The social world of assisted living

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Abstract

This study defines assisted living as a unique social world and is based on a 22-month ethnography in three facilities and completion of the program required of certified assisted living facility (ALF) managers in Oregon. The focus was on how daily operations are affected by central values (i.e., independence, choice, privacy) defined by Oregon Administrative Rules (OAR). In their efforts to legitimize this newly constructed social world, proponents and providers have developed a package consisting of a unique vocabulary and two organizational practices, the Negotiated Service Agreement (NSA) and Managed Risk Agreement (MRA). This package is integral to the maintenance of this social world, providing the means for defining and defending assisted living. These organizational tools offer a contemporary perspective on the rights of chronically ill and disabled seniors to make choices about their health care, even choices that might be defined as risky by medical professionals.

Introduction

This article is based on an ethnographic study of Oregon's assisted living facility (ALF) program, a type of housing for persons, primarily elderly, with physical and cognitive impairments. It presents the world of assisted living as seen through the eyes of assisted living practitioners, direct care staff, and nurses. It is about the collective action of people involved in the daily practice of ALFs. Their actions and beliefs construct the social world of assisted living, including vocabulary terms, boundaries, legitimacy strategies, and practice standards.

Oregon Administrative Rules (OAR) define a set of six abstract principles that providers at ALFs are expected to implement—resident independence, individuality, dignity, privacy, choice, and a home-like setting. These principles, defined as elements of the social model approach to long-term care (Kane & Wilson, 1993; Mollica, Wilson, Ryther, & Lamarche, 1995), led me to question whether it is possible to govern such abstract concepts as independence, individuality, and choice in the daily practice of commercial long-term care facilities. Thus, this research began with a broad question: What difference do the assisted living values make in daily practice?

This article is both seminal and descriptive. It describes the creation and maintenance of the social world of assisted living. By examining the current legitimacy processes of this world, I explain the central features they seek to project to others outside this world. With this foundation, I suggest that researchers interested in assisted living can evaluate (1) whether the projected approach is likely to be a useful one, and (2) whether the reality of assisted living corresponds to the image it attempts to project.

Defining assisted living as a unique social world became the organizing framework for this study (Becker, 1982; Clarke, 1997, Fujimura, 1996, Pratt, 1982, Shibutani, 1955, Strauss, 1982). From a popular culture standpoint, to describe a group as a “different world” is to recognize that the behaviors and values of one group are unique, possibly different from others. To use the phrase a “different world” to describe a particular set of people—say airline pilots, political pundits, or soccer moms—allows one to summarize the unique characteristics of the group without going into specifics. From a theoretical perspective, it is not enough to recognize assisted living as a different world. Instead, a social world is defined as “a set of common or joint activities or concerns, bound together by a network of communication” (Strauss, 1982, p. 172). This communication network helps proponents and providers to both define and defend their world from similar others.

Section snippets

Background and key terms

The term “assisted living” is so straightforward it would seem to define itself. Yet, the very breadth of the term means that it can be applied to nearly any type of assistance with living. Thus, both policy makers and researchers, especially those who rely on a quantitative approach, are frustrated with the lack of a standard definition. However, it is this lack of a uniform definition that makes ethnographic research in this setting both compelling and appropriate. For the purposes of this

Method of inquiry

I approached ALFs as a cultural anthropologist might approach a rural community or urban neighborhood, intending to study the daily practices, language, and the laws governing those who work in assisted living, especially managers and direct care staff members. This approach emphasizes “the direct observation of the activity of the members of a particular social group, and the description and evaluation of such activity” (LeCompte & Goetz, 1982, p. 32). Because of my focus on a specific public

The assisted living vocabulary

Assisted living proponents have established a unique vocabulary that differs from the terms they attribute to nursing facility employees. Defining how “we're different” also explains that our ways may be “even more legitimate than those of another, earlier, established, or more powerful” social world (Strauss, 1982, p. 175). Assisted living proponents emphasize that they are part of a revolution in long-term care, and revolutions require new terms.

Ball (1970) uses the phrase “rhetoric of

Assisted living practices

The second part of the social model-inspired package includes practice standards and techniques, both those required by state rules and others that have been developed by the organizations that provide new manager training. Social worlds require standards for action and ways of evaluating whether members have met these standards. Questions of authenticity may be raised. Is this member performing by the standards? Do the staff members at that facility embody the commitment to the social model of

Discussion

What are the benefits of a social world of assisted living to members of this world? What are the implications of depending on a social model ideology? These questions must be pursued in relation to providers, residents, and the broader long-term care arena. First, what are the benefits? In Oregon, providers act on the basis that the social model is the method that works best for disabled and chronically ill seniors, adopting a vocabulary and practices designed to meet the ideals attributed to

Acknowledgements

This research was funded by a grant from the Agency for Healthcare Research and Quality (No. R03HS09886) to the author. Preparation of this manuscript was supported by a fellowship through the AHRQ-sponsored National Research Service Award to Oregon Health Sciences University. I would like to thank David L. Morgan of Portland State University for his editorial and conceptual assistance on this and earlier drafts.

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