The social world of assisted living
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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2014, Journal of Aging StudiesRelational autonomy in assisted living: A focus on diverse care settings for older adults
2012, Journal of Aging StudiesCitation Excerpt :At the national level, AL facilities are embedded in U.S. culture, which emphasizes personal autonomy, independence, and self-determination, cultural values often at odds with residents' reality (Carder, 2002; Carder & Hernandez, 2004; Eckert et al., 2009). The AL industry's emphasis on consumer choice and control is another example of this “paradoxical conjunction” (Agich, 2003:1), where residents as “consumers” typically move to AL based on need or a crisis and often have little choice or control in the decision to move, the selection of a facility, and daily routines, which are subject to regulatory constraints and rules designed to manage and negotiate risks associated with functional impairment (Ball et al., 2009, 2005; Carder, 2002; Carder & Hernandez, 2004; Eckert et al., 2009). Although many aspects of AL culture such as these are similar across states, AL culture varies somewhat at the state level based on differences in how facilities are financed, labeled, and regulated.
The vernacular landscape of assisted living
2011, Journal of Aging StudiesCitation Excerpt :Assisted living (AL) developed over 25 years ago as a way to address some of the more dehumanizing aspects of nursing home care1 (Kane et al., 2003). The concept emphasizes a home-like environment that fosters respect for an individual's sense of autonomy, privacy, and freedom of choice (Carder, 2002). In contrast to the typical nursing home, most ALs offer private rooms with a bathroom, a kitchenette with microwave, and locks on the doors, all in a hotel-like setting.
Opting out while fitting in: How residents make sense of assisted living and cope with community life
2011, Journal of Aging StudiesCitation Excerpt :Since elderly adults are living longer and with more chronic health conditions, residents in assisted living are increasingly older and more impaired (Ball et al., 2004). They usually have one or more conditions requiring physical assistance with daily activities or have mild confusion, memory loss, or impaired judgment (Carder, 2002). The move itself is usually triggered by an unexpected life event (e.g., acute illness, death of a spouse, and lengthy hospitalization) and is commonly facilitated by relatives (most often an adult daughter or niece) and social workers with limited or no input from the individual (Levin & Kane, 2006).
Communication in assisted living
2009, Journal of Aging StudiesCitation Excerpt :In contrast, ALFs are based on a philosophy of maintaining autonomy and agency in achieving a social, less institutional model of care. This may account for the increasing popularity of ALFs as an alternative to nursing home care although the success of ALFs in achieving these goals remains undetermined (Carder, 2002; Golant, 1999; Morgan et al., 2006). The environment of the nursing home, compared to Assisted Living, is also poorer.