Being in Place: Toward a Situational Perspective on Care

An optimum focus in any care situation is creating and sustaining environments that facilitate an ongoing sense of "being in place" for all involved. Using this rationale, we propose a Situational Model of Care for exploring dynamic relationships among aging persons receiving care, the convoy of persons offering this care and support, and the place where this occurs, as evolving situations throughout the course of a disease. The model is grounded in extant literature and illustrated through a case study derived from in-home observations and interviews. Emphasizing an underlying goal of fostering a sense of being in place as a desirable outcome facilitates situationally nuanced directions in research and clinical care.

Sensory Processing Abnormalities in Community-Dwelling Older Adults with Cognitive Impairment: A Mixed Methods Study

Mild cognitive impairment (MCI) or dementia often leads to behavioral and psychiatric symptoms of dementia (BPSD). Sensory processing abnormalities may be associated with BPSD. The purpose of this study was to explore relationships among sensory processing, behavior, and environmental features within the homes of people with MCI or dementia. This project used mixed methods to assess participants' sensory processing, care partner perspectives on behaviors, and in situ observations of the home environment. Nine participants with cognitive impairment (MCI n = 8, early dementia = 1) and their care partners were included. Seven participants with cognitive impairment were reported to have abnormal sensory processing. Findings suggest that unique environmental adaptations, tailored to personal and sensory preferences for each participant, were associated with a decreased level of behavioral disruption during the observation periods. Implementing sensory-based approaches to maximize environment adaptation may be beneficial in reducing disruptive behaviors for adults with cognitive impairment.

Exploring college students' attitudes toward older adults: A description of methods used by the gerontological literacy network

Recognizing the pervasiveness of negative societal attitudes toward aging and older adults is critical, as research indicates how older adults are viewed subsequently influences how they are treated. The Gerontological Literacy Network (GLN) is a multi-university collaboration established to address ingrained beliefs that underlie ageism and gerontophobia. The GLN developed a data-gathering protocol that uses drawing as a foundation to assess the gerontological literacy of college students. The protocol includes drawing what aging means, writing a paragraph describing the drawing, indicating the age at which someone is "old," and writing words associated with "old person" and "grandma/grandpa." Results from 1,609 protocols confirm that college students have negative views of aging as depicted in drawings of negative emotional states, illness, physical decline, and death. The presence of positive representations of aging (e.g., smiling) reveals the heterogeneity of perceptions and suggests the potential to achieve more accurate perceptions through educational interventions. This article provides an overview of the protocols and suggestions for future efforts related to gerontophobia and ageism.

Clinical geography: A proposal to embrace space, place and wellbeing through person-centered practice

This essay envisions how geography can operationalize nuanced understandings of space and place to enrich the lives of individuals across the lifespan. We propose a focused integration of geography into person-centered practice: a clinical geography dedicated to working directly with people to promote optimal physical and mental health outcomes and wellbeing. Our proposal integrates spatial modifications to facilitate access and utility, behavioral interventions to maximize effectiveness in using space, and therapeutic engagement to nurture a deeper sense of 'being in place' that enhances wellbeing and quality of life. This focus is timely given societal instability and precariousness resulting from incongruous person-environment situations. In addition to investigating, explaining, and critiquing hazardous and inappropriate conditions, geographers might also directly and more immediately intervene with people who find themselves in such situations.

Toward a Regional Gerontological Agenda: The Use of Empowerment Evaluation

This article describes the application of an empowerment evaluation approach to nurturing the growth and priority setting of a regional organization. A model is provided of the processes whereby the Southern Gerontological Society (SGS) identified research and service priorities by conducting a survey of stakeholder perceptions of regional needs. The survey goal was to identify important issues faced by older adults in the South as a prelude to refining SGS research and service priorities and developing its contemporary regional gerontological agenda. We trace how the survey findings were translated into actions including shaping the annual meeting program, creating new standing committees, and developing service activities. Underlying the process of developing and refining this agenda are a set of key principles that have come to characterize the operation of SGS. These principles are discussed and provide a model for comparable organizations seeking to develop agendas consistent with their mission and identity.

Managing employment among pre-retirement aged cancer survivors

Introduction

Successfully maintaining (managing) paid employment can be a challenge as people negotiate the cancer care pathway and survivorship. Little research explores the influence of age on this situation. The purpose of this project was to explore the role of age in managing employment for survivors from age 45 to 64 years.

Method

A qualitative descriptive design was conducted to explore the intersection of age and managing employment for cancer survivors. In-depth semi-structured interviews were conducted with 19 United States cancer survivors (lung, breast, colorectal). Interviews were conducted in person or by phone. Verbatim transcripts were analyzed using thematic analysis. Codes were grouped by categories, incorporated into separate topical files, and then aggregated into broader emergent themes.

Findings

Survivors are not just “returning” to work after treatment. They are often managing work both during and after treatment. Age may have benefits but can also provide barriers to positive survivorship and employment experiences. Fulfilling the role of employee and maintaining a worker identity was a strong driver for many participants. Again, this was potentially both a support and a barrier. It was discovered that health care providers provided little support to facilitate employment.

Conclusion

Age is a factor that is poorly understood but influences both health and personal aspects of the experience of managing paid employment during and after cancer treatment. Occupational therapy practitioners should acknowledge this important role in addressing cancer survivorship.

DO WHAT I SAY, NOT WHAT I DO? CHALLENGING CONTEMPORARY WISDOM ABOUT RESIDENCE IN OLD AGE

An environmental gerontologist teaching about “aging and environment” for 30 years, I had it all figured out. Downsize and divest, stair free environment, universal design, environmental centralization, location close to services. At 60, I was consulting with an architect to design an age friendly home and searching for a level plot. But then, serendipitously, we found our current home, a residence defying all of these principles. An irresponsible denial of aging and pending frailty? Thirteen years later, I’m not so sure. In this presentation, I explain why, focusing on processes of “making and remaking home” and “being in place” that have been central themes in my research career. I explore ways in which as my wife and I grow older, harnessing modern technologies, newly emergent living arrangements and contemporary communication, we anticipate being able to age in place far longer than has been possible for previous generations.

RETHINKING RURAL GERONTOLOGY THROUGH A DEWEYAN PRAGMATIST PERSPECTIVE

Rural aging as we have conceived of it in the gerontological literature of the past 50 years no longer exists, if it ever did. In this presentation, we contribute toward a reframing of the discourse on rural aging through a critique of established views of rural aging as an ecological, cultural, and phenomenological experience. We argue that each view is limited in its ability to encapsulate the essence of rural living and community. Our critique provides a context for a dynamic perspective on rural aging that embraces the situational uniqueness of each rural environment. We introduce that perspective, based in John Dewey’s philosophy, and grounded in the idea of situationally defined manifestations of place integration within an ever-changing milieu. We conclude with a discussion of key implications, including how this perspective reshapes the roles of researchers and older rural residents in the process of ongoing rural gerontological inquiry.

Habituation and Being in Place

Over the duration of our lives, we each develop a rhythm and a routine in our use of space and in our relationships with the places of our lives that provide a sense of being in place. We gradually come to wear our environment like a glove, as, with increasing familiarity, it almost literally becomes a part of our persona. As we grow older or become increasingly frail, we adapt to reduced physical capabilities and changes in our environment in a manner that allows us to continue functioning effectively. This article explores the implications for occupational therapy of habitual use of the environment by older people and the sense of being in place that characteristically results. It is argued that sensitivity to the development and the maintenance of being in place provides a template for effective intervention when physical capabilities are compromised. Using the framework provided by complexity theory, and empirical observations from an ethnographic study of growing old in an Appalachian community, the article considers homeostatic adjustments that older people make in the use and the meaning of the spaces and the places of their lives as they accommodate to changing circumstances. By exploring the role and the uses of habituation (learning through repetition) in this process of gradual, often almost imperceptible, environmental adjustment, occupational therapists will be able to enrich their potential for developing strategies for intervention that effectively use a knowledge of habit in treatment.

Persistent Elderly Poverty in Rural Appalachia

This article focuses on the persistence of poverty among the elderly of rural Appalachia. A case study of current poverty levels in the 49 counties of Appalachian eastern Kentucky indicates continutng high levels of poverty, particularly among elderly women, in an environment characterized by limited resources. Demographic and economic change within the region threaten the continuing existence of traditional social and cultural buffers that, historically, have ameliorated the worst effects of poverty Such buffers include informal support systems and an egalitarian community ideology As the economic, social, and cultural context of poverty in the region changes due to increased integration in a national economic system and society, there is a need for a "new vision" that will provide a culturally appropriate, locally based, response to the structural conditions that perpetuate poverty among the elderly.

Community Integration of a Rural Nursing Home

Based on an ethnographic case study of Mountain View, a rural nursing home, the stereotype of the nursing home as an environment separated from its community context is challenged. Participant observation and repeated in-depth semistructured interviews with residents, family members, and staff, over a period of two years, and interviews with community officials reveal that the nursing home is historically, economically, socially, and psychologically integrated within the local setting. A high level of community integration is manifest in the permeability of the walls of the facility. Many residents are able to retain strong ties within the community through trips outside the facility and as a result of community involvement in activities at the nursing home. Most important, the community integration of Mountain View allows residents to maintain a temporal continuity in their lives. High levels of community integration may enable nursing homes to play an expanded role in the rural long-term care continuum.

Current Research in Rural Models of Integrated Long-Term Care

This introductory article describes four commissioned articles in this issue that review the research on integrated models of long-term care and the rural implications of these models. Most models have been tested in urban areas or with urban population bases. Rural regions have both barriers and opportunities in implementing integrated long-term care. Although a full range of long-term care services may be failing to meet the needs of home and community-based care, rural areas may have better cooperation among acute and long-term care providers. Managed care penetration and experience are limited in most rural regions,b ut examples are given of Program for All-inclusive Care of the Elderly programs,the Arizona long-term care system,the Carle Clinic demonstration,and developments in several states for serving rural long-term care populations with new models that integrate across providers, funders, and/or services.

Toward a physical environmental continuum for occupational intervention in a rehabilitation hospital

ABSTRACT A study was conducted to explore occupational therapists' perceptions of rehabilitation environments and the influence of these perceptions on practice and occupational interventions. Traditionally, inpatient occupational therapists have a choice of intervention environments, ranging from a gym-like to a more home-like setting. Choosing to provide interventions in these different environments can have an impact on occupational performance. In this qualitative exploration, 21 occupational therapists participated in focus groups designed to explore their perceptions of practice environments. Analysis of the transcribed data revealed that therapists felt rehabilitation environments should offer choices and be flexible, that environments influenced intervention strategies, and that the practice environment had an impact on professional identity. On the basis of this data, a conceptual matrix of the intersection of environmental setting and occupation-based interventions is presented to highlight the importance of these two aspects of therapy. Future research in this understudied area is needed to transform this matrix into a clinically useful model.

Geriatric education in the health professions: are we making progress?

PURPOSE

Relative to the overall population, older adults consume a disproportionally large percentage of health care resources. Despite advocacy and efforts initiated more than 30 years ago, the number of providers with specialized training in geriatrics is still not commensurate with the growing population of older adults. This contribution provides a contemporary update on the status of geriatric education and explores how geriatric coverage is valued, how geriatric competence is defined, and how students are evaluated for geriatric competencies.

DESIGN AND METHODS

Semi-structured interviews were conducted with curriculum representatives from 7 health profession disciplines in a case study of one academic medical center.

FINDINGS

Geriatric training varies across health professions' disciplines. Although participants recognized the unique needs of older patients and valued geriatric coverage, they identified shortage of time in packed curricula, lack of geriatrics-trained educators, absence of financial incentive, and low student demand (resulting from limited exposure to older adults and gerontological stereotyping) as barriers to improving geriatric training.

IMPLICATIONS

Progress in including geriatric training within curricula across the health professions continues to lag behind need as a result of the continuing presence of barriers identified several decades ago. There remains an urgent need for institutional commitment to enhance geriatric education as a component of health professions curricula.

Patient-provider communication: understanding diabetes management among adult females

OBJECTIVE

The purpose of this study was to explore how adult women manage their diabetes. Recommendations for improving adherence and opportunities to maximize communication between the healthcare provider and individuals who have type 2 diabetes also were described.

METHODS

An exploratory qualitative descriptive design was used to describe the experience of living with type 2 diabetes in adult females. Data were obtained via individual in-depth interviews with five women over age 50 with type 2 diabetes. Participants were interviewed individually and participated in a focus group.

RESULTS

Participants clearly identified three major themes affecting adherence to treatment regimens: communication with the healthcare provider, knowledge of diabetes, and the consequences of poor glycemic control. For these participants, patient-provider communication was the most important factor affecting diabetes adherence.

CONCLUSION

Individual autonomy asserted in day-to-day management is often perceived as non-compliance by the healthcare provider; while provider's descriptions of potential severe complications are viewed as scare tactics by the patients.

PRACTICE IMPLICATIONS

Improved communication offers the clinician the opportunity to develop a partnership with patients to build mutually acceptable treatment plans and reach mutually agreed upon goals. Empowering the individual with skills needed to negotiate treatment regimens will encourage positive health decisions and improved outcomes.

Analysis of key decision-making incidents in the life of a nursing home resident

PURPOSE

This study examined change in the decision-making autonomy of a single nursing facility resident.

DESIGN AND METHODS

This case analysis was part of a larger 3-year ethnographic investigation of decision-making events in four nursing facilities. In this case analysis, the resident, her daughter, and three staff members closely associated with the resident's care were each interviewed five times over a 15-month period.

RESULTS

Analysis of interview transcripts revealed four themes in decision making. Temporal change was evident in a complex scenario regarding room changes. Spatial context reflected the need for predictability and adaptability in decisions using space. Interdependence of decisions and decision makers was most evident with medical treatment and health care decisions. Awareness, being informed, and knowing what was going on was the final theme.

IMPLICATIONS

Despite having the best interests of the resident in mind, the process of decision making in nursing facilities may contribute to a pattern of gradual withdrawal of decisional autonomy from residents regardless of their ability to make decisions.

Effects of the quality of dyadic relationships on the psychological well-being of elderly care-recipients

The purpose of this study was to examine the association of the quality of caregiver relationships with the psychological well-being of elderly care-recipients. Sociodemographic variables and characteristics of the care-recipient situation (e.g., self-rated physical health, amount of instrumental support needed) were explored as potential predictors of the psychological well-being of elderly individuals. A secondary analysis of data collected during in-home interviews with 37 community-dwelling older adults revealed no significant correlations between the quality of the primary intimate relationship and any dimension of psychological well-being. However, better self-rated health was associated with fewer depressive symptoms, higher morale, greater life satisfaction, and better quality of life. The more instrumental support needed by an individual, the greater their depressive symptoms and the lower their morale. The findings also revealed that the older the individual was, the greater the depressive symptoms were and the lower life satisfaction became. Self-rated physical health predicted each dimension of psychological well-being. The findings suggest that age, the amount of instrumental support needed, and perceptions of physical health are important indicators of the psychological well-being of elderly care-recipients.

Individualizing care: family roles in nursing home decision-making

l. Family members remain fully involved in nursing home decision-making after their relative has been admitted to a facility. 2. Family involvement in nursing home decision-making serves to individualize care and provide a continuing link to the resident's personal history and preferences. 3. Family members assume an array of decision-making roles in nursing homes, including: caregiving, pampering, comforting, engaging, educating, monitoring, mediating, colluding and controlling.

Returning Home: The Interstate Transportation of Human Remains

Many people who die in the United States are transported across state boundaries for burial at a place viewed as “home” by the decedent or the next of kin. This article employs an analysis of data from death certificates to explore the transportation of human remains from Arizona where, in 1983, 17.1 percent of those who died were shipped beyond the state. A sample of 783 removals reveals a predominant geographical pattern of flows to the Upper Midwest and Great Lakes states. This pattern is the reverse of recent patterns of both seasonal (“snowbird”) and permanent in-migration of the living to Arizona. A propensity for individuals to be transported back to their state of birth or to their most recent previous residence is also revealed.

Nursing home room changes: toward a decision-making model

Although nursing home relocation has been extensively studied, very little research has investigated the more commonly occurring phenomenon of room changes within nursing homes. Room changes were monitored in four nursing homes over a one-year period. Participant observation; repeated interviews with residents, family members and nursing home staff; and event analyses were used in developing detailed case studies of the room change decision-making process. A model of the room change process and factors influencing this process is offered, involving five distinctive phases--precursors, initiation, decision, action, and outcomes.

Community elders: prevalence and correlates of depressive symptoms

This pilot study examined the prevalence and correlates of depressive symptoms among community-dwelling elders 75 years of age and older. Forty subjects were recruited from a research volunteer pool. Cross-sectional data were collected during structured in-home interviews. High depressive symptoms were reported by 10 (25%) of the elders; of these, 8 were males. Depressive symptoms were positively related to the need for instrumental support. Higher depressive symptoms were associated with poorer functional health status and self-rated health and with lower morale, life satisfaction, and quality of life. Nurses working with community-dwelling elders 75 years of age or older should be alert for depressive symptoms among those with indications of poor physical and functional health, and instrumental support needs should be assessed. Further investigation into the age/gender issue as it relates to the development of depressive symptoms is warranted.

Elderly migration and development in small communities

"This paper develops a conceptual model of the process of community change [in the United States] in response to elderly inmigration. Analysis of intra-regional variation in elderly migration patterns in Appalachia, and synthesis of an emergent literature on the benefits and costs of attracting elderly migrants, serve as a backdrop for case studies, based on field observations and interviews, of three contrasting Appalachian communities at different stages of development as retirement destinations."

Beyond performance: being in place as a component of occupational therapy

Emphasis on knowing and doing as focal concerns of occupational therapy has tended to overshadow being as an essential ingredient of human experience. This article advocates greater concern with understanding our clients' being in place--that is, their immersion within a lifeworld that provides the culturally defined spatiotemporal setting or horizon of their everyday lives. It is suggested that naturalistic and qualitative research strategies are appropriate for the exploration of this realm of experience. Illustration is provided from an ethnographic study of aging in a rural Appalachian community. The time-space rhythms of taken-for-granted behavior, the significance of the surveillance zone (space within the visual field of the dwelling), and the way in which the environment may come to be a component of the self, are identified as themes within being in place that have significant implications for enhancing occupational therapy practice.

The significance of elderly migration to changes in elderly population concentration in the United States: 1960-1980

Analysis of county level elderly and nonelderly net migration data revealed that, overall, migration was of less importance in explaining changes in elderly population concentration between 1970 and 1980 than it had been in the previous decade. However, because of the spatial restructuring of both elderly and nonelderly migration, the contribution of elderly migration relative to nonelderly migration increased from 1960 to 1980. Recognizable regional variations were apparent. Elderly migration not only remained significant in explaining changes in elderly population concentrations in "traditional" Sunbelt retirement states but also showed increased importance in newly emergent southern retirement states and in several northern states, including a group in New England.

Between worlds: a relocation dilemma for the Appalachian elderly

An historically based spatial separation of old people from their children has generated a critical relocation dilemma for the present generation of Appalachian elderly--reconciling the physical, social, and emotional support of a familiar environment with the desire to be close to family. This article, based on a four-year participant observation study of a panel of elderly persons in a rural northern Appalachian community, explores the tension between factors that reinforce inertia and those that encourage relocation to the homes of children living outside Appalachian. The article traces and illustrates a normative trajectory involving several phases--departure of children, accommodation, seasonal migration, crisis, relocation, holding on, and severance--that characterize the decision process whereby, over a period of years, the dilemma is gradually resolved.