Autonomy in elderly care: A literature review

Autonomy in elderly care: A literature review Introduction Older persons in history have been regarded as dependent because of the physical body changes that come with growing older. These physical changes greatly affect the normal functioning and the effectiveness with which they operate and hence the need for external support both at the physical and social levels (Agich, 2003). As the physical energy wanes, so does the level of activity not only to support themselves physically but also on a wider scale. It is these very changes that bring to light the issues of care and dependence of older persons on caregivers and/or family support. However and important to note, like in the rest of other social groups, older persons are a heterogeneous group in terms of gender, race, culture, class and otherwise (Bond and Corner, 2004) and therefore, there needs vary accordingly. Further, as Bond and Cabrero (113: 2007) point out, mental and physical incapacity and disability which lead to dependence are common stereotypes of human ageing. Older people in care or not have been seen as frail and therefore unable to make decisions, communicate, and engage in meaningful relationships with their surrounding environment. As a result, their autonomy in care has been compromised. Jacob (1999) cited in Townsend (2009) compounds it further that professionals and families of older people as well consciously and unconsciously bear discriminatory assumptions about them. To this end, this paper explores autonomy of older people in care in depth, evaluates existing social work practice and suggests strategies to ensure both caregivers and service users promote an interdependence that would help in reinforcing control and respect for service users. Collopy (1988) defines autonomy as a set of notions that promote freedom, self-determination, independence that is signifying control and the power to make decisions by the individual. From a medical view point once one is admitted into care they are not well and therefore cannot cope on their own let alone make decisions. Because of this, they are viewed as patients who are incapacitated and therefore have to depend on caregivers. However, one wonders whether all older persons are incapacitated on all fronts. Even when they are fragile, do the Caregivers have sufficient expertise to socialize and communicate with them? These and other questions remain largely unanswered. This view therefore tends to ignore the strengths and abilities of the older persons. Like Runciman cited in Bond and Corner (2004) explains, in understanding social status, it is more meaningful to study individuals from their perspective and values so as correct judgments are made about them. Like all other social groups, older people too would be better understood from the view point of their everyday experiences at an individual level other than having to impose what we think is best for them. This would imply that understanding older persons’ desires means a lot to them rather than assuming that we know all they need. Understanding of Autonomy and Care for Older Persons Contextually Autonomy as a concept connotes a different set of meanings depending on the setting or context. It is defined differently in a sense that it means different things to different users and therefore taking one meaning or usage would very much complicate its very usage at the different cultural and societal levels on the whole (Agich, 2003). The fact that it spells out different meanings and qualities, in care for older persons too, would be quite a challenge for both the service users and the Caregivers themselves. Autonomy as a cultural ideal under the guise of freedom of choice especially in the western context is very much viewed as a necessary feature for any individual. In regard to United States for example, freedom is seen as a basic of life and therefore without which, is deprivation of an individual of a basic right (Agich, 2003). It is important to note that this freedom starts at birth throughout life and therefore including in old age, whether in care or not. In care too, w ithout the liberty for one to advance their choices would be seen as degrading by the service user and therefore subservient to the caregiver (Agich, 2003). However this raises the question of what might happen when the service user is suffering from a severe cognitive impairment? This clearly indicates the challenge of according full autonomy to service users. On the other hand in countries like South Africa where the elderly are seen as very important assets within their communities, it is argued that freedom begins with avoiding taking elders away from their very communities to institutionalized care (Lombard and Kruger, 2009). Institutionalized care would be seen as denying older persons an environment they consider natural and fulfilling. This entails an environment which allows them to share their older age with their kith and kin; who in this case know them better and therefore interdependence remains natural. Further, this kind of setting allows for respect and control of older persons based on cultural values. Even when older persons are mentally incapacitated, the family caregiver will know what they have always desired that is, their favorite food, dressings, entertainment and the like. This in a sense allows for older persons freedom in a manner that is fulfilling in this kind of context. However, it cannot go without mention th at this kind of setting requires strong family structures that allow for time and financial capacity from the family members to take care of the elderly. With the spread of neo-liberalism that promotes capitalism and individualism, some of these especially extended family systems have broken down hence rendering older persons susceptible to dependence on hired caregivers in a family setting or institutional care (Lombard and Kruger, 2009). Evaluation of Existing Social Work Practice and Care Provision for Older People Inasmuch as the intentions of care for older persons are seen as good, the outcomes of both institutionalized and family care are not always pleasant (Talerico, 2004). When service users are put into care, the assumption is that it is for the wellbeing of the service users because they are being given help physically, socially and otherwise. This in many a case does not always happen because of the very nature of how older person are perceived in the eyes of the caregivers. The societal perceptions of older persons delude caregivers of the capacities and strengths that service users possess. As Townsend (2006) theorizes it, these very perceptions give birth to the ideas of ‘structured dependence’ for older persons. For example a situation where the state deliberately introduces structures and policies like compulsory institutional care for older persons that are very much underpinned by the very disempowering and biased perceptions held strongly by society. Caregivers base their understanding of service users on the very notions they grow up with which in many cases misguides their treatment of older persons (Jacobs, 1999 cited in Townsend, 2003). In which case, service users find themselves in a difficult situation that is, cannot voice their concerns either because the surrounding environment is not supportive enough or for fear of retaliation from the caregivers (Townsend, 2006). In an investigation conducted in the United Kingdom by ‘Help the Aged International’ (2002), older persons in long-term care have suffered a series of blows partly due to the lack of quality assurance on part of the institutions and also a lack of competence from the caregivers on how to communicate with service users to deliver the required services (Townsend, 2006). A classic example in this investigation highlights a woman who was suffering from Alzheimer’s disease; she was dying of dehydration but no one could tell and she finally pas sed on. This is clearly an indication of lack of expertise on part of the Caregivers and as well an indicator of many others who are in the same or even worse-off situation. The fact that they could not communicate with her, they decided to take matters in their own hands; clears indicates of how dependence on Caregiver can get messy especially when there is a lacking in skills or quality assurance by the caregivers whether in institutional or family setting. On the other hand, very few studies explore the experience of older persons’ autonomy in care, whether in institutionalized or family in the developing world. Nonetheless, in a study conducted in South Africa, there is an indication of a shift in policy of primarily taking away older persons from institutionalized care to community based care with a view of keeping them closer to their kith and kin (Lombard and Kruger, 2009). However, due to issues of neo-liberalism which advance capitalism and individualism, this leaves older persons in family care at even greater risk as would-be caregivers opt for work and hire caregivers who despite the cultural attachment with these older persons, are little known to the service users. Despite being in family settings, little is known whether the hired caregivers promote values of preferences and control of older persons. This puts the issues of meaningful relationships and interdependence in question for the older person in this kind of setting. As cited by Zubi and Conolly (2013), as well in cases where the institutional care exists, there are cases of understaffing and under funding of care activities for older persons. As a result, this raises the levels of fatigue and emotional exhaustion which leads to compromise in the quality of care. This is a clear depiction that with burnout of caregivers, self-determination of service users is not anything that would be given priority. Further, in a study conducted by Leece and peace (2009), in which an attempt to understand what autonomy and independence of service users in care meant to caregivers, majority of them concluded that a service user had to be in a position to do everything on their own. Considering the wider and contextual understanding of autonomy; for example in terms of decision making and positive relationships, this is an indicator of how caregivers unconsciously take service users for granted in care and hence a need for evaluation of social care practice. It is important to note that inasmuch as some service user are not in a position to make decisions on their own, Talerico (2003) stresses that caregivers have taken no initiative in trying to understand how to communicate with them so as to create an environment of interdependence; that is understanding their daily activities, abilities, values and histories. All this would go a long way in shaping the caregiver’s approach to interdepen dence in care (Agich, 2003). Strategies to Improve Older Persons’ Autonomy in Care As stressed by Talerico (2004), care settings are congregated environment in which the most important thing is maximizing health and support. She adds that these very goals defeat the very purpose of autonomy because as oppose to individual choices generalist care is promoted. It should be noted however that this can raise ethical questions because service users are different and therefore their needs vary. As fronted by Leece and Peace (2009), establishment of personalized care for services users would go a long way in addressing this. This means that caregivers give a special attention to individual to not only understand their histories, values and choices but establishing effective skills of communicating with them on the whole. Even older persons with cognitive difficulties can communicate (Agich, 2003). Therefore, Caregivers must be equipped with these skills to give more meaning to care for older persons. From the earlier discussion of caregivers who understood autonomy of older persons in care as only being able to perform tasks independently, it is very clear that communities of practice are very important. These mainly refer to a multidisciplinary approach to working with older persons in care. This emphasizes working with different professionals who work together to determine what’s best for service users (wenger et al cited in May, 2009). As nurses focus on the medical component, social workers focus on their values and preferences and policy makers advance policies that promote older people’s necessities at all levels. This promotes a better understanding older person whether in care or not. As well, this implies better working relationship not only among professionals but also with service users who are engaged at different levels. Further, this in a sense, promotes interdependence among them as dependence is phased out. In addition to promoting a better understan ding older persons, specialist skills training would be important for the effective intervention of professionals at different levels. This explains the case for being able to communicate, identify their strengths and abilities and the like. Advocacy for the rights of older people would serve to bring their issues to the forefront (HelpAge International, 2010). Historically and socially, older people have been looked at from a medical view point as frail and therefore unable to perform task let alone making their own decisions. This is clearly a sweeping generalization that does not fit the bracket of all older persons. But because this has been the case for a long time, it has come to be accepted and upheld. This line of thought therefore very much underpins the policies and activities that are geared towards older people where they are seen as ‘dependent’ as oppose to partners in working. Therefore, in deconstructing this line of thought, advocacy through community dialogue and raising aware awareness of older persons’ issues autonomy in care among which, would go a long way rectifying the age-old negative connotations about ageing. As communities accept to dialogue and become aware of the reality o f old age, policies and agendas will begin to come up. In the long run this shapes the societal outlook of older persons at every single level. HelpAge International (2010) highlights how Tanzanian older women have been branded witches by their societies. As a result, this explains the kind of nasty treatment that they have been accorded whether in care or not. But by dialoguing with communities, the trend is changing for the better. Important to note is that advocacy would not directly promote autonomy in care for older persons but rather it goes a long way in pushing for older persons’ concerns high on the agenda. With the guidance of social workers, this in the short run would guide social policy and in the long run challenge and change societal outlook of ageism. Conclusion In a nutshell, if older persons are to gain control over their lives in care, then there needs to be a re-conceptualization of caring for older people; â€Å"where caregivers become supporters and advocates but not custodians and guardians as it were† (Nolan et al, 2001). As oppose to older persons being passive recipients of care, they become active participants who have some sort of control over their life while in care. This very much promotes interdependence between service users and caregivers. Concretely, as advanced by Rogers (1974), an individual-centered approach to caring, where the service user is placed at the centre of activities, would help caregivers in identifying the specific strengths and abilities of service users and therefore creating better working relationships which in the end promote interdependence and an acceptable level of control of service users. References Agich G. J. (2003) Dependence and Autonomy in Old age: An Ethical framework for Long-term Care, 2nd Edition, Cambridge: Cambridge University press. Bond, J and Cabrero, G.R. (2007) Ageing in Society: European perspectives on Gerontology 3rd Edition, London: Sage publications Bond, J and Corner, L. (2004) Quality of life and Older people, 1st edition, McGraw Hill: Open University Press Fine, M. and Glendinning, C. (2005) ‘Dependence, independence or inter-dependence? Revisiting the concepts of ‘care’ and ‘dependency’. Ageing and Society, 25, 601-21, available online at http://eprints.whiterose.ac.uk/1653/1/dependency.pdf [accessed 2 January 2014] HelpAge International (2010) Women’s rights in Tanzania. [Online] Available from http://www.helpage.org/what-we-do/rights/womens-rights-in-tanzania/ [Accessed 3 January 2014]. Katz, P.R., R.L. Kane, Mezey, and D. Mathy (Eds.). 1995. Quality Care in Geriatric Settings: Focus on Ethical Issues. New York: Springer. Leece, J and Peace, S (2010) Developing New Understandings of Independence and Autonomy in the Personalized Relationship. British Journal of Social work, 40, 1847–1865. Lombard, A. Kruger, E. (2009) older persons, the case of South Africa. Ageing International, 34: 119 – 135, available from http://web.ebscohost.com.proxy.library.lincoln.ac.uk/ehost/pdfviewer/pdfviewer?sid=0294ee3e-afec-4dad-882a-3b6fd4656d61%40sessionmgr4001vid=2hid=4204 [Accessed 1 January 2014] May, L. A. (2009) Communities of practice in Health and Social Care. 2nd edition, Sussex: Wiley-Blackwell Nolan, M., Davies, S., and Grant, G. (2001) Working with older people and their families. Open University Press: McGraw Hill Education Rogers, C. (1974) On Becoming a Person: A therapist’s view of psychotherapy. London: Constable. Talerico, K. (2004) Honoring Resident Autonomy in Long-Term Care Special Considerations. Journal of Psychosocial Nursing, 42, (1) Townsend, P. (2006)‘Policies for the aged in the 21st century: more ‘structured dependency’ or the realization of human rights?’Ageing and Society, 26 (02): 161 – 179 Zubi, Y. and Conolly, P. (2013) Recollected experiences of first hospitalization for acute psychosis among persons diagnosed with schizophrenia in South Africa. South African Journal of Psychiatry, 19 (3), p81-85. Little Red Riding Hood: Angela Carter Little Red Riding Hood: Angela Carter All fairy tales, both old and new that exist today can be said to have a long history that lies beneath them. However, some aspects of the fairy-tale history are somewhat hard to trace because its only the literary forms that can obviously survive. Furthermore, what we do know is that the majority of them have been around and retold for many years. Most, if not all of the famous fairy tales that we know have been adapted into various new versions as products of new challenging ideas around the society in which we live. Bonner states that fairy tales are the usual subjects of adaptation because of their massive appeal to both adults and children worldwide.  [1]  The story Little Red Riding Hood arguably offers a very interesting and challenging tale for enhancements through the application of the chosen contemporary theories in literary criticism that some critics have noticed throughout the years of its existence. Furthermore, in this essay I intend to compare Perraults version o f Little Red Riding Hood with Angela Carters version Company of Wolves. Little Red Riding Hood, Little Red Cap or simply Red Riding Hood is a European fairy-tale about a young innocent girl and a wolf. The tale was first published by Charles Perrault in 1697, which in fact was an adaptation of an older tale still. Thus, Perraults version ever since has been adapted and criticised throughout its history. Zipes holds the genre is relevant to contemporary culture as it holds issues that exist within gender and its society.  [2]   Perraults version was named Little Red Riding Hood. The red hood is seen as a popular symbol in Europe and North America. In the 19th century young daughters of wealthy families were painted in red caps or hoods. Erich Fromm considers the hood to symbolise menstruation and the approaching puberty that lingers upon the young person that wears it.  [3]   Perraults version can be described as a much more descriptive fairytale than many others. It begins with once upon a time  [4]  which the traditional way to start a fairy-tale and also gives the image of timelessness throughout the tale. This relates to the narration and the structure within the fairy-tale of which certainly precedes the middle classs existence within. It portrays the image of the little girl being highly attractive the prettiest creature who was ever seen.  [5]  She is also said to be extremely naÃÆ' ¯ve, the poor child who did not know it was dangerous to stay and hear the wolf talk.  [6]  This shows her innocence and that she isnt aware of the bad happenings in the outside world due to her controlled life at home and within her society, this relates to Trimmers view that both children and childrens tales should be kept away from such happenings within society that are out of the norm.  [7]   In Perraults version of the tale the little girls mother simply instructs her to take some food for her grandmother: never mentioning danger or anything that she should avoid on her journey, thus showing how safe society was perceived throughout the time. Tater argues it resembles a somewhat cautious tale to society, a wakeup call.  [8]   Moreover, the existence of the wolf within the tale gives the audience an image of a villain being portrayed. The wolf is seen as a popular image of danger in fairy tales as it is seen in this and other stories such as The Three Little Pigs. It is an obvious predator that exists within the forest and thus relates to a natural choice for the story rather than witches etc. it can also be portrayed as a metaphor for a sexually predatory man. He is of course the only male gender within the tale thus is portrayed as a powerful and strong figure, seen in the phrase gaffer wolf  [9]  personifying the wolf as the boss within the tale. He shows a strong influence upon the naÃÆ' ¯ve country girl as he persuades her to divert from the safe path in which she was on after foolishly telling him exactly where she was going. This clearly portrays to the audience a somewhat clear contrast between the village and its surrounding in which the girl lives, which is seen as safe and the dangers tha t are withheld in the wide world past what the little girl is used to. Hence, holding a strong morality message throughout the fairytale, warning people to stick to what they know. Tater identifies the tale as a place to work through people thoughts and anxieties about sexuality, gender and sometimes violence.  [10]  When Little Red Riding Hood makes it to the house, she has no sense of anything wrong and states What big arms you have!  [11]  Exclamation can be argued to be the favourite story element for tales, being seen as a story building tool that creates the anticipation and horror for the reader as they know that she isnt talking to her grandmother. Warner considers her initial failure to distinguish the wolf from her grandma as a crucial element within the story, as it creates the tension before the horrific ending of the fairy-tale. Furthermore, critics that exist such as Freud argue that there is evidence of underlying sexual motivations and tensions, evidence of this is the Hungry wolf simply not just eating the poor old grandmother, but he fell upon the good woman.  [12]  Feminist critics portray this as an image of rape and sexual tension. In addition, before he sadly digests the young girl he invites her to bed, come and lie down with me.  [13]  This can be seen as another sexual connotation within the tale, and also a disturbing image for its older audience. Thus being an innocent, clueless little girl she climbs into bed with him. Therefore by disobeying her mothers instructions and talking to strangers Freud dramatically insinuates that this struggle can only lead to her death which is the exact fate of Little Red Riding Hood, as he ate her up too.  [14]  The terrifying ending makes the tale seems more realistic leading to the moral at the end of the story of not talking to strangers and stay ing to paths in life you are familiar with; Bettelheim says it deliberately threatens the child with its anxiety producing ending.  [15]   Moreover, the tale of Little Red Riding Hood has been seen to undergo adaptation in relation to society of the time. Hence, in comparison to Perraults version, The Company of Wolves by Angela Carter. This can be found in her selection of short stories within Bloody Chamber. Throughout the short story Carter retells the famous fairytale in a somewhat gothic light. It is said to convey the completeness of corruption and unconventional ideas of sexuality and an ability to defend one using characteristics which are usually conveyed through a male such as slyness and confidence.  [16]  However, unlike the Perraults version, it takes place in a mountainous country on Christmas Eve in the dead of winter. Thus, in comparison to Perrault there are no flowers or sunshine present for the little girl to get distracted by on her walk to Grandma. Angela spends the first part of the story telling the reader terrifying folk tales of wolfs and werewolves that bombard society and proceed to do ruthless and evil deeds that live to kill. Clearly it adapts with the time within the story when food would be scarce and these creatures are said to lack the ability to listen to reason.  [17]  They are portrayed as forest assassins, grey members of a nightmare.  [18]  They were feared so great that children carried knifes around with them, seen as different to the original Little Red Riding Hood who isnt even warned of the dangers that she could encounter on her journey. In Carters version, the wolves are disguised as men and have to become naked to become a werewolf within the tale, If you spy a naked man in the forest run as if the devil were after you.  [19]  Moreover this can be seen to link to Perraults version, as it holds the notion of sexual tension and desires and involves the wolf as a sexual predator, a symbol of bo th danger and desire. However, Carters version holds a twist within the tale in that the young girl is able to triumph, by adapting her new found sexual desires and power and thus, gives in to notions of somewhat carnal desire, unlike Perraults characters that are seen to be weak and unable to fend for themselves. Furthermore, similar to Perraults version we see Little Red Riding Hood again to be all innocent as she is described as an unbroken egg, a sealed vessel  [20]  and also beautiful with pale skin and dark hair. In addition, as before she is taking food to her sick grandmother; however we see a sense of time and self-defence within this tale as she takes a large knife for her 2 hour trip,  [21]  and we are told its Christmas Eve again portraying that sense of time and place. However, due to her naivety and the way she has been brought up se doesnt think she is in danger as she is too loved to ever feel scared.  [22]  She is portrayed as the most beautiful and young girl in the family thus they want to keep her young. However, the difference between this girl and Perraults version is that she has a notion of menstruation and sexual readiness about her evidence of this is, the childs cheeks are an emblematic and scarlet white.  [23]  This portrays the young girl as being o n the verge of puberty and menstruation, thus adding to the idea of her vulnerability. This is further shown when she bumps into the wolf in the forest who is in fact a hunter and finds him immediately attractive. Compared to Perraults version of events Little Red Riding Hood makes friends with this stranger and foolishly lets him carry her basket which has her knife in. After a long walk, and when she has told him were she is going, he bribes her with a kiss for the winner of whoever gets to grandmas house first. Liking this idea she agrees and allows him to leave with her basket, this gives the image of bargaining with the notion of seduction. Unlike before little red riding hood shows her adolescence and sticks to the path shes on. However, she walks slowly to ensure he gets his kiss again showing her sexuality and desires. The wolf arrives at the grandmothers house as a completely different person that we have just witnessed before; he is chewing meat of his catch like a savage. Carter then links in the sexual connotations as he strips naked revealing a naked, hairy, lie covered body,  [24]  and his nipples that are as red as poison fruit.  [25]  He then devours her. However disgusting this image, it is portrayed as somewhat attractive and sexually arousing. The grandmother within the tale is old and feeble as in Perraults version also, however, she lives alone with her dog and bible. In the past she has lived her life as a devoted Christian and wife. She throws the bible at him showing some self-defence which the original grandmother doesnt even attempt in Perraults version, sadly though this isnt enough to help her against the wolf that is upon her. He then disposes all evidence and waits for the girl to arrive. Unlike the little girl in Perraults version upon her arrival in Carters short story she immediately realises that something isnt right and senses danger in grandmothers house, fear does her no good so she refuses to be afraid.  [26]  When she arrives there are uses of the same rhymes within the Perraults version, thus showing connections within the adapted version. However, in this tale the girl sees the wolf as strange, unknown creature and thus gives him his owed kiss and starts to undress herself. It is argued by Bettelheim that we can see Little Red Riding Hood wear her desires and sexuality literally on her sleeve. This is seen through her cape, as it portrays a sexual readiness and again symbolising menstruation and blood that she will shed when she loses her virginity. She shows a somewhat sexual power that allows her to intoxicate the lustful creature, small breasts gleamed as if snow had entered the room.  [27]  Evidently, the seduction gets reversed and we see the p ower shift as the girl becomes the sexual creature within the tale. This can be seen as the reason why grandma and the original little red riding hood didnt survive, she was old and lacked wit and tactfulness, Little Red Riding hood refuses to be weak and vulnerable as she survives and sacrifices her virginity to save her life, showing that self-defence that the original girl didnt have. She comments on the wolves teeth as in the original but when the wolf says all the better to eat you with  [28]  instead of screaming and having her fate decided, she laughs and says im nobodys meat  [29]  , Bacchilega interprets this meaning as acting out sexual desires offering her flesh not meat, hence sacrificing her body to him sexually then burning her cape in order to become one of the werewolves herself and adapt to his kind. The cottage is then surrounded by wolves howling a marriage song and the girl engages in a marriage ceremony conducted by the choir. Thus feminists state that s he does not call upon god or scream or get eaten. She freely exercises her own sexual power, trusting her own nature.  [30]  This then leads to sleeps in grannys bed, between the paws of her tender wolf.  [31]  A disturbing image towards its audience. It is also interesting to see that Carter uses a werewolf instead of a wolf that is used in Perraults version. Timmer states that this produces a moral message to its audience, whether that be children or adults that people should not judge others, people arent always what they seem.  [32]  Thus using a half wolf half human villain within the story allows us to identify with the wolf as people and maybe realise that we all have a little beast in us at some point. In conclusion, one of the many adapted versions of Perraults implies that sexuality is not something within our society that should be something we loath, fear or runaway from and a bad end, which we see within the Perraults version comes only form those in servile situations. Through Carter, we see the young girl take the power into her own hands and use it without fear or shame in order to survive unscathed unlike Perraults version, what ends in tragedy from both the grandma and Little Red Riding Hood. However, both versions are heavily criticised by many, especially feminists as they say it is full on female liberation that implies the view to the reader that nothing else in the world will save you against such horror and the only way to survive is through temptation, desire and the ability to fight fire with fire.