Contents:
Although a somewhat overused and imprecise term, this goal often is referred to as aging-in-place Ghantous, Policy makers at several levels have utilized aging-in-place initiatives. At the very least, 9 of 10 seniors prefer any living arrangement other than a nursing home AARP, Whether warranted or not, substantial trepidation and stigma exist regarding nursing home care, even to the extent that some call for the virtual abandonment of this care option Kane, With this backdrop, it is not surprising that AL has flourished.
Nevertheless, AL care comes with its own issues, which have not been well examined. Thus, these three books are a welcome addition to the AL literature. We have substantial knowledge about nursing homes because they are one of the most regulated health care facilities in the United States, but we have a relative paucity of information about AL. In the past, our ignorance of AL may have had few consequences.
AL cared for a few wealthy patrons, and it was assumed that they received care consistent with costs. Over the past 15 years, however, AL has substantially expanded its clientele, services, scale of care, and scope of care. When I visit AL settings today, they remind me more and more of nursing homes. AL facilities seem to have inherited many of the issues we have seen in nursing homes. Some vigilance may be wise on our part if we are to protect seniors in these settings. In fact, an opportunity may exist to learn from our past mistakes in nursing homes. The three books reviewed provide an exemplary framework for this much needed dialog on AL.
One of the most significant influences on nursing home care is the staff. Moreover, staffing levels, agency staff use, and staff turnover in nursing homes have shown themselves to be intransigent problems Castle, I can think of few authors who are as well qualified to undertake this task. Workforce issues touched upon include job satisfaction, absenteeism, turnover, staffing levels, vacancies, and training to name just six. It is clear that we have substantial challenges in each area. Moreover, the work environment for many of these staff is portrayed as immoral—I would even call it dangerous and hostile for many workers.
Stone leaves us in no doubt that these staff are the foundation of quality care in AL and that we must make a greater investment in this foundation if care is to improve. The first is lack of consistent regulation. The AL industry is not regulated by federal legislation but by the states.
In fieldnotes, an ethnographer described one of her interactions with him: Also, those under 19 cannot be permanent residents. A combination of federal, state and local laws provide other determining factors as well as provide funding. Through excerpts from fieldnotes and in-depth interviews, we will hear from residents, family members, and staff in both the AL and the IL buildings at The Riverside. Sign In Please sign in to access your account. Additionally, changes in health status that require higher levels of care may lead to moves within a multi-level facility. So there have been complaints because he is not [a member of the affinity group] he doesn't understand how he is supposed to behave…Many of them tie it back to being [a member]… they aren't going to include them because …you're not [a member] and you don't know what it's all about.
State regulations, standards, and oversight are highly variable, but for the most part, the industry does not have a high degree of oversight. Such lack of regulation can lead to use of facility-specific contracts and negotiated risk i. The second reason offered by Polivka for our lack of understanding of AL is that definitions of AL are so varied: AL is composed of as many as 20 different types of settings, which are called by varying names Carlson, ; Zimmerman et al. Much of the text expands upon many of the contextual questions about AL care raised by Robyn Stone in the opening chapter.
Assisted living is the fastest-growing alternative to skilled nursing care for frail older persons in the United States. The expectations, settings, and missions of. Editorial Reviews. From Publishers Weekly. The authors—researchers and academics with the Center for Aging Studies at the Erickson School and with the .
Many of these motivations are laudable and are based on the care ethic, but, as the authors note, market values such as pay and working conditions are not inconsequential and over time may become more important. As the chapter title suggests, AL workers are shown to perform a multitude of tasks, including heavy resident care responsibilities. Echoing many other opinions presented in this text, the authors note that the configuration and level of effort asked of AL workers can and will have a large influence on the AL industry.
I found the implications of cultural conflict in AL to be especially enlightening. This chapter provides a cogent overview of the nature, extent, and powerful influence of the relationships DCWs develop with residents. The substantial understanding and analysis of the AL industry and DCWs are effectively portrayed in the final chapters 10 and 11 of Frontline Workers in Assisted Living wherein important insights for researchers, practitioners, and policy makers are presented.
These are far ranging and too numerous to list some are touched upon above. The authors close with a note that many of the challenges rest on the shoulders of AL mangers. As a researcher with an interest in this area of the influence of top management, I would welcome and encourage investigation of AL managers as the next endeavor of these authors. A second recent book on the topic of assisted living is Inside Assisted Living: A powerful testament to the significant contribution of this text is first provided in the Foreword by Bill Thomas. He clearly understands the significant contribution of qualitative research and the importance of listening to elders.
Both the historical and regulatory contexts of AL development are elegantly described. Moreover, the text is presented as a view of AL from the inside i. The subsequent narratives certainly deliver. This story profoundly grounds us in the trials and tribulations that many family members and elders undergo in simply arriving at an AL facility. This chapter reveals something that we often forget: Placement is monumental in many ways for both elders and family. The number of broken bones, falls, surgeries, and visits to health providers are extensive.
This chapter serves as an apt reminder of the medical and social assistance that can be required in AL. The interesting twist in this account is that Opal was not well integrated or well liked at the facility. Just like the profound revelations in the prior chapter, in this account, we are reminded that AL is a group setting.
As such, many social rules as well as facility rules and regulations come into play. Not every elder can be expected harmonize with all of these rules. In some cases, this can be a euphemism for finance-driven care, such that free choice and autonomy are available if resources are available to purchase them. Key dimensions of these cultures include 1 restrictive to accommodating and 2 medicalized to less medicalized. That is, much of AL choice is predicated on avoiding nursing home care. Also, despite much of the rhetoric that AL provides consumer-driven care, it is clear that the primary consumers in many cases are family rather than residents.
This chapter lists critical in-depth political, economic, social, and cultural opportunities and challenges. While these two books focus on describing the inside world of assisted living, Nursing Homes and Assisted Living: The challenges presented include the adjustments, expectations, emotions, roles, and relationship challenges for family and elders.
The information presented in Nursing Homes and Assisted Living: Using what we have learned at The Riverside and Stonemont we examine the impact of the built environment on social grouping. Please don't put me on that other side. Those people are crazy. But she kept telling me, no, she wasn't going over; she absolutely would not go over there. The Riverside's website describes how the founders looked to nostalgic inns and picturesque homes for inspiration to express their senior housing vision.
They successfully created a large-scale residential community that incorporates visual cues to an era when the residents were younger. The cultural meaning of Victorian porches and themed gathering places may speak of home — or at least a posh hotel — but seem to confer a somewhat contrived effect to the setting. The tree-shaded walks and quaint common areas appear to mitigate the reality for residents wherein the social and physical manifestations of levels of care reflect their fears of increased dependence.
The campus consists of two buildings connected by a second floor link. Seldom will IL residents venture to visit former friends who have made the transition across the link to AL, and few AL residents visit former neighbors on the IL side. One ethnographer described the stigma she observed:. Residents then tell staff who should move to AL. In fact, to these IL residents, all of assisted living is somewhat suspect. The only practical use for the link for independent residents is to provide an inside passage to the hair salon in AL and then back home.
This facility purports a social model of assisted living care. Services are provided to help older adults adjust to age-related losses, both physical and cognitive. However, the most salient stigmatizing discourse that was documented at this site was directed by the residents of the IL toward the AL building and its residents. An excerpt from an interview with an IL resident demonstrated the stigma attached to the loss of cognitive ability and aimed at AL:.
Well, we have an older resident that's really now, is really getting more forgetful. She's been here a while, so they seem to think she'll be going on the other side, but I hope she doesn't because she likes it on this side. The staff at The Riverside was aware of the tendency towards stigmatization and has made attempts to mitigate it. There is no lock on the link between IL and AL, and the doors at both ends are kept open. We play for money. They play for a bag of popcorn or some such thing. We don't see that much of people from the other two communities.
The independent living residents do not want to go to assisted living as a general rule. One of the hardest things in our community really is to get people to transition from one area to the next. Again the phenomenon of othering and the desire to distance oneself from devalued housemates were documented by the ethnographers:. Harmon, in a stage whisper, commented that she does that a lot and felt that this woman should be placed in the area [the DCU] for people like that….
She felt this resident had no business living in AL with them. Stonemont, built by accretion over time, has a dated institutional appearance with various additions, some in matching granite, and some in mismatched yellow brick. Originally a private estate, Stonemont was purchased by an affinity group in the 's who renovated and added to the existing mansion to create a home for elderly, indigent members of the group and their widows. Eligibility is determined by membership in the regional affinity group or kinship to a member, with twenty eligible kinship relationships identified.
There are three wings, built or renovated at various times and connected by glassed-in breezeways and a maze of interior hallways. While there are no locked areas, certain units have security alarms that are activated when people exit without entering a pass code. There are several places where residents of different levels mix in common areas, informally or for shared planned activities.
During one of the renovations at Stonemont, independent apartments with full kitchens and private assisted living rooms were retrofitted into two wings that had existed as dormitory- style units with rows of beds. The large dining hall on the second floor serves as a link between the two wings and is shared by AL and IL, although IL residents tend to come for the evening meal only. On the AL side of the dining hall, is a sitting area where residents wait to enter the dining room prior to meals.
Adjacent to the dining room is a grand hall used for meetings and family gatherings. Another shared space is a large lounge on the first floor where regular, facility-wide Bingo games are held. All of these places serve as social ecotones where it is possible for residents from IL and AL to interact. The most recent addition to Stonemont is a three-floor wing that includes a terrace level AL and two upper floors for residents who need more extensive care than can be provided in the AL wing. The upper floors also provide temporary rooms for independent and assisted living residents recuperating from hospitalization.
This most recent wing appears more like a medical unit than the rest of the campus as an ethnographer describes:. On both floors one and two, I detected strong odors where residents were gathered at the nurses' station. These residents appeared to be among the most impaired, cognitively and physically, at [Stonement]. Few people seemed to be in their rooms, and nearly all of the doors were open. An excerpt from a fieldnote shows how another ethnographer explained the lack of clear boundaries between the care levels at Stonemont:. It makes sense since many of them…were residents there before they moved to the terrace.
In an interview with an IL resident, the fluidity of movement at Stonemont is discussed, as follows:. Is there much visiting back and forth do you notice…between the different levels? Like if your neighbor, if someone you know moves, do people go back and forth to visit. Yeah, because there's no problem to go downstairs.
Like a real good friend of ours in Assisted Living had to go down on the terrace, which is like the lowest level of Assisted Living, … and we've been down to visit her. Of course, she can't wait to get back to her own room. Well, if they have a real bad spell or a fall or something that sets them back then … they used to put them right in health care, but now they try to put them on the terrace, which is the in-between. While care levels are housed in different areas of the building, there is no locked DCU, though memory of what was once a locked DCU persists.
Several years ago, one of the floors of the most recent wing was a locked dementia floor and this floor continues to be negatively regarded. The floor appears to retain this negative cachet from the time it was a locked DCU, despite the fact that residents of varying cognitive abilities are mixed together on both the upper floors of the wing. There seems to be residual stigma ascribed to this floor because of its past as a locked DCU.
Stigma was attached to other areas in the medical care unit. Many residents preferred to sit near the central nurses' stations. Yet, we note that the built environment at Stonemont appears to lessen the power of stigma as it is attached to place. While the nature of stigma in this site built by accretion appears to be less focused on a particular place than in The Riverside, a purpose-built environment, socio-cultural factors may work to mitigate othering and must be considered in any discussion of stigma.
Stonemont is embedded within an affinity community where the culture of mutual support encourages relationships among the generations.
Clearly, for purposes of anonymity, we cannot disclose the specific affinity group here. Residents who share affiliation with the affinity group share values and experiences passed along within families. These values may also be shared with people who have been indirectly associated with the group through kinship with a member. Stonemont is adjacent to the headquarters of the affinity organization that, for nearly a century, has hosted events for affinity clubs from around the region. Local clubs associated with the group regularly visit the home. Families attend these traditional events and volunteer their time with Bingo and other activities, even though they may not be related to residents.
Many of the residents we met visited Stonemont throughout their lives. This association over the life course influences many of the people who choose to live in the home and may serve to mute any tendency to other co-residents. During interviews several residents mentioned that they came to the home as children or young adults to visit the elders living there. James jumped right in to tell me how she and her husband had selected [Stonemont]. Her father was a [member of the group] and her sister had moved in about three years before they did.
She knew the place well before she and her husband decided to move there. Residents who share a common culture and intergenerational contact with the home may have formed a bond that lessens or diffuses the stigma we have seen at more recently built sites that lack the longevity and cultural connectivity of Stonemont. But not all residents have a strong association with the affinity group. Because various kin of members are eligible, some residents are not themselves members of the affinity group and may be excluded and shunned.
One of the administrators explained the social dynamic:. While it appears that stigma exists at Stonemont, we suggest it is stronger in the form of attachment to an individual, rather than to a specific space. In one case, a resident was shunned for his lack of membership in the affinity group.
The director told us about Stanley, whose son was a high-ranking member, but who himself had never joined. Stanley was from a different part of the country and had a distinct regional accent. At Stonemont, Stanley became stigmatized by others. Several residents and staff commented on Stanley's differences from the other men. It appears that Stanley has internalized this stigma, as evidenced by his apparent low self-esteem.
He would not agree to a recorded interview. In fieldnotes, an ethnographer described one of her interactions with him:. Not only did Stanley not belong to the affinity group but he also did not follow its fixed gender roles and social norms. Instead of socializing primarily with men, Stanley flirted with women. The staff was aware of the situation. The Executive Director explained in her interview how his behavior is inappropriate:.
So there have been complaints because he is not [a member of the affinity group] he doesn't understand how he is supposed to behave…Many of them tie it back to being [a member]… they aren't going to include them because …you're not [a member] and you don't know what it's all about. They said they had nothing in common with him. Stanley's case shows how, in this affinity-based setting, individual differences can lead to stigmatizing behavior.
Although residents at Stonemont are grouped by care levels, the barriers to interaction between residents are not as evident as at The Riverside. Unlike the single link that connects the buildings at The Riverside, there are multiple intersections between care levels at Stonemont. These intersections reduce physical separations between residents of varying care levels.
We suggest that the presence of shared spaces, or social ecotones, may diffuse stigmatizing behavior. Whether driven by the way the spaces are designed or by social factors, for example corporate policy, Stonemont appears to be more socially integrated than The Riverside. The medical unit at Stonemont has its own activities calendar, but IL and AL, including AL in the terrace of the new wing, share a calendar.
The stigma observed at Stonemont seemed more directed at individuals rather than a particular place. There were social cliques and exclusionary behavior, as we have found in most of the settings we have studied, but these did not seem to have the focus on place that was observed in The Riverside Dobbs, et al. In Environment and Aging Theory , M. The external situation of increasing levels of care and dependence as manifested in the built environment is internalized in the anticipated loss of control that threatens the imagined future self. Fear and avoidance of that place and those people may become embedded in the culture of the setting.
There are many factors that can mitigate or aggravate stigma. Each setting we have studied has unique issues associated with collective living. Most residents expect to age-in place, that is, die in the setting. Many residents share cohort memories and values of past times. Why, then, is there a profound and disturbing distancing from housemates who exhibit signs of decline? When The Riverside was built, its founders envisioned a lovely setting where older adults could transition smoothly from one care level to the next.
But in its second decade, the fear and avoidance of the AL building by IL residents negatively influences perceptions of residents who live in Al, and this fear prohibits social interactions.
Friends who move from IL to AL are often forgotten: The belief that the move into The Riverside's independent apartment would be the last move, from the perspective of the resident, has been proven false. Stonemont may not be as efficient as The Riverside, with its warren of hallways and mixed levels of care, however the interaction that is promoted by the prevalence of social ecotones in shared spaces and shared activities appears to diffuse the stigma that is associated with age-related decline.
Further study is needed to understand how social ecotones in the built environment may promote relationships between groups that would not otherwise interact and in turn, mitigate stigma. In all the sites in which we have conducted fieldwork for the larger study, we have observed instances when stigmatizing behavior appeared to negatively impact the health of residents.