resource system is avail
able to meet essential needs for physical well-being. For
those having children who represent potential caretakers,
the children are reported as willing to take them but the
patient will not "burden" their children or "get in the
way." Thus, the patient sees the nursing home as a re
source rather than a place of confinement.


109
P.G.l
1. TOTAL DISEASE ROSTER, cont.
Number
in
of Times Entered
Patient Charts
115.
Shoulder. Injury
1
116.
Sinusitis
5
117.
Speech difficulty
1
118.
Stroke Syndrome
2
119.
Syncope
2
120.
Synonitis
2
121.
Tachycardia
1
122.
Teeth absent
1
123.
Thr omb ophlebitis
1
124.
Transient Ischemic Attack (TIA)
1
125.
Ulcer
3
126.
Urinary Tract Infection (UTI)
1
127.
Visions
1


xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID EXRT7JIOC_N34D6D INGEST_TIME 2014-12-11T21:12:08Z PACKAGE AA00026464_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES


FIGURE 4
HEAVY CARE CORRIDOR


96
too sick. Expulsion from the institution and life is
the ultimate outcome. Patients adopt a fatalistic outlook
regarding their membership in a nursing home population.
Their control over their own destinies has been undermined
by chronic disease, unemployment, and institutionalization.
Therefore, they accept their lot not having capacities to
retaliate.
One form of adaptation is to selectively attend to
the positive virtues of their current life and institution
al home. Given the lack of better possibilities, patients
report "their" nursing home as the best possible setting
other than self-sufficient community life.
Conflict-avoidance serves to maintain the belief in
the high quality of their situation by minimizing disrup
tive events. This pressure is exacerbated by long-term
institutional living. Additional pressure is leveled by
the nursing and administrative staffs to convey an aura
of serenity in order to reduce family complaints and
inquiries. Although staff groups exert efforts to deny
conflict, the patients likewise construct perspectives
ultimately useful in psychological adaptation to the long
term institutional environment.
Patients also engage in resource identification and
exploitation within their community. The physical and
psychosocial environments have been met as surmountable
challenges rather than insurmountable obstacles. Thus,
food procurement strategies, role invention, and


61
Perhaps the task most associated with nurses' aides'
duties is "bed check. By federal regulation, all nonambu
latory patients must be routinely checked for incontinence.
Bed check thus consists of visual or physical inspection of
incontinent patients. Soiled clothing, bed linens, bed
frames and patients must be changed or cleaned.
Gubrium (1975) refers to this part of nurses' aides'
duties as "bed and body" work. It is this task category
that most undermines the patients' and nurses' aides' sense
of propriety. Bed and body work peels away the cosmetics of
one's daily "act" to reveal the "underside" of a lifetime of
culturally appropriate impression management. The locked
door that screens the toilet habits occurring in the Ameri
can bathroom (cf. Miner 1956) is ripped from its hinges for
both the patients and nurses' aides.
Bed check is considered the most mentally and physi
cally taxing job task. One's performance here leads to peer
ranking along a continuum of good to bad. The stresses in
volved for aides and patients in bed check are immense and
are expressed in the following vignette from my participa
tion and observation:
"Now you're really gonna get broken in,"
the female nurses' aide told me as I
approached Mr. Joe Green's (pseudonym)
room. Mr. Green lay in his nursing home
bed in a near-visible order of inconti
nence. He is a diabetic, an alcoholic,
an amputee, a hemiplegic from an old
cardiovascular accident, is non-ambula
tory and generally considered to be ill-
tempered. As he lies in bed, Mr. Green
often hollers as if sharp pains momen-


115
Butler, Robert N.
1975 Why Survive?: Being Old in America. New York:
Harper & Row.
1978a Unravelling the Secrets of Aging. Aging (July-
August): Numbers 285-286. Pps. 5-8.
1978b Thoughts on Aging. American Journal of Psychiatry
135: Supplement: 14-16.
Brody, Elaine M.
1977a Number of Elderly in Institutions to Rise Says
Expert in Field. Aging (November-December), Numbers
277-278. Washington: DHEW Office of Human Develop
ment, Administration on Aging.
1977b Number of Elderly. Aging (November-December),
Numbers 277-278. Washington: DHEW Office of Human
Development, Administration on Aging. Page 15.
1977c Long-term Care of Older People. New York: Human
Sciences Press.
Caudill, William
1961 Around the clock patient care in Japanese psychiatric
hospitals: the role of the tsukisoi. American
Sociological Review 26:204-214.
Clark, Grahame
1969 World Prehistory. Cambridge: Cambridge University
Press.
Clark, Margaret
1973 Contributions of Cultural Anthropology to the
Study of Aging. In Cultural Illness and Health.
L. Nader and T. W. Maretzki, eds. American Anthro
pological Association, Anthropological Studies,
Number 9. Washington, D.C.
Clark, Margaret and Barbara G. Anderson
1967 Culture and Aging: An Anthropological Study of
Older Americans. Springfield: Thomas.
Cohen, E. S.
1974 An Overview of Long-Term Care Facilities. In
A Social-Work Guide for Long-Term Care Facilities.
Brody, E. M. and contributors. Washington: DHEW
Publication Number (HSM) 73-9106, U. S. GPO.
Cowgill, Donald 0. and Lowell Holmes, Editors.
1972 Aging and Modernization. New York: Appleton-
Century-Crofts.
Cowgill, Donald 0.
1974 Aging and Modernization: A Revision of the Theory.
In Late Life. Jaber F. Gubrium, ed. Springfield:
Thomas.


State of Oklahoma
Tulsa County
9.9%
Oklahoma County
9.9%
Marshall County
20.6%
PERCENT OF POPULATION 65+ BY SELECTED COUNTY
Figure 2


91
Several factors are involved in the development of
the dual role of the housekeepers. First, the potential
for engaging interaction is greater with the housekeepers
than with the nurses' aides because in-room task assign
ments typically require longer periods of time for house
keepers. Whereas rapid in-and-out activity signals appro
priate work modes for aides, the opposite is true for
housekeepers.
Proper cleaning requires lengthy task performance per
room. Thus, informal job-related normative pressures pro
mote in-depth interaction between the patients and the
housekeepers.
Babby Heath (pseudonym), one of the housekeepers,
spoke of her dual role (edited):
JNH: We'd be wondering why . why
they (patients) seem to visit with you
all (housekeepers) so much.
BH: I think probably it's because
maybe we're in the rooms longer and
we don't wear white and they, they seem
closer to us. Because they'll tell us
things maybe that they won't tell
someone else.
JNH: . because they talk to you
and Doris (pseudonym; housekeeper) and
they wouldn't talk to an aide?
BH: Well, ok, another reason, Joe. See,
I've been here now for quite awhile,
you know. And I worked as an aide on
the mornings and I worked on the evenings.
And they, really, they feel like they
know me better than they do some of the
other girls. And I think the same way on
Doris because Doris has been out here a
long time too, and a lot of these old


6
investigation in a proprietary nursing home, the harsh
reality of the participants' situation is tempered by the
human ability to adjust and adapt to prevailing circum
stances. The circumstances to which these aged people must
adjust and adapt center about the entity known as the
"nursing home.
Care for the sick elderly is known in all societies
regardless of the level of technological proficiency or
sociopolitical organization. The existence of senilicide
among band and tribal societies is not uncommon, but
exists only when necessary. The usual motivating factors
are related to vital components of band and tribal subsis
tence: mobility and productivity. Those who interfere with
these basic requirements are killed or allowed to die (see
Simmons 1946 and 1960). Among some state level societies,
such as the Inca of Peru and the Aztec of Mexico, tribute
from the productive citizens was redistributed to the needy
including the infirm elderly (Simmons 1960:70).
Another element of aging recognized cross-culturally
is a distinction between productive old age and nonfunc
tional old age. The nonfunctional and often sick elderly
are referred to as "overaged," "useless," in the "sleeping
period," in the "age-grade of dying," and "already dead"
(Simmons 1960:87). Among the Hopi of Arizona, for example,
when people are in the "helpless stage" their death is
assisted by purposeful neglect (Simmons 1945:89).


8
fueled the development of institutions specifically designed
for long-term care of the aged.
During Cohens third phase, 1929 marks the date by
which nonprofit institutions were primarily responsible
for care of the elderly. The programs of the Social Secur
ity Act subsequently provided assistance for the aged.
Privately-owned boarding homes began to house the elderly
and when nurses were added, the boarding home became a
nursing home. By 1939, Cohens fourth phase, there were
1200 long-term care institutions with a 25,000-bed capacity
nationally.
By 1954, Cohen's fifth phase, there was a noticeable
increase in the number of proprietary nursing homes. The
number had risen to 25,000 institutions with a 450,000-bed
capacity. Cohen suggests that this increase reflected a
backlog of potential patients.
After 1965, Cohen's sixth phase, long-term care became
institutionalized into the fabric of government policy,
medicine, and business. In 1965, legislation allocated
funds to nursing home patients and passed the Older Ameri
cans Act. The number of facilities expanded and in 1977
there were 1.2 million nursing home beds.
It was during the phase of rapid expansion of nursing
homes in the U.S. that Pecan Grove Manor (pseudonym) nursing
home was built in southern Oklahoma. Pecan Grove Manor was
built in 1963 as a 30-bed proprietary facility. Within two
years, it was expanded to a 60-bed facility and within


CHAPTER FIVE
THE DAILY CYCLE: RITUALS OF FABRICATED LIFE
Pecan Grove Manor is a society of elders experiencing
life at imminent risk of death while their progress toward
this end is monitored by paid attendants. However, the
American propensity for denial of death demands illusion to
mask the cultural apparatus of lingering death. This
stance is like the mesmerizing qualities of the magician's
slight-of-hand that allows transcendence beyond the plane
of mundane experience into the mystifying realm of reality
denied. Thus, the functional reality of the nursing home
is obscured by a daily series of rituals fabricating the
illusion of meaningfully transacted life.
The critical elements of nursing home life involve
a triad of patients, nurses' aides, and care-giving patterns
associated with chronic debilitating disease necessitating
long-term care. Interactional exchanges between nurses'
aides and patients are characterized by daily, intensive
contact with each other. In this environment of long-term
exposure to patients, the nurses' aides, though generally
untrained, become highly sensitized to patients' typical
behavioral patterns and ultimately become diviners of
exacerbated illness episodes who may treat or report their
findings to licensed nursing personnel who then carry out a
treatment protocol. Also, patients are able to manipulate
their hosts by exploiting informal mechanisms of social
control and identifying resources within the nursing home
43


27
have handrails, but usually only in physical therapy areas,
and residential homes are devoid of such devices. While
hospitals share with nursing homes items such as bedrails,
bedpans, stethescopes, and white uniforms, and private
residences share with nursing homes things such as personal
furniture, patios, and bathrooms, the continuous rail-lined
corridor is to be found not in the hospital or private
residence, but only in the nursing home.
The handrail is both a metaphor and artifact of geri
atric institutional life. As the banister of a staircase
implies that use of the stairs is a risk, handrails in a
nursing home are prominent visual symbols of people whose
lives are at risk. Still, the handrail remains a needed
prosthesis and is thus a medical artifact supportive of
those people with diminished strength or poor balance.
The rail-lined corridor is public space. Activity in
the corridor is always simple locomotion from point A to
point B. Use of the corridor as a public pathway places
one on display to all those within seeing distance. Thus,
one's abilities or disabilities become community knowledge.
Each of Pecan Grove Manor's three corridors lead to
the main lobby area. The lobby is intended to serve as a
central location for patient interaction and activities.
Here are found vending machines, a color television, maga
zines, a piano, and numerous chairs, couches and rockers.
In spite of these various attractions, the lobby at Pecan
Grove Manor is an area of little person-to-person interaction.


My uncle, Phil Sturapff, his wife 'berta, and their
four children, Kurt, Erik, Stacia, and Stephanie, all have
a part in this research. Phil provided me with complete
access not only to a research site, but to a part of his
livelihood. I hope that his trust has been well-placed.
His family has repeatedly placed their home and selves at
our disposal.
My grandmother, Mother Polly, and grandfather, Gang,
remain lifelong sources of love and inspiration. Their
home was made available to Jan and me, providing not only
physical shelter, but an experience that speaks well for
extended family kinship systems.
Those who suggest that kinship declines in importance
in industrialized societies may want to review the above
acknowledgements. However, many non-kin deserve mention.
Among them are Phyllis Maines, Sally Watkins, Wilma Davis,
and Dorothy Harrison,who all diligently work at Pecan Grove
Manor. Some figure-drawing and rough-draft typing was done
by Bobbie Bryant, Ruth Kagen, and Anita Morris.
Members of my committee have expended great efforts
on my behalf in training me in anthropology over the past
several years. I will continue to develop my anthropo
logical knowledge and skills because, if I have learned
anything, I know that the endeavor of understanding is a
lifelong process of wondering, investigating, and learning.
I particularly thank Professor Otto von Mering for sharing
his novel insights, Dr. J. Anthony Paredes whom I have
v


120
Sommer, Robert
1969 Personal Space. Englewood-Cliffs, New Jersey:
Prentice-Hall.
1970 Small Group Ecology in Institutions for the
Elderly. In Spatial Behavior of Older People.
Leon A. Pastalan and Daniel H. Carson, eds. Ann
Arbor, Michigan: University of Michigan.
Spindler, George and Louise Spindler
1974 Forward. In Fun City. Jerry Jacobs. New York:
Holt, Rhinehart, Winston.
Stern, Phillip Van Doren
1969 Prehistoric Europe: From Stone Age Man to the
Early Greeks. New York: Norton.
Steward, Julian
1950 Area Research: Theory and Practice. Social
Science Research Council Bulletin, 63.
1955 Theory of Culture Change. Urbana: University of
Illinois.
Subcommittee on Long-Term Care of the Special Committee
on Aging, U. S. Senate
1975 Nurses in Nursing Homes: The Heavy Burden (The
Reliance on Untrained and Unlicensed Personnel).
Nursing Home Care in the U.S.; Failures in Public
Policy, supporting paper No. 4 Report No. 94-00,
94th Congress, First Session.
Szasz, Thomas
1977 The Theology of Medicine. New York: Harper Colo
phon Books.
Taylor, Carol
1970 In Horizontal Orbit: Hospitals and the Cult of
Efficiency. New York: Holt, Rhinehart, and Winston.
1977 Death, American Style. Death Education 1: 177-
185.
Timasheff, Nicholas S.
1967 Sociological Theory. New York: Random House.
Tobin, Sheldon S. and Morton A. Lieberman
1976 Last Home for the Aged. San Francisco: Jossey-
Bass.
Townsend, Claire
1971 Old Age: The Last Segregation. New York: Gross
man.


112
100
90
80
70
60
50
40
30
20
10
APPENDIX 5
POPULATION PYRAMID:
PECAN GROVE MANOR
10% 5% 0%
5% 10% 15% 20% 25% 30%
MALES
FEMALES


49
"They are like children and thats
the way I treat them."
While promotion of the mother/child role behavior may
function to enhance care-giving and to animate the patients
conceptually, there are also costs that accrue. For
example, acting as a mother toward a patient will elicit
the appropriate dyadic response of a child. Adult-to-adult
interaction is thus retarded.
Particularly lacking is adult/adult interaction among
male patients and the female nursing staff. I found the men
thirsty for "man" talk. Male patients were the most anima
ted in their conversations when I sought advice about
proper carburetion on a lawn mower, inquired about hunting,
fishing, and trapping exploits, asked about farming or
ranching and other "male domains." Conversational topics
of this nature were absent during nurse/male patient
interactions. Self-generated conversation of this nature
was not common among the men due to daily familiarity of the
members and possible exhaustion of topics. My presence and
questions produced high-energy conversations due to my
newness to the nursing home, and my continual contact with
the non-nursing home community, and a perception of self-
worth in that they were being asked to share a part of their
past role experiences with a younger man.
Administrative influence on nurses' aides is seen
again in the distribution of the nursing staff in task and
wing assignment. Staffing of each wing varies according to


118
Mendelson, Mary
1974 Tender Loving Greed. New York: Knopf.
Mellaart, James,, ,,
1967 Catal Huyuk: A Neolithic Town in Anatolia.
New York: McGraw-Hill.
Miller, Dulcy B.
1969 The Extended Care Facility: A Guide to Organiza
tion and Operation. New York: McGraw-Hill.
Miner, Horace
1956 Body Ritual among the Nacirema. American
Anthropologist 58: 503-507.
Moss, Frank E. and Val J. Halamandaris
1977 Too Old, Too Sick, Too Bad. Germantown, Maryland
Aspen Systems Corporation.
Noelker, Linda and Zev Harel
1978 Predictors of Well-Being and Survival among
Institutionalized Aged. The Gerontologist 18:
562-567.
Oklahoma Health Systems Agency
1978 A Plan for Health in Oklahoma. Oklahoma City:
Oklahoma Health Systems Agency.
Opler, Morris E.
1945 Themes as Dynamic Forces in Culture. American
Journal of Sociology 51: 198-206.
Palmore, Erdman
1975 The Honorable Elders: A Cross-Cultural Analysis
of Aging in Japan. Durham: Duke University Press.
Pelto, Pertti J.
1970 Anthropological Research: The Structure of
Inquiry. New York: Harper & Row.
Rogers, Wesley W.
1971 General Administration in the Nursing Home.
Boston: Cahners Books.
Ro s enhan, D. C.
1973 On Being Sane in Insane Places. Science 179:
250-258.
Ross. Jennie-Keith
19~4 Life Goes On: Social Organization in a French
Bletirement Residence. In Late Life. Jaber F.
Bubrium, ed. Springfield: Thomas.


34
While the lobbies and entrance area are zones of
public space, there are zones of private space. The pri
vate space areas are those controlled by the nursing and
administrative staffs. At the nurses' station can be found
the R.N. (i.e., registered nurse), L.P.N.s (i.e., licensed
practical nurses), patient charts, and medications. The
area behind the nurses' station marks the private space for
staff only. Here the nursing staff can work on charts or
medications with minimal patient contact. The privacy of
this zone enables the nursing staff to exchange medical
information as well as gossip about patients, other staff
members, or their community lives.
The nursing staff also converts part of the public
dining area to private space for breaks and staff mealtime.
The "break table" functions to channel news throughout the
corridors to the nurses' aides. Thus, aides assigned else
where can review important interactions to which they were
not witness.
While all staff members spend many hours of each day
within Pecan Grove Manor, only the patients live the entire
ty of their remaining lives in the institutional environ
ment. Most of this time is spent inside their rooms. An
empty room would look much the same as any other throughout
the nursing home. However, each wing has its own distinc-:.
tive atmosphere when filled with patients and their belong
ings.


62
tarily seize him.
Mr. Green lay on his back, his
head on pillows and the stump of his
left leg (amputated at the distal end
of the femur) supported on pillows.
A plastic urinal is left between his
legs with his penis positioned inside.
The first task of the aide is to empty
the urinal. Sometimes the glans rests
on the side of the dry urinal, other
times it is submerged in urine. In
either case, the urinal is removed
by moving it away from the body. As
the penis exits the urinal, it drags
along the inside surface of the urinal
eliciting a pained cry or a stream of
expletives. Only once was it observed
that an aide positioned Mr. Green's
penis so that it didn't scrape against
the surface of the urinal.
As Mr. Green is rolled toward the
side of the bed, a liquid pool of feces
becomes visible and is filled with
recognizable bits of food. The aide
nearly vomits. The aide "lovingly"
chastises Mr. Green and begins to clean
him.
The buttocks are spread and the
corner of a Chux protective panel is
used to begin cleaning. After the majori
ty of fecal matter is removed, washcloths
are used to finish the job. Invariably,
Mr. Green screams at the aides that they
are hurting him as they clean the scrotum.
Seldom does an aide attempt to touch the
scrotum in an effort to expedite the ease
and thoroughness of cleaning.
Occasionally, a shower is required
to clean Mr. Green from incontinence. In
this instance, he may be wrapped in the
bed sheets and placed in a shower chair
to be rolled to the shower. At other times,
when the floor and aides' shoes are not in
such jeopardy, he is placed on the shower
chair nude and then covered with a sheet
preparatory to transport. At these times,
he is apt to loudly complain that "you sat
me on my nuts!" The aides generally scold
him and try to reposition him.
Interaction with Mr. Green typically
requires the services of three aides: two
to lift and clean and one to hold Mr.
Green's hands to prevent him from striking


85
JNH: Number one?
FM: It's the tops.
. . 'course Joe (JNH), I'll say that you
can make up your mind to be satisfied
with anything. Now people come here
that's dissatisfied and don't want to
come here. And people puts 'em in here
and it takes 'em a long time to get,
get satisfied. We've had one or two
to come here that's just, oh, hated
this place. Now, they like it, after
they learn what it is. Because those
old people, they thought about them
old nursing homes years ago. I still
think about 'em myself.
These comments regarding Pecan Grove Manor should not
be taken as actual evidence of a utopian nursing home
community. Underlying the positive aspects of life at
this nursing home are the expected and typical conflicts
inherent among any group of people living in the community
or an institution. What is significant, however, are the
patients' denials of conflict and reluctance to talk
about conflicts.
There exists an ethos of risk among the patients.
Their lives are, in fact, daily at risk of worsening by
having to leave the nursing home if they become too
healthy, dealing with interpersonal conflict in a small
environment, and deteriorating physically and mentally
with death always on the horizon. Of the twenty-three
elite patients interviewed, twenty-two referred to the
possibility of being dead in one year and all respondents
said that they would be dead in five years.


78
ence lasting seven-and-a-half years. Seven are males and
sixteen are females. All of their respective spouses are
dead. Prior to institutionalization, 747, lived alone, 227
lived with a relative, and 47, lived with a spouse. Members
of this sample had an average of ten-and-a-half visitors
per month (mostly by relatives) with the last visit four-
and-a-half days before the time of interview. Room changes
had occurred for 837, of them. Of these, the average number
of changes approached two. They had lived at Pecan Grove
Manor for an average of three years (upper range: eleven
years; lower range: one month; mode: one year).
In all societies, environmental adaptations involve
food procurement. In Pecan Grove Manor, prospective
patients and their families are given information about
dining that conveys a feeling of the greatest simplicity
of getting food. There is a consultant dietician and a
fulltime kitchen staff to provide complete food service
three times daily. All the patient has to do is show up.
The patient, however, discovers otherwise. As with
any new environment, there are certain ways to move effi
ciently to negotiate the system to maximize one's level of
satisfaction. So it is with food procurement at Pecan
Grove Manor.
The ambulatory dining-room patients have developed
food procurement strategies. The kitchen staff's view
is that they put the food out and all the patient has to
do is come eat. However, the patients' plane of existence


CHAPTER ONE
BACKGROUND
The regeneration of time, according to Mircea Elaide
(1963), is a driving concern of all people throughout the
world. Concepts of heirophanic eternities may represent
the products of attempts to teleologically demonstrate
regenerated time. In any case, the occupants of some
eternity have in common the passage from mundane existence
to supernatural existence; for many, from secular old age
to unencumbered old age.
Also observed worldwide is some form of peculiar
segregation of the aged. Age-grading may be explicit as
with the Karimojong of Uganda (Dyson-Hudson 1966) or
implicit as with the Americans of North America. The
segregation of aged people may be physical, as among the
Ainu of Hokkaido, Japan, who isolate the very old in small
huts (Simmons 1946:90) or conceptual, thus allowing for
physical proximity of young and old but retaining distance
socially and conceptually as found among the Chiricahua
Apache of the southwestern United States (Beals and Hoijer
1971:360). Perhaps special perspectives regarding the aged
are ultimately functions of an awareness of the elderly
approaching the mysterious phenomenon of death. Thus,
people who have lived many years are viewed positively or
negatively, as functional or non-functional, but always
recognized and distinctively engaged by others as aged.
1


92
people were here when we came here, you
know. And ... I don't know, I really
don't know why, but they will, and Doris
will probably tell you the same thing.
They tell her things that they won't tell
the nurses or even Miss Brown (pseudonym;
R.N.), you know.
JNH: That sounds like in a way you all
are more reliable ways to get to . .
information to Miss Brown or Maureen
(pseudonym; medications aide).
BH: And maybe another thing, I thought,
well maybe they (patients) don't want to
tell 'em (aides), theirself, and they
(patients) know if they tell me then I
will go tell if I think they (R.N. or
L.P.N.) should know these things then I
do go tell 'em, you know.
Well, sometime, you know, now, I know,
I never did feel like this: but some of
the aides think the housekeepers are just
the housekeepers, you know. But, sometimes
we understand the old people more than the
nurses do.
Several subsidiary factors can be identified as
enhancers of patient/housekeeper interaction. These seem
to revolve about personal characteristics of the house
keepers: employment at Pecan Grove Manor for a long time,
previous work as an aide, wearing street clothes, and they
are viewed as adults due to their middle-age status. These
personal and job-related characteristics combine to produce
a job and role category of great importance to institution
alized patients. The patients have identified and used
the housekeeping staff category as an intrainstitutional
resource in an unintended and unexpected way. While the
nurses tend to the body, the housekeepers tend to the mind.


45
Lieberman 1976), and Better Homes for the Old (Manard,
Woehle, and Heilman 1977).
An irony of expositions regarding aging and particu
larly aging in an institutional environment is that these
research efforts are done by young and middle-aged people.
It would seem especially uncommon for a nursing home patient
to do and publish research on his or her own setting. It is
here that the benefit of the anthropological data-gathering
method of participation coupled with systematic observations
and recording are highlighted. While one may never become
a member of another reality, participant-observation en
hances the depth of understanding and communication between
the researcher and the community of study. In this research
project, I was able to not only observe and record daily
events, but also participate to the extent of being a con
fidant of patients, a part-time paid employee of the nursing
home, a participant of civil/religious in-house events, a
cultural broker for new patients and families, and a paid
speaker for the state-wide nursing home association. Thus,
not only did I observe the daily cycle, but was actually an
agent in the fabrication of life.
The participants in communities undergo community-
specific socialization processes known as rituals of incor
poration which are further reinforced on occasion by
rituals of solidarity. The objects of this socialization
process are the people of the community. In order to
properly fabricate life in Pecan Grove Manor, the daily


84
JNH: What kind of things were those?
NP: Well, they just didn't take care
of 'em and they'd let 'em lay in the
bed and not take, go see about 'em or
they couldn't get nobody to come when
they wanted 'em. Things like that,
well, I've never had that.
. . Well, I wish more people under
stood how we feel out here. And that
we do have care out here. Not do like
I had, such a horror of coming. I just
really, I did have a horror of coming
out here, but after I got sick and
Dr. P. came in and told me I'd have
to come down here and stay while,
well I didn't say a word. I just
thought, "Well this I have to do."
. . It's the best place outside of
your own home that you could have to
come to.
Also, consider the report (edited) of Mr. Frank Miller
(pseudonym), a 78 year old, white male:
FM: Well, for the last 30 or 40 years
there's been a great improvement. A
great one. I can remember my father
and I went over to a certain nursing
home in Texas; were thinkin' about
puttin' my mother in there, and we
changed our mind when we visited the
nursing home.
JNH: Why is that?
FM: Well, They wadn't run like they
are now. So many old people think of
a nursing home as a horrible place to
go. They think it's just a dumpin'
ground for . Now, that the state
and federis (unintelligible), it's
run like a business more than it's- ever
been before. They've got to run right
or else! . close the door.
JNH: How does this one fit for that?
FM: It's a . I'd say number one.


18
1.
Florida
16.4%
2.
Arkansas
13.2%
3.
Iowa
12.8%
4.
Missouri
12.7%
5.
Nebraska
12.6%
5.
South Dakota
12.6%
6.
Kansas
12.5%
6.
Rhode Island
12.5%
7.
Oklahoma
12.3%
8.
Maine
11.9%
9.
Pennsylvania
11.8%
9.
West Virginia
11.8%
10.
Massachusetts
11.7%
Compiled from: The Elderly Population: Estimates
by County, 1976. DHEW #(OHDS)
78-20248.
RANK BY % OF TOTAL STATE POPULATION 65+, 1976
Figure 1


100
broker in the transmittal of sensitive messages (e.g.,
complaints regarding the nursing staff) thereby distancing
and insulating the patient from potential reprisals.
Collectively, these findings provide an example of
the utility of the ethnomedical orientation in examining
"health care cultures," the unplanned existence of agents
of psychosocial support in a nursing home in the form of
housekeepers, and the persistent depth of capacity for
human resource identification and use among institution
alized geriatric patients.
Overall, elderly Americans live a life of paradox.
Millions fall victim to the iatrogenically-induced disease
of chronic life. The technological milieu of moderniza
tion has increased longevity in the absence of cultural
milieu concommitantly generating respect for long-term
survivors. The penchant for the compartmentalization of
life is a breeding ground for reservation systems to
contain certain segments of society.
Age-segregated communities are contained segments
of society (Jacobs 1974; Angrosino 1976). Within one
such community, the nursing home, the chronically-ill
elderly are housed. At one level of abstraction, the
culture of which they have been participants negotiates
their lives by paid ritual-custodians. Within the cere
monial chambers, the curators perform rituals fabricating
signals of life which are designed to be in opposition to


47
and forty." In fact, this phrase is fairly accurate. Most
of the nurses' aides have not graduated from high school,
are married or divorced, have children, have a history of
working at a variety of semiskilled jobs, and are over
weight, white and middle-aged. Two other local industries
predominate in the same town as Pecan Grove Manor. These
industries, the manufacture of horse trailers and the
assembly of trousers, hire at minimum wage and offer
assembly-line type tasks. Employment at Pecan Grove Manor
is perceived by many as a coup because one works in a
higher-status setting with humanitarian goals and still is
paid the federal minimum wage.
The administration, however, is confronted with a
special task. While local women may aspire to employment
at Pecan Grove Manor, once there, a transformation from a
view of job goals as repetitive, quick action on inanimate
objects to a view of job goals as repetitive, quick action
on animate objects is required. The value of assembly line
efficiency is retained, but there is a shift from machine to
human as the task target.
The administrator of Pecan Grove Manor fosters a
pseudo mother/child interactional orientation between
nurses' aides and patients. The effort is to anthropomor
phize the targets of the aides' responsibilities. The
mother/child perspective also makes use of roles familiar
to the new nurses' aide employee who typically has no pro
fessional training and a meager repertoire of roles on which


12
attendant consequences. Buckingham et al. (1976) explored
the lives of dying patients on a palliative-care ward in an
acute-care hospital. Rosenhan (1973) gained otherwise
unobtainable data on the effect of labeling and institu
tional treatment of not-so-mentally-ill volunteers. The
closest precedent for this study is by Gubrium (1975) who
engaged in participant-observation studies in a nonprofit,
sectarian nursing home.
Participant-observation is not new nor does it possess
the seductive glamour of statistically-fortified ques
tionnaires coded for key-punching and resulting in reams of
computer-tallied data. Before computers (or anthropology)
existed, Frederic LePlery studied French peasant families
by living in their homes with them (Timasheff 1967). With
the formalization of anthropology as a distinct field of
inquiry, intensive coexistence with the subjects of study
has been modeled after anthropologists such as Franz Boas
and Bromslan Malinowski of the early twentieth century.
Thus, the "art and science" (Pelto 1970) of participant-
observation fieldwork has established a firm basis for its
use (Babbie 1979; LeVine 1970; Simon 1978).
Participant-observation was selected as the primary
data collection technique at Pecan Grove Manor because of
its personal, experiential nature. Suspicions generally
felt about the ulterior goals of proprietary nursing homes
would cause data collected by government statistical compi
lations, questionnaires, mail surveys or other techniques



PAGE 1

CHRONIC LIFE: AN ANTHROPOLOGICAL VIEW OF AN AMERICAN NURSING HOME BY JOSEPH NEIL HENDERSON A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1979

PAGE 2

Copyright 1979 by Joseph Neil Henderson

PAGE 3

This dissertation is dedicated to the patients and staff of Pecan Grove Manor -past, present, and future,

PAGE 4

ACKNOWLEDGEMENTS The acknowledgements made below are indications of my sincere debt to the numerous people who encouraged, assisted, and nurtured me throughout the duration of this fieldwork project. Prerequisites for successful anthropological fieldwork are many and varied. Often obscured is the value of the anthropologist's spouse. In this research project, my wife, Jan, figures prominently. She willingly worked and traveled with me throughout the rigors of university training and fieldwork, thereby delaying the realization of some of her personal ambitions. Jan also helped me in gathering data to which I otherwise would not have been privy and charmed those who were at first reluctant to be a part of this study. Besides technical talent, she exudes warmth, personality and love for those around her. My parents, Ike and Patti, have been a continual source of inspiration and sustenance for this part of my life experience. In so doing, they continue to build on an atmosphere of unconditional love and respect which they engendered at my beginning. My brother, Greg, contributes to this project and my life daily. I learned from him discipline, perseverance, humor, and a multitude of other things in the dearest way possible. He is my friend. Greg's wife, Mariquita, contributes to my dissertation by her love for Greg and for Jan and me. iv

PAGE 5

My uncle, Phil Stumpff his wife 'berta, and their four children, Kurt, Erik, Stacia, and Stephanie, all have a part in this research. Phil provided me with complete access not only to a research site, but to a part of his livelihood. I hope that his trust has been well-placed. His family has repeatedly placed their home and selves at our disposal. My grandmother, Mother Polly, and grandfather, Gang, remain lifelong sources of love and inspiration. Their home was made available to Jan and me, providing not only physical shelter, but an experience that speaks well for extended family kinship systems. Those who suggest that kinship declines in importance in industrialized societies may want to review the above acknowledgements. However, many non-kin deserve mention. Among them are Phyllis Maines, Sally Watkins Wilma Davis, and Dorothy Harrison, who all diligently work at Pecan Grove Manor. Some figure -drawing and rough-draft typing was done by Bobbie Bryant, Ruth Kagen, and Anita Morris. Members of my committee have expended great efforts on my behalf in training me in anthropology over the past several years. I will continue to develop my anthropological knowledge and skills because, if I have learned anything, I know that the endeavor of understanding is a lifelong process of wondering, investigating, and learning. I particularly thank Professor Otto von Mering for sharing his novel insights, Dr. J. Anthony Paredes whom I have v

PAGE 6

known the longest of all the committee members, for his continued interest in me and his extensive and expert influence on me, and Dr. Leslie S. Lieberman for her watchful supervision and tremendously useful discussions with me. Dr. Carol Taylor and Dr. Walter Cunningham have provided significant comments on this project, making it a more solid effort. Overall, however, I am responsible for those deficiencies present. It is my sincere hope that this dissertation contains some information benefiting even a small segment of humanity. If this is the case, my debt to those instrumental in this research may be partially repaid. VI

PAGE 7

TABLE OF CONTENTS CHAPTER PAGE ONE BACKGROUND 1 TWO METHODOLOGY 10 THREE DEMOGRAPHICS AND EPIDEMIOLOGY 17 FOUR ENVIRONMENTAL SETTING 25 Note 42 FIVE THE DAILY CYCLE: RITUALS OF FABRICATED LIFE 43 SIX THE PATIENT EXPERIENCE: THE NEXT BEST THING TO HOME 75 SEVEN CHRONIC LIFE AND AGE SEGREGATION 94 APPENDICES 1 SELECTED NURSING HOME INDICES 1977 103 2 PECAN GROVE MANOR TOTAL DISEASE ROSTER (FROM PHYSICAN LISTINGS IN PATIENTS' CHARTS) 104 3 PECAN GROVE MANOR TEN MOST PREVALENT DISEASES 110 4 DISEASE PREVALENCE PECAN GROVE MANOR Ill vn

PAGE 8

5 POPULATION PYRAMID: PECAN GROVE MANOR 112 6 WING ASSIGNMENT BY DEBILITY FACTOR 113 REFERENCES CITED 114 BIOGRAPHICAL SKETCH 121 V1XX

PAGE 9

Abstract of Dissertation Presented to the Graduate Council of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy CHRONIC LIFE: AN ANTHROPOLOGICAL VIEW OF AN AMERICAN NURSING HOME By Joseph Neil Henderson December 1979 Chairman: Otto Von Mering Major Department: Anthropology This research project examines the experience of chronically ill geriatric patients and the care-giving response patterns of unlicensed nursing personnel in a ninety-bed proprietary nursing home in southern Oklahoma. The study of the residents and staff of Pecan Grove Manor (pseudonym) is based on an anthropological community study approach, with theoretical orientations derived from functionalist and social systems models. It extended over a period of thirteen months of participant-observation. Pertinent data were also collected by personal interview, scheduled interview, patient diaries, still photography and cinematography. Overall, Pecan Grove Manor is revealed as a standard American example of a specialized age-segregated community ix

PAGE 10

which has become a commonplace sociocultural and brick-andmortar invention in response to biomedically induced longevity, prolonged debilitating disease, and the ethical proscription against senilicide. The nursing home, therefore, is the setting for observing the uniquely debilitating phenomenon of leading a "half-life of disease" within a "half -existence of social functioning." The research also documents salient features of a resident population with a significant capacity to mobilize adaptive behavioral responses to physical limitations and the formal institutional environment. A further important finding shows unlicensed nursing personnel serving as "folk healers" and surrogate mothers to the patients and non-nursing personnel (i.e., housekeepers) to be the key staff group whose normal or "proper" task performance promotes transactions rather than ritualistic contact with patients. In spite of patients' adaptive resilience, the nursing staff perceives patients as adult children whose physical and intellectual resources are exhausted. This belief, generally coupled with medical -model-induced nursing neglect of psychosocial aspects of well-being, contributes to a web of fabricated life rituals that veil the underlying efforts at palliative care. A concurrent intensive study of a special sub-group or cohort of twenty-three mentally-intact residents provides evidence that, in the main, they experience nursing home life not as ideal, but "the next best thing to home,"

PAGE 11

given their situation of unemployment and illness. This perception is partly based in fact, and in part a derivative of a need to counter-balance the inescapable stress of life under imminent, compounded health threats and the related institutional confinement. The significance of the role of the housekeepers as agents of psychosocial support is not formally recognized by either the nursing or administrative staffs. Unlike nurses' aides, proper job performance for housekeepers involves lengthy in-room tasks during which meaningful interaction can and does occur with individual residents. Housekeepers serve too as brokers between groups of residents and the nursing staff. These findings as a whole suggest that institutionalized elderly can remain adaptively resourceful for an extended period in personal body care, and do respond positively to informal or unplanned psychosocial care. It is argued that psychological care can be promoted within an existing standard program by actively rewarding the spontaneous social-support role of non-nursing staff members, like the housekeepers. The cost-benefit ratio of such a strategy is seen as potentially attractive to proprietary nursing home owners for the improvement of the quality of institutional life. XI

PAGE 12

CHAPTER ONE BACKGROUND The regeneration of time, according to Mircea Elaide (1963) is a driving concern of all people throughout the world. Concepts of heirophanic eternities may represent the products of attempts to teleologically demonstrate regenerated time. In any case, the occupants of some eternity have in common the passage from mundane existence to supernatural existence; for many, from secular old age to unencumbered old age. Also observed worldwide is some form of peculiar segregation of the aged. Age-grading may be explicit as with the Karimojong of Uganda (Dyson-Hudson 1966) or implicit as with the Americans of North America. The segregation of aged people may be physical, as among the Ainu of Hokkaido, Japan, who isolate the very old in small huts (Simmons 1946:90) or conceptual, thus allowing for physical proximity of young and old but retaining distance socially and conceptually as found among the Chiricahua Apache of the southwestern United States (Beals and Hoijer 1971:360). Perhaps special perspectives regarding the aged are ultimately functions of an awareness of the elderly approaching the mysterious phenomenon of death. Thus, people who have lived many years are viewed positively or negatively, as functional or non-functional, but always recognized and distinctively engaged by others as aged.

PAGE 13

Throughout time, the concept or label of "aged" has been assigned to people in accordance with prevailing beliefs regarding the chronological age at which someone "becomes" old. Assignment to the category of aged, then, is a combination of belief and time. In extremes, the six year old progeric patient is considered old while the Russian Abkhasians or Ecuadorian Hunza are considered old only after reaching a purported (cf. Butler 1978b and Mazess and Forman.. 1979) 100 years of age. During the middle Paleolithic, Neandertal burials at Mount Carmel disclose that of a male about 50 years of age (Clark 1969:45) although most Neandertal burials are of individuals less than 30 years of age (Stern 1969:98). Mellaart's (1967:225) excavations in Turkey show that very few of the Neolithic inhabitants of Catel Huyvik lived over 40 years of age. During the Iron Age (c. 100 B.C.), the average life span was 18 years although some rare individuals survived as septugenerians (Birren and Clayton 1975:15). By 50 B.C., the life span has increased to 25 years until the 1600s A.D. when the life span edged ahead to 32 years of age (Birren and Clayton 1975:24). During the year 1776 A.D. in America, only 207o of neonates lived to the age of 70 and only 47o of American families were comprised of three generations (Butler 1978b: 15). By 1900, the human life span was 47 years and in 1970 it was 71 years of age (Cutler and Harootyan 1975:32-34).

PAGE 14

Butler (1978b: 15) projects that the maximum limits of human longevity range between 100 and 120 years Given the rapid acceleration of human longevity and its recency, "old" is new in America and the world. It is as if a new sub-species of Homo sapiens has evolved as a product of machine-age industry and antibiotic medicine. While the subspecies designation is facitious, it can be recognized that elderly people are in some ways physiologically and intellectually distinctive. These distinctive features (e.g., change of bone density, change of arterial elasticity, digestive changes, cognitive and sensory capacity change) relate to special needs of the elderly and finally to demands placed on society pursuant to meeting those needs. The importance of addressing the needs of the elderly in America becomes clear when demographic trends are examined. The total population aged 65 and over in 1900 was 3.1 million but in 1970 was 20.2 million. The proportion of people 65 and older has increased almost 2.5 times from 1900 to 1970: 4.1% to 9.9%. However, the percent of the total population 65 and older will be 11% in 1990, decline slightly until 2020 when it will rise to 13.1%. Projections for the next five decades show that the absolute number of people 65 and older will increase from about 20 to about 40 million (Cutler and Harootyan 1975:33-35). The rapid increase in the number of aged Americans has produced a series of attempted societal adjustments aimed at

PAGE 15

adapting modern American life to a new element of the social and cultural system. In this sense, sociocultural evolution is proceeding under the guise of federal and local governmental programs providing services for needy elderly while also functioning to shift responsibility away from individual elderly persons and their families to the general public. Monetary assistance for the aged, treatment and storage facilities for the aged, separate communities for the aged, and simple ostracism appear to be the American ways of dealing with the growing aged population. Thus, the American aged population has been identified, categorized, and stigmatized as a "problem" with which the "un-old" must cope. Throughout the United States, the vast majority of aged people (hereafter meaning those persons 65 years of age and older) live in community settings with 12.1% of aged males heading a household. Relatively few aged people live alone (14.7% male; 36.2% female) and even fewer live in institutional settings (3.67o male; 4.6%, female) (Cutler and Harootyan 1975:63). This minority of institutionalized aged, however, currently total 1.2 million people (Brody 1977a: 85) and projections indicate that by the year 2000, there may be 11 million aged people residing in institutional facilities (Brody 1977b: 15). The institutional setting likely to be encountered is a privately-owned, profit-operated business selling various degrees and types of care to the elderly sick. According

PAGE 16

to Butler (1975:251), 19% of all institutions providing care for the aged sick are proprietary in nature. Nonprofit institutions for the aged provide care for 147 of the institutionalized aged and 7% of the institutionalized aged are in government -funded facilities. Characteristics of institutionalized aged populations are varied, but even so, certain clusterings of traits are apparent. The median age of institutionalized people is 82 with 437 age 85 and older. There are three times as many women as men. Most institutionalized people are white and poor and are maintained by public funds The institutionalized aged population is likely to have a variety of chronic physical impairments including circulatory disorders, arthritis, digestive disorders and mental impairment such as senility and depression (Brody 1977a: 85-89) Additionally, most institutionalized aged people have no spouse, no close relatives and the majority have no visitors. They stay in the institution almost 2.5 years with only 207o returning home, the remainder dying in the institution or at a hospital. Few can walk, 337 are incontinent and there is an average of more than four drugs taken per person each day .Moss and Halamandaris (1977:8). The above description projects a dismal existence for the participants of geriatric institutions. If it is unpleasant to be poor or sick or lonely, then the combination of these three elements can only constitute a compounded sense of demoralizing desolation. Yet, in this

PAGE 17

investigation in a proprietary nursing home, the harsh reality of the participants' situation is tempered by the human ability to adjust and adapt to prevailing circumstances. The circumstances to which these aged people must adjust and adapt center about the entity known as the "nursing home." Care for the sick elderly is known in all societies regardless of the level of technological proficiency or sociopolitical organization. The existence of senilicide among band and tribal societies is not uncommon, but exists only when necessary. The usual motivating factors are related to vital components of band and tribal subsistence: mobility and productivity. Those who interfere with these basic requirements are killed or allowed to die (see Simmons 1946 and 1960). Among some state level societies, such as the Inca of Peru and the Aztec of Mexico tribute from the productive citizens was redistributed to the needy including the infirm elderly (Simmons 1960:70). Another element of aging recognized cross-culturally is a distinction between productive old age and nonfunctional old age. The nonfunctional and often sick elderly are referred to as "overaged," "useless," in the "sleeping period," in the "age-grade of dying," and "already dead" (Simmons 1960:87). Among the Hopi of Arizona, for example, when people are in the "helpless stage" their death is assisted by purposeful neglect (Simmons 1945:89).

PAGE 18

The occupants of an American nursing home are often very old and very sick. Their membership in a geriatric institution is a symbol of their inability to negotiate even the simplest aspects of life unassisted. In response, the geriatric institution has evolved as a cultural product of technological society's ability to maintain biological life for an extremely long duration but with uneven functional capacity. Thus, nursing home patients find themselves the victims of a peculiar American pathology __ chronic life The nursing home in America has a lengthy evolutionary history. Cohen (1974) reviews the development of institutionalized care for the aged in six phases. The first is labeled the "colonial phase'' referring to the 17th and 18th centuries. Those in need (aged, orphans, sick, prisoners) all had recourse to state relief programs. Overall, however, "outdoor relief" (i.e., noninstitutional care) was more common prior to the Revolution than after it when the almshouse became the popular mode of dealing with the needy. Second, from 1800 to 1920, America was heavily influenced by England's Poor Law of 1834. The Poor Law firmly established the almshouse as the primary institution responsible for the care of all needy, including the aged. The starkness of life in the almshouse was a matter of policy so that it would not be attractive to the undeserving It was not until the 19th century that humanitarian reforms

PAGE 19

8 fueled the development of institutions specifically designed for long-term care of the aged. During Cohen's third phase, 1929 marks the date by which nonprofit institutions were primarily responsible for care of the elderly. The programs of the Social Security Act subsequently provided assistance for the aged. Privately-owned boarding homes began to house the elderly and when nurses were added, the boarding home became a nursing home. By 1939, Cohen's fourth phase, there were 1200 long-term care institutions with a 25,000-bed capacity nationally. By 1954, Cohen's fifth phase, there was a noticeable increase in the number of proprietary nursing homes. The number had risen to 25,000 institutions with a 450,000-bed capacity. Cohen suggests that this increase reflected a backlog of potential patients. After 1965, Cohen's sixth phase, long-term care became institutionalized into the fabric of government policy, medicine, and business. In 1965, legislation allocated funds to nursing home patients and passed the Older Americans Act. The number of facilities expanded and in 1977 there were 1.2 million nursing home beds. It was during the phase of rapid expansion of nursing homes in the U.S. that Pecan Grove Manor (pseudonym) nursing home was built in southern Oklahoma. Pecan Grove Manor was built in 1963 as a 30-bed proprietary facility. Within two years, it was expanded to a 60-bed facility and within

PAGE 20

another three years, 30 more beds were added to fix its present patient load at 90. Seldom does the patient load drop below its maximum capacity,

PAGE 21

CHAPTER TWO METHODOLOGY Pecan Grove Manor was initially reviewed as a potential research site because the administrator is the author's mother's brother and, thus, a close kinsman. The timeconsuming negotiations and development of rapport that would accompany commencement of fieldwork among strangers was consequently reduced. Advantage could be taken of the researcher's kin network only if such a relationship would not attenuate objectivity and access to data. Secondly, permission to engage in research was needed from the administrator as well as the cooperation of staff and patients. All of these criterion were met, leading to field entry in June 1977. A research effort affording complete access to all components of a proprietary nursing home is unusual. This project thus represents a departure from many studies regarding the phenomenon of aging. In fact, research among the institutionalized aged has been relatively neglected based on a review, for example, of the Journal of Gerontol ogy from 1946-1979 (i.e., Volume 1 through the present) and the Index Medicus from 1967-1979. This is particularly conspicuous when compared to the relatively voluminous literature on other gerontologic topics Anthropologists have virtually ignored the institutionalized aged (see Clark 1973; Holmes 1976) and only a few gerontologists have used anthropological methodologies 10

PAGE 22

11 (Gubrium 1975) None have used anthropological perspectives. Of the research activities reported by any social science discipline among the institutionalized aged, it is my distinct impression that the overwhelming majority are based on data gathered in nonprofit nursing homes affiliated with some organized religious group. This is particularly noteworthy in view of the fact that 797o of the institutionalized aged live in proprietary nursing homes (Butler 1975: 261) The few reports of research in proprietary nursing homes are generally not recent and are superficial treatments of a very complex social setting (e.g., Scott 1955; Solon 1957; Bennett and Nahemow 1965). Anthropological investigation in a proprietary nursing home is particularly appropriate. Not only does such an effort fill a gap in studies on aging, but the anthropologist brings powerful perspectives and methodologies as analytical tools that are seldom found in other human sciences. The concept of holism coupled with participantobservation data collection provides comprehensive, in-depth reification of conceptual themes (Opler 1945) and experiences of cultural systems. Furthermore, the methodology of participant-observation has proven utility in a variety of institutional health-care settings. Carol Taylor (1970; 1977) provides insight into the experience of nurse/patient interactions by underscoring the array of nonmedical manipulative behaviors exchanged among health care personnel and patients and their

PAGE 23

12 attendant consequences. Buckingham et al (1976) explored the lives of dying patients on a palliative-care ward in an acute-care hospital. Rosenhan (1973) gained otherwise unobtainable data on the effect of labeling and institutional treatment of not-so-mentally-ill volunteers. The closest precedent for this study is by Gubrium (1975) who engaged in participant-observation studies in a nonprofit, sectarian nursing home. Participant-observation is not new nor does it possess the seductive glamour of statistically-fortified questionnaires coded for key-punching and resulting in reams of computertallied data. Before computers (or anthropology) existed, Frederic LePlery studied French peasant families by living in their homes with them (Timasheff 1967) With the formalization of anthropology as a distinct field of inquiry, intensive coexistence with the subjects of study has been modeled after anthropologists such as Franz Boas and Bromslan Malinowski of the early twentieth century. Thus, the "art and science" (Pelto 1970) of participantobservation fieldwork has established a firm basis for its use (Babbie 1979; LeVine 1970; Simon 1978). Participant-observation was selected as the primary data collection technique at Pecan Grove Manor because of its personal, experiential nature. Suspicions generally felt about the ulterior goals of proprietary nursing homes would cause data collected by government statistical compilations, questionnaires, mail surveys or other techniques

PAGE 24

13 characterized by negligible encounter with the subject population to be questionable.. Conversely, participantobservation allows for first-hand data collection, in-depth experience, and observance of formally-stated ideals of behavior compared to actual expressions of behavior. My personal use of participant-observation at Pecan Grove Manor ran the entire gamut of possibilities except being actually institutionalized. Although the fieldworker may be admonished to totally immerse himself in the culture of the study population, there actually exists daily situational fluctuations of degrees of participation and observation (Gold 1969) My research site allowed for the total access to all participants: administrative, support staff, patients, and families. However, because proprietary nursing homes seem to expect negative assessments and in fact are continually under the scrutiny of government inspectors (not to mention families) observing and writing notes in public areas presented some difficulty. In anticipation, I had written nothing in public and carried no notebook for the first few weeks after my arrival. As the scene began to make more sense to me, the need to preserve my increasingly numerous meaningful observations required the immediate jotting of notes in a field notebook. On the day that I first began to write notebook entries, I contrived a scene which would allow patients and staff to see me taking notes and with the potential for them to actually read what I had written. I selected a table

PAGE 25

14 in the center of the lobby under a ceiling spotlight. Using a large notebook and opening it, I began to conspicuously look about and then record my observations. I purposely avoided any entry of a potentially sensitive nature, such as "nurses' aide Wheeler is goofing off," etc. As I suspected, the "natives" became immensely curious The curious "natives" were all employees of the nursing home who first walked nearby, barely glancing at me and then later returned to loudly speak in an overly endearing tone to some "sweet" patient. After all, I was the boss's nephew who had been sent to "spy" on them. Within fifteen minutes of my act, the assistant administrator and the R.N. very quietly came from behind me and peered over my shoulder. When I noticed them, 1 moved my arms away from my notebook, leaving it totally exposed and undefended. They immediately asked me in a friendly, shy way what I was writing. I handed over the notebook explaining that the two pages of notes were just a beginning and that I would surely require their assistance in the future. The mundane jottings were handed back to me and business went on as usual with several more months of a "marginal native" (cf. Freilich 1970) exhibiting uninterrupted "note taking behavior" (cf. Rosenhan 1973). My extent of participation included helping as a janitor, taking patients to the physician, going to the home of a prospective patient and experiencing the trip from their community home to the nursing home, being in a play to

PAGE 26

15 celebrate the Fourth of July, and working as a paid employee (nurses' aide). Thus, I was able to observe and experience much of nursing home life during my thirteenmonth stay. Although it is obvious, I never personally experienced being an old, sick, nursing home patient. Because I could not experience age beyond my years or experience the length of a hallway for an arthritic patient, other data collection techniques were used. Notable is a scheduled interview given to staff, families, and selected patients. The interview schedule contained questions specific to the respondent's role classification, but each also contained a common core of questions for intergroup comparison. Personal open-ended interviews were collected, patient diaries collected, with still-photography and sound cinematography completing the data-collection strategies. The intent here was to maximize the quality of data collected by using a multi-instrument research design revolving about personal participation and observation. In the larger view, the analytical framework used is based on the model for community study (Arensberg and Kimball 1965; Steward 1950). Conceptually, I approach Pecan Grove Manor as I would any other society regardless of geography. Pecan Grove Manor is thus viewed as a small community with its peculiar beliefs, behaviors, boundaries, rituals for incorporation and expulsion, etc., existing not as a remote, untouched bit of flotsam, but as a part of a network of other social groups of variable influence.

PAGE 27

16 While Arensberg and Kimball (1965) emphasize that a community is a microcosm of the cultural system of which it is a part, Steward (1950) states that a single community cannot be absolutely representative of its cultural system (Crane and Angrosino 1974) Much the same consideration must be made here. Pecan Grove Manor, as a community of institutionalized elderly, cannot be absolutely representative of all other nursing homes. However, there exist certain parameters that cause the methods used here and the subsequent findings to be useful in the investigation of other age-segregated, institutionalized settings. For example, Pecan Grove Manor is included in the following attributes of contemporary American nursing homes : the typical nursing home is a privately-owned business, the physical plant is most often a system of rail-lined corridors covering large distances, the patients are generally very old (80s) and there is a three-to-one femaleto-male ratio, most patients are widowed, most employees are untrained nurses' aides, patients have few visitors and seldom leave the nursing home grounds, and of those who are admitted to a nursing home and do not elect ively move to another long-term care facility, most die there or die shortly after transfer to a hospital. In these important factors, Pecan Grove Manor is strikingly similar to the profile of other American nursing homes (Moss and Halamandaris 1977)

PAGE 28

CHAPTER THREE DEMOGRAPHICS AND EPIDEMIOLOGY The patients of Pecan Grove Manor are institutionalized because of some physical or mental debility. The degree of debility among the patients is variable but must be serious enough to warrant full time care as judged by physician assessment. As a nursing home, Pecan Grove Manor is essentially a living environment designed to support a population of aged, debilitated people suffering the extended effects and acute exacerbations of chronic diseases. The purpose of this chapter is to develop a demographic and epidemiologic profile of Pecan Grove Manor's health and disease environment. These data will be seen to significantly influence the sociocultural environment of this geriatric community. Thus, chronic disease and sociocultural systems mutually influence each other. Eventually all states in America must address the needs of the expanding aged population. Those states which currently have large aged populations may serve as prototypes while other states observe and analyze their strategies for adaptation. Oklahoma is one such "pioneer state" with regard to aged populations. Demographically Oklahoma ranks seventh nationally with 12.37o of the total population 65 years of age and older (See Figure 1) In reflection of Oklahoma's sizeable aged population, 97o of the $458 per capita health care expenditures in 1976 went to pay for nursing home services (Oklahoma Health 17

PAGE 29

18 1. Florida 16 4% 2. Arkansas 13 OCT/ Z/o 3. Iowa 12. 8% 4. Missouri 12 7% 5. Nebraska 12 6% 5. South Dakota 12 6% 6. Kansas 12 5% 6. Rhode Island 12 57^ 7. Oklahoma 12 37o 8. Maine 11 97o 9. Pennsylvania 11 .8% 9. West Virginia 11 .87= 0. Massachusetts 11 .7% Compiled from: The Elderly Population: Estimates by County, 1976. DHEW #(0HDS) 78-20248. RANK BY % OF TOTAL STATE POPULATION 65+, 1976 Figure 1

PAGE 30

19 Systems Agency 1978:46). Also, Oklahoma's availability of nursing home beds is high. In 1977 Oklahoma had 80 beds per 1,000 population 65 and over, compared to the national figure of 62 beds per 1,000 population 65 and over (See Appendix 1) The geographic distribution of Oklahoma's aged population is associated with urban and rural areas (Oklahoma Health Systems Agency 1978:25a). The two large urban areas of Oklahoma are Oklahoma City (Oklahoma County) and Tulsa (Tulsa County) Other rural counties in the state have significantly higher populations of people aged 65 and over (See Figure 2) Of all the 66 counties in Oklahoma, Marshall County has one of the highest aged populations. It is in Marshall County that Pecan Grove Manor is situated (See Figure 2) As a population ages, the prevalence of chronic noninfectious disease increases. The epidemiologic profile of Pecan Grove Manor patients is characterized by a high prevalence of such diseases (See Appendix 2) Of all the disease entries in Appendix 2, arthritis has the highest prevalence rate (See Appendix 3) When the diseases at Pecan Grove Manor are collapsed into categories used by the Merck Manual cardiovascular, neurologic, psychiatric, and musculoskeletal/connective tissue diseases are by far the most prevalent (See Appendix 4) The patient population at Pecan Grove Manor is primarily female (70% female, 307o male) and the average age is

PAGE 31

20 § CO o XI AS o O
PAGE 32

21 70. A population pyramid of the patients shows the greater percentage of female patients to male patients begins in the seventh decade and persists through the ninth decade (See Appendix 5) The predominance of women is still preserved when staff is included in a Pecan Grove Manor patient/staff population pyramid. Thus, when considering the patient and staff populations, Pecan Grove Manor nursing home is predominantly female and middle-aged (average age of patients and staff is 51.7 years). The patient population is divided into three physically and conceptually distinct units based on degree of debility. Pecan Grove Manor is essentially three nursing homes in one. The configuration of the physical plant is based on "wings" radiating from a core containing the lobby, dining room, nurses' station, and administrative office (See Figure 3). Assignment to a wing is based on one's level of debility and thus the type of nursing care required. General observations give the impression that each wing is characterized by distinctly different disease entities. The level of care required on each wing would appear to be a function of progressively more serious disease types. However, disease distribution throughout the nursing home is even. Wing assignment is not related to the roster of diseases found on the patients' charts. Four factors are related to wing assignment and do not require physician assessment or orders in patient charts. At admission, the prospective patient is assessed by the

PAGE 33

22 Pi o a H > O pc; m o CD |25 U < 3 U bO W •H P-i En

PAGE 34

23 R.N. and/or assistant administrator according to continence, ambulation, location of meal-taking, and ability to feed one's self. These four patient-management factors determine wing as s ignment The wings at Pecan Grove Manor are called by the cardinal direction with which they most closely .align (See Figure 3). The North Wing is closest to the nurses' station, personnel, medications and medical equipment. Those patients on the North Wing are most likely incontinent, nonambulatory, eat meals in their rooms and must be fed. The diseases found on this wing are the same found throughout the nursing home but the degree of debility is greatest here. The efficiency of care delivery is enhanced by the proximity of the nurses' station to the wing requiring the most patient care. At the other extreme, the East Wing houses people who are most likely to be continent, ambulatory, dining room users, and self-feeders. This wing is furthest from the main nurses' station. Seldom are call lights used on this wing. In fact, patients desiring "prn" (i.e., as often as needed) medications typically walk from their rooms to the nurses' station to make such a request. The South Wing represents an intermediate transition between the "heavy care" and "light care" wings. Here the ambulatory, dining room users who feed themselves are moderately represented relative to the other wings.

PAGE 35

24 However, incontinence is highest on this wing. This is due to ambulatory patients with urinary incontinence and nocturnal-only urinary incontinence. In summary, patient-management strategies are less related to specific disease categories and more related to level of debility as indirectly reflected by degree of continence, ambulation, ability to feed one's self and location of meal-taking (See Appendix 6). In this way, Pecan Grove Manor becomes three nursing homes in one. The patients, staff, and visitors learn and are affected by the design of patient-management and the physical environment.

PAGE 36

CHAPTER FOUR ENVIRONMENTAL SETTING The physical plant of Pecan Grove Manor comprises a setting in which patients and nonpatients engage in activities for significant parts of their lives. For patients particularly, the physical plant represents the environment which they must negotiate in order to interact with others, get medicines, eat, and otherwise live their lives. The staff, too, must perform within the confines of the building. Staff activities often center about getting from one patient to another which actually means one location to another. Thus, the configuration of the physical plant has the potential to "coerce" certain behaviors from its inhabitants (Sommer 1969) Consideration for the environment as an influential component of human societal existence has a lengthy tradition in anthropology. Perhaps the cataloging of "exotic" food items, shelters, medicines, rituals, etc ., required at least a superficial treatment of the environment as the matrix from which these "goods" were extracted. As environment became a more central issue in social science, human ecology emerged as the descriptive study of the adjustment of human populations to the conditions of their respective physical environments" (Hawley 1944:404). Later, anthropology took account of environment from the cultural ecological perspective of the interactive physical and cultural environments (Steward 1955) 25

PAGE 37

26 Of specific importance here is a special type of environment known as an institution. Goffman's (1960) analysis of "total institutions" underscores the oppressive nature of the "inmates'" lives in a heavily controlled habitat. While prisons or mental hospitals may be characteristic of total institutions, many nursing homes, and particularly Pecan Grove Manor, are not. Bennett and Nahemow (1965) have developed a system of ranking an institutional facility according to its degree of institutional totality. Their perspective maintains that a nursing home represents a significantly different living environment compared to independent community life and that while a nursing home may approach the total institution, it often falls short of this extreme. To assess Pecan Grove Manor along a continuum of institutional totality requires a review of the environmental setting encountered by patients and staff. The building is comprised of three corridors attached to an open square room (See Figure 3) Corridor architecture seems to characterize the physical plant of many institutional facilities (Beckman 1971; Bennett and Eisdorfer 1975; Gubrium 1975; Koncelik 1976) Butler (1975) even refers to the "motel-like" appearance of many nursing homes. The corridor design of Pecan Grove Manor departs from the motel image in that all corridors are lined with handrails. The rail-lined corridor is the distinctive feature of many nursing home environments. Acute-care hospitals may

PAGE 38

27 have handrails, but usually only in physical therapy areas, and residential homes are devoid of such devices. While hospitals share with nursing homes items such as bedrails, bedpans, stethescopes and white uniforms, and private residences share with nursing homes things such as personal furniture, patios, and bathrooms, the continuous rail-lined corridor is to be found not in the hospital or private residence, but only in the nursing home. The handrail is both a metaphor and artifact of geriatric institutional life. As the banister' of a staircase implies that use of the stairs is a risk, handrails in a nursing home are prominent visual symbols of people whose lives are at risk. Still, the handrail remains a needed prosthesis and is thus a medical artifact supportive of those people with diminished strength or poor balance. The rail-lined corridor is public space. Activity in the corridor is always simple locomotion from point A to point B. Use of the corridor as a public pathway places one on display to all those within seeing distance. Thus, one's abilities or disabilities become community knowledge. Each of Pecan Grove Manor's three corridors lead to the main lobby area. The lobby is intended to serve as a central location for patient interaction and activities. Here are found vending machines, a color television, magazines, a piano, and numerous chairs, couches and rockers. In spite of these various attractions, the lobby at Pecan Grove Manor is an area of little person-to-person interaction.

PAGE 39

28 Observations in other nursing homes disclose a similar lack of use : In the current state of the art of building of nursing homes, lounges must be regarded as the single greatest failure as a concept. Typical lounges are the result of regulations which specify that so many square feet must be devoted to lounge space on the basis of number of beds. This device usually results in one or more very large areas devoted to socialization, relaxation, and contemplation, but not really accomodating any of these activities. (Koncelik 1976) In one corner of the main lobby is the color television set. The television area is marked by sectional vinylcovered couches facing the television and situated about 4 to 10 feet from the screen. While it is common to see patients sitting on these couches, seldom is anyone actually engaged in watching some program. Often patients fall asleep sitting up or seem to welcome any distraction (such as conversation with the researcher, an aide, a phone call, etc.). In one instance, the volume control on the color television broke, leaving video without audio. The office personnel placed a small black-and-white portable television next to the color set to use for the audio portion of programs. After a few minutes a patient changed channels on the soundless color set. The picture on the color television never matched the sound on the black-andwhite set for the remainder of the day. Still, patients came to the television area, sat or slept, and then left, never noticing the video/ audio mismatch.

PAGE 40

29 Several factors relate to the television area's inability to actually engage the potential viewer. Sensory deficiencies may make seeing the screen and hearing the sound difficult, particularly in a heavy-traffic area such as the lobby (cf. Koncelik 1976:53). At times, when the television sound is loud, nurses' aides lower the volume or as soon as no one is in the television area, turn the set off. Also, many patients have personal televisions in their rooms complete with cable service. The television area serves, too, as a brief reststop on the way to the dining room. When food trays are served, the television area is immediately vacated. Interaction among patients in the lobby is further inhibited by the arrangement of chairs and couches. The chairs and couches represent long lines of seating which occasionally meet at right angles. For persons with decreased sensory sensation and physical mobility, sitting in lines of seats facing directly ahead requires difficult bodily contortions to enable each person to twist to see and hear the other. The degree of difficulty posed by these communication obstacles is such that little interaction takes place while seated in the lobby (cf. Koncelik 1976:53; Sommer 1970:26-29) The vending machines (soft drinks, potato chips, nuts, candy, cigarettes) are located along a wall away from activity areas. In contemporary American culture, the

PAGE 41

30 media promote snack-type foods as vehicles which fuel social interaction and cement social ties. Nonetheless, the vending machines do not have chairs or tables clustered nearby to take advantage of the Madison Avenue promotion for food/love--love/food orientations. Thus, the main lobby fails as an arena of lively patient interaction in daily use. The only times at which the main lobby becomes the location of significant interaction are those of cyclical ritual events staged by the nursing home staff and/or community. These events include weekly religious services, civil/religious ceremonies (Independence Day, Mothers' Day, Memorial Day), and JudeoChristian celebrations (Christmas, Easter). The main lobby does, however, produce an impression of a spacious "homey" atmosphere. The institutional nature of Pecan Grove Manor is masked by residential-type furniture, carpeted areas, and soft pastel wall colors. There also are planters with green plants and decorative wooden support posts with woodshake shingles fronting the nurses' station. Lighting is primarily by recessed neon bulbs, but even so, table lamps are present in the lobby. Overall, the lobby generates in the observer a positive feeling about the nursing home as a whole. Certain areas of public space seem to be conducive to interaction due to some accidental configuration of design elements. Adjacent to the main lobby is a zone which serves as the main entrance to the nursing home. The entrance area is a natural, unplanned interaction zone.

PAGE 42

31 The main-entrance area promotes patient interaction by its position as a vantage point for observing the daily events within the nursing home. Other observers likewise cite entrance areas as natural vantage points (Gubrium 1975:10; Koncelik 1976:52; Sommer 1970:34). Sitting in the chairs or area near the chairs facing the entrance doors, one can see through the glass doors and adjacent glass panels to the parking area and the nearby highway. This view allows for monitoring the travels of patients, visitors, and staff. Also within sight is the nursing home business office with its attendant activities. Looking to one side offers the view of the entire ambulatory corridor. Patients move within in the corridor frequently for visiting, medicines, food, and exercise. Looking to the other side affords a comprehensive view of the main lobby, dining room and nurses' station. For those patients whose mental abilities permit, the entrance area provides a good allaround location for gathering information about the daily events of nursing home life. The entrance area is also marked by its function as a communication center. Here is found a phone for patients to use, a large monthly-activities and events calendar, and a major-event bulletin board. This area also is marked by many color photographs of past parties. Live plants are also here along with craft displays. The entrance also attracts interaction due to its midpoint location between the ambulatory corridor and the

PAGE 43

32 lobby/dining room/nurses' station cluster. Traffic in either direction can, for convenience or necessity, stop here to rest, observe and talk. Social interaction is thus promoted in the entrance area by numerous coincidental features. Seating in this area is limited, however, and most users are those who have retained higher levels of functioning. This part of the nursing home physical environment serves as a central location for patients to learn of various activities occurring in "their" building and to exchange information which is then diffused to the other corridors of the physical plant. Floor space area, whether lobby, entrance, or patient rooms, is determined by formulas based on the number of patients housed. The main lobby fulfilled the space requirements for the first thirty-bed unit and the second addition of another thirty beds. When continued construction added an additional thirty beds, however, additional lobby space had to be built. This new lobby area is at the end of the ambulatory corridor. In this new lobby, about onethird the size of the main lobby, most intrainstitutional activities occur. Intrainstitutional activities include weekly bingo games, activities such as singing and craft work, daily domino games, and other patient/ family activities such as private parties. The new lobby area also serves as a place for large groups of visitors to see their relatives.

PAGE 44

33 One final area of public space to consider is the dining room. While most other biological needs can be met in the patient rooms, eating in the dining room is considered, indicative of a relatively high level of functioning. The administrative and nursing staffs encourage dining room use for the change of scenery and social interaction. Even so, seating placement is fixed so that forgetful patients will not be so easily confused. The dining room, like the lobby, is a place of very little social interaction. Meals are brought to the tables by the kitchen staff on large fiberglass trays. In an effort to serve the food hot or cold, and to satisfy hungry patients, great haste is made in getting food trays to the tables. One result is that the kitchen staff has little time to exchange pleasantries with the patients at the tables. Other obstacles to interaction at mealtime are related" 1 to sensory deficiencies in the patients. The hearingimpaired patient has difficulty understanding another from across the table. Impaired vision may further hamper communication by disallowing lip-reading. Additionally, the kitchen is adjacent to the dining room where a very loud dishwasher operates during meals (cf. Koncelik 1976:54) Thus, food service responsibilities, sensory deficiencies, and environmental noise function to inhibit mealtime interaction.

PAGE 45

34 While the lobbies and entrance area are zones of public space, there are zones of private space. The private space areas are those controlled by the nursing and administrative staffs. At the nurses' station can be found the R.N. (i.e., registered nurse), L.P.N.s (i.e., licensed practical nurses), patient charts, and medications. The area behind the nurses' station marks the private space for staff only. Here the nursing staff can work on charts or medications with minimal patient contact. The privacy of this zone enables the nursing staff to exchange medical information as well as gossip about patients, other staff members, or their community lives. The nursing staff also converts part of the public dining area to private space for breaks and staff mealtime. The "break table" functions to channel news throughout the corridors to the nurses' aides. Thus, aides assigned elsewhere can review important interactions to which they were not witness. While all staff members spend many hours of each day within Pecan Grove Manor, only the patients live the entirety of their remaining lives in the institutional environment. Most of this time is spent inside their rooms. An empty room would look much the same as any other throughout the nursing home. However, each wing has its own distinc-:. tive atmosphere when filled with patients and their belongings.

PAGE 46

35 The three -winged configuration of Pecan Grove Manor has been used to assign patients to a particular wing not based on specific disease entities but rather on a subjective assessment of individual debility. Assignment protocol has led to describing the wings by level of care needed and has resulted in clustering of physical capacities (See Appendix 6). Likewise, the artifacts in patient rooms reflect the level of debility of those living there. The North Wing, or "heavy care" wing, houses those patients with the greatest physical and mental difficulty. An artifactual inventory of these rooms discloses a general paucity of personal belongings, residential furniture, photographs, wall decorations and personal televisions. It is here that the greatest number of restraining "halfdoors" are found (See Figure 4) These patient rooms most closely fit expectations of an institutional environment (See Figure 5) The South Wing, or "intermediate care" wing, is characterized by a mid-range level of debility relative to other patients at Pecan Grove Manor. The patient rooms are relatively well-adorned with personal memorabilia but residential furniture and personal linens and appliances are scarce. Televisions are in greater evidence but not universal. The East Wing, or "light care" wing (also "ambulatory wing") reflects the relatively high level of functioning retained by these patients. In this wing, the greatest

PAGE 47

36 3 G H Pn o o H 3 o U 3 i EC

PAGE 48

37 w ED O M Fn Pi o a H O U w Pd <' o >-< 3 w I o H W H H
PAGE 49

38 number of personal belongings, residential furniture, hand crafts, and television sets are found. A television set is present in every patient's room and occasionally one room has two televisions (See Figure 6) Those patients with high levels of functioning are fully aware of the wing-debility relationship. The nursing staff on occasion may "threaten" an ambulatory-wing patient into some behavior (typically some type of self health-care action) by simply mentioning the likelihood of being moved to the intermediate care wing. Other similar coercions exist, always with the power of the "threat" directed at movement toward the least desirable wing. There is very little voluntary contact with the heavy-care wing patients by members of the other wings, and the heavycare wing is referred to as "over on North where those pitiful people are" (cf. Gubrium 1975: 16, 26). Thus, wing assignment is a metaphor of one's functional capacity and proximity to death. Establishment of one's position within the wing—debility system is decided at admission by the R.N. and/or the assistant administrator. Room availability may also influence the initial wing assignment. Regardless of actual placement, the cognitive map of relating to the entire experience of living and dying at Pecan Grove Manor is one of initial admission to the ambulatory wing with a highlevel functional capacity, followed by physical and mental decline resulting in a move to the intermediate wing. From

PAGE 50

39 M a p o 1-1 Pn o IS H o 5 pa
PAGE 51

40 here, further decline is experienced necessitating a move to the heavy-care wing with the other "pitiful people," "poor things," and "crazy ones." Even within this wing, a final move through space signals impending death. The dying are moved to Room #1 North due to its proximity to the nurses' station. From here, the final move is final. The patient, then, learns to use this "cosmology" as a grid upon which to maintain a constant fix on his or her date with death. The experience of Pecan Grove Manor seems to be characteristic of American institutional settings for the aged. Pecan Grove Manor as an institution conforms generally to Bennett's medium level of institutional totality (Bennett and Nahemow 1965:47). However, Pecan Grove Manor's three sections have certain institutional characteristics in common but also each wing requires its own special treatment. Institutional characteristics common to all wings range from high to low levels of institutional totality. For example, the nursing home as a whole is a permanent residence (high level) socialization of new members is informal (medium level), and there exists no objective sanction system (low level) Again, using Bennett and Nahemow' s (1965:47) scheme, the heavy-care wing has seven of ten criteria commensurate with a high level of institutional totality. The mediumcare wing has only three of ten high-level characteristics, while the light-care wing has only one, that of permanence. With regard to a medium level of institutional totality, the

PAGE 52

41 heavy-care wing has only one matching item, the intermediate-care wing has seven out of ten matches. The low totality category has all three wings assigned to just one item — no objective sanctions. Overall, Pecan Grove Manor can be characterized as an institution with a medium level of totality. In this setting, patients play out their daily life cycles in association with sets of employees hired to assist and monitor this final phase of existence.

PAGE 53

42 Note In fact, on the 11 PM to 7 AM shift one night several years ago, the aides and myself were surprised to see a car drive from the highway into the nursing home parking lot. A man came into the nursing home, walked across the lobby to the nurses' station and asked for a room for the night.

PAGE 54

CHAPTER FIVE THE DAILY CYCLE: RITUALS OF FABRICATED LIFE Pecan Grove Manor is a society of elders experiencing life at imminent risk of death while their progress toward this end is monitored by paid attendants. However, the American propensity for denial of death demands illusion to mask the cultural apparatus of lingering death. This stance is like the mesmerizing qualities of the magician's slight-of-hand that allows transcendence beyond the plane of mundane experience into the mystifying realm of reality denied. Thus, the functional reality of the nursing home Is obscured by a daily series of rituals fabricating the illusion of meaningfully transacted life. The critical elements of nursing home life involve a triad of patients, nurses' aides, and care-giving patterns associated with chronic debilitating disease necessitating long-term care. Interactional exchanges between nurses' aides and patients are characterized by daily, intensive contact with each other. In this environment of long-term exposure to patients, the nurses' aides, though generally untrained, become highly sensitized to patients' typical behavioral patterns and ultimately become diviners of exacerbated illness episodes who may treat or report their findings to licensed nursing personnel who then carry out a treatment protocol. Also, patients are able to manipulate their hosts by exploiting informal mechanisms of social control and identifying resources within the nursing home 43

PAGE 55

44 community to assist them in negotiating institutional life and chronic disease. The inner workings of nursing homes have been examined from a variety of perspectives, each with its own version of reality and degree of quality. Social critics have long accused the nursing home industry of being charlatans. Consider these titles : Tender Loving Greed (Mendelson 1974), Old Age : The Last Segregation (Townsend 1971) Where They Go to Die : The Tragedy of America's Aged (Garvin and Burger 1968) and Too Old, Too Sick, Too Bad (Moss and Halamandaris 1977). Another category of nursing home speculators involves the experienced administrator teaching others to be administrators. These works are characterized by manipulative marketing techniques designed to promote a nursing home (Bachner 1974) and "how to" instructions detailing how to do to patients and families (Rogers 1971; Miller 1969). Other administratively oriented volumes attempt to be more therapeutically oriented (McQullan 1974; Kramer and Kramer 1976). A shift in orientation of perspective is observed as the authors of works examining nursing homes are identifiable as social scientists. The content of such volumes tends to be oriented toward an analytical view of the inner workings of nursing home living and ideas regarding the quality of life of the inmates. Some comprehensive volumes include Long-Term Care (Sherwood 1975) Long-Term Care of Older People (Brody 1977) Last Home for the Aged (Tobin

PAGE 56

45 Lieberman 1976) and Better Homes for the Old (Manard, Woehle, and Heilman 1977). An irony of expositions regarding aging and particularly aging in an institutional environment is that these research efforts are done by young and middle-aged people. It would seem especially uncommon for a nursing home patient to do and publish research on his or her own setting. It is here that the benefit of the anthropological data-gathering method of participation coupled with systematic observations and recording are highlighted. While one may never become a member of another reality, participant -observation enhances the depth of understanding and communication between the researcher and the community of study. In this research project, I was able to not only observe and record daily events, but also participate to the extent of being a confidant of patients, a part-time paid employee of the nursing home, a participant of civil/religious in-house events, a cultural broker for new patients and families, and a paid speaker for the state-wide nursing home association. Thus, not only did I observe the daily cycle, but was actually an agent in the fabrication of life. The participants in communities undergo communityspecific socialization processes known as rituals of incorporation which are further reinforced on occasion by rituals of solidarity. The objects of this socialization process are the people of the community. In order to properly fabricate life in Pecan Grove Manor, the daily

PAGE 57

46 participants must be identified, their roles defined and assigned, and then this system put into action. The members of this community can be classed into two general categories: managerial and target populations. The managerial group consists of the hierarchy of all paid staff groups and the target group consists of patients and their families. Implicit in this scheme is an interactional orientation characterized by managerial groups acting on target groups. The components of primary importance here are the nurses' aides as a managerial subgroup and the patients as a target subgroup, due to the enormous amount of time these two groups of people spend together engaged in fabricating rituals of life. The incorporation of nurses' aides into the ethics of the nursing home staff involves formal and informal socialization. Formally, the new aide is taught how to ideally behave in a meeting with the R.N. during which the patient is identified as most important and the administrator (i.e., boss) as least important. Even a document indicating the assimilation of this scheme is signed by the new nurses' aide and filed in her employment folder. The informal socialization of the new nurses' aide filters down from the administrator and is based on the perceived expectations of patients, their families, and government inspectors. A common phrase which circulates among the administration at Pecan Grove Manor characterizes the perception of the typical nurses' aide: "fat, white,

PAGE 58

47 and forty." In fact, this phrase is fairly accurate. Most of the nurses' aides have not graduated from high school, are married or divorced, have children, have a history of working at a variety of semiskilled jobs, and are overweight, white and middle-aged. Two other local industries predominate in the same town as Pecan Grove Manor. These industries, the manufacture of horse trailers and the assembly of trousers, hire at minimum wage and offer assembly-line type tasks. Employment at Pecan Grove Manor is perceived by many as a coup because one works in a higher-status setting with humanitarian goals and still is paid the federal minimum wage The administration, however, is confronted with a special task. While local women may aspire to employment at Pecan Grove Manor, once there, a transformation from a view of job goals as repetitive, quick action on inanimate objects to a view of job goals as repetitive, quick action on animate objects is required. The value of assembly line efficiency is retained, but there is a shift from machine to human as the task target The administrator of Pecan Grove Manor fosters a pseudo mother/child interactional orientation between nurses' aides and patients. The effort is to anthropomorphize the targets of the aides' responsibilities. The mother/child perspective also makes use of roles familiar to the new nurses' aide employee who typically has no professional training and a meager repertoire of roles on which

PAGE 59

48 to base her behavior in a nursing home setting. There exist many symbols to excite the mother role or "mothering" : helplessness, toddling, incontinence, beds with bars, diapers, etc. By focusing on the mother/child interactional pattern, a maximum level of care behavior is extracted from the untrained, low-level nurses' aide. The mother/ child role relationship is expressed in a variety of ways. The infantilization of the adult patient can be observed in child-like words for excrement ("shooshoo," "wee-wee") and diapers ("didees") One instance I observed demonstrated the nursing staff need to persist in infantilizing the patient. A nurse was examining a male patient with a distended lower abdomen. The man had a history of prostatitis. The nurse used "pee" and "make water" while the patient used "urinate" and "catch a specimen. Other expressions of infantilization are more completely explicit than referring to patients as "baby," "little one," or "little people." Consider these phrases: "... just wash them like I would one of my own children, 'cause that's just what they are." "I've got twelve kids and so I'm well suited to this job." "Like babies, they get good and warm and they pee up a storm." "I think of these people as my babies, especially the ones on North Wing because they are so helpless." "They're like children. They are there for us to spoil."

PAGE 60

49 "They are like children and that's the way I treat them." While promotion of the mother/ child role behavior may function to enhance care-giving and to animate the patients conceptually, there are also costs that accrue. For example, acting as a mother toward a patient will elicit the appropriate dyadic response of a child. Adult -toadult interaction is thus retarded. Particularly lacking is adult/adult interaction among male patients and the female nursing staff. I found the men thirsty for "man" talk. Male patients were the most animated in their conversations when I sought advice about proper carburetion on a lawn mower, inquired about hunting, fishing, and trapping exploits, asked about farming or ranching and other "male domains." Conversational topics of this nature were absent during nurse/male patient interactions. Self -generated conversation of this nature was not common among the men due to daily familiarity of the members and possible exhaustion of topics. My presence and questions produced high-energy conversations due to my newness to the nursing home, and my continual contact with the non-nursing home community, and a perception of selfworth in that they were being asked to share a part of their past role experiences with a younger man. Administrative influence on nurses' aides is seen again in the distribution of the nursing staff in task and wing assignment. Staffing of each wing varies according to

PAGE 61

50 the level of care needed and shift time. For instance, federal regulations require one nursing staff member per each ten patients on day shift (6 AM to 2:30 PM) one nursing staff member per each twenty patients on evening shift (2:30 PM to 11 PM) and one nursing staff member per each twenty-five patients on night shift (11 PM to 6:30 AM). Since Pecan Grove Manor is designed to accomodate ninety patients, the day shift has eight nurses' aides and one L.P.N. the evening shift has five aides and one L.P.N. and the night shift has three aides and one L.P.N. The distribution of aides by shift is based on level of care needed on each wing. Patients, visitors, office staff, and thus nurses' aides are the most active during the day shift. Day shift nursing staff is the most differentiated. The heavy-care wing has four aides, the intermediatecare wing has three aides and the ambulatory wing has one aide who, during part of the day shift, helps with baths and food delivery. The majority of the day shift she spends dividing her time between the other wings. The day shift begins officially at 6:00 AM, but day shift aides have informally assembled in the lobby near the nurses' station for casual socializing ranging from 5 : 15 AM until shift report. Preshift conversations are typically about personal community life. Only if something unusual regarding a patient has occurred is the topic of the nursing home related.

PAGE 62

51 Shift report begins about 5:50-5:55 AM. The day shift aides move to the nurses' station, having been summoned by the charge nurse (an L.P.N.) to review as listeners the events of the night seen as significant. The content of the shift report includes three topics: medications given, assessments made (e.g., vital signs), and unusual illness or mood changes Most shift-report information is useless to the nurses' aide. Medications given are read by name of drug, amount given and to whom it was given. After report, none of the aides were ever able to tell me what the medications were for or why they were given, with the exception of two tranquilizers, Thorazine and Sparine ("to keep them quiet"), Valium ("nerve pills") and nitroglycerin ("heart pills") Vital signs were seen as significant only if unusually exaggerated and emphasized by the charge nurse reading the report. Shift-report information that elicited response from the nurses' aides was the mention of laxatives (often read as "milk of mag"), falls, escapes, and rowdiness. Laxatives and behavior problems mean work for the aides. Reports of laxatives being given were met with such remarks as "Oh, no!," "We'll be busy today!," and "They don't need any laxatives!" In spite of the selective use of shift-report information, the entire previous -shift nursing activities were always reported. Rather than functionless ritualism,

PAGE 63

52 however, shift-report serves an important purpose. It marks a transition from mundane conversations and concerns current moments before, toward inspiring awe and respect for the medical and humanitarian tasks ahead. As one aide put it while making a bed, "I've always wanted to be in the world of medicine." The duties of the nurses' aides are seen in the most complete form on the day shift on the heavy-care wing. A typical routine for four nurses' aides Is presented in Figure 7. This daily shift routine collapses into seven main task categories plus miscellaneous ones (See Figure 8) The tasks requiring the most time per shift are feeding, bed check, and showers. Feeding is time-consuming in that on the heavy-care wing, 887 of the patients eat in their rooms and of these, 247 require feeding by an aide. At lunchtime, for example, there are four nurses' aides who pour milk and tea for each patient, place them on the trays, and take the trays to the patients. After all trays have been distributed, the four aides feed the eight patients who cannot otherwise eat. For the nurses' aides there are "feeders" (i.e., a patient requiring feeding) who are more desirable than others. Desirable features include a room furniture arrangement allowing (read: requiring) the aide to sit while feeding, a patient who does not choke, drool or otherwise "cause problems," and a patient who eats rapidly. Thus, following tray distribution, a silent race ensues among the aides to acquire the most desirable feeders.

PAGE 64

53 ACTIVITY Lights on Linens Get patients up Make beds Breakfast Bed Check (2 aides) Showers (2 aides) Shaving Break Shaving Lunch Put patients to bed Rinse dirty linens Aides lunch Shaving Talk, fix sink TIME 05:57 AM 05:58 06:06 AM 06:06 06 :28 AM 06:28 06:54 AM 06:54 08:07 AM 08:07 10:10 AM 08:07 10:55 AM 10:10 10:33 AM 10:35 10:50 AM 10:50 11:37 AM 11:37 12:58 PM 01:00 01:40 PM 01:40 01:47 PM 01:47 02:17 PM 02:17 02:25 PM 02:25 02:30 PM NURSES' AIDE TASK-TIME ACTIVITY 5 May 1978 (FOUR AIDES EXCEPT WHERE NOTED) Figure 7

PAGE 65

54 ACTIVITY TIME DURATION Patients up, down, or cleaning Food service Bed check, make beds, clean beds Shaving Break, Lunch Linen Showers Miscellaneous (rinse dirty linen, fix the sink) 1 hour 02 minutes 2 hours 22 minutes 2 hours 29 minutes 1 hour 18 minutes 45 minutes 08 minutes 2 hours 48 minutes 12 minutes 8 hours 16 minutes* 'For those nurses' aides who don't give the showers NURSES' AIDE TASK-TIME CATEGORIES 5 May 1978 Figure 8

PAGE 66

55 When I began working as a paid nurses' aide, the first striking discovery I made was that each aide has memorized a large array of personal habits of each patient that rendered their service to the patient more personal and timeefficient (cf. Taylor 1970). For instance, the placement of a juice glass on the left side of a breakfast tray for one person renders the glass more visible and accessible, two packages of sugar for one person, three for another, no napkin for that person because they eat paper, etc., is required for proper job performance. The catalog of individual patient wants is enormous and generally fulfilled. Only lengthy, daily contact would make such a feat possible. This same intimate knowledge of patients is observed in noting behavioral change that may be of medical consequence. Actual hands-on contact with patients such as feeding, bathing, clothing, changing diapers and bed linens, provides the nurses' aide with another set of information. The nurses' aide becomes aware by sheer repetition of patient-specific behavior patterns and potentials. Deviation from an expected set of behaviors warrants mention to a higher authority. For example, Mr. Robert Henry (pseudonym) is a white male, 72 years old, bed-fast, diabetic, paralyzed on his right side as a result of a cerebral vascular accident, incontinent and requires feeding. The position of Mr. Henry's bed is such that the nurses' aides continually feed him from one side of the bed. For weeks this was satisfactory until one morning a nurses' aide reported to the

PAGE 67

56 other aides that Mr. Henry seemed to be drooling very slightly from the left corner of his mouth. I later fed Mr. Henry and found the report accurate. The loss of food from his mouth was slight enough so that only the staff who worked with this patient routinely day-in-and-day-out would recognize this as a potentially significant behavioral change. Without extensive awareness of Mr. Henry's behavior patterns, the drooling may have been attributed to his position in bed, soft diet, dislike of the menu, or as just another patient who drools. This change was reported to the R.N. as evidence of a minor stroke. The aide who reported the change later told the group that the R.N. attributed the change not to stroke, but to his medications which included large quantities of Thorazine. However, Mr. Henry's chart recorded no change in medications before or after the aide's report. The nurses' aides, in spite of no medical training, are the most important health-care agents in Pecan Grove Manor. Their significance exists in their extensive contact with the patients. They may be able to identify an important change in a patient that the R.N. would be unable to do. The aide who notices some relevant change recounts her coup for several days until virtually all the staff is aware of it. Thus, the lack of training and low status of the nurses' aide is not necessarily a detriment to patient well-being.

PAGE 68

57 Noticing slight changes in patients leads the nurses' aides to engage in a variety of folk-diagnoses and prescriptions, for they "know what that patient needs." A frequent diagnosis is constipation. This does not require notification of the R.N. or laxatives unless symptoms persist. The symptoms are subtle ones such as patients who look like they are straining when they should be relaxed in bed, a patient exploring his anus with a somewhat determined facial expression, general foul mood, and deviation from expected time intervals of bowel movements. If it is determined that the patient suffers from constipation, the cure is to remove a suspected lower rectal impaction. This involves a trip to the nurses' station (otherwise off-limits to the average aide) to get a surgical glove and some "K-Y" jelly. The patient is often positioned in front of a toilet in expectation of successful therapy. If an impaction is present and removed and the dilatage action promotes a bowel movement, or even if the blockage is up higher and not immediately relieved, the diagnosis and therapy still allows the nurses' aides a brief foray into "medicine" and some assurance for themselves that it will be some time before they have to change that patient's underwear or diaper. Other folk-diagnoses made by nurses' aides revolve about observed changes in the integument. Tasks assigned to the nurses' aides require seeing and touching the patients' skin. Feeding, bathing, cleaning incontinence and clothing

PAGE 69

58 a patient provide ample opportunity for close, sustained contact with individual patients. This "hands-on" contact promotes situations in which the nurses' aides are the initial agents of health-care providing. Abnormal body temperature is susceptible to nurses' aide detection. However, since all thermometers are kept at the nurses' station, the nurses' aide in a patient's room uses her bank of past experience with a patient to determine abnormal temperature. The ability to perceive fever by a nurses' aide requires long-term contact with each patient. Several reasons exist for this prerequisite. Each person has individual responses for body temperature adjustment, air temperature in each room is variable, blankets and clothing alter skin temperatures, and rubber draw sheets, plastic-covered mattresses, or plastic air -mattresses may be present which cause skin temperature increases. Thus, one person may typically sweat enough to thoroughly dampen bed linens while showing a normal temperature. If a patient is suspected of having an abnormal body temperature, the nurses' aide goes to the nurses' station to get a sterile thermometer and "K-Y" jelly if rectal temperature is taken. Not only does this allow the nurses' aide to engage in "medical therapy" for a brief time, but it Is a legitimate time-consumer away from the more mundane, "dirty work" which is the common lot of nurses' aides. Integument changes are also noted for acute hypertension. Redness of the face is a primary symptom nurses'

PAGE 70

59 aides use to diagnose hypertension. An aide who is trained to measure blood pressure goes to the nurses' station for a stethescope and syphgmomanometer If hypertension is indicated, the nurses' aide will report it to the nurses' station with no report if the charge nurse is away or casually mentioned as a negative result to the charge nurse if present. Perhaps the most important skin signs observed by the nurses' aides is the precondition leading to decubitus ulcers. Reddened skin, particularly in regions of bony prominences, is a signal of impending bedsores. Bedsores are particular problems for long-term care bed-patients and those who sit in wheelchairs or even lounge chairs for lengthy periods of time. When reddened skin is noticed, it is desirable to massage the local area with lotion. However, this simple preventive measure is infrequently used. The technique of simple massage lacks the paraphenalia which signals highlevel medical therapy. Also, lotions that are frequently used are purchased by the patient or the patient's family and are thus generally unavailable for even distribution throughout the patient population. As a result, decubitus ulcers are present. The presence of decubitus ulcers is an embarrassment to the nursing staff. The nursing staff often blame the existence of decubitus ulcers on mismanagement of patients while they were away at a hospital. These hospital-genera-

PAGE 71

60 ted bedsores are then transferred to the nursing home. While this may be true to some extent, bedsores likewise originate in the nursing home. Yet, the nursing dictum that "bedsores are totally preventable" seems to be overly optimistic. People who are kept alive for so long that they can't be handled because deep tears in the skin occur can hardly be expected to remain free of decubitus ulcers. Likewise, the comatose geriatric patient who is incontinent and fed by a naso-gastric tube represents another nearly impossible task in decubitus ulcer management. It remains true, however, that more effort is expended in bedsore management than prevention. Also involved in the primacy of physical care is that it is expressed in physical activity. The busy aide is one who is moving. The charge nurse can look down the corridor and tell if the aides are actually working by the movement in and out of rooms. The aides assimilate this dogma rather completely and probably by transfer from other jobs. For instance, I noticed one nurses' aide leaning on a patient's bedrail and talking to the patient for about five minutes. Later, in response to my question of what she had been doing, I was told, "just foolin' around." Physical orientation to patient care is further promoted by its observability, immediacy of results, and amenability to rapid dispensing. Thus, the nurses' aide can project the good-worker image not only by activity, but by the physical proof of duty performance within the time constraints of her shift.

PAGE 72

61 Perhaps the task most associated with nurses' aides' duties is "bed check." By federal regulation, all nonambulatory patients must be routinely checked for incontinence. Bed check thus consists of visual or physical inspection of incontinent patients. Soiled clothing, bed linens, bed frames and patients must be changed or cleaned. Gubrium (1975) refers to this part of nurses' aides' duties as "bed and body" work. It is this task category that most undermines the patients' and nurses' aides' sense of propriety. Bed and body work peels away the cosmetics of one's daily "act" to reveal the "underside" of a lifetime of culturally appropriate impression management. The locked door that screens the toilet habits occurring in the American bathroom (cf Miner 1956) is ripped from its hinges for both the patients and nurses' aides. Bed check is considered the most mentally and physically taxing job task. One's performance here leads to peer ranking along a continuum of good to bad. The stresses involved for aides and patients in bed check are immense and are expressed in the following vignette from my participation and observation: "Now you're really gonna get broken in," the female nurses' aide told me as I approached Mr. Joe Green's (pseudonym) room. Mr. Green lay in his nursing home bed in a near-visible order of incontinence. He is a diabetic, an alcoholic, an amputee, a hemiplegic from an old cardiovascular accident, is non-ambulatory and generally considered to be illtempered. As he lies in bed, Mr. Green often hollers as if sharp pains momen-

PAGE 73

62 tarily seize him. Mr. Green lay on his back, his head on pillows and the stump of his left leg (amputated at the distal end of the femur) supported on pillows. A plastic urinal is left between his legs with his penis positioned inside. The first task of the aide is to empty the urinal. Sometimes the glans rests on the side of the dry urinal, other times it is submerged in urine. In either case, the urinal is removed by moving it away from the body. As the penis exits the urinal, it drags along the inside surface of the urinal eliciting a pained cry or a stream of expletives. Only once was it observed that an aide positioned Mr. Green's penis so that it didn't scrape against the surface of the urinal. As Mr. Green is rolled toward the side of the bed, a liquid pool of feces becomes visible and is filled with recognizable bits of food. The aide nearly vomits. The aide "lovingly" chastises Mr. Green and begins to clean him. The buttocks are spread and the corner of a Chux protective panel is used to begin cleaning. After the majority of fecal matter is removed, washcloths are used to finish the job. Invariably, Mr. Green screams at the aides that they are hurting him as they clean the scrotum. Seldom does an aide attempt to touch the scrotum in an effort to expedite the ease and thoroughness of cleaning. Occasionally, a shower is required to clean Mr. Green from incontinence. In this instance, he may be wrapped in the bed sheets and placed in a shower chair to be rolled to the shower. At other times, when the floor and aides shoes are not in such jeopardy, he is placed on the shower chair nude and then covered with a sheet preparatory to transport. At these times, he is apt to loudly complain that "you sat me on my nuts!" The aides generally scold him and try to reposition him. Interaction with Mr. Green typically requires the services of three aides: two to lift and clean and one to hold Mr. Green's hands to prevent him from striking

PAGE 74

63 those in reach. While Mr. Green is mentally alert, conversational, and likes to talk about his former fishing days, conversation is directed toward Mr. Green's roommate who cannot speak at all. The roommate is 54 years old, mentally retarded, behaves in a childlike manner including delight with toys and stuffed animals. A number of stresses between patients and nurses' aides are expressed in the above interaction. Observing the procedures for cleaning incontinence or reading about it does little to reify the actual, hourly, daily experience. At Pecan Grove Manor, the nurses' aide "must," from official administrative and nursing dictum, "love" all of the "little old people," do their jobs with great efficiency and above all, never, ever mistreat a patient. From a managerial perspective, expecting these superhuman qualities will not insure perfection of job performance, but will enhance the likelihood of good patient care. Acting out these exhortations with patients like Mr. Green is difficult. In spite of admonishments and reports of "loving all these little old people," occasionally more honest statements emerged: "We love all of these little old people, but we love some more than others." Thus, the good patient/bad patient distinction commonly observed in other health care settings is found here, too (cf. Lorber, 1975; von Mering and Earley, 1966) Mr. Green is considered a "bad" patient. Incontinence or other debility alone is not enough to warrant bad-patient status. These traits, however can produce bad-patient

PAGE 75

64 status in some combination with the following attributes : some degree of mental intactness, physical strength, speech, and vocal complaints. Another obstacle to care results from sexual tabus. Only once did a nurses' aide touch Mr. Green's penis to facilitate exit from the urinal. Mr. Green's scrotum often was left with some fecal material on it due to imcomplete cleaning. Other male patients who were not circumcised never, in my observations, had the foreskin retracted for thorough cleaning of the glans On the other hand, I was allowed to assist in toileting habits with a twenty-five year old, mentally retarded female except when she was menstruating. Lastly, the nurses' aides minimized interaction with Mr. Green by avoiding all but essential communications. Mr. Green' s roommate, even though he was aphasic, was the recipient of generous amounts of conversation to which he would laugh, act shy, and make "goo-goo" noises, delighting the nurses' aides. Is Mr. Green's case one of a difficult patient or a difficult staff? I personally experienced working with Mr. Green very distasteful. He did smell, look, and act badly. However, when I had the time to ask him about his life, he was responsive and I was surprised to find a rather complete, intact personality. This did not elicit in me a missionary zeal of saving this man's integrity. My willingness to talk with Mr. Green not only produced conversa-

PAGE 76

65 tion but identified me as a resource (perhaps "easy mark" should be read) for him. Mr. Green would shout from his bed for me by name to give him a cigarette. A patient smoking in bed requires the aide to stay in the room and thus interferes with the work schedule. At times I would comply and at other times I was unable to do so due to work demands Actions other than physical care directed at patient involve efforts at promoting psychosocial support for the patient population. The psychosocial environment is expected to be fueled by that part of the nursing home life known as "activities." Activities at Pecan Grove Manor are frequent and of variable quality (See Figure 9) Three features of the ritual calendar deserve mention: (1) nurses' aides' interference, (2) lack of response measurement, and (3) advertising. The nurses' aides represent interference to effective activity programs primarily with regard to the weekly secular in-house activities. For example, the "band" activity consists of the activities director assembling several patients in the east wing lobby to play various percussive instruments. She complained often that by the time she walked a few patients to the east lobby and went down the corridors to get others and walk them back to the lobby, the early arrivals had become bored and wandered off to different parts of the building. Efforts to enlist the assistance of nurses' aides were futile due to the aides'

PAGE 77

66 CATEGORY OF EVENTS PUBLIC INVOLVEMENT INTRAINSTITUTIONAL CYCLE Religious Services X WEEKLY Special Religious Celebrations : 1. Christmas X ANNUAL 2. Easter X ANNUAL Civil/Religious Celebrations : 1. Valentines Day X V ANNUAL 2. St. Patrick' s Day X X ANNUAL 3. Mother's Day X ANNUAL 4. Father's Day X ANNUAL 5. 4th of July X ANNUAL 6. Halloween X ANNUAL 7. Thanksgiving X ANNUAL Secular Activities : 1. Birthdays X MONTHLY 2. Bingo X WEEKLY 3. Beauty Shop X WEEKLY 4. Crafts X WEEKLY 5. Remotivation X WEEKLY 6. Band X -WEEKLY ACTIVITIES Figure 9

PAGE 78

67 insistence that they did not have time, or could not leave "the lights" unattended. The beauty shop is an activity that sometimes becomes a spontaneous party, even attracting male patients and office workers to the door. One L.P.N, disliked the laughing and commotion in the beauty shop because it disrupted the sanctuarylike environment she considered proper. As she told me one day, she preferred to work on shifts in the evening and night hours because families were less present, most patients were asleep, and she could engage in "puredee quality nursing care." One of those involved in activities suggested that the nurses' aides disliked patients in the beauty shop in the afternoon hours because it prevented the aides from putting the patients to bed so the aides "wouldn't have anything to do." Activities as therapy are suspect, too, because there are no assessments of improvements in patients attributable to the activity program. Benefits to patients may be slight, subtle, or nonexistent, but no one knows for certain. The visibility of physical care benefits overshadows the relative invisibility of psychosocial improvement. Activities in the religious and civil/religious categories are highly visible and receive great attention from the administrative, nursing, and activities staffs. Most important is Christmas and Mother's Day. For example, the Mother's Day celebration becomes a community competitive potlatch in which conspicuous consumption brings status to the nursing home from the community.

PAGE 79

68 Mother's Day 1978 lasted about three hours. It cost Pecan Grove Manor $897.30. Newspaper ads accounted for over $200. One nearly full-page ad outlined a "roaring 20's theme with a skit, play, snowcone stand, and antique cars parked near the highway." A competing nursing home seven miles away countered with a smaller ad announcing a new gerontologist on staff and a "peaceful visitation on Mother's Day." Pecan Grove Manor spent $85.50 on radio spots, $100 on a band, $94.90 on flowers, $137 on costumes, and $66.74 on photographs, and more on miscellaneous items. Relatives of patients, employees and townspeople totaled between 100 and 150 spectators. Patients, staff and visitors all appeared to enjoy themselves. Within a few weeks, reminiscing about the party had ceased. One month before the Mother's Day event, a group of patients were involved in an activity that they still mention over one year later. Nearby Pecan Grove Manor is a large lake with many recreational potentials. The activities director decided to arrange a fishing trip to a floating, enclosed fishing dock. The interior of the float is arranged so people can sit and fish in any type of weather. Complete services are available, ranging from a bait store and equipment rental, to a cafe. Seven male patients were selected to go on this trip. Selection was based on level of debility, behavior, and an expressed desire to go. Three men from the community were

PAGE 80

69 asked to help at the fishing site. They were expected to assist in baiting hooks, netting fish, and any other fishing-related tasks. They were invited to fish, too. The remainder of the party consisted of the activities director and myself. Twelve people participated in the outing for a cost to the nursing home of $71.71. The five-hour event took place on a Tuesday from 9 AM to 2 PM. The activities director sent a small write-up to the local weekly newspaper as is commonly done with patient birthdays. Other than this, the community-atlarge was un involved and unaware of the fishing trip. The effect of the trip on the patients and the activities director was quite noticeable. Patients were ready to go and positioned at the entrance doors 30 to 40 minutes in advance. Although everyone was ready for a rest at the end of the trip, the patients asked when they could go again. The activities director considered possible ways to continue such trips by buying some small Zebco rods-and-reels and some fishing tackle. A member of the administrative staff cautioned that the group of people wanting to go would increase in size. Overall, I had never seen these particular men so animated prior to the trip or known of a special activity that engendered such a sustained level of excitement and anticipation of another trip. Mother's Day and the fishing trip were both entered on government forms as activities. Nonetheless, each event

PAGE 81

70 served different purposes which led to the retention or loss of the event. The Mother's Day events and other major productions are opportunities to symbolically, though indirectly, communicate to the public Pecan Grove Manor's solid concern for the welfare of their patients. The more visible and lavish this public event is, the more status is given to the nursing home, and its reputation is sustained or improved. Conversely, the fishing trip was a low visibility, inexpensive event affecting seven patients. There is great opportunity for quality psychosocial improvement (judging by change in their affective mood) and maintenance but little chance for status accruement to the nursing home. Mother's Day will continue to be celebrated annually as part of the major public potlatches Over a year later, the fishing trip has not been repeated although the men participants still reminisce about it. The overall orientation toward patients in Pecan Grove Manor is one of palliative care. The presence of the medical model is expressed in ritualistic monitoring of patient decline. Mo physical or occupational therapist is present. Although a full time R.N. is not required, Pecan Grove Manor boasts one who is present during part of the day shift, five to six days per week (however, on-call twenty-four hours daily) and functions primarily as a nursing staff administrator and token representative of "high level" medical status to attract and assuage patients and families. Other personnel involved in activities for patients supportive of

PAGE 82

71 psychosocial maintenance report difficulty getting assistance from nurses' aides and a perceived low status with the hierarchy of service providers. This milieu is not conducive to maximizing the remaining potentials of the patients. Unlike palliative care units in acute-care hospitals (cf. Buckingham, et a l. 1976), this nursing home and likely most others, masks the nontherapeutic environment with a battery of rituals designed to create illusions of life for the patients, families, and staff. It is clear that the patient career (cf. Roth 1963) is most directly influenced by that segment of the nursing staff known as the nurses' aides. The style of care-giving is one in which physical care is emphasized to the neglect of psychosocial care. Several reasons exist for this skewing. The nursing staff supervisors are trained in the traditional medical model as L.P.N.s or R.N.s. Their training emphasizes physical therapy with only a slight orientation toward psychosocial parameters. Federal inspection by Title 19 requirements clearly promotes and rewards medical action. For example, Pecan Grove Manor prides itself on having patient charts up-to-date meaning that all entries had been made on a daily basis, particularly daily remarks regarding each patient. "Charting" consumes the vast majority of the L.P.N. 's time. This practice becomes so perfunctory, however, that patients who are away visiting or in the hospital have been unintentionally charted as not only pre-

PAGE 83

72 sent, but the recipient of "usual a.m. care" or "up and about; cheerful" (cf. Gubrium 1975). Still, the nursing home must meet the demands of federal government regulations. The nurses' aide/patient/long-term care institutional environment operates collectively to produce a community of daily forcedinteraction. The longevity of patient/nurses' aide interaction coupled with a mother-child interactional pattern leads to in-depth knowledge of patient behaviors. The nurses' aides being generally untrained, make use of their own physical senses and beliefs about health and disease to make decisions regarding therapeutic actions. Psychosocial care is de-emphasized due to the pressures of fulfilling physical care needs. Most important, however, is the relative invisibility of psychosocial care procedures and benefits. Additionally, benefits that accrue are likely to be relatively gradual in appearance. Lastly, there is no staff member who is trained to be perceptive of the psychosocial environment, while conversely there are plenty of staff members who have received formal education in business management and medical-model nursing. These factors are reflected in the topics for in-service training (See Figure 10). The foregoing material describes a social system oriented toward long-term palliative health care performed by unskilled nurses' aides on institutionalized aged patients. A number of tensions between aides and patients have been identified with resolution couched in an ambience of strategies particular to long-term care environment.

PAGE 84

73 J < CTv -rjr-l st H CM m O H fH fe Pi Ft) < o o r-l i— i H W fn h^ < H M S u tq o s CO g o o CO S Pm w w Pi H <;[Hiz; cr, o O o^ JHW I—i ,—1 <: h o u <: < Hftg; co <; w Pm Eh CO CO a iz: CO Pi J w • l-l o Ph O H H M O O C5 hJ O H E-i s >^ M Pm CO O pq O o M M pi 3 CO • K M CO s H £ w 2 Q CO Pi 33 > la r-l M 3 25 ^ o H r-l cu H r- !h r3 w c^ bfl CJ r-1 •H H Pn > ,£ Pi O H U CO 1 2 2: M

PAGE 85

74 Nurses' aides and patients alike have an enormously difficult task. The patient career consists of pretending to be socially functional while being totally expendable. One is the victim of chronic disease and social circumstance. The nurses' aide, dressed in white, pretends to be therapeutically functional while dispensing palliative care, One is the victim of therapeutic expectation and incurable disease. Thus, aides and patients engage in a variety of rituals to fabricate a facsimile of life. In this way the stark reality of chronic disease and old age can be partly veiled. Orientation toward patients at Pecan Grove Manor is remarkably similar to Jules Henry's (1963:474) summary of the humane Tower Nursing Home: An effort to formulate a "national character" for Tower yields the following: the staff, though animated by solicitude and kindliness seems to maintain an attitude of indulgent superiority to the patients whom they consider disoriented children in need of care, but whose confusion is to be brushed off, while their bodily needs are assiduously looked after. Tower is oriented toward body and not toward mind. The mind of the patients gets in the way of the real business of the institution, which is medical care, feeding, and asepsis. Anything rational that the patient wants is given him as quickly as possible in the brisk discharge of duty, and harsh words are rare. At the same time the staff seems to have minimal understanding of the mental characteristics of an aged person

PAGE 86

CHAPTER SIX THE PATIENT EXPERIENCE: THE NEXT BEST THING TO HOME Perhaps the most direct route to the experiential reality of patienthood in Pecan Grove Manor involves elicited response from the patients themselves. On a daily basis, the patients must negotiate the entire social system of Pecan Grove Manor. The exigencies of nursing home life that seemingly are "non-problems" to the staff, families, and researcher, in fact are real problems to the patients who must as resourcefully as possible manage their lives in this environment. Self -management in an institution becomes an exercise not in futility but in the identification and maximization of situationally-specif ic behavioral resources from a meager resource pool. Nursing home life involves institutionallyimposed constraints. Nonetheless, there exists sufficient tolerance or "slack" in the formal normative system for behavioral flexibility or creativity to emerge. Thus, the patient population can be seen to experience oppressive external controls while simultaneously engaging in the creative extraction of self-benefiting behavioral procedures. The capacity for ingenuity within a geriatric population is apparently a point of dispute. In one recent treatise on aging (Woodruff and Birren 1975) diametrically opposed statements are found: The impression one gets from environments in which aged persons live as well as from that which is written to 75

PAGE 87

76 describe such environments suggests the existence of a simplistic notion that man is infinitely adaptable. This is surely an erroneous view of man. Both common sense and empirical data demonstrate that human adaptability is finite. (Schwartz 1975:289) Old people are extremely adaptable. Birren tells a story about an experience he had while doing research on visual perception One of the volunteers for the project was a man of around 85 years old who was active in the home and a leader in the activities there He was well known by most of the residents and well liked. When Birren tested this man for visual acuity he found that the old man was functionally blind. Birren went to the nursing-home administrator and asked if the administrator knew that Mr. X was blind. The administrator couldn't believe Birren. Observing the old man's behavior very carefully, Birren found that the man was always accompanied by his wife, and she very subtly guided him and gave him cues so that, although this man was functionally blind, not even the nursing-home staff were aware of it. This remarkable example stresses the adaptability of old people. (Woodruff 1975:190) The assessment of patient resourcefulness involves direct observation and questioning of the patient population. Recently, assessments of personal nursing home living experiences have found salient data not in sociodemographic variables or in elaborate physiological workups but in subjective perceptions of the inmates about their membership in an institution (Noelker and Rarel 1978). Therefore, much important data about the sociocultural system comes directly from the patients themselves. Twenty-three patients at Pecan Grove Manor were identified as mentally intact by my personal assessment and

PAGE 88

77 their scoring on the Mental Status Questionnaire (Kahn, et al 1960) at the time of interview. All but one were ambulatory. The term "resident" is often used in gerontological literature when referring to institutionalized people with the greatest amount of ability. However, in this community of elderly people, all of the non-staff are considered and called "patients." They are simply patients with a lesser dependence on help from the nurses' aides. Still, they are medicated, monitored, required to see a physician monthly, have call-lights in their rooms, and their bowel movements are daily charted. Their distinction from others lies within themselves. The fortuitous combination of relatively intact mental and locomotor function provides them with the ability to mobilize their resourceful capacities In anthropological terms, these people are best able to undergo the psychological, behavioral, and sometimes physical contortions of adjustment to a new environment. Over time, these adjustments become routinized as adaptive responses enabling the patient to maximize their chances of a successful "fit" within the community of which they are a part. The purpose here is to examine the consequences of adaptation to a nursing home environment by a subgroup of the patient population. All twentythree patients responded to a structured interview. The average age of this sample is 82 years and 8 months with an average educational experi-

PAGE 89

78 ence lasting seven-and-a-half years. Seven are males and sixteen are females. All of their respective spouses are dead. Prior to institutionalization, 747o lived alone, 22% lived with a relative, and 47o lived with a spouse. Members of this sample had an average of ten-and-a-half visitors per month (mostly by relatives) with the last visit fourand-a-half days before the time of interview. Room changes had occurred for 837o of them. Of these, the average number of changes approached two. They had lived at Pecan Grove Manor for an average of three years (upper range: eleven years; lower range: one month; mode: one year). In all societies, environmental adaptations involve food procurement. In Pecan Grove Manor, prospective patients and their families are given information about dining that conveys a feeling of the greatest simplicity of getting food. There is a consultant dietician and a full time kitchen staff to provide complete food service three times daily. All the patient has to do is show up. The patient, however, discovers otherwise. As with any new environment, there are certain ways to move efficiently to negotiate the system to maximize one's level of satisfaction. So it is with food procurement at Pecan Grove Manor The ambulatory dining-room patients have developed food procurement strategies. The kitchen staff's view is that they put the food out and all the patient has to do is come eat. However, the patients' plane of existence

PAGE 90

79 differs from the kitchen staff in terras of corridor life and concepts of time and space. Thus, for the patient, nutrition requires special planning. Meals are never served at exactly the same time. The variance ranges from fifteen to thirty minutes and is due to mundane human factors and differing preparation times for various foods. Meals are usually served between 11:30 A.M. and 12:00 Noon. Also, patient trays are distributed by rotating the starting place of distribution. If at breakfast the first trays were placed at the west end of the dining room, at lunch they will begin at the east end. Distribution time from one end to the other is about thirty minutes The patient's goal is to coincide his or her time of arrival at the assigned table with the arrival of the food tray. If timing is correct, hot food will be hot and cold food will be cold. Patients begin leaving their rooms from 11:15 A.M. to 11:30 A.M. to walk or roll to the lobby or entrance area. Here they sit, rest and sometimes talk with those nearby. At this "way station" patients continually glance toward the dining room which they can now see to notice the earliest activity from the kitchen. One signal used by many people is the appearance of a kitchen staff member who turns on the dining room light. Tray distribution begins at one end of the dining room. Those who sit at that end walk the now short distance to their

PAGE 91

80 tray immediately. Those who sit at the opposite end typically wait until it is closer to the time their own tray arrives Thus, the necessity of eating is experienced differently by the staff and the patients. The administrative and kitchen staffs experience feeding as "food service." The patient population experiences feeding as "food procurement" with a battery of strategic behaviors necessary to adapt their physical capacities to the physical environment. The community of Pecan Grove Manor comes to acquire personal meaning beyond the brickand -mortar ediface. The most common and consistently elicited report was that living at Pecan Grove Manor is neither ideal nor desirable but it is "the next best thing to home" given their circumstance. Nursing home life is viewed by the patient as the only reasonable solution to their predicament of unemployment and chronic illness. The typical patient also suggests that no other supportive resource system is available to meet essential needs for physical well-being. For those having children who represent potential caretakers, the children are reported as willing to take them but the patient will not "burden" their children or "get in the way." Thus, the patient sees the nursing home as a resource rather than a place of confinement.

PAGE 92

81 I'd rather be here than with my kids to eliminate potential conflict with them (paraphrased, 77 year old female) If they can't get up and get around, tell 'em to come on (to Pecan Grove Manor) (77 year old male) It's a good place to live, but there's no place like home. (88 year old male) Next thing to home, but it ain't home. (91 year old male) If you can't live at home, this is tops. (78 year old male) It's more like home than if I was with my children. I'd feel in the way if I was with my children and I don't feel in the way here. (94 year old female) They (her grandchildren) have no use for old people. Don't you know that? (88 year old female) Responses to "What do you like most about living here at Pecan Grove Manor?" centered about patient/ staff dependency. The primary benefit is the security of having one's needs consistently met within a cognitive set of perceived personal risks at simply being alive. The needs were clearly biosocial: companionship of staff and other patients, food service, and perceived medical-care availability. Responses to "What do you like least about living here at Pecan Grove Manor?" were oriented toward situationspecific items rather than the nursing home itself: separation from family and friends and disvalued behavior of other patients (eg., noisy, messy). References to what these patients missed most about their life prior to being institutionalized were

PAGE 93

82 independent of the institution. The predominant response was a loss of personal independence coupled with the loss of their spouse. On the other hand, these patients experienced improvements as a result of institutionalization. The presence of nurses' aides as helpers and being around other people for socializing were likewise reported as improvements in their lives. The experience of being a nursing home patient actually begins before one enters the front door (Tobin and Lieberman, 1976) The patient brings with him previously developed' beliefs regarding nursing home life. Little is done to better precondition the prospective patient for admission to Pecan Grove Manor while in the hospital or at home prior to admission. Thus, early experiences in the nursing home can be unnecessarily traumatic. Consider the report (edited) of Mrs. Nancy Pipkin (pseudonym), a 75 year old, white female: JNH: What kind of adjustments did you make? When you think back about when you first came here. NP : Well, when I first came I was unhappy a little while. I didn't hardly know see I just come out of the hospital here and I had had a nervous breakdown. And I had a lot of adjusting to do anyway, wherever I had been. And then I just come out of it and I can just walk and do anything I want to do. And I'm happy here. JNH: What do you miss most about living in the community?

PAGE 94

83 NP : Well, anybody misses home, but outside of that But I miss home and friends But the friends come to see me and I see them, so. I just know that this is going to be my home from now on and I just accept it and try to make myself be happy. I don't have any complaints as far as myself is concerned. They are just as sweet to me as they can be. Everytime I've ever needed anything, why, they're right here to help me. I'm just I'm just thrilled I've got a place like this to stay. JNH: About how long do you remember it taking until you felt comfortable here? From the time you were first here. NP: Oh, I guess it was six months maybe before I really could just turn loose and feel at home, but after that I was Now I was never miserable understand. I when I come I knew that this was going to be my home and I was going to make it pleasant as I could. So, I haven't let myself worry and think, "Why did I have to come here?" and "Why did this have to happen to me?" I've just accepted it and I've enjoyed it I just wish every old person that has to stay alone and be in danger of not being cared for you know that couldn't take care of themselves. It's bad to have that feel in' that you might JNH: OK, how about some more on this. You were saying that you wished other people that needed to have these kinds of services could have them. Could you kinda repeat that? NP: Yeah, well I do I wish that other people could see and know how happy we are in here. I don't think that it'll be seemed like it ... that I did, I had a fear of coming down here. Before I come here, I'd heard things, you know, remarks made. And I haven't found any of that to be true in my case of what I'd heard or was afraid of.

PAGE 95

84 JNH: What kind of things were those? NP: Well, they just didn't take care of 'em and they'd let 'em lay in the bed and not take, go see about em or they couldn't get nobody to come when they wanted 'em. Things like that, well, I've never had that. Well, I wish more people understood how we feel out here. And that we do have care out here. Not do like I had, such a horror of coming. I just really, I did have a horror of coming out here, but after I got sick and Dr. P. came in and told me I'd have to come down here and stay while, well I didn't say a word. I just thought, "Well this I have to do." It's the best place outside of your own home that you could have to come to Also, consider the report (edited) of Mr. Frank Miller (pseudonym), a 78 year old, white male: FM: Well, for the last 30 or 40 years there's been a great improvement. A great one. I can remember my father and I went over to a certain nursing home in Texas; were thinkin' about put tin' my mother in there, and we changed our mind when we visited the nursing home. JNH: Why is that? FM: Well, They wadn't run like they are now. So many old people think of a nursing home as a horrible place to go. They think it's just a dump in' ground for Now, that the state and federals (unintelligible), it's run like a business more than it'sever been before. They've got to run right or else! close the door. JNH: How does this one fit for that? FM: It s a I'd say number one.

PAGE 96

85 JNH: Number one? FM: It's the tops. 'course Joe (JNH), I'll say that you can make up your mind to be satisfied with anything. Now people come here that's dissatisfied and don't want to come here. And people puts 'em in here and it takes 'em a long time to get, get satisfied. We've had one or two to come here that's just, oh, hated this place. Now, they like it, after they learn what it is. Because those old people, they thought about them old nursing homes years ago. I still think about 'em myself. These comments regarding Pecan Grove Manor should not be taken as actual evidence of a Utopian nursing home community. Underlying the positive aspects of life at this nursing home are the expected and typical conflicts inherent among any group of people living in the community or an institution. What is significant, however, are the patients' denials of conflict and reluctance to talk about conflicts. There exists an ethos of risk among the patients. Their lives are, in fact, daily at risk of worsening by having to leave the nursing home if they become too healthy, dealing with interpersonal conflict in a small environment, and deteriorating physically and mentally with death always on the horizon. Of the twentythree elite patients interviewed, twentytwo referred to the possibility of being dead in one year and all respondents said that they would be dead in five years

PAGE 97

86 Although leaving the nursing home to re-enter the community is rare (one mild stroke patient and one burn patient in the thirteen months of f ieldwork) all patients receiving public funds must have a monthly physical examination by a physician. Most patients consider the physical to be a necessary nuisance to keep receiving their funds. The patients report the physical to be superficial and a means for the physician to make money. Still, residence at public expense requires disability. The physical represents a monthly potential for discharge. Of more daily importance is the avoidance of open intragroup and intergroup conflict among patients and staff. The mechanisms which are conflict-obtrusive are partly related to features of long-term care and partly related to characteristics of institutional living. Membership in the institution is forced. There are no other viable options. The process of adjustment and incorporation into the institution develops a sense of personal investment in this community. Patients away on visits with relatives or during hospital stays speak of their desire to "get back home" to "sleep in my own bed." Thus, there is a desire to preserve their position in the nursing home. Institutional characteristics that generate conflictavoidance center about reduced private space. Open conflict in communities with a very limited territorial range is likely to be expressed beyond necessity. Those in

PAGE 98

87 conflict will constantly be near each other and have little option to retreat to quell hostilities due to reduced private space. Also in operation is institutional public life expressed in the feeling that "everyone will know my problems." One patient (86 year old female) stopped me in the hall one day finding it difficult to maintain eye contact and select her words. She eventually began with, "I know you know this already, ..." I didn't. She related in a halting voice that she suspected her roommate of conspiring with one of the cleaning women to put aluminum foil on the top part of the room windows. Her roommate is consistently too warm and she is consistently too cold. She said she didn't know whether or not this should be included in her diary which she wanted to give me. They had earlier agreed to divide ownership of the window by the two panels of glass. Even in the winter, her roommate would exercise her ownership perogative over her panel of glass by opening it, even though the window unit was not on "her side of the room." This woman was convinced that the magnitude of this conflict was such that it was surely public knowledge. She also felt quite helpless in that two people (roommate and a staff member) had conspired against her. The perceived and real lack of physical and social resources caused a minor incident to have major implications for this patient.

PAGE 99

88 Another male patient agreed to keep a diary to give to me but then rescinded. Before he returned the unused diary to me, another patient told me that this man had bragged that he was "going to be a spy for Joe." When he returned it, he very obliquely stated that he was afraid that keeping the diary might cause trouble. In an environment that houses only a small pool of people, friendships are resources with which one should not tamper. Other aspects of avoidance of open conflict exist in relation to long-term care. Not only would open conflict cause life to be difficult in close quarters, but one would experience a sustained level of tension because they will live there the rest of their lives. In acute-care hospitals, personal risk stemming from angered roommates or hospital staff would not endure indefinitely. The experience of nursing home life is very much different. At times, when complaints (though relatively innocuous) were voiced to me, I was typically told not to divulge the complaintant s name to anyone. For example, comments about unsatisfactory menus were ended with "don't tell 'em I said that." A man told me that some folding chairs borrowed from a men's club had unintentionally been kept at the nursing home. His statement was almost totally shrouded in disclaimers and caveats. The man's primary intent was to preserve a good relationship between the club and the nursing home. It was evident, however, that he didn't want to be perceived as a "trouble maker" for

PAGE 100

89 the administration. Returning the chairs to the club would be more work for an already busy staff. Another instance involved a female patient who called me to a quiet corner and asked me to move some lawn chairs back to their previous location so that they could be used as before. I was then told not to tell anyone that she had made the request. The caution exercised by the patients regarding what seemed to me to be reasonable and minor items is produced by the knowledge that one will quite literally have to live with the not-totally-predictable consequences of one's actions. The public nature of life in an institution coupled with long-term membership makes the otherwise inconsequential momentous. The administrative staff also participates in conflict obtrusion. The nurses' aides are told never to gossip or argue in the presence of patients. The patients are not to be bothered by personal staff problems. The administrative staff believe that families and patients expect an idllyic paradise and the nursing home will produce what the customer wants. It was my experience, however, that the patients thirsted for information of any type. To overhear a nurses' aide's actual personal problems was at the least better than the fiction of television soap operas. Often patients interjected comments expected to be helpful in solving some dilemma. The patients felt more alive through

PAGE 101

90 vicariously dealing with someone else's problem when their own environment minimized them. In fact, the nurses' aides are a virtual data bank for the patients to learn of community life and internal nursing home events. In spite of supervisory attempts to restrain nurses' aides' conversational topics, the aides are in intimate contact with patients for too great a time to totally prevent exchange of personal information. Patients at Pecan Grove Manor nursing home have also seized upon a naturally evolved element of their institutional setting as a personal resource: the housekeepers. The housekeepers at Pecan Grove Manor are two women who were nurses' aides at this nursing home prior to their employment as housekeepers. They routinely move through the hallways in separate, systematic routes. Each housekeeper pushes a janitorial cart containing a mop, mop bucket with "squeegee," trash bag, and numerous cleaners-, and disinfectants. The thoroughness of their work is attested to by the universal report from visitors and patients that Pecan Grove Manor is "the cleanest nursing home I've ever seen." In addition to their function as housekeepers, they represent an important resource to the patient population. They are brokers bridging the patients and the nursing staff especially with regard to sensitive issues and they are more available for conversational interaction than any other staff group.

PAGE 102

91 Several factors are involved in the development of the dual role of the housekeepers. First, the potential for engaging interaction is greater with the housekeepers than with the nurses' aides because in-room task assignments typically require longer periods of time for housekeepers. Whereas rapid in-and-out activity signals appropriate work modes for aides, the opposite is true for housekeepers Proper cleaning requires lengthy task performance per room. Thus, informal job-related normative pressures promote in-depth interaction between the patients and the housekeepers Babby Heath (pseudonym), one of the housekeepers, spoke of her dual role (edited) : JNH: We'd be wondering why why they (patients) seem to visit with you all (housekeepers) so much. BH: I think probably it's because maybe we're in the rooms longer and we don't wear white and they, they seem closer to us. Because they'll tell us things maybe that they won't tell someone else. JNH: because they talk to you and Doris (pseudonym; housekeeper) and they wouldn't talk to an aide? BH: Well, ok, another reason, Joe. See, I've been here now for quite awhile, you know. And I worked as an aide on the mornings and I worked on the evenings And they, really, they feel like they know me better than they do some of the other girls. And I think the same way on Doris because Doris has been out here a long time too, and a lot of these old

PAGE 103

92 people were here when we came here, you know. And ... I don't know, I really don't know why, but they will, and Doris will probably tell you the same thing. They tell her things that they won't tell the nurses or even Miss Brown (pseudonymR.N.) you know. JNH: That sounds like in a way you all are more reliable ways to get to information to Miss Brown or Maureen (pseudonym; medications aide) BH: And maybe another thing, I thought well maybe they (patients) don't want to tell 'em (aides), theirself, and they (patients) know if they tell me then I will go tell if I think they (R.N. or L.P.N.) should know these things then I do go tell 'em, you know. Well, sometime, you know, now, I know I never did feel like this: but some of' the aides think the housekeepers are just the housekeepers, you know. But, sometimes we understand the old people more than the nurses do. Several subsidiary factors can be identified as enhancers of patient/housekeeper interaction. These seem to revolve about personal characteristics of the housekeepers: employment at Pecan Grove Manor for a long time, previous work as an aide, wearing street clothes, and they are viewed as adults due to their middle-age status. These personal and job-related characteristics combine to produce a job and role category of great importance to institutionalized patients. The patients have identified and used the housekeeping staff category as an intrainstitutional resource in an unintended and unexpected way. While the nurses tend to the body, the housekeepers tend to the mind.

PAGE 104

93 The patient population of Pecan Grove Manor, and particularly those most able patients, actively engage themselves in their community's environment. Their efforts are aimed at resource identification and exploitation. These adaptive tasks are in constant motion due to the changing social environment and changes in their own personal capacity for negotiating shifts in physical and cognitive states. Thus, life in this nursing home is a physical and emotional challenge as was life in the noninstitutional community. Given chronic illness, unemployment, loss of spouse, and other common facts of the American "old age" experience, membership in a nursing home does not necessarily involve life without sensation or challenge. The very nature of the American proprietary nursing home generates physical and emotional challenges to the patient population on a daily basis. This is not an argument against improvements in nursing homes but just the opposite. Recognition of the naturally-existing resource pool allows for enhancement of patient life with little economic cost to the management. Observation and discussion among the patients will provide the routes to pre-established patient resources which can then be monitored, preserved, and enhanced.

PAGE 105

CHAPTER SEVEN CHRONIC LIFE AND AGE SEGREGATION Palliative-care settings, whether in hospitals or nursing homes, typically house people with chronic disease(s) and without expected recovery. The diseased state gradually usurps the psychosocial essence of humanness until the host's life, in the fullest interactive sociocultural sense, is overshadowed by disease and debility. Disease becomes established as the prominent mode of existence and life now becomes the factor of chronicity. Disease is not the target of treatment; physical existence is. Thus, a condition of chronic life exists in the presence of debilitating disease which is permanent and paramount, rendering the diseased state more prominent than wellness and life, not disease, as the target of therapy. Globally, modernization as a societal process occurs with numerous attendant changes especially in technology and health technology (Cowgill and Holmes 1972; Cowgill 1974:129). One result is increased longevity. For the very old, this is a dubious benefit (cf. Illich 1976:73). Many societies distinguish between functional old age and nonfunctional old age (Simmons 1945; Simmons 1960; Clark and Anderson 1967) Functional old age can be considered extended life while nonfunctional old age can be considered chronic life Improvements in health care technology resulting in increased longevity also increase the risk of inducing chronic life in the aged population. 94

PAGE 106

95 Clark and Anderson (1967:11) state, "The elderly have problems in our society because it takes them so long to die these days." The affliction of chronic life, then, is iatrogenic in origin. The cultural apparatus for dealing with chronic life takes various forms. Acute-care hospitals sometimes designate a section of the patient floors as palliativecare wards. The hospice is typically an institution for the terminally ill that is separate from the hospital. However, nursing homes loom most prominent as the standard American agency dealing with the biosocial penalties of longevity and incapacitating incurable disease. The ethnomedical perspective was used in the study of Pecan Grove Manor nursing home. Special emphasis was directed toward patients and paid care agents as significant role categories within the nursing home community. The ethnomedical view identified patients, nurses' aides, and housekeepers as the interactional network most meaningfully associated with long-term care quality. Within any community of people, differing points of view exist analytically as multiple realities (Gubrium 1974). This research has disclosed realities specific to various categories of people within the nursing home community. These realities characterize a category-specific ethos The patient ethos is marked by a pervasive sense of life at risk The patients risk becoming too well or

PAGE 107

96 too sick. Expulsion from the institution and life is the ultimate outcome. Patients adopt a fatalistic outlook regarding their membership in a nursing home population. Their control over their own destinies has been undermined by chronic disease, unemployment, and institutionalization. Therefore, they accept their lot not having capacities to retaliate. One form of adaptation is to selectively attend to the positive virtues of their current life and institutional home. Given the lack of better possibilities, patients report "their" nursing home as the best possible setting other than self-sufficient community life. Conflict-avoidance serves to maintain the belief in the high quality of their situation by minimizing disruptive events. This pressure is exacerbated by long-term institutional living. Additional pressure is leveled by the nursing and administrative staffs to convey an aura of serenity in order to reduce family complaints and inquiries. Although staff groups exert efforts to deny conflict, the patients likewise construct perspectives ultimately useful in psychological adaptation to the longterm institutional environment. Patients also engage in resource identification and exploitation within their community. The physical and psychosocial environments have been met as surmountable challenges rather than insurmountable obstacles. Thus, food procurement strategies, role invention, and

PAGE 108

97 non-medical use of care agents market the resourcefulness of the geriatric nursing home patient. Direct primary care from the "native" experience is the province of nurses' aides and housekeepers. Nurses' aides constitute 43% of all staff categories in nursing homes nationwide (Subcommittee on Long-Term Care 1975:361) and 41% at Pecan Grove Manor. From 1960-1976, the number of nurses' aides employed has increased by 550% (Moss and Halamandaris 1977:21). The rapid rise in the number of nurses' aides is a product of the relatively recent biomedical culture contacting the American cultural value system proscribing senilicide and thus generating "spinoffs" such as nursing homes and the emergent (cf. Landy 1974) therapeutic role of the nurses' aides. While biomedicine has charmed the medical and public sector alike, the increase in chronic incurable disease has created a therapy and therapist vacuum. This vacuum is currently being filled by middle-aged women with little or no training engaging in therapy modeled after mother/ child interactive patterns which are considered to be physically and emotionally nurturant. The response pattern of directing victims of chronic, incurable disease to folk medical practitioners rather than biomedical specialists was also found by Gould (1965) in rural North India. Over the past two decades, the role of licensed nursing personnel has shifted from patient-contact to

PAGE 109

98 paper-contact as efforts at increased education and professionalism have been pursued. The licensed nurse as mothersurrogate has declined (Schulman 1958; 1972) to be replaced by the nurses' aide, particularly in nursing homes. The maternal approach to patient care in nursing by nonlicensed personnel is not unique to the American long-term health care culture. Caudill (1961), for example, describes the Japanese tsukisoi as an untrained female providing long-term basic care to psychiatric patients. The benefit of the tsukisoi is found in the use of the mother/child interactive pattern and long-term patient contact. As among the American nurses' aide, lack of formal training is compensated by surrogate kinship roles, a thorough familiarity of the patient (often consanguineal and affinal kin, Befu 1971), and use of folk therapies. Thus, the white uniform, hospital-like environment, and other symbols of biomedicine serve only as a thin veil over the "modern" geriatric folk therapist. In summary, the nursing staff ethos is characterized by adult nursery nursing Unlicensed and untrained nurses' aides play mother roles in the discharge of their duties with patients who are conceptually seen as children. Their work consists of bed-and-body-work to the near exclusion of psychosocial support of the patients. Pragmatically, mother/child interactional patterns extract useable behaviors from pre-existing role repertoires of the generally untrained nurses' aides.

PAGE 110

99 The nurses' aides through all of the reports of love for the patients essentially monitor patient decline. Their activities are viewed as necessary to make patients as comfortable as possible until they die. This view is consistent with a medical-model oriented toward cures as success and lack of cures as failures. In order not to fail, there will be no attempt at therapy, only palliative care. In Pecan Grove Manor care agents were found to include an unexpected category of providers : housekeepers The biomedical view of health care organization excludes housekeepers as therapeutic agents. The ethnomedical view, however, identifies the housekeeper as a naturally evolved, unplanned agent of psychosocial support for patients Characteristics of the housekeepers' tasks, values regarding employment, and personal demeanor provide a field for engaging interaction rather than brief, ritualistic interaction typical of nurses' aides. These characteristics include lengthy in-room task performance (by necessity and demonstration to supervisors of thoroughness of cleaning), wearing street clothing, previous work as nurses' aide, and middle age status. Thus, the housekeeper is seen by the patient as an expected, daily visitor who can converse at length, carry information throughout the nursing home, and report on local community matters on a routine basis. Also patients use the housekeeper as a

PAGE 111

100 broker in the transmittal of sensitive messages (e.g., complaints regarding the nursing staff) thereby distancing and insulating the patient from potential reprisals. Collectively, these findings provide an example of the utility of the ethnomedical orientation in examining "health care cultures," the unplanned existence of agents of psychosocial support in a nursing home in the form of housekeepers, and the persistent depth of capacity for human resource identification and use among institutionalized geriatric patients. Overall, elderly Americans live a life of paradox. Millions fall victim to the iatrogenically-induced disease of chronic life. The technological milieu of modernization has increased longevity in the absence of cultural milieu concommitantly generating respect for long-term survivors. The penchant for the compartmentalization of life is a breeding ground for reservation systems to contain certain segments of society. Agesegregated communities are contained segments of society (Jacobs 1974; Angrosino 1976). Within one such community, the nursing home, the chronically-ill elderly are housed. At one level of abstraction, the culture of which they have been participants negotiates their lives by paid ritual-custodians. Within the ceremonial chambers, the curators perform rituals fabricating signals of life which are designed to be in opposition to

PAGE 112

101 culturally relevant negative sanctions proscribing senilicide while actually inducing the fatal course of chronic life. The medical model is elevated to such a lofty spiritual plane (Siegler and Osmond 1976; Szasz 1977) that a cure for the chronically-aged sick is not only impossible, but unimaginable. Since health is culturally signaled by freedom from acute physiological pathogenicity and cure by medical-model intervention, those who are chronically ill and not physiologically responsive to such "appropriate" intervention are housed in palliative-care institutions to await death. Their minds are numbed by the anesthetic of psychosocial starvation while their bodies are carefully tended, reducing the odor of prolonged death. Thus, nursing homes are cultural products. They are part of the machinery of living and dying in industrialized societies. Most likely, nursing homes are commonly viewed as edifices to humanitarian ideals. Nonetheless, the ominous workings of ecological, cultural, and social forces exert pressures on human groups to deal with illness and death in culturally relevant and behaviorally expedient ways

PAGE 113

102 The future is likely to see a proliferation of nursing homes as we know them today. Given this projection, research efforts may best be directed at maximum extraction and enhancement of naturally evolved beneficial behaviors and roles within a nursing home community. The costbenefit ratio of the enhancement of pre-existing behavioral systems is seen as potentially attractive to proprietary nursing home owners for the improvement of the quality of institutional life.

PAGE 114

APPENDIX I SELECTED NURSING HOME INDICES 1977 Oklahoma United States Resident Patients 23,500 1,150,000 Licensed Beds 27,036 1,277,000 Number of beds per 1000 : population aged 65 and over 80.1 62.3 Occupancy Rate 87.2 88.2 Employees Per Patient .507 .657 Source: Oklahoma Health Systems Agency, page 44 103

PAGE 115

APPENDIX 2 PECAN GROVE MANOR TOTAL DISEASE ROSTER (From physican listings in patients' charts) Number of Times Entered in Patient Charts 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18, 19, Advanced Age 1 Alcoholism 1 Amputee 1 Anal Fixation 1 Anemia 1 Aneurysm 1 Angina Pectoris 7 Aortic Systolic Murmurs 1 Aphasia 2 Arteriosclerosis 7 Arteriosclerotic Brain Syndrome 1 Arthralgia 3 Arthritis 37 Arteriosclerotic Cerebral Insufficiency ASCI 16 Arteriosclerotic Coronary Insufficiency ASCI 29 Arteriosclerotic Cardio-Vascular Disease ASCVD 29 Arteriosclerotic Hypertensive Disease ASHD 10 Asthma 3 Atrial Fibulation 2 20, Back Pain 104

PAGE 116

105 P.G.M. TOTAL DISEASE ROSTER, cont Number of Times Entered in Patient Charts 21. Bedfast/Chairfast 22. Blindness 23. Blood Sugar Unstable 24. Brain Deterioration 25. Cancer 26. Cardiac Arrythmia 27. Cardiomegaly 28. Cataracts 29. Cerebral Ischemeia & Transient CI 30. Cerebral palsy 31. Cholecystectomy 32. Cholecystitis 33 Chronic Brain Syndrome 34. Chronic Obstructive Pulmonary Disease COPD 35. Cerebral Insufficiency (CI) 36. Coronary Insufficiency (CI) 37. Club Foot 38. Colitis 39. Colostomy 40. Congestive Heart Failure (CHF) 41. Convulsive Disorder 42. Coronary Artery Disease (CAD) 43. Coronary Heart Disease (CHD) 2 5 1 1 5 4 1 2 9 2 1 4 6 3 9 18 1 3 1 4 1 1 7

PAGE 117

106 P.G.M. TOTAL DISEASE ROSTER, cont 48. Deafness 49. Debility 50. Deformity 51. Dehydration 52. Depression 53. Dermatitis 54. Diabetes Mellitus 55. Diarrhea 56. Disorientation 57. Diverticulitis 58. Sysphagia 59. Emphysema 60. Epilepsy, Petit Mai 61. Fractures 62. Gastric Neurosa 63. Gastritis 64. Gas troenter it is 65. Hallucinations Number of Times Entered in Patient Charts 44. Cerebral Vascular Accident (CVA) 17 45. Cystitis 4 46. Degenerative Disc Disease 2 47. Degenerative Joint Disease (DJD) 1 4 7 3 2 1 1 13 2 1 10 1 3 1 15 1 3 1 1 66. Hypertensive Cardio-Vascular Disease HCVD 23

PAGE 118

107 P.G.M. TOTAL DISEASE ROSTER, cont 67. Hemiplegia 68. Hemmorrhoid 69. Hernia 70. Hypertension 71. Hypoglycemia 72. Hypokalemia 73. Hypothyroidism 74. Hysterectomy 75. Indigestion 76. Labyrinthitis 77. Lumbar 78. Malnutrition 79. Mastectomy 80. Meningitis 81. Mental Abberations 82. Mental confusion 83. Mental deterioration 84. Mental retardation 85 Migraine headaches 86. Multiple Sclerosis 87. Myocardial Infarction 88. Neurological deficit of obstructive hydrocephalus 89. Obesity 90. Organic brain syndrome Number of Times Entered in Patient Charts 1 1 9 12 1 5 2 1 1 1 1 1 3 1 1 24 5 5 1 1 2 1 7 4

PAGE 119

108 P.G.M. TOTAL DISEASE ROSTER, cont Number of Times Entered in Patient Charts 91. Osteoarthritis 13 92. Osteoparesis 2 93. Osteporosis 26 94. Osteosclerosis 1 95. Paralysis 8 96. Parkinsonism 6 97. Paroxysmal artial tachycardia (PAT) 1 98. Pedal edema 1 99. Peripheral Vascular Disease (PVD) 6 100. Phlebitis 1 101. Pleural effusion 2 102. Pneumonia 2 103. Polio 1 104. Prostatitis 1 105. Prostectomy 1 106. Prosthesis 1 107. Psychoneurosis 1 108. Pyelonephritis 3 109. Radiculitis 2 110. Renal disease i 111. Rheumatoid 1 112. Sciatica Neuritis 1 113. Seizures 1 114. Senility/Senile Psychosis 14

PAGE 120

109 P.G.M. TOTAL DISEASE ROSTER, cont Number of Times Entered in Patient Charts 115. Shoulder. Injury 1 116. Sinusitis 5 117. Speech difficulty 1 118. Stroke Syndrome 2 119. Syncope 2 120. Synonitis 2 121. Tachycardia 1 122. Teeth absent 1 123. Thrombophlebitis 1 124. Transient Ischemic Attack (TIA) 1 125. Ulcer 3 126. Urinary Tract Infection (UTI) 1 127. Visions 1

PAGE 121

APPENDIX 3 PECAN GROVE MANOR TEN MOST PREVALENT DISEASES Disease Number of cases Prevalence Rate 1. Arthritis 37 39.4% 2. Arteriosclerotic Cardiovascular Disease 29 30.8% 3. Arteriosclerotic Coronary Insufficiency 29 30.8% 4. Osteoporosis 26 27.67. 5. Mental Confusion 24 25.5% 6. Hypertensive Cardiovascular Disease 23 24.5% 7. Coronary Insufficiency 18 19.1% 8. Arteriosclerotic Cerebral Insufficiency 16 17.0% 9. Cardiovascular Accident 17 18 0% 10. Fractures 15 15 9% 110

PAGE 122

APPENDIX 4 DISEASE PREVALENCE PECAN GROVE MANOR Cardiovascular Disorders Neurologic Disorders Psychiatric Disorders Musculoskeletal and Connective Tissue Disorders Gastrointestinal Disorders Genitourinary Disorders Miscellaneous Nutritional and Metabolis Disorders Respiratory Disorders Ear, Nose and Throat Disorders Endocrine Disorders Opthalmic Disorders Hepatic and Biliary Disorders Gynecology and Obstetrics and Breast Diseases Infectious and Parasitic Diseases Hematologic Disorders Dermatologic Disorders Cancer Disorders PR .2340 .2127 .1914 .1489 .1063 .0744 .0744 .0638 .0531 0319 0319 0212 0212 0212 0106 0106 0106 0106 111

PAGE 123

o 6~~ o 6"O m 6^ O 6-~ s-o 112

PAGE 124

a •H IS r-l r-l < CD r-l cti S a) 60.6% 39.4% 66.7% 33.3% 33.3% 66.7% 92.4% 7 6% CD i— 1 ctf s 65.4% 34.6% 73.1% 26.9% 42 3% 57.7% 7 6.9% 23 1% All Wings 62 0% 38 0% 68.5% 31.5% 35.9% 64 1% 88.0% 12 0% CO u S3 M IS 4->, co CO£ CD 50 r-l H crj 100 0% 0% 100.0% 0% 73.3% 26.7% 96.7% 3 3% rCl +-) p o CO a) H t3 = CD CD e U Q) O 4-1 a 41.4% 58.6% 58.6% 41 4% 24.1% 75 9% 93.1% 6 9% rd U O St j> CD cd }-i CD aj 3j C_5 45 5% 54.5% 51.5% 48 5% 12 1% 87.9% 75.8% 24.2% i < 1 < [ 2j D -i < in Continent Incontinent Ambulatory Nonambulatory Meals in Dining Area Meals in Patient Area Feeds Self Requires Feeding 113

PAGE 125

REFERENCES CITED Angrosino, Michael V. 1976 Anthropology and the Aged: a Preliminary Community Study. Geronotologist 16:174-180. Arensberg, Conrad M. and Solon T. Kimball 1965 Culture and Community. New York: Harcourt Brace, and World. Babbie, Earl R. 19 n!iJ^ P p a ?^ Ce f Social ^search. Second edition. Belmont, California: Wadsworth. Befu, Harumi 1971 Japan: an Anthropological Introduction San Francisco: Chandler. Bachner, John P. 1974 Public Relations for Nursing Homes. Springfieldinomas Beals, Ralph and Harry Hoijer 19 llv n i Intr S du £^?? t0 ^thropology. Fourth edition. New York: MacMillian. Beckman, Ronald 1971 The Therapeutic Corridor. Hospitals 45:71-80. Bennett, Ruth and Carl Eisdorfer 1975 The Institutional Environment and Behavior Change In Long-term Care: a Handbook for Researchers, Planners and Providers. Sylvia Sherwood, ed. New YorkSpectrum. Bennett, Ruth and Lucille Nahemow 1965 Institutional Totality and Criteria of Social Adjustment m Residences for the Aged. Journal of Social Issues 21:44-78. Birren, James E. and Vivian Clayton 1975 History of Gerontology. In Aging: Scientific jZHT"^ ^ S r al ISSUeif7 §ia a S WoSdruff and James E. Birren, eds New York: Van Nostrand. BUC ^ gl J iam T II ^ 1 fl W -' S A Lack, B. M. Mount, L. 0. MacLean, ana J. i. Collins 1976 Living with the Dying: Use of the Technique of JoSrnal'Sr^ll-Ins 011, Cttadaa Medical Assoc iation 114

PAGE 126

115 Butler, Robert N. 1975 Why Survive?: Being Old in America. New York: Harper & Row. 1978a Unravelling the Secrets of Aging. Aging (JulyAugust) : Numbers 285-286. Pps. 5-8. 1978b Thoughts on Aging. American Journal of Psychiatry 135: Supplement: 14-16. Brody, Elaine M. 1977a Number of Elderly in Institutions to Rise Says Expert in Field. Aging (November-December), Numbers 277-278. Washington: DHEW Office of Human Development, Administration on Aging. 1977b Number of Elderly. Aging (November-December), Numbers 277-278. Washington: DHEW Office of Human Development, Administration on Aging. Page 15. 1977c Long-term Care of Older People. New York: Human Sciences Press. Caudill, William 1961 Around the clock patient care in Japanese psychiatric hospitals : the role of the tsuklsoi American Sociological Review 26:204-214. Clark, Grahame 1969 World Prehistory. Cambridge: Cambridge University Press Clark, Margaret 1973 Contributions of Cultural Anthropology to the Study of Aging. In Cultural Illness and Health. L. Nader and T. W. Maretzki, eds American Anthropological Association, Anthropological Studies, Number 9 Washington D C Clark, Margaret and Barbara G. Anderson 1967 Culture and Aging: An Anthropological Study of Older Americans. Springfield: Thomas. Cohen, E. S. 1974 An Overview of Long-Term Care Facilities. In A Social-Work Guide for Long-Term Care Facilities. Brody, E. M. and contributors. Washington: DHEW Publication Number (HSM) 73-9106, U. S. GPO. Cowgill, Donald 0. and Lowell Holmes, Editors. 1972 Aging and Modernization. New York: AppletonCentury-Crof ts Cowgill, Donald 0. 1974 Aging and Modernization: A Revision of the Theory. In Late Life. Jaber F. Gubrium, ed. Springfield: Thomas

PAGE 127

116 Crane, Julia G. and Michael V. Angrosino 1974 Field Projects in Anthropology. Morristown: General Learning Press. Cutler, Neal E. and Robert A. Harootyan 1975 Demography of the Aged. In Aging: Scientific and Social Perspectives. Diana S. Woodruff and James E. Birr en, eds New York: Van Nostrand. Dyson-Hudson, N. 1963 The Karimojong Age System. Ethnology 2: 353-401. Eliade, Mircea 1963 Patterns in Comparative Religion. New York: New American Library. Freilech, Morris 1970 Marginal Natives. New York: Harper & Row. Garvin, Richard M. and Robert E. Burger 1968 Where They Go to Die: The Tragedy of America's Aged. New York: Delacorte Press. Goffman, Erving 1960 Characteristics of Total Institutions. In Identity and Anxiety: Survival of a Person in Mass Society. Glencoe, Illinois: Free Press. Gold, Raymond L. 1969 Roles in Sociological Field Observations. In Issues in Participant Observation. George J. McCall and J. L. Simmons, eds. Reading, Massachusetts: Addis on-Wes ley Gould, Harold A. 1965 Modern Medicine and Folk Cognition in Rural India. Human Organization 24: 201-208. Gubrium, Jaber F. 1973 The Myth of the Golden Years. Springfield: Thomas. 1974 On Multiple Realities in a Nursing Home. In Late Life. Jaber F. Gubrium, ed. Springfield: Thomas. 1975 Living and Dying at Murray Manor. New York: Martin's Press. Hawley, Amos H. 1944 Ecology and Human Ecology. Social Forces 22: 400-405. Henry, Jules 1963 Culture Against Man. New York: Random House.

PAGE 128

117 Holmes, Lowell D. 1976 Trends in Anthropological Gerontology: From Simmons to the Seventies. International Journal of Aging and Human Development 7: 211-220. Illich, Ivan 1976 Medical Nemesis: The Expropriation of Health. New York: Bantam Books. Jacobs, Jerry 1974 Fun City: An Ethnographic Study of a Retirement Community. New York: Holt, Rhinehart, and Winston. Kahn, R. L. A. I. Goldfarb, M. Pollack, and I. E. Gerber 1960 The Relationship of Mental and Physical Status in Institutionalized Aged Persons. American Journal of Psychiatry 117: 120-124. Koncelik, J. A. 1976 Designing the Open Nursing Home. Stroudsburg, Pennsylvania: Dowden, Hutchinson, and Ross. Kramer, Charles J. and Jeanette R. Kramer 1976 Basic Principles of Long-Term Patient Care: Developing a Therapeutic Community. Springfield: Thomas Landy David 1974 Role Adaptation: Traditional Curers Under the Impact of Western Medicine. American Ethnologist 1: 103-128. LeVine, Robert A. 1970 Research Design in Anthropological Fieldwork. In A Handbook of Method in Cultural Anthropology. Raoul Naroll and Ronald Cohen, eds New York: Columbia. Lorber, Judith 1975 Good Patients and Problem Patients : Conformity and Deviance in a General Hospital. Journal of Health and Social Behavior 16: 213-225. Manard, Barbara, Ralph Woehle, and James Heilman 1977 Better Homes for the Old. Lexington, Massachusetts: Lexington Books. Mazess, Richard B. and Sylvia Forman 1979 Longevity and Age by Exaggeration in Vilcabamba, Ecuador. Journal of Gerontology 34: 94-98. McQuillan, Florence L. 1974 Fundamentals of Nursing Home Administration. Second edition. Philadelphia: Saunders.

PAGE 129

118 Mendelson, Mary 1974 Tender Loving Greed. New York: Knopf. Mellaart, James,, „ 1967 Catal Huyuk: A Neolithic Town in Anatolia. Mew York: McGraw-Hill. Miller, Dulcy B. 1969 The Extended Care Facility: A Guide to Organization and Operation. New York: McGraw-Hill. Miner, Horace 1956 Body Ritual among the Nacirema. American Anthropologist 58: 503-507. Moss, Frank E. and Val J. Halamandaris 1977 Too Old, Too Sick, Too Bad. Germantown, Maryland Aspen Systems Corporation. Noelker, Linda and Zev Harel 1978 Predictors of Weil-Being and Survival among Institutionalized Aged. The Gerontologist 18: 562-567. Oklahoma Health Systems Agency 1978 A Plan for Health in Oklahoma. Oklahoma City: Oklahoma Health Systems Agency. Opler, Morris E. 1945 Themes as Dynamic Forces in Culture. American Journal of Sociology 51: 198-206. Palmore, Erdman 1975 The Honorable Elders: A Cross-Cultural Analysis of Aging in Japan. Durham: Duke University Press. Pelto, Pertti J. 1970 Anthropological Research: The Structure of enquiry. New York: Harper & Row. Rogers, Wesley W. 1971 General Administration in the Nursing Home. Boston: Cahners Books. Rosenhan, D. C. 1973 On Being Sane in Insane Places. Science 179: 250-258. Ross r Jennie-Keith 197^4 Life Goes On: Social Organization in a French Retirement Residence. In Late Life. Jaber F. 3ubrium, ed. Springfield: Thomas.

PAGE 130

119 Roth, Juluis Bobbs-Merrill. careers. Indianapolis: Schulman, Sam 19 ga t e B a a ^ iC H^ e C r ti0n ? n g^ntS ^i^i ** S — WT^^S G tl ^-"^ S N^rT 'p^ Press ILJf Surrogate-After a Decade. In Patients Physicians, and Illnp<*

PAGE 131

120 Sommer, Robert 1969 Personal Space. Englewood-Cliff s New Jersey: Prentice-Hall 1970 Small Group Ecology in Institutions for the Elderly. In Spatial Behavior of Older People. Leon A. Pastalan and Daniel H. Carson, eds Ann Arbor, Michigan: University of Michigan. Spindler, George and Louise Spindler 1974 Forward. In Fun City. Jerry Jacobs. New York: Holt, Rhinehart, Winston. Stern, Phillip Van Doren 1969 Prehistoric Europe: From Stone Age Man to the Early Greeks. New York: Norton. Steward, Julian 1950 Area Research: Theory and Practice. Social Science Research Council Bulletin, 63. 1955 Theory of Culture Change. Urbana : University of Illinois Subcommittee on Long-Term Care of the Special Committee on Aging, U. S. Senate 1975 Nurses in Nursing Homes: The Heavy Burden (The Reliance on Untrained and Unlicensed Personnel) Nursing Home Care in the U.S.; Failures in Public Policy, supporting paper No. 4 Report No. 94-00, 94th Congress, First Session. Szasz, Thomas 1977 The Theology of Medicine. New York: Harper Colophon Books. Taylor, Carol 1970 In Horizontal Orbit: Hospitals and the Cult of Efficiency. New York: Holt, Rhinehart, and Winston. 1977 Death, American Style. Death Education 1: 177185. Timasheff, Nicholas S. 1967 Sociological Theory. New York: Random House. Tobin, Sheldon S. and Morton A. Lieberman 1976 Last Home for the Aged. San Francisco: JosseyBass Townsend, Claire 1971 Old Age: The Last Segregation. New York: Grossman.

PAGE 132

121 von Mering, Otto and 0. William Earley 1966 The Diagnosis of Problem Patients. Human Organization 25: 20-23. Woodruff, Diana S. 1975 A Physiological Perspective of the Psychology of Aging. In Aging: Scientific Perspectives and Social Issues. Diana S. Woodruff and James E. Birren, eds New York: Van Nostrand. Woodruff, Diana S. and James E. Birren, eds. 1975 Aging: Scientific Perspectives and Social Issues New York: Van Nostrand.

PAGE 133

122 BIOGRAPHICAL SKETCH Joseph Neil Henderson was born February 11, 1951 in Sulphur, Oklahoma. In 1959 He moved with his family to Orlando, Florida. Educational experience includes graduation from William R. Boone High School in Orlando, Florida in 1969; a B.A. in sociology from the University of Central Florida in Orlando in 1973; a M.S. in anthropology from Florida State University in Tallahassee in 1975; and doctoral work in anthropology at the University of Florida beginning in 1975. Mr. Henderson is married to Janet Elizabeth Moran Henderson of Orlando, Florida. They now reside in Ada, Oklahoma where Mr. Henderson is an Assistant Professor of Anthropology in the Sociology Department at East Central Oklahoma State University.

PAGE 134

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy' Otto von Mering, Professor of A: ology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy' & Anthony %redes //''Professor ffi Anthropology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Leslie S. LieBerman Assistant Professor of Anthropology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy.

PAGE 135

. I certify that I have read this study and that In my opinion It conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a dissertation for the degree of Doctor of Philosophy. Walter Cunningham^' Associate Professor of Psychology This dissertation was submitted to the Graduate Faculty of the Department of English in the College of Liberal Arts and Sciences and to the Graduate Council, and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. December, 197 9 Dean, Graduate School


15
celebrate the Fourth of July, and working as a paid
employee (nurses' aide). Thus, I was able to observe and
experience much of nursing home life during my thirteen-
month stay. Although it is obvious, I never personally
experienced being an old, sick, nursing home patient.
Because I could not experience age beyond my years or
experience the length of a hallway for an arthritic patient,
other data collection techniques were used. Notable is a
scheduled interview given to staff, families, and selected
patients. The interview schedule contained questions
specific to the respondent's role classification, but each
also contained a common core of questions for intergroup
comparison. Personal open-ended interviews were collected,
patient diaries collected, with still-photography and
sound cinematography completing the data-collection
strategies. The intent here was to maximize the quality of
data collected by using a multi-instrument research design
revolving about personal participation and observation.
In the larger view, the analytical framework used is
based on the model for community study (Arensberg and
Kimball 1965; Steward 1950). Conceptually, I approach
Pecan Grove Manor as I would any other society regardless
of geography. Pecan Grove Manor is thus viewed as a small
community with its peculiar beliefs, behaviors, boundaries,
rituals for incorporation and expulsion, etc., existing not
as a remote, untouched bit of flotsam, but as a part of a
network of other social groups of variable influence.


86
Although leaving the nursing home to re-enter the
community is rare (one mild stroke patient and one burn
patient in the thirteen months of fieldwork), all patients
receiving public funds must have a monthly physical exami
nation by a physician. Most patients consider the physical
to be a necessary nuisance to keep receiving their funds.
The patients report the physical to be superficial and a
means for the physician to make money. Still, residence
at public expense requires disability. The physical rep
resents, a monthly potential for discharge.
Of more daily importance is the avoidance of open
intragroup and intergroup conflict among patients and
staff. The mechanisms which are conflict-obtrusive are
partly related to features of long-term care and partly
related to characteristics of institutional living.
Membership in the institution is forced. There are
no other viable options. The process of adjustment and
incorporation into the institution develops a sense of
personal investment in this community. Patients away on
visits with relatives or during hospital stays speak of
their desire to "get back home" to "sleep in my own bed."
Thus, there is a desire to preserve their position in
the nursing home.
Institutional characteristics that generate conflict-
avoidance center about reduced private space. Open con
flict in communities with a very limited territorial
range is likely to be expressed beyond necessity. Those in


35
The three-winged configuration of Pecan Grove Manor has
been used to assign patients to a particular wing not based
on specific disease entities but rather on a subjective
assessment of individual debility. Assignment protocol has
led to describing the wings by level of care needed and
has resulted in clustering of physical capacities (See
Appendix 6). Likewise, the artifacts in patient rooms
reflect the level of debility of those living there.
The North Wing, or "heavy care" wing, houses those
patients with the greatest physical and mental difficulty.
An artifactual inventory of these rooms discloses a general
paucity of personal belongings, residential furniture,
photographs, wall decorations and personal televisions.
It is here that the greatest number of restraining "half
doors" are found (See Figure 4). These patient rooms most
closely fit expectations of an institutional environment
(See Figure 5).
The South Wing, o:r "intermediate care" wing, is charac
terized by a mid-range level of debility relative to other
patients at Pecan Grove Manor. The patient rooms are
relatively well-adorned with personal memorabilia but resi
dential furniture and personal linens and appliances are
scarce. Televisions are in greater evidence but not uni
versal.
The East Wing, or "light care" wing (also "ambulatory
wing"), reflects the relatively high level of functioning
retained by these patients. In this wing, the greatest


16
While Arensberg and Kimball (1965) emphasize that a
community is a microcosm of the cultural system of which it
is a part, Steward (1950) states that a single community
cannot be absolutely representative of its cultural system
(Crane and Angrosino 1974). Much the same consideration
must be made here. Pecan Grove Manor, as a community of
institutionalized elderly, cannot be absolutely representa
tive of all other nursing homes. However, there exist
certain parameters that cause the methods used here and the
subsequent findings to be useful in the investigation of
other age-segregated, institutionalized settings. For
example, Pecan Grove Manor is included in the following
attributes of contemporary American nursing homes: the
typical nursing home is a privately-owned business, the
physical plant is most often a system of rail-lined
corridors covering large distances, the patients are
generally very old (80s) and there is a three-to-one female-
to-male ratio, most patients are widowed, most employees
are untrained nurses' aides, patients have few visitors and
seldom leave the nursing home grounds, and of those who are
admitted to a nursing home and do not electively move to
another long-term care facility, most die there or die
shortly after transfer to a hospital. In these important
factors, Pecan Grove Manor is strikingly similar to the
profile of other American nursing homes (Moss and Halaman-
daris 1977) .


11
(Gubrium 1975). None have used anthropological perspec
tives. Of the research activities reported by any social
science discipline among the institutionalized aged, it is
my distinct impression that the overwhelming majority are
based on data gathered in nonprofit nursing homes affiliated
with some organized religious group. This is particularly
noteworthy in view of the fact that 79% of the institution
alized aged live in proprietary nursing homes (Butler 1975:
261). The few reports of research in proprietary nursing
homes are generally not recent and are superficial treat
ments of a very complex social setting (e.g., Scott 1955;
Solon 1957; Bennett and Nahemow 1965).
Anthropological investigation in a proprietary nursing
home is particularly appropriate. Not only does such an
effort fill a gap in studies on aging, but the anthro
pologist brings powerful perspectives and methodologies as
analytical tools that are seldom found in other human
sciences. The concept of holism coupled with participant-
observation data collection provides comprehensive, in-depth
reification of conceptual themes (Opler 1945) and experi
ences of cultural systems.
Furthermore, the methodology of participant-observation
has proven utility in a variety of institutional health-care
settings. Carol Taylor (1970; 1977) provides insight into
the experience of nurse/patient interactions by underscoring
the array of nonmedical manipulative behaviors exchanged
among health care personnel and patients and their


3
Butler (1978b:15) projects that the maximum limits of
human longevity range between 100 and 120 years.
Given the rapid acceleration of human longevity and
its recency, "old" is new in America and the world. It is
as if a new sub-species of Homo sapiens has evolved as a
product of machine-age industry and antibiotic medicine.
While the subspecies designation is facitious, it can be
recognized that elderly people are in some ways physio
logically and intellectually distinctive. These distinctive
features (e.g., change of bone density, change of arterial
elasticity, digestive changes, cognitive and sensory
capacity change) relate to special needs of the elderly and
finally to demands placed on society pursuant to meeting
those needs.
The importance of addressing the needs of the elderly
in America becomes clear when demographic trends are
examined. The total population aged 65 and over in 1900
was 3.1 million but in 1970 was 20.2 million. The propor
tion of people 65 and older has increased almost 2.5 times
from 1900 to 1970: 4.1%, to 9.9%. However, the percent of
the total population 65 and older will be 11% in 1990,
decline slightly until 2020 when it will rise to 13.1%.
Projections for the next five decades show that the abso
lute number of people 65 and older will increase from about
20 to about 40 million (Cutler and Harootyan 1975:33-35).
The rapid increase in the number of aged Americans has
produced a series of attempted societal adjustments aimed at


89
the administration. Returning the chairs to the club
would be more work for an already busy staff. Another
instance involved a female patient who called me to a
quiet corner and asked me to move some lawn chairs back
to their previous location so that they could be used as
before. I was then told not to tell anyone that she had
made the request.
The caution exercised by the patients regarding what
seemed to me to be reasonable and minor items is produced
by the knowledge that one will quite literally have to
live with the not-totally-predictable consequences of one's
actions. The public nature of life in an institution
coupled with long-term membership makes the otherwise
inconsequential momentous.
The administrative staff also participates in conflict
obtrusion. The nurses' aides are told never to gossip or
argue in the presence of patients. The patients are not
to be bothered by personal staff problems. The administra
tive staff believe that families and patients expect an
idllyic paradise and the nursing home will produce what
the customer wants.
It was my experience, however, that the patients
thirsted for information of any type. To overhear a
nurses' aide's actual personal problems was at the least
better than the fiction of television soap operas. Often
patients interjected comments expected to be helpful in
solving some dilemma. The patients felt more alive through


63
those in reach. While Mr. Green is
mentally alert, conversational, and
likes to talk about his former fishing
days, conversation is directed toward
Mr. Green's roommate who cannot speak
at all. The roommate is 54 years old,
mentally retarded, behaves in a child
like manner including delight with toys
and stuffed animals.
A number of stresses between patients and nurses' aides
are expressed in the above interaction. Observing the pro
cedures for cleaning incontinence or reading about it does
little to reify the actual, hourly, daily experience.
At Pecan Grove Manor, the nurses' aide "must," from
official administrative and nursing dictum, "love" all of
the "little old people," do their jobs with great efficiency
and above all, never, ever mistreat a patient. From a
managerial perspective, expecting these superhuman qualities
will not insure perfection of job performance, but will en
hance the likelihood of good patient care. Acting out these
exhortations with patients like Mr. Green is difficult.
In spite of admonishments and reports of "loving all
these little old people," occasionally more honest state
ments emerged: "We love all of these little old people, but
we love some more than others." Thus, the good patient/bad
patient distinction commonly observed in other health care
settings is found here, too (cf. Lorber, 1975; von Mering
and Earley, 1966).
Mr. Green is considered a "bad" patient. Incontinence
or other debility alone is not enough to warrant bad-patient
status. These traits, however, can produce bad-patient


122
BIOGRAPHICAL SKETCH
Joseph Neil Henderson was bom February 11, 1951 in
Sulphur, Oklahoma. In 1959 He moved with his family to
Orlando, Florida. Educational experience includes gradua
tion from William R. Boone High School in Orlando, Florida
in 1969; a B.A. in sociology from the University of Central
Florida in Orlando in 1973; a M.S. in anthropology from
Florida State University in Tallahassee in 1975; and
doctoral work in anthropology at the University of Florida
beginning in 1975.
Mr. Henderson is married to Janet Elizabeth Moran
Henderson of Orlando, Florida. They now reside in Ada,
Oklahoma where Mr. Henderson is an Assistant Professor of
Anthropology in the Sociology Department at East Central
Oklahoma State University.


65
tion but identified me as a resource (perhaps "easy mark"
should be read) for him. Mr. Green would shout from his
bed for me by name to give him a cigarette. A patient
smoking in bed requires the aide to stay in the room and
thus interferes with the work schedule. At times I would
comply and at other times I was unable to do so due to work
demands.
Actions other than physical care directed at patient
involve efforts at promoting psychosocial support for the
patient population. The psychosocial environment is expec
ted to be fueled by that part of the nursing home life known
as "activities." Activities at Pecan Grove Manor are fre
quent and of variable quality (See Figure 9). Three fea
tures of the ritual calendar deserve mention: (1) nurses'
aides' interference, (2) lack of response measurement, and
(3) advertising.
The nurses' aides represent interference to effective
activity programs, primarily with regard to the weekly
secular in-house activities. For example, the "band"
activity consists of the activities director assembling
several patients in the east wing lobby to play various
percussive instruments. She complained often that by the
time she walked a few patients to the east lobby and went
down the corridors to get others and walk them back to the
lobby, the early arrivals had become bored and wandered off
to different parts of the building. Efforts to enlist the
assistance of nurses' aides were futile due to the aides'


52
however, shift-report serves an important purpose. It
marks a transition from mundane conversations and concerns
current moments before, toward inspiring awe and respect
for the medical and humanitarian tasks ahead. As one aide
put it while making a bed, "I've always wanted to be in the
world of medicine."
The duties of the nurses' aides are seen in the most
complete form on the day shift on the heavy-care wing. A
typical routine for four nurses' aides is presented in
Figure 7. This daily shift routine collapses into seven
main task categories plus miscellaneous ones (See Figure 8).
The tasks requiring the most time per shift are feed
ing, bed check, and showers. Feeding is time-consuming in
that on the heavy-care wing, 887 of the patients eat in
their rooms and of these, 247. require feeding by an aide.
At lunchtime, for example, there are four nurses'
aides who pour milk and tea for each patient, place them
on the trays, and take the trays to the patients. After all
trays have been distributed, the four aides feed the eight
patients who cannot otherwise eat. For the nurses' aides
there are "feeders" (i.e., a patient requiring feeding)
who are more desirable than others. Desirable features
include a room furniture arrangement allowing (read: requir
ing) the aide to sit while feeding, a patient who does not
choke, drool or otherwise "cause problems," and a patient
who eats rapidly. Thus, following tray distribution, a
silent race ensues among the aides to acquire the most de
sirable feeders.


46
participants must be identified, their roles defined and
assigned, and then this system put into action.
The members of this community can be classed into two
general categories: managerial and target populations.
The managerial group consists of the hierarchy of all paid
staff groups and the target group consists of patients and
their families. Implicit in this scheme is an interactional
orientation characterized by managerial groups acting on
target groups. The components of primary importance here
are the nurses' aides as a managerial subgroup and the
patients as a target subgroup, due to the enormous amount
of time these two groups of people spend together engaged in
fabricating rituals of life.
The incorporation of nurses1 aides into the ethics of
the nursing home staff involves formal and informal sociali
zation. Formally, the new aide is taught how to ideally
behave in a meeting with the R.N. during which the patient
is identified as most important and the administrator (i.e.,
boss) as least important. Even a document indicating the
assimilation of this scheme is signed by the new nurses
aide and filed in her employment folder.
The informal socialization of the new nurses' aide
filters down from the administrator and is based on the
perceived expectations of patients, their families, and
government inspectors. A common phrase which circulates
among the administration at Pecan Grove Manor characterizes
the perception of the typical nurses' aide: "fat, white,


28
Observations in other nursing homes disclose a similar
lack of use:
In the current state of the art of
building of nursing homes, lounges
must be regarded as the single great
est failure as a concept. Typical
lounges are the result of regulations
which specify that so many square feet
must be devoted to lounge space on the
basis of number of beds. This device
usually results in one or more very
large areas devoted to socialization,
relaxation, and contemplation, but not
really accomodating any of these
activities. (Koncelik 1976)
In one corner of the main lobby is the color television
set. The television area is marked by sectional vinyl-
covered couches facing the television and situated about
4 to 10 feet from the screen. While it is common to see
patients sitting on these couches, seldom is anyone actually
engaged in watching some program. Often patients fall
asleep sitting up or seem to welcome any distraction
(such as conversation with the researcher, an aide, a
phone call, etc.). In one instance, the volume control on
the color television broke, leaving video without audio.
The office personnel placed a small black-and-white portable
television next to the color set to use for the audio por
tion of programs. After a few minutes a patient changed
channels on the soundless color set. The picture on the
color television never matched the sound on the black-and-
white set for the remainder of the day. Still, patients
came to the television area, sat or slept, and then left,
never noticing the video/audio mismatch.


Abstract of Dissertation Presented to
the Graduate Council of the University of Florida
in Partial Fulfillment of the Requirements for
the Degree of Doctor of Philosophy
CHRONIC LIFE:
AN ANTHROPOLOGICAL VIEW OF AN
AMERICAN NURSING HOME
By
Joseph Neil Henderson
December 1979
Chairman: Otto Von Mering
Major Department: Anthropology
This research project examines the experience of
chronically ill geriatric patients and the care-giving
response patterns of unlicensed nursing personnel in a
ninety-bed proprietary nursing home in southern Oklahoma.
The study of the residents and staff of Pecan Grove
Manor (pseudonym) is based on an anthropological community
study approach, with theoretical orientations derived from
functionalist and social systems models. It extended over
a period of thirteen months of participant-observation.
Pertinent data were also collected by personal interview,
scheduled interview, patient diaries, still photography
and cinematography.
Overall, Pecan Grove Manor is revealed as a standard
American example of a specialized age-segregated community
IX


APPENDIX I
SELECTED NURSING HOME INDICES 1977
Oklahoma
United States
Resident Patients
23,500
1,150,000
Licensed Beds
27,036
1,277,000
Number of beds per
1000: population
aged 65 and over
80.1
62.3
Occupancy Rate
87.2
88.2
Employees Per Patient
.507
.657
Source: Oklahoma Health Systems Agency, page 44
103


CHAPTER THREE
DEMOGRAPHICS AND EPIDEMIOLOGY
The patients of Pecan Grove Manor are institutionalized
because of some physical or mental debility. The degree
of debility among the patients is variable but must be
serious enough to warrant fulltime care as judged by
physician assessment. As a nursing home, Pecan Grove Manor
is essentially a living environment designed to support a
population of aged, debilitated people suffering the
extended effects and acute exacerbations of chronic dis
eases. The purpose of this chapter is to develop a demo
graphic and epidemiologic profile of Pecan Grove Manor's
health and disease environment. These data will be seen
to significantly influence the sociocultural environment
of this geriatric community. Thus, chronic disease and
sociocultural systems mutually influence each other.
Eventually all states in America must address the needs
of the expanding aged population. Those states which
currently have large aged populations may serve as proto
types while other states observe and analyze their strate
gies for adaptation. Oklahoma is one such "pioneer state"
with regard to aged populations. Demographically, Oklahoma
ranks seventh nationally with 12.37, of the total population
65 years of age and older (See Figure 1).
In reflection of Oklahoma's sizeable aged population,
97 of the $458 per capita health care expenditures in 1976
went to pay for nursing home services (Oklahoma Health
17