Taking care of the elderly at home was portrayed as a family crisis that was shaped by dependence, burden, obligation, exhaustion and conflict (Pruchno & Rose, 2000). Placement in a long-term facility was frequently seen as a last resort resulting from the supportive role of the family at home failing (Montgomery, 1983). The likelihood of placing the elderly in a facility was closely associated with a sense of frailty involving a loss in different domains of functioning, both physical and cognitive, a high risk of chronic conditions, a high level of impairment and a lack of family care resources (Lee, 1997, 1999; Reschovsky, 1998; Schuurmans, Steverink, Lindenberg, Frieswijk & Slaets, 2004). With their failing abilities, the elderly are depicted to be unable to manage their own decline and to sustain their sense of wellbeing following the onset of dependency.
Lee Ming, a resident who had had a stroke which had resulted in left paraplegia, was very respectful of Parkview‟s rules and appreciated that the staff were usually able to help him meet his needs. Nevertheless, he felt there was a constant tension that came from living with groups of people in a public place.
My two gripes about living in Parkview were “the shared rooms”, which is supposed to be a ward environment rather than a “home”. Each resident should have his or her own private area and the staff working here … not because they are not experienced, but most of the time it is the nursing aide‟s way and my way as to accept how my care should be done. (Lee Ming, Sum‟s
husband)
The work of the staff working in the facility is considered unique. Most staff focus their efforts on maintenance of functional status, management of chronic illness and assistance with activities of daily living such as bathing, toileting and feeding. Facility staff are characterised as providing technical and specialised tasks, implementing regulations and hierarchical authority (Diamond, 1992; Wellin & Jaffe, 2004). Staff, including nurses, nursing aides, social workers, physiotherapists, occupational therapists and cleaners, are attempting to manage a large workload with limited time and inadequate manpower. They are expected by their employers to deliver on this “system of care” which demands efficient, uniform and documentable care within a specific time frame.
Showers are scheduled by day and shift. For example, my shower is scheduled as an afternoon shower and if I want a day shower, I have to have a reason for requesting the change and have to apply one day before. My schedule may be changed if they can accommodate you. Each nursing aide has a set number of showers to give per shift. If residents want to change the time of their shower to a different shift they usually have to wait until all scheduled residents have finished or a scheduled resident has refused a shower. (Lee Ming)
I was told I take too long in the shower, that everyone has to finish it within twenty minutes as someone who needs help in the shower is waiting. (King)
As staff are experts in the care of the elderly, input from family members is usually considered secondary to that of the professional staff in Parkview. This example was noted down in my field notes:
Lee Ming had a stroke. He is not able to control food and saliva in his mouth and has difficulty swallowing solid food. Sum, his wife, was not allowed to assist in feeding for fear of having food or liquids going the wrong way and into his lungs. Neither can Lee Ming try to feed on his own as he usually takes hours to finish his meal and creates a mess on both his face and clothing. (field note)
Parkview‟s staff are engaged in a number of tasks and have to manage completing the mandated tasks within time limitations.
My husband takes more time than other residents to get ready in the morning because he is dependent on the staff to use the mechanical lift because of his limited mobility. Staff feel it is easier to complete the care of residents who can be done quickly, so that they don‟t feel rushed in providing care to my husband who takes longer. Therefore, my husband usually has to wait longer for their care in the morning. But he will also stay up later in the evening as the staff said it would decrease the chance of sores on his back. Both my husband and I have little to say about this decision for wake-up and going to bed time. (Sum,
Lee Ming‟s wife)
When I go to bed, I am turned every four hours. I am put back in my bed at seven o‟clock in the evening. They skip the turning at 8 p.m., and then I have my
midnight and 4 a.m. turns and then usually have to wait until all the other residents are seated in the dining room for breakfast. I am wheeled to the dining room and join them. Can you image being confined to that schedule for the rest of your life? (Lee Ming)
Goffman (1961) presented a view that “being institutionalized for the blind, the aged, the orphaned and the indigent” was a simple breakdown of the three spheres of life into sleep, work and play (p. 2). This resulted in residents being treated as a single, homogenous group, with staff performing, controlling and gate keeping to keep things running smoothly in this system.
Conflicts never go away. I noticed that if you have a problem… it doesn‟t go away when you bring it up… or it creates further tension so I would rather not bring it up. I would rather keep it to myself and not allow my wife and myself to show the tension „cos they are the professionals who know best. (Lee Ming)
Being considered frail is closely related to the stigma of dependency. In the staff- driven triad, the resident appears to be a willing participant, believing that the staff should be in charge and will help them to meet their basic needs. The resident is obedient and compliant, while the staff enacts a traditional hierarchical relationship in which professionals know best. This is a pivotal attribute that characterises the routinisation of care as priority, ranging from highly specific tasks to everyday and mundane activities in Parkview.